Introduction. There are over 110 special tests described in the literature for clinical examination of the shoulder, but there is no general consensus as to which of these are the most appropriate to use. Individual opinion appears to dictate clinical practice. Rationalising which tests and clinical signs are the most useful would not only be helpful for trainees, but would also improve day to day practice and promote better communication and understanding between clinicians. Methodology. We sent a questionnaire survey to all shoulder surgeons in the UK (BESS members), asking which clinical tests each surgeon found most helpful in diagnosing specific shoulder pathologies; namely sub-acromial impingement, biceps tendonitis, rotator cuff tears and instability; both anterior and posterior. Results. For impingement; Hawkins-Kennedy and Neer's tests were used by the majority of respondents, with 50% also routinely performing Neer's injection test. For frozen shoulder; the shoulder quadrant test was the commonest used, followed by loss of passive range of motion and loss of external rotation. For biceps tendonitis; Speed's and Yergason's tests were by far the commonest used. For rotator cuff tears the commonest signs were; the Napoleon belly press, Hornblower's sign, Gerber's sign, Jobe's sign and Codman's drop arm sign. For instability; the apprehension test, the Gerber-Ganz drawer test, load and shift test and Jobe's relocation test were the commonest used, with the jerk test also popular for posterior instability. We are also currently assessing how individuals actually perform these tests, and whether they are as the original authors described them. Conclusion. Our results demonstrated some variation in which tests were being used, but with an increased preference for certain tests. Interestingly a large number of respondents commented that the history was of paramount importance and that clinical signs should only substantiate the clinician's diagnosis

Introduction. Anterior tibial translation (ATT) is assessed in the acutely injured knee to investigate for ligamentous injury and rotational laxity. Specifically, there is a growing recognition of the significance of anterior medial rotary laxity (AMRI) as a crucial element in assessing knee stability. Anterior cruciate ligament (ACL) injuries are often accompanied with medial collateral ligament (MCL) damage. It has been suggested that Deep MCL (dMCL) fibres are a primary restraint in rotational displacement. This research aims to quantify the difference in rotational laxity of patients with ACL and MCL injuries to deem if the Feagin-Thomas test can robustly capture metrics of AMRI. 2. Methods. AMRI was assessed using the Feagin-Thomas test in 7 isolated ACL (iACL) injured participants, 3 combined ACL and superficial fibre MCL (sMCL) injuries, 5 combined ACL and deep fibre MCL injuries, and 21 healthy controls. Displacement values were recorded using an optical motion capture (OMC) system and bespoke processing pipeline which map and model the knee's anterior displacement values relative to the medial compartment. Since absolute values (mm) of rotational laxity vary dependant on the person, values were recorded as a proportion of the rotational laxity obtained from the subject's contralateral leg. Values were compared between each patient group using an ANOVA test and Tukey's honesty significant difference post hoc test. 3. Results. The healthy control group had a median proportion of 0.97 (3SF), whilst the iACL was 1.12 (3SF), a 12% increase in rotational laxity in the injured leg. The sMCL group yielded a result of 1.64 (3SF), a 64% increase in rotational laxity in the injured leg; finally, dMCL resulted in a proportion of rotational laxity of 1.90 (3SF), a 90% increase in rotational laxity [table 1]. Whilst all groups showed differences in the increase of rotational laxity, dMCL was significantly different from the healthy control group (P value 0.0041). 4. Conclusion. ACL injuries with MCL involvement led to an increase in anterior medial rotary laxity and this is more evident in patients where deep MCL fibres are involved. The Feagin-Thomas test appears to be sensitive in detecting differences in AMRI and should be considered when performing comprehensive clinical knee examination. For any figures or tables, please contact authors directly

Aims

There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures.

