Smith's fractures generally occur when falling on a flexed wrist; however, orthopedic trauma surgeons often encounter distal radius fractures with volar displacement in patients who have allegedly fallen on the palm of their hands. This study aimed to reveal both the basic and clinical pathogenesis of Smith's fracture through a step-by-step investigation. We enrolled 17 patients with Smith's fractures, of which 71% fell on the palm and only 6% on the dorsum of the hand. First, we interviewed the outpatients to determine the mechanics of the injury and the position of their arm during injury. Second, we created a three-dimensional (3D) finite element model to predict the arm's position when the Smith's fracture occurred, which finite element analysis revealed as a 30° angle between the long axis of the forearm and the ground in the sagittal plane. Third, using this predicted position, we conducted experiments on 10 fresh frozen cadavers to prove the possibility of causing a Smith's fracture by falling on the palm of the hand. The results showed Smith-type fractures in seven of 10 wrists, whereas Colles-type fractures did not occur. Finally, we analyzed stress distribution in the distal radius when a Smith's fracture occurs using the 3D finite element model. In conclusion, this study demonstrates that Smith's fractures can also occur by falling on the palm of the hand

Aims. The localization of necrotic areas has been reported to impact the prognosis and treatment strategy for osteonecrosis of the femoral head (ONFH). Anteroposterior localization of the necrotic area after a femoral neck fracture (FNF) has not been properly investigated. We hypothesize that the change of the weight loading direction on the femoral head due to residual posterior tilt caused by malunited FNF may affect the location of ONFH. We investigate the relationship between the posterior tilt angle (PTA) and anteroposterior localization of osteonecrosis using lateral hip radiographs. Methods. Patients aged younger than 55 years diagnosed with ONFH after FNF were retrospectively reviewed. Overall, 65 hips (38 males and 27 females; mean age 32.6 years (SD 12.2)) met the inclusion criteria. Patients with stage 1 or 4 ONFH, as per the Association Research Circulation Osseous classification, were excluded. The ratios of anterior and posterior viable areas and necrotic areas of the femoral head to the articular surface were calculated by setting the femoral head centre as the reference point. The PTA was measured using Palm’s method. The association between the PTA and viable or necrotic areas of the femoral head was assessed using Spearman’s rank correlation analysis (median PTA 6.0° (interquartile range 3 to 11.5)). Results. We identified a negative correlation between PTA and anterior viable areas (rho −0.477; p = 0.001), and no correlation between PTA and necrotic (rho 0.229; p = 0.067) or posterior viable areas (rho 0.204; p = 0.132). Conclusion. Our results suggest that residual posterior tilt after FNF could affect the anteroposterior localization of necrosis. Cite this article: Bone Jt Open 2024;5(5):394–400

