There is continued concern over complication rates (20–30% of cases) in locked proximal humeral plating. The most common sequelae of this is screw penetration of the humeral head. This is associated with natural settling of the fracture, malreducition in varus, insufficent medial support of the fracture. The proximity of the screws to the articular surface can also be influential on outcome if collapse occurs. Our operative technique is to establish the rotation of the humeral head where the drill appears closest to the articular margin (by sequential xray screening) and subtract from this to avoid intra-articular penetration of the humeral head. 55 Consecutive patients of average age 56.4 years (14.7–86.1), 17 male and 38 females, who underwent PHILOS plating were identified using Bluespier database. Xrays were analysed for fracture pattern, restoration of neck-shaft angle, plate positioning, number and configuration of screws and presence of screw penetration both intra-operatively and at postoperative follow-up. There were 6.07 screws used per head (total 330). There was one intraoperative screw penetration and 3 patients had evidence of screw penetration at follow-up, which required implant removal (total screw penetration rate of 7%). There was one case of AVN. The mean neck shaft angle was 137 degrees (anatomical 135 degrees). Accurate reduction of fractures and placement of screws in the humeral head using image intensifier can act to minimise risk of screw penetration and make some of the complications of locked proximal humeral plating avoidable

Aim: Subtle intra-articular screw penetration of the distal radius during fracture fixation is difficult to determine using standard PA and lateral radiographs. The purpose of our study was to determine which radiographs most reliably identify penetration into the joint. Methods: A distal volar locking plate was applied to an isolated cadaveric radius bone and a series of plain radiographs taken. The radius, fixed along its long axis, was allowed to rotate through 180 degrees and inclined, in increments, to 40 degrees. In the control group the distal screws did not breach the articular surface. In the study group the screws penetrated the articular surface by 1mm. In each group 65 plain radiographs were taken and the presence or absence of screw penetration scored by two blinded observers. Results: Using Weighted Kappa analysis the overall inter-observer agreement for all views was 0.5 (CI 0.39 –0.63). However in 7 radiographs there was complete inter-observer agreement correctly identifying screw penetration of the articular surface. The articular surface was correctly identified as intact in 13 views. Only a 75 degrees pronated view, without inclination, was 100% sensitive and specific for identifying the absence or presence of screw penetration through the articular surface. Conclusion: The intra-operative use of a 75 degrees pronated view may reduce the need for repeated use of the image intensifier and excessive irradiation during plate fixation of distal radius fractures

Aim: Subtle intra-articular screw penetration of the distal radius during fracture fixation is difficult to determine using standard PA and lateral radiographs. The purpose of our study was to determine which radiographs most reliably identify penetration into the joint. Methods: A distal volar locking plate was applied to an isolated radius bone and a series of plain radiographs taken. The radius, fixed along its long axis, was allowed to rotate through 180 degrees and inclined, in increments, to 40 degrees. In the control group the distal screws did not breach the articular surface. In the study group the screws penetrated the articular surface by 2mm. In each group 65 plain radiographs were taken and the presence or absence of screw penetration scored by two blinded observers. Results: Using Weighted Kappa analysis the overall inter-observer agreement for all views was 0.5 (CI 0.39–0.63). However in 7 radiographs there was complete inter-observer agreement correctly identifying screw penetration of the articular surface. The articular surface was correctly identified as intact in 13 views. Only a 75 degrees pronated view, without inclination, was 100 % sensitive and specific for identifying the absence or presence of screw penetration through the articular surface. Conclusion: The intra-operative use of a 75 degrees pronated view may reduce the need for repeated use of the image intensifier and excessive irradiation during plate fixation of distal radius fractures

