29 cases of complex elbow injuries were reviewed at a mean period of 15 months. Outcome measures included MEPS and DASH score. Patients who had defined early surgery were significantly better than those in whom surgery was delayed. We concluded that Management of complex elbow injuries can be improved by early definitive surgery. The magnitude and type of soft tissue injuries should be identified. MRI scans should be liberally used for this purpose. We believe that early, adequate and appropriate management of soft tissue injuries including use of articulated external fixator for early mobilisation improves the outcome of complex elbow injuries.

Contoured locking plates are commonly used to fix the proximal humerus fractures. Their long-term results are unknown. We present long-term radiological and functional outcome of three and four part fractures of the proximal humerus treated with PHILOS plate.

We prospectively analysed 53 consecutive three and four part proximal humerus fractures treated with PHILOS plate between 2002 and 2007. Patients were assessed using Oxford Shoulder Score and DASH score. 44 fractures (21 three part and 23 four part) were available at the final follow up.

At a mean follow-up of 8.5 years (6.4 years–10.8 years) the average Oxford Shoulder Score was 43.9 (range 23–48) and the average DASH score was 7.7 (range 0–36.7). 30% of patients required re-operation (five for hemiarthroplasty, three for impingement syndrome, five for removal of implant). Avascular necrosis (AVN) developed in 10 patients, of which only three required hemiarthroplasty. All except one patient were satisfied with the result of their operation.

Our study supports the use of locking plates for the treatment of three and four part proximal humeral fractures. In spite of some patients requiring secondary surgical intervention in the first few years, the function of the shoulder continues to improve and in the long term patients were satisfied with the outcome. An important finding of our study is that the post-traumatic AVN of humeral head does not necessarily need major surgical intervention. We believe that the possibility of avascular necrosis should not be a major determinant in the choice of surgical treatment of proximal humeral fractures.

Lunate or perilunate dislocations are common carpal injuries. Current treatment of these injuries by repair or reconstruction of intra-carpal ligaments is largely based on Mayfield's description of sequential failure of these ligaments.

We do treat significant number of these injuries. We have observed that dorsal wrist capsule is attached to dorsal aspect of proximal carpal row and its interosseous ligaments by vertically oriented identifiable fibres. This can be seen as carpal bones suspended from dorsal capsule, akin to cloths suspended from a washing line. We have also observed that in lunate or perilunate dislocations, dorsal capsule is peeled off from the dorsal aspect of lunate and distal radius, similar to a Bankart lesion in the shoulder. We believe that dorsal capsule plays a bigger role in the stabilising mechanism of carpal bone than the intercarpal ligaments. It has not been described before.

We dissected three cadaveric wrists and found vertical fibres running from dorsal wrist capsule/ligaments to the dorsal components of the scapholunate and lunotriquetralinterosseous ligaments. We have modified the Mayo approach to dorsal wrist capsule and use suture anchors to attach dorsal capsule/ligaments to scaphoid, lunate and triquetrum rather than repairing intra-carpal ligament. We have used this technique in 26 patients so far. Follow up for more than 4 years have shown satisfactory results and no significant recurrence of instability.

We present a novel, so far unreported, method of repairing the intracarpal injuries, using the dorsal capsule/ligaments, based on anatomic and intra-operative observations.

Split tendons are widely used for reconstructive procedures around wrist and hand. Different materials are used to split the tendons. There is no consensus about the most suitable material for splitting a live tendon. We compared a range of commonly available suture materials to find the best material for the purpose.

11 different suture materials (Vicryl 2/0, Ethibond 0, Ethibond 2/0, Prolene 2/0, Prolene 3/0, Silk 2/0, Steel Wire 2/0, Steel Wire 3/0, Steel Wire 4/0, PDS 2/0, Fibrewire 2/0) were used to split the flexor tendons of pig’s trotters. They were assessed for

their ablity to split the tendon successfully,

Each material was tested on 3 different tendons at different times. Quality of split tendons were assessed by 2 independent and blinded observers.

All suture materials except Vicryl 2/0 were successful in splitting the tendon. Silk produced a poor quality split whilst steel wire and fibre wire resulted in excellent quality grafts. The rest produced intermediate results. The force required to split the tendon was the least for PDS 2/0 followed by Fibrewire. Steel wire and silk required higher forces to split the tendon.

From our study we concluded that fibre wire is the best material to split a live tendon as it produced a high quality split with excellent handling characteristics and required minimal strength. Wire suture produced a high quality split, however they were awkward to use as they necessitated use of a holder due to the higher forces required to split the tendon.

