Abstract. Introduction. A lipohaemarthrosis seen on Horizontal beam lateral X-ray in acute knee injury is often considered predictive of an intra-articular fracture requiring further urgent imaging. Methodology. We retrospectively searched a five-year X-ray database for the term “lipohaemarthrosis”. We excluded cases if the report concluded “no lipohaemarthrosis” or “lipohaemarthrosis” AND “fracture”. All remaining cases were reviewed by an Orthopaedic Consultant with a special interest in knee injuries (AD) blinded to the report. X-rays were excluded if a fracture was seen, established osteoarthritic change was present, a pre-existing arthroplasty present or no lipohaemarthrosis present. Remaining cases were then studied for any subsequent Radiological or Orthopaedic surgical procedures. Results. 136 cases were identified and reviewed by an Orthopaedic Consultant. 31 were excluded for no lipohaemarthrosis (n= 11), for degenerative change (n=9), for fracture (n=4), for existing arthroplasty (n=4) and for data errors (n=3). The remaining 105 patients had a mean age of 32, and range 5–90 years. 66 patients underwent further imaging in the form of MRI scan (n=47), CT Scan (n=9) repeat x-rays (n=9) and ultrasound (n=1). 27 fractures were identified. Surgery was performed in 12 cases (11%). Two (2%) urgently (One ACL reconstruction plus meniscus repair, one for ORIF of tibial plateau fracture). Ten (10%) had elective surgery (6 for ACL reconstruction, 2 for ACL reconstruction plus meniscus repair, 2 for loose body removal. Conclusion. The presence of a lipohaemarthrosis on x-ray following acute knee injury was a poor predictor of intra-articular fracture (26%) or need for urgent surgery (2%)

Introduction: The magnitude of the initial chondral injury and the residual articular step-off are amongst prognostic factors implicated in outcome following intra-articular fractures. The alignment of an intra-articular fracture line may be an as yet unrecognised prognostic variable. Hypothesis: That fractures in the coronal plane of the medial femoral condyle result in worse outcomes than those in the sagittal plane. Aim: To compare the effect of displaced intra-articular osteotomies (ie simulating fractures fixed in an incongruent position) of the medial femoral condyle – in one group performed in the sagittal plane, in the other in the coronal plane. Materials and Methods: The study was conducted in two arms: in vitro and in vivo. In vitro study: A pneumo-electric rig was designed and built. Ten freshly harvested porcine knee joints underwent osteotomy (test specimens: 5 sagittal, 5 coronal). 5 control specimens underwent no osteotomy. Specimens were mounted on the rig and subjected to cyclical flexion and extension under load (40,000 cycles over 11 hours). Transarticular pressure measurements were performed before and after testing. Surface roughness was measured following testing using laser interferometry. In vivo study: Three groups (A to C), each comprising 15 New Zealand white rabbits were utilised. Rabbits from each group were consigned to a control (5), coronal osteotomy (5) or sagittal osteotomy (5) group. Rabbits in group A were sacrificed at 3 weeks (early outcome), group B at 10 weeks (immediate) and group C at 20 weeks (long term). The knee was then harvested en bloc and prepared for light microscopy. A further 10 specimens underwent electron microscopy of the medial meniscus. Results:. In vitro study: A significant difference in loading patterns was noted between the sagittal, coronal and control groups. Specimens from the sagittal group sustained significantly more wear on the apposing medial tibial articular surface (p=0.04), with the meniscus having a protective effect on the underlying articular surface. In vivo study: Light microscopy confirmed degenerative changes in the apposing tibial articular cartilage, being more marked in sagittal specimens. On the femoral side of the knee, the healing response of the femoral osteotomy was significantly better in sagittal test specimens than coronal (p< 0.05). Conclusion: In contrast to the hypothesis, sagittal femoral step-offs gave rise to more tibial wear. This can be explained by the short duration of exposure of the coronal incongruity to the apposing joint during the flexion extension cycle. The sagittal step-off was constantly exposed, giving rise to persistently elevated tibial joint loading pressures opposite the high side of the step-off. In contrast, the coronal femoral osteotomies had a worse healing response. The alignment of the fracture line perpendicular to the plane of motion of the joint exposes the repair tissue within it to increased shear and tensile stresses. This may play a negative role in the repair of these coronal defects when compared to sagittal osteotomies, which are relatively protected from the high transarticular pressures and showed a greater tendency to remodel their articular surface

