Basal thumb arthritis is a common condition seen in hand clinics across the United Kingdom and is often associated with other pathological conditions such as carpal tunnel syndrome and scaphotrapezial arthritis. Typically, patients complain of pain localised to the base of the thumb. This pain is often activity related, particularly after excessive use involving forceful pinch. A detailed history and examination is normally all that is needed to make the diagnosis. Provocative manoeuvres may be helpful in localising symptoms to the basal joint with degenerative changes or synovitis. Radiographs are useful for confirming the diagnosis and staging the disease in order to plan for surgery. The mainstay of initial treatment of basal thumb arthritis of any stage is activity modifications, rest, nonsteroidal anti-inflammatory drugs, exercises and splinting. A variety of surgical procedures are available to treat the condition when conservative measures have failed, in order to control symptoms and improve function. We review the current literature and discuss the clinical aspects of this condition, staging, and treatment options available, and the difficulties treating this group of patients.

The small fragment AO clavicular hook plate is indicated for certain fractures of the lateral end of clavicle and for symptomatic acromio-clavicular joint dislocations where there is rupture of the stabilizing ligaments. The complex anatomy and biomechanics of the acromio-clavicular joint can lead to complications that result in damage to the joint itself or acromial erosion. In addition, the rotator cuff complex is at risk of injury when inserting the plate. We report three cases where patients who underwent hook plate fixation subsequently required removal of the implant due to complications previously unreported in current literature.

INTRODUCTION Dynamic hip screw (DHS) fixation for proximal femur fractures is one of the most common procedures in trauma that requires the use of fluoroscopy. Emphasis is often placed on producing the 'perfect picture', which may lead to excessive use of fluoroscopy, without added patient benefit. This study, the largest of its kind, aimed to determine the effect of surgical experience on the amount of radiation exposure from fluoroscopy during DHS fixation. METHODS All hospital admissions for extracapsular proximal femur fractures to our institution between 2007 and 2012 were analysed. Patient demographics, fracture configuration, grade of surgeon and the total radiation dose after fixation were recorded. Analysis of variance was performed to assess differences in radiation levels between different grades of surgeon. RESULTS A total of 1,203 patients with a mean age of 81.3 years (range: 21-105 years) were included in the study. The majority of the fractures were three-part (33.3%), followed by two-part (32.2%), four-part (25.7%) and basicervical (8.9%). Registrars (ST3-ST8) used a significantly higher radiation dose than consultants for all fracture types (p=0.009). When analysed separately by trainee group, the most junior registrars (ST3-ST4) and the most senior registrars (ST7-ST8) were found to use significantly higher radiation levels than consultants (p=0.037 and p<0.001 respectively). CONCLUSIONS The level of surgical experience does influence the amount of radiation exposure from fluoroscopy during DHS fixation. Surgical trainees should not ignore the potential harmful effects of radiation and should be equipped with the knowledge of how to keep the radiation exposure as low as possible.

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This study highlights the lack of agreement between senior clinicians when applying the modified lateral pillar classification. The results from the Herring group were significantly better than ours, but utilized a weighted κ for analysis, which may have given artificially high scores. To our knowledge, this is the first time the modified lateral pillar classification has been independently tested for its reproducibility by a specialist pediatric orthopaedic unit.