Purpose: The management of comminuted inter trochanteric fracture are a serious and difficult problem. The proper selection of fixation device is must to avoid significant complication in the management of this common fracture.

The use of contoured side plate screw attached to the sliding screw plate anchors the comminuted fragments thus gives better stability, compression, early mobility and bony union to this fracture where other implant fails.

Material and method: Since 1997 to 2000, 60 comminuted inter trochanteric fracture- age of 67yrs (46–91year) were treated by close/open reduction and internal fixation with 135 dynamic hip screw plate +side screw plate.

The side plate is a narrow D.C.P. (4/5 hole) which is contoured to the fl are of greater trochanter proximally and is attached to the sliding screw plate. The proximal holes of side plate hold the comminuted fragment of greater trochanter with cancellous screw above the sliding hip screw The patient were encouraged to walk on 2nd post operative day with support to start with partial weight bearing followed by weight bearing at 4 wk.

Result: On an average 12-week (8–16 wk) all the Tranzo grade II/ III fracture went into union . There was lengthening of 2.5cm (2–5 cm) in 15 cases due to valgus reduction which reduced to 1.5 cm (2–3cm) at end of 6 months. Backing up of the side plate screw and sliding hip screw was seen in 40% of case (24) (mainly in poor bone stock and valgus reduction case).

Conclusion: The side plate/ screw with sliding hip screw stables buttress for comminuted trochanter fragments gives compression, prevent rotation and better bony union the piece. This implant is an extended arm for holding fragment. The major trochanteric fracture fragment are held by side plate to sliding screw plate thus gives stability to the device, better bony contact thus early mobility and union. The sliding screw device with side plate is “forgiving” it allows subsequent displacement to achieve stability in comminuted fracture. The success of the implant assembly rest on the ability of slide and hold the fragment to give stability and bony union. This method gives an option of open reduction and bone grafting.

Coronoid fractures account for 2 to 15% of the cases with elbow dislocations and usually occur as part of complex injuries. Comminuted fractures and non-unions necessitate coronoid fixation, reconstruction or replacement. The aim of this biomechanical study was to compare the axial stability achieved via an individualized 3D printed prosthesis with curved cemented intramedullary stem to both radial head grafted reconstruction and coronoid fixation with 2 screws. It was hypothesized that the prosthetic replacement will provide superior stability over the grafted reconstruction and screw fixation. Following CT scanning, 18 human cadaveric proximal ulnas were osteotomized at 40% of the coronoid height and randomized to 3 groups (n = 6). The specimens in Group 1 were treated with an individually designed 3D printed stainless steel coronoid prosthesis with curved cemented intramedullary stem, individually designed based on the contralateral coronoid scan. The ulnas in Group 2 were reconstructed with an ipsilateral radial head autograft fixed with two anteroposterior screws, whereas the osteotomized coronoids in Group 3 were fixed in situ with two anteroposterior screws. All specimens were biomechanically tested under ramped quasi-static axial loading to failure at a rate of 10 mm/min. Construct stiffness and failure load were calculated. Statistical analysis was performed at a level of significance set at 0.05. Prosthetic treatment (Group 1) resulted in significantly higher stiffness and failure load compared to both radial head autograft reconstruction (Group 2) and coronoid screw fixation, p ≤ 0.002. Stiffness and failure load did not reveal any significant differences between Group 2 and Group 3, p ≥ 0.846. In cases of coronoid deficiency, replacement of the coronoid process with an anatomically shaped individually designed 3D printed prosthesis with a curved cemented intramedullary stem seems to be an effective method to restore the buttress function of the coronoid under axial loading. This method provides superior stability over both radial head graft reconstruction and coronoid screw fixation, while achieving anatomical articular congruity. Therefore, better load distribution with less stress at the bone-implant interface can be anticipated. In the clinical practice, implementation of this prosthesis type could allow for early patient mobilization with better short- and long-term treatment outcomes and may be beneficial for patients with irreparable comminuted coronoid fractures, severe arthritic changes or non-unions

