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Background A ‘limping child’ commonly presents to the emergency department (ED). In the absence of trauma, many are diagnosed with irritable hip (IH). The aetiology of IH is not well understood and there may be geographical and seasonal variations. We previously established one year (2016) epidemiological data of IH presenting to the Royal Hospital for Children (RHCG) ED in Glasgow, Scotland. The sentinel findings in that year were (i) an age distribution shift to younger (peak at two years of age), (ii) no marked association with social class, and (iii) a spring preponderance. We sought to strengthen or refute these findings by repeating our study to obtain comparative data for 2017. Methods We performed a retrospective analysis of all children discharged from the RHCG ED from January to December 2017. Relevant discharge codes were determined, and patient records screened. Patients without a discharge code had their presenting complaint and medical record screened. These data were compared to that of the previously published study from the same ED (2016). Results Several findings were consistent with the conclusions of the 2016 study. The incidence was similar with 362 and 354 cases diagnosed in 2017 and 2016 respectively. The boy-girl ratio was consistent across both data-sets, 2:1 and 1.9:1 respectively. The mean age of presentation was similar (3.3 vs 3.5 years) across both years, with the same medians (three years) and peaks (two years). There was no overt difference in incidence or correlation to social deprivation. However, in 2016, a spring preponderance was seen whereas there was an autumn preponderance in 2017. Pooling data from the two cohorts, 93% (n=668) of patients were managed exclusively by ED physicians, with 70% (n=504) not requiring any further follow-up. The majority of patients who required follow-up were seen in ED clinics (169/212, 79.7%). No patient initially diagnosed as IH was found to have septic arthritis (SA). Conclusion In this follow-up study, we again found (i) a younger age profile than other studies, and (ii) no overt association with social deprivation. The major difference between the previous (2016) and current (2017) study was the apparent seasonal peaks: spring (2016), and autumn (2017). This difference does not negate the 'antecedent infection' hypothesis, but any aetiological proposal should be capable of accounting for this discrepancy. Additionally, our studies highlight that the majority of these patients can be managed in the ED alone.

With the heightened popularity of childhood sporting activity, the number of paediatric anterior cruciate ligament (ACL) ruptures has increased. Management of these injuries presents a particular challenge due to the open femoral and tibial growth plates. Physeal damage has the potential to cause angular deformity or length discrepancy. This review was conducted to determine the best way to treat this injury. A primary search of Ovid MEDLINE (1 October 2017) used the terms: (ACL or anterior cruciate ligament) and (young or child or children or pediatric or immature or pre-pubescent). Titles/Abstracts of 369 articles were screened for relevance. A total of 217 were excluded, leaving 152 articles for full-paper retrieval. Of these, 9 articles remained with one further article identified during cross-referencing; 10 papers (1 level 2 and 9 level 3) were included for analysis. Comparative studies investigating surgical (140 knees) versus conservative (110 knees) treatment provide evidence in favour of the former, in reducing instability and meniscal tears and improving return to previous activity. Of the papers analysed (163 reconstructions), there was only one case of growth arrest (0.6%) and no cases of length discrepancy. In those studies investigating early (218 patients) versus delayed (140 patients) reconstruction, medial meniscal tears and chondral injuries occurred more frequently in the delayed group. To conclude, for children, there is level 2/3 evidence that early operative ACL reconstruction offers the best chance of a return to pre-injury sporting activity and minimises the risks of further structural damage. Iatrogenic growth disturbance remains a rare but worrying complication.

Publications in peer-reviewed journals are a key and official requirement for progression to a consultant surgeon post. Paradoxically, a stipulation that should enhance the importance of surgical research may, in fact, contribute to a pressure that is one of the causes of research misconduct. Consultant trainers can go some way to mitigating against this danger with appropriate teaching and an emphasis on the core values surrounding research ethics.

Background A 'limping child' commonly presents to the emergency department (ED), often without a history of trauma. It is important that serious underlying pathology is ruled out before a diagnosis of benign irritable hip (IH). The aetiology of IH is not well understood and there may be geographical and seasonal variation. The aim of this study was to determine the basic epidemiology of IH in the Glasgow Population. Methods A retrospective analysis was carried out of all children discharged from the Glasgow Children's Emergency Department from January to December 2016. Relevant discharge codes were determined and patient records screened. Any patient who did not have a discharge code had their presenting complaint and medical record screened. Results A total of 354 patients were diagnosed with IH, of which 319 and 189 were in the Greater Glasgow and Clyde and City of Glasgow catchment areas, respectively. The majority of these patients (n = 254) were diagnosed clinically. The incidence of IH was 177.7 per 100,000 children with a boy:girl ratio of 1.9:1 (209:110). The mean age of presentation was 3.5 years and the recurrence rate was 5.9% (n = 18). There was an increased incidence in spring (n = 111), especially in March (n = 42) and April (n = 40). There was no incidence variation or influence discernible by social deprivation. Conclusion In this population, IH has: (i) an atypical age profile (age distribution shift to younger), (ii) no marked association with social deprivation (in contrast to other studies), and (iii) a 'spring preponderance'. We suggest that most cases can safely be managed in the ED without recourse to further investigations or speciality referral.

