In children with obstetric brachial plexus palsy (OBPP) who develop an internal rotation deformity of the shoulder, release of subscapularis improves the range of external rotation of the shoulder and the strength of supination of the forearm. We studied the strength of supination in 35 healthy adult volunteers at 45° of both internal and external rotation. The mean and maximum torques were greater in external than internal rotation by 8.7% and 7.5%, respectively. This was highly significant (p < 0.0001). The increased strength of supination in external rotation is probably because the maximum power of biceps, particularly the long head, may be exerted in this position. In children the difference may be even greater due to anatomical differences causing the dramatic increases in the strength of supination after surgery for OBPP. In adults our findings suggest that the supination exercises which are undertaken after injury or surgery to the forearm or wrist should be performed in external rotation

Two children with radial club hand and absence of the biceps muscle were treated by centralisation of the ulna into the carpus and triceps transfer. The two operations were performed only a short time apart so that the period between the procedures could be used to stretch the triceps and to enable the children to adapt to an altered position of the wrist and to mobility of the elbow at one step and following a single period of plaster immobilisation. It is very likely that function is better than it would have been had the condition remained untreated. Before operation the children had only a crude hook function of the hand against the forearm and could not bring the hand to the mouth. Even if function is not much improved, the improvement in appearance is considerable and is by itself sufficient to justify the procedures

Our aim was to determine whether the length and function of the flexor carpi ulnaris muscle were affected by separating it from its soft tissue connections. We measured the length of flexor carpi ulnaris before and after its dissection in ten patients with cerebral palsy. After tenotomy, tetanic contraction shortened the muscle by a mean of 8 mm. Subsequent dissection to separate it from all soft tissue connections, resulted in a further mean shortening of 17 mm (p < 0.001). This indicated that the dissected connective tissue had been strong enough to maintain the length of the contracting muscle. Passive extension of the wrist still lengthened the muscle after tenotomy, whereas this excursion significantly decreased after subsequent dissection. We conclude that the connective tissue envelope, which may be dissected during tendon transfer of flexor carpi ulnaris may act as a myofascial pathway for the transmission of force. This may have clinical implications for the outcome after tendon transfer

A control system for a multifunctional hand prosthesis, which requires a minimum of training for the amputee, has been developed. The great advantage of the pattern recognition technique in making it possible to control as many as six prosthetic movements has prompted this study. The development of a complete miniaturised system has allowed a clinical trial on four patients. Two different tests have been employed to evaluate this system: an objective computer test and a test representing activities of daily living (ADL test). The computer test shows that a high rate of correct recognition is obtained immediately after the prosthesis is applied to the amputee. The ADL test shows that forearm rotation, and flexion and extension of the wrist are used in most activities, indicating that few compensatory movements are performed. It is suggested that this control system is feasible and that long periods of training are unnecessary

1. A modification of the McLaughlin technique of lag screw fixation of the fractured scaphoid is described. 2. Fifty-six patients operated upon between 1956 and 1966 have been reviewed and their fractures classified under the headings recent, delayed union and non-union. 3. Plaster casts were avoided and early return to work encouraged; 95 per cent did so within two months. 4. Of twenty-two recent fractures, including three perilunar trans-scaphoid dislocations, nineteen united; of fifteen showing delayed union, eight united: and of nineteen cases of non-union, only two united. 5. The function of the wrist in the seventeen cases of persistent non-union stabilised by lag-screw was surprisingly good; only one patient has required arthrodesis to date. 6. The indications and contra-indications for the operation are discussed

We performed a prospective study in 186 patients with a minimum follow-up of two years in order to attempt to predict successful major re-implantation of the upper limb. There were 137 men and 49 women with 24 amputations of the palm, 75 of the wrist, 50 of the forearm, 9 disarticulations through the elbow, and 28 amputations through the upper arm. The degree of injury to the amputated segment and the stump were good predictors of the rate of success and the final outcome. Adequate preservation, contraction of the muscle in the amputated part after stimulation, the level of injury and a smoking habit were fair indicators, but the serum potassium concentration in the amputated segment was the best objective predictor. When it is higher than 6.5 mmol/l 30 minutes after re-perfusion, re-implantation should be avoided. A high systemic venous serum potassium concentration was also found before clinical signs of the re-perfusion syndrome were seen