Purpose: Intra-articular screw penetration with the use of proximal humeral locking plates has a reported incidence in the literature of up 25%. It may occur early, due to an intra-operative unrecognized technical error, or as a result of late fracture collapse. This study was designed to demonstrate the “approach-withdraw” technique of intra-operative fluoroscopy which can be used to minimize the rate of early unrecognized intra-articular screw penetration. Method: A radiographic review was undertaken of 37 patients with proximal humerus fractures fixed with either the PHILOS plate (Synthes, Westchester, Pennsylvania) or the Periloc proximal humerus plate (Smith and Nephew, Memphis, TN) by the senior author (JY) between 2002 and 2009. Intra-operative fluoroscopy was used in each case to ensure there was no intra-articular screw encroachment by visualizing each screw tip approach and then withdraw from the articular surface during live fluoroscopy as the shoulder was taken through a range of motion. Patients were then followed for an average of nine months with serial radiographs for post-operative intra-articular screw penetration, screw loosening, and maintenance of reduction. Maintenance of reduction was evaluated using the change in neck shaft angle and greater tuberosity to humeral height difference on the initial post-operative x-rays as compared to the x-rays at final follow-up. Results: An average of six screws (range three to nine) was placed into the humeral head per patient. There was no incidence of intra-articular screw penetration on immediate post-operative radiographs. One patient had loss of reduction with a single screw breaching the sub-chondral bone and four screws loosening after a fall in the early postoperative period. The remainder of patients had no evidence of intra-articular screw penetration or screw loosening at last follow-up. One patient developed a non-union and had a subsequent reconstruction. The average change in neck shaft angle was four degrees (range 0° to 16°) and greater tuberosity to humeral head height difference was 1.9 mm (range 0 – 8.9). Conclusion: The approach-withdraw technique is a useful intra-operative fluoroscopic test which may be utilized in the fixation of proximal humerus fractures to avoid unrecognized intra-operative screw penetration of the glenohumeral joint

Extensor tendon ruptures have been reported in up to 8.8% of patients after volar plating and long screws have been implicated. The dihedral dorsal surface of the distal radius hinders accurate screw length determination using standard radiographic views (lateral; pronation and supination). A ‘dorsal tangential’ view has recently been described, but has not been validated.

To validate this view, we mounted a plate-instrumented sawbone onto a jig. Radiographs at different angles were reviewed independently by 11 individuals. Skyline views clearly demonstrated all screw tips, whereas only 69% of screw tips were identifiable on standard views.

With screws 2mm proud of the dorsal surface, skyline views detected 67% of long screws (sensitivity). The best of the standard views achieved only 11% sensitivity. At 4mm long, skyline sensitivity was 85%, compared with 25% for standard views. At 6mm long, 100% of long screws were detected on skylines, but only 50% of 8mm long screws were detected by standard views. Inter and intra-observer variability was 0.97 (p=0.005).

For dorsal screw length determination of the distal radius, the skyline view is superior to standard views. It is simple to perform and its introduction should reduce the incidence of volar plate-related extensor tendon rupture.

Purpose of the Study: We evaluated the complications of proximal humeral fractures, which are treated with locked plates. Materials and Methods: 103 patients (70 female, 33 male) with proximal humeral fractures with an average follow-up time of 19 months (2 weeks– 43 months) and an average 62,1 (21–90) years of age are treated with open reduction and internal fixation from September 2005 to April 2009 in our clinic. Internal fixation was performed with PHILOS plate in 93 patients and S3 Humeral plate in 10 patients. Early and late complications that are encountered during the follow-up time is presented. Results: Complications occurred in 10 patients (7 females, 3 males) with an average age of 67,1 (41–89) years from which 5 of them had varus inclination, 5 had inter-joint screw penetration, 1 had fixation failure, 1 had breakage of the implant and 1 had infection. Complication rate (10 of the 103 patients) was 9.7%. The rates of varus inclination (5 of the 103 patients) and the rates of screw penetration (5 out of 103) were both 4.85%. During the follow-up time 3 of the 5 patients with varus inclination (60%) had progression (displacement of varus). 4 of the 5 patients with varus inclination (80%) had screw penetration. All of the 4 patients (100%) with varus displacement had screw penetration. The average Constant Murley shoulder score of the complication group were 67.8 (50–90). Conclusion: Surgical treatment of the proximal humeral fractures has a high rate of complications. Screw penetration rates of the patients with varus inclination is 60%. Accurate indication, protection of the head’s inclination angle with an appropriate surgical approach and a proper technique, fine calculation of the screw lengths are needed for a successful functional result. In our study, where we have found fewer rates of complications than the literature, we have pointed out the reasons of the complications and we have stated the noteworthy precautions to lower the rates of these

