Developmental dysplasia of the hip (DDH), a developmental deformity with an incidence of 0.1-3.4%, lacks an objective and reliable definition and assessment metric by which to conduct timely diagnosis. This work aims to address this challenge by developing a system of analysis to accurately detect 22 key anatomical landmarks in anteroposterior pelvic radiographs of the juvenile hip, from which a range of novel salient morphological measures can be derived. A coarse-to-fine approach was implemented, with six model variations of the U-Net deep neural network architecture compared for the coarse model and four variations for the fine model; model variations included differences in data augmentation applied, image input size, network attention gates, and loss function design. The best performing combination achieved a root-mean-square error in the positional accuracy of landmark detection of 3.79 mm with a bias and precision in the x-direction of 0.03 ± 17.6 mm and y-direction of 1.76 ± 22.5 mm in the image frame of reference. Average errors for each morphological metric are in line with the performance of clinical experts. Future work will use this system to perform a population analysis to accurately characterize hip joint morphology and develop an objective and reliable assessment metric for DDH.

Introduction:Surgical site infection (SSI) related to magnetic intramedullary lengthening nails (MILNs) can lead to delayed consolidation or loss of limb function, resulting in deleterious effects to a patient's quality of life. With the rise of MILNs, we sought to determine the incidence rate and risk factors for infection during limb lengthening with MILNs. Methods:We reviewed a consecutive series of patients who underwent femoral and/or tibial lengthening with an MILN at a single institution between 2012 and 2020 (n = 420). SSI was defined according to CDC-NHSN criteria (including superficial and deep infections) with postoperative surveillance time of 12 months. Demographic, health metrics, comorbidities, limb- and surgery-related factors, were assessed as potential risk mediators of SSI. Results:Incidence of SSI was 3.3 % (14/420). This was divided into superficial (0.5 %,2/420) and deep (2.9 %, 12/420) infections. Of deep infections, 75 % (9/12) were osteomyelitis. Of the 14 limbs that developed SSI, 57 % (8/14) had a history of prior external fixation in the same limb and 38 % (5/14) had a previous infection of the same limb. A subanalysis of patients with a history of prior external fixation in the same bone was associated with SSI, as compared to those without previous external fixation. None of the surgery-related infection risk factors reached statistical significance. Discussion and conclusion:The total incidence of infection with MILNs was 3.3 % at 24 months follow-up. The risk of deep infection was 2.9 %. Patients with a history of previous external fixation and prior infection show an independent association with increased rate of infection recurrence in the same bone. These patients could be considered a high-risk group for developing deep tissue infection. Potential algorithms include prolonged oral antibiotics after MILN insertion or simultaneous injection of absorbable antibiotic at the time of the nail insertion.

Background: Joint-preserving hip operations can help relieve pain and delay the need for long-term joint arthroplasty. Previous research has not identified procedures that can compromise outcomes following total hip arthroplasty (THA). This meta-analysis aims to evaluate the effect of joint-preserving hip operations on outcomes following subsequent THA. Methods: MEDLINE, EMBASE and Scopus databases were searched from the date of inception until February 2024. All studies comparing outcomes following THA in individuals with (PS) and without prior surgery (NPS) of the femur or pelvis were included. Data on operative time, blood loss, intra- and post-operative complications, functional outcomes, and implant survivorship were extracted. Results: 16 studies, comprising 2576 patients were included (PS = 939, NPS = 1637). The PS group was associated with significantly longer operative time [MD: 8.1, 95% CI: 4.6–11.6], significantly greater blood loss [MD: 167.8, 95% CI: 135.6–200.0], and a higher risk of intra-operative peri-prosthetic fracture [RR: 1.9, 95% CI: 1.2–3.0], specifically, with prior femoral osteotomy. There were no differences in terms of risks of dislocation [RR: 1.8, 95% CI: 1.0–3.2], implant loosening [RR: 1.0, 95% CI: 0.7–1.5], or revision surgery [RR: 1.3, 95% CI: 1.0–1.7] between the two groups. The PS group was associated with significantly poorer improvements in functional outcome [MD: −5.6, 95% CI: −7.6–(−3.5)], specifically, with prior acetabular osteotomy. Implant survivorship in the two groups was comparable after one year [HR: 1.9, 95% CI: 0.6–6.2] but significantly inferior in the PS group after five years [HR: 2.5, 95% CI: 1.4–4.7], specifically, with prior femoral osteotomy. Conclusion: Joint-preserving hip operations are associated with greater intra-operative challenges and complications. In subsequent joint arthroplasty, prior acetabular procedures affect functional outcomes while prior femoral procedures influence implant survivorship. Hip pain due to the morphological sequelae of pediatric hip pathology can be debilitating at a young age. Surgical decision-making at that time needs to consider the survivorship of a THA implanted at that young age against the consequences of hip preservation surgery on further THA.

