A retrospective analysis of all paediatric patients admitted to Camp Bastion Role 3 between June 2006 and March 2013 was conducted from the UK trauma database. Patient demographics, mechanism of injury, anatomical distribution of injury and treatment are described.

Two hundred and ninety eight children were admitted, 225 males with a median age of 9 years old. The highest number of cases (78) was recorded in 2011. Overall there were 55 fatalities (85.6% male). Most injuries were by IED (68% of cases) with 74% requiring operative intervention. Seventy-four percent of casualties had three or more anatomical regional injuries. Whilst the most commonly injured region was the lower limb (78%), head injuries were seen in 41%, abdominal injuries in 48% and thorax injuries in 44%. Debridement (including amputations) (59.4%) and laparotomy (30.6%) were the commonest operations performed. Sixty percent of cases were in theatre within one hour of arrival. Amongst survivors the mean ISS score was 17 and amongst fatalities 43; NISS 22 and 51; RTS 5.45 and 2.91.

Paediatric blast injuries represent a significant burden to medical facilities in contemporary conflict. Whilst limb injuries predominate, the proportion of head and torso injuries is higher than seen in adult blast injuries.

With the drawdown from Afghanistan focus turns towards future operations, and their demands on the DMS. Training for surgeons deploying to military operations will have to take into account the decreased opportunities and experience gained by current conflicts. The aim is to focus on current UK surgical training for military operations specifically. A comparison is made with US surgical training.

A questionnaire was distributed to UK military surgical consultants in General Surgery, Trauma and Orthopaedics and Plastic Surgery. A similar questionnaire was sent to deployed US surgeons in SE Afghanistan. Response rates of 55% were achieved. Respondents were questioned on their confidence to perform several key procedures. Most UK consultants were satisfied with their overall training for deployment. Satisfaction rates were high for the MOST course and Danish Surgery. US satisfaction with pre-deployment training was poor. The majority of respondents felt confident to perform all haemorrhage and contamination control procedures in an emergency. However, most felt training for military personnel should be lengthened by a year or more to include greater exposure to other specialties.

Whilst satisfaction with surgical training is high, many UK surgeons appear to suggest an increase in specialty exposure in preparation for future deployments.

Subacromial corticosteroid injections are a well-recognised management for chronic shoulder pain and are routinely used in general practice and musculoskeletal clinics. Mycobacterium tuberculosis (TB) of a joint is a rare presentation in the United Kingdom. International literature exists for cases of reactivated latent tuberculosis following intra-articular corticosteroid injections in a knee; however there are no reports of a primary presentation of undiagnosed TB in a joint following therapeutic corticosteroid injections.

A seventy-four year old lady presented with a one-year history of a painful shoulder, which clinically manifested as a rotator cuff tear with impingement syndrome. Following three subacromial depo-medrone injections, the patient developed a painless “cold” lump which was investigated as a suspicious, possibly metastatic lesion. This lump slowly developed a sinus and a subsequent MRI scan identified a large intra-articular abscess formation. The sinus then progressed to a large intra-articular 5×8 cm cavity with exposed bone (picture available). The patient had no diagnosis of TB but had pathogen exposure as a child via her parents.

The patient underwent three weeks of multiple débridement and intravenous amoxicillin/flucloxacillin to treat Staphylococcus aureus grown on an initial culture. Despite best efforts the wound further dehisced with a very painful and immobile shoulder. Given the poor response to penicillin and ongoing wound breakdown there was a suspicion of TB. After a further fortnight, Mycobacterium tuberculosis was eventually cultured and quadruple antimicrobial therapy commenced. Ongoing débridement of the rotator cuff and bone was required alongside two months of unremitting closed vacuum dressing. The wound remained persistently open and excision of the humeral head was necessary, followed by secondary wound closure. There were no extra-articular manifestations of TB in this patient. At present the shoulder is de-functioned, the wound healed and shoulder pain free.