Objectives. Our objective was to perform a systematic review of the literature and conduct a meta- analysis to investigate the effect of initial varus or valgus displacement of proximal humerus on the outcomes of patients with proximal humerus fractures treated with open reduction and internal fixation. Methods. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies comparing postoperative outcomes associated with initial varus versus initial valgus displacement of proximal humerus fracture. The Newcastle–Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data. Results. We identified two retrospective cohort studies and one retrospective analysis of a prospective database, enrolling a total of 243 patients with proximal humerus fractures. Our analysis showed that initial varus displacement was associated with a higher risk of overall complication (RR 2.28, 95% CI 1.12–4.64, P = 0.02), screw penetration (RR 2.30, 95% CI 1.06–5.02, P = 0.04), varus displacement (RR 4.38, 95% CI 2.22–8.65, P < 0.0001), and reoperation (RR 3.01, 95% CI 1.80–5.03, P < 0.0001) compared to valgus displacement. There was no significant difference in avascular necrosis (RR 1.43, 95% CI 0.62–3.27, P = 0.40), infection (RR 1.49, 95% CI 0.46–4.84, P = 0.51), and non-union or malunion (RR 1.37, 95% CI 0.37–5.04, P = 0.64). Conclusions. The best available evidence demonstrates that initial varus displacement of proximal humerus fractures is associated with higher risk of overall complication, screw penetration, varus displacement, and reoperation compared to initial valgus displacement. The best available evidence is not adequately robust to make definitive conclusions. Further high quality studies, that are adequately powered, are required to investigate the outcomes of initial varus and valgus displacement in specific fracture types

Prophylactic fixation of the contralateral hip in cases of unilateral slipped capital femoral epiphysis (SCFE) remains contentious. Our senior author reported a 10 year series in 2006 that identified a rate of subsequent contralateral slip of 25percnt; when prophylactic fixation was not performed. This led to a change in local practice and employment of prophylactic fixation as standard. We report the 10 year outcomes following this change in practice. A prospective study of all patients who presented with diagnosis of SCFE between 2004 and 2014 in our region. Intra-operative complication and post-operative complication were the primary outcomes. 31 patients presented during the study period: 16 male patients and 15 female patients. The mean age was 12.16 (8–16, SD 2.07). 25 patients had stable SCFE and 5 had unstable SCFE. Stability was uncertain in 1 patient. 25 patients had unilateral SCFE and 6 had bilateral SCFE. 24 patients who had unilateral SUFE had contralateral pinning performed. 1 unilateral SCFE did not have contralateral pinning performed as there was partial fusion of physis on contralateral side. In the hips fixed prophylactically there was 1 cases of transient intraoperative screw penetration into the joint and 1 case of minor wound dehiscence. There were no cases or chondrolysis or AVN. There were no further contralateral slips. This change in practice has been adopted with minimal complication. The fixation of the contralateral side is not without risk but by adopting this model the risk of subsequent slip has been reduced from 25percnt; to 0percnt;

