The trampoline is a popular source of recreational and competitive sport. However, little is documented about the dangers associated with its use particularly in the paediatric population. We reviewed paediatric patients referred to our service from April to September 2005 inclusively, having been injured on a trampoline. This unit services a catchment area of approximately 400,000 patients. Eighty-eight patients were assessed (mean age: 8 years 6 months). There were 33 males and 55 females. Most injuries (53/88) occurred while bouncing on the trampoline, while 34 were secondary to falls off the trampoline. The injured child was supervised in only 40% cases. In 31 cases, the injury was attributable to the presence of others on the trampoline. Thirty-six children required surgery. Fracturesof the upper extremities occurred in 70% of cases. Injuries related to the recreational use of trampolines are an important and significant cause of paediatric injury. These results strongly suggest that there is a clear need for guidelines.
Fractures of the proximal humerus account for 4–5% of all fractures with 80% requiring no surgical treatment. However, the management of the other 20% remains controversial. Multiple surgical modalities have been examined with no consensus as to which if any is the most effective. This study followed a series of 27 patients who had PHILOS plate fixation of their proximal humeral fractures. All patients were followed up clinically and radiologically for at least one year to a mean of 27.6+/−7.8 months. We reviewed 27 patients with a mean age of 62.2 years (16 patients were aged at least 60 years). The patients were classified as per the AO system into type A (n=11), type B (n=12) and type C (n=3) fractures. The mean DASH score was 51.8. The mean SF-36 scores for physical and social functions were 68.7 and 88.0 respectively. The mean Constant score was 50.5%. These results how that the PHILOS plate offers good functional outcomes across a spectrum of fracture severities and in an older population group. Its use should be considered where appropriate in the management of displaced proximal humeral fractures.
In patients with DM (Diabetes Mellitus types I &
II), primary frozen shoulders tend to be refractory to all forms of treatment. We collected tissue from the joint capsule of shoulder joints from a variety of patients undergoing surgery as follows:
Diabetic Group (DFS): patients with DM who have primary frozen shoulders. Other patients suffering from primary frozen shoulders (FS) Control group (NS). Patients undergoing shoulder surgery that does not involve stiffness of the gleno-humeral joint. Tissue was collected from near to the rotator interval under arthroscopic control. Fibroblast lines were established by serial passage. Thereafter they were exposed to graded concentrations of insulin in vitro for 24 hours and the supernatant retained for assay. Fibroblast lines were analysed from 3 subjects in each group (n=9). Luminex multiplex analysis was performed for MMPs (Matrix Metalloproteinases). TIMP-1 (Tissue Inhibitor of MetalloProteinases) expression. Informed consent was obtained from all subjects.
This is the first time these enzymes have been measured and quantified in cells derived from shoulder tissues. Primary Frozen Shoulders produce less MMPs and have a smaller MMP/TIMP ratio than controls. Similarly the diabetic patient derived cells produce less MMP-1, at an even lower level. These deficiencies in MMP1 production may reflect an altered capacity for local tissue re-modelling. MMP modulation may allow therapeutic intervention in the diabetic and frozen shoulder group of patients.
The purpose of this study was to evaluate the effect on movement under load of different techniques of reat-tachment of the humeral tuberosities following 4-part proximal humeral fracture. Biomechanical test sawbones were used. 4-part fracture was simulated and a cemented Neer3 prosthesis inserted. Three different techniques of reattachment of the tuberosities were used – 1)tuberosities attached to the shaft, and to each other through the lateral fins in the prosthesis with one cerclage suture through the anterior hole in the prosthesis, 2)as 1 without cerclage suture, and 3)tuberosities attached to the prosthesis and to the shaft. All methods used a number 5 ethibond suture. Both tuberosities and the shaft had multiple markers attached. Two Digital cameras formed an orthogonal photogrammetric system allowing all segments to be tracked in a 3-D axis system. Humeri were incrementally loaded in abduction using an Instron machine, to a minimum 1200N, and sequential photographs taken. Photographic data was analysed to give 3-D linear and angular motions of all segments with respect to the anatomically relevant humeral axis, allowing intertuberosity and tuberosity-shaft displacement to be measured. Techniques 1 and 2 were the most stable constructs with technique 3 allowing greater separation of fragments and angular movement. True intertuberosity separation at the midpoint of the tuberosities was significantly greater using technique 3 (p<
0.05). The cerclage suture used in technique 2 added no further stability to the fixation. In conclusion, our model suggests that the most effective and simplest technique of reattachment involves suturing the tuberosities to each other as well as to the shaft of the humerus. The cerclage suture appears to add little to the fixation in abduction, although the literature would suggest it may have a role in resisting rotatory movements.
