Introduction: Radiation dose exposure to patients in a main X-ray department in a hospital is well documented and controlled. Few studies report the radiation exposure to patients undergoing spinal surgery received from an image intensifier. There are no recommended doses published when using the image intensifier

Methods: We reviewed the radiation doses and exposure times from computer and radiation log records of all the patients who underwent trauma & orthopaedic surgery which required an image intensifier between January and September 2005. The Dose-Area-Product (Gray/cm2) and screening time was recorded.

Results: More than 600 patients underwent trauma & orthopaedic surgery that required an image intensifier at the time of surgery. The mean screening Dose Area Product of the patients undergoing spinal surgery and other common procedures are shown (Gray/cm2):- Lumbar fusion – 23. Disc replacement – 10. Discogram – 4.9. Foraminal injection – 4.4. DHS – 1.86. IMHS – 1.33. ORIF Ankle – 0.89. MUA k-wire wrist – 0.04. The four surgical procedures which required the most radiation were spinal procedures. The maximum radiation is given to patients undergoing lumbar spinal fusion.

Conclusion: Patients undergoing spinal surgery can receive as much radiation exposure as those undergoing procedures such as barium swallow or standard lumbar spine films. Efforts should be made to reduce radiation exposure to orthopaedic patients, and operating surgeons especially those undergoing spinal surgery. By publishing our radiation exposure doses, we can begin to establish guidelines for recommended patient doses.

To describe a discrete fascial canal containing the medial plantar cutaneous nerve of the great toe in operations of the great toe. Clinical Relevance: The medial plantar cutaneous nerve of the great toe is one of the terminal branches of the medial plantar nerve which itself is the anterior division of Posterior tibial nerve. This branch provides sensation to the dorsomedial aspect of the distal phalanx of the great toe.

Motor branches of the medial branch are given off proximal to the first metatarsophalangeal joint. A medial incision centred over the first metatarsophalangeal and creation of distally based capsular flap is employed in number of operations of the Hallux, e.g. Modified Silver’s McBride, Chevron Osteotomy, Replacement of the MTP Joint. The medial plantar cutaneous nerve is prone to injury if it is not identified and protected, leaving the patient with loss of sensation to the medial surface of the great toe. After dissection of the skin and superficial fascia over the medial side of the 1st MTP joint, a discrete layer of dense connective tissue is seen passing from the medial sesamoid to the medial plantar aspect of the first metatarsal. The closed blades of dissecting scissors can be inserted under this layer proximally to distally and the medial plantar cutaneous nerve can be seen to enter the canal at its proximal end. This fascial layer can then be opened and the underlying nerve thus identified and protected. Opening the tunnel proximally and identifying the nerve ensures nerve is not divided with plantar arm of distally based capsular flap. Identification and protection of this nerve prevents the complication of loss of sensation and the development of a painful neuroma, giving the patients a better outcome following surgery.

Trampoline was used by British & American fighter pilots as a training device during World War II. It became popular among Civilian as a recreational sports during 50s and 60s. Trampoline related injuries including quadriplegia and death have been reported from United States and Europe. We are reporting the incidence, type and distribution of trampoline-related injuries in children in a District General Hospital in United Kingdom.

Recently we treated three serious injuries – proximal tibial fracture associated with popliteal artery injury, subtrochanteric fracture of femur and cervical fracture-dislocation leading to quadriplegia, that lead to an audit study. This is a retrospective analysis of trampoline-related injuries in children seen in the Accident & Emergency Department over three months period. The casualty cards and admission records were reviewed.

The mechanism of injury was fall on or off the trampoline in 98.15%(53/54). All injuries occurred on back-garden or leisure-centre trampoline. 74% of injuries were sustained while unsupervised.

The incidence of soft tissue injuries were 59.25%(32/54) and fractures 40.75%(22/54). Soft tissue injuries commonly involved lower limb(16), upper limb(7) and head and neck(4). Fractures commonly involved upper limb(13), lower limb(8) and nasal bone(1). The fractures involved wrist and forearm in eight cases, ankle in five, elbow in four and one case each involving finger, hip, knee and toe. The treatment of trampoline-related injuries varied from reassurance, analgesia, tubigrip bandage to plaster cast. Fourteen(26%) patients were admitted into the wards and ten(18.5%) required surgical treatment.

The incidence of trampoline-related injuries in back-garden and leisure-centre when unsupervised was high. The supervision by an adult has not proved to be very effective in preventing the injuries as 26% of trampoline-related injuries occurred under supervision of an adult.

The morbidity related to leisure trampolining is high probably due to lack of training and non-compliance to the manufacturer instructions in the use of trampoline. We would recommend banning the routine use of back garden trampoline without proper training and supervision.

Introduction Surgeons request cross-match based on habit not evidence. The spinal unit requested 686 units of blood during 2002–2003 and transfused only 42 for elective lumbar spine surgery. This wastes money, time and blood.

Aim Optimise the transfusion requests in elective lumbar spinal surgery by creating evidence based guidelines.

Methods The data on elective operations performed on the lumbar spine during the period June 2002 to June 2003 was collected from the spinal unit database and cross-referenced with the records of blood transfusion. Cross-match: Transfusion ratios (C:T Ratio) and Transfusion Index (TI) for common procedures were calculated. Based on these results, a Maximum Surgical Blood Ordering Schedule (MSBOS) was created and prospectively audited for six months.

Conclusion Eighty units were cross-matched during the prospective audit. Therefore, in one year one hundred and sixty units would be requested. This represents a reduction of over five hundred units.

Introduction: Atlanto-axial rotatory fixation is a rare condition which occurs more. commonly in children than in adults. The terminology can be confusing and the condition is also known as. ‘ atlanto-axial rotatory sub-luxation’ and ‘atlanto-axial rotary dislocation’ . Rotatory fixation is the preferred term however , as in most cases the fixation occurs within the normal range of rotation of the joint and by definition therefore the joint is neither subluxed nor dislocated. Atlanto-axial rotatory fixation is a cause of acquired torticollis. Diagnosis can be difficult and is often delayed. The classification. system proposed by Fielding in 1977 is most frequently used and will be discussed in detail. Given that this classification system was devised in the days before CT, as well as the fact that combined atlanto-axial and atlanto-occipital rotatory subluxation is omitted from the classification, we propose a modification to the classification of this rare but significant disorder.

Methods and Results: The radiological findings in six cases of atlanto-axial rotatory fixation will be illustrated, including a case with associated atlanto-occipital sub-luxation. The pertinent literature will be reviewed and a more comprehensive classification system proposed. The imaging approach to diagnosis and the orthopaedic approach to management will be discussed.

Conclusion: In general, children who present with a traumatic torticollis should be treated conservatively with cervical collar and anti-inflammatory medication for one week. Those children whose torticollis fails to resolve after one week require aggressive investigation by ‘dynamic’ computed tomography to assess whether the joint is fixed. If however there is a history of significant trauma then immediate radiological assessment is advised. This approach will avoid over-investigation and over-treatment yet will still detect atlanto-axial rotatory fixation early enough to achieve a good outcome.