Late complications following clavicular fractures and their operative management.

We describe our experience of the operative treatment of sequelae from high-energy injuries of the clavicle. Surgery was performed on 17 patients who often had more than one indication. This included the following: painful non-union (nine patients), neurogenic thoracic outlet syndrome (TOS), hypertrophic non-union three patients, hypertrophic malunion five patients, bony spike two patients), vascular TOS (two patients) and brachial plexus neuroma (one patient). At clinical review, functional outcome was assessed by using a Constant score, a visual analogue pain score, return to work status and by patient subjective satisfaction rating. We performed 11 decompressions with callus excision, three simple neurolysis, eight fixations for non-union, one osteotomy and three excisions of bone spikes. Two patients required a further decompression procedure; one patient developed deep sepsis requiring sequestrectomy and two patients required removal of metalwork. At mean follow-up of 49 months the average Constant score was 64 (range 27-93). The mean pain score was 4. Ten patients returned to work at an average of 8 months. Five patients were completely asymptomatic, eight reported occasional paraesthesiae and three had significant cold intolerance. Patient satisfaction scores were 14% very satisfied, 50% satisfied, 14% unsatisfied and 22% very unsatisfied. High-energy clavicle injuries can cause significant morbidity due to non-union and TOS. Refractory symptoms can be improved by operative intervention with satisfactory functional outcome. However, the majority of patients experience some degree of residual symptoms.

Carpal tunnel syndrome despite negative neurophysiological studies.

The purpose of the present study was to compare the results of conservative and operative treatment for patients with carpal tunnel syndrome having normal neurophysiological studies. We studied 125 patients with normal neurophysiological studies and analysed eight symptoms and signs as "prognostic factors". Ninety-six patients were treated conservatively (splintage, steroid injection, antiinflammatory medications, activity modification) and 29 were treated surgically (open decompression). One year after initiation of treatment we assessed the outcome and statistically analysed (chi-square test) the differences between the two groups. We did not find any statistically significant correlation between "prognostic factors" and outcome. Twenty four percent of the group treated non-operatively had a good or excellent outcome, whereas 90% of the group treated operatively had a good or excellent outcome. This difference was statistically significant (p < 0.0001). Our study supports the view that the diagnosis of carpal tunnel syndrome is clinical and not neurophysiological. We now recommend operative treatment for these patients.

Internal fixation of scaphoid non-union: a comparative study of three methods.

In this study we compared the results of three methods of fixation for scaphoid non-union. The implants used were the AO 2 mm mini-fragment screw, the Herbert screw and the Kirschner (K) wires. Between 1990 and 1999, 132 patients underwent surgery for scaphoid fractures. We used the modified Filan and Herbert classification. Patients with acute fractures and patients requiring vascularised bone grafts were excluded. Twenty-six non-unions were fixed with an AO mini-fragment screw, 58 with a Herbert screw, and nine with K-wires. Radiological union was achieved in 85% of cases using the AO screw, 77% using the Herbert screw and 55% using the K-wire fixation. Statistically there was no significant difference between the AO and Herbert screw groups in terms of rate and speed of radiological union. The mechanical strength of the implant and the compression achieved did not seem to influence the union rate and speed. The type of bone graft (iliac crest or distal radius) did not significantly affect the union rates. Finally, K-wire fixation, either as a primary method or as a salvage procedure, produced inferior results and required prolonged immobilisation in plaster.

Controlled active motion following primary flexor tendon repair: a prospective study over 9 years.

One hundred and thirty patients with 339 divided flexor tendons affecting 208 fingers were studied prospectively between 1988 and 1996, to assess a regime of primary flexor tendon suture and active postoperative motion, combined with a modified Kleinert dynamic traction splint. The tendon suture technique used was a high-strength multistrand technique using a modified Kessler core and a Halsted peripheral stitch. The results were influenced by the zone in which the tendon was divided, by the physiotherapy and to a lesser extent by the grade of surgeon operating. Overall results by Strickland criteria were 92% excellent or good, 7% fair and 1% poor. There were 43 complications in 31 patients including five zone 2 ruptures (5.7%) and one further rupture in zone 5. This method of flexor tendon repair requires good physiotherapy and splint-making capability but gives good results with minimal need for further surgery.