Fractures of the clavicle remain common in clinical practice. The main changes that have occurred in the last five years are in the indications for surgical intervention. The traditional indications remain. For example, complex cases such as compound fractures, those in which the skin is threatened, fractures of the clavicle associated with a floating shoulder, fractures of the clavicle associated with vascular injury and unstable lateral clavicle fractures.

Fractures of the middle 1/3 of the clavicle with displacement of greater than 2 cm have been identified as having a poorer outcome based on patient related factors. In adults these fractures are now recommended for surgical stabilisation.

A number of surgical techniques have been described including internal fixation with plates and intramedullary pins. It is the author's preference to use plate fixation as it provides stable fixation of the clavicle including rotational control. Although there are some authors that do recommend pin fixation, insertion of these pins can be technically demanding and there is a risk of displacement of undisplaced fragments. The intramedullary pins do not provide rotational control of the fracture.

When performing internal fixation of clavicle fractures it is important to be aware of the risk of major neurovascular compromise. In the second quarter (from the medial edge of the clavicle) the major neurovascular structures are at risk and care is required to ensure that drills and screws do not penetrate the inferior cortex of the clavicle and violate these neurovascular structures.

Adolescents with fractures of the clavicle are often managed without surgical intervention even if there is significant displacement. However, further work is required to identify the natural history of this group.

Non-union of the clavicle is a relatively uncommon event. For those patients who have a persistent symptomatic non-union, surgical stabilisation and bone grafting is recommended.

Purpose

To elucidate whether there is an advantage in external fixation supplementation of K-wires in comparison to K-wires and plaster, in the treatment of distal radius fractures without metaphyseal comminution.

The authors are not aware of any research comparing computed tomography (CT) and avascular necrosis (AVN) of the scaphoid bone. The primary aim of our study was to investigate the use of longitudinal CT in predicting AVN of the proximal pole of the scaphoid, and subsequent fracture nonunion following internal fixation.

Thirty-two patients operated on by the senior author for scaphoid fracture were included. Preoperative CT scans were independently assessed for deformity, comminution, fracture position, proximal pole sclerosis, and bridging trabeculae. Intra-operative biopsy of the proximal pole was assessed independently by a blinded musculoskeletal histologist. AVN was determined by histology of a proximal pole biopsy, using the criteria described by Ficat. Post-operative CT scan was utilised to determine fracture union.

Preoperative CT features which significantly correlated with AVN were, increased radiodensity of the proximal pole, the absence of any bridging trabeculae comminution, dorsal cortical angle, proximal fracture and age less than 20. Features predictive of subsequent nonunion were fractures of the proximal, increased radiodensity of the proximal pole, and AVN.

Preoperative CT scan findings are significantly correlated with histologically confirmed AVN and fracture union. Preoperative longitudinal CT scan is of significant prognostic value and should be considered to assist in predicting outcome and assessing treatment options.

The purpose of the study was to describe the normal anatomy of glenoid labrum.

20 dry bone scapulas and 19 cadaveric shoulders were examined. Light microscopy was performed on 12 radial slices through the glenoid.

An external capsular circumferential ridge, 7–8mm medial to the glenoid rim marks the attachment of the capsule. A separate internal labral circumferential ridge 4mm central to the glenoid rim marks the interface for the labrum and articular cartilage. A superior-posterior articular facet contains the superior labrum. Two thirds of the long head of biceps arise from the supraglenoid tubercle, the remainder from the labrum.

The superior labrum is concave and is loosely attached to the articular cartilage and glenoid rim. In contrast the anterior-inferior labrum is convex, attaches 4mm central to the glenoid rim and has a strong attachment to articular cartilage and bone.

The anatomy of the superior and anterior-inferior labrum are fundamentally different.

Complex carpal injuries can be difficult to assess and manage. They usually occur following high energy injuries to the wrist.

Imaging in the form of traction views and a CT scan can help understand the detail of the fracture dislocation pattern.

Perilunate dislocations and perilunate fracture dislocations are commonly managed with a dorsal approach to provide an anatomic reduction. A volar approach can be used is median nerve entrapment and allows a surgical repair of the volar aspect of the lunotriquetral ligament.