Summary Statement. We measured scapulothoracic motions during humeral abduction with different humeral rotations in healthy subjects and whole cadaver models and clarified that humeral rotation significantly influenced scapular kinematics. Introduction. Scapular dyskinesis has been observed in various shoulder disorders such as impingement syndrome or rotator cuff tears. However, the relationship between scapular kinematics and humeral positions remains unclear. We hypothesised that humeral rotation would influence scapular motions during humeral abduction and measured scapular motion relative to the thorax in the healthy subjects and whole cadavers. Methods. Healthy Subjects: Twenty-four shoulders of twelve healthy subjects without shoulder disorders were enrolled. Three electromagnetic sensors were attached on the skin over the sternum, scapula and humerus. Scapular motions during scapular plane abduction (abduction) were measured. The measurements were performed with four hand positions, palm up, thumb up, palm down and thumb down. The elbow was kept extended in all measurements. Each measurement took 5 seconds and repeated three times. Cadavers: Twelve shoulders from 6 fresh whole cadavers were used. A cadaver was set in sitting position on a wooden chair without interrupting scapular motions. Electromagnetic sensors were attached on the thorax, scapula and humerus rigidly with transcortical pins. The elbow was kept in extended position by holding the forearm and the arm was moved passively. The measurements were performed during scapular plane abduction and scapular kinematics were measured in four hand positions, 1: thumb up, 2; palm up, 3; palm down, 4; thumb down as well as the healthy subjects. Each measurement took 5 seconds and repeated three times. Data Analysis: The coordinate system and rotation angles of the thorax, scapula and humerus were decided following ISB recommendation. A one-way analysis of variance was used to test the differences in 4 arm positions. Dunnet's multiple post hoc tests were used to identify the difference between thumb up model (neutral rotation) and other three arm positions. Results. Scapular posterior tilt increased during palm up abduction (healthy subjects −2.0° to 0.1°, cadaver −3.2° to −1.4° at 120° of abduction). During thumb-down abduction, scapular posterior tilt decreased (healthy subjects −4.1° to −8.0° at 110° of abduction, cadaver −3.2° to −8.6° at 120° of abduction) and scapular upward rotation increased (healthy subjects 21.0° to 26.1° at 110° of abduction, cadaver 25.3° to 31.1° at 120° of abduction). Thumb down abduction demonstrated no significant difference from thumb up position. Discussion. Scapular motions measured in healthy subjects and cadaver models showed similar patterns indicating that surface markers on the healthy subjects could track scapular motions successfully as bone markers in cadaver models. Humeral external rotation increased scapular posterior tilt and humeral internal rotation increased scapular anterior tilt and upward rotation. This suggests that position of the greater and lesser tuberosity and tension of the joint capsule caused scapular tilt and scapular upward rotation. Kinematic changes caused by humeral rotations were observed in earlier phase of abduction in healthy subjects than in cadaver models. This suggests that healthy subjects set scapular position beforehand not to increase subacromial pressure. Conclusion. Humeral rotation significantly influenced scapular kinematics. Assessment for these patterns is important for evaluation of shoulder pathology associated with abnormal scapular kinematics

Clinician expectation and anatomical studies suggest that the distribution of sensory dysfunction in carpal tunnel syndrome (CTS) should be confined to the thumb, index, middle and half of the ring fingers. We mapped the distribution of disturbance to evaluate the accuracy of these assumptions. We evaluated 64 wrists in 64 patients with nerve conduction study confirmed CTS. Each patient filled out a Katz hand diagram and we collated the distribution of pain and non-painful (tingling, numbness & decreased sensation) sensory disturbance. Frequency of reporting was analysed; dividing symptoms into thenar and hypo-thenar eminence, distal palm, each digit, posterior hand and forearm. Non-painful sensory disturbance occurred in all patients. The index finger was the most common location (94%) followed by the middle finger (91%), the distal palm (84%), the ring finger (72%), the thumb (69%), the thenar eminence (63%), the little finger (39%), the dorsal hand (31%), the hypothenar eminence (25%) and the forearm (13%). Pain was less common, reported in 59% of cases. Pain occurred most frequently over the wrist crease (33%) followed by thenar eminence (27%), the forearm (20%), the middle finger (23%), the index finger (22%), the ring finger (19%), the distal palm (16%), the thumb (14%), the dorsal hand (11%), the little finger (11%) and least frequently the hypothenar eminence (6%). In CTS sensory disturbance occurs most frequently in the median nerve distribution; however it occurs almost as often elsewhere. An atypical distribution of symptoms should not discourage diagnosis of CTS

To study in resolution of triggering 12 months after injection with either a soluble methylprednisolone acetate or dexamethasone for idiopathic trigger finger. Twenty-eight patients were enrolled in a prospective randomized controlled trial comparing methylprednisolone acetate and dexamethasone injection for idiopathic trigger finger. Twenty-seven patients completed the 6-week follow-up (11 methylprednisolone acetate arm, 16 dexamethasone arm) and thirteen patients completed the 3-month follow-up (4 methylprednisolone acetate arm, 9 dexamethasone arm). Outcome measures included resolution of triggering, recurrence rate of trigger finger, satisfaction on a visual analog scale, tender, snapping, locking, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and tip to palm distance (mm.) at 2, 6, 12 and 24 weeks follow-up. Eight patients were repeated a second injection (3 methylprednisolone acetate arm, 5 dexamethasone arm) at 6-week follow-up. To preserve autonomy, patients were permitted operative treatment any time. The analysis was according to intention to treat principles. Six weeks after injection. Absence of triggering was documented in 6 of 11 patients in the methylprednisolone cohort and in 6 of 16 patients in the dexamethasone cohort. The rate 3-month after injection were 2 of 4 patients in the methylprednisolone cohort and in 8 of 9 patients in the dexamethasone cohort. There were no significant difference between recurrence rate of trigger finger, satisfaction on a visual analog scale, tender, snapping, locking, the Disabilities of the Arm, Shoulder and Hand (DASH) scores and tip to palm distance (mm.) at 2, 6, 12 and 24 weeks follow-up. Although there were no differences 3months after injection, our data suggest that in the dexamethasone cohort was better in resolution of triggering than the methylprednisolone cohort at 12-week follow-up