Background. Distal radius fractures are common injuries but no clear consensus regarding optimal management of unstable fractures exists. Open reduction and internal fixation with volar plates is an increasingly popular but the associated complication rate can be 10%. Intramedullary nails are an alternative offering the potential advantages of reduced risk of tendon injury and intra-articular screw penetration. This article systematically reviews the published literature evaluating the biomechanics, outcomes and complications of intramedullary nails in the management of distal radius fractures. Methods. A systematic review of Medline and EMBASE databases was performed for studies reporting the biomechanics, functional outcome or complications following intramedullary nailing of distal radius fractures. Critical appraisal was performed with respect to validated quality assessment scales. Results. 16 studies were included for review. The biomechanical studies concluded that intramedullary nails had at least comparable strength to locking plates. The clinical studies reported that IM nailing was associated with comparable ROM, functional outcome and grip strength to alternative fixation techniques. However, the mean complication rate was 17.6% (range 0 to 50%) with the most common complication being neurapraxia of the superficial radial nerve in 9.5%. Conclusion. This systematic review of pooled data from published series has shown that IM nailing can give comparable clinical results to current treatment modalities in extra-articular and simple intra-articular distal radius fractures. However the evidence is insufficient to determine whether IM nailing has any clinically important advantage over well-established alternatives. The complication rate reported is higher than that in contemporary studies for volar plating and this raises concerns about the role of this technique particularly when comparative studies have failed to show any major advantage to its use. Further adequately powered RCTs comparing the technique to both volar plates and percutaneous wire fixation are required. Level of evidence. IIa – systematic review of cohort studies. Conflict of Interests. The authors confirm that they have no relevant financial disclosures or conflicts of interest. Ethical approval was not sought as this was a systematic review

Purpose. The undulating pattern of the distal femur is well recognized. Radiographs do not always represent the full extent of the undulations. With recent increasing use of guided growth technique in the distal femur, it is important to define safe zones for screw placement. Method. We performed an anatomical study on 26 cadaveric distal femoral epiphyses, ages 3–18 years. High resolution three-dimensional surface scans were obtained with a laser scanner, and were analyzed to determine the absolute height of the central physeal ridge, and the central physeal ridge height with respect to the highest points medially and laterally. Results. The average height of the central physeal ridge was 5.5mm (range 2.9–9.8mm) with respect to the lowest point on the physis. When normalized to the size of the physis, both the height and surface area of the central physeal ridge decreased with increasing age. The amount that the central peak protruded superior to a line from the medial to lateral physeal edges is shown. In all specimens ages 13 years and older the central peak was below the medial-lateral line, in specimens ages 8–12 years it was no more than 4mm above the line, and in specimens under 8 years it was no more than 8mm above the line. Conclusion. The central physeal ridge is the major structure within the distal femoral physis. In patients 13 years and older the medial-lateral physeal line defines a safe zone one should stay above to avoid screw penetration into the central physis. In patients ages 8–12 years one should stay 4mm above the medial-lateral line, and in patients 8 years and under one should stay 8mm above the line

Complications in internal fixation of proximal humeral fractures can lead to an unsatisfactory outcome. We retrospectively reviewed 22 patients at a mean follow-up of 13 months (range 3–30). The average age was 58 years (36–86) in 10 male and 12 female patients. The mechanism of injury involved a simple fall in 17, MCA in 3, assault in 1 and metastasis in 1. The operation was performed at a mean of 11 days after the injury (range 1–29). There were 12 3-part, 6 2-part, 2 4-part fractures, 1 fracture dislocation and 1 pathological fracture. Only 13 out of 22 patients (59%) did not develop any complications. We had hardware problems in 5 patients including hardware pull-out, plate prominence, screw penetration, loosening or breakage. 2 wound infections, 1 axillary nerve palsy and 1 peri-operative death. 3 patients (14%) had reoperations to remove the plate, 1 had revision fixation, 1 MUA, 1 open capsular release and 1 I+D of wound. Radiographic union was achieved in 18 patients (82%). We identified a relatively high rate of complications especially in alcoholic or unfit patients. Better patient selection and familiarity with the implant and operative technique are essential for a good outcome. Pain relief and union rate were satisfactory

