Fibular Hemimelia is not just a fibular anomaly but there is entire limb involvement with varied expression in each segment. Factors which we have considered in treatment are the amount of fibula present, percentage of shortening, tibial and leg deformity and foot deformity. Residual or recurrent foot deformity is the prime reason for unsatisfactory results, so we have used Paley's classification which takes into consideration foot deformity. Our series is of 29 cases, Paley type I-7, Type II-6, Type III-16 and none of type IV. Tibial lengthening (+/−) bow correction was performed in 28 cases. Supramalleolar osteotomy was done in 4 cases. In foot, soft tissue release only was done in 6 cases and soft tissue release with osteotomy (subtalar or calcaneal) was done in 14 cases. Amputation was done in 2 cases. Age ranged from 11 months to 16 years. Mean follow up was 4.2 years. Mean lengthening was 3.5 cm. Desires lengthening was achieved in 21/29 cases and plantigrade foot was achieved in 16/29 cases. Complications faced were recurrence of foot deformity, knee valgus, knee fixed flexion deformity, knee subluxation and pin tract problems. Less than 3 rays and more than 25 cm of limb length discrepancy were poor prognostic factors. We had 7 excellent, 16 good and 6 poor results. To conclude, it is difficult to achieve the aim of plantigrade foot and limb length equality in all cases but radical surgery with foot correction and tibial lengthening can give good results.

Patient's non acceptance of a bulky external fixator, the incidence of fractures of the regenerate, muscle transfixion giving rise to contractures especially in the Tendo Achilles, increased index of consolidation and the frequency of infections has made Limb lengthening with external fixators alone unpopular.

In a retrospective study, we evaluated the technique of limb lengthening over a sub muscular plate combined with Ilizarov external fixator as an alternative to external fixator alone and whether the combined procedure is successful in reducing the external fixator period. 15 patients (14 with length discrepancy in the lower limb and 1 with low stature) and a total of 16 limbs (15 tibiae and 1 femur) were lengthened over a sub muscular plate fixed on the proximal segment followed by corticotomy and application of external fixator. Lengthening was achieved at 1 mm/day followed by distal segment fixation with three or four screws on reaching the target length. The pre operative target length was successfully achieved in all patients at a mean of 4.4 cm (2.2 to 6.5 cm). The mean duration of external fixation was 59.2 days (33 to 107 days) with the mean external fixation index at 16.7 days/cm (10.95 to 23.78). Infection complicated the procedure in two patients and one patient had mild Tendo Achilles contracture. Lengthening over a plate drastically reduces the time external fixator needs to worn and is preferred by patients to limb lengthening over an external fixator alone. patient Lengthening over a plate provides an alternative method for limb lengthening, can be applied to children with open physes and to deformed bones.

[Lengthening over a Plate]

Aims

To assess the accuracy of posterior and anterolateral methods of injection into the subacromial space (SAS) of the shoulder.

An Extended Scope Practitoner Physiotherapist (ESP) developed a problem shoulder clinic to support the physiotherapy management of patients with shoulder pathology across one healthcare trust. The impact of the clinic on the management of patients and their onward referral to a shoulder surgeon was evaluated. Physiotherapists had access to a problem shoulder clinic that was managed by an ESP with a special interest in shoulders. The clinic provided assessment and advice on the management of patients with shoulder pathology who were receiving physiotherapy treatment. Throughout a three-year period the opinion of the ESP was sought on 256 patients. 69 patients were seen in a face-to-face consultation, the remainder were diuscussed with their treating physiotherapist and advice was offered. 211 patients were managed and discharged through the physiotherapy service. The ESP referred 45 patients to the shoulder surgeon, of which 53% underwent surgery; 20% are awaiting investigations, 22% were managed with injection therapy and five per cent were discharged. The problem shoulder clinic was shown to be a valuable addition to the clinical mentoring system in physiotherapy. It proved to be an important gate-keeping mechanism between physiotherapy and consultant care as 82% of patients referred to the clinic were managed within physiotherapy. The clinic also proved to be an effective means of identifying patients requiring surgery. Of those that were referred to the shoulder surgeon only five per cent were discharged with no further intervention. A planned development as a consequence of this evaluation is a physiotherapy advocate for shoulders for each outlying hospital within the trust. The aim of this will be to strengthen communication links between the shoulder surgeon and physiotherapy departments over a wide geographic area and to facilitate prompt identification of patients in need of referral to the shoulder surgeon.