Aims. Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. Methods. A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). Results. The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (p. preop. = 0.05; p. discharge. < 0.001) and need for narcotics (p. preop. = 0.064; p. postop. = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. Conclusion. Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746–754

Aims. Management of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures and those in whom surgery was highly likely to produce an equivocal functional outcome with potential post-operative complications. Methods. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and post-operative fracture geometry with Computed Tomography (CT) used for pre-operative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score. Results. Fifty-eight intra-articular calcaneal fractures (fifty-three patients including five bilateral, mean age = 46.91 years) were included. Forty-nine patients were injured as a result of a fall from a height (92.4%). Mean time from presentation to surgery was 3.23 days (range 0–21). Mean Maryland Foot score was found to be 77.6 (+/− 16.22) in forty-five patients. Five patients (9.4%) had wound complications; two superficial (3.7%) and three deep (5.6%). Conclusion. Intra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of post-operative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management

Background: Closed reduction of intra-articular calcaneal fractures sometimes lack the accuracy desired for restoring the normal anatomy of the articular surface of the calcaneus. In this study, we evaluate the preliminary results of closed reduction of the intra-articular calcaneal fractures with an Ilizarov frame. Patients and Method: Forty patients (25 males and 15 females) with 50 intra-articular fracture calcaneal fractures were treated with closed reduction and an Ilizarov frame. The mean age was 25.4 years (range from 19 to 65). Union was achieved after two months. The results were evaluated on the basis of combined clinical and radiological examination at the latest follow-up. Results were classified according to the protocol and scoring system used by Paley and Hall 1993. Results: The mean follow up period was 1.9 years (range 6 months to 4 years). At final follow up there were 15 excellent feet, 26 were good, 6 fair and 3 poor. The mean Bohler angle postoperatively was 260 (range 17 to 35). Superficial infection occurred in seven feet and was controlled. Skin pressure necrosis of the posterior aspect of the heel occurred in three feet. One needed a skin graft. Conclusion: This method is a minimally invasive technique. The technique has the ability to restore the normal anatomy, shape and length of the calcaneal body, especially in Sander’s type III and type IV fractures. It is particularly useful for osteoprotic bone as it provides rigid fixation

Background. Optimal management of displaced intra-articular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiological outcomes of minimally invasive surgery (MIS) versus non-operative treatment in displaced intra-articular calcaneal fracture up to 2-years. Methods. All displaced intra-articular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma centre were considered for inclusion. The decision to treat was made by a multidisciplinary meeting. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction & internal fixation. Non-operative protocol involved symptomatic management with no attempt at closed reduction. All fractures were classified, and the MOXFQ/EQ-5D-5L scores were used to assess foot and ankle and general health-related quality of life outcomes respectively. Results. 101 patients were recruited at a level 1 major trauma centre, between August 2014 and January 2019. Our propensity score matched 44 patients in the surgical cohort to 44 patients in the non-surgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (p<0.05) however the patients in the surgical cohort had a significantly higher EQ-5D-5L Index score (p<0.05). There was also a higher return to work (91% vs 72%, p<0.05) and physical activity rate (46 vs. 35%, p<0.05) in the surgical cohort despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. 14% of patients in the non-operative cohort subsequently underwent arthrodesis compared to none of the patients in the surgical cohort. Conclusion. In this study, we found operative treatments were associated with low rates of surgical complication at 2-years and long term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared to nonoperative treatment

Distal radius fractures (DRFs) are one of the most common types of fracture and one which is often treated surgically. Standard X-rays are obtained for DRFs, and in most cases that have an intra-articular component, a routine CT is also performed. However, it is estimated that CT is only required in 20% of cases and therefore routine CT's results in the overutilisation of resources burdening radiology and emergency departments. In this study, we explore the feasibility of using deep learning to differentiate intra- and extra-articular DRFs automatically and help streamline which fractures require a CT. Retrospectively x-ray images were retrieved from 615 DRF patients who were treated with an ORIF at the Royal Brisbane and Women's Hospital. The images were classified into AO Type A, B or C fractures by three training registrars supervised by a consultant. Deep learning was utilised in a two-stage process: 1) localise and focus the region of interest around the wrist using the YOLOv5 object detection network and 2) classify the fracture using a EfficientNet-B3 network to differentiate intra- and extra-articular fractures. The distal radius region of interest (ROI) detection stage using the ensemble model of YOLO networks detected all ROIs on the test set with no false positives. The average intersection over union between the YOLO detections and the ROI ground truth was Error! Digit expected.. The DRF classification stage using the EfficientNet-B3 ensemble achieved an area under the receiver operating characteristic curve of 0.82 for differentiating intra-articular fractures. The proposed DRF classification framework using ensemble models of YOLO and EfficientNet achieved satisfactory performance in intra- and extra-articular fracture classification. This work demonstrates the potential in automatic fracture characterization using deep learning and can serve to streamline decision making for axial imaging helping to reduce unnecessary CT scans

