There is ambiguity surrounding the degree of scaphoid union required to safely allow mobilization following scaphoid waist fracture. Premature mobilization could lead to refracture, but late mobilization may cause stiffness and delay return to normal function. This study aims to explore the risk of refracture at different stages of scaphoid waist fracture union in three common fracture patterns, using a novel finite element method. The most common anatomical variant of the scaphoid was modelled from a CT scan of a healthy hand and wrist using 3D Slicer freeware. This model was uploaded into COMSOL Multiphysics software to enable the application of physiological enhancements. Three common waist fracture patterns were produced following the Russe classification. Each fracture had differing stages of healing, ranging from 10% to 90% partial union, with increments of 10% union assessed. A physiological force of 100 N acting on the distal pole was applied, with the risk of refracture assessed using the Von Mises stress.Aims
Methods
Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care. Questionnaires were sent to orthopaedic waiting list patients at the start of the UK’s first COVID-19 lockdown to capture key quantitative and qualitative aspects of patients’ health. A total of 888 respondents were divided into quintiles, with sampling stratified based on the Index of Multiple Deprivation (IMD); level 1 represented the ‘most deprived’ cohort and level 5 the ‘least deprived’.Aims
Methods
Scaphoid waist fractures (SWF) are notable in upper limb trauma and predominantly occur in young men. Morbidities associated with SWF include fracture non-union, premature arthritis and humpback deformity. Delayed treatment and non-adherence to fracture immobilisation increases likelihood of these complications. There is evidence that men engage in negative health behaviours such as delayed help-seeking. The Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) conducted interviews in individuals who had sustained a SWF. Although SWIFFT showed multiple social determinants for the overall injury and healing experience, a key factor this novel study considers is age and sex. This study aimed to analyse interview data from young male participants in SWIFFT to help distinguish the experience of SWF in young men, through exploring the influence of masculinity. A purposive sample of 12 young male participants were selected from SWIFFT. These participants were enrolled from a possibility of 13 different centres across Britain. There were 17 semi-structured interviews produced from these participants, and this was thought to be sufficient for data saturation. These interviews were evaluated through deductive thematic analysis with an open-coding approach, with respondents’ experiences being compared against themes documented in men's health literature. The “Braun and Clarke (2006) Six Phases of Thematic Analysis” methodology was adopted to perform this.Introduction and Objective
Materials and Methods
This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI. MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder.Aims
Methods
COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms. A minimum representative sample of 824 patients was required for quantitative analysis to provide a 3% margin of error. Sampling was stratified by body region (upper/lower limb, spine) and duration on the waiting list. Questionnaires were sent to a random sample of elective orthopaedic waiting list patients with their planned intervention paused due to COVID-19. Analyzed parameters included baseline health, change in physical/mental health status, challenges and coping strategies, preferences/concerns regarding treatment, and objective quality of life (EuroQol five-dimension questionnaire (EQ-5D), Generalized Anxiety Disorder 2-item scale (GAD-2)). Qualitative analysis was performed via the Normalization Process Theory.Aims
Methods
Our goal is to increase diagnostic accuracy of synovial fluid testing in differentiating prosthetic joint infection(PJI) by more exhaustively studying simple and inexpensive biomarkers. For that purpose, we sought to determine: 1) if synovial fluid C-reactive protein(CRP), alpha-2-macrogloblulin(A2M), procalcitonin and adenosine deaminase(ADA) concentrations are different between infected and aseptic cases; 2) performance and optimal cutoff values of each marker; 3) whether any such test may help improve diagnostic performance of traditional leukocyte count. Between January/2013 and December/2015 total hip or knee arthroplasty revision cases (regardless of preoperative diagnosis) were prospectively included provided enough synovial fluid for biomarker analysis was collected and at least four tissue samples as well as the implant for sonication were gathered for microbiological study. Definitive diagnosis was classified as infection or aseptic on the basis of the recent International Consensus Meeting definition of PJI. Using receiver operating characteristic curves, we determined cutoff values as well as sensitivity and specificity for each marker.Aim
Method
Our aim was to compare the biomechanical strength modified side-to-side repair with modified pulvertaft technique keeping overlap length, anchor points, type of suture, suture throw and amount of suture similar. In our study, we have used turkey tendons. Two investigators performed 34 repairs during one summer month. All mechanical testing was carried out using the tensile load testing machine. Variables measured were maximum load, load to first failure, modulus, load at break, mode of failure, site of failure, tensile strain, and tensile stress. The statistical comparison was carried by Levene's test and T test for means. The mean maximum load tolerated by modified side-to-side repair was 50.3N(S.D13.7) and that by modified pulvertaft 46.96N(S.D: 16.4), overall it was 48.29 N (S.D: 14.57). The tensile stress at maximum load for modified pulvertaft and modified side-to-side repair was 4.2MPa(S.D: 3.1) and 4.7 MPa (S.D: 3.8) respectively {Overall 4.3MPa(S.D: 3.5)}. The tensile stress at yield was 4.01 MPa (S.D: 3.1) and 5.5 MPa (S.D: 3.7) respectively for modified pulvertaft and modified side-to-side repair {overall 4.44 MPa (S.D: 3.45)}. The tensile strain at maximum load respectively for side-to-side and modified pulvertaft repair was 7.87%(S.D: 33.3) and 7.84%(S.D: 34.02) respectively. We found no statistical difference between 2 repairs in terms of strength, load to first failure, and maximum load to failure. The suture cut through was the commonest mode of failure. Our study uniquely compares two techniques under standard conditions, and contrary to existing evidence found no difference.
