Abstract

Scapula fractures mostly occur following high energy trauma, however, the demographics are unknown in deployed soldiers. We analysed the incidence, aetiology, associated injuries, treatment and complications of these fractures in military personnel from Afghanistan and Iraq (2004–2014). Forty-four scapula fractures from 572 upper limb fractures (7.7%) were sustained. 85% were caused by blast or gunshot wounds and 54% were open blast fractures. Multiple injuries were noted including lung, head, vascular and nerve injuries. Injury Severity Scores were almost double compared to the average upper limb injury without a scapula fracture (21 vs. 11). Brachial plexus injuries (17%) have a favourable outcome following GSW compared to blast injuries. Glenoid fractures or floating shoulders were internally fixed (10%) and resulted from high velocity gunshot wounds or mounted blast ejections. There were no cases of deep soft tissue infection or osteomyelitis and all scapula fractures united. Scapula fractures have a 20 times higher incidence in military personnel compared to the civilian population. These fractures are often associated with multiple injuries, including brachial plexus injuries, where those sustained from blast have less favourable outcome. High rates of union following fixation and low rates of infection are expected despite significant contamination and soft tissue loss.

Major upper limb arterial injuries sustained in combat are associated with significant trauma. We analysed the survival and complication rates following upper limb vascular injury in Iraq and Afghanistan (2004–2014). Fifty-two soldiers sustained 59 major arterial injuries in 54 limbs. Axillary artery injuries were more likely to be caused by gunshot wounds (86%), whilst brachial and ulnar artery injuries were primarily associated with blasts (72% and 87% respectively); no such correlation was identified with radial artery injuries. Apart from three temporary shunts, all vascular injuries were treated definitively in the local field hospital before repatriation. Proximal injuries were predominantly treated with long saphenous vein grafts and distal injuries with ligation. One soldier required an immediate amputation following failed LSV grafting, however no amputations followed repatriation. There were five identified graft failures (21%), although these were not associated with subsequent perfusion issues. There were no graft failures following temporary shunting. Associated nerve injuries often required operative intervention and have a guarded outcome. 100% of radial fractures went onto non-union if combined with a radial artery injury. Successful immediate re-perfusion of a vascular compromised upper limb correlates with excellent long-term limb survival, despite a significant number of grafts developing secondary failure.

We present the results of a bi-centre, retrospective study examining the clinical, functional and radiological outcomes of distal radius fracture fixation with the Aptus locking plates and Tri-Lock® variable angle locking screws. We assessed 61 patients with distal radius fractures with a minimum of six months follow-up. Functional assessment was made using the DASH score. We measured wrist range of movement and grip strength, and reviewed radiographs to assess restoration of anatomy, fracture union and complications. All fractures united within six weeks. Mean ranges of movement and grip strength were only mildly restricted compared to the normal wrist. The mean DASH score was 18.2. Seven patients had screws misplaced outside the distal radius although 3 of these remained asymptomatic. Five other patients developed minor complications. Variable angle locking systems benefit from flexibility of implant positioning and may allow enhanced inter-fragmentary reduction for accurate fixation of intra-articular fractures. However, variable-angle systems may lead to increased rates of screw misplacement.

Hand injuries are common in military personnel deployed on Operations. We present an analysis of 6 years of isolated hand injuries from Afghanistan or Iraq. The AEROMED database was interrogated for all casualties with isolated hand injuries requiring repatriation between April 2003 and 2009. We excluded cases not returned to Royal Centre for Defence Medicine (RCDM). Of the 414 identified in the study period, 207 were not transferred to RCDM, 12 were incorrectly coded and 41 notes were unavailable. The remaining 154 notes were reviewed. 69% were from Iraq; only 14 % were battle injuries. 35% were crush injuries, 20% falls, 17% lacerations, 6% sport, 5% gun-shot wounds and 4% blast.

Injuries sustained were closed fractures (43%), open fractures (10%), simple wounds (17%), closed soft tissue injuries (8%) tendon division (7%), nerve division (3%), nerve/tendon division (3%) complex hand injuries (4%). 112 (73%) of the casualties required surgery. Of these 44 (40%) had surgery only in RCDM, 32 (28%) were operated on only in deployed medical facilities and 36 (32%) required surgery before and after repatriation. All 4 isolated nerve injuries were repaired at RCDM; 2 of the 4 cases with tendon and nerve transection were repaired before repatriation. Of the 10 tendon repairs performed prior to repatriation 5 were subsequently revised at RCDM.

