Fractures of the humeral shaft represent 3% to 5% of all fractures. The most common treatment for isolated humeral diaphysis fractures in the UK is non-operative using functional bracing, which carries a low risk of complications, but is associated with a longer healing time and a greater risk of nonunion than surgery. There is an increasing trend to surgical treatment, which may lead to quicker functional recovery and lower rates of fracture nonunion than functional bracing. However, surgery carries inherent risk, including infection, bleeding, and nerve damage. The aim of this trial is to evaluate the clinical and cost-effectiveness of functional bracing compared to surgical fixation for the treatment of humeral shaft fractures. The HUmeral SHaft (HUSH) fracture study is a multicentre, prospective randomized superiority trial of surgical versus non-surgical interventions for humeral shaft fractures in adult patients. Participants will be randomized to receive either functional bracing or surgery. With 334 participants, the trial will have 90% power to detect a clinically important difference for the Disabilities of the Arm, Shoulder and Hand questionnaire score, assuming 20% loss to follow-up. Secondary outcomes will include function, pain, quality of life, complications, cost-effectiveness, time off work, and ability to drive.Aims
Methods
Distal third clavicle (DTC) fractures represent 2.6 to 4% of all adult fractures but there is no consensus as to the surgical management of these injuries. The primary outcomes of this study were to determine the frequency of DTC fractures and their management. Secondary outcomes included complications, further procedures, fracture union and the breakdown of treatment by modified Neer classification. A multicentre cohort study was conducted between 1st January 2019–31st December 2019. All patients, over 18 years old, with an isolated DTC fracture were included. Demographic variables, management, mechanism of injury, modified Neer classification and fracture union were recorded. Simple statistical analysis was performed as a total dataset and as a breakdown of major trauma centres (MTCs) vs trauma units (TUs).Abstract
Background
Methods
Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation. We collected data on 182 consecutive patients with a type II, IIIA, or IIIB open fracture of the tibia who presented to our hospital between July and December 2016. For the purposes of the study, the patients were jointly treated by experienced consultant orthopaedic and plastic surgeons who determined the type of treatment. Separately, the study team (SP, HS, AD, JD) independently calculated the GHS and prospectively collected data on six outcomes for each patient. These included time to bony union, number of admissions, length of hospital stay, total length of treatment, final functional score, and number of operations. Spearman’s correlation was used to compare GHS with each outcome. Forward stepwise linear regression was used to generate predictive models based on components of the GHS. Five-fold cross-validation was used to prevent models from over-fitting.Aims
Methods
Periprosthetic femoral fractures following total hip arthroplasty are relatively uncommon but are associated with significant morbidity. With an increasing number of total hip arthroplasties being carried out in an aging population we need to ensure correct implants are chosen for our patients. A recent review of NJR data suggested a significantly higher revision risk for the Zimmer CPT stems due to periprosthetic fractures when compared to the Stryker Exeter stems. Our aim was to compare the biomechanics of periprosthetic fractures around the CPT and Exeter V40 stems in a composite saw bone model to identify if a difference in fracture risk exists between the two stems. We also compared the engineering design of the two implants in order to analyse the possible effect this may have on fracture risk.Background
Objectives
Our aim was to compare the biomechanical strength modified side-to-side repair with modified pulvertaft technique keeping overlap length, anchor points, type of suture, suture throw and amount of suture similar. In our study, we have used turkey tendons. Two investigators performed 34 repairs during one summer month. All mechanical testing was carried out using the tensile load testing machine. Variables measured were maximum load, load to first failure, modulus, load at break, mode of failure, site of failure, tensile strain, and tensile stress. The statistical comparison was carried by Levene's test and T test for means. The mean maximum load tolerated by modified side-to-side repair was 50.3N(S.D13.7) and that by modified pulvertaft 46.96N(S.D: 16.4), overall it was 48.29 N (S.D: 14.57). The tensile stress at maximum load for modified pulvertaft and modified side-to-side repair was 4.2MPa(S.D: 3.1) and 4.7 MPa (S.D: 3.8) respectively {Overall 4.3MPa(S.D: 3.5)}. The tensile stress at yield was 4.01 MPa (S.D: 3.1) and 5.5 MPa (S.D: 3.7) respectively for modified pulvertaft and modified side-to-side repair {overall 4.44 MPa (S.D: 3.45)}. The tensile strain at maximum load respectively for side-to-side and modified pulvertaft repair was 7.87%(S.D: 33.3) and 7.84%(S.D: 34.02) respectively. We found no statistical difference between 2 repairs in terms of strength, load to first failure, and maximum load to failure. The suture cut through was the commonest mode of failure. Our study uniquely compares two techniques under standard conditions, and contrary to existing evidence found no difference.
