The pattern of injury to the carpal ligaments following wrist trauma is unclear. Different imaging techniques often prove inconclusive rendering the diagnosis difficult and hence the treatment controversial. This study aimed to observe and evaluate the differences in scapholunate kinematics before and after sectioning the scapholunate interosseous ligament (SLIL) and radioscaphocapitate ligament (RSC).

Twenty two embalmed cadaveric wrists were used. There were four males and seven females with an average age of 84 years. Their medical records confirmed the absence of previous history of wrist diseases or injuries. The extensor and flexors tendons of the wrist were removed leaving the capsule intact. Two drill bits (1.5 mm) were used to make a hole each in scaphoid and lunate, one centimeter apart. The drill bits were left in the bones to act as metal wires for calibration. Each wrist was moved through a set of motions and each movement was performed thrice; first one with the ligaments intact, second with SLIL sectioned and the last one with RSC excised. Digital photographs were taken and angles measured with MB Ruler software. Analysis of variance was done using SPSS 12.

There was no angle between the metal pointers when the ligaments were intact. There was movement and change in angle detected when SLIL and RSC were sectioned. The sectioning of the SLIL lead to a significant increase in the angle between the pointers in all the movements recorded (p value < 0.001). Subsequent sectioning of the RSC further increased this angle but this increase was much smaller compared to that after sectioning SLIL. On completion of the measurements the wrist capsule was opened to reveal that both the ligaments had been successfully sectioned and there were no degenerative changes in the bones or ligaments in any wrist.

This first cadaveric evaluation of alterations in scapholunate motion with sectioning of SLIL and RSC revealed that SLIL has a significant influence on the scapholunate kinematics, where as sectioning of the RSC has little additional effect. This in-vivo finding might have implications of importance of preserving SLIL during wrist surgeries and its role in management of carpal instabilities.

We performed a double-blind, randomised controlled trial to assess the effectiveness of a continuous-infusion brachial plexus block with levobupivacaine compared with that of a standard single injection for the management of post-operative pain after surgery on the shoulder.

Eight patients were randomised to receive a pre-operative brachial plexus block using 30 ml of levobupivacaine 0.5% with adrenaline 1:200 000 followed by insertion of a 20-gauge polyamide catheter. This was connected to a disposable elastometric pump, set immediately after surgery to administer a continuous flow of levobupivacaine 0.25% at a rate of 5 ml per hour. The other eight patients were randomised to receive only the initial injection of 30 ml. The study was double-blinded with the aid of sham catheters and clamped pumps.

All patients were given regular paracetamol and were prescribed morphine through a patient-controlled analgesia pump. Motor and sensory block assessments, visual analogue scale pain scores and consumption of morphine were recorded after the operation and then at 6, 12 and 24 hours after administration of the block.

Satisfactory motor and sensory block was achieved in all patients. The mean visual analogue scale pain score at 12 hours and consumption of morphine at 24 hours after injection were significantly lower (p < 0.05) in the continuous-infusion group. This group also took longer to request their first additional analgesia and reported a significantly higher overall level of satisfaction.

Our study has shown that continuous interscalene infusion of levobupivacaine is an effective method of post-operative analgesia after major surgery of the shoulder.

Objectives: The current study evaluates the effectiveness of a direct access physiotherapy shoulder clinic, in terms of a faster treatment, levels of patient satisfaction and consultant’s workload relief.

Material and Methods: A protocol of management of shoulder Pain was created establishing the patient’s pathway from general practice to orthopaedic surgery. A clinical specialist physiotherapist was trained to lead a shoulder clinic, with shoulder treatment courses, shadowing of consultants at 3 shoulder clinics and in-service training on interpretation of x-rays with consultant radiologist. A course on injections taught by consultants was followed by a training period of 10 supervised injections. After this initial period, a letter was sent to all GPs in the catchment area informing that patients could be referred direct to the physio-shoulder clinic. In addition, patients coded for a primary consultation were also re-directed to that clinic. Only patients who did not improve after the initial treatment or who presented more complicate screening problems were redirected through a short cut to the consultant led clinic. A patient satisfaction questionnaire was used during the first 5 months.

