Hormone-releasing contraceptive implants: our experience of complex removals using preoperative ultrasound.

A known complication of hormone-releasing contraceptive implants is a nonpalpable device at time of intended removal. We report a preprocedure outpatient assessment that includes an ultrasound scan and surface marking. This technique, with avoidance of local infiltration anesthesia, facilitates implant removal and negates the need for concomitant imaging on the day of surgery. The cases we present were referred to our upper limb clinic after previous failed attempts at removal.

Using orthopaedic journals for continuing professional development.

Continuing professional development (CPD) refers to the ongoing participation in activities that keep a doctor up to date and fit to practise once they have completed formal training. It is something that most will do naturally to serve their patients and to enable them to run a safe and profitable practice. Increasingly, regulators are formalising the requirements for evidence of CPD, often as part of a process of revalidation or relicensing. This paper reviews how orthopaedic journals can be used as part of the process of continuing professional development.

The prevalence of pseudoepiphyses in the metacarpals of the growing hand.

Normally the metacarpals have an epiphysis at one end--distally for the second to fifth and proximally for the first. Pseudoepiphyses are notches or clefts that occur at the non-epiphyseal ends of bones where an epiphyseal plate would be expected and are common incidental findings in the metacarpals of the growing hand. We aimed to identify the prevalence of pseudoepiphyses on serial radiographs of 610 healthy asymptomatic children. Pseudoepiphyses in the form of notches or clefts were common, identified most often in the second metacarpal (15.25%), fifth metacarpal (7.21%), and third metacarpal (0.49%). Complete pseudoepiphyses, in which the cleft extended across the full width of the metacarpal, were seen in the first metacarpal (1.97%) and the second metacarpal (1.31%). Pseudoepiphyses are a normal variant of metacarpal ossification and should not be confused with fractures in skeletally immature patients.

Soft tissue injuries: 7 Shoulder and elbow.

A description of soft tissue injuries to the shoulder and elbow, together with assessment, imaging and treatment considerations.

The distribution of bone islands and juxta-articular bone cysts in the growing hand.

Bone islands and juxta-articular bone cysts are relatively common incidental findings when X-rays are taken for other purposes. We have identified that the incidence of bone islands in the hands of asymptomatic children between the ages of 5 and 13 years is 3.8% and the incidence of cysts in the same population is 2.8%. Bone islands were most common in the scaphoid, whilst juxta-articular bone cysts were most common in the capitate. The age at which they appear has not been reported previously. This study first identifies their presence in the hands of children of age 10 years and 2 months (bone islands) and 10 years 0 months (juxta-articular bone cysts). Most of the lesions were already present on the first radiograph taken. New bone islands appeared in five cases between the ages of 13 years and 1 month and 15 years and 3 months. New juxta-articular bone cysts were observed to appear in five cases between the ages of 10 years 10 months and 15 years 0 months. No island or cyst changed in size during the review period.

Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review.

The management of radial nerve palsy associated with fractures of the shaft of the humerus has been disputed for several decades. This study has systematically reviewed the published evidence and developed an algorithm to guide management. We searched web-based databases for studies published in the past 40 years and identified further pages through manual searches of the bibliography in papers identified electronically. Of 391 papers identified initially, encompassing a total of 1045 patients with radial nerve palsy, 35 papers met all our criteria for eligibility. Meticulous extraction of the data was carried out according to a preset protocol. The overall prevalence of radial nerve palsy after fracture of the shaft of the humerus in 21 papers was 11.8% (532 palsies in 4517 fractures). Fractures of the middle and middle-distal parts of the shaft had a significantly higher association with radial nerve palsy than those in other parts. Transverse and spiral fractures were more likely to be associated with radial nerve palsy than oblique and comminuted patterns of fracture (p < 0.001). The overall rate of recovery was 88.1% (921 of 1045), with spontaneous recovery reaching 70.7% (411 of 581) in patients treated conservatively. There was no significant difference in the final results when comparing groups which were initially managed expectantly with those explored early, suggesting that the initial expectant treatment did not affect the extent of nerve recovery adversely and would avoid many unnecessary operations. A treatment algorithm for the management of radial nerve palsy associated with fracture of the shaft of the humerus is recommended by the authors.