The management of comminuted metaphyseal fractures is a technical challenge and satisfactory outcomes of such fixations often remain elusive. The small articular fragments and bone loss often make it difficult for standard fixation implants for proper fixation. We developed a novel technique to achieve anatomical reduction in multiple cases of comminuted metaphyseal fractures at different sites by employing the cantilever mechanism with the help of multiple thin Kirschner wires augmented by standard fixation implants. We performed a retrospective study of 10 patients with different metaphyseal fractures complicated by comminution and loss of bone stock. All patients were treated with the help of cantilever mechanism using multiple Kirschner wires augmented by compression plates. All the patients were operated by the same surgeon between November 2020 to March 2021 and followed up till March 2023. Surgical outcomes were evaluated according to the clinical and radiological criteria. A total of 10 patients were included in the study. Since we only included patients with highly unstable and comminuted fractures which were difficult to fix with traditional methods, the number of patients in the study were less. All 10 patients showed satisfactory clinical and radiological union at the end of the study with good range of motion. One of the patient in the study had post-operative wound complication which was managed conservatively with regular dressings and oral antibiotics. Comminuted metaphyseal fractures might differ in pattern and presentation with every patient and there can be no standard treatment for all. The cantilever technique of fracture fixation is based on the principle of cantilever mechanism used in bridges and helps achieve good anatomical reduction and fixation. It provides a decent alternative when standard modes of fixation don't give desired result owing to comminuted nature of fractures and deficiency of bone stock

Background. Comminuted fractures involving the tibia are associated with a high level of complications including delayed healing and non-union, in conjunction with dramatically increased healthcare costs. Certain clinicians utilise a Pixel Value Ratio (PRV) of 1 to indicate such fracture healing. The subjectivity of this method has led to mixed outcomes including regenerate fracture. The poor prognosis of complex load bearing fractures is accentuated by the fact that no quantitative gold standard currently exists to which clinicians can reference regarding the definition of a healed fracture. The aim of the current study is to use patient specific finite element analysis of complex tibial fractures treated with Ilizarov frames to demonstrate callus maturation and to determine the optimum frame removal time. Methods. 3 patients (2 males, 1 female) were analysed following presentation with complex tibial fractures treated with Ilizarov frames. Patient specific computational analysis was performed according to radiographic data, incorporating maturing material properties to analyse the callus response to weight bearing over the healing timeframe. Computational results were compared to the PVR method to evaluate its efficacy in determining the optimum Ilizarov frame removal time. Results. All fractures were observed to clinically heal at a mean of 25.4 (±2.404) weeks. Following computational analysis however, the mean optimum Ilizarov frame removal time was seen to be 23.5 (±2.323) weeks. When compared with the PVR method, the suggested removal time presented a mean PVR of 1.025 (±0.017). Conclusion. Computational models of patient specific tibial fractures has shown promising correlations with the PVR method and has shown efficacy in predicting callus strength and subsequent optimum frame removal time. Level of Evidence. Level 4

Seventy-eight children, with 79 femoral fractures, treated with titanium elastic intramedullary nails were reviewed for complications. Insertion site symptoms (41), malunion (8), refracture (2), transient neurological deficit (2), superficial wound infection (2), and reoperation prior to union (10). Malunion/loss of reduction was increased with mismatched nails (p=0.02) and comminution (p=0.02). Insertion site symptoms were increased with nail ends that were bent (p=0.02), or > 10mm prominent (p=0.002). Nails remain implanted in 25 children without problems. Nail ends should lie against the femur to avoid insertion site symptoms. Nails of different diameters should not be implanted. Comminuted fractures require close monitoring

Background. Leg length discrepancy (LLD) after intramedullary nailing of femoral shaft fractures is a common problem reported in up to 43% of cases. Comminuted fractures with radiographic loss of bony landmarks have an increased possibility of being fixed with unequal leg lengths. Aims. The purpose of this report is to evaluate the efficacy of routinely obtaining a CT scanogram post-operatively on patients of comminuted femoral shaft fractures treated with intramedullary nailing and immediate correction of limb length inequality if indicated. Results. Twenty one patients with comminuted femoral shaft fractures that were treated with intramedullary nailing and underwent a CT scannogram for evaluation of LLD were included in the study. There were 12 patients with Winquist III and 9 with a Winquist IV fracture pattern. Following surgery leg lengths were measured from the CT scanograms using a computerised measuring ruler. The largest leg length discrepancy noted on scannogram was 4 cm. The average limb length discrepancy was 0.67 cm. Eight patients had a discrepancy of 1cm or greater. We also measured the tibial length in all patients and found only 3 patients with exactly equal tibial lengths. A tibial length discrepancy less than 5mm was observed in 11 patients. In 7 patients it was between 5-9mm and in 3 patients it was 10mm or greater. Four patients underwent leg length correction during the same admission. Conclusion. The decision to undertake correction of the LLD is primarily dependant on the degree of discrepancy. The degree of LLD that requires correction remains undefined. In this study LLD of greater than 15mm was considered for equalisation. Immediate equalisation saves cost, morbidity, delayed sequelae and litigation. Tibial length discrepancy may contribute to the total leg length discrepancy and requires consideration. We recommend a post-operative scanogram costing $380 in patients of comminuted femoral shaft fractures treated with intramedullary nailing