Our aim was to determine whether children with buckle fractures of the distal radius could be managed at home after initial hospital treatment. There were 87 patients in the trial: 40 had their short-arm backslab removed at home three weeks after the initial injury, and 47 followed normal practice by attending the fracture clinic after three weeks for removal of the backslab. Clinical examination six weeks after the injury showed no significant difference in deformity of the wrist, tenderness, range of movement and satisfaction between the two groups. Fourteen (33%) of the hospital group compared with five (14%) (p = 0.04) of those managed in the community stated that they had problems with the care of their child’s fracture. It was found that both groups, given a choice, would prefer to remove their child’s backslab at home (p < 0.001). Our findings show that it is clinically safe to manage children with buckle fractures within the community

Aims

The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery.

Aims

Arthroplasty skills need to be acquired safely during training, yet operative experience is increasingly hard to acquire by trainees. Virtual reality (VR) training using headsets and motion-tracked controllers can simulate complex open procedures in a fully immersive operating theatre. The present study aimed to determine if trainees trained using VR perform better than those using conventional preparation for performing total hip arthroplasty (THA).

This is a retrospective study of primary repairs of flexor pollicis longus in 16 children under 15 years of age. Patients with injuries to the median or ulnar nerve at the wrist, crush injuries, skin loss or fracture were excluded. Repairs were carried out within 24 hours using a modified Kessler technique. The mean follow-up was for two years. The final results were evaluated using the criteria of Buck-Gramko and Tubiana. They were good or excellent in all except one patient who had a secondary tendon rupture. When compared with the non-injured thumb, however, there was a significant decrease in active interphalangeal flexion (> 30°) in one-third of cases. A new method of assessment is proposed for the recovery of function of the flexor pollicis tendon which is more suitable for children. Postoperative immobilisation using a short splint had a negative effect on outcome. The zone of injury, an early mobilisation programme or concurrent injury to the digital nerve had no significant effect on the final result

We reviewed the records of 431 patients who had open reduction and internal fixation of the scaphoid performed by one surgeon (TJH) over a 13-year period. The Herbert bone screw provided adequate internal fixation without the use of plaster immobilisation, promoting a rapid functional recovery. On average, patients returned to work 4.7 weeks after surgery and wrist function was significantly improved, even when the fracture failed to unite. Healing rates for acute fractures were better than those reported for plaster immobilisation and were independent of fracture location. In the case of established nonunions, healing depended on the stage and location of the fracture, but the progress of arthritis was halted and carpal collapse significantly improved. Internal fixation of the scaphoid using the Herbert bone screw, although technically demanding, has few complications and appears to offer significant advantages over other methods of treatment

We carried out arthrodesis of the radiolunate joint in 46 wrists (38 patients) for pain and ulnar translation of the carpus because of rheumatoid (42) or psoriatic arthritis (4). At follow-up, three patients had died and in three (1 bilateral) an additional midcarpal arthrodesis had been undertaken. The remaining 32 patients (39 wrists) were evaluated after a mean of five years. The clinical results were good with a mean visual analogue score of 8.3 for pain, 7.2 for hand function and 9 for overall satisfaction. Except for palmar flexion, mobility was equal to or better than before operation. Radiologically, there was deterioration of the midcarpal joint with an increase in the Larsen score from 1.8 to 2.7 (p < 0.001), some decrease in carpal height and recurrence of carpal translation. Radiolunate arthrodesis gives good clinical results at five years although there is some deterioration radiologically

1. The bad reputation of fractures of the scaphoid bone is based on a) past disasters caused by inadequate splintage and premature resort to operation; and b) selection of disabling cases for publication. 2. The results obtained in five series comprising over 1,000 fractures suggest that 95 per cent of adequately studied fractures less than a month old unite if properly treated. 3. Sixty cases of established non-union have provided evidence that disability is almost always the result of further injury and that the disability is usually relieved by a short time in plaster. 4. There is no evidence to support the widely held beliefs that a) union by bone can occur only if the fracture is immobilised throughout the process; and b) union after prolonged immobilisation is due to the immobilisation. 5. A policy of treating the wrist and not merely its radiological appearances is advocated

