Data was collected for patients referred to the orthopaedic department at Forth Valley Royal Hospital with metatarsalgia who subsequently received an ultrasound. Patients found to have a Morton's neuroma were divided into groups based on its size. A total of 90 patients received an ultrasound scan and neuroma was confirmed in 58 with an alternative diagnosis found in 32 patients and a total of 42 were included in the final analysis. All 14 patients with neuroma < 6mm reported resolution of symptoms. 4 (28.5%) underwent surgical excision as first line, 1 (7%) received a single corticosteroid injection and 9 (64%) were treated with metatarsal bars. There were 27 patients with neuroma > 6mm; 8 (29.6%) underwent surgical excision as first line treatment, 5 (18.5%) received metatarsal bars and 14 (51.9%) received injections. 7 (25.9%) patients reported resolution of symptoms after 1 injection, 1 (3.7%) patient required 2 injections and 1 (3.7%) patient required 3 injections to achieve resolution. 5 (18.5%) patients required surgical excision following ongoing symptoms despite non-surgical treatment. 9 (33.3%) reported resolution of symptoms following injection. 5 (18.5%) reported resolution of symptoms following use of metatarsal bars. A total of 71% of patients with a neuroma measuring < 6mm reported full resolution of symptoms with non-surgical treatment. For patients with neuroma >6mm, 64.3% had resolution of symptoms with injections alone and 18.5% required surgical excision despite injection. In conclusion, there is a benefit to offering non-surgical treatment as first line in patients with a neuroma regardless of size

Patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma have been recently established. However, little is known regarding what patient factors affect these outcomes. This is the first and largest prospective study to determine which patient factors influence surgical outcome following Morton's neuroma excision. Over a seven-year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively. Patient demographics were recorded in addition to co-morbidities, deprivation, associated neuroma excision and other forefoot surgery. Obesity, deprivation and revision surgery proved to statistically worsen MOXFQ outcomes post-operatively (p=0.005, p=0.002 and p=0.004 respectively). Deprivation significantly worsened the mental component of the SF12 (p=0.043) and depression the physical component (p=0.026). No difference in outcome was identified for age, sex, time from diagnosis to surgery, multiple neuroma excision and other forefoot surgeries. 23.5percnt; of deprived patients were dissatisfied with their surgery compared to 7percnt; of the remaining cohort. Patient reported outcomes following resection of symptomatic Morton's neuroma are shown to be less favourable in those patients who display characteristics of obesity, depression, deprivation and in those who undertake revision neuroma resection. Surgery can be safely delayed, as time to surgery from diagnosis bears no impact on clinical outcome

The aim of our study was to compare the clinical versus radiological diagnosis of patients suffering from a Morton's neuroma. Clinical assessments and pre operative radiological imaging of patients who underwent operative procedures for an excision of a Morton's neuroma were retrospectively compared. This review included 43 excised Morton's neuromas from 36 different patients over a period of 68 months, performed by one surgical team. The commonest clinical symptoms were those of pain or tingling on the plantar aspect of the affected webspace on direct palpation (100%), pain of weight bearing (91%) which was relieved by rest (81%) and pain on stretching the toes (79%). The most sensitive clinical sign was a Mulder's click. Our results showed that clinical assessment was the most sensitive method of diagnosing these neuromas (98%). All of our patients had at least one mode of radiological investigation. Ultrasonography was the commonest requested single imaging modality in our series. It was found to have a sensitivity of 90% (28/31). This imaging technique has the disadvantage of being operator dependant, as highlighted by the fact that one of our patients had a correct radiological diagnosis after a repeat ultrasound to the affected area was requested. Magnetic Resonance Image scan is a more expensive technique as it has the advantage of producing static reproducible images. As a single imaging modality, it was found to have a sensitivity of 92% (12/13) in our series. 3 patients had both imaging modalities; initial ultrasound failed to convincingly diagnose a neuroma in 2 cases and in the other case, the initial MRI did not show any pathology. In all these cases, the repeat imaging techniques confirmed the clinical diagnosis. We conclude that there is no absolute requirement for ultrasonography or magnetic resonance imaging in patients who clinically are suspected to have a Morton's neuroma, as the clinical examination was found to be the most sensitive method of diagnosis. We suggest that the two main indications for performing some form of imaging is (a) an unclear clinical assessment and (b) cases when more than one webspace appears to be affected. An ultrasound of the webspaces should be the radiological investigation of choice, followed by a magnetic resonance scanning if any uncertainty still remains

Current knowledge regarding outcomes following surgical treatment of Morton's neuroma remains incomplete. This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma. Over a seven year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively. Statistically significant differences were found between the mean pre- and post-operative MOXFQ and physical component of the SF-12 (p<0.05). No difference in outcome was identified in patients in whom multiple neuromas were operated compared to single site surgery. However, revision surgery proved to statistically worsen MOXFQ outcomes post-operatively p<0.004. Overall satisfaction was reported as excellent (49%) or good (29%) by the majority of patients but 10% were dissatisfied with poor (8%) or very poor (2%) results expressed. Only 64% were pain free at the time of follow-up and 8% of patients MOXFQ scores worsened. These findings illustrate that overall, patient reported outcomes following resection of symptomatic Morton's neuroma are acceptable but may not be as favourable as earlier studies suggest. Caution should be taken when considering revision surgery which has shown to be a poor prognostic indicator. Contrary to current knowledge, multiple site surgery can be safely undertaken