Larsen syndrome (LS) is an autosomal dominant condition occurring due to certain types of mutation in filamin-B (FLN-B), in which there are consequent multiple large joint dislocations (those of the knees being signature), cervical spine vertebral body hypoplasia, and characteristic flattened facies. However, LS is an uncommon (

Bladder exstrophy is a rare condition, resulting from a failure of fusion of midline tissues at the lower abdominal region (including the anterior urogenital elements), wherein the inner surface of the urethra and posterior bladder wall are exposed anteriorly, associated with bilateral hemipelvic posterolateral rotation, a substantial pubic diastasis, and a deficient lower abdominal wall. The goals of treatment include a successful primary closure and the eventual achievement of urinary continence. Successful and sustained urogenital reconstruction is dependent on a tension-free closure of the anterior soft tissues, facilitated by pelvic osteotomies, to avoid wound dehiscence and need for revision surgery. This chapter will offer a comprehensive review of the associated musculoskeletal and urogenital pathoanatomy, clinical aspects and natural history, for both classic bladder exstrophy and cloacal exstrophy, as well as a description of pelvic osteotomy techniques. A brief overview of the principles of urogenital reconstruction in bladder exstrophy will also be covered.

Juvenile idiopathic arthritis (JIA) is a group of heterogeneous conditions characterised by chronic inflammatory arthritis in children (

A 25-year-old, non-smoker, expectant mother in her first pregnancy, had her ‘anomaly ultrasound scan’ at 20 weeks. This showed an apparently isolated (ie, no associated intrauterine anomalies) talipes equinovarus (TEV), or clubfoot. There was no family history of any musculoskeletal condition. After the scan, she asked what the chances are that her child will (i) be normal, (ii) have associated anomalies not picked up on the ultrasound scan or (iii) have isolated idiopathic clubfoot. For an antenatal ultrasound scan showing an apparently isolated TEV deformity, what does the evidence suggest as the postnatal sequelae? A primary search was performed (21 May 2016) in PubMed: (antenatal[All Fields] OR prenatal[All Fields] OR anomaly[All Fields]) AND ((“Ultrasound”[Journal] OR “ultrasound”[All Fields] OR “Appl Radiol”[Journal] OR “ultrasound”[All Fields]) OR (“scan”[All Fields]) AND (clubfeet[All Fields] OR clubfoot[All Fields] OR talipes[All Fields] OR equinovarus[All Fields]) (accessed 21 May 2016). A secondary search of the Cochrane database did not retrieve additional material. The titles and abstracts of the 140 retrievals were screened for relevance; 98 were excluded, leaving 42 for full-paper retrieval. Further articles were excluded on the basis of (i) describing ≤5 fetally diagnosed isolated TEV cases (eg, case reports and small series) or (ii) having no relevant original data (eg, review articles).1 Twenty-three studies (22 retrospective case series2–23 and 1 prospective observational study24) with patient data subsequent to ultrasound scans showing an apparent isolated TEV (defined as an intrauterine clubfoot deformity without other associated congenital anomalies identified) were examined. Seven were excluded as they did not adequately define the key population (fetally diagnosed isolated TEV), either because apparent isolated TEV and ‘complex’ cases were inappropriately treated as a homogeneous group …

In cerebral palsy (CP), the spastic motor type is most common, associated with a velocity-dependent increase in muscle stiffness that precedes the development of fixed muscle contracture - a permanent shortening of the muscle tendon unit even when relaxed. Intra-muscular injections of botulinum toxin type A (BTX-A) have become popular for the treatment of spastic muscle contractures but unfortunately its use has not resulted in long-term functional benefits and, paradoxically, has been associated with a persistent loss of contractile material. Recent biomechanical work has shown that the stiffness of the CP muscle increases in proportion to total collagen content within the perimysial extra-cellular matrix. Thus, rather than the use of tone-reducing agents, we hypothesize that the focal use of a selective collagenase, injected into spastic muscle at an appropriate dilution and concentration, may serve to reduce the extent of muscle contracture, improving clinical range of motion and perhaps sarcomere length.

Surgical procedure 'preference lists' are used worldwide, but their practice varies widely. Despite being positioned at a critical point in a surgical care pathway, they are often underemphasized, poorly maintained, and substandard. The following editorial material is gleaned from our experience in the set-up of a tertiary hospital on a green field site in Qatar. We comment on the use of preference lists, and contend that focus on standardizing and maintaining preference lists within an electronic record affords substantial opportunities for cost containment, whilst adding efficiency, safety, and value. We believe this approach represents an 'easy win' which would be applicable elsewhere.

