Postero-lateral rotator instability (PLRI) is the most common pattern of recurrent elbow instability. Unfortunately, current imaging to aid PLRI diagnosis is limited. We have developed an ultrasound (US) technique to measure ulnohumeral joint gap with and without stress of the lateral ulnocollateral ligament. We sought to define lateral ulnohumeral joint gap measurements in the resting and stressed state to provide insight into how US may aid diagnosis of PLRI.

Sixteen elbows were evaluated in eight healthy volunteers. Lateral ulnohumeral gap was measured on US in the resting position and with posterolateral drawer stress test maneuver applied. Joint laxity was calculated as the difference between stress and rest conditions. Measurements were performed by two independent readers with comparison performed between stress and rest positions.

A highly significant difference in ulnohumeral gap was seen between stress and rest conditions (Reader 1: p < 0 .0001 and Reader 2: p=0.0002) with median values of 2.93 mm and 2.50 mm at rest and 3.92 mm and 3.40 mm at stress for Reader 1 and 2 respectively. Median joint laxity was 1.02 mm and 0.74 mm respectively for each reader. Correlation and agreement between readers was good.

This study provides key new insight into use of US for diagnosis as PLRI as it defines normal ulnohumeral distances and demonstrates widening when applying the posterolateral drawer stress maneuver. Further evaluation of this technique is required in patients with PLRI.

To report the case of an asymptomatic simultaneous bilateral neck of femur fracture following vitamin D deficiency which was missed, misdiagnosed and treated for coexisting severe bilateral osteoarthritis knee.

A male aged 62 years presented with severe osteoarthritis of both knee joints confining him to bed about eight weeks prior to presentation. The patient did not have any complaints pertaining to his hip joints/axial skeleton. Examination of the hip joints revealed only crepitus with absence of straight leg rising. Radiological survey showed bilateral displaced fracture neck of femur. He had elevated serum alkaline phosphatase; 119IU/L(N:39–117IU/L), decreased Serum 25 (OH) Vit D level;6.03ng/ml(N:7.6–75ng/ml), decreased spot urinary calcium;78mg/day(N:100–300mg/day) with normal serum calcium, phosphorus and highly raised parathormone levels;142.51pg/ml(N:12–72pg/ml). Tc-99 Bone scan showed increased radiotracer uptake in both the hip joints and knee joints. Bone Mineral Density was in favour of osteoporosis. Biopsy fromthe heads of both femurs also revealed osteoporosis.

Bilateral staged total hip arthroplasty was done and he was put on Vitamin D replacement therapy. Patient was on regular monthly follow-up for intial one year and three monthly follow-up thereafter. At present with three year follow-up patient is community ambulant with a walking frame. Despite medical advice patient had denied total knee arthroplasty for osteoarthritis of his knee joints.

Asymptomatic simultaneous bilateral neck of femur fracture is a rare injury and poses a diagnostic challenge to the treating orthopaedic surgeon with its bizarre clinical picture. Similar presentation of metabolic bone disease can be easily missed without a proper screening, keeping in mind a high index of suspicion for the above disorders. Besides proper clinical examination of both hip and knee joint should be performed in patients presenting with bilateral knee pain. A good functional outcome may be achieved with prompt surgical intervention and medical treatment.

We present the case of a previously well 18 year old female who presented with an acute onset swollen painful right ankle with an overlying non-blanching purpuric rash. There were no associated systemic features. Ankle joint aspirate grew Neisseria Meningitides. She was treated with intravenous third generation cephalosporin's and surgical washout of the joint with improvement. Primary meningococcal arthritis (PMA) is rare and mostly associated with the knee joint. Presentation of meningococcal disease in this manner is easily missed or misdiagnosed as gonococcal disease or overlying cellulitis.

Primary meningococcal arthritis is a rare form of septic arthritis. It can be misdiagnosed as an overlying cellulitis or as a gonococcal rash. Physicians should be aware of the possibility of this microorganism presenting as a septic arthritis, and understand the importance of joint aspiration at the centre of diagnosis.

Conservative management remains the gold standard for many fractures of the humeral diaphysis with union rates of over 90% often quoted. Success with closed management however is not universal.

Aim: To evaluate outcomes in humeral shaft fractures treated non-operatively and to identify possible causes for non-union.

Methods: Patients were identified through a manual search of the operating theatre register and all plaster room forms for the period 1/1/02 – 31/12/05. Patient files and radiographs were then examined for factors that might influence rate of non-union.

Results: 45 fractures were identified in 44 patients. 28 of these were treated conservatively with a hanging cast and functional brace. Of these, 11(39.6%) went onto non-union requiring ORIF + bone grafting.

There was a strong correlation between the length of time spent in the hanging cast and a high rate of non-union. The average length of time spent in cast for the non-union group was 48 days as opposed to 30.9days in the group that went onto unite (p=0.0601)

There was a statistically significant correlation between non-union and the radiographic degree of distraction at the time of first application of hanging cast (p=0.016) and also at the six week check (p=0.001).

Other factors associated with a poor outcome were the degree of varus angulation at presentation (p=0.0078), male sex, right humerus, dominant side, older age group, high energy injury, NSAID use, significant co-morbidities and associated injuries.