Chauffeur fractures or isolated radial styloid fractures (IRSF) are known to be associated with scapholunate ligament (SL) injuries. Diagnosis without arthroscopic confirmation is difficult in acute fractures. Acute management of this injury with early repair may prevent the need for more complex reconstructive procedures for chronic injuries. We investigated if all IRSF should be assessed arthroscopically for concomitant SL injuries. We performed a prospective cohort study on patients above the age of 16, presenting to the Gold Coast University Hospital with an IRSF, over 2 years. Plain radiographs and computerized tomography (CT) scans were performed. All patients had a diagnostic wrist arthroscopy performed in addition to an internal fixation of the IRSF. Patients were followed up for at least 3 months post operatively. SL repair was performed for all Geissler Grade 3/4 injuries. 10 consecutive patients were included in the study. There was no radiographic evidence of SL injuries in all patients. SL injuries were identified arthroscopically in 60% of patients and one third of these required surgical stabilisation. There were no post operative complications associated with wrist arthroscopy. We found that SL injuries occurred in 60% of IRSF and 20% of patients require surgical stabilisation. This finding is in line with the literature where SL injuries are reported in up to 40-80% of patients. Radiographic investigations were not reliable in predicting possible SL injuries in IRSF. However, no SL injuries were identified in undisplaced IRSF. In addition to identifying SL injuries, arthroscopy also aids in assisting and confirming the reduction of these intra-articular fractures. In conclusion, we should have a high index of suspicion of SL injury in IRSF. Arthroscopic assisted fixation should be considered in all displaced IRSF. This is a safe additional procedure which may prevent missed SL injuries and their potential sequelae

Background. Anatomical reduction of unstable Lisfranc injuries is crucial. Evidence as to the best methods of surgical stabilization remains sparse, with small patient numbers a particular issue. Dorsal bridge plating offers rigid stability and joint preservation. The primary aim of this study was to assess the medium-term functional outcomes for patients treated with this technique at our centre. Additionally, we review for risk factors that influence outcomes. Methods. 85 patients who underwent open reduction and dorsal bridge plate fixation of unstable Lisfranc injuries between January 2014 and January 2019 were identified. Metalwork was not routinely removed. A retrospective review of case notes was conducted. The Manchester-Oxford Foot Questionnaire summary index (MOXFQ-Index) was the primary outcome measure, collected at final follow-up, with a minimum follow-up of 24 months. The American Orthopedic Foot and Ankle Society (AOFAS) midfoot scale, complications, and all-cause re-operation rates were secondary outcome measures. Univariate and multivariate analyses were used to identify risk factors associated with poorer outcomes. Results. Mean follow-up 40.8 months (24–72). Mean MOXFQ-Index 27.0 (SD 7.1). Mean AOFAS score 72.6 (SD 11.6). 48/85 patients had injury patterns that included an intra-articular fracture and this was associated with poorer outcomes, with worse MOXFQ and AOFAS scores (both p < 0.001). 18 patients (21%) required the removal of metalwork for either prominence or stiffness. Female patients were more likely to require metalwork removal (OR 3.89, 95% CI 1.27 to 12.0, p = 0.02). Eight patients (9%) required secondary arthrodesis. Conclusions. This is the largest series of Lisfranc injuries treated with dorsal bridge plate fixation reported to date and the only to routinely retain metalwork. The technique is safe and effective. The presence of an intraarticular fracture is a poor prognostic indicator. Metalwork removal is more likely to be needed in female patients but routine removal may not be essential