IntroductionThere is no doubt that the future of limb lengthening lies with internal lengthening. Complication rates are reduced and patient satisfaction is increased. The evolution of internal lengthening peaked with the dual direction, easily inserted and externally controlled PRECICE Nail. It has excelled in performance in accuracy and satisfaction. Its versatility increased with smaller sizes and increased excursion. A field safety notice was issued was issued in October 2021 by the parent company NuVasive. The advice was monitoring of current cases and a hold on implantation until after a review of process. At the National Orthopaedic Hospital Cappagh we elected to remove all implanted nails and assess the nail integrity and physiological changes associated with implantation.Materials & MethodsAll patients in who a retained Precice nail at the time of the field safety notice were identified. Patients and families were contacted to explain the issued safety notice from the company and explain that we would be scheduling them for nail removal. This was part of our standard care but we prioritised this group on our waiting list. Consent was obtained for nail removal but also for histological assessment of canal scrapings, blood ion level analysis and independent assessment of the retrieved nail by our academic collaborators at University College Dublin. Ion levels were then repeated at an interval post removal with consent.ResultsWe identified 7 Precice nails in 5 patients still implanted. All patients had consolidated after lengthening and were ready for nail removal. Elevated Titanium blood ion levels were identified at the time of retrieval. Histological abnormalities consistent with metalosis were identified. In all cases the nail was grossly intact and examination of the motor showed no evidence of wear or failure. Follow up ion levels obtained post retrieval showed persistent elevation.ConclusionsOur retrieval audit shows persistent elevation of Titanium ion levels and abnormal histology despite apparent nail integrity. These findings require further evaluation in a larger retrieval series to determine if there is a high incidence of this phenomenon and if ion levels have a clinical effect.

Introduction Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects.

