Introduction: K wiring is a popular technique to help maintain anatomic reduction of distal radial fractures. It has the advantage of being a semi-closed procedure, which is simple to perform. Complications related to K wires include infection, migration and damage to tendons and nerves.

We aimed to perform a randomized prospective study to determine the outcome of Buried versus Exposed K wire placement.

Methods: We prospectively recruited 60 consecutive patients with displaced distal radius fractures requiring K wiring to our study. They were randomized to Buried versus Exposed K wire groups.

Patient details were collected and follow up was performed at 2 and 6 weeks post op.

Infection at pin sites was measured on a 0 to 6 point scale. Superficial radial nerve was assessed with light touch and 2 point discrimination. EPL tendon was also assessed for damage.

Results: 60 consecutive patients were recruited to the study and randomized to buried or exposed k wires. There were 30 patients in each group.

No damage to EPL tendon was recorded in either group at 6/52 follow up.

There was a slight increased rate of superficial infection at exposed pin sites noted at 2/52 follow up however this was not seen at the 6/52 follow up. Superficial radial nerve damage was noted in one case only. This was in the buried k wire group and occurred following removal of the radial wire.

Conclusion: There appears to be slight increased risk of superficial pin site infection in the exposed k wire group at 2/52 but this is not seen at 6/52 follow up. Buried k wires require a second procedure to remove the wires and this runs the risk of superficial radial nerve damage.

Introduction: K wiring is a popular technique to help maintain anatomic reduction of distal radial fractures. It has the advantage of being a semi-closed procedure, which is simple to perform. Complications related to K wires include infection, migration and damage to tendons and nerves.

We aimed to perform a randomized prospective study to determine the outcome of Buried versus Exposed K wire placement.

Methods: We prospectively recruited 60 consecutive patients with displaced distal radius fractures requiring K wiring to our study. They were randomized to Buried versus Exposed K wire groups.

Patient details were collected and follow up was performed at 2 and 6 weeks post op.

Infection at pin sites was measured on a 0 to 6 point scale. Superficial radial nerve was assessed with light touch and 2 point discrimination. EPL tendon was also assessed for damage.

Results: 60 consecutive patients were recruited to the study and randomized to buried or exposed k wires. There were 30 patients in each group.

No damage to EPL tendon was recorded in either group at 6/52 follow up.

There was a slight increased rate of superficial infection at exposed pin sites noted at 2/52 follow up however this was not seen at the 6/52 follow up. Superficial radial nerve damage was noted in one case only. This was in the buried k wire group and occurred following removal of the radial wire.

Conclusion: There appears to be slight increased risk of superficial pin site infection in the exposed k wire group at 2/52 but this is not seen at 6/52 follow up. Buried k wires require a second procedure to remove the wires and this runs the risk of superficial radial nerve damage.

Thus it would appear that leaving k wires exposed is the safer and more convenient method of K wiring the displaced distal radius fracture.

In a prospective randomized trial, we divided a group of patients with a clinically suspicious, although radiographically normal, acute fracture of the scaphoid into 2 groups, 1 treated with a cast (group I), the other with a splint (group II). There were 14 patients in group I, and 18 in group II. Patients were reviewed at 2,6, and 12 weeks for range of movement, grip strength, pain and satisfaction rating. Work disability costs were also calculated for both groups. Patients in group II had better range of movement and grip strength at 2 weeks, although complained of more pain. There was no difference in range of movement, grip strength, or pain at 6 or 12 weeks. Group II was more satisfied at 2 weeks, although not at 6 or 12 weeks. Group I required more time off work, and disability costs were significantly higher [€15,209 per person compared to €3,317 per person]. We recommend that all patients, with only a clinical suspicion of a fractured scaphoid, should have a short period of splint immobilization until symptoms resolve, or until further investigations reveal a fracture which can be appropriately treated. This policy is cost efficient and improves the short term outcome.

Introduction: Fasting overnight NPO (Nulla per os) has been routine before surgery for the past century. The practice was previously designed to reduce the risk of pulmonary aspiration on induction. However this practice has been challenged over the recent years and is changing anaesthetic practices are now more liberal. There are many new concepts aimed at improving patient outcome by regulating metabolic, endocrine, inflammatory and immune responses. This combined with better patient satisfaction and lower anxiety has led to research in this area.