Our Purpose is to present the results of treatment of 35 (thirty five) comminuted fractures of the diaphyses of Tibia and Fibula with combination of Orthofix External Fixator and Sarmiento Brace. In Syros General Hospital, during the last 8 (eight) years, 35 (thirty five) comminuted fractures of the Diaphyses of Tibia and Fibula were treated. Twenty were closed and 15 (fifteen) compound. Five were type 1, 8 (eight) type 2 and 2 type 3 Gustilo. Our Method : After a good surgical cleaning all fractures were reduced and stabilized with Orthofix External Fixator. We used two pins above and two pins below the fracture. According to the union of the fracture, we allowed partial weight bearing with dynamization. In three months the External Fixator was removed and a Sarmiento Brace was put. With the Brace we allowed full weight bearing until the fracture was united. Results: All fractures united. It took five months for the close and six months for the compound. There was no displacement in any fracture. In four fractures we had pin infection that was cured with antibiotics and lack of weight bearing for 15 days. Conclusion : Comminuted fractures of Tibia are a challenge for every Orthopaedic Surgeon. We believe that the combination of those two methods that are simple and safe solve the treatment of those difficult fractures

Purpose: To calculate a clinically relevant and intra-operatively accessible measure of olecranon length that could be reliably applied by the operating surgeon to optimise comminuted olecranon fracture fixation. Materials: One hundred normal adult anteroposterior and lateral radiographs of the elbow were studied with respect to the proximal olecranon width (OW), greater sigmoid notch width (SW) on lateral views, trans-epicondylar distance (TED), and trochlear width distance (TWD) on AP views. The mean ratios of TWD/SW and TED/SW and an index OW X SW/TED along with their standard deviation and normal ranges were calculated. Results: The average olecranon width was 24mm (range 21mm–28mm), sigmoid width was 25.8 mm (range 21mm–32 mm), trans-epicondylar distance was 58.53mm (range 49mm–74 mm), and the trochlear width distance was 27.1mm (range 22mm–32 mm). The average ratio of TWD: SW was 1.05 with a standard deviation of 0.09 and that of TED: SW was 2.27 with a standard deviation of 0.19. The average index worked out to be 10.58 with a standard deviation of 0.2. Conclusions: Comminuted fractures of olecranon are a surgical challenge since it is often impossible to gauge the correct length of the olecranon process. There have been no objective data described to prevent shortening or lengthening of the greater sigmoid notch after reconstruction. Our data can be easily applied to the clinical situation, by taking intra-operative radiographs, and calculating the index as demonstrated above. This index will guide the surgeon to obtain a more reliable length of the olecranon, and devolve surgical guesswork from the final outcome

Treatment of comminuted intraarticular calcaneal fractures remains controversial and challenging. Anatomic reduction with stable fixation has demonstrated better outcomes than nonoperative treatment of displaced intraarticular fractures involving the posterior facet and anterior calcaneocuboid joint (CCJ) articulating surface of the calcaneus. The aim of this study was to investigate the biomechanical performance of three different methods for fixation of comminuted intraarticular calcaneal fractures. Comminuted calcaneal fractures, including Sanders III-AB fracture of the posterior facet and Kinner II-B fracture of the CCJ articulating calcaneal surface, were simulated in 18 fresh-frozen human cadaveric lower legs by means of osteotomies. The ankle joint, medial soft tissues and midtarsal bones along with the ligaments were preserved. The specimens were randomized according to their bone mineral density to 3 groups for fixation with either (1) 2.7 mm variable-angle locking anterolateral calcaneal plate in combination with one 4.5 mm and one 6.5 mm cannulated screw (Group 1), (2) 2.7 mm variable-angle locking lateral calcaneal plate (Group 2), or (3) interlocking calcaneal nail with 3.5 mm screws in combination with 3 separate 4.0 mm cannulated screws (Group 3). All specimens were biomechanically tested until failure under axial loading with the foot in simulated midstance position. Each test commenced with an initial quasi-static compression ramp from 50 N to 200 N, followed by progressively increasing cyclic loading at 2Hz. Starting from 200 N, the peak load of each cycle increased at a rate of 0.2 N/cycle. Interfragmentary movements were captured by means of optical motion tracking. In addition, mediolateral X-rays were taken every 250 cycles with a triggered C-arm. Varus deformation between the tuber calcanei and lateral calcaneal fragments, plantar gapping between the anterior process and tuber fragments, displacement at the plantar aspect of the CCJ articular calcaneal surface, and Böhler angle were evaluated. Varus deformation of 10° was reached at significantly lower number of cycles in Group 2 compared to Group 1 and Group 3 (P ≤ 0.017). Both cycles to 10° plantar gapping and 2 mm displacement at the CCJ articular calcaneal surface revealed no significant differences between the groups (P ≥ 0.773). Böhler angle after 5000 cycles (1200 N peak load) had significantly bigger decrease in Group 2 compared to both other groups (P ≤ 0.020). From biomechanical perspective, treatment of comminuted intraarticular calcaneal fractures using variable-angle locked plate with additional longitudinal screws or interlocked nail in combination with separate transversal screws seems to provide superior stability as opposed to variable-angle locked plating only