Introduction Both bone diaphyseal forearm fractures are common in children. If the reduction is unstable, intramedullary fixation using elastic intramedullary nails (EIN) is an option. Intramedullary fixation may be either of single (S-EIN) or both (double) bones (D-EIN). Some reports have shown poorer outcomes with S-EIN. Our aim was to critically analyse the radiological features of EIN cases, comparing results for single and both bone fixation. Method Retrospective review (two years: November 2014–November 2016) of EIN forearm procedures. Radiological reduction of the radius/ ulna (AP/lateral) was measured on theatre fluoroscopy and six week radiographs. The results were categorised by angulation: (i) 20°. Results Of 36 patients (19 boys, 17 girls), 13 had S-EIN (mean age 9.6 years, range 7–14) and 23 had D-EIN (mean age 10 years, range 7–14). In the S-EIN group, two and 11 had the ulna and radius fixed, respectively. Intraoperatively, of the 13 S-EIN patients, nine had 20°. All 23 D-EIN patients had intraoperative radiology showing 20°. No patient in either group had revisional treatment. Time in cast postoperatively was similar in both groups: S-EIN, 6.15 weeks (4–12) and D-EIN, 5.5 weeks (3–8). Operative time was 64 mins (43–82) and 76 mins (45–86) in S-EIN and D-EIN groups, respectively. No other complications were recorded. Conclusion Though there may be particular reasons for selecting single bone fixation, this series shows a propensity to increased angulation of fractures fixed by S-EIN (7/13 in this group). We advise caution in the use of single bone fixation for both bone forearm fractures.

Introduction For supracondylar humeral (SCH) fractures, biomechanical studies suggest the most stable wire configuration achieves bi-columnar fixation. Achieving medial column fixation using lateral-entry-only wires may require an intracapsular entry point. The aim of this study was to identify the rate of bi-columnar fixation achieved in our department when treating SCH fractures with percutaneous wire fixation. A secondary aim was to identify the rate of placement of an intra-articular wire. Further aims were to examine if failure to achieve bi-columnar fixation was associated with an increased loss of fixation and whether the placement of an intra-articular wire resulted in any cases of deep infection or septic arthritis. Material and methods All Gartland type 3 supracondylar humeral fractures, June 2014 to December 2016, were retrospectively identified. Intra-operative films were reviewed to determine bi-columnar fixation and the presence/absence of an intra-articular wire. Loss of reduction requiring revision and post-operative infections were determined from the electronic patient record. Results Of 49 supracondylar fractures identified, 42 were fixed with lateral-entry only wires (24 with two wires and 18 with three wires), and seven were fixed with medial/lateral cross wires (four with one lateral wire, two with two wires, and one with three wires). Bi-columnar fixation was achieved in 41/49 cases (84%). All cases where bi-columnar fixation was not achieved were fixed with lateral-entry-only wires. One out of 49 fractures (2%) required the revision of fixation at 10 days due to loss of reduction. In this case, the initial fixation was with two lateral-entry-only wires, without bi-columnar fixation. An intra-articular wire was present in 44 out of 49 cases (90%). One out of 49 cases (2%) had a superficial wound infection. There were no cases of deep infection or septic arthritis. Conclusion In our department, the rate of bi-columnar fixation was high and, in this group, no cases required revision fixation. One of eight cases judged to not have bi-columnar fixation initially, required revision due to loss of fixation. We contend that bi-columnar fixation generally achieves a stable wire configuration even using lateral-entry-only wires for SCH fractures. The rate of intra-articular wire placement was high; however, infection rates were low with no cases of septic arthritis.

With the heightened popularity of childhood sporting activity, the number of paediatric anterior cruciate ligament (ACL) ruptures has increased. Management of these injuries presents a particular challenge due to the open femoral and tibial growth plates. Physeal damage has the potential to cause angular deformity or length discrepancy. This review was conducted to determine the best way to treat this injury. A primary search of Ovid MEDLINE (1 October 2017) used the terms: (ACL or anterior cruciate ligament) and (young or child or children or pediatric or immature or pre-pubescent). Titles/Abstracts of 369 articles were screened for relevance. A total of 217 were excluded, leaving 152 articles for full-paper retrieval. Of these, 9 articles remained with one further article identified during cross-referencing; 10 papers (1 level 2 and 9 level 3) were included for analysis. Comparative studies investigating surgical (140 knees) versus conservative (110 knees) treatment provide evidence in favour of the former, in reducing instability and meniscal tears and improving return to previous activity. Of the papers analysed (163 reconstructions), there was only one case of growth arrest (0.6%) and no cases of length discrepancy. In those studies investigating early (218 patients) versus delayed (140 patients) reconstruction, medial meniscal tears and chondral injuries occurred more frequently in the delayed group. To conclude, for children, there is level 2/3 evidence that early operative ACL reconstruction offers the best chance of a return to pre-injury sporting activity and minimises the risks of further structural damage. Iatrogenic growth disturbance remains a rare but worrying complication.

