Nerve entrapment around elbow.

Entrapment neuropathy around elbow is a common cause of disability across all age groups. The major nerves that traverse the elbow are ulnar, median and radial nerves and their branches. Cubital tunnel syndrome leading to ulnar nerve compression can often present with significant pain, paresthesia or weakness. Median and Radial nerve compression around the elbow, albeit less frequent, can also lead to significant morbidity and must be kept in the differential diagnosis when dealing with patients complaining of persistent pain around the elbow and weakness of forearm/hand muscles. Electrodiagnostic studies can be a useful adjunct to clinical examination, to help localize the site and quantify the grade of compression. Management should involve a trial of conservative treatment and failing that, surgical treatment should be considered. We hereby provide an overview of nerve entrapments around the elbow including their applied anatomy, etiology, clinical assessment and overview of the current concepts in surgical treatment.

Current concepts in the management of clavicle fractures.

Clavicle fractures comprise approximately 3% of all adult fractures and there is evidence that the incidence is increasing. Fractures of the lateral and middle third of the clavicle present distinct challenges in both surgical fixation techniques and clinical outcome, as such they should be recognised as separate clinical entities. Despite conflicting evidence, most studies indicate that superior clinical results are found in patients with united clavicle fractures rather than those that go onto non-union. Furthermore there is level-1 evidence that operative treatment of clavicle fractures leads to significantly increased rates of union. Despite these findings, significant controversy still exists on which patients would benefit from primary fixation and those who could successfully be managed non-operatively. We present an evidence-based review of clavicle fracture management including surgical indications, techniques, and results.

Outcomes following arthroplasty for proximal humeral fractures.

Fractures of the proximal humerus are very common and increasing in incidence within an ageing population. The majority of undisplaced fractures can be treated conservatively. Displaced fractures in good quality bone or in the young are considered for surgical fixation. However, displaced and comminuted fractures with or without dislocation, especially in the elderly, cannot be reliably treated with fixation. These patients are generally considered for joint arthroplasty. This review article focuses on the outcome following arthroplasty for proximal humeral fractures.

Magnetic resonance imaging scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis.

BACKGROUND: We investigated whether magnetic resonance imaging (MRI) scans can accurately diagnose arthritis of the acromioclavicular joint (ACJ) because it has recently been suggested that bone marrow oedema on MRI scans is a predictive sign of symptomatic ACJ arthritis. METHODS: The MRI scans of 43 patients (50 shoulders) who underwent ACJ excision for clinically symptomatic ACJ arthritis were compared to a control group of 43 age- and sex-matched patients (48 shoulders) who underwent an MRI scan for investigation of shoulder pain but did not have clinical symptoms or signs of ACJ arthritis. The scans were evaluated by an experienced musculoskeletal radiologist, who was blinded to the examination findings. RESULTS: Bone marrow oedema was present in only 15 (30%) shoulders in the ACJ excision group, although this was higher than the six shoulders in the asymptomatic group (p = 0.03). Forty-one (82%) shoulders in the symptomatic group had grade III/IV ACJ arthritis compared to 31 (65%) in the asymptomatic group (p = 0.05). However, 44 out of 48 (92%) shoulders in the asymptomatic group had signs of osteoarthritis on MRI scans. CONCLUSIONS: In contrast to recent reports, the present study shows that MRI is not helpful in making the diagnosis of ACJ arthritis. A focused history and clinical examination should remain the mainstay for surgical decision making. LEVEL OF EVIDENCE: Level 3.

Trans-triquetral Perilunate fracture dislocation.

Perilunate dislocations and perilunate fracture dislocations are rare and serious injuries. Perilunate dislocations represent less than 10% of all carpal injuries of which 61% represent transcaphoid fractures. Because of their rarity, up to 25% of perilunate dislocations are initially missed on first assessment. We present the case of a 66-year-old-gentleman who sustained an isolated trans-triquetral perilunate fracture dislocation while walking his dog. This was diagnosed in the emergency department and he underwent open reduction internal fixation after failed attempts at closed reduction in the ED and in theatre under general anaesthesia. After further removal of his Kirschner wires and physiotherapy he is noted to have had a successful outcome with his treatment at 9 months follow up post operatively. We found that this is the first case of it's kind reported in the literature highlighting the rarity of this injury pattern.

