Documentation of neurovascular status in supracondylar fractures and the development of an assessment proforma.

BACKGROUND: Supracondylar fractures are associated with a high incidence of neurovascular complications. Comprehensive clinical evaluation is a necessity when children with these injuries present to the emergency department. Neurovascular assessment can be difficult due to pain, anxiety and the young age of these patients; however, it is crucial findings are well documented to identify patients requiring urgent surgical intervention, in addition to allowing the neurovascular status to be monitored over time. The aim of this study was to evaluate the preoperative neurovascular documentation in children presenting with displaced supracondylar fractures and devise an emergency department assessment proforma to facilitate comprehensive evaluation. METHODS: A retrospective case-note review was performed on patients with Gartland grades 2 and 3 supracondylar fractures observed in a 2-year period from July 2008 to July 2010. RESULTS: 137 patients were included; only 12 patients (8.8%) and 19 patients (13.9%), respectively, had a complete preoperative neurological or vascular assessment documented. Regarding the individual nerves, 59 (43.1%) patients had median nerve integrity documented, 55 (40.1%) ulnar nerve and 49 (35.8%) radial nerve integrity documented. Only 18 patients (13.1%) had their anterior interosseous nerve (AIN) function documented. CONCLUSIONS: Preoperative documentation of neurovascular status in children with displaced supracondylar fractures was poor. Documentation of AIN examination was particularly poor. The introduction of a proforma (Liverpool upper limb fracture assessment) is proposed to increase documentation of neurovascular assessment and optimise emergency department evaluation of children presenting with upper limb injuries.

Hallux varus: A literature review.

Hallux varus is a rare foot deformity due to iatrogenic, post-traumatic, idiopathic, inflammatory, spontaneous, or congenital pathologies. Acquired hallux varus, in particular, iatrogenic type, is the commonest. The primary pathology is the abnormal musculotendinous forces secondary to soft tissue or bony imbalance exerting varus deforming force. Understanding the anatomy of the hallux stabilisers and the pathophysiology of hallux varus is vital in its management. It would be helpful to understand the potential surgical pitfalls leading to iatrogenic hallux varus. This literature review summarises all the published facts about hallux varus, focussing on anatomy, pathophysiology, clinical and radiological assessment, and management.

Bilateral hamstring origin calcification: rare presentation of Gitelman syndrome.

This case report is the first case to our knowledge of intratendinous or peritendinous calcification reported in Gitelman syndrome (GS) patients. GS represents the clinical manifestations of inactivation of the Slc12a3 genes encoding the thiazide-sensitive sodium chloride cotransporter and the Trpm6-Mg genes encoding the magnesium transporters in the distal convoluted tubule. Hence, the biochemical findings resemble those with thiazide diuretics such as hypokalaemia, hypomagnesaemia, hypocalciuria, metabolic alkalosis and low normal blood pressure. Serum calcium and phosphate levels are usually unaffected in GS unless associated with hyperparathyroidism or other hypercalcaemic aetiologies. We report a 69-year-old male patient with a history of GS who presented with bilateral ischial tuberosity tenderness. Further investigations confirmed the calcification of bilateral hamstring origin. Chondrocalcinosis is a known association of GS; however, extra-articular calcification is rare. Literature review illustrates sclerochoroidal calcification as the only reported soft tissue calcification apart from chondrocalcinosis.

Medium-term results following large diameter metal-on-metal total hip arthroplasty: increasing failure after 6 years.

PURPOSE: The main aim of our study is to report the medium-term survivorship of Birmingham Hip Resurfacing (BHR) cup and a large modular metal head (MMT) on an uncemented Freeman femoral stem. No results have been reported till date with these implants combinations. METHODS: A total of 205 metal-on-metal total hip replacements (MoM THRs) were performed on 190 patients from October 2002 to November 2004. Prior to the Medicines and Healthcare Products Regulatory Agency (MHRA) guidelines, the patients were followed up at 3, 6 and 12 months postoperatively and annually thereafter. Following the MHRA alert in 2010, the patients were followed-up as per the MHRA guidelines.All statistical analyses were conducted using Stata 13. RESULTS: At a mean follow-up of 10.5 years, a total of 42 out of 205 hips were revised for reasons related to ALTR. The failure rates increased significantly over time (7% at 6 years and 29% at 10-year follow-up). The analysis showed no statistically significant association to age, gender, side, BMI or component size or position (p<0.05). Blood metal ions showed a poor discriminant ability to separate failed from well-functioning MoM hip replacements. CONCLUSIONS: Large head MoM BHR on an uncemented stem has extremely high failure rate. The authors do not recommend the use of large head MoM articulation in total hip arthroplasty in the wake of this report and similar findings across the world. Continued surveillance of these implants is required as the failure rates increase with time.

Radiographic measurements of normal elbows: clinical relevance to olecranon fractures.

This study aims to calculate a clinically relevant and intra-operatively accessible measure of olecranon length that could be reliably applied by the operating surgeon to optimise fixation of comminuted olecranon fractures. One hundred normal adult antero-posterior and lateral radiographs of the elbow were studied with respect to the proximal olecranon height (OH), trochlear notch width (TW) on lateral views, and trans-epicondylar distance (TED) and trochlear width distance (TWD) on AP views. Three mean ratios were then derived: TWD/TW, TED/TW and OH/TW. The average OH was 26.2 mm (range 21-29), TW was 24.7 mm (range 21-32), TED was 58.7 mm (range 49-74), and the TWD was 27.0 mm (range 22-32). The average ratio of TWD: TW was 1.08 (SD = 0.08), that of TED: TW was 2.38 (SD = 0.18) and OH/TW was 1.06 (SD = 0.08). Comminuted fractures of the olecranon are a surgical challenge since it is often impossible to gauge the correct length to achieve in reconstruction of the olecranon process. Our data can be easily applied to the clinical situation, by taking intra-operative radiographs, and calculating the ratios as demonstrated above. These will guide the surgeon to obtain a more reliable length of the olecranon intra-operatively.