Mid-shaft humeral fractures in adults are common these days and often present with a management dilemma between operative and non-operative treatment. This study evaluates the outcome of such fractures treated non-operatively over a span of 10 years.

In this retrospective study, a review of case notes and radiographs of patients whose mid-shaft humerus fractures were treated non-operatively between 1994 and 2004 was done. Those younger than 16 years and/or who had surgery primarily were excluded. Various factors including patient demographics, mechanism of injury, AO fracture classification and time to union were studied. Mean patient follow-up was 4 years and 6 months. The Oxford shoulder score was used for functional assessment.

There was a total of 43 patients, mostly men with involvement of the dominant arm. 5 patients required open reduction and internal fixation with bone grafting for non-union. The average Oxford shoulder score was 18. The majority of patients could resume their jobs and the average time to union was 9 weeks.

We conclude from this study that there is a high union rate in the mid-shaft humeral fractures in adults treated non-operatively, with an acceptable functional outcome.

Introduction: Lumbar disc disease comprises of a heavy portion of the workload in spinal as well as general orthopaedic clinic.

It is well accepted that nerve root tension signs such as straight leg raise (SLR) & Lasegue’s test are sensitive at diagnosing nerve root impingement secondary to lumbar disc degeneration. In isolation, however, they lack specificity & have a poor positive predictive value (PPV). This can lead to uncertainty in clinical diagnosis.

Our study proves that a structured approach to clinical examination with cumulative nerve root tension signs (RTS) significantly increases the tests’ specificity and PPV, therefore giving clinicians more confidence in their diagnosis.

Methods: Prospective review of 1303 patients seen in one Orthopaedic consultant’s spinal clinic from 2004 until 2008. Data was collected using a standardized proforma. Pattern of pain as well as RTS (SLR, Lasegue, bowstring and crossover) were recorded and cross-referenced with subsequent MRI findings. In our dataset a positive MRI result was one in which the demonstrated disc lesion and nerve impingement corresponded with patient symptoms. Patients included were all those presenting with lower back and/or neuropathic leg pain. Patients had to be excluded from series due to incomplete datasets & missing MRI scans.

Results: N = 858. Our results showed that as we progressed from 1 RTS up to 4 RTS there was a significant increase in the PPV : 1RTS PPV = 0.333 (CI 0.25 – 0.43), 2RTS PPV = 0.78 (CI 0.69 – 0.86), 3RTS PPV 0.87 (CI 0.81 – 0.91), 4RTS PPV 0.93 (CI 0.66 – 0.99). There was also significant increases in specificity compared with 1RTS: 1RTS 0.75 (CI 0.70 – 0.8), 2RTS 0.94 (CI 0.91 – 0.96), 3RTS 0.92 (CI 0.89 – 0.95), 4RTS 0.99 (CI 0.98 – 0.99).

Discussion: This study shows that combining root tension signs as part of a structured assessment leads to a significant cumulative increase in the PPV and specificity of the diagnosis of nerve root impingement. Hence proving the importance of clinical examination. This method of sequential, cumulative RTS has not previously been documented in the literature.

Introduction: Ankle fractures are common in trauma practice. Traditional teaching has been to use two screws for medial malleolar fixation to achieve better rotational control. However, the evidence for this is limited. This study compares the outcome following either one or two screws for medial malleolar fracture fixation.

Materials and Methods: Retrospective analysis of case notes and x-rays of all medial malleolar fracture fixations performed between 2002 to 2007. Two groups were formed (group-I and group-II) depending upon the use of either one or two screws, respectively.

Both groups were age and sex matched. Besides patient demographics, fracture pattern according to Dennis–Webber classification, orientation of the medial malleolar fracture, position of screw in relation to fracture, post-operative fracture displacement and union (bony and clinical) were assessed. Patients were also contacted to assess whether they had returned to their pre-injury level of activities.

Results: There were total of 76 patients (group-I had 37 and group-II had 39 patients). The majority were females with age range between 19 and 84 years with involvement of the right ankle mostly.

In group-I, 15 patients had bi-malleolar Dennis-Webber type B fractures, 9 had bi-malleolar Dennis-Webber type C and 10 had tri-malleolar fractures. 3 had uni-malleolar fracture.

In group-II, 20 patients had bi-malleolar Dennis-Webber type B fractures, 9 had bi-malleolar Dennis-Webber type C fractures and there were 5 tri-malleolar fractures. 5 had uni-malleolar fracture.

