Introduction Most proximal humeral fractures are treated conservatively. However, treatment for the severely displaced fractures (Neer’s grade IV) is more challenging. This is especially in the adolescent age group where the remodelling potential is reduced. We report on our 8-year experience of fixing severely displaced proximal humeral fractures in children using ESIN.

Method Between 1996 and 2003, we treated 14 children (7 metaphyseal and 7 epiphyseal fractures) using ESIN. 11 were completely displaced and 12 were caused by high energy forces. Our indications included unstable fracture with severe displacement (> 2/3 shaft diameter), age above 12 years and multiple injuries/polytrauma. Manipulation of the fractures and the operative technique is described. Post-operatively, the arm is kept in a sling for 2 weeks. All patients were reviewed on a monthly basis until clinical and radiological healing. Following the removal of the nails, the patients are only discharged when they demonstrate full pain-free range of movement.

Results The double nail technique was used in the first 2 cases and a single nail was used for the subsequent 12 cases. The fracture was reduced by open technique in 1 case. In another, the nail was inserted antegrade. Time from injury to surgery was 2.4 days. The mean operation time was 65 minutes and hospital stay 2.1 days. Time to clinical healing (complete pain-free range of movement) was 2.4 months and radiological healing 3.2 months. All nails were removed by 6 months. Shoulder and elbow range of movement returned to normal at 3.5 and 3.2 months. Complications included 4 cases of elbow stiffness due to nail prominence and 1 case of nail breakage during removal. 1 patient had 10 degrees of varus and in 2 other patients, 5 degrees of varus and 1 cm of shortening and 1.5 cm of shortening respectively. At the final follow-up (14.6 months), all patients had symptom free full range of movement.

Conclusion ESIN is a valid treatment for the severely displaced proximal humeral fractures in the adolescence. It avoids lengthy and awkward immobilization and allows early post-operative mobilization. The single nail technique proved to be adequate to maintain alignment and allow fracture healing, keeping the invasiveness of the procedure to a minimum.

Introduction ESIN is an established method of treatment of long bone fractures in children, which has been in regular use in our institution since 1996. We report on our 7-year experience of using ESIN for the treatment of long bone fractures in children.

Method 92 fractures were nailed (26 femoral, 12 tibial, 17 humeral and 37 forearm). The average age was 12 years (7–15) and average follow-up 15 months. Main indications included unstable and severely displaced fractures, failure of conservative treatment and polytrauma or head injury. Data collection included mechanism of injury, fracture configuration, treatment delay, operation time and technique, length of hospital stay, rehabilitation, healing, nail removal and complications.

Results 49% of fractures were caused by road traffic accidents. All were diaphyseal apart from 14 proximal humeral fractures. The average surgery delay was 7 days and operation time 78 minutes. Open reduction was performed in 3 femoral, 1 humeral and 18 forearm fractures. Single nailing was used for the proximal humeral and forearm fracture. The average hospital stay was 5.8 days, ranging from 12 days for femoral to 2 days for forearm fractures. Clinical healing was achieved at 3.5, 4.3, 2.4 and 2.1 months respectively for femoral, tibial, humeral and forearm fractures.

The commonest complication (25%) was skiin irritation around the entry site, which invariably resolved after implant removal. Delayed union occurred in 2 femoral and 2 tibial fractures (all healed following bone marrow injection). 2 tibial fractures mal-united and 1 tibial fracture was complicated with compartment syndrome. The average nail removal time was 9 months. The nails could not be removed in 4 cases.

Conclusion ESIN is minimally invasive and has a low complication rate. It avoids the lengthy immobilization of conservative treatment, and the surgical trauma of plating without the association of refractures or nerve damage. We believe it represents a valid option in the treatment of long bone fractures.

Study Design: A prospective cohort study of patients undergoing surgery for prolapsed intervertebral disc.

Objective: To assess a patient’s ability to recall information discussed pre-operatively at the time of informed consent six weeks following surgery.

Subjects: Sixty-one consecutive patients undergoing discectomy for prolapsed intervertebral disc with follow up six weeks after surgery.

Outcome measures: Patients were assessed, using a pre-prepared questionnaire, to establish their understanding of disc surgery prior to signing a consent form. All information on the questionnaire had previously been given to the patient at the time of being put on the waiting list via a copy of the clinic letter to the general practitioner. If patients were unable to complete the questionnaire, they were then tutored using visual aids such as posters and models until they were able to answer the questions correctly. The consent form was then signed. Six weeks following surgery, patients were then asked the same questionnaire to establish their ability to recall the information discussed pre-operatively about disc surgery.

