Estimated cumulative X-ray exposure and additional cancer risk during the evaluation and treatment of scoliosis in children and young people requiring surgery.

INTRODUCTION: Clinicians and patients must weigh the benefits of radiological imaging against the risks of radiation exposure in the diagnosis and treatment of scoliosis. This report aims to estimate the cumulative absorbed and equivalent dose of radiation in patients undergoing surgical treatment for scoliosis, and to present this as an estimated risk of cancer compared to background radiation levels. METHODS: Retrospective review of estimated absorbed dose on the Computerised Radiology Information System (CRIS®). Patients undergoing surgical correction of scoliosis (age ≤ 25) from August 2010 to August 2015 investigated. Estimated absorbed dose [milligrays (mGy)] recorded. Pedicle screws inserted using image intensification. Equivalent dose [millisieverts (mSv)] and additional cancer risk calculated from the National Research Council document 'Health risks from exposure to low levels of ionising radiation' (2006). RESULTS: 271 patients identified. Mean age 15 (range 2-25). Mean total absorbed dose 2136 mGy [standard deviation (SD) 1700 mGy]. Mean number of plain spine radiographs was 8 (SD 3) with total 1884 mGy exposure (SD 1609 mGy). Additional dose provided by CT (mean 0.17 episodes), plain chest and abdominal radiographs and image intensification. Mean number of image intensification episodes was 1.1 with mean estimated exposure 180 mGy (SD 238 mGy). Image intensification accounted for 8% of the estimated absorbed dose during treatment. Estimated mean effective dose delivered was 20.952 mSv equating to an additional cancer risk of 0.27-0.45%. CONCLUSION: Additional cancer risk from cumulative imaging is small and equivalent to approximately 8 years of natural background radiation. Use of image intensification for pedicle screw insertion is a minor contribution (8%) to the total patient dose.

Multiple digit camptodactyly caused by anomalous ulnar sided flexor digitorum superficialis insertions.

We report an anomalous insertion of the flexor digitorum superficialis (FDS) tendon causing multiple digit camptodactyly. The abnormal tendon was present in the ring and middle fingers, passing from the FDS tendon (proximal to the proximal interphalangeal-PIP-joint) to the extensor expansion (distal to the PIP joint). It was present on the ulnar aspect only, with no corresponding structure on the radial side. Division of the anomalous insertion corrected the fixed flexion deformity at the PIP joint. This anomaly has not been reported in clinical or cadaveric studies and could have been overlooked if a volar approach had been used.

A safe technique for insertion of heel wires for hindfoot external fixation frames: an anatomical study.

Aims: Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum. Materials and Methods: A total of 20 embalmed cadaveric lower limbs were divided into two groups. Wires were inserted using two possible insertion points and at varying angles. In Group A, wires were inserted one-third along a line between the point of the heel and the tip of the lateral malleolus while in Group B, wires were inserted halfway along this line. Standard dissection techniques identified the structures at risk and the distance of wires from neurovascular structures was measured. The results from 19 limbs were subject to analysis. Results: In Group A, no wires pierced the PTNVB. Wires were inserted a median 22.3 mm (range 4.7 to 39.6) from the PTNVB; two wires (4%) passed within 5 mm. In Group B, 24 (46%) wires passed within 5 mm of the PTNVB, with 11 wires piercing it. The median distance of wires from the PTNVB was 5.5 mm (range 0 to 30). A Mann-Whitney U test showed that this was significantly closer than in Group A (Hodges-Lehmann shift, 14.06 mm; 95% confidence interval (CI) 10.52 to 16.88; p < 0.0001). In Group B, with an increased angle of insertion there was greater risk to the PTNVB (rs = -0.80; p < 0.01). Conclusion: Insertion of wires using an entry point one-third along a line from the point of the heel to the tip of the lateral malleolus (Group A) appears to be the safer technique. An insertion angle of up to 30° to the coronal plane can be used without significant risk to the PTNVB. Insertion of wires halfway along a line from the point of the heel to the tip of the lateral malleolus (Group B) carried a significantly higher risk of injury to neurovascular structures and, if necessary, an angle of insertion parallel to the coronal plane should be used. Cite this article: Bone Joint J 2018;100-B:1054-9.

