Lateral Clavicle Fracture Fixation Using a Superiorly Placed Locking Plate.

Clavicle fractures are common injuries that account for 4% of all fractures, and approximately 21% of clavicle fractures are lateral. Studies have demonstrated that displaced lateral clavicle fractures with disruption of the coracoclavicular ligaments have nonunion rates as high as 28%. Many surgical techniques for fixation of lateral-end clavicle fractures have been proposed. More recently, locking plate technology has led to the development of superiorly placed locking plates, which are used when the distal fragment is large enough and which offer greater biomechanical stability in osteoporotic or metaphyseal bone. Our surgical technique for use of a compression plate for an unstable and displaced lateral clavicle fracture consists of the following steps. Step 1: identification of the fracture pattern and surgical planning. Step 2: setup of the operating room with the image intensifier in an optimum position for satisfactory intraoperative images. Step 3: approach, through a bra-strap incision centered over the fracture. Step 4: reduction of the fracture and temporary stabilization. Step 5: implant selection based on sizing and patient anatomy. Step 6: application of the plate of choice and fixation with a combination of proximal bicortical screws and distal locking screws. Step 7: closure in layers and application of postoperative slings and dressings. Patients follow a graduated physiotherapy regimen postoperatively. Studies have demonstrated high union rates following lateral clavicle fracture fixation with good-to-excellent functional outcomes and a combined complication rate of approximately 6%.

Vertical or horizontal orientation of foot radiographs does not affect image interpretation.

This study determined whether the orientation of dorsoplantar and oblique foot radiographs has an effect on radiograph interpretation. A test set of 50 consecutive foot radiographs were selected (25 with fractures, and 25 normal), and duplicated in the horizontal orientation. The images were randomly arranged, numbered 1 through 100, and analysed by six image interpreters. Vertical and horizontal area under the ROC curve, accuracy, sensitivity and specificity were calculated for each image interpreter. There was no significant difference in the area under the ROC curve, accuracy, sensitivity or specificity of image interpretation between images viewed in the vertical or horizontal orientation. While conventions for display of radiographs may help to improve the development of an efficient visual search strategy in trainees, and allow for standardisation of publication of radiographic images, variation from the convention in clinical practice does not appear to affect the sensitivity or specificity of image interpretation.

Pitfalls in the diagnosis of infection around the shoulder joint--report of three cases.

Infection around the shoulder joint is rare. Clinical suspicion and diagnostic imaging are required for accurate diagnosis. We present three cases that emphasise particular diagnostic challenges when dealing with infection around the shoulder joint. Discussion includes the role of ultrasound as a screening tool and the importance of magnetic resonance imaging (MRI) in the accurate diagnosis and localisation of infections around the shoulder.

Peroneal tendons subluxation.

Subluxation of the peroneal tendons is uncommon. It occurs especially in skiing, soccer, basketball, rugby, ice skating, judo, sprint, water-skiing, mountaineering, and gymnastics. We present an overview of the injury, with the classification commonly used. Many surgical techniques have been described to manage recurrent subluxation of the peroneal tendons, but only Level IV/Grade C evidence has been produced. Thus, randomized controlled trials are necessary to determinate the best surgical management method. It appears that high-demand individuals should be primarily managed surgically, and retinaculoplasty seems to be, when indicated, the best surgical option: it affords less complications and a high rate of return to sports without reducing their activity levels.

Management of recurrent subluxation of the peroneal tendons.

Recurrent peroneal subluxation occurs when an acute injury is misdiagnosed or not adequately managed. The primary pathology is failure of the SPR, the principal restraint to the peroneal tendons. Several surgical techniques have been described. Determining the most effective technique from the small case series and reports in the literature is impossible. If an anatomic approach to treating the pathology is used, reattachment of the SPR, as we have described, seems a most appropriate technique. Rarely, the retinaculum in recurrent cases may not be robust enough to withstand repair, and a different approach to the problem may be required. In the future, there may be an emerging role for minimally invasive SPR repair with the use of endoscopic techniques.

Epidemiology of sprains of the lateral ankle ligament complex.

Lateral ankle sprains account for 85% of all ankle sprains. This common injury is most frequently sustained during sporting activity. The ATFL is the weakest of the lateral ankle ligament complex, and is most frequently injured. Ankle sprains are often undertreated, resulting in chronic pain, muscular weakness, and instability. The consequence of this common injury for professional sports clubs is days lost in training and matches missed due to injury as well as the cost of rehabilitation. In the UK, an estimated 302,000 ankle sprains are seen each year in Accident and Emergency Departments.

Recurrent subluxation of the peroneal tendons.

BACKGROUND: Recurrent peroneal tendon subluxation is uncommon. HYPOTHESIS: The authors tested the null hypothesis that there are no differences between preoperative and postoperative status after anatomical repair of the superior peroneal retinaculum. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In the period 1996 to 2001, the authors operated on 14 patients (all men; mean age, 25.3 +/- 6.3 years; range, 18-37 years) with traumatic recurrent unilateral peroneal tendon subluxation, with a follow-up of 38 +/- 3 months (range, 22-47 months). RESULTS: No patient experienced a further episode of peroneal tendon subluxation, and all had returned to their normal activities. Maximum calf circumference, functional ability, peak torque, total work, and mean power of plantar flexion were always lower in the operated leg, but the differences did not reach statistical significance. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score increased significantly from 54.3 +/- 11.4 to 94.5 +/- 6.4 (P = .03), with 5 patients reporting a fully normal ankle. CONCLUSION: If an anatomical approach is used, reattachment of the superior retinaculum is a most appropriate technique. It returns patients to a high level of physical activity and gives a high rate of satisfactory results both objectively and subjectively. Randomized control trials may be the way forward in determining the best surgical management method. However, the relative rarity of the condition and the large number of techniques make such a study difficult.