Aim

Fractures are the second commonest presentation of non-accidental injury (NAI) in children. Approximately one third of abused children will present to Acute Trauma Services (ATS) with fractures. Any cases of suspected child maltreatment should be referred to Safeguarding Services for follow-up, as outlined by Trust Guidelines. Our aim was to examine the referral of children with suspicious fractures to safeguarding and assess if cases with high risk of abuse are being missed by ATS.

Aim: to determine the proportion of patients with fragility fractures who underwent risk assessment for osteoporosis as a result of their fracture clinic attendance prior to and following reinforcement of guidelines

Methods: The inclusion criteria were defined as: new patients fifty years of age or over sustaining a fragility fracture of their distal radius presenting during two three month periods in 2004 (April to June and October to December). Guidelines for osteoporosis risk assessment (the Northumberland guidelines) were reinforced during the interim period. Patients were identified from hospital records and the notes obtained to confirm the fracture type as fragility. The number assessed during each period was determined from outpatient referral for DEXA records and compared. Patients who had undergone DEXA scanning in the year prior to their fracture clinic attendance were excluded from the analysis.

Results: from April to June there were forty-six patients (39 women and 7 men) with a mean age of 73 years while between October and December there were fifty-four patients (48 women and 6 men) with an average age of 68 years. In the April to June cohort 3 patients had already had a DEXA scan prior to fracture clinic attendance. Of the 43 remaining patients 3 were risk assessed for osteoporosis (7%). Within the October to December group two patients had previously undergone DEXA scanning and of the remaining 52 patients 16 (31%) underwent osteoporosis risk assessment.

Conclusion: Risk assessment for osteoporosis is still carried out ineffectively by orthopaedic surgeons even following enforcement of guidelines.

We wished to determine the most accurate and reliable technique for insertion of tibial prostheses, with tibial resection guided by either intramedullary (IM) or extramedullary (EM) alignment jigs.

135 consecutive AGC cemented total knee replacements in 126 patients in a single unit were performed by, or directly supervised by, four consultant surgeons. Ethical approval and patient consent was obtained. Intramedullary alignment was used for the femoral cuts and patients were randomised at the time of operation to have either IM or EM guides for resection of the proximal tibia, cut with a zero degree posterior slope in both. The protocol only entered patients into the trial if their knees were suitable for use with both IM and EM tibial alignment although, in the event, no patients were excluded. Long leg radiographs (standing hip to ankle) were taken by a standardised method three months after the surgery. A blinded assessor, unaware of the alignment method used, evaluated acceptable films and measured tibial component alignment. The proportion of tibial prostheses aligned within two degrees of 90 was the endpoint of the study.

Of the 135 knees 100 suitable x-rays were assessed. Correct tibial alignment was more likely in the IM group (85%) than the EM group (65%), p=0. 019. Though mean alignment was similar, variation (standard deviation) was less in the IM group (2. 0 vv 2. 2).

In the AGC knee, intramedullary alignment guides are superior to extramedullary guides for alignment of the tibial prosthesis. We recommend the routine use of intramedullary tibial alignment.

Shoulder active range of flexion, abduction and external rotation was measured with three devices in 33 subjects using a blinded protocol. The aim was to compare the accuracy and interobserver reliability of the goniometers. The devices used were the routine clinical goniometer as used clinically with and without the elbow flexed to 90 degrees, differential goniometers incorporated into a tightly fitting brace holding the elbow at 90 degrees flexion, and the Isotrak II electromagnetic coupling laboratory equipment which was used as the reference tool and in addition was used to make simultaneous measurements of trunkal movements.

For the measurement of flexion and external rotation, there was no significant difference in interobserver reliability between the goniometric methods. There was a small difference when measuring abduction with the brace mounted differential goniometers being the most accurate. The striking finding was the poor accuracy and over-measurement error of both goniometric methods, over-measuring by 34 degrees for flexion, 43 degrees for abduction, and 15 degrees for external rotation. Trunkal movements are shown to account for part of this error but humeral rotation was also noted.