Aim: To assess the clinical and functional outcome of proximal humeral fractures (2,3 and 4 parts) fixation with PHILOS (Proximal Humeral interlocked Osteosynthesis) plate using Oxford and DASH scoring system. Methods: Forty-eight consecutive patients were treated with PHILOS plate from the complex proximal humeral fractures. One senior surgeon, using PHILOS plates, operated all patients. The patients were regularly assessed clinically, and plain radiographic evaluation was performed for fracture healing, avascular necrosis, and implant failure. Clinical outcome was measured using Oxford shoulder scores and DASH (Disability of the arm, shoulder, and hand) scores. Patients, who died, lost the follow up or the follow up was less than 3 months were excluded from the study. Results: There were nine male patients (Age: 29–89 yrs) and twenty-nine female patients (Age: 35–93 yrs). Average age: 65 yrs. 74% were two part and three part fractures. Five patients died and four were lost in follow-up. These patients were excluded from the study. Mean follow-up time: 21.7 months (range: 6–44 months). Mean oxford shoulder scores: 41.8 (range: 14–60), Mean DASH scores: 30.2 (range: 0–83.3). There were no cases of non-union. Two plates were removed after fracture healing for complications of impingement and screw cutout. Discussion & conclusion: Proximal humeral fractures constitute 5–7% of all fractures and 26% of humeral fractures.13–16% of proximal humeral fractures are 3 & 4 parts. Proximal humeral fractures have been a challenge to acquire stable fixation. Difficulties have been multifactorial, including osteoporotic bone, angular instability and non-availability of the low-profile implant to avoid impingements. PHILOS plate having locking screws provides angular stability and better hold in osteoporotic bone. It is low profile, which avoids subacromial impingement. Multiple holes in the proximal part of plate for suture anchors helps for soft tissue augmentation. PHILOS plate can provide an excellent stable construct even in multifragmented Osteoporotic proximal humeral fractures. Our study has shown that PHILOS plates are reliable implants for internal fixation of proximal humerus fractures. An inverse correlation was seen between oxford shoulder scores and DASH scores. Patients with higher oxford scores indicating a good outcome had lesser disability scores. Comminuted fractures (four part fractures) had less than satisfactory shoulder scores and higher disability scores. In general, younger patients did better than older patients. This study demonstrates that PHILOS plates provide stable internal fixation for proximal humerus fractures. Age and fracture configuration play a significant role in the clinical outcome of these fractures after internal fixation

Aims

Low-energy distal radius fractures (DRFs) are the most common upper arm fractures correlated with bone fragility. Vitamin D deficiency is an important risk factor associated with DRFs. However, the relationship between DRF severity and vitamin D deficiency is not elucidated. Therefore, this study aimed to identify the correlation between DRF severity and serum 25-hydroxyvitamin-D level, which is an indicator of vitamin D deficiency.

