W. Angus Wallace

Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus

We reviewed 27 patients who had sustained displaced three- or four-part fractures of the proximal humerus and who were treated with a humeral hemiarthroplasty. Seventeen patients had a three-part fracture, and 10 had a four-part fracture. The mean follow-up period was 39 months (12 to 94 months). All fractures were classified according to Neers classification. The Constant score was used for their follow-up evaluation. The median Constant score at follow-up was 51 for the three-part fractures and 46 for the four-part fractures. The median range of movement for all the patients in flexion was 70 degrees, abduction 70 degrees, internal rotation 50 degrees, and external rotation 45 degrees. Nine patients still had moderate or severe pain. Eight patients had moderate or severe disability. Our results were disappointing, and further studies on open reduction and fixation are therefore justified.

Long-Term Follow-Up for Mortality and Cancer in a Randomized Placebo-Controlled Trial of Vitamin D3 and/or Calcium (RECORD Trial)

CONTEXT Vitamin D or calcium supplementation may have effects on vascular disease and cancer. OBJECTIVE Our objective was to investigate whether vitamin D or calcium supplementation affects mortality, vascular disease, and cancer in older people. DESIGN AND SETTING The study included long-term follow-up of participants in a two by two factorial, randomized controlled trial from 21 orthopedic centers in the United Kingdom. PARTICIPANTS Participants were 5292 people (85% women) aged at least 70 yr with previous low-trauma fracture. INTERVENTIONS Participants were randomly allocated to daily vitamin D(3) (800 IU), calcium (1000 mg), both, or placebo for 24-62 months, with a follow-up of 3 yr after intervention. MAIN OUTCOME MEASURES All-cause mortality, vascular disease mortality, cancer mortality, and cancer incidence were evaluated. RESULTS In intention-to-treat analyses, mortality [hazard ratio (HR) = 0.93; 95% confidence interval (CI) = 0.85-1.02], vascular disease mortality (HR = 0.91; 95% CI = 0.79-1.05), cancer mortality (HR = 0.85; 95% CI = 0.68-1.06), and cancer incidence (HR = 1.07; 95% CI = 0.92-1.25) did not differ significantly between participants allocated vitamin D and those not. All-cause mortality (HR = 1.03; 95% CI = 0.94-1.13), vascular disease mortality (HR = 1.07; 95% CI = 0.92-1.24), cancer mortality (HR = 1.13; 95% CI = 0.91-1.40), and cancer incidence (HR = 1.06; 95% CI = 0.91-1.23) also did not differ significantly between participants allocated calcium and those not. In a post hoc statistical analysis adjusting for compliance, thus with fewer participants, trends for reduced mortality with vitamin D and increased mortality with calcium were accentuated, although all results remain nonsignificant. CONCLUSIONS Daily vitamin D or calcium supplementation did not affect mortality, vascular disease, cancer mortality, or cancer incidence.

Closed percutaneous K-wire stabilization for displaced fractures of the surgical neck of the humerus

We report a series of 22 displaced fractures of the proximal humerus treated by percutaneous Kirschner wire stabilization. Poor results (69 per cent) in the older age group of patients is a reflection of the severity of the fracture and the difficulties of closed reduction. Reduction in a poor position in this series has led to a poor range of movement. Good functional results can only be expected with a good reduction. Experience of migration with smooth K-wires has resulted in a strong recommendation for the use of threaded pins.

Double-blind comparison study of two doses of botulinum toxin A injected into calf muscles in children with hemiplegic cerebral palsy.

Despite several trials showing reductions in tone and improvements in gait, the relation between botulinum toxin A (BTX‐A) dose and response has rarely been investigated. A double‐blind randomized comparison of two doses of BTX‐A in children with spastic hemiplegic cerebral palsy (n=48, mean age 7 years 6 months, range 3 to 15 years) was undertaken. The two doses selected were representative of the lower and the higher doses used in clinical practice (24 units/kg body weight and 8 units/kg body weight). Using gait analysis we evaluated hip, knee, and ankle joint kinetics and sagittal kinematics throughout the gait cycle. Gastrocnemius muscle length was calculated at each visit using the method described by Eames and used as our primary outcome measure. Our secondary outcome variable was maximum ankle angle measured during stance and swing phases. In summary, we found that there were indications that 24 units/kg body weight was more effective and lasted longer than 8 units/kg. Analysis in terms of absolute dose suggested that the dose‐response correlation was non‐linear, and that the optimal range lay between 200 and 500 units BTX‐A (Dysport).

The Significance of Pes Planus in Juvenile Hallux Valgus

Pes planus of the foot is believed to be an important etiological factor in hallux valgus. This study compares the degree of pes planus in normal and hallux valgus feet. The arch index, or ratio of the area of the middle third of the foot to the total footprint area, was calculated on 128 footprints. An unpaired t-test determined no significant difference between the arch index of 32 11-year-old children with hallux valgus and 11-year-olds with no first metatarsophalangeal joint deformity (P >.05). The height of the arch is not relevant to the hallux valgus deformity. Arch supports designed to raise the height of the arch can play only a palliative role in the management of the condition.

