Introduction:The COVID -19 outbreak has had a profound effect on the management of healthcare service provision in the UK. Orthopaedic departments have been no exception to this and have needed to adapt to the changing circumstances by releasing resources and focusing on 'essential' activity. The aim of this study is to quantify the reduction in trauma and, in addition, describe any changes in the type of referrals to the trust which may have been affected by the pandemic itself and the social distancing measures employed by the UK government.Methods: : The study was performed in a UK District Hospital which is also a Trauma Unit providing trauma and orthopaedic care to a population of 625,0 0 0 people.The trust based electronic database of trauma referrals was used to compare the numbers of, and types of referral to our trauma service during the COVID-19 pandemic and the corresponding time periods in the previous 3 years. Results:The mean number of referrals per week to the service reduced by 33% in the time period following the confirmation of the outbreak as a pandemic ( p < 0.0 0 01). Number of operations performed per week reduced by 26% ( p = 0.001). There was no change in the number of referrals relating to domestic abuse or non-accidental injury. In addition, numbers of hip fractures, periprosthetic fractures and prosthetic joint dislocations were unchanged. There was a significant reduction in the number of referrals for simple fractures, native joint dislocations, wounds and soft tissue injuries. Within the paediatric population, similarly, a reduction in simple fracture referrals was demonstrated.Discussion: An association between the outbreak of the pandemic and a reduction in referral numbers to our department has been demonstrated. The direct cause of this may be multifactorial but proposing that it is, in part, due to the social distancing measures introduced by the government is certainly conceivable. The patterns of injury would reflect this also with low energy and fragility trauma persisting whilst injuries associated with younger people have reduced. We would suggest that information such as this could be useful in healthcare planning and resource allocation in future pandemic situations.

Highly crosslinked polyethylene undergoes substantially less wear than conventional polyethylene at medium term. The effect of hip arthroplasty longevity will need to be assessed with longer-term studies, but this may lead to a decreased need for revision as a result of less wear and osteolysis.

Level III--retrospective comparative study.

ESIN is a successful treatment for paediatric diaphyseal femoral fractures and allows early mobilisation and discharge. A statistically significant LLD is observed in children aged 4-8 years although clinically only one patient in the entire series was aware of a leg length discrepancy. In addition clinical methods of leg length measurement are sensitive for LLD and we conclude that routine radiographic follow up is not necessary unless clinically indicated.

The Severn Deanery offers a compulsory human-factors training course for surgeons at the start of their career. Given the importance of reducing human error, maintaining patient safety and the introduction of competency-based training with an emphasis on simulation, human-factors training has a vital place in surgical training, and is highly recommended to others involved in training junior surgical trainees.

In order to perform motion-preserving procedures for wrist arthritis rather than total joint fusion, it is important to determine the integrity of specific areas of wrist cartilage. This is generally performed using a wrist arthroscope and by directly visualising the cartilage. Twenty patients with wrist pain were investigated over a 1-year period with both MRI and wrist arthroscopy. Kappa analysis was used to compare the two methods of cartilage assessment. There is only a fair correlation (K = 0.38) between the two methods. With only a fair correlation between arthroscopy and MRI, it cannot be concluded that the two methods are equivalent for assessing wrist cartilage and, as such, wrist arthroscopy still has an important role to play in the assessment of a painful degenerative wrist.

Bilateral insufficiency fractures of the proximal femur often have a pathological basis. Diagnosis of rare causes of insufficiency fractures can be challenging. Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome of mesenchymal tumours which leads to hypophosphataemia and osteomalacia. Suspected pathological fractures should be investigated thoroughly including a fasting serum phosphate level. Further investigations should include serum levels of fibroblast growth factor 23 (FGF23) which is a peptide hormone secreted by mesenchymal tumours. Available imaging modalities include Octreotide scanning which detects somatostatin receptors commonly expressed on mesenchymal tumours. After localisation and resection of the tumour, a full recovery from TIO is achievable.

We recommend the organisation of skills courses to any trainee. By following key ground rules, the surgical trainee can enable the acquisition of advanced learning opportunities and the ability to demonstrate valuable organisational skills.