The fracture orientation in both the groups was mostly horizontal than oblique and the screw placement was at an angle to the fracture in the majority of cases in both of them.

There was no significant difference between the two groups, in terms of clinical union, post-operative fracture displacement and return of patients to their pre-injury level of activity.

Conclusion: Medial malleolar fractures can be efficiently fixed with one screw only, which does not increase the risk of post-operative fracture fragment displacement, compared to using two screws.

Introduction: Hallux valgus is a common presentation at the elective orthopaedic clinics. Patients complain of pain and deformity of the big toe. Treatment is aimed at improving the cosmesis and alleviating pain in the fore foot.

This study assesses the pre and post-operative pedal pressures during stance phase of dynamic gait cycle to identify objective biomechanical factors which influence the final outcome.

Materials and Methods: This is a prospective study, approved by the local research and ethics committee, in which 17 feet were assessed with moderate to severe hallux valgus. Distal-L and Scarf osteotomies were performed for moderate and severe deformities, respectively.

Pedobarography was performed before and 8 months after surgery, on an average. Sole was divided into eight segments i.e. heel, midfoot, lateral forefoot, central forefoot, medial forefoot, II–V toes, hallux and total sole area. Variables compared were contact area, peak pressure, mean pressure and contact time. Manchester-Oxford foot questionnaire (MOXFQ) was used to assess the clinical disability. The inter-metatarsal and metatarso-phalengeal angles were measured radiographically. Both clinical and radiological assessments were performed pre and post-operatively.

Results: 11 had distal-L and 6 had Scarf osteotomies. There were significant improvements in all the three domains of the subjective MOXFQ questionnaire i.e. walking/standing (p 0.013), pain (p 0.001) and social limitation (p 0.002).

The inter-metatarsal angle reduced from 15 to 7 (p 0.001) and the metatarso-phalengeal angle reduced from 32 to 9 (p 0.001).

There was significant reduction in heel contact area (p 0.002), the medial forefoot (p 0.030) and II – V toes (p 0.048) contact time.

Conclusion: Both distal-L and Scarf osteotomies resulted in significant improvements in clinical and radiographic outcome. Although there was reduction in heel contact area and medial forefoot contact time, there were no significant changes in pedal pressures at 8 months postoperatively.

Introduction: Distal Radius Fractures (DRF) and Hip Fractures are considered as fragility fractures. The purpose of this study was to assess whether DRF precedes hip fracture or not. This retrospective analysis was carried out in a group of patients who sustained bilateral non contemporary hip fractures.

Materials and Methods: Retrospective analysis of radiographs and notes of all the patients requiring surgery for bilateral neck of femur fractures, from January 1994 to June 2005 at a district general hospital. Data included ages at the first and second fractures, mechanisms of injury, types of fracture and implants used. Time interval between the two fractures was also noted.

These were analyzed for presence of any Distal Radius Fractures (DRF) prior to first admission for hip fracture and time period between first and second admission. It was also analyzed whether a DRF was sustained between these two episodes.

Results: Ninety five patients had bilateral neck of femur fractures during the study period with an average age of 76 years at the first fracture. There were eighty-three females and twelve males. The time interval between bilateral non contemporary hip fracture was 2.5 years.

Out of these ninety five patients a small minority of patients had a DRF preceding their first hip fracture. Those sustaining DRF prior to their second hip fracture was also studied and statistical methods were employed to predict the presence of DRF prior to hip fractures

Conclusion: This study shows that there is no correlation between sustaining two fragility fractures i.e DRF & Hip Fracture and DRF may not necessarily precede a Hip Fracture.

INTRODUCTION: Median Nerve has small vessel on the volar aspect of the nerve which is filled with blood and results in so called ‘ BLUSHING’ of the nerve once it has been decompressed. It was thought that the nerve which didnot blush meant an inadequate decompression was carried out.

PURPOSE: To evaluate whether ‘Blushing’ of the Median Nerve is correlated with adequate decompression and level of recovery in Carpal Tunnel Syndrome through Mini Palmar Incision.

METHODS & MATERIALS: Retrospective analysis of a Single Surgeon practise where it was documented in operation notes whether the nerve was seen to ‘Blushed’ at the time of surgery.They were assessed postoperatively from notes for complete resolution of symptoms and whether there was any recurrence of symptoms.