A dynamic investigation of the burst fracture process using a combined experimental and finite element approach.

Spinal burst fractures account for about 15% of spinal injuries and, because of their predominance in the younger population, there are large associated social and healthcare costs. Although several experimental studies have investigated the burst fracture process, little work has been undertaken using computational methods. The aim of this study was to develop a finite element model of the fracture process and, in combination with experimental data, gain a better understanding of the fracture event and mechanism of injury. Experimental tests were undertaken to simulate the burst fracture process in a bovine spine model. After impact, each specimen was dissected and the severity of fracture assessed. Two of the specimens tested at the highest impact rate were also dynamically filmed during the impact. A finite element model, based on CT data of an experimental specimen, was constructed and appropriate high strain rate material properties assigned to each component. Dynamic validation was undertaken by comparison with high-speed video data of an experimental impact. The model was used to determine the mechanism of fracture and the postfracture impact of the bony fragment onto the spinal cord. The dissection of the experimental specimens showed burst fractures of increasing severity with increasing impact energy. The finite element model demonstrated that a high tensile strain region was generated in the posterior of the vertebral body due to the interaction of the articular processes. The region of highest strain corresponded well with the experimental specimens. A second simulation was used to analyse the fragment projection into the spinal canal following fracture. The results showed that the posterior longitudinal ligament became stretched and at higher energies the spinal cord and the dura mater were compressed by the fragment. These structures deformed to a maximum level before forcing the fragment back towards the vertebral body. The final position of the fragment did not therefore represent the maximum dynamic canal occlusion.

Measurement of canal occlusion during the thoracolumbar burst fracture process.

Post-injury CT scans are often used following burst fracture trauma as an indication for decompressive surgery. Literature suggests, however, that there is little correlation between the observed fragment position and the level of neurological injury or recovery. Several studies have aimed to establish the processes that occur during the fracture using indirect methods such as pressure measurements and pre/post impact CT scans. The purpose of this study was to develop a direct method of measuring spinal canal occlusion during a simulated burst fracture by using a high-speed video technique. The fractures were produced by dropping a mass from a measured height onto three-vertebra bovine specimens in a custom-built rig. The specimens were constrained to deform only in the impact direction such that pure compression fractures were generated. The spinal cord was removed prior to testing and the video system set up to film the inside of the spinal canal during the impact. A second camera was used to film the outside of the specimen to observe possible buckling during impact. The video images were analysed to determine how the cross-sectional area of the spinal canal changed during the event. The images clearly showed a fragment of bone being projected from the vertebral body into the spinal canal and recoiling to the final resting position. To validate the results, CT scans were taken pre- and post-impact and the percentage canal occlusion was calculated. There was good agreement between the final canal occlusion measured from the video images and the CT scans.

Laser morphometric analysis of the glenoid fossa of the scapula.

We have assessed the topography of the articular surface of the glenoid fossa using a laser morphometric technique. Eighteen cadaveric scapulae from individuals aged 66 to 90 years were scanned and the degree of version of five lines constructed in the horizontal plane was determined. The lines comprised a transverse reference line (equatorial midline) located midway between the superior and inferior tubercles of the fossa, lines at 45% of the height of the glenoid fossa above and below the equatorial line, and further lines midway between these pairs. The cartilage-covered glenoid articular surface displayed differences in version between its superior and inferior aspects; the mean difference in version between the superior and inferior lines was 11.2 degrees, with the most superior line being retroverted 8.2 degrees with respect to the equatorial midline and the most inferior line anteverted 3.2 degrees. These data may be of importance in understanding the kinematics of the glenohumeral joint and in translating this knowledge to joint replacement surgery.

Does 'canal clearance' affect neurological outcome after thoracolumbar burst fractures?

