Paediatric supracondylar fractures: assessment and management.

Supracondylar fractures of the distal humerus are the most common fracture around the elbow in children. A thorough initial assessment must be conducted to identify any associated neurovascular injury and carefully documented. The assessment should include a vascular examination of the radial pulse, temperature, colour and capillary refill time. A neurological examination must comment on the motor and sensory function of the radial, median and ulnar nerves. X-rays allow an evaluation of the fracture location and type, and the degree of displacement. Immobilisation in plaster is the gold standard treatment for paediatric supracondylar fracture of the humerus where the degree of displacement is within acceptable parameters. Casting should be followed by orthogonal radiographs and a repeat neurovascular assessment of the limb. Oral analgesia and safety netting information should be provided on discharge, and the child reviewed in a fracture clinic within 1 week of the injury. The British Orthopaedic Association Standards for Trauma and Orthopaedics for supracondylar fractures of the humerus in children are useful for junior orthopaedic and emergency medicine clinicians to refer to when dealing with these injuries.

Surgical treatments for acute unstable acromioclavicular joint dislocations.

INTRODUCTION: Surgical treatment is usually recommended for acute, high-grade acromioclavicular joint (ACJ) injuries. A wide variety of surgical techniques exist, and the literature does not strongly support one over the other. In this literature review, we describe and compare the results of different surgical treatments for the management of acute unstable ACJ dislocation and aim to guide surgeons on optimal treatment. MATERIALS AND METHODS: A literature review was performed by searching PubMed, Medline, Cochrane, and Embase databases. Seventeen studies met the inclusion criteria and were analyzed. Only studies with comparative data were included. The clinical and radiological outcomes of these studies were reviewed. RESULTS: Seventeen studies were included in this literature review. We found no difference in outcomes between open and arthroscopic procedures. Coracoclavicular ligament (CCL) reconstruction techniques provide better results than the more rigid hook plate fixation. There is no evidence that biologic repair with tendon graft is superior to synthetic grafts. Furthermore, an autograft is not shown to be better than an allograft. Rigid fixation between the clavicle and coracoid and the non-anatomic Weaver-Dunn technique appears less popular in recent literature. The hook plate is associated with subacromial osteolysis, acromial erosion, and the morbidity of a secondary procedure. DISCUSSION: There is a recent increase in publications on the reconstruction of the ACJ after injury, with new techniques focusing on the anatomic reconstruction of the CCLs aiming to restore both vertical and horizontal plane stability of the ACJ using synthetic/biological grafts. Despite the plethora of new techniques introduced, meaningful comparisons are difficult to draw due to the heterogeneity of the treatments used and the outcome measure used to assess the results.

The role of biodegradable spacer implantation under local anesthesia for patients with massive rotator cuff tears and significant medical comorbidities.

Background: Massive rotator cuff tears are common, and the incidence increases with age. They are a challenging problem to deal with as many are irreparable. While there are a host of surgical options available, these can be prolonged procedures requiring general anesthesia and thus not suitable for elderly patients or those with significant medical comorbidities. In this study, we evaluate the role of a biodegradable balloon inserted under local anesthetic for a series of patients with massive cuff tears and significant medical comorbidities. Methods: A prospective pilot study was performed on a series of patients between June 2018 and April 2019. Demographic data, as well as preoperative and postoperative clinical data including Subjective Shoulder Value and Oxford Shoulder Scores, were obtained. Results: Four patients with magnetic resonance imaging-proven massive rotator cuff tears involving the supraspinatus were treated with an InSpace balloon under local anesthesia. All were of American Society of Anesthesiologists grade 4 and had exhausted nonoperative treatment. The mean Oxford Shoulder Score improved from a preoperative baseline of 17.25 (range 6-25) to a peak of 25.75 (range 15-34) at the 6-week postoperative mark before declining to 13.67 (range 6-23) at the final follow-up of 6 months. Subjective Shoulder Values also improved initially from a mean of 31.25 (range of 20-40) to a peak of 58.75 (range of 50-70) before reducing to 36.67 (range of 30-50) at the final follow-up of 6 months. Conclusion: We have described the safety and early benefit from the use of a biodegradable balloon spacer inserted under local anesthetic as a management option for patients with massive rotator cuff tears, who may be unfit for other extensive reconstruction options, particularly for short-term pain relief as significant long-term gains were not demonstrated.

Measuring outcomes in rotator cuff disorders.

Measuring the outcome of treatment for rotator cuff disorders has evolved over the last three decades. Objective surgeon-derived outcomes such as clinical examination findings and imaging of the rotator cuff have the limitation of marginalising the patients perception of their condition. Patient reported outcome measures (PROMs) have evolved and become popular in an attempt to demonstrate meaningful outcome data. There are a large number in use today and as a result, the heterogeneity of scores used across the literature can make comparison difficult. Patient reported outcome scores can be general health related quality of life scores, joint-specific and disease specific. Qualitative outcomes are also being used now, and these help us to better understand the context of quantitative research scores. In this article, we provide an overview of the outcome measures used in rotator cuff disorders.

Superior capsular reconstruction for irreparable rotator cuff tears: A literature review and specialist practice report.

