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Objectives The mechanisms of upper limb injuries in road traffic accidents have not been widely investigated or understood. The present study was designed to obtain more specific information on upper limb injuries sustained by front seat occupants involved in front- and side-impact collision car accidents. Its purpose was to identify injuries that are a priority for prevention and further research. Methods Hospital records, radiographs and, where appropriate, crash data were reviewed. Data were analyzed to identify the frequency and severity of upper limb injuries, the mechanism of injury and the impairment sustained, in accordance with the American Medical Association guide. The total financial costs for NHS management, as well as that relating to the upper limb injury, were calculated. Results Sixty-two cases were reviewed (34 males), with a mean (range) age of 44 years (18 years to 83 years). There were 20 clavicle fractures of which 18 were right sided, and often attributed to a ‘seat-belt effect’. There were also 17 wrist and 13 forearm fractures. The median (range) upper limb Abbreviated Injury Score was 2 (2 to 4) and the overall Injury Severity Score was in the range 1 to 50 (median 6). In terms of impairment, the upper extremity sensory deficit was in the range 0% to 9% and motor deficit 0% to 22.5%, giving up to 5% sensory and 13.5% motor ‘whole person impairment’. The mean treatment cost for upper limb management was £2200 compared to a mean total injury treatment cost of £11,000 per person. Discussion The present study has served to identify the range and subsequent costs (impairment and financial) of upper limb injuries in road traffic accidents. These data will be used by researchers to advance the design of current and future car crash dummies in the upper limb and to allow accurate finite element remodelling. These data may be used in support of legislative changes in the future.

The risk of recurrent instability, subsequent to primary traumatic anterior shoulder dislocation that has been managed conservatively, is highest in young patients. The overall risk is 58%, with up to 87% of problems being noted within 2 years. The majority of young patients sustain an anterior glenoid labral detachment (Bankart lesion) leading to instability problems. This comprehensive literature review explores the evidence for both conservative and surgical management in young patients sustaining a primary traumatic anterior shoulder dislocation. There is no consensus on length or type of shoulder immobilization for conservative management. The initial evidence suggesting that immobilization in external rotation is beneficial has subsequently been contradicted. A prolonged period of immobilization has also failed to show any benefit. The randomized control trial evidence shows a consistent and significant reduction in recurrent instability risk with acute stabilization surgery. The gold standard surgical approach of open stabilization (Bankart repair) is now closely matched in outcome by contemporary arthroscopic stabilization. Significant bone defects must be excluded as these lead to failure of soft tissue stabilization surgery (Bankart repair) and require a tailored management strategy. Young males, including those involved in contact sports and overhead activities, have the highest instability risk and would gain the greatest benefit from acute stabilization surgery.

Background An experimental study was carried out to assess the influence of Bone Mineral Density (BMD) of the humeral head, neck and greater tuberosity in seven pairs of fresh frozen humeri on the pull out strength of the Ultra-Fix Anchor (Stryker, Inc, USA) and the standard intra-osseous sutures used to repair rotator cuff tears. Method An anchor and a transosseous suture were placed in a trough, created with a 6 mm burr in the cuff footprint of each humeral head by the same specialist shoulder surgeon (L.N.). The technique for intra-osseous suture and anchor localisation were standardised using a 5 Metric (No 2) braided polyester suture (Ethibond, Ethicon, UK). Both fixation methods were subjected to tensile testing with the humeri mounted at 30° of abduction corresponding to the direction of anatomical pull of the supraspinatus muscle. Results and discussion There was a significant linear correlation (p = 0.007) between Ultra-fix anchor pull-out strength and humeral head BMD as well as between bone suture failure strength and humeral neck BMD (p = 0.015) There was no correlation between the BMD of the greater tuberosity and failure strengths of both fixation methods. (p = 0.23 for anchor and p = 0.29 for bone suture) The Ultra-fix anchor was significantly stronger in pull-out when compared to the bone suture (p = 0.05). Conclusion The mean pull-out strength of the Ultrafix rotator cuff anchor is significantly higher when compared to the traditional bone suture technique for anchorage into a proximal humerus trough (141.7 N and 111.6 N, respectively).There is a significant correlation between the total BMD of the proximal humerus (head, neck and greater tuberosity regions) and the pull-out strength of both the anchor (p = 0.039) and bone sutures (p = 0.024).