Femoral neck non union is a relatively uncommon complication following intracapsular hip fracture in the young patient. Almost all patients with femoral neck non union are symptomatic for which they will require some form of revision surgery. This review discusses the role of valgus osteotomy in managing the younger patient with femoral neck non union.

Statement of purpose of study: To determine how effective Flexible Intramedullary Nails are in treating tibial and femoral fractures in adolescents. Summary of Methods used: Retrospective review of consecutive adolescent patients treated over a seven year period with Flexible Intramedullary Nails for tibial and femoral fractures. Statement of Conclusion: We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures. Introduction Flexible intramedullary nails (FIN) are increasingly used in the management of paediatric tibial and femoral fractures. Recently, concerns have been raised regarding the use of FIN in older children. The aim of this study was to determine how effective FIN9s are in treating tibial and femoral fractures in adolescents. Methods Hospital records were used to identify all patients aged 11 years or older under going FIN for tibial and femoral fractures between 2003 and 2009. Radiographs and case notes were reviewed to identify complications. Results 35 consecutive adolescent patients underwent FIN for tibial (n=21) and femoral fractures (n=15) with a mean age of 12.9 years. 2 femoral and 9 tibial fractures were open. Eight patients sustained multiple injuries. Mean radiographic follow up was 29 weeks. 60% (n=9) and 38% (n=9) of femoral and tibial fractures respectively malunited. Fracture severity was associated with increased malunion for both tibial and femoral fractures (P=0.046 and P=0.044 respectively). There were no cases of non-union. 2 femoral fractures took longer than 20 weeks to unite and 7 tibial fractures took longer than 16 weeks to unite. One patient developed post operative compartment syndrome, one patient developed deep infection and two patients were treated with post operative traction for loss of fracture position. Discussion Previous publications from multiple centres, including ours, have demonstrated excellent results of FIN for tibial and femoral fractures in the general paediatric population. However, concerns have recently been raised about the use of FIN in older, heavier children and with unstable fracture patterns. This is the first published series of adolescent patients undergoing FIN. We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures.

BackgroundOrthopaedic surgeons are increasingly pressured to consider thromboprophylaxis for patients when little evidence exists. The aim of this study was to determine the incidence of fatal pulm...

Background. "Lead hands" are frequently used to maintain hand and finger position in hand surgery. The malleability and strength of lead make it ideal for this purpose. The aim of this study was to determine the amount of lead transferred to a surgeon's glove during handling of a lead hand. Method. Sterile surgical gloves were wiped over the surface of a lead hand. The number of wipes was varied, the gloves were then sent to a trace elements laboratory, and the lead content transferred to each glove was determined. Results. The amount of lead transferred to each glove increased with increasing exposure to the lead hand. After twenty wipes, up to 2 mg of lead was transferred to the surgeon's glove. Covering the lead hand with a sterile drape markedly reduced the lead transferred to the surgeon's glove. Conclusion. Significant amount of lead is transferred on to the gloves after handling a lead hand. This risks wound contamination and a foreign body reaction. Covering the lead hand with a sterile drape may minimise the risk of surgical wound contamination.

Management of unstable distal radius fractures has evolved considerably in recent years. This review describes the assessment and management of distal radius fractures in light of these recent changes.

The traumatised bariatric patient presents unique challenges and difficulties. Approximately 25% of adults in the United Kingdom are obese and 2% are morbidly obese. With an increasing incidence of obesity, understanding the specific challenges of managing the traumatised obese patient is vital for trauma practitioners.

INTRODUCTION Intra-articular fractures of the distal humerus frequently require internal fixation. Several approaches have been described, with the posterior approaches being most common. We present a new approach to the distal humerus via the lateral border of the triceps muscle. PATIENTS AND METHODS The senior author has used this technique for fixation of intra-articular fractures of the distal humerus in 12 patients. RESULTS The approach is equally useful for intra- and extra-articular fractures. No cases of postoperative ulna nerve neuropraxia have been encountered. There have been no postoperative wound complications. The exposure has allowed sufficient access to allow anatomically contoured plates to be easily applied to both sides of the distal humerus with confirmation of intra-articular fracture reduction. CONCLUSIONS The approach has the advantages of leaving the muscular bed of the ulna nerve undisturbed, whilst still providing excellent exposure of the distal humerus. The triceps mechanism is not divided or split allowing rapid recovery of extensor function. Additionally, because of the natural carrying angle of the elbow, repositioning of the reflected triceps aponeurosis is easy.

