Medical employment standards (MES) are used to identify and quantify the effects of pathology on a person's ability to carry out their duties. Any person requiring a change in their MES for longer than 28 days should have their permanent MES altered accordingly. In the Royal Air Force this is undertaken by Medical Boards.

A retrospective review was performed of all personnel attending RAF Medical Boards for a change in their PMES between 15/1/12 and 31/10/13. The primary reason for downgrade was recorded using ICD-10 code.

There were 1,583 PMES downgrades, approximately 800/year. This is approximately 2% of all regular RAF personnel. Musculoskeletal disease accounted for 58% of all cases (923 cases, 500/year). Other causes included medicine and general surgery (23%), mental health (10%), obstetrics and gynaecology (5%) and other causes (4%). The majority of the musculoskeletal cases were arthropathy (42%) or back pain (31%).

Musculoskeletal disease is the most common cause for medical downgrade in the RAF. More data are required to ascertain the precise nature of these cases and the level of the imposed limitations. This will allow targeted use of increasingly limited resources to ensure that our personnel are as fit as possible to execute their duties.

Introduction

We reports the accuracy of direct Magnetic Resonance Arthrography (MRA) in detecting Triangular Fibrocartilage Complex (TFCC), Scapho-Lunate Ligament (SLL) and Luno-Triquetral Ligament (LTL) tears using wrist arthroscopy as the gold standard.

Background: PIP joint surface replacement has been shown to be effective in the treatment of arthritis. We performed a retrospective review to evaluate the clinical results and functional outcome of pyrocarbon proximal interphalangeal joint replacement, motion preserving and function in selected patients.

Method: The patients who underwent pyrocarbon PIP joint arthroplasty by the two senior authors were reviewed. Clinical assessment included range of motion, degree of pain and deformity pre and post operatively. Independent functional scores were collected. Radiographs were reviewed for evidence of loosening, fracture and dislocation. Patient overall satisfaction was assessed.

Results: 25 patients had 27 pyrocarbon PIP joint replacements between 2004 and 2008. Of these patients, there were 21 female (84%) and 4 male (16%) with average age of 62.5 (43–78). Indications for surgery were pain and loss of function. The preoperative diagnosis was post traumatic osteoarthritis in 9 (33.3%) and primary osteoarthritis in 18 (66.7%). The average arc of motion preoperatively was 42.3 (5–60), and the average postoperative one was 74.3 (45–100). Pain was relieved in majority of patients. 23 patients (92%) were satisfied completely with the procedure. Pain was relieved in the majority of cases and we had 2 dislocations requiring revision to silicone joint replacement and 2 adhesions/stiffness requiring tenolysis. There were no infections.

Conclusion: Our experience of pyrocarbon PIP joint replacement over the 4 years showed this implant is useful for relief of pain and function. A technically demanding procedure, it improves arc of motion, corrects deformity and achieves satisfactory function. We had 7 % revision rate and longer term follow-up is required.

The CMI pyrocarbon implant is a unipolar arthroplasty for trapeziometacarpal joint arthritis which is implanted in to the thumb metacarpal. Previous case series have shown these implants provide significant pain relief and good patient satisfaction. We report the first cases of pyrocarbon hemiarthroplasty from Peterborough.

Seventeen cases in fifteen patients were retrospectively reviewed. The average patient age was 59.7 years (range 47–72). 7 patients were men and 8 were women. Five were discharged with good outcome at a mean of 11.5 months (range 6–19). One failed to attend follow up.

Most patients in whom the implant survived were afforded good pain relief by the procedure and had a good functional range of thumb movement. Radiologically 8 implants were subluxed by at least 50%. One implant was revised after dislocation and loosening of the prosthesis which was associated with trauma. She made excellent clinical progress after revision of the prosthesis. One of the thirteen cases dislocated and was revised to a trapeziumectomy after 11 months.

Preliminary results suggest that this implant affords good pain relief and functional improvement in managing OA at the TMC joint. Longer term follow up will be required to correlate clinical and radiological outcomes.