The aim of the study was to prospectively review the incidence of shoulder injuries in a group of professional rugby union players and to identify any relationship between the injury and the causes, position of play, treatment and time to return to playing. An electronic database system was developed specifically to identify the objectives listed above with a view of reducing injury incidence and recurrence through identification of trends. The system was implemented in both Cardiff(2000–2003) and Llanelli(2005–2007) Rugby Football clubs. Extensive prospective data was collected by the team physiotherapists including: Type of injury(Orchard Coding), playing position, session, mechanism of injury and days lost per injury. Shoulder injuries represented 14% of all injuries sustained. Soft tissue injuries account for about 50% of the injuries and result in an average loss of five playing days. AC joint injuries ( 26%) with a recovery period of 5 days were all treated conservatively. Glenohumeral dislocations caused an average loss of 150 days and all required surgery. Fractures around the shoulder were rare with an incidence of 4%. The most common mechanism for shoulder injury was the tackle (43%). Collisions accounted for 15% of injuries whereas weight training was responsible for 31%. Contact situation training was as risky as real game situations. Back row players were more likely to sustain AC joint injuries. Surgical intervention was needed in only 11% of all shoulder injuries. Our data has shown that most shoulder injuries were from contact related areas. Physiotherapy played a key role in the rehabilitation of these players with surgery only indicated in glenohumeral dislocations and fractures. Careful planning of training sessions with emphasis on tackling and weight lifting techniques may reduce the incidence of such injuries.

Introduction: Complex fractures and singular acute orthopaedic admissions in an individual hospital form only a small proportion of admissions. An average orthopaedic surgeon does not gain and maintain enough experience to provide proficient care. Referral with in the department to a sub-specialist for that anatomical region is forming a norm. We studied the practice in our department to assess how much specialist care we provide.

Materials & Methods: Prospective study over four month’s period with specialist referrals reported by teams and Trauma Fellow. We observed the time spent before making the referrals and that taken by specialists in carrying out management. The spectrum of investigations by various specialist teams was also noted. Number of referrals made to each sub speciality was observed.

Results: Of a total of 836 acute admissions in the department over this four months period, 98 (11.7%) were referred to sub-specialists. Referrals were made on an average of 1.8 days after admission and were seen by the specialist after another 2.1 days. Average time to surgery was 4.7 days after referral. Special Imaging investigations were performed in 84 (86%) patients of whom 31 had been organised before the referral was made. 81 (82%) patients were operated by the specialist teams while rest underwent conservative treatment.

Discussion: With the changing structure and decreasing duration of higher specialist training, expertise in complex trauma is expected to be limited to the anatomical region of surgeons’ interest. Specialist management provides better patient care with improved satisfaction.

Conclusion: In the modern orthopaedic practice with intensive but limited expertise, specialist referrals are the acceptable solution both to the patient and the provider. This should be encouraged. Specialists should provide appropriate investigation and referral protocols.

Proximal humeral fractures are common and often occur in osteoporotic bone. Suture fixation utilises the rotator cuff tendons as well as bone providing adequate stability and avoids complications associated with metalwork insertion.

Surgical exposure was via a delto-pectoral approach with minimal dissection of the fracture site. Initially a 2 suture technique was utilized with heavy ethibond sutures passed through drill holes either side of the bicipital groove; however, because of concerns about varus instability the technique now uses a third suture placed laterally acting as a tension band to prevent varus collapse. Patients with Neer 2 and 3 part fractures treated with suture fixation were assessed clinically (using the Constant score) and radiologically at a mean of 27 months post fracture.

To date 24 patients have been studied. The average age of the patients in our series was 70.2. All fractures progressed to union with no cases of radiological avascular necrosis. We had 2 cases of mal-union (-one varus and one valgus-), both with a 2-suture technique. One patient had early loss of fixation; re-exploration was performed with stability conferred by a third lateral suture. Active abduction > 120o was achieved in 9 patients with a mean Constant score of 72 compared to 89 on the un-injured contra-lateral side. We have demonstrated that suture fixation of displaced proximal humeral fractures is an effective alternative to fixation using metalwork. The advantages are that minimal soft tissue stripping of the fracture site is required and the potential problems associated with metalwork insertion into osteoporotic bone are avoided. Following one case of varus mal-union with a 2-suture technique we now routinely use a third suture to act as a lateral tension band.