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome

A Morton's neuroma is a painful forefoot disorder characterised by plantar pain and toe paraesthesia. Many treatments have been tried including modification of shoe wear, injections and surgery. The results from different treatment modalities are extremely variable in the scientific literature. We reviewed 79 patients who presented with an ultrasound proven Morton's Neuromata at an average of 60 months following treatment in a patient blind randomised trial. 35 had surgery with resection of the Morton's Neuromata. We compared the results of the patients who had had a steroid injection and surgery, a steroid injection alone, a placebo injection and then surgery and a placebo injection alone. We looked at the requirement for further consultations, pain scores, activity restrictions, footwear restriction, overall satisfaction with their treatment and overall quality of life scores. We found no significant difference between the groups. Overall 80% of the surgical patients had a good or excellent result and 67% of the non- operatively managed patients had a good or excellent result. There was no difference in their quality of life scores. Previous studies have shown little benefit in steroid injections in the treatment of Morton's Neuromata. We conclude at the five year mark there is no significant differences between operating on Morton's Neuromata and treating them conservatively. Further research should focus on comparing operative vs conservative treatment in the short to medium term. In order to justify the risks and costs of surgery

Introduction. We present a series of patients who have had secondary reconstruction of war injuries to the upper and lower limbs, sustained during the Iraq and Afghanistan conflicts. Material and Methods. All patients were seen at the combined Peripheral Nerve Injuries Clinic at the Defence Medical Centre for Rehabilitation, Headley Court. All surgery was performed at Odstock Hospital. Procedures include scar excision and neurolysis (all patients), release of scar contractures, tenolysis, tendon transfers, revision nerve grafts, excision of neuroma, and soft tissue reconstruction using pedicled or free flaps. Results. 24 patients have been treated at the time of submission. We have using 13 free flaps (1 free groin flap, 9 anterolateral thigh, 3 parascapular, with 4 as through-flow flaps) and 1 pedicled groin flap, with no flap losses. There were 6 amputation stump revisions (1 above elbow, 5 below knee). The majority (n=23) have had nerve recovery distal to the level of injury following revision surgery. Conclusions. Nerve repairs recover following neurolysis (and revision nerve graft if necessary) with provision of good soft tissue cover. Release of scar contractures with flap cover allows healing of chronic wounds and permits mobilisation of joints. Thin fasciocutaneous flaps provide good contour and can be elevated more easily than skin grafted muscle flaps for secondary surgery. Free or regional flaps are preferable to local flaps in high energy-transfer military wounds. Immediate complex reconstruction is not always appropriate in multiply-injured patients

Aims

We aimed to identify the pattern of nerve injury associated with paediatric supracondylar fractures of the humerus.

Aims

Amputation in intractable cases of complex regional pain syndrome (CRPS) remains controversial.

The likelihood of recurrent Complex Regional Pain Syndrome (CRPS), residual and phantom limb pain and persistent disability after amputation is poorly described in the literature. The aims of this study were to compare pain, function, depression and quality of life between patients with intractable CRPS who underwent amputation and those in whom amputation was considered but not performed.

A total of 20 patients with a depressed fracture of the lateral tibial plateau (Schatzker II or III) who would undergo open reduction and internal fixation were randomised to have the metaphyseal void in the bone filled with either porous titanium granules or autograft bone. Radiographs were undertaken within one week, after six weeks, three months, six months, and after 12 months.

The primary outcome measure was recurrent depression of the joint surface: a secondary outcome was the duration of surgery.

The risk of recurrent depression of the joint surface was lower (p < 0.001) and the operating time less (p < 0.002) when titanium granules were used.

The indication is that it is therefore beneficial to use porous titanium granules than autograft bone to fill the void created by reducing a depressed fracture of the lateral tibial plateau. There is no donor site morbidity, the operating time is shorter and the risk of recurrent depression of the articular surface is less.

Cite this article: Bone Joint J 2015; 97-B:836–41

Injuries to the limb are the most frequent cause of permanent disability following combat wounds. We reviewed the medical records of 450 soldiers to determine the type of upper limb nerve injuries sustained, the rate of remaining motor and sensory deficits at final follow-up, and the type of Army disability ratings granted. Of 189 soldiers with an injury of the upper limb, 70 had nerve-related trauma. There were 62 men and eight women with a mean age of 25 years (18 to 49). Disabilities due to nerve injuries were associated with loss of function, neuropathic pain or both. The mean nerve-related disability was 26% (0% to 70%), accounting for over one-half of this cohort’s cumulative disability. Patients injured in an explosion had higher disability ratings than those injured by gunshot. The ulnar nerve was most commonly injured, but most disability was associated with radial nerve trauma. In terms of the final outcome, at military discharge 59 subjects (84%) experienced persistent weakness, 48 (69%) had a persistent sensory deficit and 17 (24%) experienced chronic pain from scar-related or neuropathic pain. Nerve injury was the cause of frequent and substantial disability in our cohort of wounded soldiers.

Cite this article: Bone Joint J 2014;96-B:254–8.

We studied prospectively the regional inflammatory response to a unilateral distal radial fracture in 114 patients at eight to nine weeks after injury and again at one year. Our aim was to identify patients at risk for a delayed recovery and particularly those likely to develop complex regional pain syndrome. In order to quantify clinically the inflammatory response, a regional inflammatory score was developed. In addition, blood samples were collected from the antecubital veins of both arms for comparative biochemical and blood-gas analysis.

The severity of the inflammatory response was related to the type of treatment (Kruskal-Wallis test, p = 0.002). A highly significantly-positive correlation was found between the regional inflammatory score and the length of time to full recovery (r² = 0.92, p = 0.01, linear regession). A regional inflammatory score of 5 points with a sensitivity of 100% but a specificity of only 16% also identified patients at risk of complex regional pain syndrome. None of the biochemical parameters studied correlated with regional inflammatory score or predicted the development of complex regional pain syndrome.

Our study suggests that patients with a distal radial fracture and a regional inflammatory score of 5 points or more at eight to nine weeks after injury should be considered for specific anti-inflammatory treatment.