Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome

We examined 524 patients with whiplash injuries for delayed onset of shoulder pain in order to establish whether this was due to impingement syndrome. A total of 476 patients (91%) responded to a questionnaire of which 102 (22%) were entered into the study; 43 had both a positive impingement sign and Neer test. The incidence of impingement-type pain was 9%. After treatment 23 patients (5%) had a significant improvement in their symptoms, ten (2%) had a moderate improvement and nine had no improvement. Impingement-type pain can occur after whiplash injuries and can be successfully treated

A prospective trial was performed, comparing the use of silver sulphadiazine occlusive dressings with Fucidin gauze compressive dressings in the treatment of injuries to the finger-tip in patients presenting at the casualty department. Sixty-four patients were seen, four of whom had severe injury with extensive loss of pulp. The time taken for the wound to heal, the incidence of infection, and the duration of absence from work were compared for both types of treatment. The results showed that silver sulphadiazine occlusive dressings were the most effective in the treatment of these injuries even when they were severe

1. Three cases of injury to the femoro-popliteal artery complicating fracture of the femoral shaft are described. 2. In all three cases restoration of peripheral circulation by arterial repair carried out within ten hours of injury succeeded in saving the limb from permanent damage. 3. The importance of adequate resuscitation, early diagnosis and early adequate surgical intervention is stressed. 4. The mechanism of injury and the clinical features of help in early diagnosis are discussed. 5. The place of internal fixation of the femoral fragments is discussed and its advantages and disadvantages are compared with those of treatment by skeletal or skin traction

We have investigated whether cells derived from haemarthrosis caused by injury to the anterior cruciate ligament could differentiate into the osteoblast lineage in vitro. Haemarthroses associated with anterior cruciate ligament injuries were aspirated and cultured. After treatment with β-glycerophosphate, ascorbic acid and dexamethasone or 1,25 (OH). 2. D. 3. , a significant increase in the activity of alkaline phosphatase was observed. Matrix mineralisation was demonstrated after 28 days and mRNA levels in osteoblast-related genes were enhanced. Our results suggest that the haemarthrosis induced by injury to the anterior cruciate ligament contains osteoprogenitor cells and is a potential alternative source for cell-based treatment in such injury

We report 21 cases of stress injury of the distal radial growth plate-occurring in gymnasts before skeletal maturity. The injury appears to be caused by inability of the growth plate to withstand rotational and compressive forces. Our observations have confirmed that the skeletal age of gymnasts is retarded, which increases the length of time during which the epiphysis is at risk of damage

Fractures of the proximal humerus with concomitant vascular injury are rare in children. We describe the presentation, diagnosis, and treatment of a fracture of the proximal humerus in association with an axillary artery injury in a child

The effect of cortisone on the repair of simple muscle injury was studied in rabbits. The histological findings in the crushed muscle are described for a period up to twenty-one days after injury. Cortisone defers the onset of muscle regeneration, and retards its progress, but it does not change the course of the repair process or alter its eventual outcome under the conditions of the experiment. This apparent refractoriness of repair of muscle, as compared with that of other connective tissues, is discussed

Injuries to the ankle are common in children. We investigated whether decreased dorsiflexion predisposes to such fractures and sprains. Passive dorsiflexion in children with ankle injuries was compared with that in a control group of patients with a normal ankle. The uninjured side was examined to determine flexibility in those patients with ankle injuries. In 82, the mean dorsiflexion was 5.7° with the knee extended and 11.2° with the knee flexed. In 85 controls, the mean dorsiflexion was 12.8° with the knee extended and 21.5° with the knee flexed (p < 0.001, Student’s t-test). There was a strong association between decreased ankle dorsiflexion and injury in children. A flexible triceps surae appeared to absorb energy and protect the bone and ligaments, while stiffness predisposed to injury. We suggest that children with tight calf muscles should undergo a regimen of stretching exercises to improve their flexibility