Private companies now offer risk assessment packages to Trusts. Data are collected using ICD coding and complication rates for individual surgeons are calculated and published. A risk assessment document was recently published at the Royal Gwent Hospital presenting complication rates and misadventures on league tables of specialty and consultants. Serious concerns were raised about the quality of the data. We undertook a study to independently evaluate the accuracy of data used to calculate these complication rates.

Two Orthopaedic Surgeons with the highest published complication rates were studied. The notes of patients who had suffered complications were retrieved and the published complication data was compared with the clinical interpretation of the actual complication. One hundred and fifty reported complications were analyzed.

In most cases data accuracy was woefully inadequate. For example revision procedures were counted as complications for the revision surgeon irrespective of who carried out the primary procedure. The normal work-up of these patients including procedures to investigate the presence of infection are recorded as complications with some patients being recorded as having up to four separate complications. Misadventures published for surgeons included dural tap during epidural anesthesia. The results of this study highlight the potentially devastating consequences of data inaccuracy. Inaccurate published data on complications, used to form league tables for individual surgeons, can be career- jeopardizing. We advocate that consultation with the clinicians involved should always occur before data are published so that these inaccuracies can be picked up and the potentially damming consequences of falsely high complication rates can be avoided.

Introduction and Aims: Private companies now offer risk assessment packages to hospital trusts. Data is collected using ICD coding and complication rates for individual surgeons are calculated and published. A risk assessment document was recently published at the Royal Gwent Hospital presenting complication rates and misadventures on league tables of specialty and consultants. Serious concerns were raised about the quality of the data.

Method: We undertook a study to independently evaluate the accuracy of data used to calculate these complication rates. Two orthopaedic surgeons with the highest published complication rates were studied. The notes of patients who had suffered complications were retrieved and the published complication data was compared with the clinical interpretation of the actual complication. One hundred and fifty reported complications were analysed.

Results: In most cases data accuracy was woefully inadequate (table 1). For example, revision procedures were counted as complications for the revision surgeon irrespective of who carried out the primary procedure. The normal work up of these patients, including procedures to investigate the presence of infection, are recorded as complications, with some patients being recorded as having up to four separate complications. Misadventures published for surgeons included dural tap during epidural anaesthesia.

Conclusion: The results of this study highlight the potentially devastating consequences of data inaccuracy. Inaccurate published data on complications, used to form league tables for individual surgeons can be career jeopardising. We advocate that consultation with the clinicians involved should always occur before data is published so that these inaccuracies can be picked up and the potentially damning consequences of falsely high complication rates can be avoided.

Aim: To evaluate patient satisfaction and the effectiveness of a telephone clinic designed to follow up patients who have received shoulder or elbow surgery.

Method: Following wound checks in the community, patients are followed up in our department at six weeks, then three and six months respectively to assess level of progress and answer any questions patients may have. As outcome measures are already assessed by physiotherapists, a telephone clinic was devised to make better use of Consultant time. Patients were contacted by telephone at a pre-determined time by an extended scope practitioner physiotherapist who used a set of standard questions to obtain information about the patients’ progress. An opportunity was then given to the patients to discuss any issues they may have with regards to their treatment so far.

Urgent hospital follow – up was arranged for patients requiring it depending on their level of progress and problems identified.

Patients’ satisfaction and opinions with regards to the use of the telephone as a method of post-operative follow -up were ascertained by an independent researcher.

Results: 50 patients were contacted over a 12-week period.

Patients were satisfied by the level of information they were provided with and their subsequent management as a result of the telephone clinic. Patients particularly commented on the advantages of getting information at home with the avoidance of problems associated with attending for a hospital appointment.

Three patients were given an urgent follow-up appointment as a result of the information gleaned during the telephone clinic. These included a patient with a stitch abscess and two with adhesive capsulitis.

Conclusion: Telephone clinic follow up is an effective and safe method for monitoring patient progress post – operatively following shoulder or elbow surgery. It is well received by patients who save the time and effort associated with attending for a hospital consultation that often only lasts a few minutes. In the subject group identified the method of questioning was sufficiently sensitive to identify problems that required further management.

Aim: To study the role of total elbow replacement in the management of distal humeral fractures in elderly patients.

Patients and methods: Between 1995 and 2003, 25 consecutive patients with fractures of the distal humerus were treated by primary total elbow replacement using the Coonrad-Morrey prosthesis. All surgeries were performed by one of the senior authors in two centers in South Wales. There were 18 females and 7 males and none of them had inflammatory or degenerative arthritis of the elbow. The mean age at the time of injury was 78 years (68–84). According to the AO classification, 16 patients had suffered a C3 injury, five type B3 and three type A3. One fracture was unclassified. The mean time to follow-up was 4 years (1–9 years).