Aims: To confirm that the augmented (MGH) Becker extensor tendon repair is a strong four-strand technique that allows earlier mobilisation of repaired tendons after only 3/52 of postoperative static splinting and to assess functional outcome using revised disabilities of arm, shoulder and hand (DASH) score. Methods: In this prospective study we used the augmented Becker (MGH) suturing technique with Ethilon. Postoperatively patients were immobilised 3 weeks in volar splint and then fully mobilised with physiotherapy. 3/12 postoperatively all patients had final assessment in hand clinic for: pulp to palm distance, power grip, pinch grip, pain, Dragan criteria of progress, total active motions (TAM) of the fingers and revised DASH score. Results: Eighteen patients had extensor tendon lacerations repaired with augmented Becker (MGH) technique. Results were compared with the uninjured hand and statistically evaluated. At the final assessment the average pulp to palm distance was 0cm. All patients had good pinch and power grip (> 80% of uninjured hand for dominant hand and > 60% for non-dominant hand) and were free of pain with excellent progress using Dragan criteria. Average TAM was 268° without statistically significant difference between this and the uninjured side. Average scaled DASH score was 7.6 and within normal values. We had no wound complications or ruptures of repaired tendons. Conclusion: Augmented (MGH) Becker technique is a strong four-strand extensor tendon repair technique that allows early mobilization of patients after only 3/52 of static splinting postoperatively. Injured fingers can then be safely mobilized with expected full return of movements at 3/12 postoperatively

The Constant-Murley score has gained wide acceptance for evaluation of shoulder function. The strength component of the Constant score accounts for 25 out of 100 points. It has been criticized for lack of consistency in defined measurement method. The aim of this study was to evaluate the effect of various variables on the strength component measurement of the Constant score. Material & Methods We conducted a series of experiments using a digital force gauge (EZ force). We evaluated the effect of strength measurements with 1) patient in sitting & standing positions 2) strength gauge fixed to an immobile platform or hanging free fixed to the floor by the examiners foot 3) patient’s arm in 45 degrees and 90 degrees of abduction 4) plane of elevation in frontal or scapular plane and 5) patient making a fist or keeping the palm open during the test. These experiments were done in groups of 20 patients. We have compared as well this device and the Isobex Myometer. Results No statistical differences were found between individual measurements with regard to patient’s position (standing-sitting), device setting (Fixed –Hanging), position of the arm in varying degrees of abduction or the plane of elevation. Strength assessment obtained when patient made a fist compared to open palm was found to be higher (p=0.006). The measurements showed good intra-observer reliability. The readings of the EZ force and the Isobex myometer were comparable. Conclusions It seems that the shoulder strength measurements as part of the Constant functional score may be performed with the patient sitting or standing, with the arm at varying degrees of abduction and in different planes of elevation without causing any significant deviation in the measurement. No influence was found as well to the device being either fixed to an immobile platform or fixed to the floor by the examiner’s foot. These make these measurements easy to perform and reproducible using the newly designed digital force gauge (EZ force)