Aims

Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

We prospectively assessed the diagnostic accuracy of the gravity stress test and clinical findings to evaluate the stability of the ankle mortise in patients with supination–external rotation-type fractures of the lateral malleolus without widening of the medial clear space. The cohort included 79 patients with a mean age of 44 years (16 to 82). Two surgeons assessed medial tenderness, swelling and ecchymosis and performed the external rotation (ER) stress test (a reference standard). A diagnostic radiographer performed the gravity stress test. For the gravity stress test, the positive likelihood ratio (LR) was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate change from the pre-test probability. Medial tenderness, both alone and in combination with swelling and/or ecchymosis, indicated a small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47), whereas swelling and ecchymosis indicated only minimal changes (positive LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). . In conclusion, when gravity stress test results are in agreement with clinical findings, the result is likely to predict stability of the ankle mortise with an accuracy equivalent to ER stress test results. When clinical examination suggests a medial-side injury, however, the gravity stress test may give a false negative result. Cite this article: Bone Joint J 2015; 97-B:1126–31

We treated 17 knees in 15 patients with severe ligament derangement and dislocation by open repair and reconstruction. We assessed the competence of all structures thought to be important for stability by clinical examination, MRI interpretation, and surgery. Our findings showed that in these polytrauma patients clinical examination was not an accurate predictor of the extent or site of soft-tissue injury (53% to 82% correct) due mainly to the limitations of associated injuries. MRI was more accurate (85% to 100% correct) except for a negative result for the lateral collateral ligament and posterolateral capsule. The detail and reliability of MRI are invaluable in the preoperative planning of the surgical repair and reconstruction of dislocated knees

Aims

The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated.

Objectives. Nonunion is one of the most troublesome complications to treat in orthopaedics. Former authors believed that atrophic nonunion occurred as a result of lack of mesenchymal stem cells (MSCs). We evaluated the number and viability of MSCs in site of atrophic nonunion compared with those in iliac crest. Methods. We enrolled five patients with neglected atrophic nonunions of long bones confirmed by clinical examinations and plain radiographs into this study. As much as 10 ml bone marrow aspirate was obtained from both the nonunion site and the iliac crest and cultured for three weeks. Cell numbers were counted using a haemocytometer and vitality of the cells was determined by trypan blue staining. The cells were confirmed as MSCs by evaluating their expression marker (CD 105, CD 73, HLA-DR, CD 34, CD 45, CD 14, and CD 19). Cells number and viability were compared between the nonunion and iliac creat sites. Results. After three weeks, numbers of 6.08×10. 6. cells (. sd. 2.07) and 4.98×10. 6. cells (. sd. 1.15) were obtained from the nonunion site and the iliac crest, respectively, with viability of 87.1% (81.7% to 90.8%) and 89.8% (84.7% to 94.5%), respectively. No differences was found between the two sources of MSCs regarding cells number (p = 0.347) and viability (p = 0.175). Conclusions. Our findings showed the existence of MSCs in the site of atrophic nonunion, at a similar number and viability to those isolated from the iliac crest

We present (with intra-operative imaging) 4 patients who sustained Pectoralis major ruptures on the same piece of equipment of the “Tarzan” assault course at the Commando Training Centre, Royal Marines (CTCRM). Recruits jump at running pace, carrying 21 pounds of equipment and a weapon (8 pounds) across a 6ft gap onto a vertical cargo-net. The recruits punch horizontally through the net, before adducting their arm to catch themselves, and all weight, on their axilla. All patients presented with immediate pain and reduced function. 2 had ruptures demonstrated on MRI, 1 on USS and one via clinical examination. All 4 patients were found, at operation, to have sustained type IIIE injuries. All patients underwent Pectoralis major repair using a uni-cortical button fixation and had an uneventful immediate post operative course. Patient 1 left Royal Marines training after the injury (out of choice, not because of failure to rehabilitate). All other patients are under active rehabilitation hoping to return to training. Review of 10 years of records at CTCRM reveal no documented Pectoralis major rupture prior to our first case in October 2013. There has been no change to the obstacle or technique used and all patients deny the use of steroids

Aims

It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management.

Myotome values for the upper limb appear to have been established in the early twentieth century based on historical work. Supraclavicular brachial plexus injuries present with a pattern of neurological loss consistent to the nerve roots affected. Recent advances in radiological imaging and intraoperative nerve stimulation have allowed confirmation of the affected nerve roots. The records of 43 patients with partial injuries to the supraclavicular brachial plexus were reviewed. The injuries covered the full range of injury patterns including those affecting C5, C5-6, C5-7, C5-8, C7-T1 and C8-T1 roots. All cases with upper plexus injuries had surgical exploration of the brachial plexus with the injury pattern being classified on the basis of whether the roots were in continuity, ruptured, or avulsed, and, if seen in continuity, the presence or absence of a response to stimulation. For lower plexus injuries the classification relied on identification of avulsed roots on Magnetic Resonance Imaging. Muscle powers recorded on clinical examination using the MRC grading system. In upper plexus injuries paralysis of flexor carpi radialis indicated involvement of C7 in addition to C5-6, and paralysis of triceps and pectoralis major suggested loss of C8 function. A major input from T1 was confirmed for flexor digitorum superficialis, flexor digitorum profundus (FDP) to the radial digits, and extensor pollicis longus. C8 was the predominant innervation to the ulnar side of FDP and intrinsic muscles innervated by the ulnar nerve with some contribution from C7. A revised myotome chart for the upper limb is proposed