Distal clavicle fractures associated with coracoclavicular ligament disruption are potentially unstable. 1. Internal fixation of these fractures is often inadequate due to two anatomical problems:. Inadequate distal fragment size and. Displacement and instability consequent to ligament disruption. We hypothesize that a contour-matched locking plate coupled with a coracoclavicular ligament repair device would provide a potentially safe and minimally invasive method for adequate fixation. Between 2006 and 2008, 5 patients were surgically treated for non-comminuted distal clavicular fractures associated with coracoclavicular ligament disruption. The surgical technique consisted of. neutralization of muscular forces on the proximal fragment by using a minimally invasive ligament repair device (TightRope. ™. , Arthrex, FL), and. Internal fixation using a contour-matched locking plate (Distal radial locking plate, Synthes). Technical tips to optimize this new procedure are presented. Outcome measures consisted of. Constant shoulder score. Radiographic union. The retrospective follow-up period varied from 8 weeks to 24 months. A statistically significant improvement in the Constant score was observed in every patient. All patients progressed to satisfactory bony union. Plate removal was not necessary in any patient. Potential complications include screw penetration of the acromioclavicular joint, acromioclavicular ligament disruption, and distal fragment comminution. A contour-matched locking plate coupled with a coracoclavicular ligament repair device is a new lesser invasive and safe anatomical approach for achieving fixation adequacy in a highly unstable but non-comminuted distal clavicular fracture subgroup. We recommend strict adherence to the guidelines presented (technical tips) to achieve an optimal result

Our aim was to analyse radiological outcome of proximal humerus fractures treated with Philos plate and to assess its usefulness in treatment of malunion and non-union. Seventy-seven patients were treated with Philos plate (24 men and 53 women). Mean age was 61 years (15–88). There were 66 acute fractures, 6 nonunion, 4 mal-union and one periprosthetic fracture. Acute fractures included 29 two part, 30 three part and five 4 part fractures. Seven had associated dislocation. There were two head splitting fractures. Deltopectoral approach was used in all. No acute fractures were bonegrafted however all nonunions had bonegraft. Postoperative radiographs were available for review for 59. Average union time was 12 weeks (8–24). Satisfactory union occurred in 51 (86.4%). Twenty-three (39 %) fractures had inadequate reduction. Malplacement of plate was observed in 25 (42%) leading to significant malunion in 11.8%. Satisfactory union was occurred in all of last 30 patients. Nonunion occurred in 2 with infection in one. Other complications included screw penetration into glenohumeral joint, avascular necrosis, screw backing out and tuberosity detachment. Philos plate fixation was used for treatment of 6 nonunions, 4 malunions and one periprosthetic fracture with satisfactory outcome in all. Relatively high rate of complications was observed in early cases in this series. This could be attributed to the steep learning curve with this technique. Emphasis should be put on careful and adequate reduction of fracture and optimal placement of plate (about 8 mm from the tip of tuberosity) to avoid impingement and to achieve correct screw placement in the humeral head. In conclusion, Philos plate has been of benefit in management of complex fractures as well as management of non-union of proximal humerus. Quality of reduction and optimal placement of plate appear to be the two most important parameters for a successful outcome

This aim of this study is to evaluate the efficacy of the Plant Tan plate, a new implant introduced for comminuted proximal humerus fractures. This paper presents the results of 10 patients who underwent the procedure over a two year period. Methods : Two and three part proximal humeral fractures continue to be a difficult problem and accurate fixation is necessary for optimum functional outcome. Ten patient had plant Tan plate fixation for proximal humerus fractures from January 2002 till January 2004. Details including patient demographics, the type of fracture, the bone quality, significant co morbid factors, the surgical approach union rate and complications were noted. Outcome was assessed using the Constant score and comparing with the opposite side and the Oxford shoulder questionnaire. Results : After an average follow up of 6 months, 80% of the patients were satisfied with the result of surgery at the time of the most recent examination. The union rate was 85 %. The significant complications were infection ( 20 % ) and the development of avascular necrosis (1/10). The screw penetration into the shoulder joint was found to be as high as 50 % though it was not associated with poor result. Conclusion : The early results of the Plant Tan plate are encouraging with good functional results in most patients. Careful case selection with proper indication, accurate reduction, and subchondral screw placement with purchase in the inferior portion of the humeral head along with early mobilisation should be considered as key factors for better outcome