Background: Surgical Hip Dislocation (SHD) is a powerful tool in the armamentarium of any surgeon treating conditions affecting the hips of children presenting with sequelae of a number of common conditions including Legg-Calv'ePerthes disease (LCPD) and slipped capital femoral epiphysis (SCFE). Risks associated with the procedure are well described. We investigated to assess if SHD is associated with significant surgical risk and if it improved clinical outcomes for patients. Methods: We conducted a prospective cohort study. We reviewed 18 (11 males and 7 females; mean age 13.7 years (6e17) with symptomatic hip pathology, secondary to femoroacetabular impingement (FAI) between 2017 and 2021. All patients underwent a surgical hip dislocation approach and femoral head-neck osteochondroplasty, Head Split osteotomy or both. Clinical improvement was assessed using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index. The minimum follow-up was 6 months (mean, 22 months; range, 6e42 months). Results: WOMAC scores improved at final follow-up from 10 to 3 for pain, 33 to 10 for function, and 4 to 2 for the stiffness subscales. All radiographic measures improved significantly of the postoperative X-rays. No patients developed osteonecrosis, implant failure, deep infection, or nonunion. Conclusion: Surgical Hip Dislocation, in the short term, we found improvement in WOMAC scores and radiographic indices with a low complication rate. (c) 2022 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Introduction Legg-Calve-Perthes (Perthes Disease) was first recognised by three physicians, Arthur Legg (1874–1939), Jacqui Calve (1875–1954) and George Perthes (1869 – 1927) in 1910. Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood supply to the femoral head is disrupted. Without this blood supply, the bone cells die and avascular necrosis can occur. The Herring classification is used to diagnose the stages of Perthes Disease. It is an important prognostic factor. There are three classifications, Herring A, B and C. Herring A has no involvement of the lateral pillar with no density changes noted on x-ray. Herring B has at least 50% of the lateral pillar height maintained on x-ray. Herring C has less than 50% of the lateral pillar height on x-ray (Herring et al, 1992). Children with Perthes disease require specialist Limb Reconstruction team throughout their treatment journey, this includes Orthopaedic surgery and therapy (Physiotherapy and Occupational Therapy). The National Limb Reconstruction Therapy Team is based at the National Orthopaedic Hospital, Cappagh. The therapy team consists of 1 Clinical Specialist Physiotherapist, 1 Senior Physiotherapist and 1 Senior Occupational Therapist who provide input to this cohort. This study aims to analyse the importance of a comprehensive pre-operative assessment by the therapy team (Physiotherapist and Occupational Therapist) to maximise patient outcomes post operatively. Methodology This is a quantitative research study conducted by the National Limb Reconstructive Therapy Service of the National Orthopaedic Hospital in Cappagh, Dublin. The inclusion criteria for this study consisted of: Age – Patient must be part of the Paediatric Service, i.e., under the age of 16. Diagnosis – Patient must have a diagnosis of Perthes Disease with a Herring Classification documented. Application of a Hip Distractor Frame formed part of the patient's surgical management. Surgery was completed by Mr Connor Green. Surgery was completed between January 2021 and December 2022. Patient were required to have their external hip distractor frame removed by December 2022. Exclusion Criteria: Those not meeting the above inclusion criteria. Following the inclusion criteria, a number of cases were identified of which 10 cases were selected at random. A retrospective analysis of these samples was completed. The medical charts were reviewed as well as patient electronic healthcare records. Microsoft Excel was utilised to analyse the data and capture results. Results From analysing the data, the following results were identified: 80% of the sample cohort had a length of stay of 5 days following surgery. There were two outliers due to infection who had a length of stay of 14 days. 90% of the sample received a pre-operative Physiotherapy and Occupational Therapy assessment. This assessment included information gathering regarding the child's home and social environment; their functional baseline and anticipated post-operative needs. Standardised and non-standardised assessments were used. 88.89% of those who completed a pre-operative assessment required referral to community Occupational Therapy teams for equipment provision (wheelchair, transfer aids) to allow for timely discharge. On average, each patient in the sample required 17 physiotherapy outpatient sessions prior to handover to the community teams. 100% of our sample required post operation onward referral for MDT input in the community (Occupational Therapy and Physiotherapy). Conclusions The importance of a multi-disciplinary approach towards family and children was highlighted in this study. A comprehensive pre-operative therapy assessment optimizes care for this cohort by preparing them in terms of equipment provisions, local team input and expectations for therapy. The data suggests future Limb Reconstruction team should include Physiotherapy and Occupational Therapy as part of the multi-disciplinary team, in the treatment of children with Perthe's Disease. We suggest an MDT pre-assessment is completed to optimize patient care, reduce length of stay and improve patient satisfaction in the acute hospital setting.

INTRODUCTION:Developmental dysplasia of the hip (DDH) refers to congenital and/or developmental hip instability that can result in hip joint subluxation or dislocation. When detected neonatally, conservative treatment with hip bracing can restore normal hip anatomy. Missed detection of DDH in the neonatal period or late development of DDH often requires surgical intervention to correct the abnormal anatomy. Furthermore, despite surgical intervention, residual sequelae may persist leading to early osteoarthritis of the hip joint requiring joint replacement surgery. AIM:This study investigates the prevalence of hip dysplasia in patients undergoing total hip arthroplasty (THA) under 50 years of age. METHODS:The hip arthroplasty database at a national referral centre was investigated from January 2014 to December 2020. In patients under 50 years of age, those with an adequate pre-operative anteroposterior pelvic radiograph without previous hip arthroplasty were included, while those with inadequate radiographs were excluded. The following measurements were made on the contralateral non-operated hip: (1) lateral centre-edge angle (LCEA), (2) Tönnis angle, (3) acetabular version, (4) acetabular depth, (5) femoral head lateralisation, (6) femoral head extrusion index, and (7) acetabular depth-to-width ratio. RESULTS:In total, 451 patients were included in this study. Twenty two percent of the patients had hip dysplasia, based on a LCEA of <25° and 42.6% of patients had hip dysplasia, based on a Tönnis angle of > 10°. The mean LCEA and Tönnis angle were 31.47 ± 9.64 and 9.82 ± 6.79°, respectively. CONCLUSION:Hip dysplasia is common in patients undergoing THA under the age of 50 years with over 40% having dysplasia according to the Tönnis angle. Classification of primary and secondary osteoarthritis in the joint registries will benefit our knowledge on the prevalence of DDH in the adult population.

