The aim of our study was to assess the use of the Clavicular Hook Plate in treating acromio–clavicular joint dislocations and fractures of the distal clavicle. The prospective study was carried out at two hospitals- a teaching hospital and a district general hospital.

Between 2001 and 2004 a total of 37 patients with AC joint injuries and distal clavicle fractures were treated surgically with this device. Four of the patients had sustained a Neers Type 2 fracture of the distal clavicle, while 33 patients had acromio-clavicular joint dislocation (Rockwood Type 3 or higher). Mean age of the study group was 35.2 years. Post operatively, shoulder pendulum exercises were commenced on the second day and all patients discharged within 48 hours. During the first few weeks, we restricted shoulder abduction to 90 degrees. At the first postoperative follow up appointment at 2 weeks, average shoulder abduction was 30 degrees and forward elevation −40 degrees. This improved at 6 weeks to 85 degrees and 105 degrees respectively. The plates were removed at an average time interval of 11 weeks for the ACJ dislocations (range 8–12 weeks) and 15 weeks for the clavicle fractures (range 12–16 weeks). At three months after plate removal, we evaluated patients to measure the Visual Analogue Score(VAS) and Constant Score. The mean VAS was 1.4 (range 0–6) and the mean Constant score was 92 (range 72 to 98). Wound healing problems occurred in two patients, while two had a stress riser clavicle fracture. These had to be subsequently fixed with a Dynamic Compression Plate. One patient developed a superficial wound infection. Seven patients had problems due to impingement between the hook and the under surface of the acromion. A 45 year old female patient developed ACJ instability after plate removal. Radiographs revealed widening of the AC joint and some osteophyte formation. She went on to develop frozen shoulder which was treated with intensive physiotherapy.

The AO hook plate represents an improvement over previous implants in treating injuries around the AC Joint. However, the need for a second operation to remove the plate remains a significant problem. Complications resulting from impingement were common in our patients and represent a major drawback of this implant.

Two stainless steel ‘TriMed’ distal radial fracture reduction techniques were tested to compare the relative stability of the two in vitro for a pre-determined fracture pattern. The movement of the bony segments were plotted over time using an ARAMIS 3 dimensional non-contacting displacement mapping system (GOM mbH, Braunschweig, Germany) to give quantitative data. The data was used to calculate the relative motion of the bony segments with the aim of investigating regions of compression across the fracture line, which is thought to accelerate fracture healing, and shear between bony segments, which is detrimental to fracture healing.

Ten third generation adult radius biomechanical model Sawbones (Sawbones, Malmö, Sweden) were cut to simulate AO type C2 fractures with dorsal comminution. Five bones were plated using the TriMed fixed angle volar bearing plate and five were plated using the TriMed radius and ulnar plating technique. Samples were potted and loaded cyclically at 1 Hz via a floating scaphoid-lunate bearing onto the end of the radius at incrementally increasing loads of 100 N – 500 N with 1000 load cycles applied for each load level.

The results showed the radius and ulnar pin-plate configuration allowed greater movement of the articular surface, with relative shear motion and separation between the two segments, although the relative shear movement between the two distal segments was below 2mm, which is considered the definition of failed fixa-tion. With the volar bearing plate the two distal segments moved as single unit and compression with minimal shear was applied across the fracture line to the proximal radius. Thus the radius and ulnar plates allowed shear across all three fracture lines, while the volar plate held the two distal segments fixed relative to each other and allowed compression across the interface with the proximal radius. The ARAMIS system allowed the three dimensional motion of the bony segments to be followed, in particular the relative motion between the segments, indicating the type of healing to be expected clinically. The study demonstrated the value of ARAMIS in investigating the stability of wrist fractures fixations and can easily be adapted to investigate other orthopaedic fixation systems.

A prospective clinical investigation to determine the optimum knee flexion angle for the ‘skyline’ patellofemoral joint radiograph.

Plain radiography of the patello-femoral joint includes the axial or ‘skyline’ radiograph. The optimum knee flexion angle for making this image remains unclear.

We therefore performed a prospective clinical study in which patients underwent three skyline radiographs with knee flexion angles of 30(or minimal flexion), 50 and 90 degrees. The patients were new patients, aged between 12 and 30, presenting to a knee clinic with anterior knee pain. Two observers evaluated the radiographs, making a standardised series of measurements. Blinding was organised so that the observers were unable to use any information other than the radiographic image alone. One observer evaluated all the films on two separate occasions to allow calculation of intra- and interassessor agreement.

There were 67 knees from 46 patients. There was a high level of intra- and inter-observer agreement. There were a number of patients in which the radiographic appearance of the patello-femoral varied markedly between the different views; in all cases the abnormality was best demonstrated by the 30-degree view. There were however a number of minimal flexion views in which the film contained incomplete information because part of the patello-femoral joint was missing from the image.

We conclude that whilst a minimal flexion skyline view is the most sensitive method for the detection of patellar tilt and subluxation, not all knees can be successfully imaged at the required position. A flexible approach is therefore needed, to obtain satisfactory images at minimal flexion.

We describe the use of MRI to establish the exact diagnosis in a swollen elbow in a neonate. Urgent diagnosis was needed for medical and social reasons. We accomplished this without the use of an invasive procedure or anaesthesia for a fracture that is recognised to be difficult to diagnose in patients of this age group.