BACKGROUND: Recent evidence continues to confirm the effectiveness of arthroscopic superior capsular reconstruction (SCR) in relieving pain and improving function in an irreparable cuff deficient shoulder. This paper presents an up-to-date literature review on SCRand a tertiary referral unit experience in the United Kingdom. METHODS: Data was prospectively collected on patients undergoing SCR for irreparable rotator cuff tears using a dermal allograft. Patients with already established arthritis were excluded. The first 49 consecutive cases performed by 3 surgeons over 3 years (including their learning curve) with average follow-up of 19 months (range 3-37 months) were analysed. The outcomes assessed were re-operation rates, patient satisfaction and complications. The study group was analysed to identify the factors predicting outcomes. RESULTS: The average age of the cohort was 56 years. The re-operation rate in this group was 12.2% with each of these 6 patients subsequently undergoing a reverse total shoulder arthroplasty. Forty (82%) patients were satisfied with the outcome of the procedure with 35 (72%) of them showing complete pain relief, 5 (10%) having dull aches and clicks and the remaining 9 (18%) unsatisfied due to pain. There was no difference in satisfaction rates between different age groups (p > 0.05). The pre-operative factors associated with poor outcomes included patients with multiple previous surgeries on the same shoulder (p = 0.02) and teres minor atrophy or tear (p = 0.03). The other factors that showed a trend towards inferior outcomes (but not statistically significant) included patients with degenerative tears, symptoms of longer duration (>24 months) and subscapularis tear/atrophy. No serious adverse effects such as graft rejection, infection or neuro-vascular injury were observed. CONCLUSION: Early results of superior capsular reconstruction are promising and may offer an answer to a challenging group of patients with symptomatic irreparable rotator cuff tears. It is likely that the relatively low re-operation rates can be further improved by considering the negative prognostic factors in defining indications for surgery.

A Biomechanical Comparison of Two Techniques of Latarjet Procedure in Cadaveric Shoulders.

Traumatic anterior instability of the shoulder is commonly treated with the Latarjet procedure, which involves transfer of the coracoid process with a conjoint tendon to the anterior aspect of the glenoid. The two most common techniques of the Latarjet are the classical and congruent arc techniques. The aim of this study was to evaluate the difference in force required to dislocate the shoulder after classical and congruent arc Latarjet procedures were performed. Fourteen cadaveric shoulders were dissected and osteotomised to produce a bony Bankart lesion of 25% of the articular surface leading to an "inverted pear-shaped" glenoid. An anteroinferior force was applied whilst the arm was in abduction and external rotation using a pulley system. The force needed to dislocate was noted, and then the shoulders underwent coracoid transfer with the classical and congruent arc techniques. The average force required to dislocate the shoulder after osteotomy was 123.57 N. After classical Latarjet, the average force required was 325.71 N, compared with 327.14 N after the congruent arc technique. This was not statistically significant. In this biomechanical cadaveric study, there is no difference in the force required to dislocate a shoulder after classical and congruent arc techniques of Latarjet, suggesting that both methods are equally effective at preventing anterior dislocation in the position of abduction and external rotation.

Shoulder arthroplasty for juvenile idiopathic arthritis.

There is limited literature to guide shoulder surgeons in the management of juvenile idiopathic arthritis (JIA). We aim to help clinicians to formulate an approach to the surgical management of the condition through a review of the available literature on arthroplasty in JIA, general considerations when operating on patients with inflammatory arthropathy and recommendations based on the authors' experience. Four articles report formal data on arthroplasty in JIA with favourable improvements in post-operative pain and function scores after the long-term follow-up. Significant heterogeneity in treatment and a lack of standardisation in quantitative outcomes highlights the need for further larger scale and higher quality research. The aim of this study is to review the evidence and provide information on preoperative evaluation of surgical candidates, operative techniques, choice of implant design and to evaluate functional outcomes in patients who undergo shoulder arthroplasty.

A Bizarre, Unexplained, and Progressive External Rotation of the Shoulder as a Presentation of a Metastatic Deposit in the Rotator Cuff.

We describe the first reported case of a tumour deposit within the rotator cuff presenting as a bizarre, progressive, and fixed external rotation deformity of the shoulder. It is also the first reported case to our knowledge of an oesophageal primary metastasising to the rotator cuff.

An unusual cause of an ankle mass.

We report the case of a patient who presented with a 7-year history of a mass over the medial aspect of his right ankle, which had been gradually increasing in size. He had given up his occupation as a bus driver due to decreased movement of his ankle. An initial diagnosis of endemic syphilis was made after treponemal antibody and treponema pallidum particle agglutination tests were positive. However, following surgical debulking, cultures grew Fusarium solani and the diagnosis was changed to eumycetoma. He received prolonged treatment with antifungal agents and at 18 months follow-up remains well.

A rare cause of wound infection after an open fracture: Shewanella putrefaciens.

An elderly gentleman presented with an open fracture of the calcaneum and ankle, following a boating accident. Despite treatment with repeated surgical debridement, delayed closure, prolonged antibiotics and strict adherence to national guidelines on the management of open fractures, he developed a wound infection with a rare organism, Shewanella putrefaciens, that appears to be increasing in prevalence.