Background: The aim of minimizing the risks of complicationsand adverse events is at the center of surgical practice. Thisstudy aimed to assess the evidence on which pediatric orthopaedicsurgical procedures are described as “safe.” In particular,the objective was to ascertain the proportion of studiesdescribing a procedure as “safe,” which achieved a 95% upperlimit confidence interval of risk of 5% or less for major adverseevents.Method: A primary search of Journal of Paediatric Orthopaedics2009 to 2014 for the single term “safe” returned 71 papers appropriatefor analysis. Of these, 60 positively identified at least 1intervention as “safe.” These papers were analyzed and thenumber of interventions and the number of complicationsrecorded. Data sets (n=67) were created and the 95%upper confidence interval calculated for the probability of acomplication.Results: Only 16 data sets (ex 67) provided evidence that theprobability of a major complication was under 5%.Conclusions: This work suggests there is widespread failure ofunderstanding of how low sample sizes or can lead to an unjustifiableclaim that procedures are “safe.”

Club foot is a common congenital abnormality, and a complex deformity. In the past twenty years, the deformity has been better classified by considering the different components of deformity. The Pirani scoring system is widely used – and analagous standardised photographic views can be used to document this condition and its progress. Here I describe four views that aid in deformity assessment, correlating to component deformities assessed in the Pirani score.

Botulinum toxin is a potent neurotoxin that is widely used (and has been for many years) for the treatment of focal spasticity. Its short-term effects have been well documented. There remains considerable ambivalence over its long-term effects, and some concern over side-effects. A scoping assessment of the literature defines the paucity of the evidence base concerning long-term effectiveness. Only three level 1 and two level 2 studies could be identified, on lower limb effects of botulinum toxin in children with cerebral palsy at a time interval greater than 1 year. Furthermore, our interpretation of the results of these studies is that there is no evidence of clinical benefit. We hope this analysis and summary can guide clinicians in counseling parents and patients as regards long-term expectations, and reservations/implications of management.

Clavicular pseudarthrosis is a rare condition. Its natural history is not well established, as to the risks of progression in size, deformity or pain. It is known that it does not heal spontaneously. Operative indications, best age for surgery and principles/type of surgery are not agreed; there is a diversity of opinion on all these aspects. An assessment of the literature defines the paucity of evidence. There are only 3 level III studies (all of which have small numbers and possible confounders, limitations sufficient to warrant downgrading their quality of evidence). Furthermore, the conclusions of two of the retrospective comparative studies, in terms of superior results from type of fixation (plate or intramedullary wire), are contradictory. There are 16 case series of note (level IV). Although there is little by way of concrete recommendation, it is hoped that this analysis and summary can aid pragmatic and considered decision-making when encountering a patient with this diagnosis.

Practising surgeons may be unable to keep up with current practice – what seems up to date today can be redundant tomorrow. In paediatric orthopaedics, and the setting of a busy clinical practice, it is challenging to find time to retrieve the best available studies, let alone analyse them, or synthesise the resulting information into a form applicable to one’s own practice. We are hardly alone in this regard (eg, Narayanan and Wright [1]), so this book is a collective effort to probe the common questions arising in our speciality – and look critically for answers within the literature. In this work, we are proud to have brought together the thinking of more than fifty leading paediatric orthopaedic surgeons to assemble the evidence underpinning elements of current practice. The approach has been that of the ‘evidence-based medicine’ pragmatist, written by frontline practitioners.

The aim of treatment of Pes cavus deformity is to achieve a plantigrade foot that is mobile and pain-free. The discerning surgeon would wish to know what treatment would achieve this outcome with the best results. Unfortunately a simplistic (evidence-informed) conclusion is not feasible for several reasons: Pes cavus is an anatomical condition with multiple aetiologies which have different natural histories and prognoses. Historically, poliomyelitis and untreated/recurrent clubfoot accounted for a substantial load of Pes cavus patients – but these are now comparatively infrequent; the largest group is ‘Neurological’, and here the prognosis differs markedly between those with progressive (as opposed to non-progressive) neurological conditions. Patients present at different stages of maturity, with variable severity of deformity; many have had previous surgery. There is a paucity of definitive outcome measures; surgeons have used different instruments to define their surgical outcome, making it problematic to directly compare different treatments. Surgical planning is largely individualised, taking into account the disparity of factors. Surgery can be divided into soft tissue surgery, bony surgery and fusion. Triple arthrodesis has been the mainstay of surgery in the past but has not always produced satisfactory results. Joint-sparing surgery is gaining more popularity, especially where the deformity is flexible. The evidence base is extremely limited.

This paper outlines the recent development of an exchange Travelling Fellowship scheme between the British and American Orthopaedic Research Societies. ©2009 British Editorial Society of Bone and Joint Surgery.

