We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up

Aims

The aim of this study was to determine the differences in spinal imaging characteristics between subjects with or without lumbar developmental spinal stenosis (DSS) in a population-based cohort.

We describe the results of surgical treatment in a prospective study of 183 consecutive cases of subluxation (101) and dislocation (82) of the shoulder secondary to obstetric brachial plexus palsy between 1995 and 2000. Neurological recovery was rated ‘good’ or ‘useful’ in all children, whose lesions fell into groups 1, 2 or 3 of the Narakas classification. The mean age at operation was 47 months (3 to 204). The mean follow-up was 40 months (24 to 124). The mean gain in function was 3.6 levels (9.4 to 13) using the Mallet score and 2 (2.1 to 4.1) on the Gilbert score. The mean active global range of shoulder movement was increased by 73°; the mean range of active lateral rotation by 58° and that of supination of the forearm by 51°. Active medial rotation was decreased by a mean of 10°. There were 20 failures. The functional outcome is related to the severity of the neurological lesion, the duration of the dislocation and onset of deformity

Aims

We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable.

The August 2014 Shoulder & Elbow Roundup. 360 . looks at: Myofibroblasts perhaps not implicated in post-traumatic elbow stiffness; olecranon tip biomechanically sound for coranoid reconstruction; obesity and elbow replacement don’t mix; single column plating successful for extra-articular distal humeral fractures; satisfaction not predictable in frozen shoulder; tenodesis and repair both acceptable in Grade II SLAP tears; glenoid bone grafting is effective and glenohumeral articular lesions best seen with an arthroscope

Aims

Although chondrosarcomas (CSs) display true malignant features, including local recurrence (LR) and metastases, their behaviour in the hands and feet is thought to differ from that in other parts of the axial and appendicular skeleton by having a lower metastatic potential. The purpose of this study was to investigate the disease-specific and surgical factors that affect the local and systemic prognosis of CS of the hands and feet.

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To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele.

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Non-coding microRNA (miRNA) in extracellular vesicles (EVs) derived from mesenchymal stem cells (MSCs) may promote neuronal repair after spinal cord injury (SCI). In this paper we report on the effects of MSC-EV-microRNA-381 (miR-381) in a rodent model of SCI.

Aims. This study aims to assess first, whether mutations in the epidermal growth factor receptor (EGFR) and Kirsten rat sarcoma (kRAS) genes are associated with overall survival (OS) in patients who present with symptomatic bone metastases from non-small cell lung cancer (NSCLC) and secondly, whether mutation status should be incorporated into prognostic models that are used when deciding on the appropriate palliative treatment for symptomatic bone metastases. Patients and Methods. We studied 139 patients with NSCLC treated between 2007 and 2014 for symptomatic bone metastases and whose mutation status was known. The association between mutation status and overall survival was analysed and the results applied to a recently published prognostic model to determine whether including the mutation status would improve its discriminatory power. Results. The median OS was 3.9 months (95% confidence interval (CI) 2.1 to 5.7). Patients with EGFR (15%) or kRAS mutations (34%) had a median OS of 17.3 months (95% CI 12.7 to 22.0) and 1.8 months (95% CI 1.0 to 2.7), respectively. Compared with EGFR-positive patients, EGFR-negative patients had a 2.5 times higher risk of death (95% CI 1.5 to 4.2). Incorporating EGFR mutation status in the prognostic model improved its discriminatory power. Conclusion. Survival prediction models for patients with symptomatic bone metastases are used to determine the most appropriate (surgical) treatment for painful or fractured lesions. This study shows that NSCLC should not be regarded as a single entity in such models. Cite this article: Bone Joint J 2017;99-B:516–21

The February 2015 Shoulder & Elbow Roundup. 360 . looks at: Proximal Humerus fractures a comprehensive review, Predicting complications in shoulder ORIF, The Coronoid Revisited, Remplissage and bankart repair for Hill-Sach’s lesions, Diabetes and elbow arthroplasty, Salvage surgery for failed bankart repair, Sternoclavicular Joint Reconstruction, Steroids effective in the short-term for tennis elbow

Aims

To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes.

The December 2014 Foot & Ankle Roundup360 looks at: Charcot feet, biomarkers and diabetes; weight bearing following Achilles tendon rupture; endobuttons and mal-reduced diastasis; evidence for stem cell therapies in osteochondral lesions of the talus; syndesmosis fixation in SER ankle fractures; and self-reporting for foot and ankle outcomes

We reviewed 16 patients with spina bifida and unilateral dislocation of the hip at an average age of 17 years. Nine had a high neurological level (thoracic to L3) and seven a low lesion (L4 to sacral). We assessed the influence of unilateral dislocation of the hip on leg-length discrepancy, hip pain, hip stiffness and pressure sores of the ischial tuberosity. In non-walking patients with high-level lesions, unilateral dislocation gave little functional disability and did not appear to require reduction. In walking patients with low-level lesions, leg-length discrepancy led to a poor gait and functional problems which could be prevented by reduction of the dislocation. In all patients with low lesions, surgery was successful in maintaining reduction; in two of five patients with high lesions it was unsuccessful

Early decompression in Pott's paraplegia gives encouraging results. It produces speedy recovery from paraplegia and ensures rapid healing of the lesion. Lateral extrapleural decompression without fusion for lesions of thoracic vertebrae is safe and satisfactory. It gives adequate exposure of the anterior and posterior parts of the vertebral bodies and of the theca, without endangering the stability of the spine. Age, sex and site of the lesion have no influence on the prognosis, whereas paraplegia of longer duration, paraplegia in flexion, and paraplegia presenting as a spinal cord tumour carry a bad prognosis. In early lesions there is reconstitution of vertebral bodies whereas in advanced lesions there is consolidation or bony fusion

