A new acute scaphoid fracture assessment method: a reliability study of the 'long axis' measurement.

BACKGROUND: The aim of this study was to assess the inter observer and intra observer reliability of acute scaphoid fracture classification methods including a novel 'long axis' measurement, a simple method which we have developed with the aim of improving agreement when describing acute fractures. METHODS: We identified sixty patients with acute scaphoid fractures at two centres who had been investigated with both plain radiographs and a CT (Computed Tomography) scan within 4 weeks of injury. The fractures were assessed by three observers at each centre using three commonly used classification systems and the 'long axis' method. RESULTS: Inter observer reliability: based on X-rays the 'long axis' measurement demonstrated substantial agreement (Intraclass Correlation Coefficient (ICC) =0.76) and was significantly more reliable than the Mayo (p < 0.01), the most reliable of the established classification systems with moderate levels of agreement (kappa = 0.56). Intra observer reliability: the long axis measurement demonstrated almost perfect agreement whether based on X-ray (ICC = 0.905) or CT (ICC = 0.900). CONCLUSIONS: This study describes a novel pragmatic 'long axis' method for the assessment of acute scaphoid fractures which demonstrates substantial inter and intra observer reliability. The 'long axis' measurement has clear potential benefits over traditional classification systems which should be explored in future clinical research.

Delayed presentation of lateral femoral circumflex artery injury post cannulated hip screw surgery--a case report.

An elderly patient underwent cannulated hip screw surgery for a subcapital neck of femur fracture. Nine days post surgery, she was noted to have collapsed with a falling haemoglobin level. Computed tomography revealed a large haematoma to the thigh. Further angiography showed active bleeding from one of the branches of the lateral femoral circumflex artery (LFCA), which we postulate was caused by the sharp tip of a version guidewire used during fracture fixation surgery. Iatrogenic injury during hip fracture fixation is a rare event, particularly to the circumflex branches of the profunda femoris artery (PFA), and may occur from hard wire use intra-operatively or from the fracture itself. The LFCA branches laterally from the PFA, runs anterior to the femoral neck, where we suspect it was injured in our case. Whilst a version wire is a useful radiological guide intra-operatively, manually clearing a passage for its insertion into the femoral head/neck junction and using the blunt end is recommended. A combination of acute swelling in the operated region and falling haemoglobin post surgery should alert the clinician to possible vascular injury. Compared to duplex ultrasonography, CT angiography remains the gold standard in its specificity and sensitivity for diagnosing arterial injuries. With early recognition and prompt radiological intervention, this rare complication of fracture fixation surgery can be treated without the need for further surgery.

Outcomes of total elbow arthroplasty for rheumatoid arthritis: comparative study of three implants.

BACKGROUND: As the English-language literature on prosthetic elbow arthroplasty contains only two comparative studies of implants in contemporary use, to our knowledge, comparisons of prosthetic performance is difficult. An improved knowledge of comparative outcomes would be valuable in guiding implant selection. METHODS: We identified three groups of consecutive patients who had undergone prosthetic elbow arthroplasty with the Souter-Strathclyde, Kudo, or Coonrad-Morrey implant for the treatment of rheumatoid arthritis. There were thirty-three elbows in each group. All procedures were done by or under the supervision of one surgeon. Surviving patients in whom the elbow had not been revised were followed for a mean of sixty-one months after treatment with the Souter-Strathclyde implant, sixty-seven months after treatment with the Kudo implant, and sixty-eight months after treatment with the Coonrad-Morrey implant. Clinical function was assessed on the basis of pain relief and the range of flexion. Survivorship was assessed with use of a life-table method, with revision surgery and radiographic signs of loosening as the end points. RESULTS: The groups were comparable in terms of age, sex, and mean duration of follow-up. All three implant procedures relieved pain. Sustained improvement in the range of flexion was comparable among the three groups, with no implant procedure dramatically changing the fixed flexion deformity and all three improving maximum flexion. Revision surgery was needed because of infection, dislocation, and aseptic loosening. Survival of the Coonrad-Morrey implant was better than that of the other two implants. The five-year survival rates, with revision and radiographic signs of loosening as the end points, were 85% and 81% for the Souter-Strathclyde implant, 93% and 82% for the Kudo implant, and 90% and 86% for the Coonrad-Morrey implant. While radiographic evidence of loosening of the Coonrad-Morrey implants was less common, we noted focal osteolysis adjacent to 16% of these ulnar components and half of these cases progressed to frank loosening. CONCLUSIONS: The clinical function of these implants was similar in terms of pain relief and range of motion. We believe that component linkage with the Coonrad-Morrey implant prevents dislocation without increasing the risk of loosening.

Boutonnière deformity after correction of childhood swan-neck deformity: a case report.

After a successful Littler procedure (spiral oblique retinacular ligament reconstruction) for swan-neck deformity, a 14-year-old patient developed progressive boutonnière deformity. We propose that the problem arose from gradual tightening of the tendon transfer as the finger grew.

Scaphotrapezial joint arthroscopy: a palmar portal.

PURPOSE: Arthroscopy of the scaphotrapezial trapezoid (STT) joint is performed traditionally through a dorsal radial midcarpal portal. This portal allows visualization of the dorsal rim of the STT joint but is difficult to approach owing to lack of surface landmarks and it passes close to the radial artery and nerve. The purpose of this study was to assess the safety, ease of access, and visualization of the STT joint through a palmar portal. METHODS: Five cadaveric wrists were dissected initially to identify the anatomy around the palmar aspect of the STT joint and to identify a safe route for an arthroscopic portal. A further 5 cadaveric wrists then were used to confirm the efficacy of the portal. RESULTS: A palmar portal to the STT joint can be established 3 mm ulnar to the abductor pollicis longus tendon, 6 mm radial to the scaphoid tubercle, and midway between the radial styloid and base of the first metacarpal. CONCLUSIONS: A palmar arthroscopic portal to the STT joint can be identified readily because of the palpable surface landmarks, improves the visualization of its articular surface compared with a dorsal portal because of the orientation of the joint, is safe, and provides a second portal through which therapeutic interventions may be considered.