The aim of this study was to describe the measurements of range of circumduction in normal volunteers and develop summaries of the data, develop the rate and rhythm of circumduction of the wrist with the use of Biometric electrogoniometer, reproducibility, reliability and accuracy of these measures of circumduction. Forty healthy subjects with a mean age of 42.6 years were assessed with flexible biaxial electrogoniometry in standard 90° pronated position of wrist for kinematic assessment of movement in orthogonal planes. Functional range of flexion-extension, ulnar-radial deviation and circumduction was measured and analysis of the digital output produced a visual display of the results as Lissajous's figures. This also allowed measurement of the total range of circumduction as two-dimensional area under the curve measurement. The rate and rhythm of movements were mathematically calculated and displayed over the two dimensional circumduction curves. The average arc of uniplanar flexion and extension is greater than the flexion and extension component of the circumduction curve but mean uniplanar radial ulnar deviation arc is similar to the radial-ulnar deviation component of the circumduction curve. The area of circumduction and circumference of the circumduction curve was used to measure the total range of circumduction. The four quadrants for the velocity of circumduction showed that the rate was faster in the deviation components as compared to flexion and extension. Quadrant analysis showed the changes in the rhythm was less in the deviation components compared to flexion and extension. The accuracy for measuring uniplanar movements showed a standard deviation of 6°. The accuracy for measuring circumduction showed a standard deviation of 347 °° (7%). Accuracy for measuring velocity of circumduction showed a standard deviation of 17°/s. This technique was found to be accurate and reliable in measuring the rate, range and rhythm of wrist circumduction.
Both intrinsic and extrinsic hand muscles contribute to finger flexion; however there are different ways in which individuals can flex their fingers. Due to different muscle insertions, it is possible to distinguish the mechanical effect of intrinsic muscles from extrinsic muscles. The aim of this observational study was to investigate the degree to which individuals in the population rely on either their intrinsic or extrinsic hand muscles. A high frequency camera was used to record the hands of 31 healthy participants, aged between 18 to 40, while they made a fist repeatedly. The hands were placed on a horizontal plane and the video was taken from the ulnar side, aligned horizontally with the hand. The maximum vertical distance between the fingertip and the distal palmer creases (XY) was recorded using WIN analyze 3D software. Three examiners independently analysed the videos and classified them into intrinsic dominant, extrinsic dominant or a mixed pattern. A t-test was performed on the XY values for the three different categories. The XY height difference between the intrinsic and extrinsic groups were statistically significant (P=0.001). The XY of mixed and intrinsic was also statistically significant (p=0.012) but not for mixed and extrinsic (p=0.46). Assessment of time when movement starts at each individual joint showed significant difference with intrinsic predominant moving the MCPJ before IPJ and extrinsic dominant individual moving their IPJ before MCPJ. This study shows that there is a difference in hand muscle dominance between individuals. More importantly it shows that there are individuals who rely on their intrinsic hand muscles more than their extrinsic muscles.