The different attributes of the Patient Evaluation Measure (PEM) questionnaire were investigated in 80 patients with a fracture of the scaphoid. Assessments were made at 2, 8, 12, 26 and 52 weeks. Reliability was assessed by measurement of the internal consistency of the different questions in 275 completed PEM forms. Cronbach’s alpha, which needs to lie between 0.7 and 0.9, was 0.9 for the PEM. Pain, tenderness, swelling, wrist movement and grip strength correlated with the PEM score confirming the validity of the assessment. Changes in the different variables between visits correlated significantly with changes in the PEM score; its effect size and standardised response mean were comparable to those of grip strength and movement, confirming the responsiveness of this questionnaire. Gender, dominance and the side injured did not influence the scores. Older patients had a poorer outcome as assessed by the score which appeared to be a true effect and not age bias. Our study confirmed that the PEM is a reliable, valid and responsive instrument in assessing outcomes of disorders of the hand

The capacity for physiotherapy to improve the outcome after fracture of the distal radius is unproven. We carried out a randomised controlled trial on 96 patients, comparing conventional physiotherapy with a regime of home exercises. The function of the upper limb was assessed at the time of removal of the plaster cast and at three and six months after injury. Factors which may predict poor outcome in these patients were sought. Grip strength and hand function did not significantly differ between the two groups. Flexion and extension of the wrist were the only movements to improve with physiotherapy at six months (p = 0.001). Predictors of poor functional outcome were malunion and impaired function before the fracture. These patients presented with pain, decreased rotation of the forearm and low functional scores at six weeks. Our study has shown that home exercises are adequate rehabilitation after uncomplicated fracture of the distal radius, and routine referral for a course of physiotherapy should be discouraged. The role of physiotherapy in patients at high risk of a poor outcome requires further investigation

We treated 31 intra-articular fractures of the distal radius by arthroscopically-assisted reduction and percutaneous fixation with Kirschner (K-) wires. Tears of the triangular fibrocartilage (58%), scapholunate (85%) and lunotriquetral (61%) instability and osteochondral lesions (19%) were also treated. A total of 26 patients was independently reviewed at an average of 19 months. The mean pain score was 1.3/10, the range of movement 79% and the grip strength 90% of the contralateral wrist. Using the New York Orthopaedic Hospital score, 88% were graded excellent to good. On follow-up radiographs, 65% had no step and 31% had a step of ≤1 mm. Pain was significantly related to the size of the step. There was a significant difference in the incidence of persistent scapholunate diastasis and the Leibovic and Geissler grade (p < 0.01): I (0%), II (0%), III (42%) and IV (100%). We recommend anatomical reduction and acceptance of a step of < 1 mm since the size of the step is related to the incidence of pain

1. Tendon grafts, in order to survive, have to develop a blood supply from their immediate environment. This causes adhesions. 2. Their final range of movement is therefore a sum of the length to which these vascular adhesions will stretch, and the range of movement of the normal tissues to which the tendon has become adherent. 3. Thus it is important that the tendon graft should lie in a bed of yielding material, and that no unyielding structures should be divided in the same wound. When possible, blunt tunnelling between short transverse incisions is the method of choice for placement of grafts. 4. The most crippling adhesions are those that grow from an imperfectly sutured cut end of tendon, leaving it unsatisfied. A new method of tendon anastomosis designed to prevent such adhesions is described. 5. A tendon grafting technique for intrinsic paralysis of the fingers in leprosy, using a radial extensor of the wrist as the motor and the plantaris tendon as the graft, is described. 6. A study of 861 fingers after the operation is presented. 7. The importance of re-education after operation is stressed

1. A study of fifty patients with dislocations of the lunate bone or perilunar dislocations has been made. The period of observation was adequate in thirty-eight. 2. The injuries generally occur in young or middle-aged men after unusually severe trauma. 3. Associated injuries are frequent, and the most common of these is damage to the median nerve. 4. In one-third of the cases the nature of the lesion was not initially diagnosed or the initial treatment was inadequate. 5. A dislocated lunate bone may be replaced even at a late stage and even if the displacement is severe so long as there is some soft-tissue attachment. The anterior approach may safely be used for the replacement. 6. The lunate bone may be removed without involving the necessity for arthrodesis of the wrist. 7. Open reduction should be employed for trans-scaphoid dislocations whenever exact realignment and good fixation cannot be achieved by closed methods. 8. Excision of the proximal row of the carpus gives the possibility of salvage of a reasonable degree of function, and may be preferable to arthrodesis or removal of only part of the proximal row