A common injury pattern in current military experience is traumatic lower limb amputation from improvised explosive devices. This injury can coexist with pelvic girdle fractures. Of 67 consecutive patients with traumatic lower limb amputations treated in Camp Bastion Hospital Afghanistan, 16 (24%) had an associated pelvic fracture (10 APC/vertical shear and 6 acetabular or pubic rami fractures). Traumatic single amputees (n=28) had a 14% incidence of associated pelvic fracture with traumatic double amputees (n=39) increasing this association to 31%. However if the double amputations were above knee the incidence of associated open book fractures was 26% (6/23) with 39% (9/23) sustaining some form of pelvic bony injury. The majority of patients (95%) had a pelvic X-ray as part of the primary survey. Of these 51% (n=34) had a Sam sling(r) in situ but only fifteen were deemed appropriately applied. Given the high risk of pelvic fractures in patients with traumatic bilateral lower limb amputations, particularly those involving opening of the pelvic ring, it is imperative that the earliest and proper application of a pelvic binder be initiated.

The aim of this study was to assess the accuracy of placement of pelvic binders and to determine whether circumferential compression at the level of the greater trochanters is the best method of reducing a symphyseal diastasis.

Patients were identified by a retrospective review of all pelvic radiographs performed at a military hospital over a period of 30 months. We analysed any pelvic radiograph on which the buckle of the pelvic binder was clearly visible. The patients were divided into groups according to the position of the buckle in relation to the greater trochanters: high, trochanteric or low. Reduction of the symphyseal diastasis was measured in a subgroup of patients with an open-book fracture, which consisted of an injury to the symphysis and disruption of the posterior pelvic arch (AO/OTA 61-B/C).

We identified 172 radiographs with a visible pelvic binder. Five cases were excluded due to inadequate radiographs. In 83 (50%) the binder was positioned at the level of the greater trochanters. A high position was the most common site of inaccurate placement, occurring in 65 (39%). Seventeen patients were identified as a subgroup to assess the effect of the position of the binder on reduction of the diastasis. The mean gap was 2.8 times greater (mean difference 22 mm) in the high group compared with the trochanteric group (p < 0.01).

Application of a pelvic binder above the level of the greater trochanters is common and is an inadequate method of reducing pelvic fractures and is likely to delay cardiovascular recovery in these seriously injured patients.

Introduction: Hoffa’s fat pad (HFP) of the knee is affected by a variety of tumours and tumour-like conditions. HFP can be affected by diffuse or solitary, focal disease. Solitary tumours are relatively uncommon but with widespread uptake of Magnetic Resonance Imaging Scans (MRI) an increasing number of Hoffa’s fat pad tumours (HFP) are being recognized.

Methods: This paper reports a consecutive series of 20 cases of solitary symptomatic HFP tumours referred to Oxford bone and soft tissue tumour service between 1999 and 2008. The commonest presenting symptom was anterior knee pain. All patients underwent open excision after diagnostic magnetic resonance imaging (MRI).

Results: Histology revealed varied diagnoses with the commonest being pigmented villonodular synovitis (PVNS) and ganglia. American Knee Society scores improved from 76 pre-operatively to 96 post-operatively with an improvement in functional scores from 92 to 100. In one patient, MRI identified the cause of hypo-phosphataemic osteomalacia as an HFP phosphaturic mesenchyma tumour despite the lack of local symptoms.

Discussion In conclusion the majority of solitary HFP tumours are benign and may be either cystic or solid. MRI and plain radiographs are the imaging of choice. The definitive treatment of both cystic and solid tumours should be selective arthrotomy and excision biopsy. Arthroscopic resection is not advised, as complete excision is not always possible. None of the 20 patients in this series had a malignant tumour but this has been reported in the literature. Calcification on plain radiographs may indicate a malignant lesion. All patients in our series reported substantial improvement in symptoms following open tumour resection.

Inflammatory changes in synovial tissues occur commonly in knee osteoarthritis (OA) and are termed “inflammatory OA”. The pathogenic significance of this inflammatory OA is uncertain. It is also not known whether inflammatory changes in the synovial membrane are reflected in the synovial fluid (SF) and whether the SF contains a similar inflammatory cell infiltrate.

This study examined 34 cases of knee joint OA and cytologically and immunohistochemically characterised inflammatory cells in the synovial membrane and SF. Specimens of SF and synovial membrane were taken at the time of knee arthroplasty.

All cases of inflammatory OA synovium contained (CD68+) macrophages; several cases also contained a scattered, focally heavy (CD3+) lymphocytic infiltrate and occasional lymphoid aggregates. Inflammatory changes in OA SF reflected this cell composition with numerous CD68+ macrophages and CD3+ lymphocytes being noted in inflammatory OA cases. The SF volume was greater (> 5ml) in cases of inflammatory OA. Non-inflammatory OA knee joints contained very few inflammatory cells, which were mainly macrophages, in both the synovial membrane and SF.

Our findings indicate that inflammatory changes in the synovial membrane of OA knee joints are reflected in the SF and that the volume of SF is commonly increased in cases of inflammatory OA. Both macrophages and lymphocytes in the inflammatory infiltrate of knee joint SF may contribute to joint destruction in OA by providing mononuclear phagocyte osteoclast precursors and the production of inflammatory cytokines and growth factors that promote osteoclastogenesis.

In conclusion, the cytology of SF and synovitic membrane are similar in inflammatory OA. With knee effusions of greater than 5mls and inflammatory synovitic membrane consideration of total knee arthoplasty in the presence of single compartment disease should be considered because of the risk of further joint destruction.

Pectoralis major tendon rupture is a relatively rare injury, resulting from violent, eccentric contraction of the muscle. Over fifty percent of these injuries occur in athletes classically in weight-lifters during bench press. In this study, thirteen cases of distal rupture of the pectoralis major muscle in athletes are presented. All patients underwent surgical repair.

Physical findings and surgical technique are described. Magnetic resonance imaging was used in the diagnosis of all patients and intra-operative findings correlated with the reported scans in eleven patients with minor differences in two patients. During follow up examination, six patients had excellent results, six had good results and one had a fair result. Eleven patients could return to sports activity at their preoperative level.

Among our patients we emphasize that of an orthopaedic resident who suffered a rupture of his pectoralis major tendon as an unusual complication of closed manipulation of an anterior shoulder dislocation.

According to the literature and our experience, we suggest that only surgical repair of the pectoralis major rupture will result in complete recovery and restoration of the full strength of the muscle which is essential for the active athlete.