Forearm fractures are common paediatric injuries. This study aimed to describe the epidemiology and treatment of paediatric forearm fractures in the urban population of Glasgow. We reviewed all forearm fractures treated by the orthopaedic service in Yorkhill Children's Hospital in 2008 up to the age of 13 years. Data were gathered from case-notes and radiographs using the prospective orthopaedic database to identify patients with forearm fractures. The age, sex, side and type of fracture, the timing and mechanism of the injury and treatment were documented for the 439 fractures. Census data were used to derive absolute age-specific incidences. Distinction was made between torus and other types of fractures. Torus fractures require no specific orthopaedic treatment and were segregated out. For the remaining 314 fractures, the age and sex distribution, seasonal variation of fractures and treatments for each type of fracture were examined. The incidence of forearm fractures in our population is 411 fractures per 100,000 population per year and 294 fractures per 100,000 population per year for non-torus fractures. An increased number of fractures occurred between May and August. A fall from less than 1 m was the most common mechanism of injury. Sporting injuries were the second most common. This study identifies some features which are in agreement with studies from elsewhere in Britain. However, there are also interesting differences, such as the Glasgow peak incidence for forearm fractures being at age eight, with a marked decline by 12 years. Furthermore, our findings have been extended to consideration of type of intervention and likelihood of successful treatment.

Varicella-zoster is a common paediatric viral infection that usually runs a benign self-limiting course but has a risk of complications. The most common sequelae are bacterial skin infections, which are usually mild. However, bacteraemia/septic shock, toxic shock syndrome, pneumonia, ataxia, encephalitis and purpura fulminans are also possible. Although rare, musculoskeletal sequelae (osteomyelitis, septic arthritis, pyomyositis and necrotizing fasciitis) can occur in otherwise healthy children. These latter complications are potentially life- and limb-threatening and must be considered in a child post-varicella with pain in a limb or joint. We describe two patients who had musculoskeletal complications after varicella: (1) a 16-month-old boy who developed pyomyositis of the thigh and septic arthritis of the hip and (2) a two-year-seven-month-old girl who developed septic arthritis of the hip and knee and a ‘bare area’ subperiosteal abscess of the femur. Their clinical presentations, detailed management plans and outcomes are reported. These cases highlight the importance of prompt diagnosis, appropriate investigation (including the important role of magnetic resonance imaging) and surgery when an otherwise healthy post-varicella child deteriorates.

Swellings around the paediatric knee have a large differential diagnosis, although the majority can be diagnosed clinically. Some swellings merit further investigation by Magnetic Resonance Imaging (MRI). Clin. Anat. 24:914–917, 2011. © 2011 Wiley-Liss, Inc.

Aims. Patients who misuse alcohol may be at increased risk of surgical complications and poorer function following hip replacement. Identification and intervention may lead to harm reduction and improve the outcomes of surgery. The aim of this study was to determine the prevalence of biomarker elevation in patients undergoing hip replacement and to investigate any correlation with functional scores and complications.Methods. We performed a retrospective study that examined the profile of biomarkers of alcohol misuse in 1049 patients undergoing hip replacement.Results. Gamma-glutamyltransferase was elevated in 150 (17.6%), and mean corpuscular volume was elevated in 23 (4%). At one year general physical health was poorer where there was elevation ofγGT, and the mental health and hip function was poorer with elevation of MCV. There were no differences in complications.Discussion. Raised biomarkers can alert clinicians to potential problems. They also provide an opportunity to perform further investigation and offer intervention. Future research should focus on the use in orthopaedic practice of validated screening questionnaires and more sensitive biomarkers of alcohol misuse.Conclusion. This study demonstrates a potential substantial proportion of unrecognised alcohol misuse that is associated with poorer functional scores in patients after total hip replacement.

The osteotome is ostensibly a simple surgical instrument. In fact it was carefully designed to allow accurate aseptic osteotomy for deformities around the knee. Here we outline William Macewen's classic work on the design of this tool and set this work in the context of his life.

A 5-year-old girl with diplegic cerebral palsy has been seen regularly since the age of 3 years. As part of the management for lower limb spasticity, she has undergone three previous intramuscular botulinum toxin A injections (BoTN-A) to her gastrocnemii. During the consent process for a further injection, the mother asks if this treatment will be of benefit to her daughter in the future. In children with cerebral palsy receiving intramuscular injection of BoTN-A is there any clinically relevant long-term (greater than 1 year) effect? A literature search was performed in January 2013 using MEDLINE, PubMed and the Cochrane Database (table 1). The population identifier of ‘cerebral palsy’ and intervention of either botulinum toxin(s), Botulinum, BoNT-A, BoNT-B, BtA, BtB, BT, Botox or Dysport was used, limited to English language, from the year 1993 and the age limit of child (0–18 years) (N=2159). This was then restricted to ‘randomised controlled trials’ (N=58). These were …