Comminuted subtrochanteric fractures pose a clinical challenge; locking plate technology has been theorized to offer treatment advantages. A comminuted subtrochanteric femoral fracture model was created with a 2 cm gap below the lesser trochanter in fifteen matched pairs of human cadaveric femora confirmed to be non-osteoporotic. The femora were randomized to treatment with a trochanteric femoral nail (TFN), proximal femoral locking plate (PFLP), or 95° angled blade plate (ABP). Each was tested under incrementally increasing cyclic load up to 90,000 cycles to simulate progressive weight bearing during three months. The TFN was the strongest implant: it withstood significantly more cycles, failed at a significantly higher force, and withstood a significantly greater load than either plate (p< 0.001). Varus collapse was significantly lower in the TFN construct (p< 0.0001). Mode of failure differed among implants, with damage to the femoral head through implant cut-out in five of ten blade plate specimens and two of ten nail specimens, whereas no damage to the femoral head bone was observed in any of the PFLP specimens. The TFN was biomechanically stronger than the PFLP and this may have clinical relevance during the slow healing of subtrochanteric femoral fractures. The PFLP was biomechanically equivalent to the ABP but failure occurred without significant damage to the femoral head, suggesting that although biomechanically equivalent, the PFLP might have clinically relevant advantages in its mode of failure over the ABP

Background. Comminuted radial head fractures are challenging to treat with open reduction and internal fixation. Complicating matters further, radial head fractures are often associated with other elbow fractures and soft tissue injuries. Radial head arthroplasty is a favorable technique for the treatment of radial head fractures. The purpose of this study was to evaluate the functional outcomes of radial head arthroplasty using Modular Pyrocarbon radial head prosthesis in patients with unreconstructible radial head fractures. Methods. This single surgeon, single centre study retrospectively reviewed the functional and radiological outcomes of 21 consecutive patients requiring radial head arthroplasty for unreconstructible radial head fractures between July 2003 and July 2009. Patients were at least one year post-op and completed a Short-Form 36 (SF-36) questionnaire, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and the Mayo Elbow Performance Index (MEPI). These patients were independently physically examined and their post-operative radiographs were independently reviewed. Results. 21 patients (9 males and 12 females) were reviewed at a minimum of 12 months follow-up. The mean DASH score was 10.8 (0-34.1), the mean SF-36 physical score was 76.9 (35-96), the mean SF-36 mental score was 83.8 (60-94), and their MEPI score was 86.4 (70-100). Patients maintained 90% of their grip strength in their injured arm when compared to their un-injured arm and had 17. o. of fixed flexion in the affected arm. Radiologically, 14 cases had some degree of post-traumatic osteoarthritis, 12 cases had evidence of heterotrophic ossification, 5 had some evidence of periprosthetic lucency and 3 of our cases were radiologically but not functionally ‘overstuffed’. Conclusion. Radial Head Arthroplasty with Pyrocarbon Radial Head Prosthesis is a safe and effective option when treating unreconstructable comminuted radial head fractures yielding good functional and radiological outcomes and remains the treatment option of choice at our institution

Introduction. Comminuted mid-foot fractures are uncommon. Maintenance of the length and alignment of the medial column, with restoration of articular surface congruity, is associated with improved outcomes. Conventional surgery has utilised open or closed reduction with K-wire fixation, percutaneous techniques, ORIF, external fixation or a combination of these methods. In 2003 temporary bridge plating of the medial column was described to reconstruct and stabilise the medial column. The added advantage of locking plates is the use of angle-stable fixation. We present our experience with temporary locking plates in complex mid-foot fractures. Materials and methods. Prospective audit database of 12 patients over a 6 year period (2003-2009). 5 males 7 females mean age 41.9. Mechanism of injury: 11 high-energy injuries (6 falls from height, 5 RTCs), 1 low energy injury. Fracture type: All involved the medial column - 12 fracture dislocations of the medial column. 4 concomitant injuries to the lateral column. All underwent ORIF, realignment, and stabilisation with locking plates across the mid-foot. Results. Median length of time to plate removal: 3 months (range 2-6). Prior to removal of the metalwork, there was no loss of reduction, no infections, and no implant breakage. 10 out of 12 required plate removal at 3 months. Long-term follow-up (Mean 12.4 months, range 4-32): 11 have minimal symptoms of swelling or discomfort from the midfoot which does not restrict their ADLs, whilst 1 patient developed post-traumatic arthritis with medial arch collapse. No secondary procedures following plate removal. The two patients with the plate in-situ were asymptomatic with regards to the metalwork at final follow-up. Conclusion. Locking plates provide adequate stabilisation following open reduction and internal fixation of complex and unstable midfoot fracture dislocations. However, the majority will require removal of the metalwork. Following removal of the metalwork, satisfactory length and alignment, and stability of the midfoot, is maintained

