Aims

Carpal malalignment after a distal radial fracture occurs due to loss of volar tilt. Several studies have shown that this has an adverse influence on function. We aimed to investigate the magnitude of dorsal tilt that leads to carpal malalignment, whether reduction of dorsal tilt will correct carpal malalignment, and which measure of carpal malalignment is the most useful.

We aim to describe mortality in orthopaedic patients with Clostridium difficile associated diarrhoea (CDAD), to identify prognostic factors for 30 day mortality, and to modify a CDAD risk score to fit to orthopaedic patients.

This was a two centre, retrospective, observational study including consecutive patients with a first episode of CDAD between 2005–2007. 79 patients were identified, comprising 11 elective patients (14%) and 68 emergency patients (86%). 73 patients (92%) underwent surgery and all but two patients received broad spectrum antibiotics prior to CDAD. The overall 30 day mortality was 29% (n=26). The predominant diagnosis was a fractured femoral neck (66%, n=52).

The most significant multivariable model in predicting 30 day mortality comprised increasing white cell count (WCC, OR 1.20 [for 10% variable increase]; 95% CI 1.06–1.36 p=0.003) and decreasing albumin (OR 0.86 [for single unit decrease]; 0.86–0.95, p=0.003), with adjustment for age ł80 years (OR 6.39, 1.15–35.52, p=0.04). CRP was found to be not significant. Based on this, modification of the previously described Clostridium difficile prognostic index leads to a point awarded for WCC ł20, albumin Ł20, age ł80, urea ł15 or clinically severe disease (peritonitis, sepsis, ł10 episodes of diarrhoea per day). This produces low (0–1 points), medium (2–3 points) and high (4–5 points) risk of death groups, with mortalities of 15%, 47% and 75% respectively for all orthopaedic patients, and 14%, 41% and 67% respectively in only the validation cohort.

CDAD in orthopaedic patients mainly affects emergency patients, in particular those with fractured femoral neck. Inpatient mortality is high, and a high white count and low albumin are significant predictors of mortality. Modification of an easily remembered scoring system based on this can help identify orthopaedic patients likely to die from an episode of CDAD, allowing early aggressive therapy and early objective referral to gastrointestinal teams.

Background: An important sign in the assessment of distal radioulnar joint instability is the ballottement test were passive movement of the affected joint is compared to the contralateral normal side. The subjective appreciation of increased laxity renders the test positive.

In cases in which the contralateral side can not be tested or is known to be abnormal the relevance of the ballottement test is compromised.

Based on the observation that distal radioulnar joint passive mobility decreases in normal subjects when the wrist is radially deviated we propose a modification of the ballottement test in which mobility of the DRUJ is tested both in radial and ulnar wrist deviation.

Objectives: We aim to verify the observed decreased range of motion of the DRUJ in normal individuals when assessed in radial deviation compared to ulnar deviation and report the intraoperative findings of a series of patients who demonstrated an abnormal modified ballottement test in the abscense of bony deformity in the DRUJ.

Method: A group of 38 healthy volunteers (76 wrists) with no history of significant wrist injuries were assessed and the amount of DRUJ mobility given a subjective score of between 1 and 3. All wrists were assessed in ulnar and radial deviation as well as in neutral. The average age of the participants was 32.4 years. There were 22 female and 16 male subjects.

Our clinical case series reports the review of clinic notes and operative records of 32 patients (age gender) (32 wrists) who demonstrated an abnormal modified ballottement test and whose degree of instability granted surgical intervention.

Results: Out of the 76 normal wrists, 72 demonstrated decreased range of movement of the DRUJ in wrist radial deviation compared to examination in neutral or ulnar deviation. In the remaining 4 no difference was perceived but examination in neutral was considered “stiff” (less than average on the examiners experience).

All patients in the case series were found to have an ulnar detachment of the dorsal aspect of the TFCC (Palmer 1B) for which they underwent open repair.

Conclusion: DRUJ mobility in normal wrists decreases in radial deviation compared to neutral.

The observed decreased mobility of the DRUJ is likely to be due to tightening of the ulno-carpal ligaments.

An abnormal modified ballottement test was an indicator of severity as those with a positive result required surgical intervention and also correlated with the anatomical lesion found at surgery (Palmer 1B TFCC tear)

We believe the proposed modification enhances the diagnostic value of the DRUJ ballottement test and also allows to detect abnormalities in those cases in which the contralateral side can not be examined.

The aim of this study was to assess the outcome of a pre-contoured anatomic plate in the treatment of midshaft clavicle fractures.

We treated thirty patients consecutively for middle third clavicle fractures between March 2001 to March 2006. Surgery was performed for acute fractures, non-unions and malunions by a senior surgeon.

Fifteen patients were treated by open reduction and internal fixation with a precontoured small fragment clavicle plate (mean age of thirty-eight years).

Our control group consisted of a consecutive series of fifteen patients treated by internal fixation with conventional plates (mean age of forty-one years). Ten patients had fixation of their clavicles with a reconstruction plate whilst five patients had fixation with a dynamic compression plate (DCP).

Outcomes assessed for both groups were; complications, need for removal of plate, post-operative outcome, and time to union.

All patients were followed up for an average of eighteen months (range eight to thirty months). In the pre-contoured plate group none required removal of hardware. Five patients had complications. Three of these patients complained of numbness around the caudal aspect of the wound which subsequently resolved within six to eight weeks of the operation. The remaining two patients suffered from adhesive capsulitis postoperatively. Their symptoms resolved completely after four months. All patients regained full range of motion. All patients went on to clinical and radiological union with average time to union being 4.7 months (range three to ten months).

In the conventional plate group, nine patients required removal of their plate. Average time to removal of plate from index operation was 7.7 months (range four to thirteen months). Of the nine plate removals there were two plate breakages, five removals for local soft tissue irritation and two persistent painful non-unions. Three patients required subsequent re-plating for non-unions. All fractures united in this group with mean time to union of 5.4 months (range 2 to 14 months).

A pre-contoured clavicle plate provides rigid fixation without compromising plate stiffness and fatigue strength. We have successfully treated patients with acute fractures, nonunions and malunions of midshaft clavicle fractures, where there was gross distortion of normal anatomy. None of our patients required the removal of their plates (minimum follow-up of 8 months). We have also found these plates to be a valuable anatomical template when reconstructing a malunion, nonunion or highly comminuted fracture.

In conclusion, this is the first reported series demonstrating the use of anatomical pre-contoured plates for clavicle fractures. They can reduce time spent on intra-operative contouring, are low-profile and thus far, plate removal has not been necessary.

Coagulase-negative staphylococci produce an exocellular glycolipid antigen which has potential as a serological marker of infection in bone. The value of this newly detected antigen was investigated by enzyme-linked immunosorbent assay (ELISA) in 15 patients with culture-proven infection of prostheses caused by Gram-positive bacteria. The antigen was purified by gel-permeation chromatography from the culture supernatants of coagulase-negative staphylococci grown in a chemically defined medium.

There were significant differences (p < 0.0001) between the serum IgG and IgM levels in patients with infection due to Gram-positive staphylococci and those of a control group of 32 patients with no infection. The ELISA test, which has potential for the diagnosis of infection, may be valuable in distinguishing between staphylococcal infection around prostheses and aseptic loosening.