Perilunate dislocations are often classified into greater and lesser arc injuries. The greater arc injuries include fractures which go through the radial styloid, scaphoid, capitate or triquetrum. Lesser arc injuries are through the scapholunate ligament and lunotriquetral ligament. It is common for there to be a combination of greater and lesser arc injuries.

We have also identified a complex injury which is a lunate intra-arc injury. This is a fracture through the lunate. With this translunate perilunate dislocation it is important to stabilise the lunate prior to stabilising the remainder of the carpus.

The authors have reviewed a series of complex injuries and developed a classification system based on the above findings. In complex cases where reconstruction is difficult then salvage procedures can be performed. SLAC wrist procedure, proximal row carpectomy and full wrist fusion can be performed particularly in highly comminuted cases or cases with a delayed presentation.

Limited wrist arthrodesis has been shown to be an effective treatment for the degenerative and unstable wrist, abolishing pain but limiting motion. The aim of the study was to assess the effect of excision of the scaphoid and triquetrum on wrist joint range of motion, in the setting of a limited midcarpal arthrodesis. Twelve cadaveric wrists had the range of motion measured, before and after, ulnar four-corner fusion (lunate, capitate, triquetrum and hamate fusion). This was measured again following sequential scaphoid and triquetral resection.

Scaphoid excision after four-corner arthrodesis resulted in a 12 degrees increase in the radio-ulnar (R-U) arc and 10 degrees increase in the flexion-extension (F-E) arc range of motion. Subsequent excision of the triquetrum, to produce a three-corner fusion, further increased R-U arc by seven degrees and F-E arc by six degrees.

These results demonstrate that three-corner fusion with excision of scaphoid and triquetrum results in improvement in wrist motion when compared to four-corner fusion with scaphoid excision alone. From this we conclude that triquetrum excision should be considered in Scapholunate advanced collapse (SLAC) wrist reconstruction to improve residual wrist range of motion.

The purpose of the study was to describe the normal anatomy of glenoid labrum. Twenty dry bone scapulas and 19 cadaveric shoulders were examined. Light microscopy was performed on 12 radial slices through the glenoid.

An external capsular circumferential ridge, 7–8mm medial to the glenoid rim marks the attachment of the capsule. A separate internal labral circumferential ridge 4mm central to the glenoid rim marks the interface for the labrum and articular cartilage. A superior-posterior articular facet contains the superior labrum. Two thirds of the long head of biceps arise from the supraglenoid tubercle, the remainder from the labrum. The superior labrum is concave and is loosely attached to the articular cartilage and glenoid rim. In contrast the anterior-inferior labrum is convex, attaches 4mm central to the glenoid rim and has a strong attachment to articular cartilage and bone.

The anatomy of the superior and anteroinferior labrum are fundamentally different. Suture anchor repair of the superior labrum should be 7mm medial to the glenoid rim whereas the anterior-inferior labrum should be repaired to the face of the glenoid. By defining the normal anatomy of the superior labrum, pathological tears can be identified.

Symptomatic isolated scaphotrapeziotrapezoid joint arthritis affects approximately 10% of the population. Involvement of the scaphotrapeziotrapezoid (STT) joint occurs in 15–30% of all degenerate wrists. Investigation of the technique of arthroscopic debridement of this joint was undertaken to assess the symptom relief achieved and record any resulting postoperative morbidity which limits the success of other techniques used for this condition.

Ten consecutive patients with persistent symptoms were assessed prospectively by a research nurse. Measurements of range of motion and grip strength were obtained before and after surgery. Visual analogue scores for pain and satisfaction levels were also recorded and any limitation to activities of daily living was noted. Assessment included clinical examination for local tenderness over the STT joint.

Good or excellent subjective results were achieved in nine patients at final review at an average of 36 (12–65) months after arthroscopic debridement. One patient graded the result as fair due to failure to achieve normal range of motion. All patients described significant reduction in visual analogue pain scores from an average of 86.5 to 14.1 points. The Green and O’Brien wrist scores improved from a mean of 63.2 to 91.2 during the same time frame. Eight of the patients were in employment and returned to work at 3 months post-surgery without the use of any external splints. The wrist scores were maintained in the five patients reviewed at least three years post-operation.