Introduction. Diaphyseal tibial fractures account for approximately 1.9% of adult fractures. Studies have demonstrated a high proportion have ipsilateral occult posterior malleolus fractures. We hypothesize that this rotational element will be highlighted using the Mason & Molloy Classification. Materials and Methods. A retrospective review of a prospectively collected database was performed at Liverpool University Hospitals NHS Foundation Trust between 1/1/2013 and 9/11/2020. The inclusion criteria were patients over 16, with a diaphyseal tibial fracture, who underwent a CT. The Mason and Molloy posterior malleolus fracture classification system was used. Results. 764 diaphyseal tibial fractures were analysed, 300 had a CT. 127 were intra-articular fractures. 83 (27.7%) were classifiable using Mason and Molloy classification. There were 8 type 1 (9.6%), 43 type 2 (51.8%), 5 type 2B (6.0%) and 27 type 3 (32.5%). 90.4% (n=75) of the posterior malleolar fractures, were undisplaced. The majority of PM fractures occurred in type 42A1 (65 of 142 tibia fractures) and 42B1 (11 of 16). Conclusions. Most PM fractures occurred after a rotational mechanism. Unlike, the PM fractures of the ankle, the majority of PM fractures associated with tibia fractures are undisplaced. We theorise that unlike the force transmission in ankle fractures where the rotational force is in the axial plane in a distal-proximal direction, in the PM fractures related to fractures of the tibia, the rotational force in the axial plane progresses from proximal-distal. Therefore, the force transmission which exits posteriorly, finally dissipates the force and thus unlikely to displace

Introduction. Diaphyseal tibial fractures account for approximately 1.9% of adult fractures. Several studies demonstrate a high proportion of diaphyseal tibial fractures have ipsilateral occult posterior malleolus fractures, this ranges from 22–92.3%. Materials and Methods. A retrospective review of a prospectively collected database was performed at Liverpool University Hospitals NHS Foundation Trust between 1/1/2013 and 9/11/2020. The inclusion criteria were patients over 16, with a diaphyseal tibial fracture and who underwent a CT. The articular fracture extension was categorised into either posterior malleolar (PM) or other fracture. Results. 764 fractures were analysed, 300 had a CT. There were 127 intra-articular fractures. 83 (65.4%) cases were PM and 44 were other fractures. On univariate analysis for PM fractures, fibular spiral (p=.016) fractures, no fibular fracture(p=.003), lateral direction of the tibial fracture (p=.04), female gender (p=.002), AO 42B1 (p=.033) and an increasing angle of tibial fracture. On multivariate regression analysis a high angle of tibia fracture was significant. Other fracture extensions were associated with no fibular fracture (p=.002), medial direction of tibia fracture (p=.004), female gender (p=.000), and AO 42A1 (p=.004), 42A2 (p=.029), 42B3 (p=.035) and 42C2 (p=.032). On multivariate analysis, the lateral direction of tibia fracture, and AO classification 42A1 and 42A2 were significant. Conclusions. Articular extension happened in 42.3%. A number of factors were associated with the extension, however multivariate analysis did not create a suitable prediction model. Nevertheless, rotational tibia fractures with a high angle of fracture should have further investigation with a CT

Radial head fractures are among the most common fractures around the elbow. Radial head arthroplasty is one of the surgical treatment options after complex radial head fractures. This surgery is usually done under general anaesthesia. However, there is a recent anaesthetic technique - wide awake local anaesthesia no tourniquet (WALANT) - that has proven useful in different surgical settings, such as in distal radius or olecranon fractures. It allows a good haemostatic control without the use of a tourniquet and allows the patient to actively collaborate during the surgical procedure. Furthermore, there are no side effects or complications caused by the general anaesthesia and there's an earlier patient discharge. The authors present the case of a seventy-six-year-old woman who presented to the emergency department after a fall from standing height with direct trauma to the left elbow. The radiological examination revealed a complete intra-articular comminuted fracture of the radial head (Mason III). Clinical management: The patient was submitted to surgery with radial head arthroplasty, using WALANT. The surgery was successfully completed without pain. There were no intra or immediate post-operative complications and the patient was discharged on the same day. Six weeks after surgery, the patient had almost full range of motion and was very pleased with the functional outcome, with no limitations on her activities of daily living. The use of WALANT has been expanded beyond the hand and wrist surgery. It is a safe and simple option for patients at high risk of general anaesthesia, allowing similar surgical outcomes without the intraoperative and postoperative complications of general anaesthesia and permitting an earlier hospital discharge. Furthermore, it allows the patient to actively collaborate during the surgery, providing the surgeons the opportunity to evaluate active mobility and stability, permitting final corrections before closing the incision

