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Background/Aims Rheumatoid vasculitis (RV) is an extra-articular manifestation of rheumatoid arthritis (RA) which is usually seen in long-standing severe disease, affecting approximately 1-5% of the patient population. It involves small- to medium-sized arteries and has a high mortality rate of 40% at 5 years post-diagnosis. Methods In this report we describe a case of a 58-year-old male with no significant past medical history other than previous heavy smoking, who presented with a several week history of weakness, paraesthesia, numbness and pain affecting both hands and feet. He had also experienced weight loss of 12lbs in a short period, night sweats, and arthralgia in his hands, along with a six-week history of Raynaud’s phenomenon. Results Examination revealed nailfold infarcts but there was no evidence of synovitis and this was subsequently confirmed to be absent on ultrasound of the small joints of the hands and feet. Investigations showed: CRP 79, ESR 52, rheumatoid factor >130 and anti-CCP >733. Cryoglobulins were not detected, complement was normal and neuropathy screen bloods including viral and autoantibody screens were otherwise unremarkable. During admission he developed nodular lesions over the extensor aspect of his forearms bilaterally, consistent with rheumatoid nodules. These evolved over a period of four days. He also developed a vasculitic rash over the medial malleolus of his left foot. Nerve conduction studies demonstrated mononeuritis multiplex and PET CT showed evidence of small vessel vasculitis. CT chest, abdomen and pelvis identified a 3cm hypodense lesion within the tail of the pancreas, subsequently found to be a benign lymphoepithelial cyst on biopsy. Treatment with intravenous methylprednisolone for three days resulted in a rapid improvement in both motor and sensory function of his limbs. On discharge, he was commenced on oral methotrexate and a reducing course of prednisolone, starting at 30mg daily. The clinical picture was highly suggestive of RV in the absence of an established inflammatory arthritis. When reviewed three months post-discharge he reported continuing improvement of his symptoms; the nodules had regressed in size and almost disappeared. Conclusion To our knowledge, only seven cases have been reported in the literature of a patient with RV at initial diagnosis of RA and two cases in which a diagnosis of RV preceded the diagnosis of RA. Due to its high mortality and morbidity we would like to increase awareness amongst clinicians of this unusual vasculitic form of clinical presentation of RA. Disclosure D.A.J. Cromie: None. S.K. Stewart: None. G.D. Wright: None.

The management of symptomatic osteochondral lesions of the talus (OLTs) can be challenging. The number of ways of treating these lesions has increased considerably during the last decade, with published studies often providing conflicting, low-level evidence. This paper aims to present an up-to-date concise overview of the best evidence for the surgical treatment of OLTs. Management options are reviewed based on the size of the lesion and include bone marrow stimulation, bone grafting options, drilling techniques, biological preparations, and resurfacing. Although many of these techniques have shown promising results, there remains little high level evidence, and further large scale prospective studies and systematic reviews will be required to identify the optimal form of treatment for these lesions. Cite this article: Bone Joint J 2021;103-B(2):207–212.

Bone is one of the most highly adaptive tissues in the body, possessing the capability to alter its morphology and function in response to stimuli in its surrounding environment. The ability of bone to sense and convert external mechanical stimuli into a biochemical response, which ultimately alters the phenotype and function of the cell, is described as mechanotransduction. This review aims to describe the fundamental physiology and biomechanisms that occur to induce osteogenic adaptation of a cell following application of a physical stimulus. Considerable developments have been made in recent years in our understanding of how cells orchestrate this complex interplay of processes, and have become the focus of research in osteogenesis. We will discuss current areas of preclinical and clinical research exploring the harnessing of mechanotransductive properties of cells and applying them therapeutically, both in the context of fracture healing and de novo bone formation in situations such as nonunion.Cite this article: Bone Joint Res 2019;9(1):1–14.

