The Pronator Quadratus (PQ) is commonly damaged in the surgical approach to the distal radius during volar plating. This study explored the functional strength of the PQ muscle, 12 months after volar plating of a distal radial fracture. Testing of treated and contralateral forearms was carried out using a custom-made Torque Measuring Device (TMD) and surface Electromyography (sEMG). To assess both the direct and indirect function of PQ in participants treated with volar plating and compared to the contralateral non-injured forearms. The angle of elbow flexion was varied from 45o, 90o and 135o when measuring forearm pronation. Mean peak torque of the major pronating muscles, PQ and Pronator Teres (PT) was directly measured with the TMD and the indirect activation of the PQ and PT was measured with sEMG. In total 27 participants were studied. A statistically significant reduction in mean peak pronation torque was observed in the volar plated forearms (P<0.05 SE 0.015, CI 95%). This is unlikely to be of clinical significance as the mean reduction was small (13.43Nm treated v 13.48Nm none treated). Pairwise comparison found no statistically significant reduction in peak torque between 45o, 90o and 135o of elbow flexion. There was an increase in PQ muscle activation at 135o compared to 45o elbow flexion. The converse was identified in PT. The small but statistically significant difference in mean peak torque in treated and uninjured forearms is unlikely to be of clinical significance and results suggest adequate functional recovery of the PQ after volar plating

Introduction. A new triggered electromyography test for detection of stimulus diffusion to intercostal muscles of the contralateral side during thoracic pedicle screw placement was evaluated. Experimental research was carried out in order to determine if, using this test, neural contact at different aspects of the spinal cord and nerve roots could be discriminated. Methods. Nine industrial pigs (60–75 kg) had 108 pedicle screws placed bilaterally in the thoracic spine (T8–T13). Neural structures were stimulated under direct vision at different anatomic locations from T9 to T12. Recording electrodes were placed over the right and left intercostal muscles. Increasing intensity of the stimulus was applied until muscle response was detected at the contralateral side (diffusion phenomenon). After this first experiment, the thoracic spine was instrumented. Screws were placed in the pedicle in two different positions, the anatomic intrapedicular location and with purposeful contact with the neural elements. Results. Response thresholds to direct stimulation of nerve root at different points were significantly lower than those obtained by stimulation of the dorsal aspect of the spinal cord (0.44±0.22 mA vs 1.38±0.71 mA). However, a 24-fold stimulation intensity (6.50±0.29 mA) was necessary to obtain diffusion of the EMG response to the opposite left side if the right nerve root was stimulated. Only a 2-fold increment (3.17±0.93 mA) was able to elicit diffusion of EMG responses to the contralateral side when stimulation was applied to the dorsal aspect of the spinal cord. Contralateral EMG responses after high increases of stimulation thresholds indicated nerve root contact. Diffusion phenomenon after low threshold increments reflected medullar contact. Electromyography recordings after triggered stimulation of the screws showed that only screws in contact with the spinal cord had significantly lower responses (2.72±1.48 mA). Conclusion. Stimulus-triggered EMG could only discriminate screws with violation of the medial pedicle wall if they were contact with neural tissues. Recording EMG-potentials at the contralateral paraspinal muscles (stimulus diffusion phenomenon) proved to be a reliable method to discriminate which of the neural structures was at risk

In the time since Letournel popularised the surgical treatment of acetabular fractures, more than 25 years ago, there have been many changes within the field, related to patients, surgical technique, implants and post-operative care. However, the long-term outcomes appear largely unchanged. Does this represent stasis or have the advances been mitigated by other negative factors? In this article we have attempted to document the recent changes within the surgery of patients with a fracture involving the acetabulum, outline contemporary management, and identify the major problem areas where further research is most needed.

Cite this article: Bone Joint J 2017;99-B:1125–31

The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.