Scaphoid fractures with displacement have a higher incidence of nonunion and unite in a humpback position that can cause pain and reduced movement, strength and function. The aim of this study is to review the evidence available and establish the risk of nonunion associated with management of displaced scaphoid fractures in a plaster cast. Electronic databases were searched using the MeSH (Medical Subject Headings) controlled vocabulary (scaphoid fractures, AND'd with explode displaced, or explode nonunion, or explode non-healing or explode cast immobilisation, or explode plaster, or explode surgery). As no randomised or controlled studies were identified, the search was limited to observational studies based on consecutive cases with displaced scaphoid fractures treated in a plaster cast. The criterion for displacement was limited to gap or step of more than 1mm. The ‘random effects’ calculation was used to allow for the possibility that the results from the separate studies differ more than would be expected by chance.Background
Methods
This study reviewed the efficacy of a CT arthrogram in clinical decision making for wrist disorders. Sixty four consecutive CT arthrograms done in a three year period at Glenfield Hospital were selected. All patients were referred by hand consultants at the Glenfield Hospital and all investigations were performed by a single senior musculoskeletal radiologist. CT arthrograms focussed on the following areas: scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament (LTIL), peripheral and central triangular fibrocartilage complex (TFCC) tears, and articular surface disorders. Referral and clinic letters for all patients were obtained. We collected patient demographic detail, prescan diagnosis and clinical plan, CT arthrogram findings, postscan diagnosis and clinical plan and the final outcome. A decision was made whether the scan helped in the clinician's management plan and if so how it helped.Aim
Methods
Brachial plexus blocks are used widely to provide intra-operative and post-operative analgesia. Their efficacy is well established, but little is known about discharging patients with a numb or weak arm. We need to quantify the risk of complications for improved informed consent. To assess whether patients can be safely discharged from hospital before the brachial plexus block has worn off and record any complications and concerns.Introduction
Objectives
To assess the effect of deformity on Grip strength characteristics in the Rheumatoid Hands using force time curves. Forty seven (6 males and 41 females) patients with mean age 62 years (29–79 yrs) with Rheumatoid arthritis had their handgrip strength measured with closed fluid dynamometer generating force-time curves. These were analysed further in blinded fashion for:
peak force; average force; time to peak and variance of the force data through the plateau region (final 60% of curve). Data was also collected on joint mobility, pain and disability using Patient Evaluation Measure (PEM) and Functional Disability Scores (FDS). The patients were divided into five groups according to the degree of deformity: No deformity, ulnar deviation, Boutonniere, Swan neck or combined deformities (two or more deformities). These patient groups showed significant differences in grip strength (p value <
0.01). Patients with combination of deformities showed low peak and average forces as measured on force-time curves. The hands with Swan neck deformities had the highest variability in the plateau region of the curve and had the greatest disability scores both with PEM and FDS scores (P Value <
0.005). This group was particularly disabled (P Value <
0.007) being less able to sustain the grip over time. Swan Neck Deformity causes the most significant dysfunction and this should be carefully considered when making decisions regarding surgery.
Treatment of a partial laceration in zone two of a flexor tendon remains controversial. The intact part of the tendon can sustain forces of normal un-resisted motion, and repaired partially treated tendons can actually be weaker than un-repaired ones. Trimming these lacerations has been shown to be beneficial in partially lacerated tendons with triggering or entrapment. The purpose of this study is to observe the behaviour of a partially lacerated and subsequently trimmed tendon under strain, and measure their friction coefficient at different flexion angle and load. Ten long flexor tendons from long digit of turkey foot, along with the equivalent of A2 pulley were used. All experiments were carried out for intact, lacerated (50%) and trimmed tendon at 10, 30, 50 and 70 degrees of flexion and two load settings of 200 and 400g. The friction forces were measured by the difference between the two load transducers and the friction coefficient was measured using this formula, μ = Ln[(F2/F1)]/Ø. Friction coefficient (μ), Tension forces (F2 and F1), arc of tendon and pulley contact (Ø). Results: Friction coefficient increased significantly by three folds (0.3) after laceration compare with intact tendon (0.12) at both loads. This was reduced significantly after trimming the tendon but the friction coefficient was still approximately twice the value of the intact tendon (0.2). Triggering was noticed in all tendon lacerations. Triggering was reduced after trimming in 10 and 30 degrees of flexion but increased markedly at 50 and 70 degrees of flexion associated with tendon fragmentation at the trimmed area. Trimming partially lacerated flexor tendons will reduce the gliding resistance of the tendon through the pulley but this can lead to further fragmentation and triggering at higher flexion degrees and loads.
This study describes the method and results of a new way of stabilising painful unstable sternoclavicular joints using the sternocleidomastoid tendon. Painful instability of the sternoclavicular joint is a rare condition whose cause is either of spontaneous onset in young principally females with generalised joint laxity or of traumatic onset. The direction of instability can be anterior, superior or posterior. Surgical stabilisation is difficult and has principally consisted of using periosteum or subclavius and reefing the joint to the first rib with its attendant risks and variable results. We describe eight cases of painful sternoclavicular joint instability treated by using the sternocleidomastoid tendon and passing it through the medial clavicle and onto the manubrium of the sternum to stabilise the joint. This method of treatment is simpler, is reproducible and avoids the potential risks of reefing the joint to the first rib. There is no decrease in function of the sternocleidomastoid muscle from this procedure. All directions of instability can be treated using this tendon by varying the position of the bone hole. The results show comparable outcome for stability with other studies. We conclude that using the sternocleidomastoid tendon to stabilise the sternoclavicular joint is a simpler and safer method of treating these injuries and gives comparable results to the other methods of surgical stabilisation.
