We describe a lateral approach to the distal humerus based on initial location of the superficial branches of the radial nerve, the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm. In 18 upper limbs the superficial branches of the radial nerve were located in the subcutaneous tissue between the triceps and brachioradialis muscles and dissected proximally to their origin from the radial nerve, exposing the shaft of the humerus. The inferior lateral cutaneous nerve of the arm arose from the radial nerve at the lower part of the spiral groove, at a mean of 14.2 cm proximal to the lateral epicondyle. The posterior cutaneous nerve of the forearm arose from the inferior lateral cutaneous nerve at a mean of 6.9 cm (6.0 to 8.1) proximal to the lateral epicondyle and descended vertically along the dorsal aspect of the forearm. The size and constant site of emergence between the triceps and brachioradialis muscles constitute a readily identifiable landmark to explore the radial nerve and expose the humeral shaft

Helical plates are preferably used for proximal humeral shaft fracture fixation and potentially avoid radial nerve irritation as compared to straight plates. Aims:(1) to investigate the safety of applying different long plate designs (straight, 45°-, 90°-helical and ALPS) in MIPO-technique to the humerus. (2) to assess and compare their distances to adjacent anatomical structures at risk. MIPO was performed in 16 human cadaveric humeri using either a straight plate (group1), a 45°-helical (group2), a 90°-helical (group3) or an ALPS (group4). Using CT-angiography, distances between brachial arteries and plates were evaluated. Following, all specimens were dissected, and distances to the axillary, radial and musculocutaneous nerve were evaluated. None of the specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mm(range)) between each plate and the radial nerve was 1(1-3) in group1, 7(2-11) in group2, 14(7-25) in group3 and 6(3-8) in group4. It was significantly longer in group3 and significantly shorter in group1 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the musculocutaneous nerve was 16(8-28) in group1, 11(7-18) in group2, 3(2-4) in group3 and 6(3-8) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the brachial artery was 21(18-23) in group1, 7(6-7) in group2, 4(3-5) in group3 and 7(6-7) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.021. MIPO with 45°- and 90°-helical plates as well as ALPS is safely feasible and showed a significant greater distance to the radial nerve compared to straight plates. However, distances remain low, and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is used with ALPS, 45°- and 90°-helical implants. Anterior parts of the deltoid insertion will be detached using 90°-helical and ALPS implants in MIPO-technique

Proximal humeral shaft fractures are commonly treated with long straight locking plates endangering the radial nerve distally. The aim of this study was to investigate the biomechanical competence in a human cadaveric bone model of 90°-helical PHILOS plates versus conventional straight PHILOS plates in proximal third comminuted humeral shaft fractures. Eight pairs of humeral cadaveric humeri were instrumented using either a long 90°-helical plate (group1) or a straight long PHILOS plate (group2). An unstable proximal humeral shaft fracture was simulated by means of an osteotomy maintaining a gap of 5cm. All specimens were tested under quasi-static loading in axial compression, internal and external rotation as well as bending in 4 directions. Subsequently, progressively increasing internal rotational loading until failure was applied and interfragmentary movements were monitored by means of optical motion tracking. Flexion/extension deformation (°) in group1 was (2.00±1.77) and (0.88±1.12) in group2, p=0.003. Varus/valgus deformation (°) was (6.14±1.58) in group1 and (6.16±0.73) in group2, p=0.976. Shear (mm) and displacement (°) under torsional load were (1.40±0.63 and 8.96±0.46) in group1 and (1.12±0.61 and 9.02±0.48) in group2, p≥0.390. However, during cyclic testing shear and torsional displacements and torsion were both significantly higher in group 1, p≤0.038. Cycles to catastrophic failure were (9960±1967) in group1 and (9234±1566) in group2, p=0.24. Although 90°-helical plating was associated with improved resistance against varus/valgus deformation, it demonstrated lower resistance to flexion/extension and internal rotation as well as higher flexion/extension, torsional and shear movements compared to straight plates. From a biomechanical perspective, 90°-helical plates performed inferior compared to straight plates and alternative helical plate designs with lower twist should be investigated in future paired cadaveric studies