Pelvic fractures, although infrequent, are a significant cause of morbidity and mortality in the trauma population. Currently, the mainstay of emergent management of a suspected pelvic fracture is placement of a pelvic binder, and their use in the prehospital setting is recommended for any individual involved in high-energy trauma. Obesity in the trauma patient has been shown to be an independent risk factor of morbidity and mortality, and the incidence of pelvic and lower extremity fractures has consistently demonstrated to be higher in the obese patient compared with an individual with a normal body habitus. This article aims to highlight the challenges associated with pelvic fracture in the obese population.

IntroductionDeath as a consequence of underbody blast (UBB) can most commonly be attributed to central nervous system injury. UBB may be considered a form of tertiary blast injury but is at a higher rate and somewhat more predictable than injury caused by more classical forms of tertiary injury. Recent studies have focused on the transmission of axial load through the cervical spine with clinically relevant injury caused by resultant compression and flexion. This paper seeks to clarify the pattern of head and neck injuries in fatal UBB incidents using a pragmatic anatomical classification.MethodsThis retrospective study investigated fatal UBB incidents in UK triservice members during recent operations in Afghanistan and Iraq. Head and neck injuries were classified by anatomical site into: skull vault fractures, parenchymal brain injuries, base of skull fractures, brain stem injuries and cervical spine fractures. Incidence of all injuries and of each injury type in isolation was compared.Results129 fatalities as a consequence of UBB were identified of whom 94 sustained head or neck injuries. 87 casualties had injuries amenable to analysis. Parenchymal brain injuries (75%) occurred most commonly followed by skull vault (55%) and base of skull fractures (32%). Cervical spine fractures occurred in only 18% of casualties. 62% of casualties had multiple sites of injury with only one casualty sustaining an isolated cervical spine fracture.ConclusionImprovement of UBB survivability requires the understanding of fatal injury mechanisms. Although previous biomechanical studies have concentrated on the effect of axial load transmission and resultant injury to the cervical spine, our work demonstrates that cervical spine injuries are of limited clinical relevance for UBB survivability and that research should focus on severe brain injury secondary to direct head impact.

IntroductionFractures have been a common denominator of the injury patterns observed over the past century of warfare. The fractures typified by the blast and ballistic injuries of war lead to high rates of bone loss, soft tissue injury and infection, greatly increasing the likelihood of non-union. Despite this, no reliable treatment strategy for non-union exists. This literature review aims to explore the rates of non-union across a century of conflict, in order to determine whether our ability to heal the fractures of war has improved.MethodsA systematic review of the literature was conducted, evaluating the rates of union in fractures sustained in a combat environment over a 100-year period. Only those fractures sustained through a ballistic or blast mechanism were included. The review was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Quality and bias assessment was also undertaken.ResultsThirty studies met the inclusion criteria, with a total of 3232 fractures described across 15 different conflicts from the period 1919–2019. Male subjects made up 96% of cases, and tibial fractures predominated (39%). The lowest fracture union rate observed in a series was 50%. Linear regression analysis demonstrated that increasing years had no statistically significant impact on union rate.ConclusionsFailure to improve fracture union rates is likely a result of numerous factors, including greater use of blast weaponry and better survivability of casualties. Finding novel strategies to promote fracture healing is a key defence research priority in order to improve the rates of fractures sustained in a combat environment.

We report a case of isolated compartment syndrome within the extensor carpi ulnaris (ECU) compartment in the forearm of a 40-year-old diabetic man. Magnetic resonance imaging of his forearm showed isolated changes in the ECU muscle belly; compartment syndrome was confirmed on manometry. In view of the short history of symptoms and his diabetic status, the patient was managed conservatively. Twenty-four hours after onset of the symptoms, the pain and swelling resolved and he was able to be discharged. To date, 3 cases of ECU compartment syndrome secondary to trauma have been reported. This report illustrates a case of confirmed compartment syndrome without antecedent trauma, highly unusual in terms of both its etiology and its anatomical location.

