Background: Growing demands upon orthopaedic services in the United Kingdom have resulted in increasing waiting times for orthopaedic consultations. The increasing pressure of new government targets has led to role delegation within the NHS. Magnetic Resonance Imaging (MRI) is a limited resource that requires judicious and validated use. We evaluated the use of MRI in the assessment of patients presenting with back pain to a service managed by an Physiotherapy Extended Scope Practitioner (ESP) working in a secondary care referral centre, against the standard as practiced by orthopaedic surgeons in a separate secondary care referral centre without a dedicated operative spinal service.

Methodology: A retrospective review of 130 lumbar MRI scans requested by an ESP service was compared with a retrospective review of 145 lumbar MRI scans requested by orthopaedic surgeons. In both cases cross-site tertiary referral was required if surgery was to be considered. Presenting symptoms and signs, abnormalities detected on the MRI scans and subsequent management were recorded with rate of listing for operative management used as a measure of appropriate MRI usage. Simple descriptive analysis was undertaken.

Results: 82% and 91% respectively of orthopaedic and ESP referrals for MRI had either neurological signs or symptoms. However, a higher rate of neurological signs was reported by ESP 70% versus 42%).

Despite reported differences in patient presentation the abnormal scan rate was comparable (ESP 91%, orthopaedics 92%).

The tertiary referral rate was also comparable (ESP 47%, orthopaedics 37%).

Of the patients referred to the tertiary referral centres the percentage listed for operative intervention was 68% and 72% respectively for ESP and orthopaedic surgeons. In terms of the number of patients investigated by MRI scan 32% and 26% of patients from the ESP and Orthopaedic centres respectively were listed for surgery.

Discussion: This study shows that physiotherapy ESP use of MRI in the investigation of patients presenting with back pain is comparable to orthopaedic surgeons in a centre without a dedicated spinal service. With adequate training and knowledge of red/ yellow flag signs applicable to assessment of spinal problems we support the role of physiotherapy ESPs in the assessment of patients with spine related problems.

We describe the results of treatment of open tibial fractures in 92 children; 22 fractures were Gustilo type I, 51 type II and 19 type III. All children received tetanus prophylaxis, systemic antibiotics for 48 hours and thorough debridement and irrigation of the wound. Fifty-one wounds with minimal soft-tissue injury were closed primarily. The other 41 were initially left open; of these, 18 small wounds were allowed to heal secondarily and 23 larger wounds required split skin grafts or soft-tissue local or microvascular free flaps. Stable fractures were reduced and immobilised in an above-knee plaster cast (71%) and external fixation (28%) was used for unstable fractures, extensive soft-tissue injury and multiple injuries. Short-term complications included compartment syndrome (4%), superficial infection (8%), deep infection (3%), delayed union (16%), nonunion (7.5%) and malunion (6.5%): these incidences are similar to those reported in adults. Selective primary closure of wounds did not increase the incidence of infection. External fixation was associated with a greater occurrence of delayed and nonunion than plaster immobilisation, but this technique was used most often for the more severe injuries. Late review, at 1.5 to 9.8 years, showed a high incidence of continuing morbidity including pain at the healed fracture site (50%), restriction of sporting activity (23%), joint stiffness (23%), cosmetic defects (23%) and minor leg-length discrepancies (64%). Open tibial fractures in children are associated with a high incidence of early and late complications, which are more frequent in children with Gustilo type III injuries. The Gustilo classification was a useful guide for predicting the outcome and planning treatment.

A prospective randomised clinical trial was undertaken to compare biodegradable polyglycolic acid pins with standard Kirschner wires used to fix displaced elbow fractures in children. Twenty-four children were enrolled in the trial; 14 had fractures of the lateral condyle of the humerus, eight of the medial epicondyle and two had olecranon fractures. Eleven fractures were fixed with Kirschner wires and 13 with polyglycolic acid pins. Fracture union with full function occurred in all cases within six months. Kirschner wires caused problems including infection in three cases, soft-tissue ossification in one and they required removal under general anaesthesia in nine cases. No such complications occurred with polyglycolic acid pins but one patient in this group developed avascular necrosis and premature fusion of the medial epicondyle.

We reviewed a series of 91 patients with deep infection of a cemented total hip arthroplasty caused by coagulase-negative staphylococci (C-NS). Of these, 72 were treated by one-stage exchange arthroplasty with a failure rate of 13% due to recurrence of infection. The other 19 patients have started or completed treatment by a two-stage exchange without failure to date. In 27 of the 91 patients multiple strains of C-NS were discovered, many being resistant to previously used antibiotics. The use of gentamicin-containing cement in the primary arthroplasty was significantly associated with the emergence of gentamicin-resistant C-NS in subsequent deep infection. Bacteriological diagnosis of such infections must take into consideration the possibility that multiple strains of the organism are involved.

Three cases of anterior interosseous nerve palsy were diagnosed after internal fixation of fractures of the proximal radius. The suggestion that the nerve was injured at operation by bone-holding forceps was supported by operations on 12 cadaver forearms, in which the nerve was frequently trapped. Care should be taken to place such forceps in a subperiosteal plane.