The use of extended duration thromboprophylaxis following hip and knee arthroplasty is becoming widespread. The aim of our study was to determine patient compliance with extended duration thromboprophylaxis using low molecular weight (LMWH) injections following hip and knee arthroplasty.42 consecutive patients undergoing hip and knee arthroplasty were prospectively contacted during their fifth post operative week. A fully anonymised questionnaire was completed by each patient. All patients responded. One was excluded having been prescribed warfarin for pre existing atrial fibrillation. Twenty nine (71%) patients were discharged with the intention of self administering LMWH injections. Eight (20%) and four (9%) patients were discharged with the intention of administration by a relative or district nurse respectively. No patient required the person administering the injections to be changed after discharge from hospital. 90% (n=37) of patients reported not missing any doses. 10% (n=2) of patients missed one dose and 10% (n=2) missed two doses. Patient compliance with extended duration thromboprophylaxis using LMWH injections is extremely high. Oral thromboprophylaxis may be useful in the minority of patients requiring daily visits by a nurse to administer injections.

Purpose Flexible intramedullary nails (FIN) are increasingly used in the management of paediatric tibial and femoral fractures. Concerns have recently been raised regarding the use of FIN in older children. The aim of this study was to determine how effective FIN is in treating tibial and femoral fractures in adolescents.Methods Patients aged 11 years or older undergoing FIN for tibial and femoral fractures between 2003 and 2009 were identified. Radiographs and case notes were reviewed to identify complications.Results Thirty-five consecutive adolescent patients underwent FIN for tibial (n = 21) and femoral fractures (n = 15), with a mean age of 12.9 years. The mean radiographic follow up was 29 weeks. Sixty percent (60%, n = 9) and 38% (n = 9) of femoral and tibial fractures, respectively, malunited. Fracture severity was associated with increased malunion for both tibial and femoral fractures (P = 0.046 and P = 0.044, respectively). Two femoral fractures took longer than 20 weeks to unite and seven tibial fractures took longer than 16 weeks to unite.Conclusion The higher than expected rates of malunion and delayed union in this study suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures.

During uncemented hemi-arthroplasty for hip fracture, the femoral neck must be cut parallel to the collar of the prosthesis. This cut is often made by ‘eyeballing’ the required angle from the top of the rasp (Fig. 1). The soft tissues often displace the rasp making it difficult to achieve an accurate neck cut. A standard K-wire can be bent to the required angle and the end slid up the femur below the vastus muscle. The cut can then be marked on the femur using the K-wire as a guide. This allows a perfectly angled cut to be made. Figure 1 K-wire bent to the required neck cut angle as determined by the rasp.

Traumatic hip dislocation occurs during high-energy trauma and is often associated with other life threatening injuries. Dislocation can be anterior or posterior and urgent reduction is mandatory to reduce the risk of avascular necrosis of the femoral head. Undisplaced femoral neck fractures should be excluded prior to attempted reduction. Various closed reduction techniques have been described and most dislocations can be reduced with a closed technique. Failure to achieve reduction makes open reduction mandatory. This review describes the diagnosis, investigation and management of this complex and challenging injury.

The role of wrist arthoscopy is expanding in the management of wrist disorders. We have found certain shortcomings in the custom probes that are supplied with existing wrist arthroscopy equipment. A useful alternative is the depth gauge that is found on small fragment hand sets (Fig. 1). These sets are often used during procedures requiring arthroscopy of the radiocarpal joint, such as ulnar shortening. The hook at the tip of the depth gauge is the perfect size and shape for use in the radiocarpal joint and it has proved a useful alternative to the custom probes in our experience. Figure 1 The depth gauge as viewed during wrist arthroscopy.

Outcome measures following hip fracture usually consider morbidity and mortality following injury.(5) Few studies have looked at post injury discharge location as an outcome measure following hip fracture. Discharging patients to a different location frequently delays discharge whilst the necessary social arrangements are made. Early identification of these patients could reduce these delays. The aim of this study was to determine factors influencing discharge location following hip fracture.Three thousand two hundred and forty consecutive patients were admitted to our centre with a fractured neck of femur. Data was prospectively collected by independent audit clerks on a standardised proforma. Our outcome measure was whether the patient was discharged from hospital either to their place of normal residence or to an alternative location. Factors influencing discharge location were identified using multivariate logistic regression analysis.Increasing age was associated with increasing risk of requiring discharge to an alternative location (DAL) (p<0.001). This risk rose from 13% in the sixth decade by approximately 10% every additional decade. Males were 2.5 times more likely than females to require DAL. Patients who were more independent prior to injury were less likely to require DAL. Patients who sustained their injury whilst in hospital were 2.3 times more likely to require DAL compared to those who fell in their own homes.The following risk factors are associated with increased risk of requiring discharge to an alternative location: (1) pre-injury dependence, (2) increasing age, (3) male sex, (4) injury sustained whilst in hospital. Early identification of patients requiring DAL could reduce inpatient delays.

