Avulsion Fractures at the Base of the 2^nd Metacarpal Due to the Extensor Carpi Radialis Longus Tendon: A Case Report and Review of the Literature

Introduction: Simultaneous contraction of the extensor carpi radialis longus (ECRL) with forced hyperflexion of the wrist can result in avulsion of the tendon and its bony attachment at its insertion at the dorsum of the base of the second metacarpal. This is a rare and often unreported fracture pattern. Case Presentation: We present a 31- year- old male who sustained a hyperflexion injury. He was managed surgically and had good post-operative outcomes. A literature search revealed 16 papers covering 18 cases of similar injuries. 12 were initially managed surgically and 6 were managed conservatively. Conclusions: Of the open reductions and internal fixations, 11 (92%) were successful and patients made a full recovery. Conservative management was unsuccessful in 4 cases; one patient required surgery for metacarpal boss, one patient had retraction of the tendon at one week follow up and another had weak flexion of the wrist. We recommend open reduction and internal fixation for these injuries. It may allow a faster recovery and therefore allow an earlier return to work and activit

Auditing the Management of Vaccine-Preventable Disease Outbreaks: The Need for a Tool

Public health activities, especially infectious disease control, depend on effective teamwork. We present the results of a pilot audit questionnaire aimed at assessing the quality of public health services in the management of VPD outbreaks. Audit questionnaire with three main areas indicators (structure, process and results) was developed. Guidelines were set and each indicator was assessed by three auditors. Differences in indicator scores according to median size of outbreaks were determined by ANOVA (significance at p≤0.05). Of 154 outbreaks; eighteen indicators had a satisfactory mean score, indicator “updated guidelines” and “timely reporting” had a poor mean score (2.84±106 and 2.44±1.67, respectively). Statistically significant differences were found according to outbreak size, in the indicators “availability of guidelines/protocol updated less than 3 years ago” (p = 0.03) and “days needed for outbreak control” (p = 0.04). Improving availability of updated guidelines, enhancing timely reporting and adequate recording of control procedures taken is needed to allow for management assessment and improvement

Rotator cuff tears in athletes

A rotator cuff tear in the athlete is different to the classic, more common cuff tear in the elderly. It is either a traumatic or an overhead, overuse injury in high functional demand patients, so it requires more active and earlier intervention, suspicion of injury, and specific assessment and treatment to enable return to the pre-injury level of sport

Innate arthroscopic skills in medical students and variation in learning curves.

BACKGROUND: Technical skill is an essential domain of surgical competence, and arthroscopic surgery requires a particularly challenging subset of technical skills. The innate ability to acquire arthroscopic skills is not fully understood. The aim of this study was to investigate the innate arthroscopic skills and learning curve patterns of medical students. METHODS: Tests of two arthroscopic tasks (one shoulder and one knee task designed to represent core skills required for arthroscopic training) were conducted in a surgical skills laboratory. The performance of twenty medical students with no previous arthroscopic surgery experience was assessed as they performed thirty repetitions of each task. The primary outcome measure for each repetition was success or failure in performing the task. An individual was deemed "competent" at the conclusion of the testing if he or she achieved stabilization of the learning curve (success on all subsequent repetitions) within twenty repetitions of the task. The secondary outcome measures were objective assessments of technical dexterity (time taken to complete the task, total length of the path traveled by the subject's hands, and number of hand movements) measured with use of a validated motion analysis system. RESULTS: The performance on each task varied among the students. Seven students were unable to achieve competence in the shoulder task and four were unable to achieve competence in the knee task. Motion analysis demonstrated that students who achieved task competence had better objective technical dexterity and thus better innate arthroscopic ability. The total path length and the number of hand movements differed significantly between the students who did and did not become competent at the shoulder task (p < 0.05, Mann-Whitney U test). The difference in path length was also significant for students performing the knee task (p < 0.05). CONCLUSIONS: Variation in innate arthroscopic skill exists among future surgeons, with some individuals being unable to achieve competence in basic arthroscopic tasks despite sustained practice

Identifying orthopaedic surgeons of the future: the inability of some medical students to achieve competence in basic arthroscopic tasks despite training: a randomised study.