Conclusion: Arthroscopic debridement is simple, safe and effective when compared with other treatment modalities, achieving excellent pain relief and restoration in function in the short term in patients with isolated idiopathic STT arthritis. Longer term follow-up is no doubt required.

To investigate whether radioscapholunate arthrodesis [RSLA] can provide functional wrist movement with satisfactory pain relief. 19 patients with radio-carpal arthritis underwent RSLA. There were 3 diagnostic groups [post-traumatic osteoarthritis, rheumatoid arthritis and Kienbock’s disease].

The total flexion-extension range decreased. There was a decrease in pain post-operatively. Grip strength increased in Kienbock’s but fell-in patients with osteoarthritis. 95% of patients were satisfied with their result.

The normal ‘functional’ arc is 35 degrees. Pain was reduced in all of our patients, whilst maintaining the functional arc. With only one failure and no complications, we feel the procedure is safe and reliable.

Introduction and Aims: Kinematic and morphologic suggests the scaphoid may be moved differently between individuals. This study therefore aims to determine to what extent the morphology and ligamentous support of the scaphoid supports the suggestion of variable scaphoid motion. The influence of scaphoid motion on the remainder of the carpus will be considered.

Method: Embalmed specimens were either dissected (n=50) using 3x loupes, sectioned histologically (n=30) or sectioned macroscopically (n=20).

Results: Two distinct morphological patterns were observed. Some scaphoids had a shallow capitate facet and were supported by a series of ligaments that may prevent flexion/extension, but allow/facilitate rotation about the longitudinal axis of the scaphoid. Others had deeply concave capitate facets and were supported by ligaments that may prevent rotation but allow flexion/ extension. These patterns may be continuous throughout the proximal row of the carpus.

Conclusion: Two morphological patterns may dictate the mechanical pattern of the carpus. A flexing and extending scaphoid is restricted by the capitate to its radial position, while a rotating scaphoid may be allowed to translate along the proximoulnar aspect of the capitate.

Introduction and Aims: The close proximity of the major nerves to the elbow places them at risk with elbow arthroscopy. New techniques of endoscopic ulnar nerve release, biceps bursoscopy and anterior elbow arthroscopy portal will be presented.

Method: In a cadaveric model needles were used to transfix the major nerves to the elbow joint capsule. From an arthroscopic perspective the needles were located to assess the position of each nerve. Capsular windows were created to provide arthroscopic visualisation of each nerve. A technique of endoscopic ulnar nerve release using the Agee system will be presented including a cadaveric study assessing its safety. Endoscopic biceps bursoscopy will also be demonstrated.

Results: The ulnar nerve passes on the postero-medial capsule and is at risk with debridement of the medial gutter. The radial nerve passes on the anterior-lateral capsule and is at risk during lateral portal placement, anterior capsular release, synovectomy and radial head excision. The median nerve passes anterior to the brachialis muscle and is protected. In a cadaveric model we were able to reproducibly perform a release of the arcade of Struthers, cubital retinaculum and Osborne’s FCU fascia with no injuries to the ulnar nerve or branches. Biceps bursoscopy can be performed for partial tears of the biceps tendon. Through the biceps bed an anterior elbow arthroscopy portal can safely be created.

Conclusion: An understanding of the proximity radial and ulnar nerves allows elbow arthroscopy to be more safely performed. The endoscopic ulnar nerve release, biceps bursoscopy and anterior elbow arthroscopy portal are new techniques extending the therapeutic options.

Introduction Radio-scapho-lunate (RSL) arthrodesis has been shown to be an effective treatment for arthritis limited to the radio-carpal joint. It preserves wrist motion at the mid-carpal joint while relieving pain. The main shortcoming of this procedure has been restricted residual wrist range of motion (ROM) compromising clinical outcome. The aim of the study was to assess the effect of excision of distal scaphoid and triquetrum on wrist motion following RSL arthrodesis.