Calcium is thought to be an important regulator of chondrocyte death associated with articular cartilage injury. Our objective was to determine the influence of extracellular calcium on chondrocyte death following mechanical injury. Using a surgically relevant model of sharp mechanical injury (with a scalpel) and confocal laser scanning microscopy (CLSM), in situ chondrocyte death was quantified within the full thickness of articular cartilage as a function of medium calcium concentration and time (2.5 h and 7 days). Exposure of articular cartilage to calcium-free media (approximately 0 mM) significantly reduced superficial zone chondrocyte death after mechanical injury compared with exposure to calcium-rich media (2-20 mM, ANOVA at 2.5 h, p = 0.002). In calcium-rich media, although the extent of chondrocyte death increased with increasing medium calcium concentration, cell death remained localized to the superficial zone of articular cartilage over 7 days (ANOVA, p < 0.05). However, in calcium-free media, there was an increase in chondrocyte death within deeper zones of articular cartilage over 7 days. The early (within hours) chondroprotective effect in calcium-free media suggests that the use of joint irrigation solutions without added calcium may decrease chondrocyte death from mechanical injury during articular surgery. The delayed (within days) increase in chondrocyte death in calcium-free media supports the use of calcium supplementation in media used during cartilage culture for tissue engineering or transplantation.

Two hundred and fifty subjects were recruited. Age, sex, hand preference and anthropometric measurements were recorded for each subject. Grip strength was measured using a Jamar hydraulic dynamometer. Multiple regression analyses were performed. One hundred and seventy two subjects were men and 78 were women. Twenty-six subjects were left hand dominant. Hand grip strength was greatest for the 35 to 44 year old group for both sexes. Grip strength was consistently greater for men than women. Contralateral grip strength predicted maximum grip strength for both sexes. Forearm circumference predicted maximum hand grip strength for men. Although there was a large range of forearm circumferences in the population, there was little difference between sides for each subject (100% less than 2 cm). The demonstrated relationships between: (i) contralateral grip strengths and (ii) grip strength and forearm circumference lead us to suggest that for certain pathologies, a difference in forearm circumference greater than 2 cm may lend credence to a measurement of diminished grip strength.

Summary Introduction Autologous osteochondral grafting is in widespread use for focal defects of articular cartilage. There is major concern over the nature of the tissue bridging graft elements and graft/recipient cartilage. Chondrocyte viability is thought to be an important determinant of the quality of repair. The aim of the current study was to compare the zone of death for osteochondral grafts harvested with the commercially available Acufex , and an osteotome with a specially designed cutting-edge. Materials/methods The circular osteotomes were the Acufex 4.5mm MP (Smith & Nephew) and the Lissimore , which has a different cutting-tip geometry and sharpness. These implements were used to harvest osteochondral plugs from macroscopically non-degenerate human lateral condyle explants obtained from the anterior femoral cuts of knee replacement surgery. Confocal laser scanning microscopy with vital staining was used to quantify the zone of marginal chondrocyte death for the entire perimeter of the plugs. Results The increase in cartilage plug diameter (reference the osteotome minimal internal diameter) was significantly greater for the Acufex (Mann–Whitney; n =5; P =0.0079), with the diameter (mm) increasing by 0.49±0.03 (10.9%), compared with 0.16±0.02 (3.3%) for the Lissimore . Osteochondral plugs had a significantly (Mann–Whitney; n =5; P =0.0079) lower mean margin of cell death with the Lissimore osteotome (117.8±8.97μm) than the Acufex MP (315.3±5.90μm). Conclusions Cutting-tip profile is an important factor in determining the extent of marginal death in circular osteochondral grafts. We have designed and assessed an alternative cutting-tip, which caused significantly less marginal death than the commercially available Acufex . We conclude that there is scope for improvement of osteochondral harvest techniques.

Background: Autologous osteochondral transfer is an option for the treatment of articular defects. However, there are concerns about graft integration and the nature of the tissue forming the cartilage-cartilage bridge. Chondrocyte viability at graft and recipient edges is thought to be an important determinant of the quality of repair. The purpose of the present study was to evaluate early cell viability at the edges of osteochondral grafts from ex vivo human femoral condyles. Methods: Fresh human tissue was obtained from eleven knees at the time of total knee arthroplasty for the treatment of osteoarthritis. Osteochondral cylinders were harvested with use of a 4.5-mm-diameter mosaicplasty osteotome from regions of the anterolateral aspect of the femoral condyle that were macroscopically nondegenerate and histologically nonfibrillated. Plugs were assessed for marginal cell viability by means of confocal laser scanning microscopy. Results: The diameter of the cartilaginous portion of the osteochondral plugs was a mean (and standard error of the mean) of 4.84 ± 0.12 mm (as determined on the basis of three plugs). This value was approximately 300 μm greater than the measured internal diameter of the osteotome. There was a substantial margin of superficial zone cell death (mean thickness, 382 ± 68.2 μm), with >99% cell viability seen more centrally (as determined on the basis of five plugs). Demiplugs were created by splitting the mosaicplasty explants with a fresh number-11 scalpel blade. The margin of superficial zone cell death at the curved edge was significantly greater than that at the site of the scalpel cut (390.3 ± 18.8 μm compared with 34.8 ± 3.2 μm; p = 0.0286). Similar findings were observed when the cartilage alone was breached and the bone was left intact, with the margin of superficial zone cell death being significantly greater than that obtained in association with the straight scalpel incision (268 ± 38.9 μm compared with 41.3 ± 13.4 μm; p = 0.0286). The margin of superficial zone cell death showed no increase during the time-period between fifteen minutes and two hours after plug harvest. A mathematical approximation of the mosaicplasty region suggested that early cell death of this magnitude affects about one third of the superficial graft area. Conclusions: The results of the present study suggest that mosaicplasty, while capable of transposing viable hyaline cartilage, is associated with an extensive margin of cell death that is likely to compromise lateral integration and articular reconstruction. Clinical Relevance: The data suggest that there is a need to improve the plug-harvest technique, which may improve graft-recipient healing and clinical outcomes.

