IntroductionWe present a systematic review of the literature for the management of tibial eminence fractures in the paediatric population. Our aims were to assess modalities of injury, treatment options available and their associated complications.Materials and methodsWe found 740 relevant citations in the English literature up to 1 October 2012, of which 36 full text articles met our inclusion criteria.ResultsOur results show that skiing, sports and motor vehicle accidents are increasingly common modes of injury, in addition to the commonly described fall off of a bicycle. Most studies advocate non-operative management for type I Meyer’s and McKeever’s fractures and reduction and internal fixation for type II and III fractures. Better long-term results have been reported with arthroscopic surgery compared to open surgery. There is no consensus as to which type of fixation is best suited for tibial eminence fractures; methods available include excision of the bony fragment, K-wire, screw and, absorbable suture fixation, and more recently, suture anchor and meniscal arrow. The main complications reported include arthrofibrosis, non-union, mal-union, pain and severe laxity. Early post-operative range of motion exercises have been shown to reduce the incidence of arthrofibrosis.ConclusionAs all papers report results from small case series, Level I studies are required to produce more definitive evidence for the management of paediatric tibial eminence fractures.

A 19-year-old female patient sustained a closed spiral midshaft femoral fracture and subsequently underwent femoral intramedullary nail insertion. At followup she complained of difficulty in walking and was found to have a unilateral in-toeing gait. CT imaging revealed 30 degrees of internal rotation at the fracture site, which had healed. A circumferential osteotomy was performed distal to the united fracture site using a Gigli saw with the intramedullary femoral nail in situ. The static distal interlocking screws were removed and the malrotation was corrected. Two further static distal interlocking screws were inserted to secure the intramedullary nail in position. The osteotomy went on to union and her symptoms of pain, walking difficulty, and in-toeing resolved. Our paper is the first to describe a technique for derotation osteotomy following intramedullary malreduction that leaves the intramedullary nail in situ.

We present a rare case of a subscapularis pyomyositis in a 38-year-old woman and examine the diagnostic and surgical challenges posed. History and examination features were similar to that of septic shoulder arthritis without overlying features of warmth or erythema. Serological markers revealed a C-reactive protein of 221 mg/L and white cell count of 11.1×10/L. A dry shoulder aspirate was obtained. Contrast-enhanced MRI demonstrated a peripheral rim-enhancing lesion within the subscapularis muscle belly with lack of central enhancement. These features are consistently seen with an infective aetiology. A deltopectoral approach to surgical drainage was utilised and subsequent fluid cultures grew Panton-Valentine Leukocidin positive species. This rare bacterium is associated with an increased risk of osteomyelitis and despite making a full recovery, the patient was advised to reattend if any future shoulder pain was encountered.

Background: Advances in shoulder magnetic resonance imaging (MRI) and arthrography (MRA) have revolutionised musculoskeletal diagnosis and surgical planning. Despite this, the overall accuracy of MRI, with or without intra-articular contrast, can be variable. Methods: In this prospective non-randomised analysis, 200 participants (74.5% males) with suspected shoulder injuries underwent MRI (41.0%) or MRA followed by arthroscopy. A study specific proforma was developed to ensure consistency of reporting by radiologists and surgeons. The reports were compared to assess the predictive power of MRI/MRA. Specific assessment of rotator cuff tendon appearance, long head of biceps (LHB) tendon appearance, position and anchor, subacromial space, glenoid labrum and humeral cartilage grade were included. Results: Shoulder MRA demonstrated a higher agreement with arthroscopy than MRI for supraspinatus, infraspinatus and subscapularis tendon appearance (κ = 0.77 vs. κ = 0.61, κ = 0.55 vs. κ = 0.53 and κ = 0.58 vs. κ = 0.46 respectively). There were also superior agreement rates with MRA compared to MRI for LHB tendon appearance (κ = 0.70 vs. κ =0.54) and position (κ = 0.89 vs. κ = 0.72). As an overall assessor of shoulder pathology we found significantly higher total agreement scores when MRA was used (p = 0.002). Discussion: Whilst magnetic resonance imaging with arthrography is an extremely useful tool to assess underlying pathological shoulder states it does not confer 100% accuracy. In cases whereby this modality is inconclusive, an examination under anaesthesia and diagnostic arthroscopic assessment for the detection of intra-articular shoulder pathology may be considered.