We describe a new technique for fixing the proximal pole scaphoid fractures both in acute and chronic setting and present our preliminary results.

We prospectively studied fixation of 25 proximal pole scaphoid fractures (1 acute displaced and 24 non unions) with this technique between 1999 and 2007. Mean age of patients was 25 years and mean time to the operation was 6 months.

The technique involves making a transverse dorsal incision over the radius along the radio-carpal junction. The retinaculum is split in line with its fibres. Access to the radio-carpal joint is achieved through the third extensor compartment. The ligament attachment to the scaphoid is preserved by using a modified Mayo approach. A window is created initially at the proximal end of the dorsal ridge. The fracture is reduced and stabilised with an appropriate length Herbert screw. The fracture site is curetted through this window and cancellous bone graft from the distal radius is packed into the fracture site. The capsule and extensor retinaculum is then closed in layers.

Radiological union was achieved in 23 cases, one case required refixation and one case was lost to follow up. Our technique is tendon sparing, capsule retaining, and ensures maintenance of articular surface congruity. So far this technique has led to excellent results.

Scaphoid non-union usually requires surgical treatment in form of reconstructive or salvage procedure. Imaging helps in planning the surgical procedure. Wrist arthroscopy may also be helpful in the pre-operative assessment. This study was conducted to find the usefulness of wrist arthroscopy in formulating a management plan to treat scaphoid non-union.

We prospectively studied 17 patients of scaphoid non-unions by wrist arthroscopy. Non-union was assessed; and site and extent of any articular wear if present was noted. Some patients had additional procedures such as synovial debridement, removal of loose bodies or debridement of TFC tears. It was possible to formulate the further management plan at the same time.

Our study included 14 men and 3 women with a mean age of 34.5 years (range 18 to 49). Arthroscopic findings included mild radiocarpal wear in 3 cases and severe articular wear in 1. Additionally, in two thirds of cases there was some degree of wear present over the radial styloid region. 6 cases had TFCC tears. 4 patients had synovial debridement and in 5 cases loose bodies were removed. Based on the arthroscopic findings, it was decided to proceed to a reconstructive procedure in 12 cases and a salvage procedure in remaining 5.

We concluded that in scaphoid non-unions:

Articular surface wear is often less than suggested by imaging.

Introduction: We performed a prospective cohort study to investigate the comparability of subjective and objective assessment scores of shoulder function following surgery for rotator cuff pathology.

Materials and Methods: A consecutive series of 372 patients underwent surgery for rotator cuff disorders with post-operative follow up over 24 months. 248 patients solely underwent subacromial decompression, whereas 124 had additional rotator cuff repair (93 arthroscopic; 31 open). Assessments were made pre-operatively, and at 3, 6, 12, and 24 post-operative months using the Disabilities of the Arm, Shoulder, and Hand (DASH) score; Oxford Shoulder Questionnaire (OSQ); and the Constant score, which was used as a reference. Standardisation calculations were performed to convert all scores into a 0 to 100 scale, with 100 representing a normal shoulder. The student’s t test was used to compare the mean score for each subjective tool (DASH and OSQ) with the objective score (Constant) at each time point. Correlation coefficients (Pearson’s) were used to analyse the changes with time (post-operative course). Each statistical test was used for all surgeries collectively and for the individual surgery types.

Results: The relationship between the DASH and the Constant score was robust in all types of surgery. The relationship between the Oxford and Constant was generally robust, except in the open rotator cuff group. There was no statistical difference between the mean DASH and Constant scores for all interventions at each time point. A significant difference was seen between the mean Oxford and Constant scores for at least one time point in all but the open rotator cuff repair group.

Conclusion: We demonstrate the DASH and Oxford scoring systems would be useful substitutes for the Constant score, obviating the need for the trained investigator and specialist equipment required to perform the Constant score, alongside the associated cost benefits.

Complex proximal humerus fractures have been described as the unsolved fracture. Review of literature shows a variety of treatment methods and results. We present the results of a prospective study of 47 complex proximal humerus fractures treated by PHILOS (Proximal Humeral Internal Locking System) plate. The aim of this study was to assess the effectiveness of the PHILOS plate in the surgical treatment of Neer’s type 3 & 4 fractures.

We operated upon 47 patients (mean age 56yrs) between March 2002 and January 2006 for fixation of 3 part (28 patients) and 4 part (19 patients) fractures at a level 1 trauma centre. An independent observer reviewed patients at 6 monthly intervals for clinical and radiological assessment. Outcome measures included DASH and Constant scores.