Results: At follow-up 19 patients (76%) reported no pain, five (20%) had mild pain with activity and one had mild pain at rest. The mean flexion arc was 28 degrees to 105 degrees. The mean supination was 69 degrees (50–90) and pronation 70 degrees (50–80). No elbow was unstable. Mean Mayo elbow performance score was 71.5(25–100). Four patients (16%) developed ulnar neuropraxia following surgery that improved with time, 2 patients developed superficial wound infection (staphylococcus aureus), which was treated with antibiotics only. None of the above elbows required revision to date. Radiological evaluation revealed only one patient with a radio-lucent line at the cement -bone interface. It was between 1 and 2mm in length, was present on the initial postoperative radiograph and was non-progressive at the time of follow-up.

Conclusion: Primary total elbow arthroplasty is an acceptable option for the management of comminuted fractures of the distal humerus in elderly patients when the configuration of the fracture and the quality of the bone make reconstruction difficult.

A previous study done in our unit showed good results in terms of union, stability and function following 2-suture repair of proximal humeral fractures. Healing took place usually with a mild degree of varus angulation but one failure of this technique when the fracture slipped into varus prompted us to re-evaluate our technique. The addition of a third (lateral) suture to the repair has been used as routine following this.

A prospective series of 24 patients with displaced Neer 2 and 3 part proximal humeral fractures was studied. The patients were reviewed at a mean of 22.5 months post fixation. The patients were reviewed clinically and graded according to the Constant Shoulder Score to assess range of movement, power, function and pain. This was compared to the contralateral uninjured shoulder.

Radiographic evaluation of fracture union, avascular necrosis and malunion was performed, and any complications of treatment were noted.

There were 24 2- and 3-part fractures. All the fractures united with no radiological evidence of avascular necrosis. At follow-up there was a mean Constant Score of 71.05 compared with a mean score of 84.5 on the uninjured contralateral shoulder. Active abduction of > 120° was achieved in 9 patients. Intraoperative stability in the varus/valgus plane was noted to be better.

All patients were satisfied with the results; the problem of instability in the coronal plane has not been a problem and the fractures have healed with no varus mal-union. There have been no additional complications with this technique compared to the 2-suture method.

We have successfully achieved stability after open reduction and suture fixation of 2- and 3-oart fractures of the proximal humerus. Following one case of varus instability using a 2 suture technique,

We have routinely supplemented this with a third (lateral) suture. There have been no additional complications using this method, the angulation of the fractures once healed are improved and none of the repairs have had a problem with varus slip.

To identify any shoulder joint pathology on MRI of young patients (< 35 yrs) with a single simple antero- inferior dislocation of the shoulder at minimum 5-year follow-up.

Patients aged 16–35 years with a single antero-inferior shoulder dislocation with a minimum 5-year (range5–9 yrs) follow-up were identified. A history of recurrent dislocation or surgery excluded patients from study. Ethical approval was obtained and identified patients were asked to volunteer for clinical review and have an MRI scan. Shoulders were clinically examined, noting specifically any signs/symptoms of rotator cuff pathology or instability. All shoulders were imaged with a 1.5 Tesla open MRI scan to assess any pathology.

In a 5-year period (1994–1998), 349 patients sustained an antero-inferior dislocation. 251 were in patients aged 35 years or less. 136 of these were excluded either due to recurrent dislocations. 62 patients were lost to follow-up of 53 eligible patients 7 could attend for study. Only one patient had a positive anterior apprehension sign but he did not have any symptoms of instability in his daily activities or sport. The only abnormality demonstrated on MRI was of a united greater tuberosity fracture in one shoulder. The glenolabral and bicipitolabral complexes were normal in all shoulders imaged.

Bankart lesions, both bony and labral, are known to be associated with recurrent anterior shoulder dislocations.This study has shown no shoulder joint pathology on MRI at minimum 5-year follow-up in young patients who have sustained a single antero-inferior shoulder dislocation, confirming that labral pathology seems to be important in recurrent dislocations. Further study to image more patients is underway. These results indicate that acute imaging of dislocated shoulders may be useful to help predict young patients who are unlikely to re-dislocate and thus unlikely to require surgery.