It is common practice in wrist arthroscopy to suspend the patient’s arm using Chinese finger traps and to distract the wrist joint by applying weight to the arm at the elbow. It is possible that this may cause significant pressure to be applied to the fingers, and potentially damage the digital nerves. We examined the pressure applied by finger traps and consider the risk this poses to the digital nerves.

Standard finger traps were suspended from a spring balance and the author’s fingers inserted along with a length of rubber tubing. The tubing was filled with saline and connected to a digital compartment pressure monitor. The hanging mass was gradually increased and the pressure in the rubber tubing noted. This pressure was taken as analogous to the pressure affecting the neurovascular bundle.

Pressure increases linearly with increasing mass. A pressure of 500mmHg has been suggested as necessary to cause nerve injury1. Using non-invasive technique it was not possible to accurately measure the absolute pressure acting on the digital nerves. However the increase in pressure was noted.

Using weight to distract the wrist during arthroscopy has potential to cause nerve injury. We suggest that pressure insufflation combined with Chinese finger traps with minimum weight traction provides a more than satisfactory view at wrist arthroscopy and can avoid potential digital nerve injury. However traction through finger traps for other purposes such as fracture reduction may be used with caution.

Introduction A retrospective analysis of aeromedical evacuation of casualties from OP TELIC contrasting the demand for evacuation and nature of injury during both war fighting and peace enforcement missions. The study was performed to address a perception of clinicians working within the operational theatre that service personnel outside of times of conflict were being evacuated with increasingly trivial or chronic injuries compared with those evacuated when war fighting was occurring.

Methods A comprehensive record of patients evacuated was retrospectively studied. Consecutive cases were classified by diagnosis. The period of study was 1^st March 2003 to 30^th June 2004.

Results In the sixteen month period a total of one thousand nine hundred and twenty four patients were evacuated by air to the United Kingdom. In the first three months (immediately before, during and post conflict) eight hundred and thirty patients were evacuated, an average of 280 per month. Of these, 2.8% were as a result of battle. During the conflict phase, an average of 60 patients a month were evacuated due to a chronic orthopaedic condition. This is in contrast to an average of 10 a month in the post conflict phase. In the three months following the conflict (incorporating the Iraqi summer) four hundred and seventy one troops were evacuated - an average of 157 per month. Of these, heat illness accounted for 28%. In the following ten months 621 troops were evacuated, averaging 62 per month. During the post conflict period, Battle injuries accounted for 5.6% of those evacuated, which is double that seen during conflict. Chronic general surgery maintained a similar percentage of total sent home throughout both phases. Other specialities were more sporadic with no particular pattern other than a decrease in raw figures compared to the war fighting phase.

Conclusion This pattern of aeromedical evacuation in a modern major deployment illustrates the paucity of battle injury at the time of fighting in relation to non battle injury. It also highlights the impact of chronic injury on a deployed force, especially injury related to back pain. The study has shown that contrary to perception by the clinicians in theatre, there was no obvious increase in evacuation of troops as a result of chronic or minor injuries in the post conflict period. Heat illness clearly places an important predictable strain on this method of evacuation.

Scientific Background The Coracoid process of scapula is a principal landmark in shoulder surgery. Brachial plexus is at risk of injury during surgery around the coracoid, e.g. Weaver-Dunn procedure. Magnetic resonance imaging is the method of choice for evaluating the anatomy and pathology of the brachial plexus and has good resolution compared to Computed tomography or Ultrasound (Ref: 1).

Aim The aim was to study the proximity of brachial plexus to coracoid process in various Shoulder positions. The objective was to define the position of safety for operating around the coracoid.

