Introduction. Quantification of daily upper-limb activity is a key determinant in evaluation of shoulder surgery. For a number of shoulder diseases, problem in performing daily activities have been expressed in terms of upper-limb usage and non-usage. Many instruments measure upper-limb movement but do not focus on the differentiations between the use of left or right shoulder. Several methods have been used to measure it using only accelerometers, pressure sensors or video-based analysis. However, there is no standard or widely used objective measure for upper-limb movement. We report here on an objective method to measure the movement of upper-limb and we examined the use of 3D accelerometers and 3D gyroscopes for that purpose. Methods. We studied 8 subjects with unilateral pathological shoulder (8 rotator cuff disease: 53 years old ± 8) and compared them to 18 control subjects (10 right handed, 8 left handed: 32 years old ± 8, younger than the patient group to be almost sure they don_t have any unrecognized shoulder pathology). The Simple Shoulder Test (SST) and Disabilities of the Arm and Shoulder Score (DASH) questionnaires were completed by each subject. Two modules with 3 miniature capacitive gyroscopes and 3 miniature accelerometers were fixed by a patch on the dorsal side of the distal humerus, and one module with 3 gyroscopes and 3 accelerometers were fixed on the thorax. The subject wore the system during one day (8 hours), at home or wherever he/she went. We used a technique based on the 3D acceleration and the 3D angular velocities from the modules attached on the humerus. Results. As expected, we observed that for the stand and sit postures the right side is more used than the left side for a healthy right-handed person(idem on the left side for a healthy left-handed person). Subjects used their dominant upper-limb 18% more than the non-dominant upper-limb. The measurements on patients in daily life have shown that the patient has used more his non affected and non dominant side during daily activity if the dominant side = affected shoulder. If the dominant side ≠ affected shoulder, the difference can be showed only during walking period. Discussion-Conclusion. The technique developed and used allowed the quantification of the difference between dominant and non dominant side, affected and unaffected upper-limb activity. These results were encouraging for future evaluation of patients with shoulder injuries, before and after surgery. The feasibility and patient acceptability of the method using body fixed sensors for ambulatory evaluation of upper limbs kinematics was shown

We reviewed the results of reconstruction of 97 upper limbs in a consecutive series of 57 tetraplegic patients, treated from 1982 to 1990. Of these, 49 had functional and eight had cosmetic reconstructions. The principal functional objectives were to provide active elbow extension, hook grip, and key pinch. Elbow extension was provided in 34 limbs, using deltoid-to-triceps transfer. Hook grip was provided in 58 limbs, mostly using extensor carpi radialis longus to flexor pollicis longus transfer, and key pinch in 68, mostly using brachioradialis to flexor pollicis longus transfer. Many other procedures were employed. At an average follow-up of 37 months, 70% had good or excellent subjective results, and objective measurements of function compared favourably with other series. Revisions were required for 11 active transfers and three tenodeses, while complications included rupture of anastomoses and problems with thumb interphalangeal joint stabilisation and wound healing. We report a reliable clinical method for differentiating between the activity of extensor carpi radialis longus and brevis and describe a successful new split flexor pollicis longus tenodesis for stabilising the thumb interphalangeal joint. Bilateral simultaneous surgery gave generally better results than did unilateral surgery.

Aims

The primary aim of this study is to quantify and compare outcomes following a dorsally displaced fracture of the distal radius in elderly patients (aged ≥ 65 years) who are managed conservatively versus with surgical fixation (open reduction and internal fixation). Secondary aims are to assess and compare upper limb-specific function, health-related quality of life, wrist pain, complications, grip strength, range of motion, radiological parameters, healthcare resource use, and cost-effectiveness between the groups.

Abstract. INTRODUCTION. With increasing use of fluoroscopy in Orthopaedic theatres in recent years, the occupational radiation exposure to the surgeons and the theatre staff has increased significantly. Thyroid is one of the most radio-sensitive tissues in the body, but there is a clear lack of awareness among theatre staff of risks of radiation to thyroid. METHODS. We prospectively reviewed the use of thyroid shield by the theatre staff in the orthopaedic theatre for two weeks period. We also recorded the number of fluoroscopic images taken and total radiation dosage for each case. RESULTS. Our results showed that of 249 staff in the theatres of which, only 35 people (14.2%) wore thyroid shields during fluoroscopy, whereas 100% were complaint with body protection shield. We noticed that only 30% of the surgeons, 40% of the scrub nurses and 5% anaesthetist use this, while 95% of the radiographers uses thyroid protection in theatre. Average total radiation during upper-limb procedures was 1.25 cGy, during lower-limb procedures it was 43.48 cGy. Total radiations were very high particularly during lower-limb nailing procedures (80.98 cGy). CONCLUSION. Extensive use of fluoroscopy has a stochastic effect (accumulative effect) on thyroid gland particularly, if the dose in higher than 65 cGy. Despite its availability, only 14% people use the thyroid protection shield. We must emphasise the use of thyroid protection shield to the Orthopaedic surgeons, particularly during lower-limb procedures