Conclusions: Our results compares unfavorably with Sarmiento who quotes a non-union rate of 2.5% in patients who are treated on average only 9 days in hanging cast. Our high rate of non-union is associated with a high degree of distraction at time of first application of hanging cast and an extended period of time spent in cast.

The use of tapered titanium femoral stems has gained in popularity for primary total hip arthroplasty. One of the basic stem designs is a fully grit blast square tapered stem with distal fixation (Zweymuller-type). Another stem design (Muller-type), a proximally porous coated flat wedge stem with proximal fixation is associated with a low but significant perioperative femoral fracture risk. Both of these implant types are inserted with a broach-only technique. We theorize that the Zweymuller-type implant can be inserted safely with pneumatic broaching with a very low fracture risk even when broached by rotating residents with no prior experience.

We prospectively reviewed 300 consecutive hip arthroplasty cases using Zweymuller-type stems from eight different manufacturers implanted using the Woodpecker TM pneumatic broaching system. The series included both THA and hemiarthroplasty cases with a wide range of cortical/canal indexes. Patient age ranged from 14 to 98 (avg. 68). Half of the hip stems were inserted through a posterolateral modified Kocher-Gibson approach, and half through an anterolateral Hardinge approach. Approximately 25 rotating residents who were initially unfamiliar with this broaching technique and stem implant type performed the majority of the procedures. We routinely obtained an intra-operative AP pelvis x-ray to confirm trial implant size, alignment, and adjust the leg lengths.

The overall technique/implant-related perioperative complication rate was 2% (6/300). These included intra-operative femoral fractures(2), post-operative femoral fractures (1), dislocations(3), and deep infections(2). There were no cases of nerve palsy or leg length inequality > 1cm. Rates of post-op blood transfusions and venous thromboembolism were not reviewed for the purposes of this study. Only one of the complications (one deep infection) required exchange of the original femoral component. There was no significant difference in complication rates between type of surgical approach, brand of square tapered stem manufacturer, or experience of the operating surgeon.

We conclude that hip arthroplasty using pneumatically broached, square tapered, cementless distal fixation (Zweymuller-type) hip stems has a low learning curve and can be implanted safely even in very osteoporotic bone. This technique/implant gives the surgeon control of stem anteversion for stability and leg length inequality correction. The incidence of certain perioperative complications can be reduced by using Zweymuller-type stems using pneumatic broaching regardless of approach, implant manufacturer, or surgeon experience. These patients will continue to be followed clinically for implant survivorship.

Introduction: It is standard procedure in our unit to use compartment pressure monitoring in all patients presenting with tibial fractures. A sustained difference of less than 30mmhg between the diastolic blood pressure and the compartment pressure (known as the delta pressure) is taken as an indication for fasciotomy.

Aim: To review the impact continuous compartment pressure monitoring has on the management of patients with tibial fractures.

Methods and materials: Between January 2004 and June 2006, 28 patients admitted to our unit following tibial fracture had a compartment pressure monitor inserted. The outer sheath from a 16G cannula connected to an arterial manometer was used in each case.

The records of these 28 patients were reviewed. Twenty three were male. Ages ranged from 19 to 83 years old. Eight patients had open fractures and 20 had closed fractures. Seven patients (25%) had difficulties with communication which could have impeded or delayed the diagnosis of a compartment syndrome.

Results: Average delta pressure ranged from nine to 69mmHg in our patient population. High energy injuries resulted in a significantly lower delta pressure (p=0.05). Open fractures were more likely to result from high energy, although this was not statistically significant (p=0.068). Two patients had fasciotomy performed based on clinical picture and a sustained decrease in delta pressure. No patient had a missed compartment syndrome.

Conclusion: Continuous compartment pressure monitoring is especially useful in patients who are most at risk for compartment syndrome i.e. those having sustained high energy injury or open fractures. It can also aid decision making when the clinical picture of compartment syndrome is equivocal, or when a patient’s ability to communicate pain is impaired.

However, due to the ease of use and the low cost involved, we recommend that all patients with tibial fracture should have continuous compartment pressure monitoring performed.

In 1993 a specialist limb length discrepancy and deformity clinic was established at Our Lady’s Hospital for Sick Children. Since then, the senior author has performed 193 lower limb lengthenings. Of these, there were 50 paediatric cases who had 74 segments lengthened using the Ilizarov method of distraction osteogenesis. A retrospective study of data and radiographic review of these children was performed. In particular, the grade of severity of deformity and complications encountered whilst lengthening were documented.

Complications were defined as any unwanted event and graded as minor or major with the major complications being further classed as serious or severe. Each patients deformity was classified using the Dahl Deformity Severity Scale which grades deformity according to percentage length discrepancy.

There were 26 females and 24 males in the study population, their average age being 13.1 years (range 2.8–18 years). 65% of the lengthenings had a congenital aetiology for the deformity. The mean hospital stay was 7 days and the average length achieved was 4.9cm. There were 79 minor complications and 48 major complications. The overall complication rate (total complications divided by the number of segments lengthened) was 1.74%.

This study shows how the Deformity Severity Scale may be used as a prognostic indicator to identify limb deformity at high risk of lengthening complication. It may also be used to determine the relative complication risk for each patient according to his or her percentage limb length discrepancy.