We investigated the effect of delay before nerve repair on neuropathic pain after injury to the brachial plexus. We studied 148 patients, 85 prospectively and 63 retrospectively. The mean number of avulsed spinal nerves was 3.2 (1 to 5). Pain was measured by a linear visual analogue scale and by the peripheral nerve injury scale. Early repair was more effective than delayed repair in the relief from pain and there was a strong correlation between functional recovery and relief from pain

1. The types of ischaemia that accompany injuries to a limb are described. 2. The ischaemia may be total or local. 3. Thirty-seven cases of total or local ischaemia of a limb are analysed and conclusions are drawn therefrom

Although the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was designed, and has been validated, as a measure of disability in patients with disorders of the upper limb, the influence of those of the lower limb on disability as measured by the DASH score has not been assessed. The aim of this study was to investigate whether it exclusively measures disability associated with injuries to the upper limb. The Short Musculoskeletal Functional Assessment, a general musculoskeletal assessment instrument, was also completed by participants. Disability was compared in 206 participants, 84 with an injury to the upper limb, 73 with injury to the lower limb and 49 controls. We found that the DASH score also measured disability in patients with injuries to the lower limb. Care must therefore be taken when attributing disability measured by the DASH score to injuries of the upper limb when problems are also present in the lower limb. Its inability to discriminate clearly between disability due to problems at these separate sites must be taken into account when using this instrument in clinical practice or research

From 1981 to 1986 we treated 413 patients for acute spinal-cord injuries. We reviewed 356 patients followed for a minimum of two years of whom 71 (20%) developed heterotopic ossification around one or more joints. Heterotopic ossification occurred more often in male patients (23%) than in female (10%), and was most frequent in the 20- to 30-year age group. It was also more common after injuries of the lower cervical or thoracic spine than after those of the lumbar spine. Patients with severe neurological deficits (Frankel grades A and B) showed significantly more heterotopic ossification but there was no correlation with the number or severity of associated head and limb injuries. Serum calcium levels did not change significantly in either group for 30 weeks after injury, but the erythrocyte sedimentation rate and the alkaline phosphatase level were significantly increased at six weeks in patients with heterotopic ossification

Shoulder arthrodesis is often used to treat flail shoulder after a brachial plexus injury, but has a high complication rate and entails loss of passive mobility. We have reviewed 27 patients with brachial plexus injury treated by transfer of the trapezius to the proximal humerus at an average time from injury of 31.3 months. Pre-operatively, all 27 shoulders were subluxated, with an average abduction of 3.5 degrees. Postoperatively, shoulder abduction averaged 45.4 degrees, and subluxation was abolished. All patients were satisfied with their improvement in function. Trapezius transfer is recommended as a simple procedure that requires only a brief period in hospital, allows early rehabilitation, and gives a satisfactory outcome, while retaining passive mobility of the shoulder

Severe crush injuries affecting the bones of the carpus are rare. We review the nine cases that have previously been described and report four additional cases which we have treated and followed up. All 13 present remarkable similarities, with disruption of the carpal arch through the capitate-hamate articulation distally and the piso-triquetral joint proximally. Three slightly different variations of this pattern of fracture-dislocation are identified. The flexor retinaculum must be involved to allow the displacement which is seen, and there is usually an extensive laceration of the thenar eminence. Treatment by closed reduction is usually successful. Long-term follow-up shows that, in the absence of nerve or vascular damage, the results are surprisingly good

Aims. Improvements in the evaluation of outcome after nerve transfers are required. The assessment of force using the Medical Research Council (MRC) grades (0 to 5) is not suitable for this purpose. A ceiling effect is encountered within MRC grade 4/5 rendering this tool insensitive. Our aim was to show how the strength of flexion of the elbow could be assessed in patients who have undergone a re-innervation procedure using a continuous measurement scale. Methods. A total of 26 patients, 23 men and three women, with a mean age of 37.3 years (16 to 66), at the time of presentation, attended for review from a cohort of 52 patients who had undergone surgery to restore flexion of the elbow after a brachial plexus injury and were included in this retrospective study. The mean follow-up after nerve transfer was 56 months (28 to 101, standard deviation (. sd. ) 20.79). The strength of flexion of the elbow was measured in a standard outpatient environment with a static dynamometer. Results. In total, 21 patients (81%) gained MRC grade 4 strength of flexion of the elbow. The mean force of flexion was 7.2 kgf (3 to 15.5, . sd. 3.3). Conclusion. This study establishes that the dynamometer may be used for assessing the strength of flexion of the elbow in the outpatient department after nerve reconstructive surgery. Cite this article: Bone Joint J 2016;98-B:1517–20