We present 10–15 year follow-up of 33 patients who underwent Elmslie-Trillat osteotomy for severe patellar subluxation or dislocation. In the literature it has been reported that tibial tubercle osteotomy predisposes to subsequent patella-femoral arthritis, however it has never been documented if pre-existent knee chondral damage has any role in this development. In our group all patients had pre-op knee arthroscopy performed and extant of chondral damage was documented. We preformed an evaluation by long-term follow-up to determine weather pre-op chondral damage was the cause of subsequent osteoarthritis of patella-femoral joint. All patients were invited to attend outpatient clinic for clinical examination and knee radiographs and assessed by an independent research surgeon. Mean age at follow-up was 43 years and average follow-up was 10.5 years (range 10–15 years). 90% follow-up was achieved. Knee function was assessed by clinical scores (Lysholm knee score, American Knee Score, Oxford Knee score, Tegner and Insall knee scores) and three radiographs (AP, Lateral and Merchant views). Four patients had developed significant arthritis and underwent joint arthroplasty. Majority of patients reported good results with no further dislocation. However we noticed that extant of pre-op chondral damage was a significant factor in subsequent development of patella-femoral arthritis. We will present our data which is unique as no previous such long-term results have been reported for tibial tubercle transfers followed-up for more than 10 years and have pre-op arthroscopic documented chondral damage

Objective. Surgical treatment of trigger finger is usually performed as an outpatient surgery under local anesthesia n this study we present our results of surgical treatment of trigger finger performed with an ophthalmic knife which is less invasive for patient and easer for surgeon. Material and Method. 19 gauges microvitreoretinal ophthalmic knifes have a rhombus like edge with both sharp sides. The length of the knife's cutting side is 3 mm at each side. There were 40 women and 10 men with a mean age of 51.7 ± 5.7 (min: 40 max: 62). The thumb was involved in 32, the index finger in 10, and the middle in 8 patients. The procedure can be performed as an outpatient surgery under local anesthesia. The surface landmarks of the proximal and distal edges of the A1 pulley are marked on the skin. Percutaneous placement of a 25-gauge needle 5mm proximal to the PDC marked the distal extent of the release. The duration of procedure was under five minutes. Clinical examination was repeated on the postoperative 3rd day, 10th day and patients were re-examined or spoken to by telephone at a mean follow-up of 6.4 months. Results. Of the 50 digits treated, there was complete resolution of symptoms in 45 digits (90%). 3 thumbs had residual grade 1–2 triggering at the second follow up. 2 patients with locked trigger thumbs had persistent, despite relief of the triggering. Discussion. In this study we noted that percutaneous release with a 19 gauges MVR ophthalmic knife is a safe, cheap, quick, less scaring and comfortable treatment

This study describes the long term clinical and patient reported outcomes following simple dislocation of the elbow. We identified all adult patients treated at our trauma centre for a simple dislocation of the elbow over 10 years. 140 patients were identified and 110 (79%) patients were reviewed at a mean of 88 (95% CI 80–96) months after injury. This included clinical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, an Oxford Elbow questionnaire and a patient satisfaction questionnaire. Patients reported long-term residual deficits in range of movement. The mean DASH score was 6.5 (95% CI 4 to 9). The mean Oxford Elbow score was 43.5 (95% CI 42.2 to 44.8). The mean satisfaction score was 85.6 (95% CI 82.2 to 89). Sixty-two patients (56%) reported persistent subjective stiffness of the elbow. Nine (8%) reported subjective instability and 68 (62%) complained of continued pain. The DASH, Oxford Elbow and satisfaction scores all showed good correlation with absolute range of movement in the injured elbow. After multivariate analysis, a larger elbow flexion contracture and female gender were both independent predictors of worse DASH scores. Poorer Oxford Elbow scores and overall satisfaction ratings were predicted by reduced flexion-extension arc of movement. Patients report good long term functional outcomes after simple dislocations of the elbow. These are not entirely benign injuries. There is a high rate of residual pain and stiffness. Functional instability is less common and does not often limit activities

