We present our experience of managing patients with iatropathic brachial plexus injury after delayed fixation of a fracture of the clavicle. It is a retrospective cohort study of patients treated at our peripheral nerve injury unit and a single illustrative case report. We identified 21 patients in whom a brachial plexus injury occurred as a direct consequence of fixation of a fracture of the clavicle between September 2000 and September 2011. The predominant injury involved the C5/C6 nerves, upper trunk, lateral cord and the suprascapular nerve. In all patients, the injured nerve was found to be tethered to the under surface of the clavicle by scar tissue at the site of the fracture and was usually associated with pathognomonic neuropathic pain and paralysis. Delayed fixation of a fracture of the clavicle, especially between two and four weeks after injury, can result in iatropathic brachial plexus injury. The risk can be reduced by thorough release of the tissues from the inferior surface of the clavicle before mobilisation of the fracture fragments. If features of nerve damage appear post-operatively urgent specialist referral is recommended. Cite this article: Bone Joint J 2013;95-B:106–10

Nerve damage is a complication of THA and TKA procedures. The incidence of subclinical nerve injury following arthroplasty is unknown. The aim was to determine the prevalence of asymptomatic nerve deficits in an arthroplasty population group, and the incidence of post-operative changes in nerve function. A Secondary aim was to identify the nature of any deficits. And the association between nerve deficits and history of backache. A non-randomised prospective series of patients undergoing lower limb arthroplasty for osteoarthritis were studied at a single hospital. The peroneal nerve was investigated using nerve conduction in forty patients. Twenty patients had upper limb testing to differentiate between a polyneuropathy or isolated lower limb neuropathy. Nerve function deficits were detected in the peroneal nerve in fifteen patients pre-operatively and fifteen post-operatively, of those twelve had A waves detected suggestive of a generalised neuropathy. Ten patients who had upper limb testing had a conduction defect (five had asymptomatic Carpal tunnel). There was a positive correlation between presence of post-operative deficit and age(r=0.389, p=0.013). A negative correlation was found for presence of post-operative A waves and BMI(r=−0.370, p=0.019). The prevalence of pre-operative subclinical peroneal neuropathy is much higher than expected in this group (37.5%) of arthroplasty patients. There is a strong correlation between presence of post-operative conduction abnormalities and age. There is no relationship between peripheral neuropathy and history of backache or residual post-operative deficit

This is a retrospective study of 612 cases of iatropathic injury to peripheral nerves seen in one tertiary referral unit between 1991 and 1998. A total of 291 patients was subsequently operated on to explore the nerve lesion. The most common presenting symptom was pain, which often masked underlying loss of function. The delay in diagnosis was up to 40 months. The findings at operation were analysed according to the type of nerve damaged, the nature of the injury and the referring specialty. Some of the more common causal operations and procedures are discussed. Preventive measures are listed, and early diagnosis and treatment are recommended

Introduction. The anterior mini-invasive approach to performing total hip arthroplasty (THA) is associated with less soft tissue damage and a shorter postoperative recovery than other methods. In August 2008, our hospital abandoned the traditional lateral Hardinge approach in favor of this new method. The purpose of this study was to measure changes in short-term clinical and radiological results and complications after the changeover. Methods. We compared the first 100 patients operated after the changeover to the new method (MI group) to the last 100 patients operated using the traditional method (LH group). Clinical and radiological parameters and complications were recorded pre- and postoperatively and the collected data of the two groups were statistically analyzed and compared. Results. There were no statistically significant differences between either group with regard to patient demographics or procedural data, placement of the femur component, postoperative leg discrepancy, prosthesis dislocation, blood transfusion, or postoperative dislocation of the components. The MI group had a significantly shorter hospital stay (p<0.001) and significantly fewer infections (p = 0.007) of the operative site. The LH group had a significantly shorter operative time (p<0.001), less bleeding (p = 0.035), less nerve damage (p = 0.013), and radiologically better positioning of the acetabular component regarding anteversion (p<0.001). Furthermore, a few other recorded surgical complications were more frequent in the MI group, but the difference was not statistically significant. Interpretation. Our results show that the anterior approach correlates with faster postoperative recovery and less soft tissue damage with respect to the lateral approach. Since the changeover, we observed an increase in the overall complications, but in this study this increase was not found to be statistically significant. These complications were not only found in the initial patients operated with the mini-invasive approach, but were homogeneously spread over all 100 patients. Additionally, and perhaps most worrying was the clinically significant increase in intraoperative femur fractures in the MI group. The changeover to the anterior mini-invasive approach, which was the surgeons' initial experience with the MI technique, resulted in a drastic increase in the number of overall complications. A future randomized, prospective study including functional scores and a large body of patients will be imperative to show whether the two different approaches really are equivalent

Aims

The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications.

This study aimed to evaluate the use of pin leverage in the reduction of Gartland type III supracondylar fractures of the humerus in children. The study comprised 95 children, who were split into three groups according to the type of method of reduction used. Group 1, had an open reduction, group 2, had closed reduction and percutaneous pin fixation and group 3, the pin leverage technique. Each group was analysed according to the time to surgery, the duration of the procedure, the incidence of complications, and the clinical and radiological outcome.

The mean duration of the operative procedure in groups 1, 2 and 3 was 119 minutes (80 to 235), 57 minutes (20 to 110) and 68 minutes (30 to 90), respectively. At a mean follow-up of 30 months (12 to 63) the clinical results were declared excellent or good in all children and the radiological results intermediate in five patients in group 2. The results of the closed reduction using the pin leverage technique was classified as failure in two children.

Our findings lead us to believe that the pin leverage method of reduction gives good results in the treatment of Gartland type III fractures.

The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p < 0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent.

Intramedullary tibial nailing was performed in ten paired cadavers and the insertion of a medial-to-lateral proximal oblique locking screw was simulated in each specimen. Anatomical dissection was undertaken to determine the relationship of the common peroneal nerve to the cross-screw.

The common peroneal nerve was contacted directly in four tibiae and the cross-screw was a mean of 2.6 mm (1.0 to 10.7) away from the nerve in the remaining 16. Iatrogenic injury to the common peroneal nerve by medial-to-lateral proximal oblique locking screws is therefore a significant risk during tibial nailing.