MRSA wound infection following Total joint arthroplasty is catastrophic with disastrous consequences. Our aim was to determine the prevalence and risk factors for MRSA colonization in patients presenting for orthopaedic surgery in our unit. All patients admitted to the hospital for elective arthroplasty over a four year period were included in the study. At the time of admission, a detailed questionnaire was completed by each patient. Routine nasal, throat, axilla, perineum swabs and from any pre-existing wound sites were sent for culture. Among 2900 patients studied, 42 patients (1.4%) were positive for MRSA on admission. The prevalence of MRSA colonization in patients who were admitted directly from Nursing homes or from own home was 36.7% and 1.3% respectively. All MRSA positive patients who were admitted directly from home had at least one documented hospital admission in the preceding year and/or antibiotic administration within three months prior to admission. The risk factors identified for MRSA colonization were in risk order : Nursing home residency(p<
0.05), previous hospital admission(p<
0.05), antibiotic administration in previous three months(p<
0.05), and female gender(p<
0.01 )Statistical analysis with Chi squared test for independence p<
0.05 considered significant. Present MRSA screening focuses on all patients being admitted for surgery, this contrasts to North American policies of screening only patients with risk factors. We would question the validity and economical reasoning of general rather than targeted screening procedures.
Minor trauma e.g. minor fall No neurological deficit Exclusion criteria Patients over 65years who were involved in major trauma. Non-Irish residents.
On examination two patients had a clinically evident kyphosis. The mean range of anterior flexion was 78.9° + 15°. The mean VAS pain score was 2.2 + 2.0. No significant correlation existed between the magnitude of the initial vertebral collapse and the Oswestry or SF36 scores. No significant further vertebral collapse was noted on radiographic follow up. A small cohort of patients did develop chronic back pain. These patients’ outcome could not be predicted on the basis of initial radiographs.
Existing classifications of fractures of the head of the humerus are inadequate in terms of interobserver reliability and the predictability of the clinical outcome. From a combined study of 73 fracture specimens in museums and 84 CT-three-dimensional reconstructions in patients, we have devised a classification which appears to be more useful clinically. Common patterns of fracture and a plausible mechanism of injury were observed. In 3-D most proximal humeral fractures can be organised into five basic types. These correspond in some degree to the Codman/Neer classification, but differ significantly in regard to the more complex patterns of fracture. We observed a logical progression from simple to complex fractures. An interobserver reliability study was carried out which indicated the improved usefulness of this new 3-D concept in providing a common language among clinicians for classifying these injuries. When surgery is indicated, the 3-D concept is also invaluable in guiding the restitution of anatomy through either open or percutaneous means.
Only one patient (2.5%) from Group 1 was cancelled pre-operatively; this for treatment of a chronic comorbidity. Five patients (10%) in Group 2 were cancelled on admission for surgery. Four of these patients were cancelled for acute illness that had developed following in-patient assessment, with one being discharged for treatment of a chronic illness.
Sciatic Nerve Palsy (SNP) is a recognised complication in Primary Total Hip Replacement after a transtrochanteric or a posterior approach (5). It is considered to be caused by direct trauma to the nerve during surgery. In our unit this complication was rare with an incidence of <
0.2% over the past ten years. However we know describe six cases of sciatic nerve palsy occurring in 355 consecutive primary THRs (incidence 1.60%) performed in our unit from June 2000 to June 2001. Each of these sciatic nerve palsies we believe was due to postoperative haematoma in the region of the sciatic nerve. To our knowledge there are only five reported cases in the literature of sciatic nerve palsy secondary to postoperative haematoma (1). (Each of the six patients who developed SNP was receiving prophylactic anticoagulation). Cases recognized early and drained promptly showed earlier and more complete recovery. Those in whom diagnosis was delayed and were therefore managed expectantly showed no or poor recovery. More than usual pain the buttock, significant swelling in the buttock region and sciatic nerve tenderness associated with signs of sciatic nerve irritation may suggest the presence of haematoma in the region of the sciatic nerve. It is therefore of prime importance to be vigilant for the signs and symptoms of sciatic nerve palsy in the early post operative period because if recognized and treated early the potential injury to the sciatic nerve may be reversible.
