Introduction

The British Scoliosis Society published a document in 2008 which set out the minimum standards for paediatric spinal deformity services to achieve over a period of time. But how do the UK paediatric spinal deformity centres measure up to these benchmarks?

Various studies report a correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 250 and radiocarpal malalignment with ERLF > 250. The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (one week) and late failure (six weeks) in an attempt to predict the final radiological outcome accurately

Radiographic alignment parameters were compared before and after reduction using paired t-tests and then also analysed in a multiple logistic regression analysis.

Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at one week. Age, gender, presence of dorsal comminution, ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. Late failure group: We found radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome at six weeks. Age, Gender, flattening of radial angle, ulnar styloid fracture as factors for secondary displacement when analyzed independently or in combination were not found to be significant predictors of late failure. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and both at one and six weeks when analysed independently or in combination (p< 0.01)

Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options.

The objective of this study was to determine whether immediate mobilisation and unprotected weight bearing of rigidly internally fixed fractured ankles had a significant effect on ankle function or whether it predisposed the ankle to loss of reduction or hardware failure.

We retrospectively reviewed eighty-nine patients with unstable and/or displaced Weber type-A, B or C ankle fractures. Twenty ankle fractures who underwent open reduction and internal fixation. Post operatively the patients were either treated in a non-weight bearing plaster cast (Group A) or were allowed immediate full weight bearing as tolerated without a plaster (Group B. The treatment or weight bearing status was not modified for patients with syndesmosis injuries or deltoid ligament repair. For comparison, twenty-five patients of each group were matched to a same number of historic controls with respect to age, gender, body mass index, and fracture type.

The recovery of the patients was assessed clinically with use of subjective, objective, and radiographic evaluation criteria with reviews at ten to fourteen days, six weeks and three months and one year after the operation. The follow up ranged from twenty-four to fifty-eight months with an average follow up of 37.5 months. Matched-pair analysis revealed no differences for hospital stay and functional outcome (p= 0.858) on Olerud and Molander scoring system but significant difference in time until return to work (mean 91.3 ±20.2 vs. 54.6 ±15.5 days). In the cast group; one patient had loss of internal fixation and one had non-union while four patients in non cast group had mainly wound-healing related problems. Patients in non cast group tolerated earlier full weightbearing and there were no disadvantages concerning hospital stay, pain intensities, and functional Scores.

We conclude that immediate mobilisation and unprotected weight bearing of rigidly internally fixed fractured ankles does not predispose the ankle to loss of reduction or hardware failure and the functional results compared with the conventional cast immobilisation are comparable. In our opinion early mobilization without plaster is recommended in certain populations and may result in faster rehabilitation.

Plain radiographs remain important diagnostic tools in the initial assessment of patients with suspected fractures or dislocations of the foot. Analysis of foot radiograph is a difficult task even in the hands of experts, which is misinterpreted in 2.1% cases. Human visual system is more sensitive to horizontal and vertical stimuli & cardinal orientations (Vertical and Horizontal) perceived more accurately than others. Any absolute judgement task is subject to two types of error: Systematic error and random error. Hence a system of assessment with very high random error of measurement is unlikely to be a reliable assessment method. We tried to find out the influence of experience and orientation on interpretation of foot radiograph.

AP and lateral radiograph from 25 patients who had some form of foot injury were included in this study. The radiographs were first analysed by an experienced foot surgeons for fractures with clinical details to facilitate the identification of the fracture & then presented in two different orientations (vertical and horizontal) to 38 orthopaedics surgeons of different grades and blinded about the nature of the study. We used Kappa analysis & logistic regression to find out the influence of orientation and experience on interpretation skills.

Overall agreement between the foot surgeon and other observers was 0.4. Overall agreement between the observers and the foot surgeon, in the vertical orientation, was.43 and in the horizontal orientation was.32. When experience was taken into consideration agreement between orthopaedics surgeons and the foot surgeon was.416 and agreement between registrar and foot surgeon was.367 and the SHO and foot surgeon was.369. We found that the regression coefficient for horizontal orientation was −.302 and the regression coefficient for the experience was 0.067. Hence horizontal orientation increases the chance of misinterpreting a foot radiograph by 30.2% and with increasing experience the chance of correctly identifying the fracture increases by 6.7%. From this study it is evident with all the other variables like experience, quality and adequacy of radiographs optimised, orientation of the foot radiograph alone can significantly affect the interpretation skills of the observer.