42 patients were available for follow up, which ranged from 12–66 (average 24.4) months. Recovery of movements, and relief in pain was satisfactory in most of the patients, but the strength of shoulder did not recover fully in any patient. There were two failures in our series, one due to breakage of plate and another due to non-union; both treated successfully by revision. 4 patients (8%) had radiological signs of avascular necrosis of humeral head but only 2 of them were symptomatic requiring further treatment. Pain due to impingement was noted in several patients leading to removal of plate (6 patients) and subacromial decompression (3 patients). We encountered the problem of cold welding and distortion of screw heads, while removing the plate. The broken plate was subjected to biomechanical and metallurgical analysis, which revealed that the plate is inherently weak at the site of failure.

We concluded that in spite of the above-mentioned complications, the PHILOS plate is a reliable implant to fix 3 and 4 part proximal humeral fractures. We were particularly impressed with the satisfactory results of fixation in 4 part fractures. However, we are not convinced about its strength. The plate may cause impingement in some patients necessitating its removal later on, which itself may not be easy.

Level of Evidence: Therapeutic study, level IV (case series).

Four part (Neer’s) proximal humeral fractures if treated by fixation are prone to develop avascular necrosis of humeral head; requiring further treatment and possible reoperation. This has led to the popularity of hemiarthroplasty as the primary treatment in these fractures. Since the availability of contoured locking compression plate (PHILOS) in our unit, we have treated most of the 4 part proximal humeral fractures by internal fixation. The aim of this study was to assess the usefulness of the PHILOS plate in the treatment of these fractures.

We prospectively reviewed 21 patients (mean age 57 yrs) operated between March 2002 and January 2006 at a level 1 trauma centre, using 3/5 hole PHILOS plate for fixation. An independent observer reviewed them postoperatively at 6 monthly intervals for clinical and radiological assessment. Outcome measures included DASH and Constant score. A SPECT/bone scan was done in appropriate cases.

18 patients were available for follow up, which ranged from 12–66 (average 24.4) months. Recovery of movements and relief in pain was satisfactory in most of the patients with mean Constant score of 63 points (range 37 to 95) and DASH score of 20 points (range 15–78) at last follow up.. We encountered a few complications including non-union (1); implant breakage (1) and impingement (4). Only one patient in our series required hemiarthroplasty; out of two who developed symptomatic avascular necrosis. Patient satisfaction was high in spite of moderate Constant score. Removal of PHILOS plate was difficult in some cases due to problem of cold welding and distortion of screw heads. The broken plate was subjected to biomechanical and metallurgical analysis, which revealed that the plate is inherently weak at the site of failure.

Our series is comparatively small to draw any firm conclusions but we feel that with the availability of better implants, there is a case to consider the fixation rather than arthroplasty as the primary treatment of 4 part proximal humeral fractures.

Level of evidence: Therapeutic study – Level IV (prospective case series)

Proximal humeral fractures are common injuries but there is no general agreement on the best method for fixing unstable and displaced 3 & 4 part fractures. A new implant – Proximal Humeral Internal Locking System (PHILOS) – has recently been introduced to fix these fractures. The aim of this study was to assess the effectiveness of the PHILOS plate in the surgical treatment of these fractures.

We operated upon 36 patients between March 2002 and December 2004. 33 of them were available for follow up, which ranged from 12–45 months. Assessment at follow up included radiological review, Constant and DASH scoring.

While recovery of movements and relief in pain was satisfactory, the strength of shoulder did not recover fully in any patient. There were two failures in our series, one due to breakage of plate. 4 patients have shown radiological signs of avascular necrosis of humeral head. The plate was removed in 4 patients due to impingement and / or mechanical block in abduction. Another 2 patients had to undergo arthroscopic subacromial decompression for the same reasons. We encountered the problem of cold welding and distortion of screw heads, while removing the PHILOS plate.

The broken plate was subjected to biomechanical and metallurgical analysis, which revealed that the plate is inherently weak at the site of failure.

The PHILOS plate does have inherent advantages over other implants for fixation of 3 and 4 part proximal humeral fractures but we are not convinced about its strength. Design of its proximal screws also appears less than satisfactory. The plate may cause impingement in some patients necessitating its removal later on, which itself may not be easy.

BACKGROUND: With the improvement of the ultrasound technology, there has been an increasing ability to image the soft tissues of the hand and wrist. This means structures such as tendon, ligaments and soft tissues can be visualized both statically and dynamically.