Methods Ten cadaveric wrists had their range of motion measured before and after RSL arthrodesis and after sequential distal scaphoid and then triquetral resection. The mean and standard deviation of the change in motion were calculated for each step. The two-tailed Student’s t-test with p < 0.05 was used to determine the statistical significance of the changes.

Results Distal scaphoid excision after RSL arthrodesis resulted in 25° (35%, p< 0.01) increase in flexion-extension (F-E) arc and 11° (34%, p< 0.01) increase in radio-ulnar (R-U) arc. Subsequent excision of triquetrum further increased F-E arc by 13° (13%, p< 0.05) and R-U arc by 9° (21%, p< 0.01).

Conclusions In the cadaveric wrists, distal scaphoid excision resulted in significantly improved R-U arc and F-E arc. Subsequent triquetral excision further improved wrist ROM. Modification of RSL fusion to include distal scaphoid and triquetrum excision should be considered to improve residual wrist motion.

Introduction Ulnar nerve entrapment is the second commonest upper limb nerve entrapment syndrome. The purpose of this study was to determine the safety and efficacy of the Agee endoscopic system in ulnar nerve decompression at the elbow. This is the first report of its use in the elbow.

Methods Six preserved cadaveric elbow specimens were used. One surgeon performed the endoscopic releases via a three centimetre longitudinal incision between the medial epicondyle and olecranon. All six specimens were examined independently with loupe magnification. This was done by extending the original incision to 20 cm. The ulnar nerve was assessed with regard to adequate decompression. The branching of the ulnar nerve at the elbow, as well as the presevation of these branches after the endoscopic procedure, was also studied.

Results In all six specimens, the arcade of Struthers, the cubital tunnel retinaculum, and the flexor carpiulnaris aponeurosis were completely divided. There were an average of three motor branches to flexor carpiulnaris at a mean position of 21 mm distal to the medial epicondyle. Most of these were on the radial side of the nerve. The ulnar nerve was also found to give one to two sensory branches, at a mean position of nine millimetres proximal to the medial epicondyle. All the motor and sensory branches were found to be intact after the endoscopic procedure.

Conclusions This study shows that the Agee endoscopic system is both safe and effective. It is a relatively simple procedure but cadaveric practice is recommended to obtain familiarity with the technique and the endoscopic view of the anatomy.

Introduction The close proximity of the cutaneous and major nerves around the elbow have caused orthopaedic surgeons to feel uncomfortable about the prospect of performing basic and advanced elbow arthroscopy. The aim of this study was to review the proximity of the nerves with arthroscopic vision in a cadaveric model and selected clinical cases.

Methods Open exploration of the major nerves in the elbow was performed in alcohol preserved cadaveric specimens. Arthroscopic assessment of the elbow joint was performed before and after the capsule adjacent to the nerve was excised. The arthroscopic assessment of the major nerves in these specimens provided an excellent way to visualise the nerves.

Results The radial nerve was found to be in contact with the anterior capsule of the joint and was at great risk with portal placement, lateral sided procedures including synovectomy, radial head excision, capsulotmy and capsulectomy. The medial nerve was protected by the brachialis muscle. The ulnar nerve was also at risk in the medial gutter.

Conclusions The close proximity of the major nerves to the elbow joint places them at risk, with elbow arthroscopy. The radial and ulnar nerves are particularly close and their exact position can be dissected free with arthroscopic techniques.

Intraosseous ganglia are typically found in the epiphyses of long bones with the two most common locations being the femoral head and medial malleolus. Almost a fifth of cases reported are found in the carpal bones where the ganglion may be an infrequent cause of chronic wrist pain. Persistence and severity of symptoms rather than radiological findings determine the need for further management. Curettage and bone grafting has been performed for patients with constant symptoms that have severely restricted occupational or recreational activities. Clinically the patients improve but in up to forty percent symptoms persist affecting function.

The authors describe an arthroscopic assisted technique of debridement and bone graft used to treat eight patients with intraosseous ganglions of the lunate. All patients returned to work within four months with significant improvement in function and substantial reductions in pain scores. The modified Green scores increased 33.8 points from 51.2 to 85.0 points (p=0.03) by one year postoperatively. Radiographic analysis showed trabeculation within the lunate at an average of 13.8 months following surgery.