AIM. Chronic osteomyelitis still remains challenging and expensive to treat inspite of advances in antibiotics and operative techniques. We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure. METHODS. We retrospectively identified eight patients (5 Females) with mean age of 63 yrs (Range40–71 yrs) Case notes were reviewed for co morbidities, Pre and post treatment inflammatory markers (plasma viscosity and CRP) and clinical staging. Mean follow up was 3 yrs (Range 1–6 yrs) All the patients were jointly operated by orthopaedic and plastic surgeons and underwent thorough debridement and muscle flap (Seven free flaps and one rotational flap) in the same sitting. All the patients were reviewed regularly by plastic and orthopaedic surgeons. Seven patients had free Gracilis flap and one had Triceps flap. Clinical assessment of reinfection was made on presence of erythema, wound discharge, pain and swelling. Primary outcome measure was resolution of infection. RESULTS. Seven patients had full resolution of osteomyelitis as evident by clinical examination and inflammatory markers. Three patients had graft problems to start with, but theses settled within six months One patient had minor wound discharge at three years which settled with conservative management. One further patient developed eczematous dermatitis around the flap which was managed successfully by the dermatologist. CONCLUSIONS. We believe this to be the only study in which both the procedures (debridement and muscle flap) are performed in one sitting. This technique is a successful and useful addition to the armamentarium of surgeons in the management of chronic osteomyelitis. Though our study is small but our results are encouraging

INTRODUCTION. A detailed clinical examination and investigations are required to evaluate the cause of persisting groin pain following a metal on metal (MoM) hip replacement. Adverse reaction to metallic debris (ARMD) is an emerging problem with MoM hip replacements. It is an umbrella term encompassing metallosis, pseudo-tumors and aseptic lymphocytic vasculitis associated lesions (ALVAL). The role of imaging in the diagnosis of this complex problem is still unclear. A study was undertaken to evaluate the efficacy of ultrasound in diagnosis of ARMD following a MoM hip replacement. METHODS. The study group included 35 patients with a clinical and histological diagnosis of ARMD, who had a preoperative ultrasound. All ultrasound procedures were performed on the anterior and lateral aspects of the painful hip with a high frequency probe of 9–13 MHz (Sonoline Antares – Siemens). RESULTS. All patients diagnosed with ARMD had abnormalities identified on ultrasound. Fluid inside the joint was noted in 30 out of 35 procedures (85.7 %). Fluid outside the joint was noted in 33 procedures (94.3 %). Amongst the patients with fluid outside the joint, 32 had iliopsoas and 30 had trochanteric bursitis. Echogenic reflections were noted in 31 out of 35 procedures (88.6 %). Considerable attenuation or absence of iliopsoas and gluteus tendon reflection was seen in many patients with echogenic fluid collections on the anterior and trochanteric aspects of hip. Progression of such changes was noted on further 5 patients, who had a repeat ultrasound within an interval of 3–6 months. 1 patient had a progression from anechogenic to echogenic joint effusion. DISCUSSION. Different radiological investigations including MRI scan have been used for evaluation of painful MoM hip arthroplasty. To our knowledge, this is the first study to demonstrate the efficacy of ultrasound in diagnosis of ARMD. Floating echogenic reflections and fluid collections around iliopsoas and gluteus medius/minimus tendons is highly suggestive of ARMD. Ultrasound is a cheap, non-invasive and dynamic investigation and has been shown to be reliable in diagnosis of ARMD

We have treated 94 patients with chronic instability of the lateral side of the ankle by reconstruction of the ligaments with local periosteal tissue. We reviewed 90 cases after a mean follow-up of 2.8 years (2 to 9) using a questionnaire, clinical examination and radiography. The results on a 100-point ankle score indicated that 81% had a good or excellent result. The periosteal flap-replacement technique allows anatomical reconstruction and does not sacrifice other ligaments or tendons in the foot