The ideal treatment of the unstable slipped upper femoral epiphysis (SUFE) is not clearly defined in the literature. Unstable SUFE occurs with less frequency than the stable SUFE. The incidence of unstable SUFE is between 14–25% of all SUFE’s. The literature reports a variety of accepted methods of treatment of the unstable SUFE, consequently, in Auckland there are various methods of treatment. The unstable SUFE is at risk of development of avascular necrosis (AVN) of the femoral head. The reported incidence of AVN in unstable SUFE is between 15–50%. We expect that different treatment will influence the rate of AVN. Our aim was to determine current practice and outcomes in Auckland. We reviewed the records and radiographs of all SUFE’s treated in Auckland from 2000–2007. In this time period there were 463 patients across the Auckland region, 109 of which had bilateral SUFE’s which allowed 572 treated hips to be followed. Over this time period there were 34 unstable SUFE representing 6% of treated hips. There was a difference in average weight, with unstable SUFE on average 10kgs lighter (60.5 vs 70.3kgs). Average time to surgery was 43 hours (range: 4–360hrs). Cases operated within 24 hours have a reduced rate of AVN (20%) compared to those operated after 24 hours (AVN 50%). Of the 34 cases, 13 cases had radiological evidence of AVN (35%). Of these there were 11 cases of pin penetration requiring further surgery. There was no difference in rate of AVN when comparing single screw to double screw fixation (SS 44% v DS 38%). There were 11 cases of pin penetration, 8 with single screw and 3 with double screw fixation. Our review of unstable SUFE in Auckland has shown a difference in the weight of patients when compared to stable SUFE’s presenting from the same population. We have also found that cases operated on within 24 hours have a lower rate of AVN. Single screw fixation is more common than double screw fixation. There was no statistical difference in the rate of AVN but there was a higher rate of screw penetration when using a single screw fixation

Introduction Unstable distal clavicle fractures have a high rate of non and delayed union, with many authors recommending surgical fixation. There are several techniques described in the literature reporting good results. We report the outcome of eighteen patients undergoing temporary fixation with a coracoclavicular screw, reinforced with Mersilene tape and Ethibond sutures. Methods Eighteen patients were treated by a single surgeon between October 1999 and March 2003. All patients were male with an average age of 35 years. The indication for surgery was an unstable Type II fracture of the distal third clavicle. Fixation was achieved with a 6.5 mm cancellous screw through the clavicle into the coracoid process, reinforced by Mersilene tape and number 5 Ethibond sutures around the coracoid process. The arm was immobilized for two to four weeks after surgery. Each patient had the screw removed at about 11 weeks from surgery. Results Eighteen patients achieved osseous union with painless range of motion. Union time ranged between six to 11 weeks. One patient developed a superficial skin infection, which settled with oral antibiotics, the scar required revision at time of screw removal. Two patients had screw breakage after union, which did not affect their outcome. There was no cases of screw penetration. Conclusions This method of screw fixation is a relatively safe and easy technique of open reduction and internal fixation of the unstable distal third of clavicle. The outcome of this procedure is predictable with minimal complications

