Prenatal androgen exposure has important organising effects on brain development and influences future behavioural patterns. Second to fourth digit ratio (2D:4D) is a marker for prenatal androgen exposure and as such is a sexually dimorphic trait. Smaller, more masculine second digit (index finger) to fourth digit (ring finger) ratio’s are associated with higher exposure to prenatal testosterone levels or greater sensitivity to androgens, or both. People with smaller finger ratios, a longer fourth finger than second finger, have been shown to be more successful in competitive sports, exhibit increased visuo-spatial ability, more fertile and are perceived as being more masculine and dominant by female observers. Smaller ratios have also been associated with an increased propensity to engage in aggressive behaviour. We examined the relationship between Boxer’s fractures, a traditional injury of aggression and finger length ratio.

We reviewed 1123 patient records and/or hand x rays over a seven month time frame showing 123 fifth metacarpal (Boxer’s) fractures. We then measured, using recorded radiological data, the distance in millimetres from the base of the proximal phalanx to the tip of the distal phalanx for the second, third and fourth fingers. We also recorded sex, side of injury, site of injury and mode of injury.

One hundred and twenty three Boxer’s fractures were found over a seven month time period, 110 male and 13 female; 67.27% were right sided. The average age was 27.6 yrs ±14.2. The average finger length ratio (proximal phalanx to distal phalanx) for males was 0.9 and for females was 0.94. Both ratios were smaller than the published normal digit ratio for the general population.

Smaller second digit to fourth digit ratios are positively associated with persons presenting with fifth metacarpal fractures, thereby indicating increased aggressive tendancies independently of gender

Introduction: Ischaemia-reperfusion-injury (IRI) is one of the most common metabolic insults in orthopaedic practice. It is often a mild insult after brief tourniquet use with minimal clinical implications; but much more severe insults may result from excessive tourniquet-times, vascular trauma or release of compartment-syndrome. It is mediated largely by oxidatively-induced endothe-lial disruption and leukocyte infiltration. Antioxidants attenuate or prevent this effect in animal models.

Hypothesis: That IRI can be attenuated using established antioxidant medications (ascorbate and n-acetyl-cysteine) in the controlled setting of elective knee arthroscopy.

Methods: A EudraCT registered, prospective, randomized-controlled trial was performed. Patients (n=24) undergoing elective knee arthroscopy were randomized to one of 3 groups (IV NAC/oral ascorbate/placebo). Full blood counts, a broad array of cytokines and adhesion molecules, physiological response, pain scores and analgesia were recorded pre-operatively and at 3 postoperative time-points (10mins, 2hours, 4hours).

Results: Physiological response, analgesia and VAS did not differ. Systemic leukocytes and neutrophils were increased (p=0.001) indicating a measurable reperfusion injury. Ascorbate tended to inhibit ICAM-1 (p=0.10) and IFN-gamma (p=0.080). NAC inhibited VCAM-1 (p=0.003) and tended to inhibit ICAM-1 (p=0.094). Selectins responded in a similar pattern but not significantly. NAC tended to increase circulating leukocytes (0.093), neutrophils (0.12) and monocytes (0.04) and also induced a transient early increase in IFN-gamma (p=0.022).

Conclusions: Elevated circulating leukocytes indicate reduced leukocyte trapping and infiltration due to reduced adhesion molecule expression. NAC attenuates IRI resulting from tourniquet use in knee arthroscopy. The study was underpowered to confirm the efficacy of ascorbate in this setting. Further studies are necessary on the effects of these substances in more extreme ischaemic insults in which they may confer significant local and systemic benefits for the patient. Ascorbate and NAC act at different points in the inflammatory cascade and their potential synergistic effects warrant investigation.

Introduction: The high prevalence and associated morbidity of the hallux valgus deformity has lead to a myriad treatment options being developed. These range from conservative to operative interventions, including many different forms of osteotomy. The various interventions have met with mixed success, with some operative options suffering a high level of recurrence or patient dissatisfaction. Both outcomes have been shown to correlate to inadequate correction of one or other component of the deformity. High recurrence rates result most frequently from the failure to correct for both the intermetatarsal (IMA) and the distal metatarsal-articular (DMAA) angles, instead focusing on the IMA alone. In most techniques, the use of a two-dimensional osteotomy with a concentric axis of rotation allows only for the correction of one of the involved angles, therefore is not appropriate for the correction of this geometrically complex condition. This most often results in failure to adequately correct the DMAA. The scarf osteotomy is a triplanar osteotomy with the potential to correct both the DMAA and IMA in the same procedure, thereby performing a more anatomical correction.