Introduction: Fractures account for significant morbidity during childhood. Children requiring inpatient management for their fractures represent the most serious injuries. The aim of this study was to identify injury patterns in childhood fractures requiring inpatient management at a regional trauma centre.Methods: Three thousand and forty two consecutive injured children were admitted to our orthopaedic centre over a 4-year period. Data was prospectively collected by independent audit clerks and entered onto a database. Data recorded included type of injury, mechanism of injury and place of injury. This was then used to assess injury patterns and trends.Results: Upper limb and lower limb fractures accounted for 51% (n = 1565) and 21% (n = 637) of all emergency admissions, respectively. Other causes included soft tissue injury, Infections, Polytrauma and Dislocations. Twice as many mates were admitted with upper or Lower Limb fractures compared to females (67% versus 33%) (P < 0.001). Mates were more likely to be older (P < 0.001) compared to females. Distal radial fractures accounted for 60% of upper limb fractures. Distal and midshaft tibial fractures accounted for 52% of lower limb fractures. Sports injuries were responsible for the majority of lower limb fractures with falls accounting for the majority of upper limb fractures. Fracture incidence peaked during summer months.Conclusion: Mates are twice as likely to require inpatient management for fractures as females. Mate adolescents are particularly at risk. Distal radial fractures following falls and distal tibial fractures following sports injuries are the most common fractures requiring admission. Identifying ways of minimising risk of these injuries would reduce childhood morbidity. (c) 2007 Elsevier Ltd. All rights reserved.

Between May 2001 and May 2005, all 8834 adults admitted to our hospital with fractures to the limbs and pelvis were prospectively entered onto a database. Information was cross-referenced with the Office of National Statistics, and all patients who died during the study period were identified. Mortality rates were adjusted for age, gender and type of injury and cause of death was identified from hospital records. Neck of femur fractures accounted for 32% of admissions. Younger patients were more likely to be male and older patients more likely to be female. Overall 30-day and 1-year mortalities were 4.5 and 13%, respectively. Increased mortality was associated with age, male gender and fractures of the femur or pelvis.

Introduction: The management of adult inflammatory appendix mass is evolving. Traditional management has been shown to be initially conservative, with interval appendicectomy performed after the mass resolved. This remains the most common approach in UK surgical practice. Recently, an increasing number of studies have challenged this approach. This review looks at the management of the inflammatory appendix mass in the adult in light of these recent changes and suggests a management approach based on the current evidence. Methods: A Medline, Pubmed and Cochrane database search was performed using key words including combinations of; appendix, appendiceal, interval, appendectomy, appendicectomy, mass, abscess, phlegmon, and appendicitis. All articles were cross-referenced. Findings: A conservative management approach will be successful in the majority of patients presenting with an appendix mass. The incidence of recurrence of symptoms following successful conservative management is low. Conclusion: After initial successful conservative management, routine use of interval appendicectomy is not justified in asymptomatic patients.

A 23-year-old right-handed male presented to the emergency department with a painful right wrist having previously punched an opponent’s elbow during an amateur boxing match. Examination in the Emergency Department demonstrated diffuse tenderness around the anatomical snuff box with limited range of movement at the radio-carpal joints. No pain or tenderness was elicited proximal to the wrist. Radiographs demonstrated no obvious abnormality (Fig. 1). Repeat examination and radiographs of the wrist at fracture clinic the following day revealed no change in the patient’s signs or symptoms. No tenderness was elicited at proximal to the wrist. The patient was diagnosed with a suspected scaphoid fracture and treated with a scaphoid plaster. Following review at 2 weeks the patient still complained tenderness of the anatomical snuff box and at no point complained of pain proximal to his wrist joint. Further radiograph examination showed no evidence of scaphoid fracture. Due to continuing symptoms a bone scan was arranged which was performed 3 weeks