The prevalence of pseudoepiphyses in the metacarpals of the growing hand.

Normally the metacarpals have an epiphysis at one end--distally for the second to fifth and proximally for the first. Pseudoepiphyses are notches or clefts that occur at the non-epiphyseal ends of bones where an epiphyseal plate would be expected and are common incidental findings in the metacarpals of the growing hand. We aimed to identify the prevalence of pseudoepiphyses on serial radiographs of 610 healthy asymptomatic children. Pseudoepiphyses in the form of notches or clefts were common, identified most often in the second metacarpal (15.25%), fifth metacarpal (7.21%), and third metacarpal (0.49%). Complete pseudoepiphyses, in which the cleft extended across the full width of the metacarpal, were seen in the first metacarpal (1.97%) and the second metacarpal (1.31%). Pseudoepiphyses are a normal variant of metacarpal ossification and should not be confused with fractures in skeletally immature patients.

A national survey of acute hospitals in England on their current practice in the use of femoral nerve blocks when splinting femoral fractures.

INTRODUCTION: Missed compartment syndrome can have devastating long-term impact on a patient's function. Femoral fracture has been reported in 52-58% of acute thigh compartment syndromes in the existing literature. Time to diagnosis of compartment syndrome is cited as a key determinant of outcome. Use of femoral nerve blocks in splinting of femoral fractures may mask signs of early compartment syndrome. We present the attitudes of emergency department and orthopaedic staff in NHS trusts in England with regard to this issue. METHODS AND MATERIALS: Survey of all 171 acute hospitals in the United Kingdom accepting trauma admissions. On-call middle grade doctors in emergency and orthopaedic department completed a telephone survey into departmental protocol and their experience of femoral nerve blocks for lower limb fractures. RESULTS: Middle grades from all 171 trusts completed the survey (100% response rate). 54 emergency departments (30.8%) had a protocol for the use of femoral nerve blocks. Middle grades in the ED reported using a nerve block routinely in 95 hospitals (54%) with 63 using a long-acting and 32 a short-acting agent. Of those that did not 70% (n=53) felt they were unnecessary, 21% (n=16) were not confident in the technique and 9% (n=7) had worries over compartment syndrome. 68% would be worried about compartment syndrome in high-energy injuries. Orthopaedic departmental protocols for nerve block use were reported in 16 trusts (9%). 45 orthopaedic middle grades (26%) indicated that they would use them routinely with 17 using long-acting and 28 using short-acting agents. 59.5% (n=75) of orthopaedic middle grades felt nerve blocks were unnecessary, whilst 22% (n=28) had worries about compartment syndrome and 18% (n=23) were not confident with the technique. 77% orthopaedic middle grades would be more worried about compartment syndrome in high energy injuries. CONCLUSION: Femoral nerve block is an under-utilised, effective mode of analgesia following femoral fractures. There is a low risk of associated compartment syndrome, but clinicians should be especially vigilant in high-energy injuries. We recommend that all acute trusts receiving trauma should have a protocol for the use of femoral nerve blocks agreed by the emergency and orthopaedic departments.

The 'Retro-Fibular Wire': an anatomical study describing a safe corridor for placement of fine wires in the distal tibia.

Anatomical atlases document safe corridors for placement of wires when using fine-wire circular external fixation. The furthest posterolateral corridor described in the distal tibia is through the fibula. This limits the crossing angle and stability of the frame. In this paper we describe a new, safe Retro-Fibular Wire corridor, which provides greater crossing angles and increased stability. In a cadaver study, 20 formalin-treated legs were divided into two groups. Wires were inserted into the distal quarter of the tibia using two possible corridors and standard techniques of dissection identified the distance of the wires from neurovascular structures. In both groups the posterior tibial neurovascular bundle was avoided. In group A the peroneal artery was at risk. In group B this injury was avoided. Comparison of the groups showed a significant difference (p < 0.001). We recommend the Retro-Fibular wire technique whereby wires are inserted into the tibia mid-way between the posteromedial border of the fibula and the tendo Achillis, at 30 degrees to 45 degrees to the sagittal plane, and introduced from a posterolateral to an anteromedial position. Subsequently, when using this technique in 30 patients, we have had no neurovascular complications or problems relating to tethering of the peroneal tendons.