The aim of this study was to investigate the effect of training on the arthroscopic performance of a group of medical students and to determine whether all students could be trained to competence. Thirty-three medical students with no previous experience of arthroscopy were randomised to a 'Trained' or an 'Untrained' cohort. They were required to carry out 30 episodes of two simulated arthroscopic tasks (one shoulder and one knee). The primary outcome variable was task success at each episode. Individuals achieved competence when their learning curve stabilised. The secondary outcome was technical dexterity, assessed objectively using a validated motion analysis system. Six subjects in the 'Untrained' cohort failed to achieve competence in the shoulder task, compared with one in the 'Trained' cohort. During the knee task, two subjects in each cohort failed to achieve competence. Based on the objective motion analysis parameters, the 'Trained' cohort performed better on the shoulder task (p < 0.05) but there was no significant difference for the knee task (p > 0.05). Although specific training improved the arthroscopic performance of novices, there were individuals who could not achieve competence despite focused training.These findings may have an impact on the selection process for trainees and influence individual career choices.

Identifying orthopaedic surgeons of the future: the inability of some medical students to achieve competence in basic arthroscopic tasks despite training: a randomised study.

The aim of this study was to investigate the effect of training on the arthroscopic performance of a group of medical students and to determine whether all students could be trained to competence. Thirty-three medical students with no previous experience of arthroscopy were randomised to a 'Trained' or an 'Untrained' cohort. They were required to carry out 30 episodes of two simulated arthroscopic tasks (one shoulder and one knee). The primary outcome variable was task success at each episode. Individuals achieved competence when their learning curve stabilised. The secondary outcome was technical dexterity, assessed objectively using a validated motion analysis system. Six subjects in the 'Untrained' cohort failed to achieve competence in the shoulder task, compared with one in the 'Trained' cohort. During the knee task, two subjects in each cohort failed to achieve competence. Based on the objective motion analysis parameters, the 'Trained' cohort performed better on the shoulder task (p 0.05). Although specific training improved the arthroscopic performance of novices, there were individuals who could not achieve competence despite focused training.These findings may have an impact on the selection process for trainees and influence individual career choices

Retention of arthroscopic shoulder skills learned with use of a simulator. Demonstration of a learning curve and loss of performance level after a time delay.

In orthopaedic surgery, arthroscopy is an irreplaceable diagnostic and interventional tool, and its breadth of use is increasing. The aim of this study was to investigate the surgeon's capacity for retention of an unfamiliar arthroscopic skill.Six fellowship-trained lower-limb surgeons were given standardized instruction regarding the performance of an arthroscopic Bankart suture on a laboratory-based simulator. They performed three single Bankart sutures on each of four occasions, one to two weeks apart. Six months later, the same surgeons repeated the study. They received no further instruction or guidance. Their performance was objectively assessed with use of validated motion-analysis equipment to record the total path length of the surgeon's hands, number of hand movements, and time taken to perform the sutures.A learning curve showing significant and objective improvement in performance was demonstrated for all outcome parameters in both experiments (p &lt; 0.005). The learning curve at six months was a repeated learning curve showing no significant difference from the initial learning curve.This study objectively demonstrated a loss of all of the initial improvement in the performance of an arthroscopic Bankart suture following a six-month interval in which the surgeons did not do the procedure

Genetic influences in the progression of tears of the rotator cuff.

The aim of this study was to investigate genetic influences on the development and progression of tears of the rotator cuff. From a group of siblings of patients with a tear of the rotator cuff and of controls studied five years earlier, we determined the prevalence of tears of the rotator cuff with and without associated symptoms using ultrasound and the Oxford Shoulder Score. In the five years since the previous assessment, three of 62 (4.8%) of the sibling group and one of the 68 (1.5%) controls had undergone shoulder surgery. These subjects were excluded from the follow-up. Full-thickness tears were found in 39 of 62 (62.9%) siblings and in 15 of 68 (22.1%) controls (p = 0.0001). The relative risk of full-thickness tears in siblings as opposed to controls was 2.85 (95% confidence interval (CI) 1.75 to 4.64), compared to 2.42 (95% CI 1.77 to 3.31) five years earlier. Full-thickness tears associated with pain were found in 30 of 39 (76.9%) tears in the siblings and in eight of 15 (53.3%) tears in the controls (p = 0.045). The relative risk of pain associated with a full-thickness tear in the siblings as opposed to the controls was 1.44 (95% CI 2.04 to 8.28) (p = 0.045). In the siblings group ten of 62 (16.1%) had progressed in terms of tear size or development compared to one of 68 (1.5%) in the control group which had increased in size. Full-thickness rotator cuff tears in siblings are significantly more likely to progress over a period of five years than in a control population. This implies that genetic factors have a role, not only in the development but also in the progression of full-thickness tears of the rotator cuff