To promote cultural awareness and acceptance of clinical governance by developing a simple, reproducible model for reporting critical incidents and near misses within our department.

An A4 sized departmental proforma was developed to parallel the Trust’s official adverse incident register. Prospective reporting of adverse events using the proforma was encouraged between August 2000 and June 2001. Incidents were discussed in an anonymised and a blame-free setting, at the monthly multidisciplinary clinical governance meeting and appropriate action taken.

In the 6 months prior to commencing this study only 4 adverse events were reported with no discernible action taken. Following the introduction of the proforma 61 critical incidents and near misses were reported in the period August 2000 to June 2001. As a result of effective reporting of adverse events we have developed a number of protocols to improve patient care.

A simple model for reporting critical incidents and near misses has been established. This has fostered a cultural change within the department and all members of staff feel more comfortable with reporting such incidents. The process is seen as educational and an important part of continuing professional and departmental development. Protocols and changes in organisational practice have been developed to reduce and prevent the occurrence of adverse events and offer our patients continuous improvement in care.

Aim: To determine the complication rate following fixation of olecranon fractures in the elderly.

Method: A retrospective review of clinical notes and x-rays over a 4 year period at 3 district general hospitals in South Wales was performed. Only patients with isolated, displaced olecranon fractures over 65 years were included.

Results: 80 patients who underwent olecranon fixation were identified and reviewed. It was found that 80% of these underwent tension band wiring and the operations were performed in the majority by training grade surgeons. The overall complication rate was 37%. This included an infection rate of 13%, of which the majority required re-operation.2 patients required multiple procedures including olecranon excision and triceps advancement. Prominence of metalwork was a significant problem with removal of metalwork performed in 24% of patients.

Conclusion: In what is commonly regarded as a straightforward procedure carried out by training grade surgeons we found an unacceptable re-operation rate of 37%. It is our belief that olecranon fixation in the elderly is not a benign procedure and caution should be exercised when dealing with these injuries. We propose an alternative method of surgical treatment for these injuries.

We describe the technique of open reduction and fixation of displaced 2 and 3 part proximal humeral fracture, in which, two ‘figure of 8’ heavy braided sutures are passed through drill holes deep to the bicipital groove and passed through the fracture fragments and the cuff in a tension band fashion.

A series of 12 patients, with a mean age of 65 years (range: 44–75 years), were reviewed at an average of 16 months (range: 4–18 months) after fracture fixation. The patients were assessed clinically, and radiographic evaluation of fracture healing, avascular necrosis and malunion was performed. Any complications of treatment were noted.

All fractures united with no evidence of avascular necrosis. There was some varus deformity in two cases. There was one early loss of reduction but stability was re-established at re-exploration. Good or excellent clinical results were obtained in 10 patients according to the Constant score. Active abduction > 120° was achieved in 75% (nine patients).

Paired suture fixation is an effective means of achieving stabilisation after open reduction of displaced two and three part proximal humeral fractures, with a low rate of non-union while preserving a good functional range of motion. The advantages of this technique are the minimal soft tissue stripping and the avoidance of complications associated with metalwork.

Introduction: The search for a gold standard uncemented hip prosthesis with long term results matching cemented Charnley implants continues. It has been suggested that biological fixation would reduce the incidence of aseptic loosening caused by cement and polyethylene particles. The ABG (Howmedica) is a titanium alloy stem with an anatomic design and a modular head option of vitallium or ceramic. The cup is hemispherical and is fully coated with hydroxyapatite while the stem is proximally coated for metaphyseal fixation. We present a prospective series of 100 Consecutive patients with an immediate term follow up.

Methods: 100 patients who had an ABG prosthesis inserted between 1991 & 1996 were included in the study. All patients were operated upon by the senior author or under his direct supervision. Patients underwent a preoperative assessment including a detailed history, measurement of range of motion, Postel Merle D’Aubigne scoring and ADL assessment. Clinical and radiological review was Conducted at 3 months, 6 months, 1 year and then at yearly intervals. At each visit Patients were questioned regarding the presence of any thigh pain and Complications. All patients were clinically evaluated, Postel Merle D’Aubigne Score was obtained and ADL status assessed. AP and lateral radiographs were Taken and studied. Polyethylene wear was measured by using the Livermore Method. The Kaplan- Meier method was used to explore the survival pattern of the implants.

