Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck. The trial manual illustrated the Neer classification of proximal humeral fractures. However, in addition to surgical neck displacement, surgeons assessing patient eligibility reported on whether either or both of the tuberosities were involved. Anonymised electronic versions of baseline radiographs were sought for all 250 trial participants. A protocol, data collection tool and training presentation were developed and tested in a pilot study. These were then used in a formal assessment and classification of the trial fractures by two independent senior orthopaedic shoulder trauma surgeons.Objectives
Methods
The use of botulinum is established in the management of spasticity in cerebral palsy; most series concentrate on its injection into the Gastrocnemeii and hamstrings. During the swing phase, the rectus femoris acts concentrically at the hip, and eccentrically at the knee, to accelerate the thigh while controlling the rate of knee flexion. In spasticity there is prolonged activity with some of the rectus firing concentrically, resulting in a decreased rate of knee flexion, decreased peak flexion and a delay to its occurrence. These factors contribute to poor foot clearance. Our aim was to establish whether the temporary paralysis of the rectus femoris by botulinum injection can improve knee kinematics. Patients included were ambulant diplegics with clinical and kinematic evidence of rectus femoris spasticity. Independent clinical assessment was combined with 3D gait analysis pre and post injection. Kinematic Data for sagittal plane knee flexion/extension allowed us to calculate changes in the rate of flexion, the degree of peak flexion and time to its occurrence. Clinical evidence of spasticity was detected using the fast Duncan Ely test. There were 7 patients who underwent 15 injections into Rectus Femoris. Age range: 8–25 years (mean, 14–4 years). From the sagittal plane knee flexion graphs 10/15 had improvement in the rate of knee flexion, 9/15 had improvement in the peak flexion and 8/15 in the time to peak flexion. The mean increase in the fast Duncan Ely was 20. 5 degrees. Using 3 Dimensional gait analysis we observed an improvement in the kinematic data following injection of the rectus femoris with botulinum. This was accompanied by a clinical reduction of spasticity as measured by the Duncan Ely test. As with other muscle groups, botulinum injection of the rectus femoris has the potential to be both therapeutic and diagnostic.