Introduction- Proximal humeral fractures remain a challenging problem. Most authors agree that anatomical reduction and stable fixation are essential to allow early range of motion. A variety of techniques have been described such as threaded pins, tension band wiring, screws, nails, plates and primary prosthesis. Locking plates score over other implants by the virtue of providing greater angular stability and better biomechanical properties. The Aim of the Study is to evaluate the functional outcome of PHILOS plate Osteosynthesis of displaced proximal humeral fractures. Materials and Methods- A retrospective study of 50 patients treated with PHILOS plating for the 2 part, 3part and 4 part proximal humeral fractures with a minimum follow up of 1 year. All the patients were assessed in clinic by Constant Murley and ASES scoring systems. X-ray evaluation was done for fracture healing, AVN, mal-union, non-union, collapse of head, screw penetration and impingement of plate. Results- Total of 50 acute displaced fractures of proximal humerus treated with PHILOS plating between 2003–2005 were assessed. Mean age was 64 years (15–86) Male to female ratio was 12:38, dominant to non-dominant ratio was 32:18. According to Neer’s classification 16 fractures were 2 part, 24 fractures were 3 part and 10fractures were 4 part. The overall mean Constant score was 73.4(range20–100) and ASES score was 71.7(range 25–98). Under 60 years of age the mean Constant and ASES scores were 83.5 and 83, over 60 years of age scores were 63.1 and 60.4 respectively. The complications include two deep infections which needed excision arthroplasty, one malunion, one subacromial impingement which needed plate removal after fracture healing. No mechanical failure, no non-union, no ANV was noted. Conclusions- PHILOS plate Osteosynthesis is a reliable method of treating complex proximal humeral fractures. It provides good mechanical stability and allows rapid mobilization with out compromising fracture healing

Increased use of locking volar plates for distal radius fractures led to a number of reports in literature of flexor tendon injuries from impingement and attrition against hardware. Repair of the pronator quadratus is critical in preventing tendon injury. We present a pronator quadratus sparing approach to the distal radius. The senior author has used a pronator quadratus sparing lateral pillar approach for for the past five years. A lateral incision is used over the radial styloid. The first dorsal compartment is released and APL and EPB tendons retracted. The underlying brachio-radialis tendon and insertion fascia is split and the palmar portion elevated off the distal radius with the pronator quadratus as a single contiguous sheet. The distal edge of the pronator quadratus is elevated from the wrist capsule by sharp dissection. The radial artery is protected by the retracted tissue. Repair of the brachio-radialis tendon and insertion fascia is much more robust than that of the pronator quadratus covering the entire plate. Since 2004, the senior author has used the pronator quadratus sparing approach for volar plating of the distal radius, in 183 cases. At last follow-up there were no instances of flexor tendon injury, which was considered to be one of the outcome measures and end-points. There was no impingement in the first dorsal compartment, except in two cases of lateral pillar hardware impingement from additional lateral pillar plate fixation through the same approach. Nine cases had minor persistent superficial radial nerve parasthesia. One case had a superficial wound infection requiring drainage. The repaired pronator quadratus formed a barrier protecting the plate. The infection was aggressively treated and the plate left in situ for three months till fracture union. Cultures from the retrieved plate showed no organisms. Another implant had two of the locking screws back out. The pronator quadratus fascia was tented with an underlying haematoma. The fascia however only showed minimum screw penetration and no flexor tendon injury. Average wrist dorsiflexion was 72 deg and palmar flexion 65 deg. Average pronation was 81 deg and average supination 69 deg. Supination range was slow to recover in younger patients. One explanation could be the tight pronator quadratus repair. Average PRWE and DASH scores were 19. The quadratus sparing approach to the volar distal radius is easy to perform and protects the flexor tendons at the wrist. Cases demonstrated that an intact pronator quadratus can act as an effective barrier to prominent hardware and superficial infection. Supination range may be reduced by this approach due to a tight repair, though a palmar DRUJ capsule contracture may also be an explanation

