Imaging for patients presenting with a painful shoulder.

Shoulder pain is a common cause of musculoskeletal presentation in primary care, where both traumatic and atraumatic pathologies can also lead to emergency department attendances. This article discusses common acute and chronic presentations of a painful shoulder, looking at the typical history of patients presenting with a painful shoulder, examination findings and the most appropriate imaging modalities to consider. Strengths and weaknesses of each imaging modality are discussed along with their role in aiding diagnosis, as well as management of the various pathologies encountered in primary and secondary care.

Impact of the National Lockdown Due to the COVID-19 Pandemic On Upper Limb Trauma Workload in Central London: A Multi-Centre Longitudinal Observational Study During Implementation and Ease of National Lockdown.

Background: This study assessed the impact of the COVID-19 pandemic on acute upper limb referrals and operative case-mix at the beginning and ease of British lockdown. Methods: A longitudinal multicentre observational cohort study was conducted for both upper limb trauma referrals and operative case-mix over a 12-week period (6 weeks from the beginning and 6 weeks from the ease of the national lockdown). Statistical analysis included median (± median absolute deviation), risk and odds ratios, and Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05. Results: There was a 158% (n = 456 vs. 177) increase in upper limb referrals and 133% (n = 91 vs. 39) increase in the operative trauma caseload at the ease of lockdown compared with its commencement. An increase in sporting injuries was demonstrated (p=0.02), specifically cycling (p=0.004, OR=2.58). A significant increase in COVID-19 testing was demonstrated during the ease of lockdown (p=0.0001) with more patients having their management changed during the beginning of the pandemic (9.6% vs. 0.7%, p=0.0001). Of these patients, 47% went on to have delayed surgery within 6 months. No patients who underwent surgery tested positive for COVID-19 infection within 14 days post-operatively and no mortalities were recorded at 30 days. Conclusion: The ease of lockdown has seen upper limb referrals and operations more than double compared to early lockdown. With no patients testing positive for COVID-19 within 14 days of the procedure, this demonstrates that having upper limb surgery during the current pandemic is safe.

Should I use steroid injections to treat shoulder pain during the COVID-19 pandemic?

Corticosteroid (CS) injections are commonly used both in primary and secondary care in the management of chronic shoulder pain. On March 11, 2020, the World Health Organization declared the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the causative virus for COVID-19) outbreak a pandemic and global health emergency. There was initial concern with the use of CS injections during the COVID-19 pandemic because of the increased potential for adrenal insufficiency and altered immune response. This led to the publication of guidelines from societies around the world. The aim of this article is to critically appraise the evidence that form the rationale behind these guidelines and to review the alternative treatment options for the management of shoulder pain during the COVID-19 pandemic.

Hip fractures.

In the UK the incidence of hip fractures is nearly 76 000 cases per year, with the vast majority of these fractures occurring in patients over the age of 70 years. Most patients who sustain a hip fracture will have significant comorbidities and up to 40% will have cognitive impairment. For patients, sustaining a hip fracture can potentially be a devastating event. This article provides an overview of the presentation, assessment and management of hip fractures for core surgical, acute care common stem and emergency medicine trainees.

The impact of COVID-19 on the future of orthopaedic training in the UK.

The COVID-19 pandemic has had a major impact on global healthcare systems, has drastically affected patient care, and has had widespread effects upon medical education. As plans are being devised to reinstate elective surgical services, it is important to consider the impact that the pandemic has had and will continue to have on surgical training. We describe the effect COVID-19 has had at all levels of training in the UK within trauma and orthopaedics and evaluate how training might change in the future. We found that the COVID-19 pandemic has significantly impacted trainees within trauma and orthopaedics at all levels of training. It had led to reduced operative exposure, cancellations of examinations and courses, and modifications to speciality recruitment and annual appraisals. This cohort of trainees is witnessing novel methods of delivering orthopaedic services, which will continue to develop and become part of routine practice even once the pandemic has resolved. It will be important to observe the extent to which the rapid changes currently being introduced will impact the personal health, safety, and career progression of current trainees.

