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Highlights Virtual clinics improved adherence to the BOAST COVID-19 guidelines. An early consultant opinion reduces face to face clinic appointments, rationing resources, improving efficiency and clinical safety. Virtually assessing the 26 patients who were incorrectly initially seen face-to face would have saved 22 appointments and 13 Xray attendances. Triaging all patients through virtual clinic improved compliance to the BOAST COVID-19 guidelines to 99%.

Purpose The COVID pandemic has decreased orthopaedic fracture operative intervention and follow-up and increased the use of virtual telemedicine clinics. We assessed the implications of this management on future orthopaedic practice. We also surveyed patient satisfaction of our virtual fracture follow-up clinics. Method We prospectively analysed 154 patients during two weeks of 'lockdown' assessing their management. We surveyed 100 virtual fracture clinic follow-up patients for satisfaction, time off work and travel. Results Forty-nine percent of patients had decisions affected by COVID. Twelve percent of patients were discharged at diagnosis having potentially unstable fractures. These were all upper limb fractures which may go onto mal-union. Twenty-nine percent of patients were discharged who would have normally had clinal or radiological follow-up. No patients had any long-term union follow-up. Virtual telemedicine clinics have been incredibly successful. The average satisfaction was 4.8/5. In only 6% of cases, the clinician felt a further face-to-face evaluation was required. Eighty-nine percent of patients would have chosen virtual followup under normal conditions. Conclusion Lessons for the future include potentially large numbers of upper limb mal-unions which may be symptomatic. The non-union rate is likely to be the same, but these patients are unknown due to lack of late imaging. Telemedicine certainly has a role in future orthopaedic management as it is well tolerated and efficient and provides economic and environmental benefits to both clinicians and patients.

Coracoid pain is not a common presenting symptom in the shoulder clinic, however a small minority of patients do present complaining of pain well localised to the coracoid. To aid clinicians we present the findings of a review of the literature on coracoid pain. We divide the causes of pain into soft tissue and bony causes. We review and discuss the literature and present the evidence on diagnostic investigations and treatments.

Introduction: Pain maps can help quantify the distribution of pain but are not commonly used in shoulder pathology. This prospective study aims to quantify severity, type and distribution of pain associated with common shoulder pathologies using patient derived pain maps. Material and Methods: 219 patients with 5 common shoulder pathologies were prospectively recruited with diagnosis confirmed definitively at time of procedure. Patients completed maps for nociceptive pain and abnormal sensation. Visual Analogue Score and a validated neuropathic pain questionnaire (painDetect) were completed. Maps were generated with images stacked and overlaid using an FFT based image algorithm to generate pathology specific heat maps. Results: Neuropathic pain was likely in 20% of all patients based on painDetectscores. Abnormal sensation was present overall in 49.3%. 16.1% experienced symptoms below the elbow and 11.6% in the hand. Frozen shoulder appears to have the highest frequency of distal limb symptoms. Conclusion: This study provides a clear guide to the distribution and nature of pain arising from procedure confirmed common shoulder conditions. We have demonstrated that neuropathic pain is prevalent in common shoulder pathologies and may spread as far as the hand. Therefore, pain in this distribution should not be dismissed as cervical as this will lead to a delay in the treatment of the shoulder pathology.

Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach to the shoulder is still frequently used, for example in fracture fixation and shoulder replacement. However, it is sometimes accompanied by unexpected bleeding. The cephalic vein is the landmark for the deltopectoral interval, yet its intimate relationship with the deltoid artery, and the anatomical variations in that structure, have not previously been documented. In this study the vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded and the common variants described. Two common variants of the deltoid artery were encountered. In type I (71%) it crosses the interval and tunnels into the deltoid muscle without encountering the cephalic vein. However, in type II (21%) it crosses the interval, reaches the cephalic vein and then runs down, medial to and behind it, giving off several small arterial branches that return back across the interval to the pectoralis major. Several minor variations were also seen (8%). These variations in the deltoid artery have not previously been described and may lead to confusion and unexpected bleeding during this standard anterior surgical approach to the shoulder.

We present a rare case of a mobile diplopodia in an infant with disorganization syndrome. This was initially mistaken for polydactyly due to the more typical association between these conditions. The resulting corrective surgery was more extensive and complicated than anticipated, with the removal of a partial foot duplication and reconstruction of residual hindfoot structures, rather than the planned digit amputation. We highlight the association of diplopodia with disorganization syndrome, discuss differentiating diplopodia from polydactyly and describe the surgical management of an unusual case.