Axial loading of the foot/ankle complex is an important injury mechanism in vehicular trauma that is responsible for severe injuries such as calcaneal and tibial pilon fractures. Axial loading may be applied to the leg externally, by the toepan and/or pedals, as well as internally, by active muscle tension applied through the Achilles tendon during pre-impact bracing. The objectives of this study were to investigate the effect of Achilles tension on fracture mode and to empirically model the axial loading tolerance of the foot/ankle complex. Blunt axial impact tests were performed on forty-three (43) isolated lower extremities with and without experimentally simulated Achilles tension. The primary fracture mode was calcaneal fracture in both groups. However, fracture initiated at the distal tibia more frequently with the addition of Achilles tension (p < 0.05). Acoustic sensors mounted to the bone demonstrated that fracture initiated at the time of peak local axial force. A survival analysis was performed on the injury data set using a Weibull regression model with specimen age, gender, body mass, and peak Achilles tension as predictor variables (R2 = 0.90). A closed-form survivor function was developed to predict the risk of fracture to the foot/ankle complex in terms of axial tibial force. The axial tibial force associated with a 50% risk of injury ranged from 3.7 kN for a 65 year-old 5th percentile female to 8.3 kN for a 45 year-old 50th percentile male, assuming no Achilles tension. The survivor function presented here may be used to estimate the risk of foot/ankle fracture that a blunt axial impact would pose to a human based on the peak tibial axial force measured by an anthropomorphic test device.

We reviewed evidence on total wrist replacement from the last 5 years. Eight articles met a minimum set standard. The results of 405 prostheses were available, including seven different manufacturers. The mean follow up was 2.3-7.3 years with an average age of 52-63. Rheumatoid arthritis was the indication in 42% of patients. Motec demonstrated the best post-operative DASH scores. Only Maestro achieved a defined functional range of motion post-operatively. Universal 2 displayed the highest survival rates (100% at 3-5 years), while Elos had the lowest (57% at 5 years). Biaxial had the highest complication rates (68.7%), while Remotion had the lowest (11%). Wrist arthroplasty preserves some range of motion. Functional scores improved and were maintained over the mid- to long-term. Complication rates were higher than wrist fusion, with reports of radiological loosening and osteolysis. The evidence does not support the widespread use of arthroplasty over arthrodesis, and careful patient selection is essential.

We retrospectively compared the short-term outcomes of 18 thumbs that had a trapeziectomy and 18 that had a pyrocarbon interposition implant (Pi2) arthroplasty in 33 patients. We measured the Disability of the Arm, Shoulder, and Hand (DASH) and Short Form 36 (SF-36) scores at a mean of 20 months. Pain severity was assessed using a visual analogue scale (VAS), and level of patient satisfaction was assessed using a 5-point scale. The mean DASH scores at follow up were 27 for those that had a trapeziectomy and 35 for those that had a Pi2 arthroplasty (p = 0.001). There was no difference in the VAS for pain, SF-36 scores, or other parameters assessed. Six out of 18 (33%) thumbs in the Pi2 group had multiple operations, usually for dislocation or subluxation of the implant. The early results of Pi2 arthroplasty show a high complication rate compared with trapeziectomy and no identifiable benefit.

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Compression of the ulnar nerve in Guyon's canal is an uncommon phenomenon. Reports of ulnar nerve palsy secondary to ulnar artery pseudoaneurysm at this anatomical location are very rare and equivalent pathology just distal to this site is unheard of.Here we present such a case, which featured a delayed onset of symptoms. This followed penetrating trauma to the hand. Our methods for diagnosis, operative planning and surgical treatment are included.Compression of the ulnar nerve in Guyon's canal is an uncommon phenomenon, described as early as 1908 by Hunt. 1Reports of ulnar nerve palsy secondary to ulnar artery pseudoaneurysm at this anatomical location are very rare. Case historyA 33-year-old man presented to our clinic 3 weeks after a penetrating glass laceration to the hypothenar eminence of his non-dominant right hand. He had attended casualty at the time of his injury while on holiday abroad where the wound was treated with adhesive strips. He reported that there were no functional problems with the hand at the time of the injury but motor and sensory symptoms developed progressively over the subsequent weeks.At the time of our assessment, ulnar clawing of the hand was apparent; the ring and little metacarpophalangeal joints were held in hyperextension with flexion at the interphalangeal joints of the corresponding fingers. Clinically, a sensory deficit was apparent (light touch, 2 point discrimination) in a well demarcated medial one and a half digit ulnar distribution. There was weakness of the interosseous muscles, abductor digiti minimi and lumbricals to the ring and little fingers (Medical Research Council score 3/5). Froment's sign was positive. A pulsatile mass was palpable over the hypothenar eminence. A clinical diagnosis of pseudoaneurysm of the ulnar artery causing neurapraxia of the ulnar nerve was made. The patient underwent ultrasonography and magnetic resonance angiography provided further clarity, demonstrating a pseudoaneurysm measuring 24mm of the ulnar artery as it coursed into the palm, immediately prior to its continuation as the superficial palmar arch (Fig 1).There was no evidence of ulnar nerve transection. Maximal ulnar nerve compression was at a site just distal and

Isolated injuries of the acromioclavicular joint and clavicle shaft fracture are very common. However, the combination injury of mid-clavicular fracture with acromioclavicular dislocation is very rare. We present a case of fracture of midshaft clavicle with acromioclavicular dislocation treated with contoured clavicular locking plate and Tightrope (Arthrex Inc., Naples, FL, USA) stabilization of the acromioclavicular dislocation.

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