Introduction. Pilon fractures are complex, high-energy, intra-articular fractures of the distal tibia. Achieving good outcomes is challenging due to fracture complexity and extensive soft tissue damage. The purpose of this study was to determine the long-term functional and clinical outcomes of definitive management with fine wire Ilizarov fixation for closed pilon fractures. Materials and Methods. 185 patients treated over a 14-year period (2004–2018) were included. All patients had Ilizarov frames applied to restore mechanical axis and fine wires to control periarticular fragments. CT scans were performed post operatively to confirm satisfactory restoration of the articular surface. All frames were dynamized prior to removal. Patients' functional outcome was assessed using the validated Chertsey Outcome Score for Trauma (“COST”). Review of clinical notes and imaging was used to determine complications and time to union. Results. The mean functional outcome in the studied cohort was determined to be “average” on the “COST” score. Poorer functional outcomes were associated with younger age at time of injury and multi-fragment fracture patterns. Mean time in frame was 170 days. Complication rates were low. There were no deep infections, no amputations and only 8 patients went on to have ankle fusions. Conclusions. Good functional results and low complication rates can be achieved by managing pilon fractures with fine wire Ilizarov fixation. Nonetheless, at time of injury patients should be counselled as to the severity of the injury and impact on their functional status

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain - VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain – VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Distal radius fractures (DRF) are very common injuries. National recommendations (British Orthopaedic Association, National Institute for Health and Care Excellence (NICE)) exist in the UK to guide the management of these injuries. These guidelines provide recommendations about several aspects of care including which type of injuries to treat non-operatively and surgically, timing of surgery and routine follow-up. In particular, current recommendations include considering immobilizing patients for 4 weeks in plaster for those managed conservatively, and operating on fractures within 72 hours for intra-articular injuries and 7 days for extra-articular fractures. With increased demands for services and an ageing population, prompt surgery for those presenting with distal radius fractures is not always possible. A key factor is the need for prompt surgery for hip fracture patients. This study is an audit of the current standard of care at a busy level 2 trauma unit against national guidelines for the management of DRFs. This retrospective audit includes all patients presenting to our emergency department from June to September 2018. Patients over 18 years of age with a diagnosis of a closed distal radius fracture and follow-up in our department were included in the study. Those with open fractures were excluded. Data was retrieved from clinical coding, electronic patient records, and IMPAX Client (Picture archiving and communication system). The following data was collected on patients treated conservatively and those managed surgically:- (1)Time to surgery for surgical management; (2)Period of immobilization for both conservative and operative groups. 45 patients (13 male, 32 female) with 49 distal radius fractures (2 patients had bilateral injuries) were included. Patients had mean age 63 years (range 19 to 92 years) 30 wrists were treated non-operatively and 19 wrists treated surgically (8 K-wires, 10 ORIF, 1 MUA). Mean time to surgery in the operative group was 8 days (range 1 – 21 days, median 7 days). Mean time to surgery for intra-articular fractures was 7 days (range 1 – 21) and 12 days for extra-articular fractures (range 4 – 20). Mean immobilization period in those treated in plaster is 6 weeks (range 4 – 13 weeks, median 5.6 weeks). At busy level 2 trauma units with limited theatre capacity and a high volume of hip fracture admissions, time to surgery for less urgent injuries such as wrist fractures is often delayed. National guidelines are useful in helping to guide management however their standards are often difficult to achieve in the context of increasing populations in urban areas and an ageing population

Aim: Evaluation of intermediate clinical and radiographic results of displaced intra-articular fractures of the calcaneus treated with ORIF. Materials- Methods: From 1994 to 2002, 167 displaced intra-articular fractures of the calcaneus were treated with ORIF. There were 145 male and 12 female patients. Mean age 34 years. Standard x-rays, Broden views and CT-scan images in coronal and transverse plane were obtained pre and post operatively. Fractures were classified as type III, IV, V according to Sanders. All fractures were approached through an extended lateral L-type approach. AO calcaneal plate was used. Average follow-up was 5 years. Results: In 143 Sanders type III and IV fractures KITA-OKA score was 91. Reduction failure rate was 5.5%(8 pts). 24 patients had Sanders type V fractures and KITAOKA score was 84 and reduction failure rate was 25% (6 pts). 29/167 patients complained of peroneal tendons tenderness which subsided after hardware removal. 79/167 patients had restriction of subtalar joint movements but no complains (SF_36) There were two superficial wound infections and five patients with delayed wound closure. In a group of 45 patients with similar fracture patterns who were treated conservatively, KITA-OKA score was 71, 41 fractures were malunited, 40 patients had moderate to severe pain and early OA sings. Conclutions: Displaced intra-articular fractures of the calcaneus should be treated as any other displaced intra-articular fracture, with open reduction and stable internal fixation