Stress shielding of the proximal femur occurs in stemmed implants. Resurfacing implant does not invade the intramedullary region. We studied the stress patterns in conventional and nonstemmed designs. FE model geometry was based on standard femur from the international Society of Biomechanics Mesh Repository. Loading simulated for one- legged stance with body weight of 826 N. 2 regions were defined, R1 (40 mm from tip of head) and R2 41 mm–150 mm) of the intramedullary part of the stemmed model's interface with bone. 2 different loading conditions bending and torsion were compared for stress and strain. The FE model was solved with ANSYS version 6.1 on a single processor NT station. With conventional implants, stem shields cortical bone from being loaded. In nonstemmed implants, Von Misses stress contours show a similar distribution as intact bone, transferring loads to the cortical shell but with higher stresses and a maximum displacement of 17.39% higher than that of intact bone. 15–23 mm proximal to R2 and around 110 mm, region of the stem tip, there were higher stress and strain concentrations.Methods
Results
The aim of this study was to describe the measurements of range of circumduction in normal volunteers and develop summaries of the data, develop the rate and rhythm of circumduction of the wrist with the use of Biometric electrogoniometer, reproducibility, reliability and accuracy of these measures of circumduction. Forty healthy subjects with a mean age of 42.6 years were assessed with flexible biaxial electrogoniometry in standard 90° pronated position of wrist for kinematic assessment of movement in orthogonal planes. Functional range of flexion-extension, ulnar-radial deviation and circumduction was measured and analysis of the digital output produced a visual display of the results as Lissajous's figures. This also allowed measurement of the total range of circumduction as two-dimensional area under the curve measurement. The rate and rhythm of movements were mathematically calculated and displayed over the two dimensional circumduction curves. The average arc of uniplanar flexion and extension is greater than the flexion and extension component of the circumduction curve but mean uniplanar radial ulnar deviation arc is similar to the radial-ulnar deviation component of the circumduction curve. The area of circumduction and circumference of the circumduction curve was used to measure the total range of circumduction. The four quadrants for the velocity of circumduction showed that the rate was faster in the deviation components as compared to flexion and extension. Quadrant analysis showed the changes in the rhythm was less in the deviation components compared to flexion and extension. The accuracy for measuring uniplanar movements showed a standard deviation of 6°. The accuracy for measuring circumduction showed a standard deviation of 347 °° (7%). Accuracy for measuring velocity of circumduction showed a standard deviation of 17°/s. This technique was found to be accurate and reliable in measuring the rate, range and rhythm of wrist circumduction.
Both intrinsic and extrinsic hand muscles contribute to finger flexion; however there are different ways in which individuals can flex their fingers. Due to different muscle insertions, it is possible to distinguish the mechanical effect of intrinsic muscles from extrinsic muscles. The aim of this observational study was to investigate the degree to which individuals in the population rely on either their intrinsic or extrinsic hand muscles. A high frequency camera was used to record the hands of 31 healthy participants, aged between 18 to 40, while they made a fist repeatedly. The hands were placed on a horizontal plane and the video was taken from the ulnar side, aligned horizontally with the hand. The maximum vertical distance between the fingertip and the distal palmer creases (XY) was recorded using WIN analyze 3D software. Three examiners independently analysed the videos and classified them into intrinsic dominant, extrinsic dominant or a mixed pattern. A t-test was performed on the XY values for the three different categories. The XY height difference between the intrinsic and extrinsic groups were statistically significant (P=0.001). The XY of mixed and intrinsic was also statistically significant (p=0.012) but not for mixed and extrinsic (p=0.46). Assessment of time when movement starts at each individual joint showed significant difference with intrinsic predominant moving the MCPJ before IPJ and extrinsic dominant individual moving their IPJ before MCPJ. This study shows that there is a difference in hand muscle dominance between individuals. More importantly it shows that there are individuals who rely on their intrinsic hand muscles more than their extrinsic muscles.
Scaphoid fractures with displacement have a higher incidence of nonunion and unite in a humpback position that can cause pain and reduced movement, strength and function. The aim of this study is to review the evidence available and establish the risk of nonunion associated with management of displaced scaphoid fractures in a plaster cast. Electronic databases were searched using the MeSH (Medical Subject Headings) controlled vocabulary (scaphoid fractures, AND'd with explode displaced, or explode nonunion, or explode non-healing or explode cast immobilisation, or explode plaster, or explode surgery). As no randomised or controlled studies were identified, the search was limited to observational studies based on consecutive cases with displaced scaphoid fractures treated in a plaster cast. The criterion for displacement was limited to gap or step of more than 1mm. The ‘random effects’ calculation was used to allow for the possibility that the results from the separate studies differ more than would be expected by chance.Background
Methods
Scaphoid fracture malunion with flexion and shortening results in the ‘humpback deformity’. This is thought to be associated with poor clinical results when assessed with the lateral intra-scaphoid angle and the Green and O'Brien wrist evaluation scale. This method of deformity measurement is now considered unreliable and the functional score has not been validated in the setting of scaphoid fractures. To assess the outcome of scaphoid malunion at one year using the height to length ratio, a reliable measure of deformity, and the Patient Evaluation Measure (PEM), a functional assessment validated specifically for scaphoid fracture outcome.Background
Aims & objectives
To assess the effect of deformity on Grip strength characteristics in the Rheumatoid Hands using force time curves. Forty seven (6 males and 41 females) patients with mean age 62 years (29–79 yrs) with Rheumatoid arthritis had their handgrip strength measured with closed fluid dynamometer generating force-time curves. These were analysed further in blinded fashion for:
peak force; average force; time to peak and variance of the force data through the plateau region (final 60% of curve). Data was also collected on joint mobility, pain and disability using Patient Evaluation Measure (PEM) and Functional Disability Scores (FDS). The patients were divided into five groups according to the degree of deformity: No deformity, ulnar deviation, Boutonniere, Swan neck or combined deformities (two or more deformities). These patient groups showed significant differences in grip strength (p value <
0.01). Patients with combination of deformities showed low peak and average forces as measured on force-time curves. The hands with Swan neck deformities had the highest variability in the plateau region of the curve and had the greatest disability scores both with PEM and FDS scores (P Value <
0.005). This group was particularly disabled (P Value <
0.007) being less able to sustain the grip over time. Swan Neck Deformity causes the most significant dysfunction and this should be carefully considered when making decisions regarding surgery.
