Aims

The risk factors for recurrent instability (RI) following a primary traumatic anterior shoulder dislocation (PTASD) remain unclear. In this study, we aimed to determine the rate of RI in a large cohort of patients managed nonoperatively after PTASD and to develop a clinical prediction model.

Aims

Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries.

Aims

Currently, periprosthetic fractures are excluded from the American Society for Bone and Mineral Research (ASBMR) definition of atypical femoral fracture (AFFs). This study aims to report on a series of periprosthetic femoral fractures (PFFs) that otherwise meet the criteria for AFFs. Secondary aims were to identify predictors of periprosthetic atypical femoral fractures (PAFFs) and quantify the complications of treatment.

Aims

The Edinburgh Trauma Triage Clinic (TTC) streamlines outpatient care through consultant-led ‘virtual’ triage of referrals and the direct discharge of minor fractures from the Emergency Department. We compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the TTC.

Aims

Fracture clinics are often characterised by the referral of large numbers of unselected patients with minor injuries not requiring investigation or intervention, long waiting times and recurrent unnecessary reviews. Our experience had been of an unsustainable system and we implemented a ‘Trauma Triage Clinic’ (TTC) in order to rationalise and regulate access to our fracture service. The British Orthopaedic Association’s guidelines have required a prospective evaluation of this change of practice, and we report our experience and results.

We reviewed the records and radiographs of seven children who presented with knee pain, local tenderness over the medial femoral condyle, and radiological irregularity of the distal medial metaphysis of the femur suggestive of malignancy. In the five patients who had biopsies, histological changes were consistent with musculotendinous avulsion, and the dissection of ten cadavers confirmed the site to be the insertion of part of the adductor magnus. The recognition of this lesion and knowledge of its benign nature may avoid unnecessary anxiety and needless biopsy.

We performed a prospective randomised controlled trial of the A-V Impulse System in 82 patients treated by hemiarthroplasty for subcapital fracture of the femoral neck. The incidence of proximal deep-vein thrombosis as assessed by Doppler ultrasonography was 23% in the control group and 0% in those using the device (p less than 0.01). Calf and thigh circumferences were measured in both groups at seven to ten days after operation. In the treatment group there was a mean relative reduction of postoperative swelling of the thigh by 3.27 cm (p less than 0.001) and of the calf by 1.55 cm (p less than 0.001). The A-V Impulse System appears to be a safe and effective method of reducing the incidence of proximal deep-vein thrombosis, and of postoperative swelling.

We report five examples of physeal widening in four children with myelomeningocele. In all cases there was rapid clinical resolution with the use of the patients' normal orthoses and minor limitation of activity, and there was no evidence of early epiphyseal closure or growth disturbance. We suggest that recognition of the pathological process before fracture occurred may explain the rapid return to normal.

This paper reports the results of screening 53033 infants for congenital dislocation of the hip between 1970 and 1979, and compares them with the results of a similar screening programme between 1960 to 1969. The number of dislocations missed at neonatal examination is unaltered at 0.11 per cent of live births. Operative treatment was needed in a further 0.07 per cent of the recent series even though the dislocations had been diagnosed within 24 hours of birth. The reasons for the failure of neonatal screening are discussed, and suggestions are made which will improve the situation.

Fifty-four hips converted to low friction arthroplasty between 1965 and 1975 have been reviewed one to eleven years after operation. In many cases malposition had led to degenerative changes in the opposite hip, the lumbar spine or the knee, often with severe loss of function due to pain. It was found that total replacement could give useful relief of pain and improved function, though the range of movement obtained was not as good as in primary replacement. An outstanding feature was the correction of inequality of leg length. In general, the results were much better in cases of ankylosis acquired in adult life than in cases of spontaneous fusion after sepsis in childhood. The most important complication was a single case of sciatic palsy.

1. A scheme was started in 1960 with the object of ensuring that the hips of all babies born in the North-Eastern Region of Scotland were examined shortly after birth.

2. 1,671 children with suspected abnormalities have been seen during the ensuing ten years, and the findings are discussed.

3. Clinical examination is essential. Radiographic examination of the newborn is not necessary and may be misleading, but it does prove that some hips with limited abduction but no instability are in fact dislocated.

4. Treatment is not started when the diagnosis is made shortly after birth. The children are re-examined at three weeks, when spontaneous recovery has occurred in about half. The others, whether they show instability or only limitation of abduction of the hips, are treated in a simple splint until they are three months old. Any residual stiffness is an indication for further splintage.

5. The first radiographs are taken when the children are three months old, and no child is discharged until the radiographs show that the upper femoral epiphyses have appeared and are in normal position.

6. We appreciate that we are treating some children who would have recovered spontaneously, but we do not know how to distinguish them. There is no evidence that splintage harms a hip.

7. Eighty-six children (5 per cent of the total) needed operation usually because the diagnosis was missed at birth.

8. Children with familial joint laxity or genu recurvatum should be examined especially carefully for associated hip abnormality.

9. The incidence of abnormality of the hips at birth is about one in fifty live births.

1. Eight cases of monarticular brucellar arthritis in children are described. They have been followed up from between one and six years and all are now fully active and clinically normal.