Introduction: The surgical management for carpal tunnel syndrome is the release of pressure on the median nerve by dividing the transverse carpal ligament. There are different ways to release median nerve viz.extensive lazy ‘S’ incision from palm to forearm and the advanced arthroscopic release at wrist. We describe a simple, effective and minimally invasive surgery for C.T.S. to divide transverse carpal ligament. Material & method: We present 38cases of C.T.S. after clinical and Electro diagnosis confirmation underwent the minimal invasive surgery. A 1” transverse incision over the center of distal wrist crease placed exposing the palmeris longus (retracted/divided) and exposing transverse carpal ligament. These transverse fibers are cut in the line of skin incision and exposing the median nerve. With blunt curved scissors the transverse ligament is cut distally in the palm and proximally in the wrist separating from the median nerve thus relieving the compression. The wound is closed in layers over the drain and compression bandage applied. Post operatively hand elevated for 24hours, drain removed after 48hours and suture removed at 7th day. Results: In all the 38cases there was pain relief immediately after the surgery. There was progressive neurological recovery (sensory/motor) took place from 6months to 1year. One case developed a pulsatile swelling at the wrist (false A-V aneurysm). The false aneurysm was due to accidental nicking of superficial palmar branch of radial artery, which was ligated on second day. There was superficial marginal necrosis was observed in 6 cases, which healed in 12–16 days. Discussion: The technique is simple, short, safe, economic, effective and easily reproducible. The transverse incision gives better visualization of transverse carpal ligament; easy resection of the ligament and better exposion of median nerve at the wrist makes this procedure to have good results. This tiny incision is in the langhans line at wrist has early wound healing, a cosmetic scar and least morbidity

Median nerve release is one of the most common procedures performed in hand surgery (classical incision or endoscopic methods), with a low complication rate, but not free of morbidity conditioning work reincorporation. We present a comparative study between the classical technique and double-incision approach of median nerve preserving the intereminencial space. Material and methods. A review of 155 hands in 133 patients (all operated by the same surgeon), divided in two separate groups:. – 72 hands (61 patients) operated by classical technique. – 83 hands (72 patients) operated by double-incision approach. Excluding criteria: patients under 30 years-old, antecedents or symptoms of associated local pathology, trophic troubles of thenar or hypothenar eminences and recurrent carpal tunnel syndrome. We reviewed: per-operatory neurovascular complications, difficulties in hand activity related to pillar pain at 10 and 21 days and 3 and 12 months after surgery, discomfort in the thenar-hypothenar areas (intereminencial pruritus), remaining discomfort in the area of the surgical scar at 3 and 12 months after surgery, and recurrences at 24 months. Results: Nerve compression symptoms disappeared in all 155 hands and neither complications nor recurrences were observed at 24 months. Pillar pain conditioning hand activity:. 21 days: A-group 32 cases (44 %) %, B-group 0%. 3 months: A-group 18 cases (25 %), B-group 0%. 12 months: A-group 5 cases (7 %), B-group 0%. Discomfort in the thenar-hypothenar areas (inter-eminencial pruritus):. 21 days: A-group 0%, B-group 15 cases (18 %). 3 months: A-group 0%, B-group 6 cases (7 %) Remaining discomfort in surgical scars areas:. 3 months: A-group 18 cases (25%) palm area, B-group 4 cases (5 %) wrist area. 12 months: A-group 5 cases (7 %) palm area, B-group 0%. Conclusion: Absence of pillar pain in double-incision approach and free hand activity 3-4 weeks post-operatively were obtained, only a discrete intereminencial pruritus was observed (unusual at 3 months). We therefore consider this technique as a first choice in suitable patients as it avoids discomfort or disability. Furthermore this technique is of low risk and low cost

Cartilage injury is generally associated with cytokine release and accumulation of reactive oxygen species. These mediators trigger pathologic behaviour of the surviving chondrocytes, which respond by excessive expression of catabolic enzymes, such as matrix metalloproteinase 13 (MMP-13), reduced synthesis of type II collagen (COL2A1) and apoptosis. In the long run, these pathologic conditions can cause a posttraumatic osteoarthritis. With the objective to attenuate the progressive degradation of the extracellular matrix and, what is more, promote chondroanabolic processes, a multidirectional treatment of trauma-induced pathogenesis was tested for the first time. Therefore, we evaluated the combinations of one anabolic growth factor (IGF-1, FGF18 or BMP7) with the antioxidant N-acetyl cysteine (NAC) in a human ex vivo cartilage trauma model and compared the findings with the corresponding monotherapy. Human cartilage tissue was obtained with informed consent from donors undergoing knee joint replacement (n=24). Only macroscopically intact tissue was used to prepare explants. Cartilage explants were subjected to a blunt impact (0.59 J) by a drop-tower and treated by IGF-1 [100 ng/mL], FGF18 [200 ng/mL] or BMP7 [100 ng/mL] and/or NAC [2 mM] for 7 days. Following parameters were analysed: cell viability (live/dead staining), gene expression (qRT-PCR) as well as biosynthesis (ELISA) of type II collagen and MMP-13. For statistical analysisKruskal-Wallis or One-way ANOVA was used. All data were collected in the orthopedic research laboratory of the University of Ulm, Germany.