Developmental dysplasia of the hip (DDH) is a developmental deformity occurring in 0.1-3.4% of infants. Timely surgical intervention can ameliorate the condition in stable hips and reduce future cases of osteoarthritis and total hip replacement. However, current definitions of DDH are subjective, and thus would benefit from a more objective and reliable assessment metric. Since the shape of the femoral head and its congruence with the acetabulum are disrupted by DDH, analysis of the femoral head could potentially play a role in the development of novel objective morphological metric for stable DDH. Therefore, this paper aimed to segment the paediatric femoral head in stable hips from radiographs, which has not been attempted before in the chosen focus age group (1-16 years) where the pelvis and hip joint undergo significant development. Two techniques were compared against a baseline U-Net: data augmentation and region-of-interest (ROI) networks. Four models were developed either without, with just one, or with both techniques. Evaluated using tenfold cross-validation, the U-Net trained with both techniques achieved the best results, with a Dice Similarity Coefficient (DSC) of 0.951±0.037 (mean ± standard deviation, calculated with 720 images). Future work will use this segmentation algorithm to accurately characterise hip joint morphology and estimate the benefit of early surgical intervention in DDH.

Corrective surgery for scoliosis is a complex and challenging prospect for experienced spine surgeons due to the prolonged duration of surgery and the significant level of technical skill and expertise required. Traditionally, shorter operative time and lower blood loss have correlated well with improved outcomes and as such, efforts have been made to affect these metrics including the use of two attending surgeons for major cases in preference to one. This systematic review and meta-analysis assessed the available literature to further clarify the potential benefit that adopting a dual-surgeon approach offers over single-surgeon operations. A systematic review and meta-analysis assessed the effect of dual-surgeon operating compared to single-surgeon with respect to a number of indicators including blood loss, operative duration and length of hospital stay. In addition, we evaluated whether blood transfusion or complication rates differed between the two groups. Seven studies met our inclusion criteria. Mean difference indicated shorter duration of surgery (− 90.5 min, 95% CI [− 103.3, − 77.6]) and a lower blood loss (− 379.1, 95% CI [− 572.2, − 230.9]) in the dual-surgeon group compared to the single-surgeon group. Six studies reported mean length of stay and also favoured the dual-surgeon group. This review observed that there are no randomised control trials evaluating dual-surgeon versus single-surgeon operating for scoliosis. We provide aggregated data and analysis of available literature, suggesting that outcomes in complex scoliosis surgery may be improved by adopting a dual-surgeon approach. III.

The coronavirus disease 2019 pandemic has meant that there is growing pressure on hospital resources, not least the availability of appropriate personal protective equipment (PPE), particularly face masks and respirator masks. Within the field of orthopaedic surgery, it is a common sight to see surgeons wearing 'space suits' (SSs) which comprise a helmet, hood and surgical gown.In this study, the authors made modifications to two different SS systems to incorporate a high-efficiency particulate air (HEPA) filter into the fan inlet to assess their potential as re-usable PPE systems for surgeons with regard to protection from a virus spread via respiratory droplets. The testing was carried out using particle counters upstream and downstream on a mannequin wearing two different SS systems with and without modifications to the fan inlet.The results show that using a layer of HEPA filter, cut to size and sealed to the fan inlet in the helmet, will reduce downstream particulates at the user's mouth by >99.5%; this is equivalent to a respirator mask. HEPA filter material is relatively cheap and can be used repeatedly, making this a viable alternative to disposable, and even resterilized, respirator masks in the setting of a respiratory-droplet-spread viral pandemic.