Surgical decompression of the spinal canal is presently accepted worldwide as the method of treatment for thoracolumbar burst fractures with neurological deficit in the belief that neurological recovery may be produced or enhanced. Our clinical and laboratory experience, however, indicates that the paralysis occurs at the moment of injury and is not related to the position of the fragments of the fracture on subsequent imaging. Since the preoperative geometry of the fracture may be of no relevance, our hypothesis, backed by more than two decades of operative experience, is that alteration of the canal by 'surgical clearance' does not affect the neurological outcome. We have reviewed the existing world literature in an attempt to find evidence-based justification for the variety of surgical procedures used in the management of these fractures. We retrieved 275 publications on the management of burst fractures of which 60 met minimal inclusion criteria and were analysed more closely. Only three papers were prospective studies; the remainder were retrospective descriptive analyses. None of the 60 articles included control groups. The design of nine studies was sufficiently similar to allow pooling of their results, which failed to establish a significant advantage of surgical over non-surgical treatment as regards neurological improvement. Significant complications were reported in 75% of papers, including neurological deterioration. Surgical treatment for burst fracture in the belief that neurological improvement can be achieved is not justified, although surgery may still occasionally be indicated for structural reasons. This information should not be withheld from the patients.

A new fracture of the forearm adjacent to a healing fracture.

A 10-year-old girl sustained closed fractures of the distal radius and ulna. This was manipulated and she was treated in an above-elbow plaster for 4 weeks. Two weeks later she was discharged, only to have a second injury to the same forearm. X-ray showed a new fracture distal to undisrupted callus.

Non-communicating intramuscular ganglia.

Intramuscular ganglia are rare. Most of the previously reported cases were connected with an adjacent joint. We present the imaging findings in three patients who had intramuscular ganglia that were not connected with a joint. Magnetic resonance showed a septated, encapsulated mass that was isoor hypointense to muscle on T1-weighted and hyperintense on T2-weighted images. A post-contrast T1-weighted scan in one patient showed minimal capsular enhancement. Ultrasound performed in one case showed an encapsulated, anechoic mass.

Out-patient follow-up after total hip replacement in one health region.

A postal survey was carried out of all orthopaedic surgeons in the West Yorkshire Health region enquiring about out-patient follow-up practices after total hip replacement. Follow-up is advised to detect problems that can more effectively be resolved if detected early. A huge variation in the number, timing and nature of appointments following discharge was demonstrated. The total length of follow-up varied between 3 months and indefinite follow-up. The number of visits in the first post-operative year varied between one and four. The considerable variation in post surgery follow-up of these patients has important cost implications. Some patients will have unnecessary appointments whereas others will be inadequately reviewed. Guidance is required on the appropriate review of these patients which will allow early detection of joint failure in a way that is efficient in terms of the time and cost of out-patient follow-up.

A 10 year survey of the antimicrobial susceptibility of urinary tract isolates in the UK: the Microbe Base project.

Microbe Base is a national computerized database comprising in excess of 1.7 million patient records down-loaded from the laboratory computer systems of 61 participating UK laboratories over 10 years. This paper highlights the antimicrobial susceptibilities of organisms isolated from the urinary tract which comprise around 50% of all isolates in the database. These data may be used to determine trends in antimicrobial susceptibilities; to formulate local antibiotic policies; to compare local with national data and, overall, to assist clinicians in the rational choice of antibiotic therapy and to prevent misuse, or overuse, of antibiotics.

Sequential mechanical and pharmacological thromboprophylaxis in the surgery of hip fractures. A pilot study.

Two hundred and thirty-eight patients with femoral neck fractures were entered into a randomised pilot study comparing the use of sequential treatment by 'Flowtron DVT' garments in the perioperative period followed by Enoxaparin (Clexane-Rhône-Poulenc Rorer), and Enoxaparin alone. One hundred and ninety-three patients were excluded indicating the difficulty of achieving pure comparisons in this population. The remaining 44 were randomised: 21 received Enoxaparin from the time of admission, and 23 had sequential treatment. There was no statistically significant difference in the incidence of thromboembolism. Patient preference did not indicate a favoured treatment subjectively. The operation field was drier in the sequential group, although this did not reach significance. Sequential treatment was not shown to be better or worse than treatment with Enoxaparin, but the trends favoured sequential treatment rather than drug treatment alone. The technique allows the operation to be carried out without the problems produced by low dose heparins and mobilisation is not hindered by compression garments.