The COVID-19 pandemic presented a significant impact on orthopaedic surgical operating. This multi-centre study aimed to ascertain what factors contributed to delays to theatre in patients with shoulder and elbow trauma. A retrospective cohort study of 621 upper limb (shoulder and elbow) trauma patients between 16/03/2020 and 16/09/2021 (18-months) was extracted from trauma lists in NHS Tayside, Highland and Grampian and Picture Archiving and Communication Systems (PACS). Median patient age =51 years (range 2-98), 298 (48%) were male and 323 (52%) female. The commonest operation was olecranon open reduction internal fixation (ORIF) 106/621 cases (17.1%), followed by distal humerus ORIF − 63/621 (10.1%). Median time to surgery was 2 days (range 0-263). 281/621 (45.2%) of patients underwent surgical intervention within 0-1 days and 555/621 patients (89.9%) had an operation within 14 days of sustaining their injury. 66/621 (10.6%) patients waited >14 days for surgery. There were 325/621 (52.3%) patients with documented evidence of delay to surgery; of these 55.6% (181/325) were due to amendable causes. 66/325 (20.3%) of these patients suffered complications; the most common being post-operative stiffness in 48.6% of cases (n=32/66). To our knowledge, this is the first study to specifically explore effect of COVID-19 pandemic on upper limb trauma patients. We suggest delays to theatre may have contributed to higher rates of post-operative stiffness and require more physiotherapy during the rehabilitation phase. In future pandemic planning, we propose dedicated upper-limb trauma lists to prevent delays to theatre and optimise patients’ post-operative outcomes

This review discusses the causes, outcome and prevention of whiplash injury, which costs the economy of the United Kingdom approximately £3.64 billion per annum. Most cases occur as the result of rear-end vehicle collisions at speeds of less than 14 mph. Patients present with neck pain and stiffness, occipital headache, thoracolumbar back pain and upper-limb pain and paraesthesia. Over 66% make a full recovery and 2% are permanently disabled. The outcome can be predicted in 70% after three months

Purposes of study. Evaluation of the pre-operative documentation of neurovascular status in children presenting with Gartland Grades 2 and 3 supracondylar fractures and the development of an Emergency Department Proforma. Methods and results. A retrospective case-note review was performed on patients with Gartland Grade 2 and 3 supracondylar fractures observed in a two-year period from July 2008 – July 2010. 137 patients were included; sixteen patients (11.7%) sustained a Gartland Grade 2a fracture, sixty patients (43.8%) a Gartland Grade 2b fracture and sixty-one (44.5%) a Gartland Grade 3 fracture. Mean patient age at presentation was 5.59 years (range 12 months to 13 years). Nineteen patients (13.9%) had evidence of neurological deficit at presentation and thirteen patients (9.5%) presented with an absent radial pulse. Only twelve patients (8.8%) and nineteen patients (13.9%) respectively had a complete pre-operative neurological or vascular assessment documented. Regarding the individual nerves, fifty-nine (43.1%) patients had median nerve integrity documented, fifty-five (40.1%) ulnar nerve and forty-nine (35.8%) radial nerve integrity documented. Only eighteen patients (13.1%) had their anterior interosseous nerve function documented. Ten patients (7.3%) had post-operative neurological dysfunction, consisting of eight ulnar nerve injuries, and two radial nerve injuries. vi) Conclusions. Pre-operative documentation of neurovascular status in children with displaced supracondylar fractures was poor. Documentation of anterior interosseous nerve examination was particularly poor. We propose the introduction of a proforma (Liverpool Upper-limb Fracture Assessment – LUFA) to increase documentation of neurovascular assessment and optimise emergency department evaluation of children presenting with upper limb injuries