Trauma-induced cell death was completely prevented by NAC treatment and FGF18 or BMP7 to a large extent, respectively (p<0.0001). IGF-1 exhibited only poor cell protection. Combination of NAC and FGF18 or BMP7 did not result in enhanced effectiveness; however, IGF-1 significantly reduced NAC-mediated cell protection. While IGF-1 or BMP7 induced collagen type II gene expression (p=0.0069 and p<0.0001, respectively) and its biosynthesis (p<0.0001 and p=0.0131, respectively), NAC or FGF18 caused significant suppression of this matrix component (each p<0.001). Although COL2A1 mRNA was significantly increased by NAC plus IGF-1 (p<0.0001), biosynthesis of collagen type II was generally abolished after multidirectional treatment. Except for IGF-1, all tested therapeutics exhibited chondroprotective qualities, as demonstrated by attenuated MMP-13 expression and breakdown of type II collagen. In combination with IGF-1, NAC-mediated chondroprotection was reduced.

Overall, both chondroanabolic and antioxidative therapy had individual advantages. Since adverse interactions were found by simultaneous application of the therapeutics, a sequential approach might improve the efficacy. In support of this strategy current experiments showed that though cell and chondroprotective effects of NAC were maintained after withdrawal of the antioxidant, type II collagen expression recovered by time.

The postoperative course of median nerve decompression in the carpal tunnel syndrome may sometimes be complicated by postoperative pain, paresthesias, and other unpleasant symptoms, or be characterized by a slow recovery of nerve function due to prolonged preoperative injury causing extensive nerve damage. The aim of this study is to explore any possible effects of alpha lipoic acid (ALA) in the postoperative period after surgical decompression of the median nerve at the wrist. Patients were enrolled with proven carpal tunnel syndrome and randomly assigned into one of two groups: Group A: surgical decompression of the median nerve followed by ALA for 40 days. Group P: surgical decompression followed by placebo. The primary endpoint of the study was nerve conduction velocity at 3 months post surgery, Other endpoints were static 2 point discrimination, the Boston score for hand function, pillar pain and use of pain killers beyond the second postoperative day. ALA did not show to significantly improve nerve conduction velocity or Boston score. However, a statistically significant reduction in the postoperative incidence of pillar pain was noted in Group A. In addition, static 2 point discrimination showed to be significantly improved by ALA. Administration of ALA following decompression of the median nerve for carpal tunnel release is effective on nerve recovery, although this is not detectable through nerve conduction studies but in terms of accelerated and improved static two-point discrimination. The use of ALA as a supplementation for nerve recovery after surgical decompression may be extended to all types of compression syndromes or conditions where a nerve is freed from a mechanical insult. Furthermore, ALA limits post-decompression pain, including late pericicatricial pain at the base of the palm, the so called pillar pain, which seems to be associated with a reversible damage to the superfical sensitive small nerve fibers. In conclusion postoperative administration of ALA for 40 days post-median nerve decompression was positively associated with nerve recovery, induced a lower incidence of postoperative pillar pain and was associated with a more rapid improvement of static two-point discrimination. This treatment is well tolerated and associated with high levels of satisfaction and compliance, supporting its value as a standard postoperative supplementation after carpal tunnel decompression

Aims

The sensitivity and specificity of electrodiagnostic parameters in diagnosing carpal tunnel syndrome (CTS) have been reported differently, and this study aims to address this gap.

Aims

This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality.

Introduction: Rehabilitation of hip fracture patients is often lengthy with bed day consumption accounting for up to 85 % of the total hospitalization cost. Data suggests that patients who suffer surgical complications requiring re-operation have an excessive length of hospitalization, but the overall impact of surgical complications including those not requiring re-operations have not been examined in detail.