Background Non-union affects up to 10% of fractures and is associated with substantial morbidity. There is currently no single effective therapy for the treatment or prevention of non-union. Potential treatments are currently selected for clinical trials based on results from limited animal studies, with no attempt to compare results between therapies to determine which have the greatest potential to treat non-union. Aim The aim of this systematic review was to define the range of therapies under investigation at the preclinical stage for the prevention or treatment of fracture non-union. Additionally, through meta-analysis, it aimed to identify the most promising therapies for progression to clinical investigation. Methods MEDLINE and Embase were searched from 1St January 2004 to 10th April 2017 for controlled trials evaluating an intervention to prevent or treat fracture non-union. Data regarding the model used, study intervention and outcome measures were extracted, and risk of bias assessed. Results Of 5,171 records identified, 197 papers describing 204 therapies were included. Of these, the majority were only evaluated once (179/204, 88%), with chitosan tested most commonly (6/204, 3%). Substantial variation existed in model design, length of survival and duration of treatment, with results poorly reported. These factors, as well as a lack of consistently used objective outcome measures, precluded meta-analysis. Conclusion This review highlights the variability and poor methodological reporting of current non-union research. The authors call for a consensus on the standardisation of animal models investigating non-union, and suggest journals apply stringent criteria when considering animal work for publication.

L ife-threatening hemorrhage from the extremities is not confined to the military setting and is seen in civilian catastrophes such as terrorist attacks, postconflict improvised explosive device, land mine detonations, and natural disasters. In such settings, the demand for resources outstrips supply; the use of tourniquets may be necessitated despite not being readily available. Application of an improvised tourniquet in such a situation may be the only method of controlling bleeding. Despite this, evaluation of commercially available tourniquets have tended to favor analysis and debate, when their availability in such an event may be extremely limited. Commercially available tourniquets have had extensive investigation to arrive at an opinion of what makes an ideal tourniquet. There is currently a lack of research on the role of improvised tourniquets in situations requiring the control of catastrophic bleeding. Available literature on improvised tourniquets is often a side topic with the focus of the article being on the efficacy of commercial tourniquets. We argue that improvised tourniquets have a role in the control of hemorrhage in the prehospital environment. This is particularly in the context of civilian mass-casualty situations where commercial tourniquets may be a limited resource among caregivers. Conflicting evidence exists regarding the role improvised tourniquets have to play in such situations, from their indication for use to whether they should be used at all. This literature review sought to examine the current opinion on improvised tourniquets, albeit in its paucity, and present the arguments supporting and opposing its use in both military and civilian settings.

A case of post-operative negative pressure pulmonary oedema in a young, athletic male is reported. We discuss this rare but life-threatening condition and its aetiology, and review the published literature. Military health care providers need to be aware of this condition as young fit personnel may be at increased risk of developing negative pressure pulmonary oedema in the post-operative period.

Polyenyl-1-boronic acids, with hindered pinacol esters, are difficult to transform into the corresponding Z - or E -iodides under literature reaction conditions. However, reaction of trans -polyenyl-1-boronate pinacol esters with sodium methoxide, followed by monochloroiodide provides the corresponding E -iodides, while reaction with monochloroiodide, followed by sodium methoxide provides the corresponding Z -iodides.

Vinylboronate 1 , protected as its pinacol ester, can be cross-coupled with aryl halides in the presence of palladium(0) to give the styrylboronate 2 as the major or exclusive product under optimized reaction conditions. The styrylboronate Heck products 2 are obtained with higher yields when aryl iodides rather than aryl bromides are used. Heteroaromatic halides are only reactive when silver(I) salts are added to the reaction mixture.

Palladium(O) catalysed cross-coupling of a vinylboronate 1 , protected as its' pinacol ester, with aryl halides provides a mixture of the styryl boronates 2 and the styrenes 3 depending upon the reaction conditions.

