Analyzing shoulder kinematics is challenging as the shoulder is comprised of a complex group of multiple highly mobile joints. Unlike at the elbow or knee which has a primary flexion/extension axis, both primary shoulder joints (glenohumeral and scapulothoracic) have a large range of motion (ROM) in all three directions. As such, there are six degrees of freedom (DoF) in the shoulder joints (three translations and three rotations), and all these parameters need to be defined to fully describe shoulder motion. Despite the importance of glenohumeral and scapulothoracic coordination, it's the glenohumeral joint that is most studied in the shoulder. Additionally, the limited research on the scapulothoracic primarily focuses on planar motion such as abduction or flexion. However, more complex motions, such as internally rotating to the back, are rarely studied despite the importance for activities of daily living. A technique for analyzing shoulder kinematics which uses 4DCT has been developed and validated and will be used to conduct analysis. The objective of this study is to characterize glenohumeral and scapulothoracic motion during active internal rotation to the back, in a healthy young population, using a novel 4DCT approach.

Eight male participants over 18 with a healthy shoulder ROM were recruited. For the dynamic scan, participants performed internal rotation to the back. For this motion, the hand starts on the abdomen and is moved around the torso up the back as far as possible, unconstrained to examine variability in motion pathway. Bone models were made from the dynamic scans and registered to neutral models, from a static scan, to calculate six DoF kinematics. The resultant kinematic pathways measured over the entire motion were used to calculate the ROM for each DoF.

Results indicate that anterior tilting is the most important DoF of the scapula, the participants all followed similar paths with low variation. Conversely, it appears that protraction/retraction of the scapula is not as important for internally rotating to the back; not only was the ROM the lowest, but the pathways had the highest variation between participants. Regarding glenohumeral motion, internal rotation was by far the DoF with the highest ROM, but there was also high variation in the pathways. Summation of ROM values revealed an average glenohumeral to scapulothoracic ratio of 1.8:1, closely matching the common 2:1 ratio other studies have measured during abduction.

Due to the unconstrained nature of the motion, the complex relationship between the glenohumeral and scapulothoracic joints leads to high variation in kinematic pathways. The shoulder has redundant degrees of freedom, the same end position can result from different joint angles and positions. Therefore, some individuals might rely more on scapular motion while others might utilize primarily humeral motion to achieve a specific movement. More analysis needs to be done to identify if any direct correlations can be drawn between scapulothoracic and glenohumeral DoF. Analyzing the kinematics of the glenohumeral and scapulothoracic joint throughout motion will further improve understanding of shoulder mechanics and future work plans to examine differences with age.

Purpose

This study evaluated the acceptability of performing manipulations with intranasal diamorphine and inhaled Entonox to parents of children presenting to our Emergency Department.

Paediatric distal radial and forearm fractures account for 37.4% of all fractures in children. We present our 2.5-year results of a novel safe approach to the treatment of simple distal radial and diaphyseal fractures using intranasal diamorphine and entonox in a designated fracture reduction room in the emergency department.

All simple fractures of the distal radius and forearm admitted to our ED between March 2012 and August 2014 that could be reduced using simple manipulation techniques were included in this study. These included angulated diaphyseal fractures of the forearm, angulated metaphyseal fractures of the distal radius and Salter Harris types I and II without significant shortening. All children included were given intranasal diamorphine as well as entonox. The orthopaedic registrar on call performed all reductions.

100 children had their distal radius or forearm fracture reduced in the emergency department using entonox and diamorphine analgesia and had a same day discharge. Average age was 10 years (range 2.20–16.37 years). No complications were reported regarding the use of the analgesia and all children and parents were pleased with their treatment not requiring a hospital admission. The mean initial dorsal angulation of all fracture types was 28.05° degrees (23.91–32.23 95% CI) which was reduced to 7.03° (5.11–8.95 95% CI) post manipulation. There were 9 cases lost to follow up. Two cases lost the initial reduction of the fracture on subsequent clinic follow up and underwent internal fixation in theatre.

The use of entonox and intranasal diamorphine is a safe, effective treatment of providing adequate analgesia for children with distal radial and forearm fractures to allow manipulation of displaced dorsally angulated fractures in the emergency department. By facilitating a same day discharge, over £45,000 was saved using this safe method of treatment.

Symptomatic venous thromboembolism (SVTE) is a potentially significant complication which may occur following injury or surgery. Recent NICE guidelines, and clinical targets have all focused on decreasing in hospital death from acquired SVTE. Despite these guidelines there are no large studies investigating the risk factors for or incidence of SVTE in acute trauma admission.

Data from a prospective series of 9167 consecutive patients with a diagnosis of fractured neck of femur (NOF) at a single institution was used to construct a risk score for SVTE. Twenty three factors were screened with pairwise analysis. The cohort had an event rate of 1.4%. A multiple logistic regression model was used to construct a risk score and correct for confounding variables from nine significant factors identified by the pairwise analysis. Four factors; length of stay; chest infection; cardiac failure and transfusion were used to produce the final risk score. The score was statistically significant (p< 0.0001) and highly predictive (ROC analysis, AUC=0.76) of SVTE.