Aim: 1. To assess the role of the CT scan in management of intra-articular fractures of the calcaneum. 2. Does the scan makes any difference to the management decision, obtained from assessing the plain radiograph?. Methodology: This study involved 24 patients with intra-articular fracture of the calcaneum who had both a plain radiograph and a CT scan as a part of their assessment. Three consultants who were blinded to the actual management and names of the subjects were independently asked to grade the radiographs and CT scans, as operative or non-operative, on different occasions. The data was matched to the actual management and was subjected to statistical analysis. Results: The data was non-parametric and related. The SIGN test was used to analyse the agreement between the three observers and if the decisions made in each of the groups were significantly different from the actual management. There was no statistically significant difference, between the management decision from the radiographs or CT and the actual management. The change in management that the CT scan brought about was also assessed for each of the observers using the McNemars test. The CT scan did not make any significant difference to the decision made based on the plain radiographs, on whether to operate or not. A Cochran Q test used to assess the variability of the decisions, showed that there was more inter-observer variability in decision making, using the CT based assessment (Q=9.50, p=0.009) as compared to plain radiographs (Q=3.84, p=0.14). Conclusion: We conclude that, the CT scan should only be requested when a decision is made to operate on the fracture, based on plain radiographs. This may help with pre-operative planning of fracture fixation. It does not have to be obtained as a routine to assess all intra-articular fractures of the calcaneum

Introduction: The treatment of comminuted intra-articular fractures around the knee is one of most difficult areas of Orthopaedic traumatology. Open reduction and internal fixation is recommended by many authors. However, in severe comminuted fractures sometime it is difficult to achieve stable fixation and most cases need an additional cast immobilization following surgery. We present our experience with arthroscopic assisted closed reduction in severe comminuted knee fractures followed by fixation with Ilizarov frame. Materials and Methods: Since 1998, 17 patients with comminuted intra-articular fractures around the knee were treated by this method. 8 patients had comminuted intra-articular fractures of the distal femur and 9 patients had comminuted fractures of the tibial plateau, one of them with fractures of both knees. There were 4 males and 4 females with femoral fractures (age: 22– 56Y; mean -31Y) and 8 males and 1 female with tibial plateau fractures (age: 34–68Y; mean – 51Y). Three fractures of the distal femur and 2 of the tibial plateau were open fractures. 5/17 Pts had polytrauma. We used AO classification for distal femoral fractures and Schatzker classification for tibial plateau fractures. All patients were operated within 48 hours after injury. Results: In all patients, except two with unstable knee, closed reduction and Ilizarov external fixation was performed without knee immobilization, under knee arthroscopic control. In two cases split thickness skin graft was done following leg fasciotomies. Weight bearing was allowed 6 to 8 weeks following surgery. A second look arthroscopy was performed in 3 cases. The average time of fixation in Ilizarov frame was 4.5 months (range 3–6.5 months). On follow up of 2 to 8 years, 6/17 patients (35%) had excellent results, 8/17 patients (47%) had good results and 3 patients (17%) had fair results. No cases of osteomyelitis, neuro-vasular injuries or deep wound infection were observed. Conclusions: Based on this study it seems that arthroscopic assisted closed reduction and Ilizarov fixation is very useful for severe intra-articular comminuted knee fractures. Arthroscopy of knee enables accurate reduction of these fractures, removal of free bone fragments and treatment of other intra-articular injuries. There is an early restoration of motion in injured knee, with short immobilization time, and there are no major complications

Background. The usefulness of arthroscopic reduction for the intra-articular fracture of the distal radius has been reported, although it is technically difficult. Hypothesis. Our hypothesis is that the reduction using the external fixator is useful as equivalent to the arthroscopic reduction for the intra-articular fracture of the distal radius fracture in the fixation with the volar locking plate. Materials & Methods. The surgery was performed in both methods randomly for 40 patients; average age 64(24 to 92) years, 11 male, 29 female. Image evaluations were performed at 24 weeks after surgery. Ulnar variance, Radial inclination, Volar tilt in the X-ray image, and gap and step in the computed tomogram were evaluated. Clinical evaluation was performed at 6, 12, 24 weeks after surgery. Objective evaluations were ranges of motion and grip strength. Subjective evaluations were disabilities of the arm, shoulder, and hand (DASH). Results. The results of image and objective evaluation had no significant difference between the two groups. DASH in arthroscopic group was significantly inferior at 24 weeks because of minor complications. Discussion & Conclusion. The external fixator and the arthroscopy are equally valuable in reduction of articular surface