The incidence of comminuted proximal femur fractures is increasing, due to the growing proportion of elderly people in the general population. Severely depleted cancellous bone in the femoral head and neck prevent stable proximal purchase, mandatory for intertrochanteric and subtrochanteric fractures. Osteoporotic bones are associated with high implant failure rates, evidenced by cutout and upward screw penetration of the hip joint. A new method for femoral head fixation is described. The peg consists of a distal end that can expand in diameter from 7.8mm to 10.5mm by using pressurized saline, allowing good abutment into the femoral head. The peg may be connected to a side plate or an intramedullary device for inter or subtrochanteric fractures. Materials and Methods: Ten femoral heads were retrieved from patients who underwent hip hemiarthroplasty due to subcapital fracture. The heads were covered with a transparent epoxy resin until full solidification was obtained. An 8mm drill-hole was used to drill from the distal femoral neck along the femoral head axis, not penetrating the subchondral bone and cartilage. Afterwards, 1.4mm drill was used to penetrate the cartilage and subchondral bone of the femoral head for insertion of a pressure gage. Intraosseous pressure measurements were then recorded. The peri-prosthetic bone density was evaluated by Dual Energy X-ray Absorptiometry (DEXA) and Microradiography Computer Analysis in two stages: 1) with the peg unexpanded, and 2) with the peg expanded. In addition, Instron 8871 tested axial load, pullout and rotatory strengths of the peg. Results: Increased periprosthetic bone density following peg expansion was demonstrated on DEXA and microradiography with no increase in the intraosseous pressure. The friction coefficient of the bone implant interface, calculated by axial load measurements, was less than the coefficient of steel to steel. Pullout and rotatory strengths were as good as those reported for the Dynamic Hip Screw (DHS). Conclusions: Bone stock preservation due to compression of the depleted cancellous bone (rather than removed bone by drilling) may improve the mechanical properties of the periprosthetic bone and the stability of the fixation. Due to the strong abutment of the peg, hardware failure, mainly bone cutout can be reduced. Due to its lower friction coefficient, the hip peg will begin to slide following axial load through the plate or the intramedullary device, rather than penetrating the femoral head. Preliminary positive results indicate that this new method may be suitable for inter or subtrochanteric femoral fracture fixation

Objective: To evaluate the results of operative treatment of complex fractures of the acetabulum. Material and methods: For the period 1992 Ð 2001 þfty one patients with complex acetabular fractures were treated surgically and followed up for an average 4 years 3 months (range, 1 Ð 11 years). There were 34 males and 17 females of an average age of 39 years (range, 18 Ð 64 years). Thirty one of the patients sustained multiple trauma. The mean operation time was 9 days (range, 3 Ð 22 days). According to Judet-Letournel classiþcation there were 2 posterior clolumn/posterior wall fractures, 10 Ð transversal/posterior wall, 7 Ð T-type, 9 Ð T-type/posterior wall, 11 Ð anterior column/posterior hemitransversal and 12 Ð both column injuries. Posterior Koher-Langenbeck, ilioinguinal, extended iliofemoral or combined approaches were used depending of fracture pattern. Internal þxation was done with lag column screws, column shaped plates, brim plates or buttress plates. Spring plating with stright or T plates was widely used in cases of comminution. Ealy weight-protected motion was conducted after surgery. Results: Average operative time was 3.5 h (range 1.5 Ð 8 h), and average blood loss was 1200 ml (range 450 Ð 2300 ml). According to Mattañs criteria anatomical reduction was achieved in 23 cases, good Ð in 13, fair Ð in 11 and poor Ð in 4. Late outcome was evaluated according to Merl dñAubigne-Postel-Matta scale. Nineteen ecxellent, 16 good, 11 fair and 5 poor results were recorded. The last were due to arthritis, avascular necrosis or chondrolysis. The late results correlated strongly with quality of reduction and initial cartilage damage. Early complications were 1 case of operative bleeding, 1 intraarticular screw penetration, 5 jatrogenic nerve palsies (2 of femoral cutaneus nerve and 3 of peroneal nerve) and 1 superþcial inection. Late complications were 1 case of chondrolysis, 2 avascular necroses and 2 Grade III heterotopic ossiþcations. Conclusion: ORIF provides high prevalance of excellent and good results in complex acetabular fractures and should be considered as a method of choice. The quality of reduction is of most importance for þnal outcome. Initial cartilage condition, fracture type and degree of comminution should also be taken in mind for late prognosis. As the surgery is demanding perfect surgical skills, special experience and adequate equipment are required for þnal success