We reviewed retrospectively 236 consecutive patients seen in our soft-tissue sarcoma clinic. Of these, 95 had had a primary soft-tissue sarcoma excised elsewhere, but with histologically inadequate resection margins. All these patients had a secondary and wider re-excision. The tissues removed at the secondary re-excision were examined histologically for the presence of residual tumour. Definite tumour tissue was found in 29 of 55 lower-limb specimens, 16 of 25 upper-limb, 7 of 10 trunk and 4 of 5 head and neck specimens. In 31 cases some residual tumour was visible macroscopically, and in 56 of the 95 patients (59%) the primary tumour had been incompletely excised. Our results indicate that surgical assessment of the adequacy of excision is very inaccurate and that most local recurrences are the consequence of inadequate primary surgery. The large number of patients who had inadequate initial treatment emphasises the need for a co-ordinated multidisciplinary approach to the management of patients with soft-tissue sarcoma

Children with a mucopolysaccharidosis or mucolipidosis suffer progressive disability of the hands, particularly in relation to dysfunction of the median nerve. This is an increasing problem because bone-marrow transplantation has dramatically improved survival without apparently changing the musculoskeletal manifestations. We have reviewed 48 children with these syndromes who required carpal tunnel decompression, recording symptoms, signs, radiological, electrophysiological and operative findings, histology and upper-limb function. In these children the carpal tunnel syndrome differs from that seen in adults. Symptoms are rare but signs such as decreased sweating, pulp atrophy, thenar wasting and manual clumsiness are much more common. At operation, the flexor retinaculum was thickened and a mass of white tenosynovium engulfed the flexor tendons. Most patients had some definite nerve constriction with a thickened epineurium. Functional improvement was seen after early decompression, with some benefit from simultaneous tendon release. Regular physiotherapy helped to maintain increased hand movement. We describe our assessment protocol, the physiotherapy and operative regime and the standard functional review which helps to maximise function in the hands and upper limbs of these children

To illustrate the incidence and epidemiology of fractures due to football. All inpatient and outpatient fractures from a prospectively collected database for a defined population in 2000 were retrospectively analysed. There were 396 football fractures, 96% male. Football caused 39% of the 1022 sports fractures in 2000. This represented 5% of the 8151 fractures in total. The incidence was 61/105. 115/105 in males and 5 /105 in females. The average age was 22.9 years; 22.8 in males and 26.6 in females. 77% of fractures were treated as outpatients. The top five fractures representing 84% of the injuries were Radius+Ulna 30%, Phalanx 19%, Tibial+Fibula 18%, Metacarpal 11% and Clavicle 5%. 71% were upper-limb fractures. The busiest two months were October and May 17% and 14% respectively. The quietest two months were February and December at 5%. Although the epidemiology of football injuries will vary amongst different populations, these results can be generalized to similar population bases. Results will be valuable to medical professionals supporting football teams, enabling them to focus their attention on treating the most common injuries, the majority being treated as outpatients. Football is the most common cause of fractures in sport. As participation increases, the incidence of fractures is likely to reflect this. Upper limb fractures account for over 2/3 rd of fractures with radius+ulna fractures accounting for up to a 1/3rd of fractures; the majority can be treated as an outpatient. Therefore medical teams should be familiar with standard treatment regimes, possible impact on players’ futures and time out of sport

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain. The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04). At review, there was a mean gain of 50° in supination-pronation and 11° in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder. Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation

Aims

The primary aim of this study was to assess the feasibility of recruiting and retaining patients to a patient-blinded randomized controlled trial comparing corticosteroid injection (CSI) to autologous protein solution (APS) injection for the treatment of subacromial shoulder pain in a community care setting. The study focused on recruitment rates and retention of participants throughout, and collected data on the interventions’ safety and efficacy.