Overnight fasting can induce post operative insulin resistance. Insulin resistance is related to infectious morbidity and increased hospital length of stay (HLOS). Previously this concept was only important in diabetic patients. Surgery places the body under metabolic stress and even a short period of fasting will change the metabolic state of the patient. Indeed physical trauma can cause a triad known as the “diabetes of injury”: insulin resistance, hyperglycaemia and glucose intolerance. Preparation for surgery by maintaining a fasted state and catabolic metabolism may have deleterious consequences for the patient.

Previous studies on elective patients has shown that pre operative carbohydrate loading can reduce insulin resistance and mitigate the inflammatory response by immunomodulation. It has not previously been shown to have an effect in the hip fracture population. This particular group of patients are often elderly and require medical and anaesthetic work up. This delay can mean that the patient is kept fasting for prolonged periods and often overnight.

Methods: With full ethical approval at Connolly Hospital we prospectively randomised all femoral and hip fractures for surgery. We excluded diabetics and pregnant women from the study. A high carbohydrate drink called Nutritia Pre Op was selected. Random serum glucose was taken on admission. Patients were randomised and selected for the trial by hidden ballot. Anaesthetic approval was sought for each case. We compared our standard treatment for hip and femoral fractures of strict NPO prior to surgery versus giving patients the Pre Op drink. Each carton was 200ml and up to 4 were given the night before surgery. In the morning the patients were given another 2 drinks. There was a strict minimum 2 hour NPO period before leaving the ward. Glucose levels were then taken at 1 and 12 hours post operatively to assess whether hyperglycaemia was present. As per laboratory values a normoglycaemia was considered as 4–6mmol/l. Gender, age, type of operation, HLOS, complications and re-admissions were noted.

Results: In total 17 patients were enrolled in the study. Group A had 9 patients and were kept NPO as the control group. Group B had 8 patients enlisted in the Pre Op Drink group. In group A, 6 of 9 (67%) patients had a post operative hyperglycaemia. Average age in group A was 79.6 years with an average HLOS of 15.8 days. 4 patients between them required 8 readmissions over a 3 month post operative period. Group B showed 2 out of 8 (25%) patients had a hyperglycaemia. They had an average age of 69 years with an average HLOS of 11.75 days. 4 patients required 4 readmissions.

Conclusions: Pre Op high carbohydrate drinks significantly decrease post operative hyperglycaemia as per the laboratory ranges. This in turn supports that it decrease insulin resistance by preparing the body for surgery in a fed state. In the same way that one would not prepare for a marathon by fasting 24 hours before hand so the body recognizes that the surgical stress is not best dealt with when in a fasted state. The control group had twice as many readmissions and a longer HLOS. Previous studies show that there is decreased anxiety, thirst and hunger both pre and post operatively. We have shown that this is a safe drink to give and that post operative hyperglycaemia was better controlled.

Introduction: It is standard procedure in our unit to use compartment pressure monitoring in all patients presenting with tibial fractures. A sustained difference of less than 30mmhg between the diastolic blood pressure and the compartment pressure (known as the delta pressure) is taken as an indication for fasciotomy.

Aim: To review the impact continuous compartment pressure monitoring has on the management of patients with tibial fractures.

Methods and materials: Between January 2004 and June 2006, 28 patients admitted to our unit following tibial fracture had a compartment pressure monitor inserted. The outer sheath from a 16G cannula connected to an arterial manometer was used in each case.

The records of these 28 patients were reviewed. Twenty three were male. Ages ranged from 19 to 83 years old. Eight patients had open fractures and 20 had closed fractures. Seven patients (25%) had difficulties with communication which could have impeded or delayed the diagnosis of a compartment syndrome.

Results: Average delta pressure ranged from nine to 69mmHg in our patient population. High energy injuries resulted in a significantly lower delta pressure (p=0.05). Open fractures were more likely to result from high energy, although this was not statistically significant (p=0.068). Two patients had fasciotomy performed based on clinical picture and a sustained decrease in delta pressure. No patient had a missed compartment syndrome.

Conclusion: Continuous compartment pressure monitoring is especially useful in patients who are most at risk for compartment syndrome i.e. those having sustained high energy injury or open fractures. It can also aid decision making when the clinical picture of compartment syndrome is equivocal, or when a patient’s ability to communicate pain is impaired.

