Purpose: Hand injuries rank as the second most common category in A& E medicolegal claims. Accurate diagnosis and treatment is essential, with a high index of suspicion and low threshold for exploration. The first clinical examination for tendon and nerve injuries is crucial for prioritisation in a busy unit and surgical/anaesthetic planning.

Method: St Andrew’s being a tertiary level hand unit in the United Kindgom, has a significant throughput of trauma (head to feet) with 10–15 cases daily. Most patients are reviewed in the daily consultant/senior trainee–lead trauma clinic, with entries recorded on a computerised trauma database. We analysed the pattern of tendon and nerve injuries and accuracy of pre-operative assessment compared to operative findings. The database for a 12-month period was reviewed. After exclusions, 1670 sequential cases of adults with below-elbow, soft tissue injuries and complete clinical/operative notes were included. There were 1573 structures potentially injured in 823 digits, including 994 named tendons and 568 nerves. Knife and glass injuries predominated and 89% were operated on within 24 hours of assessment.

Results: Anatomical accuracy was greater than 98% for both tendons and nerves. Border nerves (index radial and little finger ulnar) were particularly at risk. Assessment of severity (nil, partial or total) was accurate in 60 % overall – 58% for nerves and 62% for tendons. Highest error rates(excluding true negatives) were same in all the digits. Zonewise, high error rates were encountered in flexors and nerves at wrist, while for the extensors it was at E6. On analysis of tendons individually, high false positives were encountered with FDS and FDP among the flexors.

Conclusion: This findings support our practice of low threshold for exploration. Distribution and accuracy by structure and zone are discussed, with recommendations for diagnostically difficult regions. Knowledge of potential pitfalls may prevent inappropriate choices of anaesthetic and aids prioritisation.

Purpose: The aim of this nonrandomised retrospective study was to compare the results of anterior plating with superior plating in acute mid-shaft clavicular fractures.

Method: From 2000–2005, 49 fresh midshaft clavicular fractures in adults with shortening of > 20mm on the radiographs were treated with reconstruction plates. The placement of the plate on the clavicular surface was based on the preference of the surgeon operating. Patients were discharged within a day or two of the operation depending on pain control and were allowed to mobilise their shoulder within pain limits. They were followed up at six weeks and 12 weeks post operation and were allowed to return to work by 12 weeks if there was clinical and radiological signs of union. There were 22 patients in the anterior and 27 in the superior group. The mean age in the anterior was 36.3 years and 37.6 in the superior group. Majority(65%) of the fractures were sustained following RTA.77% were involved on the dominant side in both groups. The percent of patients in light and heavy manual work were similar in both groups. Follow up varied from six months to 24 months. Functional outcome was analysed by the physiotherapist with Biodex machine using Constant score and patient satisfaction questionnaire.

Results: There was no significant difference in Constant scores (Anterior=89, Superior=86), patient satisfaction with operation, return to activity and occupation in either groups. There was a total of six implant removals out of which five were in the superior group due to prominent metalware. There were two implant failures between six to 12 weeks post operation, both of which were in the superior group which were replated anteriorly. There was no significant difference in the deep/superficial infection in either groups. Return to work and satisfaction with operation were similar in both groups.

Conclusion: In our study, the incidence of hardware failure and hardware removal was significantly higher in the superior group compared to anterior group. Necessity for hardware removal becomes low as the anteriorly placed plate is less prominent. Also the risk of injuring the important neurovascular structures is less while drilling holes from anterior to posterior compared to superior to inferior direction. Hence we recommend anterior plating of the clavicle as a better method compared to superior plating of the clavicle.

The gamma interlocking nail, designed combining the advantages of the sliding hip screw with the intramedullary nail, was initially introduced for the management of unstable proximal femoral fractures. However the unacceptably high incidence of lateral femoral shaft fractures led to the development of the long gamma nail.

This is the result of a prospective study of the use of the long gamma nail in 35 patients over a 7 year period till March 2000. The mean age of the patients was 69.9 years. There were 13 men and 22 women. All but two of the fractures had a subtrochanteric component. Ten were pathological fractures.

An identical size of nail was used in all cases. Elderly patients were permitted to mobilise without restriction, whereas partial weight bearing was imposed on the younger patients till some signs of radiological healing. Patients were reviewed at a hip fracture clinic. Mean clinical follow up was 381 days and radiological follow up was 244 days. Mean hospital stay 22 days. The post operative mortality at 30 days was 20%, rising to 45% at one year.

General complications that occurred were pneumonia – 3, fat embolism – 1, myocardial infarction – 1, and GI bleed – 1. Four cases had superficial wound infection, which resolved with oral antibiotics. Fracture related complications occurred in 4 cases. These were intra-operative femoral shaft fracture – 1, fracture at tip of nail – 1, nail breakage – 2. All went on to heal after exchange nailing.

The long gamma nail does not appear to have reduce the post-operative incidence of femoral fractures, which is most likely related to the large size of the distal locking screws and stress concentration at the tip of the nail. The two cases of nail breakage appear to reflect metal fatigue failure in the setting of delayed union in younger patients.

This is a retrospective comparative review of the clinical results of arthroscopic meniscal repairs between the use of meniscal arrows and sutures. The study group consists of 37 repairs in 35 patients carried out by 2 special knee surgeons over a five-year period.

The arrow group consisted of 23 repairs in 21 patients. There were 14 males and 7 females. The medial meniscus was repaired in 13 and the lateral in 10 cases. Associated anterior cruciate ligament injured was present in 11 patients, of whom 9 underwent concomitant reconstruction along with the meniscal repair.

The suture group comprised 14 cases. Ten were male and 4 female. There were 8 medial meniscal repairs and 6 lateral.

The anterior cruciate was also torn in 8 cases, of whom 6 had it reconstructed. The repairs were carried out use #0-PDS by an out-to-in technique.

The 2 groups were grossly age and sex matched. Tears were located in zone 0/1, mainly in the posterior third segment of the meniscus. The rehabilitation protocol was similar in both groups. Minimum follow up was 9 months. Patients were evaluated by clinical review; questionnaire based on the Lysholm score and case record analysis. The overall clinical success rate for the arrows group was 13/23 (56.5%) compared to 11/14 (78.6%) for the suture group. Complications noted were broken arrows – 4 cases, cutaneous nerve entrapment by suture – 1, and delayed portal healing due to suture irritation – 1.

In conclusion, arthroscopic suture repair provided better clinical healing rates than meniscal arrows. Arrow breakage is a significant factor contributing to non-healing of initial tear repairs.