Condensation of a 3-substituted 5-amino-1,2,4-triazole with an N-cyanocarbonimidate (RX)2CNCN, yields the title compounds, in most cases as a mixture of isomers; separation and elaboration then gives [1,2,4]triazolo[1,5-a][1,3,5]triazines bearing a range of substituents in the 5 and 7 positions. Under milder reaction conditions, less stable isomeric products (e.g., the [1,2,4]triazolo[4,3-a][1,3,5]triazine ring system or an uncyclised N-cyano intermediate) can be isolated and shown to rearrange to the [1,5-a] isomer. A second synthesis is described in which a suitably substituted 2-hydrazido-1,3,5-triazine is cyclodehydrated to give a single isomer with identical substituents in the 5 and 7 positions; the large difference in reactivity between these allows selective replacement at the 7-position with nucleophile. Additionally, the second synthesis is more readily adaptable to the introduction of substitutents at the 2 position of the bicyclic nucleus. 7 Amino-2-(2-furyl)-5-phenoxy[1,2,4]triazolo[1,5-a][1,3,5]triazine 12a is prepared independently by both synthetic sequences and its structure verified by X-ray crystallographic analysis; 1H NMR, 13C NMR and MS data are also presented in support of the proposed structures.

E- and Z-1-alkenyl iodides react with vinylboronate pinacol ester 1 under palladium(0) catalysed, Heck conditions to provide polyenylboronates in moderate yields after purification. The addition of either silver(I) or thallium(I) salts to the reaction mixture is essential. Alkenyl bromides are unreactive under identical reaction conditions.

Reaction of alkynes with ICI and an iodide source results in the stereoselective formation of diiodoalkenes in moderate to high yield. At r.t., the reaction is stereospecific, resulting in the formation of E-diiodoalkenes, however lowering the temperature and using a more soluble iodide source results in a stereoselective formation of the Z-diiodoalkenes.

Condensation of a 3-substituted 5-amino-1,2,4-triazole with an N-cyanocarbonimidate (RX)2CNCN, yields the title compounds, in most cases as a mixture of isomers; separation and elaboration then gives [1,2,4]triazolo[1,5-a][1,3,5]triazines bearing a range of substituents in the 5 and 7 positions. Under milder reaction conditions, less stable isomeric products (e.g., the [1,2,4]triazolo[4,3-a][1,3,5]triazine ring system or an uncyclised N-cyano intermediate) can be isolated and shown to rearrange to the [1,5-a] isomer. A second synthesis is described in which a suitably substituted 2-hydrazido-1,3,5-triazine is cyclodehydrated to give a single isomer with identical substituents in the 5 and 7 positions; the large difference in reactivity between these allows selective replacement at the 7-position with nucleophile. Additionally, the second synthesis is more readily adaptable to the introduction of substitutents at the 2 position of the bicyclic nucleus. 7 Amino-2-(2-furyl)-5-phenoxy[1,2,4]triazolo[1,5-a][1,3,5]triazine 12a is prepared independently by both synthetic sequences and its structure verified by X-ray crystallographic analysis; 1H NMR, 13C NMR and MS data are also presented in support of the proposed structures.

E- and Z-1-alkenyl iodides react with vinylboronate pinacol ester 1 under palladium(0) catalysed, Heck conditions to provide polyenylboronates in moderate yields after purification. The addition of either silver(I) or thallium(I) salts to the reaction mixture is essential. Alkenyl bromides are unreactive under identical reaction conditions.

Background Non-union of fractured bone is a major cause of morbidity in the orthopaedic population. Despite this, optimal management of non-union is still unclear and remains a significant clinical challenge. Research continues in animal models in an attempt to identify an effective clinical treatment. The proposed systematic review will evaluate current therapies of bone non-union in animal models, in order to identify those that may translate successfully to clinical therapies. Methods/design The methodology for the systematic review will be in accordance with standard guidelines. All potential sources for pre-clinical studies will be interrogated and the search strategy written in conjunction with a specialist in this field. Data extraction will be conducted by two reviewers to minimise bias. Analysis will be predominantly qualitative because of the heterogeneity that is likely to exist between the studies. However, quantitative synthesis will be performed where homogeneity in a sub-group of studies exists. Quality assessment will be undertaken utilising a risk of bias tool. Discussion To date, there has not been a systematic review addressing bone non-union therapies in animal models despite the plethora of pre-clinical research currently being undertaken. This protocol details and outlines the methodology and justification for such a review. Electronic supplementary material The online version of this article (doi:10.1186/s13643-015-0148-6) contains supplementary material, which is available to authorized users.