Methods With Ethics Committee approval, twelve healthy volunteers (men with average age of thirtyfive years) were recruited. Exclusion criteria included previous shoulder injury or operations, known contra-indication for MRI examination and children. An open Magnetic Resonance Scanner (1.5 Teslar) was used to facilitate shoulder positioning. Consent was obtained prior to scanning after information was given to subjects. They were placed under the scanner and images were obtained in axial, coronal and sagittal plane with shoulder in neutral, 45 degrees and 90 degrees of abduction. The images taken are T1, T2 axial spin-echo sequences with 2-mm cuts and coronal echo of a T1-3D gradient with 2 mm cuts, together with a T1 coronal spin-echo, with cuts 2 mm in width. Distance from coracoid process to the Brachial plexus bundle is measured in millimetre on the PACS system which has software to eliminate magnification.

Results The brachial plexus consistently moved away medially from the coracoid in all the subjects at 45 degrees abduction of the shoulder. It returned to the closer position to coracoid in 90Degree abduction. The statistical analysis showed that on an average the distance the brachial plexus moved away towards medial side by 4.37 mm with Standard deviation 3.57 (p= 0.014).

Conclusion The brachial plexus move medially away from coracoid process at 45 degrees shoulder abduction. This position reduces the risk of injury to the brachial plexus during surgery around the coracoid process.

Background Scaphoid non-union remains a difficult problem to treat effectively. Screw fixation and standard bone grafting techniques are good options with union reported in approximately 90% of cases. Studies of the vascular supply to the distal radius have revealed a consistent vascular bone graft source from the dorsal radius. This allows for a pedicled vascularised bone graft to be fashioned, further enhancing the local blood supply to the fracture site.

Methods 14 male patients with a mean age of 30 years (21 to 51 years) and a mean duration of injury of 57 months (15 – 348 months) underwent vascularised bone grafting of established non–union of the scaphoid. The graft was vascularised with a pedicle based on the 1, 2 intercompartmental supraretinacular branch of the radial artery. In addition the long standing deformity resulting from the non-union was corrected by a tri-cortical iliac crest bone graft. (The results were assessed with regard to evidence of union at the fracture site and resolution of pain with return of function). Some of the cases had previous operations with conventional bone graft and failed.

Results Fracture healing was demonstrated radiologically in 9 of 14 cases (64%). 12 of 14 cases (86 %) showed resolution of pain and improvement in function.

Conclusion This technique shows promising results for treating established non-union of the scaphoid, even after long intervals between initial injury and the grafting procedure.

Introduction A prospective study of consecutive hand injuries treated at a British Field Hospital revealed a distinctive pattern of injury. This is a unique review of hand injuries in a recent military deployment.

Method Patients presenting to the field hospital with hand injuries over a two-month period were entered into a database.

The parameters studied included mechanism of injury, timing and nature of treatment and ultimate disposal. An anatomical comparison of pattern of injury with six months retrospective data and a literature search was performed.

Results Of nine hundred and thirty one patients attending the hospital in this period, fifty-three had injuries to the hand.

Only seven cases resulted from battle injuries. Of the remainder, thirty-three were work related and the 13 were due to sport.

Twenty-eight of the patients required a surgical procedure; the mean time to surgery was 1.7 hours.

Twelve patients were subsequently aero medically evacuated.

Conclusion Wounds of conflict account for a small proportion of hand injuries seen in the operational environment. The injury pattern seen reflects Daily Non-Battle Injury (DNBI) – the hazards encountered by deployed troops on a daily basis

This prospective study evaluated our results of arthroscopic electrothermal capsular shrinkage intrinsic (palmar) for midcarpal instability. This method of treatment has not been described in the wrist in current literature. Following clinical and video fluoroscopic diagnosis arthroscopy of the wrist and capsular shrinkage was performed on five patients. A radiofrequency probe was mainly used on the ulnar arm of the volar arcuate ligament and the dorsal capsule of the radiocarpal joint. One patient was lost to follow up. At a mean follow up of 11 months the results were: one excellent, two good and one fair using the Green and O’Brien wrist scoring system (Table1). The average range of motion was 95 percent of the opposite wrist. We concluded that arthroscopic radiofrequency capsular shrinkage is an effective, minimally invasive method of treatment for intrinsic midcarpal instability.