Glucosamine reduces the inhibition of proteoglycan metabolism caused by local anaesthetic solution in human articular cartilage: an in vitro study.

BACKGROUND: We assessed whether local anaesthetics caused inhibition of proteoglycan metabolism in human articular cartilage and whether the addition of Glucosamine sulphate could prevent or allow recovery from this adverse effect on articular cartilage metabolism. METHODS: Cartilage explants obtained from 13 femoral heads from fracture neck of femur patients (average age 80 years, 10 female) were exposed to either 1% Lidocaine, 2% Lidocaine, 0.25% Bupivacaine, 0.5% Bupivacaine, 0.5% Levo-bupivacaine or a control solution (M199 culture medium). Glucosamine-6-Sulphate was added during or 1 h after exposure to 0.5% Bupivacaine to assess its protective and reparative effects. After exposure, the explants were incubated in culture medium containing radio labelled 35-sulphate and uptake was measured after 16 h to give an assessment of proteoglycan metabolism. RESULTS: The reduction in 35-S uptake compared to control was 65% for 1% Lidocaine (p < 0.001), 79% for 2% Lidocaine (p < 0.001), 61% for 0.25% Bupivacaine (p < 0.001), 85% for 0.5% Bupivacaine (p < 0.001) and 77% for 0.5% Levobupivacaine (p < 0.001). Glucosamine was able to protect the articular cartilage by reducing the inhibition of proteoglycan metabolism of 0.5% Bupivacaine from 85 to 30% (p < 0.001). When added after 0.5% Bupivacaine exposure, Glucosamine allowed some recovery with inhibition of metabolism to 70% (p = 0.004). CONCLUSION: Our results showed that all local anaesthetic solutions inhibited proteoglycan metabolism in articular cartilage and the addition of Glucosamine was able to reduce the inhibition of metabolism caused by 0.5% Bupivacaine. Intra-articular injection of local anaesthetics requires careful consideration of risks and benefits.

Current Concepts in the Diagnosis and Treatment of Shoulder Impingement.

Subacromial impingement syndrome (SIS) is a very common cause of shoulder pain in the young adults. It can cause debilitating pain, dysfunction, and affects the activities of daily living. It represents a spectrum of pathology ranging from bursitis to rotator cuff tendinopathy which can ultimately lead to degenerative tear of the rotator cuff. Various theories and concepts have been described and it is still a matter of debate. However, most published studies suggest that both extrinsic and intrinsic factors have a role in the development of SIS. The management is controversial as both nonoperative and operative treatments have shown to provide good results. This article aims to provide a comprehensive current concepts review of the pathogenesis, etiologies, clinical diagnosis, appropriate use of investigations, and discussion on the management of SIS.

A Comparison of Two Monofilament Suture Materials for Repair of Partial Flexor Tendon Lacerations: A Controlled In-vitro Study.

BACKGROUND: Surgical repair is advocated for flexor tendon lacerations deeper than 70%. Repair can be undertaken with different suturing techniques and using different materials. Different materials used for tendon repair will have a different gliding resistance (GR) at the joint. Previous studies have compared strength of repair and gliding resistance for various braided suture materials and for 100% laceration of flexor tendons. We directly compare the GR of two monofilament sutures when used for a peripheral running suture repair of partially lacerated tendons. METHODS: Sixteen flexor tendons and A2 pulleys were harvested from Turkey feet. They were prepared, partially lacerated to 50% depth, and then repaired with a core suture (modified Kessler technique with 4-0 Ethibond) as well as an additional superficial running suture of either 6-0 Prolene or Nylon (half randomised to each). Gliding resistance was measured for all tendons before and after repair, at different flexion angles (40 and 60 degrees) and for different loads (2N and 4N). RESULTS: After surgical repair, gliding resistance was increased for all tendons (P < 0.01). The tendons repaired with Prolene had a higher mean gliding resistance than those repaired with Nylon (P = 0.02). Increased flexion angle and load amplified the gliding resistance (both P < 0.01). CONCLUSIONS: 6-0 Nylon was associated with a lower gliding resistance than 6-0 Prolene but the minor differences bare unknown clinical significance.