This description of 6 years of isolated hand injuries in military personnel allows future planning to be focused on likely injuries and raises the issue of poor outcomes in tendon repairs performed on deployment.

Introduction: In 1979 Linburg and Comstock described anomalous tendon slips between flexor pollicus longus and the flexor digitorum profundus in 31% of individuals (Linburg, Comstock; J Hand surg 1997, Jan). The purpose of this study is to find out the incidence of Linburg-Comstock Syndrome in the British population.

Methods: A clinical examination of the hands of healthy volunteers, including office workers and medical professionals was carried out. It was determined if flexion of the thumb causes concomitant flexion of index or/and middle finger. Additionally, pain on passive extension of the fingers was also documented.

Summary of Results: 70 volunteers were included, the test for Linburg-Comstock syndrome was positive in 55% of people who had concomitant flexion of the fingers with the thumb and pain in the wrist with passive extension. In 70% of people just concomitant finger flexion was seen. In 10 cadaveric dissections no connecting tendon slips were found but one fibrinous connection between FPL and FDP was noted.

Conclusion: Our study shows that the incidence of Linburg –Comstock Syndrome is much higher than previously thought based on the clinical examination. However cadaveric dissections did not confirm a distinct structural connection except in one case where there was a fibrinous connection. It is likely that at least in some cases it is a acquired anomaly in response to repeated use/overuse of thumb and index fingers.

Aims: To establish the frequency and demographics of soft tissue sarcomas (STS) presenting in the lower limb.

Methods: Patients presenting to a tertiary referral orthopaedic oncology unit over a 10-year period were prospectively entered into a computerised database. The site of primary STS and demographic details were also recorded.

Results: 1519 STS in all body regions were treated. 1067 (70.2%) within the lower limb. 57.0% thigh, 13.0% calf, 8.2% foot and ankle, 7.7% buttock, 5.7% knee, 4.6% pelvis and 3.8% in the groin. There was a male predominance (56.2%). M:F ratio was 2.5:1 for the groin and 1.3:1 for the thigh with the other body regions approximately equal.

Conclusion: The majority of STS are found in the lower limb. In this large series there was a male predominance most marked in groin presentations.

Aims: Soft tissue sarcomas (STS) of the foot and ankle are rare tumours. The aims of this study were to examine the presenting features and highlight those associated with a delay in diagnosis.

Methods: Patients presenting during a 10-year period were identified using a computerised database within the Orthopaedic Oncology Unit at the Royal Orthopaedic Hospital, Birmingham, UK. Additional information was obtained from a systematic case note review.

Results: 1519 patients were treated for STS of which 87 (8.2%) had tumours sited in the foot and ankle. Of these, 75 (86.2%) had presented with a discrete lump (42 (56%) of them having an inadvertent “whoops” excision biopsy), 3 (3.4%) with ulceration and the remaining 9 (10.3%) with symptoms more commonly associated with other benign foot and ankle pathology. Within the group of 9 patients they had previously been treated as plantar fasciitis (3), tarsal tunnel syndrome (2), Morton’s neuroma (1) and none specific hind foot pain (3). Median delay from onset of symptoms to diagnosis as STS was 26 months for this group (mean 50; range 6–180 months) compared to 12 months (mean 32; range 3–240) for the “whoops” biopsy group and 10 months (mean 16; range 2–60 months) for the unbiopsied discrete lump group.

Conclusion: Soft tissue sarcoma in the foot and ankle may present insidiously and with symptoms of other benign pathologies. Failure to respond to initial treatment of suspected common benign pathology should be promptly investigated with further imaging e.g. MRI scan or high resolution ultrasound, or with specialist consultation.

Aims Soft tissue sarcomas (STS) of the foot and ankle are rare tumours. The aims of this study were to examine the presenting features and highlight those associated with a delay in diagnosis.