The Hunterian museum is open again. Constructed on the basis of William Hunter’s bequest and opened in 1807, it moved to its present site, the Gilbert Scott Building at the University of Glasgow, in 1870. After nearly two years of roof repairs the museum re-opened in September 2011. William Hunter (1718–1783) was an obstetrician, anatomist, teacher, scientific researcher and collector. Above all else, he was a self-made man who accumulated knowledge, wealth, artefacts and standing. He was born in East Kilbride, just south of Glasgow, the seventh of ten children. He attended the University of Glasgow (1731–1736) and then became apprentice to William Cullen (1710–1790) in Hamilton. He moved to London in 1740 to pursue further surgical training, attaching himself successively to two notable Scottish expatriate man-midwives: William Smellie (1697–1763) and James Douglas (1675–1742). By dint of consistent and unflagging endeavour he became the best anatomical lecturer and built a large and famous obstetric practice. He made notable scientific advances and became a Fellow of the Royal Society and Anatomy Professor at the Royal Academy. He accumulated great wealth, which he converted into a collection of books, paintings, medals, coins and anatomical/pathological specimens (Figures 1 and 2). This collection forms the basis of the museum. In Ellis’s A History of Surgery, it is William’s younger brother John who is attributed the major part in the development of surgery, though John’s academic debt to his older brother is acknowledged. Ten years apart (in birth and in death), the brothers were quite different characters. William was small, earnest, elegant, cultured, eloquent and always hard-working (Stephen Paget summarized: ‘He never married; he had no country house; he looks, in his portraits, a fastidious, fine gentleman; but he worked till he dropped and he lectured when he was dying’). By contrast, John was ungainly, broad-shouldered, strong and noted for profanity. The transformation of John from difficult wayward child to genius, anatomist and surgeon has been attributed to his older brothers James and (more particularly) William. William had arranged for his brother’s entrance to Lady Margaret Hall at Oxford – but John left after two months, proclaiming, in response to the tutors’ efforts to school him in Latin and Greek, ‘These schemes I cracked like so many vermin!’ John became an admirable practical anatomist and dissector for his brother, and for many years they were friendly and mutually supportive. However, the relationship between the two brothers deteriorated. It is unclear whether this was due to arguments over priority, affiliation, John’s marriage or jealousy over specimens or appointments (the appointment of John to the Royal Society antedated that of William). By 1780 their estrangement was complete, with bitter contestation at the Royal Society over precedence for the discovery of the nature of maternal circulation through the placenta. In the museum today under the banner of ‘The Enlightenment’ – the Age of Reason – is a quotation by Voltaire: ‘We look to Scotland for all our ideas of civilisation’. Prominent figures in the 18th-century Scottish Enlightenment include Adam Smith (1723–1787), Professor of Moral Philosophy (1752–1763), economist and author of the Wealth of Nations; Thomas Reid (1710–1796), Professor of Moral Philosophy (1763– 1796); William Cullen (1710–1790), Professor of Medicine (1751–1756); Joseph Black (1728–1799)

Compartment syndrome complicating a ruptured Achilles tendon has previously been reported in a surgically treated patient. However – to our knowledge – this is the first report of compartment syndrome following conservative treatment. A 45-year-old man ruptured his Achilles tendon and elected to have treatment in an equinus cast. Three weeks later, he developed compartment syndrome and despite fasciotomy, required surgical debridement of his anterior compartment. Delay in both diagnosis and subsequent fasciotomy resulted in a poor outcome. Any suspicion of compartment syndrome mandates early compartmental pressure monitoring. The exact aetiology is uncertain but we speculate that the equinus position of his ankle combined with weight-bearing, was a major contributing factor.