Bilateral, simultaneous pneumococcal septic arthritis of the knees: a normal immune system, an unknown source.

Pneumococcal septic arthritis is a rare clinical entity and is often associated with a systemic bacteraemia. A 60-year-old man was admitted with bilateral swollen, painful knees. He was feeling feverish with raised inflammatory markers. Joint aspiration yielded purulent fluid, which, when cultured, grew Streptococcus Pneumoniae bilaterally. The patient underwent repeated arthroscopic knee washouts and was treated with intravenous (IV) antibiotics. During his admission, various investigations and scans were undertaken to find an infective focus or signs of immunodeficiency; none were found. After 4 weeks of IV antibiotics and 4 knee washouts, the patient was discharged. We believe this is the only case documented of bilateral simultaneous pneumococcal septic arthritis of the knees in an immunocompetent patient with no extra-articular infective focus. This case exemplifies the importance of careful assessment of patients who present with bilateral swollen joints.

Articular cartilage and local anaesthetic: A systematic review of the current literature.

BACKGROUND: Chondrolysis involves the breakdown of cartilage following arthroscopic surgery, most commonly affecting the glenohumeral joint. METHODS: This review summarises all clinical and laboratory studies regarding local anaesthetic (LA) and its association with chondrolysis. We identified 289 papers, 41 of which met our inclusion criteria and were included in the final review. RESULTS: Bupivacaine, lidocaine, ropivacaine and levobupivacaine are all toxic to cartilage. Intra-articular infusions confer a greater toxicity to cartilage than single injections. CONCLUSIONS: Intra-articular LA pain pumps carry a high risk of chondrolysis and should be avoided. Further studies are indicated to assess long-term single exposure LA implications.

The hip fracture best practice tariff: early surgery and the implications for MRSA screening and antibiotic prophylaxis.

BACKGROUND: In April 2010, the Department of Health introduced the hip fracture best practice. Among the clinical criteria required to earn remuneration is surgery within 36 h of admission. However, early surgery may mean that methicillin-resistant Staphylococcus aureus (MRSA) colonisation status is not known before surgery, and therefore, appropriate antibiotic prophylaxis may not be administered. In view of this, our department's policy is to administer an additional dose of teicoplanin to patients with unknown MRSA status along with routine antimicrobial prophylaxis. AIM: The purpose of this study was to provide a safe and effective antimicrobial prophylaxis for hip fracture patients. METHODS: We prospectively collected details of demographics and antimicrobial prophylaxis for all patients admitted with a hip fracture in November 2011. This was repeated in February 2012 after an educational and advertising drive to improve compliance with departmental antimicrobial policy. Microbiology results were obtained from the hospital microbiology database. A cost-benefit analysis was undertaken to assess this regime. RESULTS: A total of 144 hip fracture patients were admitted during the 2 months. The average admission to surgery time was 32 h, and the average MRSA swab processing time was 35 h. 86 % of patients reached theatre with unknown MRSA status. Compliance with the departmental antimicrobial policy improved from 25 % in November 2011 to 76 % in February 2012. Potential savings of £ 40,000 were calculated. CONCLUSION: With best practice tariff resulting in 86 % of patients reaching theatre with unknown MRSA status, we advocate an additional single dose of teicoplanin to cover against possible MRSA colonisation.

Effect of different irrigation fluids on human articular cartilage: an in vitro study.