We carried out a randomised, controlled trial in 157 patients who had isolated severe Gustilo type-IIIa and type-IIIb fractures of the metaphysis or diaphysis of the leg to determine the prevalence of vascular injuries and the role of vascular repair. All patients had stable vital signs and clinically adequate circulation in their legs before operation. In a control group of 64 patients we performed conventional surgery with systematic debridement and primary stabilisation of the fractures. In the trial group of 93 patients the major vessels and nerves adjoining the compound fracture were routinely explored and repaired when necessary after the initial procedure. Two of the 28 control patients (7.1%) with type-IIIb compound fractures had signs of inadequate circulation after the first operation. Both had major vascular injuries which were demonstrated at a second procedure. In the trial group, major vascular injuries were found in two of 54 patients (3.7%) with type-IIIa and 11 of 39 patients (28.2%) with type-IIIb compound fractures. Compared with the control group the trial group showed improved results at both the immediate and long-term follow-up. Routine exploration and early repair of injured major vessels of the leg in severe compound fractures gave encouraging results

Loss of proprioception following an anterior cruciate ligament (ACL) injury has been well documented. We evaluated proprioception in both the injured and the uninjured limb in 25 patients with ACL injury and in 25 healthy controls, as assessed by joint position sense (JPS), the threshold for the detection of passive movement (TDPM) and postural sway during single-limb stance on a force plate. There were significant proprioceptive deficits in both ACL-deficient and uninjured knees compared with control knees, as assessed by the angle reproduction test (on JPS) and postural sway on single limb stance. The degree of loss of proprioception in the ACL-deficient knee and the unaffected contralateral knee joint in the same patient was similar. The TDPM in the injured knee was significantly higher than that of controls at 30° and 70° of flexion. The TDPM of the contralateral knee joint was not significantly different from that in controls. Based on these findings, the effect of proprioceptive training of the contralateral uninjured knee should be explored. Cite this article: Bone Joint J 2013;95-B:188–91

Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings. In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications. The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO

1. Biopsies of muscle were taken during the course of operation from sixteen patients with vascular injuries to the limbs. Three types of histological change were found. 2. In the first, there was massive necrosis of muscle fibres—a group of cases in which there had always been serious damage to the main artery of the limb or to the vessel supplying the affected muscles. 3. In the second type there was dense interstitial fibrosis, the muscle fibres sometimes being normal and sometimes showing necrosis or denervation—a group of cases in which the vascular injury varied from severance of the vessels by gunshot wounds to trivial damage, causing slow haemorrhage within fascial-bound spaces. 4. The third type showed scattered foci of necrosis together with patchy interstitial fibrosis—due to the pressure of tight plasters, crushing of the limb, fractures with arterial contusion, or slow haemorrhage or extravascular transfusion within fascial planes. The rise of tension within the muscles was probably sufficient to occlude the smaller arterioles with resultant patchy necrosis. 5. The vulnerability of certain muscles to vascular damage is partly related to the intramuscular vascular pattern, of which five types have been described. 6. In ischaemic muscles the intramuscular nerve trunks may be normal or they may show evidence of degeneration or necrosis; but in favourable circumstances there may be regeneration of axons. 7. In some cases there was evidence of regeneration of muscle fibres in man, the regeneration being dependent to some extent upon the efficiency of intramuscular anastomoses. 8. The prognosis, in cases of ischaemia of human voluntary muscle, depends upon the extent and the reversibility of damage to both muscle and nerve fibres and upon the extent of regeneration of muscle fibres