Clavicle fractures.

Clavicle fractures account for approximately 2-5% of all fractures in adults and 10-15% in children. There is a bimodal distribution, with two peaks occurring in patients <25 years of age as a result of direct trauma and in those >55 years of age secondary to a fall onto an outstretched arm. Approximately two-thirds of all clavicle fractures occur in men. This article provides an overview of the presentation, assessment and management of clavicle fractures for both core surgical trainees and acute care common stem/emergency medicine trainees.

Responsiveness of the EQ-5D-3L in elective shoulder surgery: Does it adequately represent patient experience?

AIM: Generic patient-reported outcome measures (PROMs) allow comparison of health-related quality of life across populations and pathologies. For these comparisons to be valid, the PROM must be responsive; the score must change when the patient's quality of life changes. This study aims to assess the responsiveness of the EQ-5D-three level (3L) in elective shoulder surgery. METHODS: Pre- and post-operative EQ-5D-3L and Oxford Shoulder Scores (OSS) were prospectively collected across a range of 204 elective shoulder surgeries. Internal responsiveness was assessed through significance testing of mean change scores and standardized response means (SRMs). External responsiveness of the EQ-5D-3L was assessed against the minimal clinically important difference in OSS, using receiver operating characteristic curve and change score correlation. RESULTS: Both EQ-5D-3L and OSS scores improved significantly over time ( p < 0.05). The SRM for the EQ-5D was 1.27 (95% CI 1.14-1.41) and for OSS 2.36 (2.22-2.52). Area under the curve for EQ-5D was 0.49. Only a weak correlation was found between EQ-5D and OSS change scores ( r = 0.21). DISCUSSION: The EQ-5D-3L is adequately internally responsive to change following elective shoulder surgery but is unable to differentiate patients demonstrating minimal clinically important change. The EQ-5D therefore only partially reflects patient experience.

Diagnosis, management and complications of distal humerus lateral condyle fractures in children.

We review the diagnosis, evaluation and management of paediatric lateral condylar fractures. The complications of these fractures are also discussed, including the management of fracture non-union.

Traumatic First Time Shoulder Dislocation: Surgery vs Non-Operative Treatment.

Management of first shoulder dislocation following reduction remains controversial. The two main options are immobilisation and arthroscopic stabilisation. The aim of this article is to highlight some of the issues that influence decision making when discussing management options with these patients, including natural history of the first time dislocation, outcomes of surgery and non-operative management particularly on the risk of future osteoarthritis (OA), the effects of delaying surgery and the optimal method of immobilisation. Extensive literature review was performed looking for previous publication addressing 4 points. i) Natural history of primary shoulder dislocation ii) Effect of surgical intervention on natural history iii) Risk of long term osteoarthritis with and without surgical intervention iv) Immobilisation techniques post reduction. Individuals younger than 25 years old are likely to re-dislocate with non-operative management. Surgery reduces risk of recurrent instability. Patients with recurrent instability appear to be at a higher risk of OA. Those who have surgical stabilisation do not appear to be at a higher risk than those who dislocate just once, but are less likely to develop OA than those with recurrent instability. Delaying surgery makes the stabilisation more demanding due to elongation of capsule, progressive labro-ligamentous injury, prevalence and severity of glenoid bone loss. Recent studies have failed to match the preliminary outcomes associated with external rotation braces. Defining the best timing and type of treatment remains a challenge and should be tailored to each individual's age, occupation and degree of physical activity.

The Boyd Interval: A Modification for Use in the Management of Elbow Trauma.

Surgical exposure of the radial head, proximal radius, capitellum, and proximal ulna can be achieved through several different approaches. The most commonly used are: the Kocher, Kaplan, and extensor digitorum communis splitting. Each of these approaches has its own limitations and dangers. In this article we describe a modified version of the less commonly used Boyd approach. We have used this approach with a transosseous lateral collateral ligament and annular ligament repair for operative treatment of fractures involving the radial head, proximal radius, proximal ulna including the coronoid, capitellum, and lateral column of the distal humerus. In our experience, the approach results in superior exposure of the lateral elbow while minimizing the risk of injury to the posterior interosseous nerve.