This unique case study highlights that intra-articular corticosteroid can precipitate the first presentation of Mycobacterium tuberculosis septic arthritis. The evolution of symptoms mimic many other shoulder complaints making confident diagnosis a challenge. The infective bone and joint destruction did not respond to the management described in the current literature. There remains a further management issues as to whether arthroplasty surgery can be offered to post-TB infected shoulder joints.

Taking a TB exposure history is indicated prior to local immunosuppressant injection, particularly in the older age group of western populations and ethnicities with known risk factors.

The aim of this study was to describe the epidemiology of elite youth soccer knee injuries from prospective data collected from forty-one English FA Football Academies over a 5 year period. 12306 players were registered from U9 to the U16 age category.

We studied the incidence of injuries around the knee with particular emphasis upon those causing greater than 28 days time off sport.

There were 609 knee injuries with a mean incidence of 0.71 knee injuries per player per year and a median of 17 training days and 2 matches missed per knee injury. Increased injury rates were seen in older players, in competitive situations and in the latter stages of each half of play. Peaks in injury numbers were seen in early season and subsequent to the winter break. Sprain was the most common diagnosis with the Medial Collateral ligament affected in 23.2% of cases. 609 injuries met the UEFA Model criteria for major injury. In total 60,091 training days and 5,272 match appearances were lost through knee injury.

Knee injuries are common in elite level youth footballers and are often severe in nature, resulting in large amounts of training time lost to injury. Diagnosis of ligament sprain is common leading to prolonged time off, and may mask more serious pathology or inappropriate management.

Distal clavicle fractures have a significant non-union rate, and are often managed operatively. Many of the fixation devices used have a high complication rate or require removal. An arthroscopic technique using the Tightrope device (Arthrex) has been used in our institution. We aimed to describe our initial results.

Eighteen cases were identified retrospectively, and the notes and radiographs reviewed. Twelve patients were male, six female, with mean age 33 years. All fractures were displaced, lateral to the coraco-clavicular ligament complex: six showed marked comminution. Mean follow-up was thirteen weeks. Fifteen fractures united, with a mean radiological time to union of 8 weeks (range 6-13 weeks). There were three surgical complications. In one, the clavicular button was not seated correctly on bone, and early failure required revision surgery. In another, there was inadequate reduction, radiographic non-union at five months and subsequent device failure. In the last, there was radiographic non-union, but the patient was asymptomatic.

The arthroscopic tightrope device provides minimally invasive stabilisation and reliable union. The complications seen were related to incorrect technique, and anticipate the complication rate to diminish as the technique is developed. We recommend the use of this technique for the stabilisation of distal clavicle fractures.

Objective: To ascertain the epidemiology of ankle injuries in elite youth football.

Design: Retrospective analysis of prospectively collected injury data from English Football Association Academies.

Setting: Forty-one FA Football Academies, between 1998 and 2006.

Participants: For the complete seasons studied, a total of 14776 players were registered from U9 to the U16 age category – a mean of 2463 players per year. All ankle injuries of sufficient severity to miss 48 hours or more training were studied – 2563 injuries in total.

Main outcome measurements: The incidence and burden of ankle injuries in this population, and factors associated with injury.

Results: There was a mean incidence of one ankle injury per player per year, and a mean of 20 training days and 2 matches were missed per ankle injury. Increased injury rates were seen in older players, in competition and later in each half of match time. Peaks in injury were observed early in the season and after the winter break. In competition, more injuries were associated with a contact situation than in training. Eighty-eight injuries (3.4%) required a lay-off of three months or more and in 18 (0.7%) cases, the player failed to return to training. In total, 52290 training days and 5182 match appearances were lost through ankle injury. The majority of injuries were sprains, but more severe injuries occurred accounted for 3.9% of the total.

Conclusions: Ankle injuries are common in young football players, and are often severe, with prolonged loss of training time. This has potential far reaching implications, both on and off the field. Further syudy in this area is suggested.