RESULTS: n=330 Carpal Tunnel Decompressions were reviewed. It was noted that those who had complete resolution of symptoms had ‘Blushing’ noted at the time of surgery compared to those who had partial or incomplete resolution of symptoms wher ‘No BUSHING’ was noticed. Average time of follow up = 6 weeks. Blushing Noted at the time of decompression 192, Recovery/ improvement of symptoms 189, Blushing not noted at the time of surgery 38, NO documentation about Blushing in 100

CONCLUSION: Blushing of Median Nerve intraoperatively is a reliable sign for complete decompression of the nerve and is correalted with good final outcome.

Introduction: Management of acute rupture of the Achilles tendon is controversial. Conservative treatment has a higher re-rupture rate while surgery has complications like infection and wound breakdown. We devised a protocol in our hospital to decide between the surgical or non-surgical options

At our institution, a well-documented and structured program of non-operative or opeartive management of Achilles tendon rupture with use of either casts or operation has been devised based on Ultrasound findings of the ‘Gap/distance between the two ends of the Tear’.

PURPOSE: The purpose of this study was to compare the incidence of Re-rupture in those treated by cast immobilization where the ends were approximating at ultrasound examination at our institution.

METHODS: This study Prospectively assessed the results in 50 consecutive patients with a complete rupture of the Achilles tendon who had been treated with our regimen depending on the findings of the ultrasound examination, between 2003 and 2006. All ruptured Tendoachilles had ultrasound done in Full Equinus position to assess whether the ends are approximating or not. If ends were approximating they were treated in an equinus cast. Patients were evaluated on the basis of the subjective results and functional outcome measure, along with validated visual analogue scores. Re-rupture rates were measured at 06 months after injury. There were 35 Male and 13 females. This was followed by a final questionnaire to assess their return to pre-injury activities. Two patients were lost to follow-up as they moved out of the area.

RESULTS: All the 48 re-ruptures available for analysis had their ultrasound done on initial presentation. 25 were treated non-operatively and 23 underwent surgery. The overall complication rate for Non Operative was minimal, with NO re-rupture or documented deep vein thromboses. In operative group there were 2 re-ruptures, 5 postoperative infection and discharge.

CONCLUSION: The results of our non-operative treatment were better overall than published results of non operative & operative repair of acute Achilles tendon rupture. In this study the ends are approximating, confirmed on ultrasound before being assigned to Cast Immobilization.

SIGNIFICANCE: The previous studies have not assigned patients into operative or non-operative groups based on whether the ends are approximating in full equines position. By assigning only those in whom the ends are approximating, to cast immobilization, re-rupture rates are less, thus resulting in better and stronger healing of TAs’ and avoiding risks of surgery.

Introduction: Distal femoral shaft and supracondylar fractures are now more common. Non-operative treatment of these challenging fractures is difficult and fraught with complications. Retrograde and supracondylar nails have emerged as a good alternative to stabilize these fractures. This study evaluates the outcome of retrograde femoral nails done over a span of 5 years at a University Hospital.

Materials and Methods: In this retrospective study, review of case notes and radiographs of 56 patients was done. All patients, who underwent retrograde and supracondylar femoral nailing between 1999 and 2003 were included. Various factors including patient demographics, mechanism of injury and fracture type were studied. Time to union, intra and post -operative complications and need for re-operation were also recorded.

Results: 41 retrograde and 15 supracondylar femoral nails were done in the study period. There were 16 males and 40 females. Most of the patients had sustained their fractures due to fall. 3 out of the 56 patients presented with open fractures. 53 patients had insertion of reamed nails and 52 of them had both ends locked. The average time of operation was 2 hours 10 minutes and the average blood loss was 500 ml. Most patients were mobilized early with partial weight bearing.

There were 3 superficial wound infections, which resolved with appropriate antibiotics. There were no cases of nerve damage or septic arthritis. 2 patients died with bronchopneumonia in the post- operative period.

55 out of 56 fractures united at an average of 16 weeks. 1 patient required re-operation for non-union, 9 months after the index operation.

Conclusion: We conclude from this study that there is a high union rate of distal femoral fractures treated with supracondylar and retrograde nails with very low complication rate. It allows early mobilization, particularly in elderly patients and seems to produce very good functional outcome with low re-operation rate.