Effect of Pronation and Supination Orthosis on Morton's Neuroma and Lower Extremity Function:

Twenty-three adult patients with Mortons neuroma of one foot were randomized to receive in-shoe orthoses made from a hard, compressed, felt material that would either pronate or supinate both feet. The response of the neuroma pain was measured using subjective visual analogue scales, an objective examination, and the MACTAR patient-specific measure of maximal function. The development of any other lower limb symptoms was also recorded. The pain associated with Mortons neuroma was not significantly altered by changing the position of the foot with the compressed felt orthosis. Forcibly pronating the foot did not produce a significant incidence of lower limb symptoms in the short term.

The aetiology of hallux valgus: a critical review of the literature

Abstract Much has been written about the cause of hallux valgus but little has been proven. While the condition is more common in shoewearing populations, shoes have not been shown to cause the problem. Metatarsus primus varus is a significant and possibly the primary component of hallux valgus, but where does metatarsus primus varus originate from? Atavistic reversion has been suggested, but the proposal is flawed. The shape and length of the first metatarsal have been advanced as aetiological factors, but square and round metatarsal head shape occurs with equal frequency in juvenile hallux valgus; and the arithmetically small increase in first metatarsal length which has been detected in the condition has not yet been explained in aetiological terms. Electromyographic studies indicate that any loss of muscle equilibrium is an effect rather than a cause of hallux valgus. Pronation of the foot has been associated with hallux valgus though it has been shown that not all pronated feet develop the condition. All that appears certain is that hallux valgus is often inherited and occurs more commonly in females. Better understanding of the cause of hallux valgus may have implications for its treatment.

MECHANISMS OF FRACTURES IN ANKLE AND HIND-FOOT INJURIES TO FRONT SEAT CAR OCCUPANTS: AN IN-DEPTH ACCIDENT DATA ANALYSIS

In this study an in-depth analysis of 200 Abbreviated Injury Score (AIS) 2+ injuries to the lower extremity in frontal collisions in the United Kingdom has been performed using impairment scales devised by the American Orthopaedic Foot and Ankle Society. The most important subgroup of injuries were identified as ankle/hindfoot injuries. There were 63 such injuries sustained by 53 occupants, and these were analyzed in greater depth. Inversion or eversion was identified as the mechanism of injury for 40% of injuries. However, in 70% of these fractures caused by inversion or eversion, minimal or no long-term impairment would be expected. Injuries associated with significant long-term impairment were attributed to axial forces (for instance loads perpendicular to the foot). Combined vehicle/injury analysis demonstrated a strong association between toe-pan intrusion and these injuries. Interaction between the occupant and the pedals was identified as a probable injury source in only 25% of injuries to the ankle and hindfoot. The results of the study are being used to plan a program of biomechanical research to establish injury risk functions for the ankle and hindfoot.(A) For the covering abstract of the conference see IRRD E201172.

Posterior sternoclavicular joint dislocation in a child: a case report with review of literature

Sternoclavicular joint (SCJ) dislocations are uncommon and usually present with anterior dislocation. Posterior SCJ dislocations are relatively rare injuries in adults and are extremely rare in children. This injury can present with very subtle physical examination findings and plain radiographs are generally inconclusive. One in 3 cases presents with compression symptoms of retrosternal structures, which can be life threatening; there have also been 5 deaths reported followingSCJ dislocation.When missed initially, they may present later with significant complications and can form basis of clinical negligence. Accurate diagnosis and prompt treatment is essential for a good functional outcome followingposterior dislocation of the SCJ. Furthermore, late presentation is more like to impede closed reduction. There is debate in the literature regarding treatment of these injuries, mainly because just over 120 cases have been reported in last 75 years, out of which only very few have been reported in children. Posterior dislocations of the SCJ in children should be treated as a separate entity due to ongoing growth at the epiphysis. While true posterior dislocation can occur in children, the majority of the injuries are posteriorly displaced fracture (of Salter-Harris 1 or 2) of the medial clavicular physis. This has been described by some authors as ‘‘pseudo-dislocation’’. Although the pathology is different, they still present in the same way and require prompt treatment. This report describes a rare case of posterior SCJ dislocation of the clavicle metaphysis in a 12-year-old

Indirect Catastrophic Injuries in Olympic Styles of Wrestling in Iran

Background: Data on indirect catastrophic injuries in wrestling are scarce. Objectives: To develop a profile of indirect catastrophic injuries in international styles of wrestling and to describe possible risk factors. Study Design: Retrospective case series; Level of evidence, 3. Methods: Indirect catastrophic injuries that occurred in wrestling clubs in Iran from July 1998 to June 2005 were identified by contacting several sources. The cases were retrospectively reviewed. Results: The injuries included 9 indirect catastrophic injuries. The injury rate was 0.62 injuries per 100 000 wrestlers per year. The majority of indirect injuries were cardiovascular events in veteran groups of wrestlers. Conclusions: Indirect catastrophic wrestling injuries are rare and present most commonly in older athletes. Coronary artery disease was the main cause.