Table 1

Total wrist score (Modified Green and O’Brien):

Large concentration of mines, unexploded ordinance and primitive infrastructure in post war Bosnia-Herzegovina poses difficulties in reaching the casualties within the “golden hour”.

As a part of the peacekeeping operation immediate response teams (IRT) are in place to save life and prevent further injury. We studied the efficacy of such a team in Sipovo, Bosnia. It depends on co-ordination between the chain of command and the IRT.

We retrospectively reviewed all our IRT call-outs at Sipovo from April 1999 till December 2001. We noted the response time and the priority state of the patients.

Weather conditions permitting the IRT call-outs has been by helicopter for priority 1 patients. There were 89 IRT call outs in the above mentioned period. The average response time from the call for help to the medical team reaching the patient was 75 minutes. Within that the average flight time was 45 minutes. The priority states at the site and of the casualties at the hospital are: Priority 1 at site 128, Priority 1 at Hospital 23, Priority 2/Priority 3 is 105, Medical Emergencies is 15, and Priority 4 being 9.

The suggested priority state was overestimated in 82% percent of the patients. There was a conflict between the chain of command and clinical judgement resulting from multiple levels of communication. However we felt the presence of the IRT was not only clinically efficacious but an important factor in uplifting the morale of the peace keeping force.

Two case reports illustrate a relatively simple procedure to preserve thumb function in trauma and locally invasive tumours.

The first case report is of a man who presented with a slowly growing chondrosarcoma involving his left thumb metacarpal. Radiological investigations and incision biopsy confirmed the diagnosis of a low-grade chondrosarcoma. Thumb function sparing wide local excision of the metacarpal, including the thenar muscles was carried out. The floating thumb was stabilised with a temporary silicone block interposed between trapezium and the proximal phalanx. After four weeks the silicone block was replaced with a tri cortical bone graft from the opposite iliac crest and fixed distally to the proximal phalanx and proximally to the trapezium.

The second case report is of a soldier who sustained multiple injuries including open fractures of left thumb metacarpal with associated soft tissue and bone loss. This was from a mortar shell explosion in the jungle. After immediate debridement locally he was transferred to the UK. On arrival he was found to be septic and with ARDS, requiring ITU treatment. One week later he underwent debridement and stabilisation of his thumb injury with an external fixator. This got infected and he went on to develop a non-union. He needed multiple visits to the Operating theatre to sort out his other injuries. Some seven months post trauma he went on to have the metacarpal successfully reconstructed using iliac crest bone graft.

These two very different cases underwent a similar reconstructive procedure to try and preserve the thumb and regain some function. After rehabilitation both patients are pleased to have had their thumb preserved.

Two case reports illustrate a relatively simple procedure to preserve thumb function in trauma and locally invasive tumours.

The first case report is of a man who presented with a slowly growing chondrosarcoma involving his left thumb metacarpal. Radiological investigations and incision biopsy confirmed the diagnosis of a low-grade chondrosarcoma. Thumb function sparing wide local excision of the metacarpal, including the thenar muscles was carried out. The floating thumb was stabilised with a temporary silicone block interposed between trapezium and the proximal phalanx. After four weeks the silicone block was replaced with a tri cortical bone graft from the opposite iliac crest and fixed distally to the proximal phalanx and proximally to the trapezium.

The second case report is of a soldier who sustained multiple injuries including open fracture of left thumb metacarpal with associated soft tissue and bone loss. This was from a mortar shell explosion in a commando operation in the jungle. After immediate debridement locally he was transferred to the UK. On arrival ARDS and sepsis requiring ITU treatment further compromised his clinical status. One week later he underwent debridement and stabilisation of his thumb injury with an external fixature. This got infected and went on to develop a non-union. Some seven months post trauma he went on to have the metacarpal reconstructed using iliac crest bone graft.

These two very different cases underwent a similar reconstructive procedure to try and preserve the thumb and regain some function. After rehabilitation both patients are pleased to have their thumb preserved.