Patients were matched for age, gender, pathology, weight, implant type, pre operative haemoglobin and senior operator in all three groups. We assessed intra-operative and total blood loss, transfusions requirements, postoperative wound complication, regaining of the range of motion, incidence of systemic effects of tourniquet and duration of hospital stay. We also looked at the effects of NSAIDS on blood loss and compared the validity of various factors reported in the literature to be predictive of future transfusion after the surgery. Statistical analysis used were, student’s t-test, univariate and multivariate analysis and regression statistical analysis.
Complex fracture patterns of the proximal humerus can be difficult to understand and to treat. Classification systems are inadequate and the exact mechanisms of injury are obscure. From inspection of 73 cases of proximal humeral fractures culled from a large number of museum specimens, we propose a hypothesis as to the nature and configuration of these injuries. It is suggested that the glenoid is the “anvil” upon which the humeral head is broken and that the particular fracture personality reflects the position of the head vis a vis the glenoid at the time of injury. From this perspective, proximal humeral fractures present in a comprehensible and progressive sequence. Five different fractures patterns are identified and account for the vast majority of these injuries. X-ray examination, especially CT 3-D reconstructions, in a small group of clinical cases (30 patients) substantiated the usefulness of looking at these fractures in this way. From a combination of the museum studies and patient material, we have constructed a “fracture wheel” diagram for the presentation of these injuries in a format which may be helpful in organizing a new and clinically useful classification system.
This study was carried out to investigate the outcome of rotator cuff repair surgery in 14 centres in th UK in a randomised controlled trial. It also looked at a comparison of a long-acting absorbable suture (Panacyrl) and a non-absorbabable suture (Ethibond). All patients were treated with open repair of their rotator cuff tear with modified Mason-Allen sutures used in 83% of cases. One hundred and fifty-nine patients were included in the analysis. patients had Constant scores carried out pre-operatively, six and 12 months as well as ultrasound real time dynamic scans at eight weeks, six and 12 months. Constant pain scores, total constant scores and re-tear rates were measured. There was a significant improvement in the Constant score after rotator cuff repair surgery. However for large tears, the re-tear rate at six months is approximately 50%. Despite this high retear rate there was still a good benefit from surgery. Is the improvement in those cases with a re-tear a consequence of the sub-acromial decompression (SAD) and what would have been the outcome with an ASD alone?
We assessed patellofemoral joint function by combining the measurement of maximal isometric extensor torque at the knee with clinical and radiological measurements in order to calculate the patellofemoral contact force. Eighteen volunteers established the normal ranges of results and the reliability of the system. Of the 39 patients with a variety of knee problems, 29 had anterior knee pain, and all had a subsequent arthroscopy. Patients with anterior knee pain and lesions in the patellar cartilage had significantly reduced isometric contact forces, but those with normal patellofemoral cartilage had normal contact forces. Our method may be useful in providing an objective assessment of anterior knee pain and a quantitative means of monitoring its treatment.
It is difficult to establish the diagnosis of an injured shoulder if only one radiographic projection is used. We have compared two lateral projections, the Neer trans-scapular and the apical oblique in 80 patients; the radiographs were presented randomly to 10 casualty officers and nine radiologists. The apical oblique view was found to permit more accurate diagnosis of fractures and of dislocation by both groups.
Forty-two shoulders in 37 patients with polyarthritis were treated with Neer total shoulder replacements and reviewed 12 to 66 months afterwards. There was good pain relief and improvement in function, but the range of movement was less than that seen after replacements for osteoarthritis; this may have been related to the fact that 34 shoulders had abnormal rotator cuff tendons. Although there was a high incidence of radiolucent lines around the glenoid component, there was no clinical evidence of loosening. There were a few complications, but on the whole we feel that the Neer total shoulder arthroplasty is a valuable procedure for a patient with polyarthritis.
A comparison was made in a laminar-flow operating room between total-body exhaust gowns and a clothing system made from Fabric 450. This disposable clothing was found to be much more comfortable and convenient than the total-body exhaust gowns. The average airborne bacterial counts obtained during total hip replacement operations from each of the clothing systems were identical when the downflow method of ventilation was used (0.7 per cubic metre) and no significant difference could be demonstrated when the crossflow system was used (2.2 per cubic metre with the total-body exhaust gowns and 3.1 per cubic metre with the disposable clothing). Tests in a dispersal chamber were carried out to find the effectiveness of each item of the disposable clothing in reducing bacterial dispersion. These tests demonstrated the relative ineffectiveness of wearing a surgical gown as compared with wearing the complete system. It was confirmed bacteriologically that the downflow system of ventilation was more efficient than the crossflow type; the importance of this observation with respect to clothing and sepsis is discussed in this paper.