However, due to the ease of use and the low cost involved, we recommend that all patients with tibial fracture should have continuous compartment pressure monitoring performed.

With the increasing availability of magnetic resonance imaging, there is potentially less emphasis being placed on making a definitive clinical diagnosis. Changes in the undergraduate curriculum have also reduced the emphasis on orthopaedic clinical evaluation. This aim of this study was to evaluate the predictability of clinical examination alone in comparison with arthroscopic findings in 50 consecutive patients presenting for arthroscopy to our service. Four trainees examined each patient; each examiner was blinded to the clinical diagnosis made by their colleagues. All patients were examined in the ward and subsequently underwent examination under anaesthesia and arthroscopy.

Of the tests for meniscal injuries joint line tenderness was the most sensitive (77%) and specific (68%). Apley’s and McMurray’s test while specific (92%, 98%) lacked sensitivity (9%, 30%). Overall the tests for anterior cruciate ligament (ACL) disruption were more reliable than the tests for meniscal injuries. The anterior drawer and Lachmann tests had high specificity (90%, 75%) and sensitivity. The pivot shift test also had very high specificity (75%) and sensitivity (98%) for detecting ACL injuries. These data demonstrate that joint line tenderness is the most reliable sign of menis-cal injury. In the absence of joint line tenderness Apley & McMurray’s tests have little role in routine clinical examination. Clinical tests and signs of ACL deficiency are consistently reliable in diagnosing ACL rupture.

The conservative management if isolated humeral shaft fractures is a long, drawn out, painful process for the patient. For the clinician, it involves multiple clinic attendances and repeated radiographic assessment and brace alteration.

The primary reason for conservative management is the excellent results, but a very definite secondary consideration is the high incidence of shoulder pathology after I.M. nailing. This is thought to be due to rotator cuff pathology at the time of surgery. We question the validity of this second argument.

Ten consecutive humeral shaft fractures attending our unit had an MRI of both shoulders carried out during the initial stages of their injury. Two of the ten had retrograde nailing and the remainder was managed conservatively. While there was no patient with an occult coracoid fracture in association with the shaft fracture. We found eight out of ten to have significant signal changes in the subacromial space on the side of the fracture only.

We conclude that there is a significant occult injury to the shoulder at the time of humeral shaft fracture and this may in fact represent a cause for the high incidence of shoulder pain post fracture.

Introduction: Operative fixation is the mainstay of treatment for displaced ankle fractures. Results however can be variable, with patients complaining of residual pain and stiffness of the ankle joint. In addition, metalwork can be problematic giving rise to symptoms in up to 25% of patients. We undertook a retrospective study to evaluate outcome in terms of functional and radiological criteria in a cohort of patients.

Aim: To assess outcome in a cohort of patients following operative treatment of ankle fractures.

Materials and Methods: Patients with suitable injuries sustained were identified from the hospital HIPE database. Data was collated from hospital records including demographic details, mechanism of injury, details of the initial injury and surgical treatment. Patients were invited to attend for clinical and radiological examination of the injured ankle. Patients completed the SF12, the Olerud ankle score and a visual analogue pain scale (VAS) on arrival at the clinic. The range of motion of both the injured and uninjured ankle were examined. Finally, the patient’s injured ankle was evaluated on plain X-rays using Cedell’s scoring system. Comparison was made with initial roentgens at the time of injury.

Results: From 106 patients treated over a four-year period, 63 were successfully followed up. Mean time of follow up was 3.5 years. Older patients had a poorer recovery, as had those with more severely displaced fractures. Pain was not a major problem for patients with 58 complaining of no pain, or pain only after prolonged exercise. 43% of patients complained of occasional swelling of the affected limb. The majority of patients (89%) had returned to their previous occupations at the time of follow up. 16% of patients (10) had their metalwork removed post operatively. In seven cases, this was due to skin problems or pain adjacent to the metalwork.

Conclusion: Older age at presentation, and severity of initial injury appear to have a significant effect on long-term outcome, which may be attributable to poorer osteosynthetic ability in an elderly osteoporotic patient. Our study underlines the importance of accurate anatomical reduction of ankle fractures in order to minimise subsequent arthrosis.