The purpose of this prospective clinical study was to identify the true incidence, pattern, and location of the injury and nature of fracture following hand injuries in different paediatric age groups attending a hand unit. Three hundred and sixty children (237 boys and 123 girls) under 16 years of age who presented with hand injuries between 1st April 2000 and 30th September 2000 were included in the study. Bony injuries accounted for 65.5% (236 injuries), 33.3% (120 injuries) were soft tissue injuries. The projected annual incidence rate for skeletal injuries was 418/100,000 children/year. Incidence was low in toddlers (34/100,000), more than doubled in pre-school children (73/100,000) and steeply increased to around 20 fold after the 10th year (663/100,000). Girls had a higher incidence of hand injuries among toddlers and pre-school children. Crushing was the most common cause of hand injury (64%) and most injuries were sustained at home (45%). Toddlers sustained soft tissue injuries predominantly (86%) and older children sustained more bony injuries (77%). Sport was the cause of injures commonly in the older children. There was a higher incidence of fracture in little finger (52%) followed by the thumb (23%). The proximal phalanx was the most frequently fractured bone (67%) among the phalanges. Diaphyseal fractures (46%) were more common in the metacarpal and basal fractures (51%) were common in the phalanges. At discharge more than 80% of the patients felt that they were cured or significantly better. This paper highlights the changing pattern and the different varieties of hand injuries in different paediatric age groups.
Volar wrist ganglion has a different mode of origin and higher complication rate after excision compared to its dorsal counterpart. This study, which is part of the Trent region ganglion audit, was carried out to prospectively evaluate the natural history and treatment outcome for volar wrist ganglia. Patients were invited to join the study between 1993 and 1995 following initial consultation with either an orthopaedic or plastic surgeon. Questionnaires were sent within the first year, at two years and finally at five to six years. The final review included a Patient Evaluation Measure (PEM) questionnaire. Of the 234 patients initially consulted, 186 joined the study, 155 of these responded, 122 at final review and 109 at year two. There were 98 females and 57 males. Three patient groups were identified: Group I: natural history (no intervention) (N=38) Group II: aspiration/injection (39) Group III: excision group (78) In conclusion, over half of volar wrist ganglia disappear without any intervention between 2 to 5 years. About 45% recur whether aspirated or excised. There is a 18% complication rate with excision, but neither aspiration/injection nor leaving them alone with reassurance was associated with any complications. Irrespective of the treatment, about 80% of patients are satisfied at five years, slightly more than at two years. This information may form a basis for patient information before deciding treatment. It could also help general practitioners advise patients before hospital referral.
A powered, randomised control trial was instigated to evaluate the advantages of subacromial injection of Methylprednisolone over conservative treatment in the management of partial rotator cuff injuries of the shoulder. Consecutive patients with possible partial rotator cuff tears were reviewed at 1 week. Inclusion criteria for a diagnosis of partial rotator cuff tear included; traumatic mechanism, greater tuberosity tenderness, painful arc, and complete resolution of disability post-Bupivicaine block. Exclusion criteria included; age <
16 years, chronic shoulder disease, acromioclavicular tenderness, and abnormal shoulder radiograph. Patients were randomly allocated to receive either 1 immediate subacromial injection of 40mg Methylprednisolone (group S) or no injection (group N). Initial outcomes measured were; visual analogue pain score (0–10) and active abduction (nearest 5°), repeated at 3, 6, and 12 weeks. All patients were instructed in analgesia usage and given identical shoulder exercises. Of 279 patients reviewed over 3 years, 90 met the inclusion criteria (6/90 patients were lost to follow-up). 50 patients were randomised to group S, 40 to group N. Mean pain score improvement at 12 weeks was comparable (S=4.95, N=4.44) (p>
0.1, CI=0.16–0.86). In patients aged >
40 years group S had significantly higher mean improvement in abduction at completion (64.28°) compared to group N (34.63°) (p<
0.02, CI 1.29–58.01). Conversely in patients aged <
40 years group S had lower mean improvements in abduction (40.55°) compared to group N (77.73°), though this was not statistically significant (p=0.1, CI 2.06–72.29) Methylprednisolone injection is more efficacious than conservative treatment alone in some patients. This benefit appears age-dependent and consequently such treatment should be reserved for patients aged >
40 years.