Introduction Virtual fracture clinics (VFCs) are being increasingly used to offer safe and efficient orthopaedic review without the requirement for face-to-face contact. With the onset of the COVID-19 pandemic, we sought to develop an online referral pathway that would allow us to provide definitive orthopaedic management plans and reduce face-to-face contact at the fracture clinics. Methods All patients presenting to the emergency department from 21March 2020 with a musculoskeletal injury or potential musculoskeletal infection deemed to require orthopaedic input were discussed using a secure messaging app. A definitive management plan was communicated by an on-call senior orthopaedic decision-maker. We analyzed the time to decision, if further information was needed, and the referral outcome. An analysis of the orthopaedic referrals for the same period in 2019 was also performed as a comparison. Results During the study period, 295 patients with mean age of 7.93 years (standard error (SE) 0.24) were reviewed. Of these, 25 (9.8%) were admitted, 17 (5.8%) were advised to return for planned surgical intervention, 105 (35.6%) were referred to a face-to-face fracture clinic, 137 (46.4%) were discharged with no follow-up, and seven (2.4%) were referred to other services. The mean time to decision was 20.14 minutes (SE 1.73). There was a significant difference in the time to decision between patients referred to fracture clinic and patients discharged (mean 25.25 minutes (SE 3.18) vs mean 2.63 (SE 1.42); p < 0.005). There were a total of 295 referrals to the fracture clinic for the same period in 2019 with a further 44 emergency admissions. There was a statistically significant difference in the weekly referrals after being triaged by the VFC (mean 59 (SE 5.15) vs mean 21 (SE 2.17); p < 0.001). Conclusion The use of an electronic referral pathway to deliver a point of care virtual fracture clinic allowed for efficient use of scarce resources and definitive management plan delivery in a safe manner. Cite this article: Bone Joint Open 2020;1-6:293–301.

BACKGROUND:Scheuermann kyphosis (SK) can be managed operatively or nonoperatively. Few studies compare the effect of operative versus nonoperative treatment on patient health-related quality of life. We compare 2-year radiographic and the Scoliosis Research Society-22 questionnaire (SRS-22) results of patients who self-selected either conservative or surgical treatment.METHODS:Single institution review of prospectively collected data for patients presenting with SK from 2006 to 2014. Forty-five of 55 patients returned for 2-year follow-up. Patients were divided into operative (n=27) or nonoperative (n=18) groups based upon their self-selected method of treatment. Radiographic data and SRS-22 scores were collected at initial presentation and 2-year follow-up.RESULTS:Operatively treated patients had larger initial sagittal Cobb angles and lower SRS-22 scores in the pain and appearance domains. Two years postoperatively, surgically treated patients had smaller Cobb angles and improved scores in these SRS-22 domains. Nonoperatively treated patients did not deteriorate over time.CONCLUSIONS:Patients who elect to receive operative treatment for SK have improved radiographic and SRS-22 parameters at 2-year follow-up compared with patients who elect nonoperative treatment. Not surprisingly, patients selecting surgical treatment had greater sagittal Cobb angles and greater levels of pain and dissatisfaction with their appearance. However, at 2-year follow-up, surgical patients experience greater (and significant) change on all parameters; exhibiting smaller Cobb angles, less pain, and greater satisfaction with their outcomes. Nonoperatively treated patients do not deteriorate over 2 years.LEVEL OF EVIDENCE:Level II-prognostic study.

Background Adolescent idiopathic scoliosis (AIS), with an incidence of 3%, is a common deformity. Correction of severe curvature of the deformity has attracted much investigation to achieve safe, reproducible results. We present our experience with a novel device for the correction of deformities across a spectrum of curve types, the rod link reducer. This system allows direct visualization of a mass derotation to achieve deformity correction. Methods Prospective cohort study of patients with severe AIS treated in our institution during 2017 with major TL/L curves. Pre- and postoperative Cobb angles and coronal balance; operative time; and estimated blood loss, fusion levels, and screw density were recorded. Our results were split between those with a Lenke A/B classification and Lenke C, with a goal of correction of curve in the former and achieving good coronal balance with a preservation of distal motion segments in the latter. Results There were 31 patients enrolled in our series. Within the Lenke A/B group, there were 18 patients, achieving a mean correction of 56% (SD 10%) and a correction of a mean coronal balance of 14.5 mm (SD 12.5 mm) of C7 from the CSVL to 10.9 mm (SD 10.6 mm). Our screw density was 1.3 screws (SD 0.1) per vertebrae fused. Our operative time was 185 min (SD 38 min). Average recorded blood loss was 721 ml (SD 289). In our Lenke C cohort, preoperative and postoperative mean Cobb angles (SD) were 73.3 (13.4) and 33.8 (11.9), respectively, with an average correction of 54% (SD 11%). The mean (SD) operative time was 03:35 (SD 00:35). Fusion levels were over a mean of 12.1 (SD 1.7) vertebrae, with a screw density of 1.3 (SD 0.1) per level. Mean intraoperative blood loss was 829 ml (SD 355). No patient received an allogenic blood transfusion. There were no adverse neurological events in this patient cohort. Conclusions The link rod system allows for excellent correction of spinal deformity and a short operative time.