Surface replacement arthroplasty for glenohumeral arthropathy in patients aged younger than fifty years: results after a minimum ten-year follow-up.

BACKGROUND: The role of cementless surface replacement arthroplasty (CSRA) in young individuals is currently unclear. The aim of this study was to evaluate CSRA long-term results for glenohumeral arthritis in young patients. METHODS: Between 1990 and 2003, 54 CSRAs were performed on 49 patients (25 men, 24 women) aged younger than 50 years. Mean age was 38.9 years (range, 22-50 years). Three patients (4 shoulders) died over time and 8 were lost to follow-up, leaving 38 patients (42 shoulders) with a mean follow-up of 14.5 years (range, 10-25 years). There were 17 total shoulder replacements with metal back glenoid, and 37 underwent humeral head resurfacing with microfracture of the glenoid. RESULTS: The indications were avascular necrosis, 16; rheumatoid arthritis, 20; instability arthropathy, 7; primary osteoarthritis, 5; fracture sequelae, 3; postinfection arthritis, 2; and psoriatic arthritis, 1. The mean relative Constant score increased from 11.5% to 71.8% (P < .0001), and the mean patient satisfaction at final follow-up was 8.7 of 10. The mean relative Constant score for the humeral head resurfacing with microfracture of the glenoid improved to 77.7% compared with 58.1% for total resurfacing arthroplasty. Two required early arthrodesis due to instability and deep infection. Seven were revised to stemmed prosthesis: 1 for traumatic fracture and 1 for glenoid erosion 16 years after the index procedure. Five shoulders in 4 patients (4 rheumatoid arthritis, 1 avascular necrosis) were revised at 8 to 14 years after surgery for cuff failure and loosening. Three were revised to stemless reverse total shoulder arthroplasty due to rotator cuff failure at 23, 16, and 13 years after surgery. CONCLUSIONS: CSRA provides good long-term symptomatic and functional results in the treatment of glenohumeral arthropathy in patients aged younger than 50 years in 81.6% of the patients. This improvement is maintained over more than 10 years after surgery, with high patient satisfaction (8.7 of 10). However, 10 shoulders (of 54) (18.5%) underwent revision arthroplasty. Resurfacing offers a valuable tool in treating young patients with glenohumeral arthritis, providing reasonably good long-term results in 81.6% of the patients, while allowing preservation of bone stock if the need for revision arises. All the revision arthroplasty options are preserved, including less invasive procedures.

Navigation knee replacement.

Total knee replacement (TKR) achieves an immediate and exceptional restoration in the quality of life that is comparable only to a few other procedures. It has been suggested that the most common cause of revision TKR is error in surgical technique, from malpositioning of the components which results in a poorer post-operative outcome. Based on the theoretical assumption that the use of computer-assisted systems (CAS) in TKRs may improve implant alignment and thus implant longevity, the use of this technology is becoming increasingly popular. This article (a) reviews whether computer-assisted TKR (CASTKR) results in improved prosthesis alignment compared with the conventional technique, (b) assesses the functional and clinical outcomes of CASTKR and (c) evaluates the cost-effectiveness of using this technology.

Distal humerus lateral condyle fracture and Monteggia lesion in a 3-year old child: a case report.

We describe a case of a Monteggia fracture dislocation and an ipsilateral lateral humeral condyle fracture in a 3-year-old child. This is a rare combination of injuries with no previously reported cases in the literature. This case emphasises that when a fracture is detected around an elbow there should be a high index of suspicion for other injuries in the region.

Revision of the femoral prosthesis with impaction allografting.

Impaction allografting is the only technique, to date, that has been shown to reverse the loss of bone stock encountered during revision hip arthroplasty. However, early stem subsidence, dislocations and a high occurrence of periprosthetic fractures are well documented with this method. This article reviews the biomechanical and biological characteristics of compacted morsellised graft, on the femoral side, and examines the clinical results of this technique and its future development.