Aim: A study was done to investigate the range in size and morphological features of a series of human clavicles.

Method: A Phillips CT scanner was used to examine morphometric properties of 42 right and 36 left adult cadaveric clavicles. The resulting data was analysed with Voxar 3D software. The length of the s-shaped clavicle was measured and the planar cross-sectional geometry of the intramedullary canal and cortical thickness assessed at 10% increments along the length of the bone. MPR (multi-plane reformat) imaging allowed ‘fly-through’ reconstruction of cross-sectional morphology as one travels along the length of the bone.

Results: The sample studied followed a normal distribution with mean size= 136.2mm (range: 112.6– 172.0 mm). In general the sternal portion of the clavicle is circular or prismatic in cross-section where as the acromial portion is flatter on its superior and inferior surfaces. A spacious, variably shaped canal is observed at the sternal and acromial thirds in contrast to the denser, smaller, more circular shaped canal in the central third of the bone. Unlike most long bones, the clavicle was observed to have an extensive network of trabeculae along the entire length of the intramedullary canal. The central third of the clavicle has the thickest cortex. The mean cortical thickness (3.37mm; range: 1.8– 7.9mm) was greatest at a point 60% from the sternal end with the mean thinnest cortex (1.37 & 1.15mm) found at the extreme sternal and acromial ends of the bone respectively.

Conclusion: The clavicle is highly variable in shape and exhibits dramatic variations in both curvature and cross-sectional geometry along its length. Contrary to previous teaching, MPR reconstruction accurately demonstrates clear visualization of a distinct intra-medullary canal.

Aim: To audit the accuracy and efficacy of injections for subacromial impingement administered by our medical staff and specialist role physiotherapist.

Methods: 49 patients presenting to the outpatient clinic with subacromial impingement agreed to take part in the study. They were allocated according to date of referral to either the consultant, the physiotherapist or registrar grade for injection via an anterior approach into the subacromial bursa. The therapeutic injection contained a specified volume of radiocontrast as well as depomedrone and lignocaine.

Antero-posterior and scapula-Y radiographs were performed immediately after injection. The Constant shoulder score was evaluated before and at six weeks after injection and all radiographs were reviewed by an independent, blinded radiologist recording the position of contrast.

Results: Accuracy rates of 67% through an anterior approach were obtained by both the consultant and the physiotherapist. At registrar level 48% accuracy was achieved.

Improvement in shoulder score was obtained in 70% of patients with accurate injections, but additionally in 59% of patients with inaccurate injections.

Only 7% of cases had contrast confined to the subacromial space; in the remainder, contrast tracked medially around the rotator cuff muscle bellies in 59%, gleno-humeral joint in 20% and within the cuff tendon in 16%.

Conclusions: In our practice, the specialist physiotherapist already has an established role in administering therapeutic subacromial injections. Our audit demonstrates acceptable and equal accuracy to the consultant which we feel justifies this particular part of their role. However, at registrar grade the level of accuracy is reduced and most likely reflects inexperience, as over time accuracy improved.

Interestingly, shoulder function scores have improved in over half of impingement patients with inaccurate injections which may reflect a generalised ‘field’ effect of steroid on the shoulder.

Aim: A case report: Symptomatic Osteochondroma of the Coracoid

Introduction: An osteochondroma is a common developmental tumour of bone characterized by abnormal periphyseal ectopic endochondral ossification. This results in a cartilage-capped subperiosteal bony projection. A solitary osteochondroma is encountered more frequently than are multiple hereditary osteochondromas. They are usually appreciated in the first decades of life and are most commonly located in the long bones, especially the femur, humerus and the tibia. Clinical presentations generally relate to the mass effect of the lesion. These lesions are said to grow to skeletal maturity. Continuous slow growth of the osteochondroma in adults should alert the clinician to the possibility of secondary malignant transformation, usually to a chondroma.

Method: We present an unusual case of shoulder pain in a 36-year-old man with a painful solitary osteochondroma of the coracoid process. Plain radiographs, computed tomographic and magnetic resonance imaging of the lesion showed a solitary osteochondroma with a visible cartilage cap eroding the under surface of the clavicle. The lesion was surgically explored and excised. Histological examination showed a benign osteochondroma. Removal of the tumour resulted in resolution of all signs and symptoms.

Conclusion: We are aware of no reported cases in the literature of osteochondroma of the coracoid process. This case was unusual in terms of age at clinical presentation and location, suggesting a continuous growth of the tumour beyond skeletal maturity.

This study presents the clinical outcome of Boyd-McLeod procedure for lateral epicondylitis of elbow. 29 cases with lateral epicondylitis with failed conservative management (rest, physiotherapy, analgesia and steroid injections) were included in the study. There were 14 male, and 15 female cases of which two had bilateral surgery. Data collection included details of patients’ occupation, number of steroid injections, radiograph evaluation and postoperative complications. Post-operative clinical out come was evaluated by Hospital for Special Surgery Total Elbow Scoring System (HSS2), clinical notes review, and telephone questionnaire.

Average age: 47 years (range: 34–65), mean post-op follow up time: 16 months (range: 6–32). 93% were manual workers. Dominant elbow involvement was seen in 64%. Mean number of steroid injections: 3 (range: 1–10). Conservative measures included NSAIDS (90%) and physiotherapy (83%). Average tourniquet time: 32 min (range: 18–59). Mean HSS2 score pre-op and post-op were 38 and 92 respectively (p value: 0.0001). 91% reported excellent/good results. Average post-op time for the continuation of professional/recreational activity was 5 weeks. 2 cases (9%) had poor results. One case had ectopic bone formation.

Boyd-McLeod procedure is done as a day case procedure involving excision of degenerative tissue from common extensor origin, decortication and decompression of lateral epicondyle and partial release of annular ligament. Although an extensive procedure, this procedure addresses the management of all offending factors that are likely to contribute to pain and disability in tennis elbow. There are few studies regarding the outcome of Boyd-McLeod procedure. There was no evidence to suggest that late presentation had any adverse effect on the post-op success. This study revealed a high success rate and a low complication rate. We conclude that Boyd-McLeod procedure is an effective treatment option in patients with resistant lateral epicondylitis.