Purpose. Displaced midshaft clavicular fractures are a common injury with a high occurrence rate in young, active individuals. Non-operative care has traditionally been the standard of care for such fractures, but more recent studies have suggested benefits following primary operative fixation. The purpose of this study was to review the literature on displaced midshaft clavicle fractures, identify randomized controlled trials of operative versus non-operative treatment, and pool the functional outcome and complication rates (including nonunion and symptomatic malunion), to arrive at summary estimates of these outcomes. Method. A systematic review of the literature was performed to identify studies of randomized controlled trials comparing operative versus non-operative care for displaced midshaft clavicle fractures. Meeting abstracts were also searched and included in this study. Results. Six randomized controlled trials (n=421 patients, mean Detsky score= 15.2) were identified and included. The nonunion rate was higher in the non-operative group (28/207) then it was in patients treated operatively (3/214) (p<0.001). The rate of symptomatic malunion was higher in the non-operative group (15/207) than the operative group (0/214) (p<0.001). The total complication rate was 71 complications in 214 operative cases (33%), and 93 complications in 207 non-operative cases (45%)(p=0.016). The Constant Shoulder scores (CS) and Disability of the Arm, Shoulder and Hand (DASH) scores showed marginally improved (mean 4.1 point increase in CS at one year, mean 5.8 point decrease in DASH at one year) functional values in the operative group: this difference was especially marked in the early post operative period. Conclusion. Operative treatment provided lower complication rates (especially nonunion and symptomatic malunion) and an earlier functional return compared to non-operative treatment. However, there is little evidence at present to show that the long term effects of operative intervention are significantly superior to non-operative care

Greater trochanter fractures after total hip replacement have been reported in up to 5% of cases. The outcomes are generally poor. Treatment options include non-operative care or surgical treatment with cerclage wires or a claw plate. We present a simple tension band technique for acute fractures with a single bony fracture fragment. We have not used the technique for chronic or comminuted fractures. Technique: 2.5mm k-wires are passed through the fragment and anterior and posterior to the femoral implant. Eighteen-gauge wire is passed through a drill hole in the femur distal to the fracture and around the k-wires in a figure eight. The patient is kept 50% weightbearing with no active abduction for 4 weeks. In four cases the fracture has gone on to healing. Patients have had a negative Trendelenburg sign without peritrochanteric pain. The tension band technique is familiar to surgeons and has been reliable

Aim. To review the evolution of the orthopaedic surgical care offered at a small rural hospital in western Nepal. The United Missions Hospital of Tansen (UMHT) was established in 1954 and has progressed substantially over the past 55 years. Located in the hills 300 km west of Kathmandu, it services not only Palpa District but also the surrounding nine districts and Indian patients from across the nearby border. The hospital has progressed from a simple medical clinic to a 165-bed hospital with four operating theatres, a new emergency department and multiple outpatient clinics. Orthopaedics in particular has come a long way from solely non-operative care such as plasters, splints and traction, to plating and intra-medullary nailing with intra-operative imaging facilities. This talk will review the progression of services in the region and highlight how western intervention has drastically improved the health care and lives of people in and around Tansen. Methods. UMHT is a 165-bed hospital with medical staff covering paediatrics, general medicine, general surgery and orthopaedics. Exact specialty coverage can vary depending on expatriate cover and locally trained staff expertise. There are around 315 Nepali employees, and eight mission appointees, mainly from the UK, USA, Australia and Sweden. There are six resident medical officers who are post internship and usually completing GP training schemes. The hospital is accredited to train 10 interns per year and frequently takes local and international medical students on rotation. Surgical facilities include daily outpatient surgical clinics of 30–60 patients, two minor operation theatres and two operating theatres. Generally, these are run as one orthopaedic and one general surgical theatre. This review is based on the experiences of Dr John Bosanquet, Dr Sandy Bosanquet and Dr Lachlan Host in their outreach trips to this hospital and in particular will focus on the progression over the last 10 years of the orthopaedic services available. Major advances have been in the provision of x-ray and CT facilities, improved supply of sterile equipment, introduction of IM nailing using the SIGN nail, and the training of local staff to continue the work. Conclusions. UMHT is a work in progress and is only made possible by the contributions of the many doctors, nurses, teachers and other professionals who willingly offer their services to help those less fortunate. Even more importantly is the funding provided from multiple organisations to sustain this outreach. The challenge remains, as in any outreach offered, of providing a service that is sustainable long-term. To date, UMHT has stood the test of time and there is much to be learnt from its example in the establishment of similar outreach projects. Future challenges for Tansen include the need for improved sterile facilities, the challenges of introducing elective surgery, particularly arthroplasty, provision of spine and neurosurgical facilities, and retention of skilled personal in what can be an isolating environment