The objective of this study was to ascertain knowledge of the normal anatomy and appreciation of components of an “adequate” or “acceptable“ reduction by the medical staff responsible for management of distal radius fractures in the emergency departments (A& E) in UK. A nation wide structured questionnaire survey based on literature review was performed on 138 doctors. Of the 100 (72%) respondents, only 40% could cite the correct values for volar tilt, radial inclination, and ulnar variance, there being a significant difference between orthopaedic n=16(64%) and A& E staff n=24(32%); p=0.031; c2 = 12.17. Only 18% respondents were aware of the acceptable ranges of adequate reduction; with orthopaedic staff n=12 (48%) being more aware than A& E staff, n=6 (8%); p=0.002; c2 = 6.38. Only 19% formally measure the key parameters before decision making [52% Orthopaedic versus 8% A& E staff; p=0.018; c2 = 7.31]. Only 14% of respondents from hospitals equipped with picture archive navigation system (PACS) stated that they used the angle measurement function.

A lack of knowledge of the normal anatomical values and implementation of generally accepted measurement criteria predictive of fractures unlikely to benefit from repeat manipulations is evident. It is important to emphasize the influence of factors reported to affect stability such as age, functional demands of the patient and extent of initial fracture displacement in decision making. The introduction of a set of guidelines and further education of the medical staff could reduce the number of inappropriately treated distal radial fractures in the A& E setting with significant economic implications.

Patients and Methods: We conducted a retrospective study of neck of femur fractures over a period of two years. Variables analysed were the perioperative haemoglobin levels, type of fracture and surgery, age, gender and blood transfusion in the perioperative period.

Results: Out of a total of 310 patients 49 required a postoperative blood transfusion.

The mean preoperative Hb of patients who required blood transfusion was 11; S.D. 1.49 while those who did not require a transfusion it was 12.5; S.D.1.42. Transfusion was required in 23% of patients having extra-capsular neck of femur fractures fixed with a DHS and in 9.5% of patients having intracapsular neck of femur fractures undergoing a hemiarthroplasty.

The univariate analysis showed a significant relationship between post-operative transfusion and the pre-operative Hb level (p=0.0001) and the type of fracture (p=0.001). However no relationship was found between transfusion and age (p=0.423) and the gender of the patient (p=0.611).

Discussion: The results of our study indicate that the most important factor in the prediction for blood transfusion in fracture neck of femur is the preoperative level of Hb as well as the type of fracture. Predicting a priori, the target population at a higher risk of requiring blood transfusion would enable us to establish appropriate prophylactic measures.

Introduction: Wrist injuries are common presentations at Accidents and Emergencies. Distal radius fractures are by far the most common. Scaphoid injuries constitute about 60% of carpal injuries. 35% occult wrist fractures are undiagnosed on 2nd visit radiography (50% distal radius/ulna). Moreover 30% patients with significant soft tissue injuries not diagnosed.

Aim: To compare the MRI (magnetic resonance imaging) and bone scans in the diagnosis of X-Ray negative wrist injuries. To functionally score these wrist at the end of 1-year to assess the outcome.

Materials and methods: A prospective study was done in 33 wrists that did not have a fracture wrist detectable on plain X-ray. The MRI and bone scan were done on the same day within 5-7 days after the injury. PD Fat Saturation Axial and Coronal images were undertaken with MRI. Clinical scoring was done after 1 year after the injury to assess the outcome of these injuries.

Results: We detected fractures in 10 wrists on bone scans and 8 fractures on MRI scans. There was a correlation between MRI and bone scan in 5 Cases. We noted 9% (3/33) of false positive cases with bone scan. Bone scans correlated with the site of injury in 10% of cases. 1 fracture was missed in both MRI and bone scan. MRI identified 4 significant soft tissue injuries and capsular edema in 29/33 cases, which were not identified on bone scans. MRI findings showed superior correlation than bone scans with clinical findings on re-examination, which was done following the scans. PRWE (patient rated wrist evaluation) was used to score the outcome of the wrists at the end of 1 year. The patients who had soft tissue or bony damage detected on MRI had significantly higher scores at 1 year of follow-up.

Conclusion: Though bone scan has high sensitivity in diagnosis of fracture, significant soft tissue injuries will be missed. On the other hand, MRI had a high sensitivity and specificity in diagnosis of a fracture and soft tissue injuries. MRI can differentiate between a bone edema and a fracture. MRI has a disadvantage of limited exposure. Clinicians must be aware of the limitations of both investigations. Though majority of these injuries do not active intervention apart from plaster or splinting, detection of these injuries is essential to prognosticate the outcome.