The technique is safe, with minimal morbidity and no re-operations.

This prospective study evaluated our results of arthroscopic electrothermal capsular shrinkage intrinsic (palmar) for midcarpal instability. This method of treatment has not been described in the wrist in current literature. Following clinical and video fluoroscopic diagnosis arthroscopy of the wrist and capsular shrinkage was performed on five patients. A radiofrequency probe was mainly used on the ulnar arm of the volar arcuate ligament and the dorsal capsule of the radiocarpal joint. One patient was lost to follow up. At a mean follow up of 11 months the results were: one excellent, two good and one fair using the Green and O’Brien wrist scoring system (Table1). The average range of motion was 95 percent of the opposite wrist. We concluded that arthroscopic radiofrequency capsular shrinkage is an effective, minimally invasive method of treatment for intrinsic midcarpal instability.

Table 1

Total wrist score (Modified Green and O’Brien):

This will be a review of the various surgical approaches which are available for approaching the elbow and will include details of the global approach which can allow exposure of the medial and or lateral sides of the elbow via a common posterior midline incision.

Purpose: To review a clinical series of patients who have had the SLAC (scapho-lunate advanced collapse) procedure.

Method: 50 patients with degenerative disorders of the wrist managed by a single surgeon using a single technique. The technique involved excision of the scaphoid and radial styloidectomy. Midcarpal arthrodesis was performed, and was stabilised with staples.

The patients were prospectively followed for two years.

Results: The majority of patients were satisfied with their outcome and their pain had decreased. Pre-operative flexion/extension was 39 degrees/38 degrees and post-operatively was 32 degrees/35 degrees. The average grip strength did not change.

Conclusion: The SLAC wrist procedure is a useful technique for patients who have localised degenerative arthritis of the wrist.

Purpose: To review the clinical outcome of patients who have had complex radial head fractures managed with titanium radial head replacement.

Methods: There were 17 patients who had insertion of the radial head replacement. The indications for the prosthesis included acute Mason type III fracture which could not be stabilised satisfactorily with internal fixation. Other indications included delayed presentation including previously failed treatment.

Patients were managed with radial head excision and insertion of the Wright Medical titanium radial head replacement. The lateral ligamentous complex was stabilised. A back slab was applied for a period of one week and then the elbow mobilised.

The patients were followed up for a minimum of one year. The Mayo elbow performance index was used.

Results: There were 7 patients with acute injuries of which 6 had associated injuries such as dislocation or coronoid process fracture. 6 of these patients had an excellent result and 1 had a good result.

There were 9 patients with a delayed insertion of the radial head replacement. There were 3 patients who had an isolated radial head fracture and 6 patients with associated injuries, there were 2 excellent, 3 fair and 4 poor.

Three of the 4 poor results had associated capitellar chondral injury. Two patients with fair results had other significant pathology in the upper limb.

In the delayed presentation group the average flexion arc improved from 78 degrees to 102 degrees and the pro-supination improved from 117 degrees to 142 degrees. The average level of satisfaction on a visual analog score was 92 per cent.

Conclusion: Patients who present with acute complex radial head fractures (including associated injuries), the results of radial head replacement are generally excellent. If there are significant associated injuries and a delay in presentation, then the outcome is often only fair. However, this group of patients have improvement in their pain, level of satisfaction and range of motion. Associated capitellar damage is a poor prognostic indicator.

The optimal wrist position between extension and flexion to achieve the highest grip strength, was assessed on the dominant hand of 20 normal female subjects aged 18–25. Seven fixed wrist positions between 60 degrees flexion and 60 degrees extension were assessed as well as a “self selected” position which was chosen by the subjects. Other variables were recorded and analyzed such as hand length, wrist circumference, height and weight of the subjects. Grip strength was recorded using an electrodynamometer. The mean self selected angle was 28 degrees wrist extension, and this position had the highest mean strength of all angles tested. The self selected angle was positively correlated with hand length. Grip strength decreased dramatically in marked wrist flexion compared to extension. The self selected wrist position increased with hand length, height, and weight.