1. During a fifteen-year period a clinical, radiological and in some cases a surgical study has been made of 319 patients suffering from spondylolisthesis–that is, forward slipping of one lumbar vertebra on another or forward sagging of the whole lumbar spine in relation to the sacrum. 2. The five etiological factors are described, and the cases are assigned to five groups according to the factor responsible for the slip. In every case slipping is permitted by a lesion of the apparatus which normally resists the forward thrust of the lower lumbar spine–that is, the hook of the neural arch composed of the pedicle, the pars interarticularis and the inferior articular facet engaging caudally over the superior articular facet of the vertebra below. 3. In Group I (congenital spondylolisthesis–sixty-six cases) the lesion is a congenital defect of the facets. In Group II (spondylolytic spondylolisthesis–164 cases) the lesion occurs in the region of the pars interarticularis and is either an elongation of the bone or a break in continuity. There are reasons for thinking that the lesion is caused by stress over a long period rather than by acute injury or by a congenital anomaly of ossification. In Group IV (degenerative spondylolisthesis–eighty cases) the lesion of the facets is degenerative. There are no good grounds for thinking that an abnormality of the angle between the facets and the pedicles is the primary lesion behind the degenerative change. 4. Group III and V comprise few cases. In the former (traumatic spondylolisthesis–three cases) the lesion–a fracture of the neural arch–is caused by a single severe injury. In Group V (pathological spondylolisthesis–six cases) the slipping is caused by weakness of bone from various causes. 5. A full description is given of the etiological and biomechanical features of each group. A special investigation has been made into the etiological factors in degenerative spondylolisthesis. 6. The incidence of involvement of nerve tissues is highest in degenerative spondylolisthesis; the most severe degrees of slip are found in congenital spondylolisthesis

We have carried out a prospective study of 17 patients (14 women, 3 men) of mean age 48 years (21 to 76) with transcervical fractures of the femur using MRI to detect early evidence of avascular necrosis of the head. Two fractures were Garden stage I, 12 stage II, and three stage III. We performed internal fixation under radiological control at a mean of five days (2 to 15) after injury using a titanium cannulated cancellous screw or a titanium compression hip screw. MRI was performed at one, six and 12 months and then yearly after operation. T1- and T2-weighted images were obtained by a spin-echo technique. The duration of follow-up of patients who did not subsequently require replacement of the head of the femur was from 2 to 5 years (mean 3.2). One month after operation eight of the 17 hips showed a band of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images indicating lesions in the femoral head away from the fracture line. These were of three types: type I was a small infarct at the superolateral region of the femoral head and was seen in three hips; type II was a shallow lesion from the superolateral region to the fovea of the femoral head (three hips); and type III was a large lesion occupying most of the femoral head (two hips). No further changes were seen in the MRI after six months from operation. Collapse of the femoral head did not occur in the three hips with type-I lesions, but two of the three type-II hips and both type-III hips subsequently collapsed. At the final follow-up the three hips with a type-I lesion and one with a type-II were still asymptomatic but radiography showed sclerosis in the femoral head corresponding to the MRI lesions. The nine hips which showed no changes on MRI at one month had no abnormal findings on physical examination, radiography or MRI at final follow-up

The treatment of osteochondritis dissecans (OCD) in children and adolescents is determined by the stability of the lesion and the state of the overlying cartilage. MRI has been advocated as an accurate way of assessing and staging such lesions. Our aim was to determine if MRI scans accurately predicted the subsequent arthroscopic findings in adolescents with OCD of the knee. Some authors have suggested that a high signal line behind a fragment on the T2-weighted image indicates the presence of synovial fluid and is a sign of an unstable lesion. More recent reports have suggested that this high signal line is due to the presence of vascular granulation tissue and may represent a healing reaction. We were able to improve the accuracy of MRI for staging the OCD lesion from 45% to 85% by interpreting the high signal T2 line as a predictor of instability only when it was accompanied by a breach in the cartilage on the T1-weighted image. We conclude that MRI can be used to stage OCD lesions accurately and that a high signal line behind the OCD fragment does not always indicate instability. We recommend the use of an MRI classification system which correlates with the arthroscopic findings

Aims

Chondrosarcoma is the second most common primary sarcoma of bone: conventional chondrosarcoma accounts for 85% of all cases. Conventional chondrosarcoma may be central or peripheral. Most studies group central and peripheral chondrosarcomas together, although there is growing evidence that their clinical behaviour and prognosis differ. The aims of this study were to analyze any differences in characteristics between central and peripheral chondrosarcomas and to investigate the incidence and role of different syndromes.

1. Sixty-three traction injuries of the brachial plexus in adults are reviewed. Most of the patients were seen at regular intervals for more than three years after injury. 2. The mechanism of injury is described. Forcible separation of the head and shoulder is the essential factor, but the type of lesion is determined by the position of the upper limb at the time of the accident. 3. In traction injuries the main damage is intraneural, and the lesions are of considerable extent. Extraneural scarring is a conspicuous feature of old injuries, but it does not cause any damage to uninjured parts of the plexus. 4. The prognosis of each type of lesion of the plexus is discussed. Satisfactory recovery occurs in most lesions of the upper three roots. Degenerative lesions of the whole plexus never recover completely. Cases with Horner's syndrome always have severe residual paralysis. 5. Conservative treatment is advocated for traction injuries of the plexus and evidence is cited against early or late operations on the plexus. Reconstructive surgical procedures are sometimes indicated