PURPOSE: The goal of this study was to examine the effect of different irrigation fluids on human articular cartilage. METHODS: Femoral heads were obtained from 9 patients with fractured neck of femur (mean age, 89 years; 7 female) and tibial plateaus from 2 female patients at the time of total knee replacement (mean age, 73 years). Chrondral explants were harvested and exposed to 1 of 4 different irrigation fluids for 1 hour: Ringer's solution, normal saline (0.9% NaCl), 1.5% glycine, or 5% mannitol. M199 culture medium was used as a positive control, and 0.5% bupivicaine, previously shown to be harmful to articular cartilage, as a negative control. After exposure, explants were incubated with radiolabeled sulfate ((35)S0(4)), and uptake was measured after 16 hours as an indicator of proteoglycan synthesis. RESULTS: (35)S0(4) uptake was inhibited 10% by Ringer's solution (P = .3), 24% by 1.5% glycine (P = .08), 31% by 5% mannitol (P = .03), 35% by normal saline (P = .04), and 90% by 0.5% bupivacaine (P < .001), compared with the M199 control. Comparisons of the different solutions showed that all solutions were less inhibitory than 0.5% bupivacaine (P < .001). The only significant difference was that between normal saline and Ringer's solution (P = .03). CONCLUSIONS: In an in vitro model of human articular cartilage, Ringer's solution had the least effect on cartilage metabolism, and normal saline caused the greatest inhibition of cartilage metabolism. CLINICAL RELEVANCE: Normal saline, the most commonly used irrigation fluid, may have an inhibitory effect on proteoglycan metabolism in articular cartilage. Additional studies are required to assess the potential damage to cartilage from normal saline in the clinical setting.

Impact of organisational changes on fracture neck of femur management.

INTRODUCTION: In 2005, University Hospitals of Leicester formed a Fracture Neck of Femur (#NOF) project group to improve care of this group of patients. SUBJECTS AND METHODS: The salient changes effected by the group were the appointment of designated orthogeriatricians, trauma co-ordinators, clinical aides, and discharge nurses. RESULTS: As a result of these measures, the number of patients going to theatre within 48 h of admission rose from 38.5% in 2005/6 to 90% in 2007/8. In-hospital mortality decreased from 16.5% in 2005/6 to 10.9% in 2007/8. The 30-day mortality dropped from 13% in 2005/6 to 10.9% in 2007/8. Hospital stay reduced from 29 days in 2005/06 to 17 days in 2007/8. CONCLUSIONS: Re-organisation of available resources has a positive impact on reducing mortality and in-hospital stay of fracture neck of femur patients.

Clostridium difficile in hip fracture patients: prevention, treatment and associated mortality.

BACKGROUND: A series of infection control measures were introduced at the University Hospitals of Leicester NHS Trust in 2006-2007 to reduce the incidence of Clostridium difficile infection. AIM: The aim of this study was to assess the impact of these measures on the incidence of C. difficile and to record the associated mortality in hip fracture patients. PATIENTS AND METHODS: A case matched comparison of mortality was conducted between C. difficile positive patients and C. difficile negative patients admitted with a hip fracture between 1st January 2003 and 30th September 2007. An interrupted time series analysis was performed to assess the effect of various infection control policies on the incidence of C. difficile infection. RESULTS: The interrupted time series analysis showed that the only effective measure was changing antimicrobial prophylaxis to Co-amoxiclav in May 2007. This reduced the incidence of C. difficile from 7.1 to 1.5% (p<0.001). Six-month mortality in C. difficile positive patients was 71% 1 year before introduction of a diarrhoea treatment policy and 65% 1 year after (p=0.5) indicating treatment was ineffective. A matched cohort comparison over a 57-month period from January 2003 to September 2007 showed that the 6-month mortality was 67% in 170 C. difficile positive patients, 27% in 3247 C. difficile negative patients and 29% in the 170 C. difficile negative matched patients. CONCLUSION: This 38% excess mortality indicated that C. difficile increased mortality and did not simply colonise the sickest patients. Changing prophylaxis to Co-amoxiclav was the most effective measure. This reduced the incidence of C. difficile by 80% and thus reduced mortality by prevention rather than cure.

Acromial stress fracture in a young wheelchair user with Charcot-Marie-Tooth disease: a case report.

: Acromial stress fractures are rare and have not been highlighted as a potential complication of wheelchair use. We report the case of a 22-year old female wheelchair bound patient with Charcot-Marie-Tooth disease who presented with a four-year history of shoulder pain which impaired mobility and quality of life. Plain radiographs showed a cortical irregularity of the acromion but no double-density sign. After CT scans a non-united acromial stress fracture was diagnosed. She had no other shoulder pathology. The new technique of using a superiorly closing wedge osteotomy with cancellous lag screw fixation was successful in correcting the mobile non-united acromial fragment and resolving her pain.