Goals: In this study we analysed the patients admitted with orthopaedic problems who had coffee ground vomitus for incidence, risk factors, investigations and the management. This project was to highlight this significant but rather neglected problem and to draw up local guidelines in the prevention.

Methods: This is a prospective study conducted for a period of six months from 1st of July 2005 to 31st of Dec 2005. All patients admitted with Orthopaedic problems who had coffee ground vomitus were included in the study after confirmation with haemoccult test. Their case notes were studied to identify the risk factors, preventive measures that could have been taken and their management.

Results: There were 34 (2.3%) patients who had coffee ground vomitus, out of 1427 orthopaedic admissions during the study period. There were 14 (41%) men and 20 (59%) women. The mean age was 73.7 yrs in men and 82.2 yrs in women. This problem was more common in 8th decade with 15 patients (45.5%). There were 6 patients each in 7th and 9th decade, 5 patients in 6th decade and only 2 patients in 5th decade.

There were 19 (55.5%) trauma admissions with fractures and 15 (45.5%) elective admissions. There were 12 (35.2%) patients with previous gastric problems. There were 20 (59%) patients who were on gastric irritant medications, out of which only 5 (25%) were on gastro protective medications. All 34(100%) patients were on low molecular weight heparin for thromboprophylaxis. There were 2 patients on steroids and 2 patients on warfarin.

Coffee ground vomitus occurred preoperatively in 4 (13.4%) and postoperatively in 26 (86.6%). It happened with in the first six hours after surgery in 25 (96.5%) patients. Only in one patient it happened after 3 weeks.

All patients were kept nil by mouth, started on fluid resuscitation and intravenous ranitidine followed by oral omeprazole. Patients who were haemodynamically unstable were investigated by endoscopy. 17 (50%) patients had oral gastroduodenoscopy. 2 patients had blood transfusion because of significant drop in haemoglobin and one died before the transfusion was started.

There were 5 (14.7%) deaths in our study group. The cause of 2 deaths was directly related to gastrointestinal bleeding and the other three were confirmed to have had concurrent chest infection.

Conclusions: Gastro intestinal bleeding is a neglected but not an uncommon problem in orthopaedic patients. Identification of high-risk patients and implementation of preventive measures could avoid this potential life threatening complication. We recommend withdrawal of gastric irritants and co-prescription of gastro protective medications for high-risk orthopaedic patients.

Total elbow arthroplasty (TEA), as a primary procedure and open reduction and internal fixation (ORIF) have been used to treat complex intra-articular distal humeral fractures in elderly patients. The failure rate after ORIF is high and TEA has often been used as a salvage procedure. Although satisfactory results have been reported after TEA as a primary procedure, there are no publications reporting the results of TEA after failed internal fixation (FIF). In this study we compared the results of patients that had TEA after FIF with those that had had primary arthroplasty (PA). We reviewed the results of 9 consecutive patients who had FIF with 12 patients who had PA. All the operations were performed by one surgeon using the same technique and same prosthesis. Both groups of patients were similar with respect to ages, sex, co-morbidity and hand dominance. The mean follow-up for both groups of patients was 5 years. At final review, patients who had had FIF had a mean Mayo score of 68 and a range of flexion/extension of 90 degrees, there was 1 infection and 1 case of loosening. The PA group had a mean Mayo score of 88 and a range of flexion/extension of 96 degrees, there were no cases of infection or loosening. This study shows the results of TEA are satisfactory either as a PA or after FIF, however the results after PA are significantly better than after FIF.

Background: The aim of this study was to analyse mid-shaft clavicle fractures in children and adults to find out the factors that would influence the healing time and the necessity of surgical intervention.

Methods: We identified all the midshaft clavicle fractures treated at Chesterfield Hospital between January 2003 and January 2006. We studied the case notes and radiographs of these patients. We grouped the midshaft fractures into those in children and those in adults. Each group was further subdivided into two part and three part fractures. It was also noted whether a vertical butterfly fragment was present in the three or more part fractures. The fractures were analysed for their incidence, presence of comminution, degree of displacement, type of treatment and the follow-up time before discharge.

Results: – Over the 3 year period, 242 middle 1/3 clavicle shaft fractures were treated. Among the mid shaft fractures there were one hundred and eight (44.6%) children and one hundred and thirty four (55.3%) adults.

There were one hundred and three children with two part clavicle fracture (95.3%) and one required surgical fixation (1%). There were only five children with three or more fracture fragments (4.7%) and one required surgical fixation (20%). All five children who had three or more fracture fragments were found to have vertical fragment on x-ray. The average time for discharge was 27.48 days for two part fractures and 49 days for three part fractures.

There were seventy-five (55.5%) adults with two part fractures and ten of them required surgical fixation (13.3%). There were fifty-nine (44.0%) with three or more fragments and eleven of them required surgical fixation (18.6%). Out of the fifty-nine fractures, which had three or more fragments, forty-eight had vertical fragment on x-ray (81.3%). Among the three part fractures, there were ten fractures with vertical fragment that required surgical fixation (20.8%).

The average time for discharge was 52.07 days for two part fractures and 93.56 days for fractures with three or more fragments. There was no difference in the discharge time for non operated three part fractures with or without vertical fragment.

Conclusion: The incidence of clavicle fractures in children is nearly as high as in adults. In children the number of days for discharge is nearly double for three part fractures when compared to two part fractures.

The presence of vertical fragment predicts higher rate of surgical intervention required due to either delayed/non union or localised skin tenting. We recommend that we should have a lower threshold to fix the 3 or more part clavicle fractures with vertical fragment.