Results: Prior to tutoring, 20 % of patients were unable to recall that their symptoms were due to disc pathology and that surgery to remove the disc would relieve their symptoms. They were also unable to recall the success rate of surgery. Following surgery, only half of this group of patients could recall these facts. Only 32% of patients were able to recall two or more risk factors of surgery prior to tutoring. This improved to 45% following surgery. Pre- and post-operative questionnaire scores were analysed using a paired t-test. There was no statistical improvement in questionnaire scores long term following tutoring.

Conclusion: In this group of patients, extensive tutoring with the use of visual aids as an adjunct, does not statistically improve their ability to recall important information about surgery for prolapsed intervertebral disc and the risks associated with it.

Aim: A retrospective study to analyse the treatment of paediatric diaphyseal forearm fractures over the preceding 6 years and to assess if there was any difference in outcome between plate and elastic stable intra-medullary nailing (ESIN).

Material and Methods: Between January 1997 and December 2002, 144 unstable fractures required surgical fixation. 59 patients were treated with both-bone plate fixation, 55 patients were treated with single-bone plate fixation and 30 patients were treated with ESIN.

The mean age of surgery was approximately 12 with peaks at age 8 and 13 years.

In the plate group, 70% to 80% were undertaken by the SpRs and in the nailing group, approximately 50% were undertaken by staff grades; 30% by Consultants and 20% by SpRs.

Results: Between each group there was no difference in time spent in plaster, clinic attendance, time to clinical union and time to restoration of normal movements. On radiographic reviews, single-bone plate fixation patients united quicker than the both-bone plate fixation or ESIN groups. Average anaesthetic times became more prolonged from single-bone to ESIN to both-bone plate fixation.

Compound fractures were approximately 10% in both groups. There were hyper-trophic scars in approximately 10% in the plate group and 3% in the nail group. There were 3 compartment syndromes in the plate group and 2 compartment syndromes in the nail group.

In the plating groups, there was a higher rate of peri-prosthetic fracture, mal-union, hyper-trophic scarring, infection and neuro-vascular complications.

Conclusion: ESIN is superior to plating in relation to surgical complications. It is therefore recommended that elastic stable intra-medullary nailing should be used for displaced paediatric diaphyseal forearm fractures.

We analysed the functional outcome (Oswestry Disability Index) after technically and radiologically successful lumbar fusion in 39 non-compensation seeking patients with chronic low back pain, who had a High Intensity Zone (HIZ) – positive MRI and subsequently underwent discography. The average follow-up was 33 months. The HIZ-positive, discogrampositive group was the only one with statistically significant improvement. The HIZ-positive, discogram-negative group had the worst outcome. Relying only on the HIZ fails to identify the group of patients who would have had negative discography at the same levels. Therefore the presence of HIZ alone should not dictate treatment plan without discography confirmation.

Routine use of Computed Tomography (CT) to evaluate discogram morphology is time consuming, costly and incurs additional radiation hazards. In our spinal unit, discography is routinely performed without the aid of CT. Discogram morphology for different stages of disc degeneration is evaluated using the modified Adam’s grading system on images obtained on fluoroscopy. Our aims were to assess the validity of the modified Adam’s grading system of discogram morphology, by assessing its inter- and intra-observer agreement.

We reviewed the discographic images (133 intervertebral levels) of 71 patients with chronic low back pain undergoing discography as part of a preoperative assessment between 1995 and 1997. Using the modified Adam’s grading system, three independent surgeon observers of three levels of experience (Senior Fellow, Senior and Junior residents) retrospectively evaluated the morphological appearance of each disc level in a randomized and blinded manner. Each observer was supplied with descriptions and illustrations of the 5 grades1, and each level was classified accordingly. The exercise was repeated three weeks later. The respective inter- and intra-observer agreements were calculated using the kappa statistic (Fleiss 1971) and generalized kappa statistic (Landis and Koch 1977).

The inter-observer agreement was excellent (kappa = 0.77; standard error = 0.054). The intra-observer agreement for each of the three observers was also excellent (kappa = 0.8, 0.8, and 0.85 with respective standard errors = 0.046, 0.049 and 0.042).

Significance and conclusions: The inter- and intra-observer agreement and therefore the reliability of the modified Adam’s grading system is excellent. This classification is easy to apply and has a high degree of reproducibility amongst observers with different levels of spinal experience. In view of the high reproducibility, we recommend the Adam’s classification for the grading of discogram morphology. The routine use of computed tomography with the concomitant radiation exposure and additional cost would seem not to be justified.