Hypothesis: Even in experienced hands the accuracy of the correction can be improved, and the limitations of attainable correction identified, with simple calculations based on pre-operative radiographs.

Methods: We generated a formula to calculate the appropriate proximal and distal translations required for a given length of osteotomy to accurately correct the deformities. Two groups, of 20 patients each, were included in the study. One group prior to introduction of the formula and a second group after the introduction of the formula. Pre and post-operative weight bearing radiographs were assessed by blinded observers pre and post-operatively to determine the accuracy of the formula. Groups were compared using the independent samples T-test.

Results: There were no differences between the pre-operative IM and DMA angles between the groups. Post operative DMAA was improved by 6.1 degrees when using the formula (p=0.02). The frequency of post-operative IMA correction to within normal limits improved from 75% to 100% and the average IMA correction was improved by 2.5 degrees (p=0.003). Post operative IM and DMA angles correlated well with the calculated results from the formula. This formula has altered procedure selection in our institution for certain patients with combined large DMA and IM angles due to the easy pre-operative identification of the limits of correction.

Discussion and Conclusion: The formula allows more precise, reproducible correction of both the IMA and DMAA. The formula also clarifies the limits of the scarf osteotomy and therefore improves appropriate patient selection.

Background: MRSA is a major economic and health issue in Ireland and as such is of particular importance in the appropriate management of orthopaedic patients. Bone, joint and implant infection can lead to unfavourable outcomes with a long protracted in hospital stay inevitable. The cost for the patient, the hospital and society are substantial. Numerous protocols have been proposed internationally to aid in the management of MRSA infection in orthopaedic patients with pre assessment and ring fencing of patients shown to have a favourable impact.

Aims: To analyse the impact of a series of infection control measures on the infection and prevalance of MRSA in both elective and trauma orthopaedic patients.

Methods: We conducted a prospective study of our unit over three time points from 2005 to 2008. All elective and trauma orthopaedic surgery was based in Merlin Park Hospital up until December 2006. Since then all elective orthopaedic surgery has remained based in Merlin Park Hospital with all trauma surgery being moved to University Hospital Galway and all trauma patients based in an exclusively ring fenced orthopaedic ward. We recorded total rates of MRSA infection and colonisation in all orthopaedic patients over nine months of each year from 2005 to 2008, pre and post separation of trauma and elective services. Of note a pre admission screening protocol was implemented in March of 2006. We also prospectively recorded all MRSA data in patients treated through our ring fenced trauma ward from its opening date in November 2006.

Results: 12259 patients were reviewed between 2005 and 2008. The mean age of all admitted patients was 46 with th emean age of all MRSA positiv epatients being 71(p=0.000). There was no statistical difference for gender distribution between MRSA positive patients, but more women were positive than men.

The rates of MRSA infection for 2005, 2006 and 2007 were 0.49%, 0.28% and 0.24% respectively (binomial comparison, 2005 to 2006, p< 0.005 and 2005 to 2007, p< 0.005). Again when trauma and elective units were seperated there was a corrected rate of infection of 0.14% and 0.33% respectively. In 2005 there was 9 Superficial Incisional (SI), 8 Organ Space Infection(OSI) and 4 Deep Incisional (DI), 2006 had 7 SI, 4 OS and 4 DI and in 2007 there was 9 SI, 9 OS and 1 DI seen in the elective unit There was no Deep MRSA infection seen in the new ring fenced trauma unit. MRSA infection was found to cause a considerable increase in length of stay with normal orthopaedic patients staying a mean of 5 days whilst MRSA patients staying 23.4 days (p=0.000).

Conclusion: The separation of emergency and elective orthopaedic services coupled with effective preoperative screening has resulted in a reduction of MRSA infection and improved patient outcome.

Objectives: Ischaemia reperfusion injury (IRI) is one of the most common metabolic insults in orthopaedic clinical practice. Oral ascorbate and both oral and intravenous n-acetylcysteine (NAC) have shown definitive beneficial effects in animal skeletal muscle IRI models. The authors hypothesized that a similar protective effect could be demonstrated in a well designed clinical trial.