Proximal humeral shaft fractures are commonly treated with long straight plates or intramedullary nails. Helical plates might overcome the downsides of these techniques as they are able to avoid the radial nerve distally. The aim of this study was to investigate in an artificial bone model: (1) the biomechanical competence of different plate designs and (2) to compare them against the alternative treatment option of intramedullary nails. Twenty-four artificial humeri were assigned in 4 groups and instrumented as follows: group1 (straight 10-hole-PHILOS), group2 (MULTILOCK-nail), group3 (45°-helical-PHILOS) and group4 (90°-helical-PHILOS). An unstable proximal humeral shaft fracture was simulated. Specimens were tested under quasi-static loading in axial compression, internal/external rotation and bending in 4 directions monitored by optical motion tracking. Axial displacement (mm) was significantly lower in group2 (0.1±0.1) compared to all other groups (1: 3.7±0.6; 3: 3.8±0.8; 4: 3.5±0.4), p<0.001. Varus stiffness in group2 (0.8±0.1) was significantly higher compared to groups1+3, p≤0.013 (1: 0.7±0.1; 3: 0.7±0.1; 4: 0.8±0.1). Varus bending (°) was significantly lower in group2 compared to all other groups (p<0.001) and group4 to group1, p=0.022. Flexion stiffness in group1 was significantly higher compared to groups2+4 (p≤0,03) and group4 to group1, p≤0,029 (1: 0.8±0.1; 2: 0.7±0.1; 3: 0.7±0.1; 4: 0.6±0.1). Flexion bending (°) in group4 was higher compared to all other groups (p≤0.024) and lower in group2 compared to groups1+4, p≤0.024. Torsional stiffness remained non significantly different, p≥0.086. Torsional deformation in group2 was significantly higher compared to all other groups, p≤0.017. Shear displacement remained non significantly different, p≥0.112. From a biomechanical perspective, helical plating with 45° and 90° may be considered as a valid alternative fixation technique to standard straight plating of proximal third humeral fractures. Intramedullary nails demonstrated higher axial and bending stiffness as well as lower fracture gap movements during axial loading compared to all plate designs. However, despite similar torsional stiffness they were associated with higher torsional movements during internal/external rotation as compared to all investigated plate designs

Background. Patients with hand injuries frequently present to Emergency Departments. The ability of junior doctors to perform an accurate clinical assessment is crucial in initiating appropriate management. Objectives. To assess the adequacy of junior doctor hand examination skills and to establish whether further training and education is required. Methods. A double-centre study was conducted using an anonymous survey assessing hand examination completed by junior doctors (Foundation year 1 and Senior House Officer grades) working in Trauma & Orthopaedics or Emergency Departments. The survey covered all aspects of hand examination including assessment of: Flexor and Extensor tendons, Nerves (motor and sensory) and Vascular status. Surveys were marked against answers pre-agreed with a Consultant hand surgeon. Results. 32 doctors completed the survey. Tendons: 59% could accurately examine extensor digitorum, 41% extensor pollicis longus, 38% flexor digitorum profundus and 28% flexor digitorum superficialis. Nerves – Motor: 53% could accurately examine the radial nerve, 37% the ulnar nerve, 22% the median nerve and 9% the anterior interosseous nerve. Nerves – Sensory: 88% could accurately examine the radial nerve, 81% the ulnar nerve, 84% the median nerve and 18.8% digital nerves. Vascular: 93% could describe 3 methods of assessing vascularity. Conclusions. Tendon and neurological aspects of hand clinical examination were poorly executed at junior doctor level in this pragmatic survey. This highlights the need for targeted education and training to improve the accuracy of junior doctor hand injury assessment and subsequent improving patient treatment and safety. Recommendations include dedicated hand examination teaching early in Orthopaedic/A&E placements and introduction of an illustrated Hand Trauma Examination Proforma. Level of evidence. III - Evidence from case, correlation, and comparative studies

The treatment of extremity ballistic injury is challenging in that the zone of injury can be extensive and determining the surgical exposure can be difficult. We describe a method of pre-operative evaluation of the zone of injury in conjunction with the regional anesthesiologist utilizing ultrasound to determine the presence of nerve disruption. This non-invasive method of examination may elucidate whether significant nerve exists and may also serve to pinpoint the location of injury. Such information allows the surgeon to more effectively and efficiently surgically expose the zone of injury and understand the boundaries of the nerve outside the zone of injury. Moreover, such preoperative evaluation may at times obviate the need for exploratory surgery at all. It is important for the anesthesiologist and surgeon to work together with respect to the ability to both interpret the ultrasound images and to clinically correlate the findings. The zone of tissue disruption in ballistic injuries is extremely variable. It is beneficial to both the surgeon and patient to engage in a collaborative effort with an experienced regional anesthesiologist who is well-versed in interpretation of ultrasound images and tissue plane disruption in an effort to minimize surgical time and the potential unintended consequences of unnecessary exploration. We present a series of cases representing instances wherein the zone of injury was small, extensive, and a unique situation in which there was in fact no injury present despite clinical symptoms and MRI consistent with radial nerve disruption

