We have a national UK database for hip fracture outcome. It has been developed synchronously with an agreed care pathway that is multi-disciplinary, including surgeons, anaesthetists, geriatricians, osteoporosis experts, healthcare managers and lay charities. Care has been improved and audit established for future evolution.

The database started in 2007 and now includes 85 units. The synchronous care pathway deals with falls and osteoporosis prevention, perioperative multi-disciplinary care, rehabilitation and outcome results.

Key issues are avoidance of delay and cancellation of surgery and how we deal with patients with medical co-morbidities. Outcome is analysed prospectively to take account of co-morbidities and variations in surgical techniques.

The care pathway and data base are now universally accepted as a national priority with advice for all UK trauma units to participate. Of the 121 registered units, only 85 actively contribute data. The cost and staff needs for data input are now accepted. To date, 12,983 clinical cases have been entered. Variation of trauma theatre list operating time per head of population and other related resource has been highlighted. This has been accepted by politicians and health managers. The NHS Institute of Improvement has started a rapid improvement plan to support units with poor resource/audit outcome. It is early days in terms of validity of outcome data for technical variations in treatment eg. fixation/replacement/use of bone cement.

We have a national increase in resouce for hip fractures. We now have some logic to interaction between surgeons and medics/managers. Objectively struggling units get active support. We accept the possible lack of validity of some outcome data. Some units who look bad on paper should not be disadvantaged.

Vascularised soft tissue transfer may be helpful in the salvage of severe sepsis involving avascular tissues hosting joint replacements or other metal work. Transferred tissue covers the exposed implants and delivers intravenous antibiotics. Twenty-one cases for the knee, elbow and shoulder are presented.

Gastrocnemius flaps were used for seven knee replacements and 10 knee fractures. Antegrade radial artery flaps were used for two elbow replacements. Pectoralis major or minor flaps were used for two shoulder replacements. All procedures were performed by an orthopaedic surgeon with supplementary plastics training. Synchronous bony surgery included revision arthroplasty in seven cases, conversion to fusion in one case and preservation of existing hardware in the remainder. Sepsis was eliminated in the longterm in 9 of 10 knee fracture fixation cases, 5 out of 7 knee replacements and both elbow replacements. Both shoulder replacements remained septic despite multiple repeat procedures. Complications included necrosis of two gastrocnemius flaps, one from pre-existing partial compartment syndrome and one when combined with fusion of the knee. One other knee replacement developed further sepsis three years post procedure. No limb required amputation.

These procedures are well within the remit of orthopaedic surgeons, the non reliance on plastics surgeons allowed prompt treatment combined with bony procedures. Results were good for the knee and elbow but disappointing for the shoulder—this, probably related to the natural mobility of the joint.

Background: Prior studies identified that crash severity (Delta V), occupant position, and restraint systems as reliable predictors of crash injuries.1–5 Others have noted that correlation between the biomedical thresholds (age, gender, height, weight) and injury pattern to the lower extremity but very little have been written on the subject of upper extremity.

METHOD: This is a retrospective analysis of CIREN database in a level trauma center focusing on upper extremity injuries. The aim was to investigate the relationship between of the ‘crash’ and ‘occupant’ factors on the pattern and severity of upper extremity injuries following a frontal impact collision. results &

Discussion:Majority of the injuries were soft tissues type. (67.6% soft tissue vs. 32.4% fractures). There were 144 fractures to the upper extremity, 12.5% were ‘open’ fractures. 66% of cases of fractures required operative intervention. 74.5% of the fractures sustained in the upper extremity occurred distal to the elbow, whereas soft tissue injuries predominated in the humerus. 21.5% of distal radius fractures were attributed to airbag deployment and all of the clavicle fractures were related to compression from seat belt. Occupants who sustained fractures had a significantly higher ISS scores (mean score 21.88 vs. 17.68, p < 0.05). Using logistic binary regression model, the ISS continued to be a significant predictor for fracture, overriding weight as a co-founding variable. Of the 144 fractures, 66% of cases required operative intervention.

Conclusion:. To advance occupant protection, it is important to understand the differences in individual variability in affecting injury tolerance in high-energy trauma. One could argue that current modern restraint systems are not designed to protect these vulnerable areas; therefore it may not come as a surprise to observe such an emerging trend of injuries to the upper extremities. There is no doubt that modern restraint systems have contributed to the overall decrease in mortality over the years. However, there are case series reported on the effect of airbag-related injuries to upper extremities as a consequence of its primary effectiveness. Our study reinforce the debate for a more ‘depowered’ airbag capable of saving lives yet simultaneously protecting the upper extremities from serious injuries.

Aim: To assess the outcome of open release of the common extensor origin in the management of tennis elbow after the failure of non operative treatment methods.

Methods: 18 patients (24 elbows) between the age group of 38 to 59 who underwent open release of the common extensor origin by the same team after a mean waiting time of 23 months from the onset of pain and a trial of failed non operative methods like analgesics/nsaids, physiotherapy, local steroid injections were contacted and asked to score the effectiveness of surgery after a gap of six months. Since the predominant troubling symptom for all patients was pain they were asked to score the pain relief correlating with the surgery.

Results: In 15 patients (83%) excellent pain relief (defined as an 8 or more out of 10 improvement) was achieved and they regained normal use of the limb. One patient (5%) had moderate improvement (score between 6 and 7 out of 10) and two further (11%) patients gained minimal benefit with persistent symptoms (score 5 out of 10). None of the patients suffered deterioration as a result of surgery.

Conclusion: This study proves that despite new advances in the treatment of tennis elbow, release of the extensor origin by the open method which is a simple and economical day case procedure, still remains an excellent option in cases where trial of non operative management has failed.