Methods Patients presenting during a 10-year period were identified using a computerised database within the Orthopaedic Oncology Unit at the Royal Orthopaedic Hospital, Birmingham, UK. Additional information was obtained from a systematic case note review.

Results 1519 patients were treated for STS of which 87 (8.2%) had tumours sited in the foot and ankle. Of these, 75 (86.2%) had presented with a discrete lump (56% of them having an inadvertent whoops excision biopsy), 3 (3.4%) with ulceration and the remaining 9 (10.3%) with symptoms more commonly associated with other benign foot and ankle pathology. The 9 had previously been treated as plantar fasciitis (3), tarsal tunnel (2), Morton’s neuroma (1) and none specific hind foot pain (3). Median delay from onset of symptoms to diagnosis as STS was 26 months for this group (mean 50; range 6–180 months) compared to 12 months (mean 32; range 3–240) for the “whoops biopsy group and 10 months (mean16; range 2–60 months) for the unbiopsied discrete lump group.

Conclusion Soft tissue sarcoma in the foot and ankle may present insidiously and with symptoms of other benign pathologies. Failure to respond to initial treatment of suspected common benign pathology should be promptly investigated further with an MRI scan.

A prospective trial of proximal femoral nail versus dynamic hip screw for unstable intertrochanteric fractures of the femur. Introduction: The proximal formal nail (PFN) is purposed to have superior bio-mechanical properties to the dynamic hip screwwhen use in the treatment of unstable intertrochantric fractures of the femur. Objective: To compare the outcome of PFN and DHS fixation of unstable proximal femoral fractures. Methods: The authors conducted a prospective study of 70 consecutive patients presenting to the orthopaedic department with acute AO/ASIF 31 -A2 and A3 fractures. Patient underwent either PFN or DHS fracture fixation depending on surgeon experience and preference. Patients were all followed up for 6 months. The main outcome measures were operative blood loss, length of hospital stay, radiographic fracture union, com-plication rates, independent mobility and residual hip pain at 6 months. Result: The two groups exhibited similar demographic characteristics, premorbid mobility and fracture severity. Operation duration was similar in the two groups although blood loss was significantly less in the PFN groups (PFN 200mls; DHS 375mls). There was a significant difference in length of hospital stay (PFN 8 days; DHS 14 days). Radiographic signs of fracture healing at 3 months were 88% PFN and 83% DHS. Three patients in the DHS groups suffered failure of fixation with screw cut out There were no implant failures or failure of fixation in the PFN groups. At 3 month PFN follow up mobility was greater in the PFN group (Wheelchair bound/walking frame/stick/no aide: group = 0%/20%/49%/14%). At 6 months both groups showed similar mobility. Persistent sever hip pain at 6 months was PFN 3% and DHS 9%. Conclusion: The proximal femoral nail may be used successfully in the fixation of unstable femoral fractures with similar result to the DHS for mobility at 6 months. There may be advantages over the DHS in term of reduced blood loss and shorter hospital stay.

Aims: To compare the outcome of PFN and DHS þxation of unstable proximal femoral fractures. Methods: The authors conducted a prospective study of 70 consecutive patients with acute AO/ASIF 31-A2 and A3 and complex intertrochantaric fractures. Patients underwent either PFN or DHS fracture þxation depending on surgeon experience and preference. Patients were all followed up for 6months. The main outcome measures were operative blood loss, length of hospital stay, radiographic fracture union, complication rates, independent mobility and residual hip pain at 6 months. Results: The two groups exhibited similar demographic characteristics, premorbid mobility and fracture severity. Operation duration was similar in the two groups although blood loss was signiþcantly less in the PFN group (PFN 275mls; DHS 475mls). There was a signiþcant difference in length of hospital stay (PFN 14 days; DHS 22 days). Three patients in the DHS group suffered failure of þxation, two of them had screw cut out. There were no implant failures or failure of þxation in the PFN group. At 6 months both groups showed similar mobility. Persistent severe hip pain at 6 months was PFN 3% and DHS 9%. Conclusion: The proximal femoral nail may be used successfully in the þxation of unstable femoral fractures with similar results to the DHS for mobility at 6 months. There may be advantages over the DHS in terms of reduced blood loss, shorter hospital stay and less morbidity.