Neurological examination in children presenting with upper limb fractures is often poorly performed in the Emergency Department (ED). We aimed to assess the improvement in documented neurological examination for children presenting with upper limb fractures following introduction of a simple guideline.We developed and introduced a simple guideline for upper limb neurological assessment in children ('rock, paper, scissors, OK'). We compared documentation of neurological examination and nerve injury detection at our hospital before and after introduction of this guideline, as well as for children admitted from external hospitals (where the guideline had not been introduced).In the period following guideline introduction, 97 children with upper limb fractures were admitted (46% presenting directly to our ED and 54% admitted from external hospitals). This cohort was similar in number and distribution to the cohort reviewed prior to the guideline. Documentation of neurological examination in our ED increased from 92% to 98% after guideline introduction. Documented information on nerves examined also increased from 2% to 68% (p0.01). Prior to the guideline, there were six nerve injuries, all of which were missed in our ED. After guideline introduction, there were four nerve injuries, all of which were detected in our ED. Documentation and nerve injury detection at external hospitals over the same time period showed no improvement.A simple guideline to assist neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and nerve injury detection.

Background Fractures of the proximal third of the ulna and radius with associated anterior radial head dislocation are uncommon in children. Early recognition and appropriate management are essential to prevent long-term consequences of loss of forearm rotation, cubitus valgus, elbow instability and chronic pain. Case presentation We present the case of a 3-year-old Caucasian boy who attended the emergency department following an un-witnessed fall, resulting in right elbow and forearm pain, swelling and deformity. Clinical and radiological examination revealed a Monteggia type IV fracture-dislocation. The patient was treated with closed manipulation and percutaneous fixation of both bone forearm fractures with intra-medullary wires. After failed attempts at closed reduction, open reduction of the radial head was required. The block to reduction was due to a buttonholing of the radial head through the anterior joint capsule, with interposition of the capsule in the radiocapitellar joint. Subsequently, alignment was maintained with fracture healing. Follow-up at five months showed a full range of elbow movement with no adverse symptoms. Conclusion Monteggia lesions of the paediatric elbow, albeit uncommon, should be considered in all forearm fractures. Accurate reduction of the radiocapitellar joint is crucial to prevent significant long-term consequences and failed closed reduction requires open reduction. Here we have described the management of a rare type IV lesion in which there was buttonholing of the radial head through the anterior capsule, causing the radiocapitellar dislocation to be irreducible (even after fixation of the radial and ulnar fractures).

Background Growth arrest lines can develop within the skeleton after physiological stress or trauma. They are usually evident on radiographs as transverse lines in the metaphyses and have been used in fields from palaeontology to orthopaedics. This report consists of three cases, two of which describe growth arrest lines in an intra-epiphyseal site hitherto rarely documented, and a third demonstrating their clinical application. Case presentation Case 1 describes a 9-year-old who suffered a knee hyperflexion injury requiring anterior cruciate ligament and posterior cruciate ligament reattachments. She subsequently developed a marked distal femoral intra-epiphyseal arrest silhouette, as well as metaphyseal arrest lines in the femur, tibia and fibula. Case 2 describes an 8-year-old who sustained a tibial spine fracture and underwent open reduction and internal fixation. Subsequent imaging shows a further example of femoral intra-epiphyseal arrest silhouette as well as tibia and fibula metaphyseal arrest lines. Case 3 describes a 10-year-old who sustained a distal tibia fracture which was managed with open reduction and internal fixation. Subsequently the metaphyseal growth arrest line was parallel to the physis, suggesting no growth arrest (a danger with such a fracture). Conclusion This case series describes two examples of rarely described intra-epiphyseal growth arrest silhouettes and demonstrates the usefulness of arrest lines when assessing for growth plate damage.

Objectives —To assess and improve deployment of a brief test for alcohol misuse: the Paddington Alcohol Test (PAT). Design —Prospective study of the effects of audit feedback. Setting —An urban accident and emergency department. Subjects —Senior house officers (SHO) (n = 13). Outcome measurements —PAT use and categorisation of patients for each SHO; observational analysis of presenting complaints according to PAT. Results —1062 of 1737 patients (61.1%) were defined as PAT possible—that is, presented with ≥ one complaint listed on the PAT test proforma. In month 1, PAT uptake was poor. PAT use improved significantly when feedback was instituted (p collapse (including “fit”, “blackout”) > head injury (including “facial injury”) > assault (including “domestic violence” and `other9) > non-specific gastrointestinal problem > “unwell” > psychiatric (including “depression”, “overdose”, “confusion”) > cardiac (including “chest pain” and “palpitations”) > self neglect > repeat attendance. Conclusions —Ongoing audit with feedback improves both PAT use and detection of alcohol misuse. The PAT is now simpler including only 10 conditions, which should further aid its use.

A brief outline of the history of sheep scab in the UK is presented together with the current chemical methods used for its control and problems associated with these. Possible alternative approaches to control are discussed, as are selected aspects of the physiology of Psoroptes ovis and the pathogenesis of the scab lesion from the perspective of control through immunisation. Evidence is provided that immunity to the disease can indeed be acquired, both naturally after a previous infection and following inoculation of mite proteins in adjuvant. These results support the view that control by vaccination may be possible, although little is known to date about the antigens involved or the mechanism of protection.