AIM: The aim of our study was to audit the types of cases who have undergone ultrasound imaging in different hand conditions in last two years.

MATERIAL AND METHODS: We studied 123 ultrasound and looked for its use in different hand and wrist conditions. These were categorized in different groups such as diagnostic, anatomical and therapeutical.

RESULTS: In our 123 patients, 49 had lumps out of which 30 ganglions, 7 vascular, 4 glomus tumours, 2 granulomas, 4 neuromas, 1 lipomas and 1 sarcoma. In another 30 patients it was useful to diagnose tendon conditions such as inflammation, rupture, triggering. Furthermore, in 31 patients it was used for diagnosis of carpal tunnel syndrome. In addition, it was used for many miscellaneous conditions.

DISCUSSION: Ultrasound is a useful tool for imaging of soft tissues in the hand. It can differentiate between solid and cystic swellings and can be used to aspirate and / or inject the later. It allows dynamic viewing thus making it an important tool in assessing complex tendon problems. We feel that it is a convenient, dependable and useful aid in diagnosing various hand conditions and should be available for widespread use.

Proximal humeral non-unions are uncommon, but when they occur they are disabling and often present a surgical challenge.

We have treated 55 cases of proximal humeral fractures by internal fixation from March 2002 to March 2004. Of these, 18 were non-unions out of which 16 were treated using AO Cannulated blade plate and bone grafting. Results of these patients are presented in this report.

14 out of 16 were available for follow up, which ranged from 18–30 months. Patients were regularly reviewed clinically and radiologically and had constant and DASH scoring at final follow up. Average Constant score was 64 and DASH score was 35.3. Range of movement recovered to 50% or more in every patient but only 3 had full range of movements. Maximum recovery in the strength of shoulder muscles measured with myometer was about 75% as compared to other side. Although X-rays showed sound bony healing in all but one case, none of the patients was completely symptom free at final review. However, they were all satisfied with the outcome of their operation.

Stable internal fixation is the key to success of surgical treatment of non-unions. We are satisfied with the usefulness of AO cannulated blade plate in providing a rigid fixation in our cases. However, it is difficult to achieve perfect results in terms of pain relief and recovery of normal function due to various reasons, which would be highlighted in our presentation. The report would also discuss the technical difficulties encountered in using this implant.

Disorders of the pisotriquetral joint can cause ulnar sided wrist pain. This joint is not usually seen during routine wrist arthrosopy because it often has a separate joint cavity. The senior author believes that it is more commonly seen from the 6R portal if looked for, than one would expect from the assumed anatomy.

This study assessed the frequency with which the pisotriquetral joint could be observed in 36 consecutive wrist arthroscopies. The connection between the radiocarpal and the pisotriquetral joint were found to vary from a complete membrane separating the two, to no membrane at all, with variations in between. The types of connections are described. The anatomy of the connections was also studied by dissecting the wrist joints of eight fresh frozen cadavers. The findings matched the arthroscopic observations.

In more than 50% of patients, the pisotriquetral joint could be clearly visualised by arthroscopy. The technique and findings have been recorded on video and form part of the presentation.

Certain cases of patello-femoral maltracking can lead to articular surface wear. Though most can be treated non-operatively, where there is increasing wear surgical intervention may be necessary. Patellar tracking is difficult to assess and though several different types of maltracking or loading have been described, each case warrants precise assessment of the wear patterns. Without this knowledge a logical approach to realignment surgery is impossible.

60 consecutive cases (age range 18–50 years) presenting with anterior knee pain were arthroscoped over a 4 year period. These patients all had been selected with either patellar instability or surface wear indicated either clinically, a positive radiograph, bone scan or MRI.

All patients were arthroscoped through standard anterolateral and antero-medial portals and also a superolateral and occasionally a supero-medial approach. The areas of articular damage were mapped on diagrams and recorded photographically. Patella views were taken in flexion and extension, and on passively stretching the patella medially and laterally.

We found 6 distinct patterns of wear which appear to indicate 6 different maltracking abnormalities. The largest group, 46 patients, consisted of lateral trackers, with 21 patients demonstrating medial facet and lateral femoral condylar wear.

Assessment of the articular surface of the patello-femoral groove from inferior portals is highly misleading and superior portals are needed for proper assessment. Medial facet wear can occur in lateral instability or medial compression. Lateral maltracking at engagement or distally are the commonest patterns.