Methods: Six hundred consecutive, unselected patients with a primary hip fracture were included between 2002 and 2004. All patients received surgery and a multimodal rehabilitation program. Surgical complications were stratified into those requiring re-operation (< six months) and those not allowed mobilization postoperatively due to instability of the fracture. Surgical complications were audited and classified as being due to a patient fall, infection or due to a suboptimal surgical procedure, specified as suboptimal operation method, fracture reduction or implant position.

Results: 19.3 % (116/600) of the admitted patients were re-operated or immobilized. Assuming that the patients with complications otherwise would have had the same length of stay as the remaining patients, 27.2 % (3814/14038) of total bed day consumption was due to surgical complications. The audit of complications showed that 64 complications (55 %) were due to a suboptimal primary surgical procedure, 18 (16 %) to infections, 6 (5 %) to falls and 28 (24 %) could not be ascribed to an apparent course.

Conclusions: Surgical complications secondary to primary hip fracture surgery accounts for 27.2 % of the total bed consumption if secondary admissions due to re-operations are taken into account. Our audit suggests that as much as half the complications potentially could be spared through optimization of surgical procedures.

The purpose of this study was to determine the normal angle of rotation of the axis of each finger using digital image analysis, whether the rotation of the digits is symmetrical in the two hands of an individual, and the reliability of this method. Standardised digital photographic images were taken of thirty healthy volunteers. The palm of each hand was placed on a flat bench top with their fingers held in extension and adducted, to give an end-on image of all four fingers. Three independent observers analysed the images using Adobe Photoshop software. The rotational angle of each finger was defined as the angle created by a straight line connecting the radial and ulnar border of the nail plate and the bench top horizon. The three observers showed Inter-Rater Reliability of 92%. The mean angles of rotation were: Index 13°, Middle 10°, Ring 5°, Little 12°. The differences in angle of rotation of the index and middle finger between the left and right hand were statistically significant (p=0.003, and p=0.002 respectively), demonstrating asymmetry between the two sides. The differences in angle of rotation of the ring and little finger of the left and right hand were not significantly significant (p= 0.312 and p=0.716 respectively). In conclusion, symmetry was seen in the little and ring but not in the index and middle fingers. Digital image analysis provides a non-invasive and reproducible method of quantifying the rotation of normal fingers and may be of use as a diagnostic tool in the assessment and management of hand injuries

Aims

In UK there are around 76,000 hip fractures occur each year 10% to 15% of which are undisplaced intracapsular. There is considerable debate whether internal fixation is the most appropriate treatment for undisplaced fractures in older patients. This study describes cannulated hip screws survivorship analysis for patients aged ≥ 60 years with undisplaced intra-capsular fractures.

Introduction: Cam-type femoroacetabular impingement (FAI) is a pre-osteoarthritic condition causing premature joint degeneration. Cam-deformities are characterised by decreased cranial offset of the femoral head/neck junction and aspherity of the femoral head causing delamination of the acetabular cartilage and detachment of the acetabular labrum. To asses the epidemiological aspects of cam-type FAI we evaluated Nötzlis alpha angle and our own Triangular Index (TI) for use on plain AP pelvic radiographs.

Materials and Methods: Cam malformation was assessed in 2.803 pelvic radiographs by the alpha (α) angle and the TI to define pathological cut off values. The α-angle and TI were assessed in AP and lateral hip radiographs of 164 patients scheduled for THR and the influence of varying rotation on the α-angle and TI was assessed in femoral specimens. The distribution of Cam-deformities was assessed in 3.712 standardized AP pelvic radiographs using the α-angle and TI.

Results: Mean AP α-angle male/female was 55°/45°. The α-angle and TI was highly interrelated, OR 8.6–35 (p< 0.001). Almost all cam-malformations were identifiable in AP projections, sensitivity 88–94% compared to axial view. The TI proved robust for cam identification during rotation (± 20°) compared to the α-angle (−10° to +20°). The distribution of pathologic TI and α-angle (Right/Left) were 11.6/12.5% and 6.1/7.4% in males and 2.2/3.2% and 2.1/3.8% in females. We found a pronounced sexrelated difference in cam-deformity distribution, OR 2.0–6.3 (p< 0.001).