Background. Distal radius fractures are common injuries but no clear consensus regarding optimal management of unstable fractures exists. Open reduction and internal fixation with volar plates is an increasingly popular but the associated complication rate can be 10%. Intramedullary nails are an alternative offering the potential advantages of reduced risk of tendon injury and intra-articular screw penetration. This article systematically reviews the published literature evaluating the biomechanics, outcomes and complications of intramedullary nails in the management of distal radius fractures. Methods. A systematic review of Medline and EMBASE databases was performed for studies reporting the biomechanics, functional outcome or complications following intramedullary nailing of distal radius fractures. Critical appraisal was performed with respect to validated quality assessment scales. Results. 16 studies were included for review. The biomechanical studies concluded that intramedullary nails had at least comparable strength to locking plates. The clinical studies reported that IM nailing was associated with comparable ROM, functional outcome and grip strength to alternative fixation techniques. However, the mean complication rate was 17.6% (range 0 to 50%) with the most common complication being neurapraxia of the superficial radial nerve in 9.5%. Conclusion. This systematic review of pooled data from published series has shown that IM nailing can give comparable clinical results to current treatment modalities in extra-articular and simple intra-articular distal radius fractures. However the evidence is insufficient to determine whether IM nailing has any clinically important advantage over well-established alternatives. The complication rate reported is higher than that in contemporary studies for volar plating and this raises concerns about the role of this technique particularly when comparative studies have failed to show any major advantage to its use. Further adequately powered RCTs comparing the technique to both volar plates and percutaneous wire fixation are required. Level of evidence. IIa – systematic review of cohort studies. Conflict of Interests. The authors confirm that they have no relevant financial disclosures or conflicts of interest. Ethical approval was not sought as this was a systematic review

Neurological examination is essential in patients with upper limb injuries and should be clearly documented. We aimed to assess the quality and documentation of neurological examination performed for children presenting with upper limb fractures to the emergency department. Clinical notes of all children admitted with upper limb fractures over a three month period were reviewed. Documentation of initial neurological assessment was analysed and clinical suspicion of any nerve injury noted. In parallel, we conducted an anonymous survey of emergency doctors evaluating their upper limb neurological examination in children. The casenotes of 121 children with upper limb fractures were reviewed. 10 children (8%) had a nerve injury (median = 4, ulnar = 2, radial = 2, anterior interosseous = 2). Neurological examination was documented in 107 (88%) of patients. However, none of the nerve injuries were detected on initial examination. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’, 2 (20%) as ‘CSM normal’, 1 (10%) as ‘moving fingers’ and 2 (20%) had no documented neurological examination. 30 emergency doctors completed the questionnaires (5 consultants, 9 registrars, 16 foundation doctors). All doctors stated that they routinely performed an upper limb neurological examination and assessed median, ulnar and radial nerves. However, 30% of doctors described incomplete examination of median nerve function, 30% inadequate ulnar nerve assessment and 50% incomplete radial nerve examination. In addition, 75% of doctors failed to identify the need for assessment of anterior interosseous nerve function. While emergency doctors recognise the importance of neurological assessment in children with upper limb injuries, it is often performed inadequately. This in part may be due to difficulties performing neurological examination in paediatric patients. As a result of this study, we have introduced local guidelines to assist neurological assessment in children

Although most peripheral nerve sheath tumours are benign, some are malignant. The management of malignant tumours usually involves wide excision and is facilitated by knowledge of the diagnosis prior to operation. Imaging modalities, including MRI, give anatomical information but do not distinguish between benign and malignant nerve tumours. We therefore introduced the use of ultrasound guided needle biopsy for suspected nerve tumours to our unit in 2004. Prior to this, excision biopsy was carried out in all cases. We aimed to review our experience with needle biopsy and determine whether it has an effective role in the management of peripheral nerve tumours. All patients who had a needle biopsy for suspected peripheral nerve tumours from January 2004 to December 2011 were identified from our tumour database and clinical notes reviewed. In all cases, biopsy was carried out under ultrasound guidance with local anaesthesia to obtain a 1mm core of tissue. From 25 patients reviewed, 21 (84%) had a successful biopsy. In 3 cases the biopsy was unable to be completed due to pain and in 1 patient insufficient tumour tissue was obtained. 1 patient had a temporary radial nerve palsy following needle biopsy which recovered fully. In biopsies that were successful, 19 (90%) showed a benign peripheral nerve tumour. Following diagnosis of a benign lesion, only 2 patients required to have surgical excision of the tumour due to pain. The remainder were managed non-operatively. In the 2 cases of malignant tumours detected by biopsy, a successful wide surgical excision was performed. Ultrasound guided core needle biopsy appears safe and gives a tissue diagnosis in most cases of suspected peripheral nerve tumours. In malignant cases it facilitates surgical planning, while most benign tumours could be managed non-operatively, therefore avoiding potential complications of nerve surgery

Objectives

There are various pin-in-plaster methods for treating fractures of the distal radius. The purpose of this study is to introduce a modified technique of ‘pin in plaster’.