Background: This article describes a new bone transport technique for femoral and tibial bone defects using lengthening nails combined with locking plates. We term it plate-assisted bone segment transport (PABST). Methods: Nine patients with five femoral and four tibial bone defects from open fractures or malignancies were treated between 2016 and 2018. Mean femoral defect length was 9.3 cm (range 7 to 11.5). Mean tibial defect was 8.9 cm (range 4.8 to 15). The patients were evaluated for time to weight bearing, consolidation index, mechanical axis deviation, and limb length discrepancy. Results: Seven of nine patients have fully consolidated. The mean consolidation time was 6.6 months. The consolidation index was 0.9 (femur) and 1.26 (tibia) mo/cm. Two patients required supplementary lengthening. One patient had mild varus, one mild valgus; the remainder had a normal mechanical axis. Limb length discrepancy remained acceptable in all patients. The main complications were heterotopic ossification, delayed healing, and reduced knee motion. Conclusion: Bone transport with lengthening nails and locking plates is an effective and patient-friendly way of treating bone defects, eliminating the adverse effects of external fixation and reducing treatment time. The plate provides stability during transport and docking; it can address concomitant fractures and facilitates acute shortenings.

INTRODUCTION:Shoulder injuries after high velocity trauma are common. Clavicle is affected in almost half of these cases. Even so, bipolar dislocation of the clavicle is an unusual injury and seldom reported in the literature. Conservative management is used for almost all the cases and only selected cases will undergo surgical treatment.CASE REPORT:A 52 year old right electrician presented to the emergency department following a fall from a push bicycle. Plain radiographs identified a left first metacarpal (MC) fracture and a bipolar fracture of his right clavicle. Following Fracture Clinic review, significant deformity of the medial clavicle was noted and a CT scan showed anterior dislocation of the medial fragment. Given the degree of deformity and this functional requirement we felt that operative treatment was most appropriate for his unstable medial clavicle fracture dislocation.CONCLUSION:Surgical treatment of floating clavicle has an important role in the management of fit and active patients. It is important to identify the mechanism of injury and deforming forces in fractures and only after this to plan to neutralise these where appropriate.

INTRODUCTION:Primary musculoskeletal extranodal non-Hodgkin lymphoma is a rare presentation and account for 5% of all primary extranodal non-Hodgkin lymphomas. Treatment uses a combination of chemotherapy and radiotherapy with good prognosis in unifocal manifestation. We report an unusual case of primary musculoskeletal extranodal lymphoma presenting as a soft tissue swelling around the wrist.CASE REPORT:A 75 year old lady was referred to the Orthopaedic Outpatients Department with a painless, slowly growing mass on the dorsum of the right wrist. Clinical examination revealed a 6 X 9 cm round painless mass on the dorsum of the distal radius adherent to both the underlying structures and skin. MRI of the wrist showed a large mass causing extensive osteolysis of the distal radius and extending proximally with abnormal replacement of the marrow. The patient was brought to theatre for biopsy and subsequent histopathological examination confirmed a B-cell non-Hodgkin lymphoma. The patient was referred to the Haematology Service for further treatment and follow-up. She received chemotherapy and radiotherapy with satisfactory results.CONCLUSION:Lymphoma presenting as a soft tissue mass is relatively uncommon and can easily be confused with a wide variety of inflammatory conditions, more common neoplasias as well as infectious diseases (tuberculosis). Though rare, extranodal lymphoma should be regularly included in the differential diagnosis of mass lesions.