This cohort study reports outcomes of patients with comminuted radial head fractures treated with a modular radial head arthroplasty. Twenty-six patients (mean age = fifty-four) were prospectively followed at three, six, twelve, and twenty-four months following surgery. Patient satisfaction with this procedure was high. This data indicates favorable results using a modular radial head arthroplasty with rapid improvement in disability and physical impairment occurring in all measures in the first six months and further improvement in most patients up to two years. The Mayo Elbow Performance Index was at one year and eighty-four at two years. To investigate the objective and subjective outcomes of unreconstructable radial head fractures treated with a modular radial head arthroplasty. This data indicates favorable results using a modular radial head arthroplasty with improvement in satisfaction, disability and physical impairment occurring in all measures in the first six-months and continued improvement for up to two-years. Comminuted radial head fractures are challenging to treat with ORIF. Radial head arthroplasty is an alternative treatment that compares favorably to reported results for ORIF of similar fractures. Significant improvements were noted over time in self-reported and measured impairments as follows: ASES pain: baseline = 30/50, two years = 15/50; ASES function: baseline = 5/36, two years 27/36; MEPI one year = eighty-two, two years = eight-four. At two years, little impairment was observed compared to the unaffected side in grip 22/26 kg, flexion 141°/145°, or pronation 74°/79°. Moderate differences were noted in extension 28°/2°, supination 57°/72° and strength measures: extension = 29/38, flexion = 31/40, supination = 43/65, pronation = 37/53 (Nm). Patient satisfaction was high at three months (9/10) and remained high at two years (9.1/10). A cohort of twenty-six patients (seventeen female, mean age fifty-four) with non-reconstructable radial head fractures was treated using a modular metallic radial head arthroplasty (Evolve TM, Wright Medical Technology, Arlington, TN). All patients were prospectively followed at three, six, twelve and twenty-four months. Self-report of limb function, general health, measured ROM and isometric strength were assessed by an independent observer. Funding Institution research foundation support was provided by Wright Medical Technology. None of the authors received direct compensation for commercial products related to the content of this study

Introduction Comminuted intra-articular fractures of the distal radius are severe injuries where the outcome depends on accurate anatomical reduction and reconstitution of the articular surface, and early mobilisation. This prospective outcome study aims to assess the anatomical and functional outcome of internal fixation of these complex fractures using a fragment specific fixation system. Methods Fifty consecutive comminuted intra-articular distal radius fractures presenting at our hospital were treated by the one surgeon (MP). Inclusion criteria were age under 80 and AO classification C-3. Various combinations of wires, buttress pins/clips and plates were utilized according to each fracture configuration. No post-op splintage was used. All patients commenced hand therapy from day one post-op. Patients were reviewed at two weekly intervals till fracture union and monthly thereafter. All patients were independently assessed by a hand therapist for range of motion and grip strength. Patient function was assessed using the DASH (Disabilities of the Arm, Shoulder and Hand) and the PRWE scores. Thirteen males and 37 female with an average age of 53.8 (29 to 72) were treated with the TriMed between February 2002 and February 2003. Average follow-up was seven months (3 to 14). Results All fractures had healed at the six week review, with mean palmar tilt of 12°, radial tilt of 19° and radioulnar variance of 5 mm, with articular step less than 1 mm. The mean DASH score was 19 (SD 9) and mean PRWE score was 19 (SD 11). Average range-of-motion was 65 (SD 17) dorsi-flexion, 55 (SD 19) palmar-flexion, 73 pronation and 67 supination. Grip strength recovered to 85% on average when compared to the opposite hand. There were no deep or superficial wound infections. Three patients had difficulty regaining early hand function, with difficulty complying with physiotherapy. One had borderline mental retardation. Two displayed symptoms of RDS, one responding to medication, and one requiring guanethidine arm block. Conclusions Intra-articular distal radius fractures can be reliably and anatomically reduced and stabilized using fragment-specific fixation. Fixation of markedly comminuted fractures is secure enough to allow immediate motion. Clinical and radiographic results are excellent, and patient satisfaction is high. Patient compliance with hand therapy is critical for a good functional result

Objectives

The paradoxical migration of the femoral neck element (FNE) superomedially against gravity, with respect to the intramedullary component of the cephalomedullary device, is a poorly understood phenomenon increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. The aim of this study was to investigate the role of bidirectional loading on the medial migration phenomenon, based on unique wear patterns seen on scanning electron microscopy of retrieved implants suggestive of FNE toggling.

Objectives

A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion.