Internal snapping often resolves with conservative treatment but persistent significant symptoms may require surgical treatment. Different surgical approaches have been suggested in the literature with varying results. We describe a modified surgical approach for internal snapping of hip in adults with good results. Patients who failed conservative treatment for internal snapping over 11/2 years were included. A skin crease incision was made just lateral to the ASIS in supine position. The psoas tendon was reached sub-periosteally along the internal iliac surface and a hole was made in periosteum. Then the tendon was hooked into the wound and divided releasing its musculotendinous junction. The patients were allowed to mobilise as able in the postoperative period. There were 8 snapping hips (7 patients, 6 females) with average age of 30 years (17-51 yrs). The mean follow-up was 11 months. The average duration of symptoms before operation was 4.5 years (range 2-10 years). Painful symptomatic clicking was relieved in all patients. Two patients felt slight weakness of hip flexion. One patient had temporary neuropraxia of lateral cutaneous nerve of thigh. The diagnosis is made by ultrasound or examination for a palpable click. Surgical correction of snapping is considered after failure of conservative treatment. Different extrapelvic (medial and iliofemoral) and intrapelvic extraperitoneal approaches have been described with varying results. With our slightly modified intrapelvic and subperiosteal approach through oblique inguinal incision in adults, psoas muscle release at musculotendinous junction seems a safe and effective method and could be used as an alternative surgical approach for treatment of internal snapping of hip in adults.

Controversy surrounds the management of displaced three- and four-part fractures of the proximal humerus. The percutaneous Resch technique of stabilisation involves minimal soft-tissue dissection and a reduced risk of stiffness and avascular necrosis. However, it requires a second operation to remove Kirschner wires and the humeral block. We describe a modification of this technique that dispenses with the need for this second operation and relies on a sequential pattern of screw placement. We report the outcome of 32 three- or four-part fractures of the proximal humerus treated in this way at a mean follow-up of 3.8 years (2 to 8)). There were 14 men and 18 women with a mean age of 56 years (28 to 83). At final follow-up the mean Oxford shoulder scores were 38 (31 to 44) and 39 (31 to 42), and the mean Constant scores were 79 (65 to 92) and 72 (70 to 80) for three- and four-part fractures, respectively. We further analysed the results in patients aged < 60 years with high-energy fractures and those aged ≥ 60 years with osteoporotic fractures. There were no cases of nonunion or avascular necrosis. The results were good and comparable to those previously reported for the Resch technique and other means of fixation for proximal humeral fractures. We would recommend this modification of the technique for the treatment of displaced three-part and four-part fractures in patients both younger and older than 60 years of age.

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This is much higher than the overall reported mortality following proximal femur fracture. This information may be useful when planning future peri-operative care and discussing overall prognosis with patients and their relatives.