2. The history was usually short, with limp, swelling of the joint and pain as the presenting symptoms. Constitutional disturbance was slight in all cases.

3. Diagnosis was confirmed by high concurrent serum agglutinin titres which were not found in control children of the same age from the same areas. Mercaptoethanol resistant antibody (IgG) and complement fixing antibodies were also demonstrated in the sera of four cases. One child had a positive blood culture.

4. The condition responded rapidly to rest and splintage and, to date, recovery seems to have been complete.

Two cases of intraosseous glomus tumour of a terminal phalanx are described and the literature is reviewed.

1. Recurrence of deformity after operations for drop foot is often associated with opening of the front of the ankle joint: this has previously been regarded as a complication of the operation.

2. This study of sixty paralytic drop feet treated conservatively reveals that this laxity was in fact present in no less than 43 per cent.

3. The laxity is most commonly found when the calf muscle is strong and it can occur within a year of the onset of the paralysis. It is not always prevented by wearing a toe-raising spring.

4. Such anterior laxity may well be a common cause of failure of many of the standard operations for drop foot.

5. Before operation for drop foot is undertaken a lateral radiograph of the ankle should be taken in forced plantar-flexiori. If this demonstrates anterior laxity any standard operation is unlikely to succeed unless the anterior fibres of the collateral ligaments are protected from strain by simultaneous tendon transplantation or unless the ankle is included in the arthrodesis.

1 . The clinical results in forty cases of repair of the median nerve at the wrist have been examined. Almost half were unsatisfactory.

2. The factors that may have predisposed to failure of adequate re-innervation are discussed.

3. The results might be improved by the use of radio-opaque markers for early detection of separation at the suture line, and by the use of frozen sections to determine the adequacy of resection.

1. The results of treatment of 134 patients with congenital dislocation of 167 hips are reviewed.

2. Late diagnosis is still a major problem.

3. Subluxations rarely give rise to poor results, but in dislocations first treated over the age of five years there is a one-in-three risk of failure.

4. Manipulative reduction is successful less often than reduction on a frame and carries a higher risk of avascular necrosis.

5. Closed reduction on a frame was satisfactory in 58 per cent of patients under the age of three years, and can succeed up to the age of five.

6. Open reduction was required in 20 per cent of cases under the age of three, and can be used successfully up to the age of six.

7. Seven anatomical barriers to closed reduction have been recognised and two or more are commonly found in one hip when open reduction is performed.

8. The acetabular roof may fail to develop after reduction, especially if this is delayed. A C.E. angle of under 20 degrees does not necessarily forebode this, unless measured on an arthrograph. Sclerosis of a sloping acetabular roof is an indication for operation. Acetabuloplasty is the proper operation for a sloping acetabulum and can be done successfully up to the age of twelve. Over this age, a shelf operation should be performed; this is appropriate also in younger patients in whom the curvature of the acetabulum is normal but does not extend far enough laterally. These operations were required in 38 per cent of hips treated in patients under the age of three, and in 64 per cent over this age. There is a one-in-three risk of avascular necrosis when acetabular reconstruction is done in patients under three.

9. Anteversion, if excessive, should be corrected by subtrochanteric osteotomy, and any valgus of the femoral neck should be corrected simultaneously.

10. Unilateral dislocations in patients over the age of six are best treated by Colonna's operation. In our few bilateral cases over this age our results have been disappointing.

11. Avascular necrosis is less common but more serious when it occurs over the age of three. Manipulative reduction and the use of frog-leg plasters are two avoidable factors which appear to increase its incidence. The more serious degrees are accompanied by stiffness of the hip, and when this sign is present weight bearing should be avoided.

12. Prolonged, though rarely permanent, limitation of movement occurs in some 10 per cent of cases. In a few, operative correction was required.

1. A medial approach is preferred for arthrodesis of the wrist in reconstructive surgery because there is no interference with the extensor tendons.

2. The value of pre-operative assessment by a trial period in plaster is mentioned.

3. The technique of operation is described.

4. In the absence of active pronation, screwing the ulna to the radius in 45 degrees of pronation is advised.

5. The necessity for securing haemostasis before closing the wound is emphasised.

6. Thirty-four cases are reviewed. The shortest follow-up was one year and the longest twelve years. The result was satisfactory in all cases. Most patients were discharged from hospital after the plaster had been changed two weeks after operation. Union occurred in about sixteen weeks.

One hundred cases of Lambrinudi's arthrodesis are reviewed. The shortest follow-up was one year. and the longest twenty-seven years. Thirty-seven per cent were successful. Nineteen per cent were failures; many of these were associated with faulty technique, and one method of operation which gives good results is described.

Success is likely if there is a balance of power between the dorsiflexors and plantarflexors of the ankle, especially if there is some fixed equinus before operation.

Success is less likely when the operation is done for a flail foot. In such circumstances arthrodesis of the ankle may have to be considered subsequently for instability of the lateral ligament, recurrence of dropfoot, or arthritis which may develop in the more active patients.

Age in itself is no bar to success, but pseudarthrosis is more likely to occur in patients over the age of twenty.