Materials and Methods: A EudraCT registered, prospective, randomized, controlled, double blind trial was performed to assess the hypothesis. Ethical approval was obtained from the competent authority. Patients (n=18) undergoing elective knee arthroscopy were randomised to one of 3 groups. The NAC group received IV NAC and preoperative oral placebo. The ascorbate group received oral ascorbate and IV placebo. The placebo group received both oral and IV placebo. Anaesthetic protocols were standardized across all groups. Phlebotomy was performed preoperatively and at 3 post-operative time points. IL-1, 2, 6 and 10, ICAM, VCAM, Selectins, TNF-alpha and malondialdehyde (MDA) were measured in systemic and local blood samples. Physiological parameters were recorded in the peri-operative period. Post-operative analgesic requirements and visual analogue scores were recorded. Leg oedema was measured using volumetric analysis and figure-of-eight tape measurement.

Results: There were no differences between the groups pre-operatively. In the post-operative period the analgesic requirements were lower in the NAC group compared to ascorbate and placebo groups. CRP and d-dimers were found to peak in the early post operative period. White cell counts decreased in all groups in the early post-operative period, with a lesser reduction in the NAC and ascorbate groups. Elevation of MDA was noted in all groups but was significantly less in the NAC group. There was a trend towards increasing IL-6 and IL-8. There was a trend towards decreasing TNF-alpha and IL-1.

Conclusions: Ascorbate and NAC appear to attenuate the inflammatory response to IRI in a clinical model. These cheap, readily available medications which are acceptable to patients and doctors alike appear offer a potential benefit to patients. Further studies are required to clarify the extent of the benefit and to examine the role of these medications in trauma and in the setting of more extensive ischaemic insults.

Background: We compared five classification systems for clavicle fractures. The aim of the study was to evaluate the prognostic value of each system.

Methods: Over a twelve month period we reviewed all new radiographs of the shoulder region and identified 227 clavicle fractures. Each radiograph was classified using five classification systems. We reviewed all subsequent x-rays and clinical records until patient discharge. We assessed each classification system’s prognostic value in predicting delayed/non-union.

Results: Our data shows that 80% of clavicle fractures occur in the middle third, 18% lateral third and 2% medial third. The overall prevalence of delayed/ non-union was 7.7%, with 3.9% requiring operative management and 3.8% developing asymptomatic non-union. The prevalence of non-union in the lateral third was 15%, all were asymptomatic. Craig’s classification had the greatest prognostic value for lateral third fractures, Robinson’s classification had the greatest prognostic value for middle third fractures.

Conclusions: Clavicle fractures are common injuries but non-union is an uncommon occurrence. Non-union is more common in the lateral third but we found these to be asymptomatic. Middle third fractures should be classified according to Robinson’s classification system and lateral third fractures according to Craig’s classification. We did not assess sufficient medial third fractures for the data to be significant.

Background: The aim of operative treatment for ankle fractures is to allow early movement after internal fixation. The hypothesis of this study was that early mobilisation facilitated by a removable cast after internal fixation of ankle fractures would improve functional recovery of patients compared with that after conventional immobilisation in a cast.

Material and Methods: Sixty two patients between the age of seventeen and sixty five with ankle fractures that required operative treatment were randomly allocated to two groups : immobilisation in a non weight bearing below knee cast for six weeks or early movement in a removable cast ( at two weeks after removal of sutures ) for the following four weeks. The follow up examinations which consisted of subjective (clinical, Olerud-Molander score, AOFAS score, SF 36 ) and objective ( swelling measurement, x-ray ) evaluations were performed at two, six, nine, twelve and twenty four weeks postoperatively. Time of return to work was recorded.

Results: There were no postoperative complications in the group treated with immobilisation in cast. There was one superficial wound infection treated with oral antibiotics in a patient with a previous dermatological condition around the fractured ankle in the group treated with early movement in a removable cast. Patients in group two ( early movement ) had higher functional scores at nine and twelve weeks follow up but not of statistical significance. They also return to work earlier ( 55.5 days ) compared with the ones treated in cast ( 98.7 days ). Patients treated in removable cast had higher mean SF-36 scores, but this difference was significant only for two of the eight aspects investigated.

Conclusions: Early movement with the use of removable cast after removal of sutures in operated ankle fractures decrease swelling, prevent calf muscle wasting, improve functional outcome and facilitate early return to work of patients. Our findings support the use of a removable cast and early exercises in selected, compliant patients after surgery of the ankle.