Results: The mean age of the patients was 52 years (range 23–72). Follow up ranged from 3 To 8 years (mean 5 years ). The mean preoperative Postel Merle D’Aubigne score Was 7 ( range 0–14) and mean score at final follow-up was 17.7(range 15–18).

Only 4 patients complained of thigh pain and most had dramatic and lasting improvement of the ADL status. Complications included 3 dislocations and 2 Superficial infections. Non progressive lucencies were noted in 6 stems and 2 cups. No stems were loose and one patient had a loose cup and is awaiting surgery. A high rate of superior polethylene wear of 0.2mm/year was identified in a Number of patients yet the survivorship was 99% after an average 5 year follow up.

Conclusion: Our results demonstrate the efficacy and excellent medium term outcome of the ABG prosthesis. A higher rate of complications in the first 2 years reiterates the lesson that every surgeon has to complete a learning curve before being technically comfortable with a new prosthesis. Of concern was the high rate of superior polyethylene wear although this did not effect the survivorship.

Aim: The objective of this study was to compare the initial stability of an uncemented curved long stem femoral component (ABR, Zimmer, Warsaw Indiana) implanted using conventional broaching to an uncemented ABR implanted as a revision using morselized compacted allograft to fill a circumferential proximal bone defect.

Materials and Methods: Primary: Eight fresh frozen human femurs were implanted with correctly sized ABR stems without cement using standard surgical instruments and 1mm distal overreaming. The implant was loaded cyclically at 3 hz on a MTS servohdraulic materials test frame in a direction representing the peak force of the stance phase of the gait (2.5 X body weight). A 3-dimensional motion measurement device with six linear variable transformers measure the relative motion between the bone and the prosthesis with an accuracy of 0.5μm. The contruct was loaded in ten cycle increments until the component was seated and then recoverable motion was recorded over a further ten loading cycles. Revision: In the revision case bone loss was modelled by removing all the cancellous bone from the proximal femur with 1mm distal overreaming. Morselized bone graft was impacted into the defect using specially prepared smooth tamps shaped to the geometry of the ABR stem. The original prosthesis was then reimplanted without the use of cement. The seating and testing cycles were repeated. Primary and revision vectors were compared using a paired students t – test.

Results: There was no statistically significant difference in the magnitude of the resultant vector of the 3 translational components of the micro motion between the two methods of implantation (p=0.19).

Conclusions: Initial stability of a cementless femoral implant is a requirement for bone ingrowth. The use of compacted morsellized allograft in a revision Total Hip Arthroplasty with a proximal circumferential defect can provide a stable bed for the implantation of an uncemented femoral component. The revised implant using the compacted allograft method was initially as stable as the primary implantation.

This technique would be particularly applicable when the surgeon would like to avoid the use of cement in a revision setting. The use of this method for uncemented revision Total Hip Arthroplasty should be studied further in a clinical setting before it is advocated for widespread use.

Introduction: The natural history of bone bruises of the knee and their clinical significance remains unclear with only a few short term studies in the literature.

Aim: This study was designed to try and elucidate the long term outcome of bone bruises of the knee following trauma.

Materials and Methods: 60 patients with bone bruises identified in their knees by MRI scans following trauma were included in the study. All patients were reviewed in a research clinic with a minimum 5 year follow up. A detailed history including mechanism of injury, persistent symptoms and functional status was obtained. Clinical examination to identify intra-articular pathology was then undertaken. All patients had a repeat MRI scan of the knee. The relationship between the injury and the bone bruise, the effect of treatment if any and the long term outcome of such lesions was studied.

Results: 80% of the patients had a twisting injury with our without a hyperextension of valgus/varus force. 58% of our series had ACL injuries and 68% of the bone bruises were in the medial condyle. 72% of the patients did not return to their pre-accident status and had continuing symptoms although the majority of them did not have signs of clinical instability. There was MRI evidence of lasting sequelae of bone bruises in the majority of patients. Detailed results will be discussed.

Conclusions: bone bruises identified on MRI following trauma to the knee are significant lesions with the potential for long term sequelae.

We report on four cases in which the diagnosis of compartment syndrome was delayed by the administration of patient controlled opiate analgesia ( PCA ) following intramedullary nailing of tibial shaft fractures. We believe that this poses a diagnostic problem and can lead to lasting sequelae as decompression is delayed. We present the 4 cases and a review of the literature. We recommend that the use of PCA in patients with intramedullary nailing following tibial shaft fractures be discontinued or used in conjunction with continuous intracompartmental pressure monitoring.