The score was separately validated in two cohorts from different Level 1 trauma centres. In one prospective consecutive cohort of 1000 NOF patients all components of the Nottingham SVTE score were found to be individually statistically significant (p< 0.0045). The score was further validated in a separate cohort of 3200 patients undergoing elective hip surgery. The score was found to be statistically significantly predictive of SVTE as a whole, and three of the four components were individually predictive in this patient cohort.

Balancing risks and benefits for thromboprophylaxis is key to reducing the risk of thromboembolic events, minimising bleeding and other complications associated with the therapy. Our study of 13,367 prospective patients is the largest of its type and we have successfully constructed and validated a scoring system that can be used to inform patient treatment decisions.

Objective

The objective was to assess whether late presentation of DDH leads to an increase in treatment magnitude and cost.

Aims

The BOA/BAPRAS guidelines for the management of open tibial fractures (2009) recommend early senior combined orthoplastics input and appropriate facilities to manage a high caseload. St Georges Hospital is one of four London Trauma Centres fulfilling these criteria. Our aim is to determine whether becoming a trauma centre has affected the management of patients with open tibial fractures.

Introduction: We present a double blinded prospective randomized controlled trial between viscoseal and intraarticular diamorphine injection in shoulder arthroscopy.

Materials & Methods: Twenty adult patients undergoing arthroscopic subacromial decompression were randomised into two groups. The Viscoseal group received 10ml of Viscoseal and 10ml of 0.5% bupivacaine injected into the subacromial bursa at completion of the procedure (n=10). The matched control group received 10mg diamorphine and 10mls of 0.5% bupivacaine (n=10). All procedures were performed by the senior author. The patients were blinded to the injections given. Post-operative regimes were standardised and all patients were assessed by visual analogue pain scores at recovery and 1, 2, 6, 12 & 24 hours post-operative. The presence or absence of nausea and time to discharge were also noted.

Results: The mean age of the Viscoseal group was 53 (range 34–70) years and in the control group 59 (32–85) years. In the Viscoseal group 40% of patients were discharged on the same day, while there were no early discharges in the diamorphine group this difference did not reach statistical significance (P=0.054 by Fisher’s exact test). There were no significant differences in post-operative pain score or the fraction pain-free between the two groups or in supplementary analgesic drug doses given (all P> 0.08). Only 10% of the Viscoseal group were nauseous post-operatively compared to 60% of the control group (P=0.03 by Fisher’s exact test).

Discussion: Arthroscopic surgery has never been more popular. Patients like smaller scars, early discharge and quick return to daily life and work; for surgeons arthroscopic surgery is skilful, satisfying and digitally recordable; and the NHS benefits from reduced hospital stay and post-operative complications.

Review of the literature involving the use of viscoseal in shoulder surgery revealed no direct comparison with diamorphine, but only to bupivacaine alone.

Many methods of post-arthroscopic pain relief are available. In our hospital diamorphine with bupivacaine is standard, at £2.57 per treatment. In the present study nausea was significantly lower in the Vicoseal group, but no significant intervention was required and oral anti-emetics sufficed. Pain was not significantly different, and there were no significant differences in supplementary analgesia or in early discharge. In our opinion, the significant improvement in nausea alone is not enough to justify the high price of £52.88 per Vicoseal treatment. We believe that the benefits for routine use have not been demonstrated.

Purpose of study: To assess whether a plane x-ray at five months is needed in a DDH screening program.

Method: Between 1990 and 2004 we operated selective hip screening, including ultrasound. Hips screened as normal had an X-ray at 5 months, initially instituted to cover the ultrasound learning curve. These were reported by a consultant radiologist and referred if thought abnormal. For the purposes of this study the notes, scans and X-rays of all patients referred at 5 months were reviewed.

Results: In Nottingham there were approximately 108,500 births between 1990 and 2004. Of these 11,425 were referred for ultrasound scan. 53 were referred to orthopaedics following the x-ray at 5 months. 47 of these had a complete data set. Of these 47 children, 30 (64%) were watched, 9 (19%) had arthrograms only, 5 (11%) had adductor tenotomy and application of a hip spica. One (2%) child had Pavlik harness treatment and 2 (4%) had a femoral osteotomy.

Graf’s alpha angles and percentage cover were reviewed from the original ultrasounds, many of which were of poor quality. This demonstrated that there was less than 50% cover for 14/30 (47%) who were watched, for 6/9 (78%) who had arthrograms, for 1/1 (100%) treated by harness, for 4/5 (80%) treated with adductor tenotomy and hip spica and for 2/2 (100%) requiring surgery. Alpha angles less than 60 degrees did not predict the need for intervention. There were no late cases from the group that had X-rays classed as normal at 5 months.

Conclusions: The importance of measuring head cover was established and is now routine in the hip instability clinic. It was clear that a large population had received unnecessary X-rays. X-rays are now only performed if US at 6 weeks reveals a low alpha angle or less than 50% cover.