Conclusion: The triangular index and the α-angle were found reliable for epidemiological purpose. Overall prevalence of definite cam-deformity was app. 10% in men and 2,5% in women.

Introduction: Re-operations after intertrochanteric fractures (ITF) are often caused by fracture displacement following postoperative mobilisation. The biomechanical complexity of the fracture, implant position, and the patient’s characteristics are known to influence postoperative outcome significantly. We investigated the importance of an intact lateral femoral wall (LFW) for the postoperative displacement after fixation by a sliding compression hip screw (SHS).

Methods: Two hundred and fourteen consecutive patients with ITF fixated by 135° SHS mounted on four hole lateral plates were included between 2002 and 2004. The fractures were preoperatively classified according to the AO/OTA classification system. The status of the greater and lesser trochanter, the integrity of the LFW and implant positioning were assessed postoperatively. Re-operations due to technical failure were recorded for six months.

Results: Only three percent of patients (5/168) with postoperatively intact LFW’s were re-operated within six months, while twenty-two percent (10/46) of patients with fractured LFW’s had been re-operated (p < 0.001). In multivariate logistic regression analyses combining demographic and biomechanical parameters, a compromised LFW was a significant predictor for reoperation (p = 0.010). Seventy-four percent (34/46) of the LFW fractures occurred during the operative procedure itself. Peri-operative LFW fractures only occurred in three percent (3/103) of the AO/OTA type 31A1–A2.1 ITF fractures, compared to thirty-one percent (31/99) of the AO/OTA type 31A2.2–A2.3 fractures (p < 0.001).

Conclusions: A postoperative fractured LFW was found to be the main predictor for reoperation after ITF. Consequently we conclude that patients with pre- or potential postoperative LFW fractures are not treated adequately by SHS. ITF should therefore be classified according to the integrity of the LFW, especially in regard to randomized trials comparing fracture implants.

Spontaneous flexor tendon ruptures of the hand are uncommon and the current understanding of these ruptures is incomplete. The purpose of this study is to report five cases of spontaneous flexor tendon rupture in the hand, and to contrast the findings to those in the literature. A retrospective review of patients with flexor tendon injuries referred to our hand surgeons identified five patients who sustained a spontaneous rupture of the flexor digitorum profundus tendon. A literature search found a total of nineteen articles describing spontaneous tendon ruptures that met our criteria. We report five cases of spontaneous rupture involving the flexor digitorum profundus tendon. One case involves an abnormal intertendinous connection between the ring and small finger profundus tendons and another involves a lumbrical muscle variant. To our knowledge, the latter has not been reported in association with spontaneous tendon rupture. In reviewing the literature for spontaneous flexor tendon ruptures, a total of fifty spontaneous ruptures in forty-three cases was found. The majority involve the profundus tendon of the small finger in the palm. The ruptures most often occur during periods of peak strain, but can also occur without identifiable trauma. This study provides a detailed overview of spontaneous flexor tendon ruptures in the hand not found in the literature. The pathogenesis of spontaneous tendon ruptures is still unclear and is likely multifactorial. Although spontaneous flexor tendon ruptures of the hand are uncommon, these ruptures occur more often than one might recognise

Purpose: We present a 12 year follow up of a patient who presented with a multiple plexiform schwannoma of the median nerve with multiple recurrences, where it was possible to salvage the limb. Patients and Methods: Multiple plexiform Schwannomas are rare nerve sheath tumours. In this case the tumour presented as a soft non-tender swelling in the palm of a child. On exploration the lesion was found to involve the median nerve from the digital nerves to the antecubital fossa. Histology confirmed a plexiform schwannoma. The tumour was locally very aggressive with multiple recurrences initially in the median nerve and ulnar nerves and later in the nerve grafts used following excision of the primary tumour. We present a pictorial review of the mode of presentation of the tumour; discuss different modalities used for limb salvage and the differential diagnosis of this rare tumour. Conclusion: There are very few reports of PS involving main nerve trunks and none describe the long term follow-up. We report a twelve year follow up of a PS involving the main nerve trunks of the upper limb with salvage despite multiple recurrences. The clinical course of the tumour is presented up to the age of sixteen where the growth tumour appears to have regressed