Introduction: Following successful introduction in 2007, all training programs except two participated in 2008. The examination was run along the principles of curriculum based, online delivery with immediate results and providing supportive information for the questions. The examination remains free of charge for the trainees and is supported by an educational grant from Depuy.

Material and methods: In 2008 a UKITE review board was appointed to create good quality questions with supportive information. We took on board the feedback from 2007 examination. Some questions from the 2008 examination were reported as ambiguous. The review board met and ambiguous questions were deleted from the examination and the scores recalculated.

Results: 648 trainees took UKITE 2008. Central organisation (86%) and local organisation (90%) were acceptable. 95% felt the examination pages were easy to use. There was difficulty in accessing the examination from NHS networks in some centers on the final day. 95% found there was educational benefit and 99% would like to sit again in 2009.

In the feedback from UKITE 2008, 85% of trainees felt it was better quality than 2007. The trainees approaching the FRCS examination are interested in using the database towards preparation.

In 2009 we aim to open the examination for SAS doctors, other surgical specialties and international trainees through elogbook.org.

Conclusion: UKITE has made progress in 2008. We aim to improve it further and open it to SAS doctors, other specialties and international trainees in 2009.

The aim of this randomised, controlled trial is to compare subacromial steroid injections, physiotherapy and both interventions with a control treatment in early painful arc of the shoulder.

Over a six-month period patients with “painful arc”, of less than six months duration, were recruited via their GPs. Eligible patients were consented to enter the trial and were then randomised, by sealed envelopes, to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. The interventions and clinic follow-ups were over an 18-week period. A final postal questionnaire was sent out at one year. The progress of the patients was monitored using the Oxford Shoulder Score (OSS) and the SF36 general health questionnaire.

Seventy-nine GPs referred 186 patients, of whom 112 were randomised (Control=27, EMTP=29, Injections=28, Both=28). 64 patients were female and 48 male. The mean age was 54.5 years (range 23–88 years). Ninety patients completed the trial (Control=20, EMTP=22, Injections=26, Both=22). Sixty-two returned the follow-up questionnaire. By paired sample t-tests, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the intervention period, or at one year. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups.

We have found no significant differences in outcome between steroid injections, a physiotherapy package, both treatments, or symptomatic treatment in our group of patients presenting with symptoms of painful arc of the shoulder.

Aims: The use of the Oxford Shoulder Score (OSS) and the Shoulder Pain and Disability Index (SPADI), both patient-administered functional scoring systems, have been validated in groups of patients presenting with a variety of shoulder conditions. The aim of the present study is to determine the test-retest reliability for these scoring systems in patients with a clinical diagnosis of subacromial impingement.

Methods: All patients attending a specialist shoulder clinic with a likely diagnosis of subacromial impingement over a ten-week period were sent the OSS and SPADI questionaires in the week prior to their appointment. Those who, after history and physical examination, had a confirmed diagnosis of impingement were asked to complete the scores again prior to treatment. The pre-attendance and attendance scores were then analysed by the Kappa statistic and correlation coefficent for individual items, and by reliability coefficient for the total score.

Results: Thirty-eight patients completed the scoring questionnaires pre-attendance and in the clinic. For the OSS, the Kappa statistic gave poor agreement (0.127) for one question about pain, but moderate to good for the remainder (0.440 to 0.794). Similarly, the correlation coefficient for individual items on the SPADI scale showed one functional item with a result of 0.584, but the other twelve items ranging from 0.668 to 0.947. Taken as scores out of 100, the mean difference in total OSS was 0 (95% CI −2.3 to +2.3), with a coefficient of repeatability of 14.7. The mean difference in SPADI was 1.0 (95% CI −2.23 to + 4.23), the coefficient of repeatability being 20.69.

Conclusions: The OSS and SPADI show good test-retest reliability for individual question items and as overall scores in patients with subacromial impingement.