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BackgroundA high incidence of missed posterior shoulder dislocations is widely recognised in the literature. Concern was raised by the upper limb multidisciplinary team at a London major trauma centre that these missed injuries were causing serious consequences due to the need for surgical intervention and poor functional outcome.ObjectiveTo identify factors contributing to missed diagnosis and propose solutions.MethodsA local quality improvement report was performed investigating time from admission to diagnosis of simple posterior dislocations and fracture dislocations over a 5-year period. Factors contributing to a delayed diagnosis were analysed.ResultsThe findings supported current evidence: a posterior shoulder dislocation was more often missed if there was concurrent fracture of the proximal humerus. Anteroposterior and scapular Y view radiographs were not always diagnostic for dislocation. Axial views were more reliable in assessment of the congruency of the joint and were associated with early diagnosis and appropriate treatment of the injury.DiscussionAs a result of these findings a new protocol was produced by the orthopaedic and radiology departments and distributed to our emergency department practitioners and radiography team. The protocol included routine axial or modified trauma axial view radiographs for all patients attending the emergency department with a shoulder injury, low clinical suspicion for dislocation and a low threshold for CT scan. Reaudit and ongoing data collection have shown significant increase in axial view radiographs and improved diagnosis.

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Due to their improved wear rates, Metal-on-metal bearings have been increasingly used in the past decade by orthopaedic surgeons carrying out total hip arthroplasty. However there is increasing evidence that there are significant complications associated with such implants. One well documented complication is that of metallic debris leading to pseudotumour formation, however there is less known about associations with other tumours within the pelvis. We present two cases where an intra-pelvic mass in patients with metal-on-metal implants were diagnosed as being of a different aetiology. This highlights the need for careful assessment of such patients in order to guide appropriate management.

numerous problems have been highlighted in the pathway directing patients with musculoskeletal pathology from primary to secondary care, such as difficulty in identification of the most appropriate service (eg patients referred to orthopaedics when rheumatology is more appropriate), lack of capacity and high demand for orthopaedics, poor availability of diagnostic imaging and long waits for the first outpatient appointment. The net effect is difficulty in reaching the 18-week 'referral to treatment' target. As a result, many primary care trusts (pcTs) have redesigned their musculoskeletal pathways, commissioning a fully integrated service with the intention of increasing the number of patients being managed in the community, thereby reducing demands on secondary care but, where necessary, supporting the achievement of the 18-week target.The availability of diagnostic imaging in primary care was seen as a key enabler for reducing the total number of secondary care referrals, as well as expediting referrals for those patients who needed orthopaedic intervention.