Rupture of the pectoralis major (PM) tendon is a rare yet severe injury. Several techniques have been described for PM fixation including a transosseus technique, when cortical buttons are placed at the superior, middle and inferior PM tendon insertion positions. The concern with this technique is the risk that bicortical drilling poses to the axillary nerve as it courses posteriorly to the humerus.

This cadaveric study investigates the proximity of the posterior branch of the axillary nerve to the drill positions for transosseus PM tendon repair. Drills were placed through the humerus at the superior, middle and inferior insertions of the PM tendon and the distance between these positions and the axillary nerve, which had previously been marked, was measured using computed tomography (CT) imaging.

This investigation demonstrates that the superior border of PM tendon insertion is the fixation position that poses the highest risk of damage to the axillary nerve.

Caution should be used when performing bicortical drilling during cortical button PM tendon repair, especially when drilling at the superior border of the PM insertion. We describe ‘safe’ and ‘danger’ zones for transosseus drilling of the humerus reflecting the risk posed to the axillary nerve.

Objective: This is a prospective, randomised, double blind trial to assess the effectiveness of intrathecal fentanyl in the relief of post-operative pain in patients undergoing lumbar spine surgery.

Method: 60 patients were recruited. All received our standard analgesic regime with morphine PCA via a syringe driver. They were electronically randomised to two groups – one received 15 micrograms of fentanyl intathecally; the other had nothing. The fentanyl was administered by the operating surgeon under direct vision at the end of the procedure.

All patients were monitored in recovery for two hours. Visual Analogue Scale (VAS) pain scores were assessed at 2, 4, 24 and 48 hours post-op. The time to first bolus delivery of PCA was recorded as was the total amount of morphine PCA used. Both patient and assessor were blinded.

Results: The patients randomised to receive fentanyl showed a significant decrease in their mean VAS pain scores for the first 24 hours. Their time to first bolus of PCA was significantly increased. They also used 40% less morphine PCA (p< 0.05 in all cases). None of the patients suffered respiratory compromise requiring treatment and they all left recovery after 2 hours to be nursed on the general ward.

Conclusion: Intrathecal fentanyl is effective at reducing post-operative pain and PCA morphine use after lumbar spinal surgery. We support its use over morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on a general ward.

Objective To assess the effectiveness of intrathecal fentanyl in the relief of post operative pain in patients undergoing lumbar decompression or fusion.

Method 60 patients undergoing lumbar spinal surgery were prospectively recruited. All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomised to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon (GM) under direct vision one or two levels above the site of the operation at the end of the procedure. VAS pain scores were taken at 2, 4, 24 and 48 hours post operatively independently. The total dose of morphine required was recorded.

Results The patients randomised to receive fentanyl showed a decrease in their mean VAS scores as well as a 40% reduction in the total morphine dose delivered. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment. All patients left recovery after 2 hours to be nursed on an open ward.

Conclusion Intrathecal fentanyl is effective at reducing mean pain VAS scores and morphine use via a PCA after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on the open ward.

Malignant change in existing benign enchondroma of phalanx of hand to chondrosarcoma of hand is extremely rare. Books suggest that chondrosarcoma does not arise in small bones of hands and feet although in literature few cases have been reported but not described comprehensively.

We report a rare case of chondrosarcoma in distal phalanx of ring finger in a 75- year old healthy female who had cystic lesion for past 25 years with recurrent fractures. Patient came to us with severe pain and tender, hard swelling of distal phalanx of left ring finger. X ray showed pronounced expansion of the terminal phalanx surrounded partially by a shell of bone, with focal spotty calcification with in the lesion. Because of sudden increase in size and pain of swelling, an amputation was performed at distal inter phalangeal joint. Histopathology showed grade II myxoid chondrosarcoma with pre-existing enchondroma. Wound healed nicely. Extensive investigation in form of CT chest and bone scan did not show any metastasis. Five year follow up did not show any local recurrence or distant metastasis.

Clinical suspicion should be aroused in an older individual with a previously relatively quiescent lesion that becomes larger and painful. Usually course of the tumour is slow and metastasis to lungs is late. Treatment of choice is disarticulation a joint proximal to lesion. Prognosis is good if metastasis has not occurred. Once diagnosis is made, patient should be investigated to look for any possible metastasis and must be regularly followed up. A literature review and discussion of salient diagnostic and treatment issues is included.

In 1996 the quality of the early management of 100 consecutive patients referred to a regional pelvic and acetabular unit between 1989 and 1992 was studied. The management of these patients was assessed in four specific areas, and guidelines were laid down. It was found that in 56% of patients the early management did not meet these suggested standards, with 34% having deficiencies in more than one area. These results were presented, published and circulated to referring hospitals.

Five years later, the early management of a further 100 consecutive referrals was assessed using these same guidelines. The treatment of 57% of patients still did not reach the guideline standards, but the number with problems in more than one area fell to 20%.

There has been some improvement in the early management of pelvic and acetabular injuries. The use of external fixators to control severe haemorrhage increased, but frames were often poorly applied. Wider access to CT scanners has reduced delays in definitive imaging.

Associated injuries are still regularly overlooked, and occasionally treatment of ipsilateral hip or femur fractures compromises pelvic surgery. Early communication with the specialist centre is encouraged but unfortunately delays in referral are still common.