We describe a method for stabilising the distal radioulnar joint using a double breasted slip of extensor retinaculum. This is a retrospective series of 30 patients with a painful wrist secondary to instability of the distal radioulnar joint. The results were assessed by a modified Mayo Score. The mean follow-up was for 38.1 months (13 months to 8 years). Twelve patients had excellent, 16 good and 2 fair outcomes. One patient had experienced temporary numbness in the distribution of the dorsal branch of the ulnar nerve. The modified Mayo wrist score increased from a pre-operative mean of 23.89 (10 to 50) to a final mean of 94.4 (85 to 100). Stabilisation of the distal radioulnar joint by the method of using a double breasted slip of the extensor retinaculum gives satisfactory results. The procedure is simple and reproducible.
There is no general consensus amongst Orthopaedic Surgeons on how best to manage the urinary tract and its complications after lower limb arthroplasty. This prospective audit investigates whether post-operative urinary retention can be predicted pre-operatively using the validated International Prostate Symptom severity score (IPSS). 182 patients undergoing lower limb arthroplasty under spinal anaesthetic were given the IPSS questionnaire to complete pre-operatively and an audit into numbers catheterised post-operatively carried out. 69% of males and 39% of females required catheterisation. Following logistic regression analysis there was 0.85 predicted probability that males over seventy years would require catheterisation. The IPSS score was not useful in predicting retention in either sex at any age. We propose that all males over seventy years undergoing this type of surgery should be catheterised pre-operatively and all other patients should be catheterised post-operatively with close monitoring of bladder volumes to prevent established urinary retention.
Introduction: Understanding the factors in progression of curves in spinal deformities are crucial to the planning of treatment. While clinical and genetic parameters appear to be involved in the progression of adolescent idiopathic scoliosis, it remains very difficult to objectively study this as it is difficult to find pedigree cohorts. We wish to report the difference in progression of adolescent idiopathic scoliosis curves in two essentially homogenous racial groups that utilise our Scoliosis service. Methods and Results: Three hundred and twenty-four patients were treated at the Scoliosis service of our Institute from 1985 to 1998. The aetiology of the curves were as follows: 218 AIS, 37 Neuromuscular, 48 Congenital, 21 other diagnostic type, and 11 aetiology not known. The racial distribution of utilisation of service: 44% Malay, 44.7% Chinese, 2.0% Indian and 9.3% not known or mixed race. The Malay and Chines groups were matched and studied. There was no difference in the menarchal age, curve size at presentation and age at presentation to the service (P=0.3). Patients were analysed in two groups: below 10 years, and above 10 years at presentation. The rate of progress of the AIS curves >
50° were fastest in the Chinese patients with a rate of 14.7°/year; with Malay patients progressing at 8.4°/year. Rates of progression of curves 30–50° were the same for both groups with Chinese at 7.7°/year, and Malays at 6.7°/year. Curves <
30° progressed at the same rate also with Chinese at 5.0°/year and Malays at 7.0°/year. Conclusion: From our data, it appears that race (genetics) does influence the rate of progression of AIS curves.
Lower limb injuries are the main cause of temporary and permanent disability among motorcyclists in the developing world of the Asia –Pacific region. They cause non-fatal but serious injuries requiring hospitalisation. This study presents computer simulation of the crash behaviour of the carry basket of a small-engined motorcycle with the lower limb using finite element (FE) methods. The results suggest that the extensive deformation of the motorcycle basket may reduce the risk of injury to the lower limb. The behaviour of the basket during collision is analogous to the crumple zone of automobiles. The use of these deformable baskets is recommended for all small engined motorcycles.
1. Seven cases of old unreduced anterior dislocation of the hip are reported. Six were complicated by myositis ossificans. 2. Four cases resulted from the fall of a heavy object on the lower back of a stooping person. 3. Trochanteric osteotomy in five cases not only corrected the deformity but gave stable, serviceable hips.
1. This case, in a girl, is the fourth case of ainhum to be reported from India. 2. The disease began in the big toe and later involved all the toes of the left foot.