Results – Over the first 2 years of the project, extending from November 2001 to December 2003, 203 patients were appointed to the open shoulder clinic. The first 60 patients were given the patient satisfaction questionnaire, with 47 returning it completed (78.3%). 28 of the 47 had been seen by a physio before. In a satisfaction scale of 1 to 5, 2 graded 3, 3 graded 4 and 42 graded 5 the advice received about their condition. In a similar scale 2 patients rated 3, 2 rated 4 and 43 rated 5 regarding their satisfaction with the opportunity to discuss their treatment/care options. Regarding arrangements for further care, 1 rated 1, 2 rated 3, 6 rated 4 and 36 rated 5. For overall satisfaction 1 rated 2, 2 rated 3, 2 rated 4 and 42 rated 5. Positive aspects of patient’s feedback included ample time to ask questions, improvement obtained with early start of treatment and more accessible discussion. Those who were not so satisfied were still worried with a long delay, difficulty in peripheral arrangements such as transport and parking and disappointment with long time for follow-up examinations such as MRI scans. 47% of the patients attending were followed up by Physiotherapy only, 18% were added directly to the surgical waiting list and 4 were referred for rheumatology. 22% were sent for further tests (MRI, USS). The waiting list for a first appointment in our upper-limb clinic was reduced from 46 weeks in 2001 to 36 weeks in 2003. Not a single patient insisted on seeing a consultant and 38% of the patients were discharged without specifically seeing one.

Conclusion – This study shows that a physio screening shoulder clinic is an effective and satisfactory way to reduce waiting times and improve patient care.

Fractures of the distal forearm are widely regarded as the result of “fragility”. We have examined the extent to which patients with Colles’ fractures have osteopenia. We measured the bone mineral density (BMD) in the contralateral radius of 235 women presenting with Colles’ fractures over a period of two years. While women of all ages had low values for ultra-distal BMD, the values, in age-matched terms, were particularly low among premenopausal women aged less than 45 years. This result was not due to the presence of women with an early menopause. This large survey confirms and extends the findings from earlier small studies. We consider that it is particularly important to investigate young patients with fractures of the distal forearm to identify those with osteoporosis, to seek an underlying cause and to consider treatment.

Introduction: The aims of this paper are to compare the results of measuring migration rates on radiographs manually and by computer assisted analysis of digitised images.

Methods: Standardised anteroposterior standing hip radiographs taken post operatively and then yearly following hip replacement were used. The radiographs were then scanned at 150 dpi (gray scale) and saved as tif files. The migration was measured manually by drawing a line along the long axis of the femoral component connecting the distal tip, to the notch which is used to impact the stem proximally. This gives us the length of the hip replacement and an axis along which migration can be measured. The tip of the greater trochanter was selected as a bony landmark. On the plain radiographs two sets of readings were made by one observer. The digitised images were then analysed in the same way using a software package (designed in house at the University of Dundee). Two sets of readings were performed by observer one and a second set by an independent observer.

Statistics: Inter and Intra observer rates were calculated using a paired sample t test.

Results: For the manual readings intra observer mean difference was 0.53 mm (CI 0.31–0.74 mm). Comparing manual vs computer readings for observer one there was a correlation of 0.89. For the computer readings intra observer mean difference was 0.36 mm (CI 0.64–0.8 mm) and inter observer mean difference 0.16 mm. Both non significant differences. This evidence shows that the readings made manually and by computer were not significantly different and that there was no significant inter and intra observer variation. The advantage of computer storage and reading being the faster analysis, the ability to store and access large numbers of radiographs. The disadvantages being the need to scan the radiographs to allow measurement.

Tibiofemoral alignment has a direct correlation with the survival of total knee arthroplasty. Traditionally, it has been measured using a goniometer on radiographs. We describe new software which measures this alignment on scanned radiographs by automatically detecting bones in the image.

Two surgeons used conventional methods and two clerical officers used the computerised routine to assess 58 radiographs of the knee on two occasions. There were no significant differences between any of the paired comparisons. The largest mean difference detected was 1.19°. Across all comparisons, the mean correlation was 0.755. A standardised routine for measuring tibiofemoral alignment was the greatest factor in reducing error in our study.

These results show that non-medical staff can reliably use the software to measure tibiofemoral alignment. It has the potential to measure all the parameters recommended by the Knee Society.

To ascertain whether patients with Colles’ fracture should be investigated for osteoporosis and the risk of future fractures, we measured the bone mineral density of the distal radius of the other arm in 31 women patients and compared the results with those of a control group of 289 normal women. We divided the patients into two groups, those younger than 66 years and those older. In 25 patients we found values for bone mineral density which were lower than one standard deviation below the mean value for their age. Younger patients had a deficit greater than that expected for their ages. We believe that women with Colles’ fracture should be evaluated routinely for osteoporosis, particularly if they are under 66 years of age.