The imaging techniques available to aid the diagnosis of ruptures of tendo Achillis, the rotator cuff and the tendon of tibialis posterior in rheumatoid patients are well described. However, ruptures of tendon or muscle at other sites are uncommon and may be overlooked. Diagnosis is often made by localised tenderness, swelling and a lack of active movement associated with a palpable defect. Clinical examination may be inconclusive and can be aided by imaging studies. We report two cases in which ruptures of a tendon were suspected, and ultrasound imaging demonstrated the palpable defect to be a cleavage plane in the subcutaneous fat – a ‘fat fracture’

The aim of our study was to compare the clinical versus radiological diagnosis of patients suffering from a Morton's neuroma. Clinical assessments and pre operative radiological imaging of patients who underwent operative procedures for an excision of a Morton's neuroma were retrospectively compared. This review included 43 excised Morton's neuromas from 36 different patients over a period of 68 months, performed by one surgical team. The commonest clinical symptoms were those of pain or tingling on the plantar aspect of the affected webspace on direct palpation (100%), pain of weight bearing (91%) which was relieved by rest (81%) and pain on stretching the toes (79%). The most sensitive clinical sign was a Mulder's click. Our results showed that clinical assessment was the most sensitive method of diagnosing these neuromas (98%). All of our patients had at least one mode of radiological investigation. Ultrasonography was the commonest requested single imaging modality in our series. It was found to have a sensitivity of 90% (28/31). This imaging technique has the disadvantage of being operator dependant, as highlighted by the fact that one of our patients had a correct radiological diagnosis after a repeat ultrasound to the affected area was requested. Magnetic Resonance Image scan is a more expensive technique as it has the advantage of producing static reproducible images. As a single imaging modality, it was found to have a sensitivity of 92% (12/13) in our series. 3 patients had both imaging modalities; initial ultrasound failed to convincingly diagnose a neuroma in 2 cases and in the other case, the initial MRI did not show any pathology. In all these cases, the repeat imaging techniques confirmed the clinical diagnosis. We conclude that there is no absolute requirement for ultrasonography or magnetic resonance imaging in patients who clinically are suspected to have a Morton's neuroma, as the clinical examination was found to be the most sensitive method of diagnosis. We suggest that the two main indications for performing some form of imaging is (a) an unclear clinical assessment and (b) cases when more than one webspace appears to be affected. An ultrasound of the webspaces should be the radiological investigation of choice, followed by a magnetic resonance scanning if any uncertainty still remains

Shoulder pain or loss of normal range of motion is a frequent complaint in the outpatient clinic. Of these presentations, rotator cuff injury is a common cause. This can range from mild, transient inflammation of the tendons, to partial tears of tendons, or even full thickness tears. Disruption of the tendons can occur from forceful forward throwing actions undertaken in some sports, for example baseball pitching, more commonly in the UK however, chronic impingement can lead eventually to a tendon tear-usually seen in an older population. Current methods of investigation of such injuries after clinical history and examination, includes plain film radiography, ultrasonography, magnetic resonance imaging and arthrography. We decided to look at how ultrasound can be used in the district general hospital for investigation of such injuries. Aims. To determine the accuracy of ultrasound as an investigative tool for clinically suspected rotator cuff tears. Methods. Seventy-five consecutive ultrasonographic study reports, in patients who subsequently underwent arthroscopic examination, were scrutinised and correlated with surgical findings. From this, sensitivity and specificity of ultrasound at this district general hospital were calculated. In addition, this data was compiled for each of the three Consultant Radiologists in order to assess the operator dependent nature of ultrasound. Results. Of the 74 cases analysed, 43 (58.1%) had full correlation with the arthroscopy findings, 13 (17.6%) had mixed correlation, and 18 cases (24.3%) had no correlation between the ultrasound and arthroscopy report. The sensitivity and specificity of ultrasound at our institution was 0.76 and 0.8 respectively with regards to a tear being detected at ultrasound and then visualised during surgery. Conclusions. There is no current national guidance as to which imaging modality should be first line following clinical examination. Magnetic resonance arthrography, widely thought of as being the gold standard investigation, is not only expensive and possible only in certain centres, but is also invasive, time consuming, and has many relative contraindications. Ultrasound offers a clinical advantage by allowing the radiologist to speak to the patient and assess their range of motion whilst performing the study. This interaction is lost totally in MRI, CT and even MR arthrography. Our study shows that ultrasonography can be quite accurate in identifying a rotator cuff tear. Although it is operator-dependent, ultrasound should be considered more often as a first-line imaging tool for suspected rotator cuff tears as it is relatively inexpensive, quick, and most importantly dynamic