Prophylactic stabilisation with internal fixation of the asymptomatic hip in unilateral slipped capital femoral epiphysis is controversial.

The incidence of bilaterality varies from 20–80% depending on the length of follow-up. The opposite hip has 2335 times higher incidence of developing a slip in cases of a unilateral slip at presentation and there is no chemical, anatomic or radiological feature which can predict a slip.

The arguments regarding prophylactic fixation are based on risks of AVN, chondrolysis, and problems with implant removal and joint penetration

We present a retrospective analysis of sixty-five patients who had prophylactic fixation of the uninvolved hip at the same time as their opposite slipped femoral physis. None had an underlying systemic or endocrine disorder and the average age was 12.5 years (range 11–15 years).A single 7.0 mm cannulated screw was used in all cases. The average time to fusion was 18 months (range 6 to 36 months) and duration of follow up ranged from 3–8 years (mean 4.5 years).

None of the patients had implant removal and at latest review did not show any evidence of chondrolysis, avascular necrosis, premature physeal arrest or secondary arthrosis in the prophylactically fixed hip. There were a couple of cases of inadvertent wire penetration into joint, which were recognised and rectified immediately, and a correct length screw inserted. Both these patients had an uneventful post-operative course with no problems of chondrolysis etc at latest follow-up (5 years). One patient (1.5%) developed a superficial wound infection, which cleared up with antibiotics.

Conclusion: This study demonstrates the safety of prophylactic fixation using a single cannulated cancellous screw and is recommended for prevention of delayed slip and hence secondary osteoarthrosis.

Introduction: To compare olecranon screw traction with percutaneous pinning for the treatment of Gartland III supracondylar fractures in children.

Methods: This was a retrospective study of 151 patients between 1986 and 1996 treated with olecranon screw traction and 92 patients between 1996 and 2002 treated with percutaneous pinning. Both sets of patients were followed up clinically and radiologically following their injuries until there was evidence of fracture union and the child could demonstrate a satisfactory range of movement. Data recorded included demographics, fracture information, neurovascular injury, operation details, length of stay, length of follow up and clinical outcome. Radiographs were used to measure initial and final Baumann angles to give an indication of outcomes of distal humerus alignment.

Results: Results are shown for the percutaneous pinning group with the olecranon screw traction results in brackets for comparison.

The percutaneous pinning study included 54 (88) males and 38 (63) females with 63% (63%) left and 37% (37%) right elbow fractures. 46% (29%) of fractures occurred at home, 46% (56%) sustained the injury whilst playing and 7% (7%) occurred at school/nursery. The mean age was 6.0 (6.8) years with a range of 21–165 (12–168) months. The radial pulse was absent in 12% (13%). None of the fractures were open (compared with 5%). There were neurological deficits in 20% (17%). The median time to surgery was 5 hours. The fracture needed to be opened in 12% of cases as satisfactory reduction could not be achieved closed. The median stay length was 1 day (compared to a median stay on traction of 14 days). Mean follow up was 15.2 weeks. (Compared to 38.0 weeks). 2 % (3%) had cubitus varus detectable clinically. Median time to recovery for neurological deficit was 24 weeks (18 weeks). Mean initial Baumann’s angle was 74.6 degrees (73.7degrees). Mean final Baumann’s angle was 75.3 degrees (76.0 degrees)

Discussion: Outcomes achieved from percutaneous pinning of displaced supracondylar fractures are similar to those from olecranon screw traction. The advantage of percutaneous pinning to both patient and provider is the reduced hospital stay and duration of follow up. Olecranon screw traction remains a possible treatment option for the management of this injury.

Dr Foster, an independent health watchdog, has produced a national league table for hospital performance in hip fracture management. This was published in the Times newspaper in November 2001. No validation of the league table was presented and so we have compared the results of a prospective audit of our hip fractures with the data provided by Dr Foster.

A prospective audit of all patients admitted with hip fracture was undertaken over a 30-month period. An independent research assistant collected data on a standardised questionnaire. Data included basic demographics, comorbidities, mental test score, mobility and social status. Mortality data was obtained from the national office for statistics. Dr Foster’s data was obtained from the Hospital Episode Statistics and they also provided additional information on data and methodology.

Dr Foster reported that our hospital had a standardised mortality ratio of 107 and a one-year mortality per 100,000 population of 112.20. The hospital workload for the year 2000 was given as 400 hip fractures with 40 deaths (10%) within 30 days of surgery. Our prospective audit showed that 738 hip fractures were admitted in the year 2000. 677 were from the local population giving an incidence of hip fracture of 100.3 per 100,000. 63 of these patients died. Thus, the one-year mortality per 100,000 population is 63. The 30-day mortality for all patients admitted during the year was 9.3%.

The league table produced by Dr Foster is based upon inaccurate date. The workload error was 46% with a 10% error for mortality and a 56% error for population mortality statistics. It is completely unacceptable that such data should be published in the public domain without validation.