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage

Objectives: The current study evaluates the effectiveness of a direct access physiotherapy shoulder clinic, in terms of a faster treatment, levels of patient satisfaction and consultants workload relief. Material and Methods: A protocol of management of shoulder Pain was created establishing the patients pathway from general practice to orthopaedic surgery. A clinical specialist physiotherapist was trained to lead a shoulder clinic. A course on injections taught by consultants was followed by a training period of 10 supervised injections. After this initial period, a letter was sent to all GPs in the area informing that patients could be referred direct to the physio-shoulder clinic. Patients coded for consultation were also re-directed to that clinic. Only patients who did not improve after the initial treatment or who presented more complicate screening problems were redirected through a short cut to the consultant led clinic. A patient satisfaction questionnaire was used during the first 5 months. Results Over the first 2 years of the project, 203 patients were appointed to the open shoulder clinic. The first 60 patients were given the patient satisfaction questionnaire, with 47 returning it completed. 28 of the 47 had been seen by a physio before. In a satisfaction scale of 1 to 5, 2 graded 3, 3 graded 4 and 42 graded 5 the advice received about their condition. In a similar scale 2 patients rated 3, 2 rated 4 and 43 rated 5 regarding their satisfaction with the opportunity to discuss their treatment/care options. Regarding arrangements for further care, 1 rated 1, 2 rated 3, 6 rated 4 and 36 rated 5. For overall satisfaction 1 rated 2, 2 rated 3, 2 rated 4 and 42 rated 5. Positive aspects of patients feedback included ample time to ask questions, improvement obtained with early start of treatment and more accessible discussion. 47% of the patients attending were followed up by Physiotherapy only, 18% were added directly to the surgical waiting list and 4 were referred for rheumatology. 22% were sent for further tests such as MRI and USS. The waiting list for a first appointment in our upper-limb clinic was reduced from 46 weeks in 2001 to 36 weeks in 2003. Not a single patient insisted on seeing a consultant and 38% of the patients were discharged without specifically seeing one. Conclusion This study shows that a physio screening shoulder clinic is an effective and satisfactory way to reduce waiting times and improve patient care

Objectives: The current study evaluates the effectiveness of a direct access physiotherapy shoulder clinic, in terms of a faster treatment, levels of patient satisfaction and consultant’s workload relief. Material and Methods: A protocol of management of shoulder Pain was created establishing the patient’s pathway from general practice to orthopaedic surgery. A clinical specialist physiotherapist was trained to lead a shoulder clinic, with shoulder treatment courses, shadowing of consultants at 3 shoulder clinics and in-service training on interpretation of x-rays with consultant radiologist. A course on injections taught by consultants was followed by a training period of 10 supervised injections. After this initial period, a letter was sent to all GPs in the catchment area informing that patients could be referred direct to the physio-shoulder clinic. In addition, patients coded for a primary consultation were also re-directed to that clinic. Only patients who did not improve after the initial treatment or who presented more complicate screening problems were redirected through a short cut to the consultant led clinic. A patient satisfaction questionnaire was used during the first 5 months. Results – Over the first 2 years of the project, extending from November 2001 to December 2003, 203 patients were appointed to the open shoulder clinic. The first 60 patients were given the patient satisfaction questionnaire, with 47 returning it completed (78.3%). 28 of the 47 had been seen by a physio before. In a satisfaction scale of 1 to 5, 2 graded 3, 3 graded 4 and 42 graded 5 the advice received about their condition. In a similar scale 2 patients rated 3, 2 rated 4 and 43 rated 5 regarding their satisfaction with the opportunity to discuss their treatment/care options. Regarding arrangements for further care, 1 rated 1, 2 rated 3, 6 rated 4 and 36 rated 5. For overall satisfaction 1 rated 2, 2 rated 3, 2 rated 4 and 42 rated 5. Positive aspects of patient’s feedback included ample time to ask questions, improvement obtained with early start of treatment and more accessible discussion. Those who were not so satisfied were still worried with a long delay, difficulty in peripheral arrangements such as transport and parking and disappointment with long time for follow-up examinations such as MRI scans. 47% of the patients attending were followed up by Physiotherapy only, 18% were added directly to the surgical waiting list and 4 were referred for rheumatology. 22% were sent for further tests (MRI, USS). The waiting list for a first appointment in our upper-limb clinic was reduced from 46 weeks in 2001 to 36 weeks in 2003. Not a single patient insisted on seeing a consultant and 38% of the patients were discharged without specifically seeing one. Conclusion – This study shows that a physio screening shoulder clinic is an effective and satisfactory way to reduce waiting times and improve patient care

Aims

The Patient-Reported Outcomes Measurement Information System (PROMIS) has demonstrated faster administration, lower burden of data capture and reduced floor and ceiling effects compared to traditional Patient Reported Outcomes Measurements (PROMs). We investigated the suitability of PROMIS Mobility score in assessing physical function in the sequelae of childhood hip disease.

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The purpose of this study was to determine whether there were long-term differences in outcomes of reverse shoulder arthroplasty (RSA) undertaken for acute proximal humeral fracture versus rotator cuff deficiency with a minimum follow-up of five years.

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To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).

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Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making.