Aims

The primary aim of this study was to report the radiological outcomes of patients with a dorsally displaced distal radius fracture who were randomized to a moulded cast or surgical fixation with wires following manipulation and closed reduction of their fracture. The secondary aim was to correlate radiological outcomes with patient-reported outcome measures (PROMs) in the year following injury.

Background. Isolated fracture of the greater trochanter is an uncommon presentation of hip fracture. Traditional teaching has been to manage these injuries nonoperatively, but modern imaging techniques have made it possible to detect occult intertrochanteric extension of the fracture in up to 90% of cases. This study aims to review the investigation and management of greater trochanter fractures in a single major trauma centre. Methods. A retrospective review was completed of patients admitted with greater trochanter fractures. These were matched to cases with 2-part extracapsular fractures. Initial management and clinical outcome was established using electronic notes and radiographs. Mortality and length of stay was calculated for both groups. Results. 85 isolated greater trochanter fractures in 84 patients were identified from 2006–2017. 81/85 patients were treated non-operatively. 78 were mobilised full weight bearing. None required readmission or operation due to fracture displacement. 58 of these patients had cross-sectional imaging with MRI or CT and 15 of those scanned had intertrochanteric extension of the fracture. In the same time period, 998 2-part extra-capsular fractures were treated, using a sliding hip screw. Length of stay was shorter in patients with greater trochanter fractures than 2-part extracapsular fractures (median 7 days vs 14 days, P<0.0001). 30-day mortality was 11.9%, with no significant difference to patients with 2-part extracapsular fractures. Discussion. Cross sectional imaging rarely changed the treatment protocol for isolated greater trochanter fractures. The outcome following non-operative treatment is good even in the presence of occult fractures identified on CT or MRI. We advocate a treatment protocol that encourages early mobilisation and repeat plain radiographs if patients fail to progress. This will reduce unnecessary morbidity from fixation of stable occult fractures

Aims

Giant cell tumour of bone (GCTB) treatment changed since the introduction of denosumab from purely surgical towards a multidisciplinary approach, with recent concerns of higher recurrence rates after denosumab. We evaluated oncological, surgical, and functional outcomes for distal radius GCTB, with a critically appraised systematic literature review.

The management of type two odontoid peg fractures remains controversial. The policy in our unit is to initially manage all of these injuries non-operatively. Patients with displaced fractures (0.2mm translation, > 15° angulation) are placed in halo vests followed by fracture reduction under radiological control. Undisplaced or minimally displaced fractures are treated in either custom-made minerva orthoses or halo vests. We report the results of 42 consecutive cases of type two odontoid peg fractures. There were 24 males and 18 females with a mean age of 53 (range 18–89) years. Twenty-one (50%) of patients were > 65 years of age. In 29 cases the fracture was undisplaced or minimally displaced and in the remaining 13 cases it was displaced (> 2mm translation, > 15° angulation) either posteriorly (extension-type)(6) or anteriorly (flexion type) (7). All displaced cases were treated in halo vests while the remainder were treated in minervas (14) or halo vests (15). Loss of reduction occurred in nine cases necessitating adjustment in five and C1/2 posterior fusion in four. Of these cases five were displaced extension type-fractures, two required fusion. Pin site infection necessitated early removal of halo vest and conversion to minerva in three cases. In all of these cases fracture union was achieved. Overall, union was achieved in 37 patients giving a non-union rate of 12%. The mean age of the five non-unions was 42 years with only one patient over 65 years of age. Four of these patients had C1/2 posterior fusions and the remaining patient refused surgery. Of the 29 patients with displaced or minimally displaced fractures five (17%) required surgery for either non-union (3) or displacement (2), whereas three (23%) of the displaced group required surgery for non-union (1) or displacement (2). All of these were extension type fractures. We conclude that a policy of non-operative management of these fractures resulted in union in a high proportion of patients of all age groups except for those with extension type fractures. This fracture pattern may warrant primary surgical intervention

Aims

There are concerns regarding nail/medullary canal mismatch and initial stability after cephalomedullary nailing in unstable pertrochanteric fractures. This study aimed to investigate the effect of an additional anteroposterior blocking screw on fixation stability in unstable pertrochanteric fracture models with a nail/medullary canal mismatch after short cephalomedullary nail (CMN) 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.

Renal neoplasm is the most frequent cause of metastases, after prostatic and breast carcinoma. Lesions are aggressive and expansive with cortical destruction and soft tissue extension. Pathological fracture is very common, up to 50%. The most frequent localizations are long bones, spine and pelvis. Aim of this work is to evaluate the usefulness of surgical treatment of soft tissue and skeletal metastases in kidney neoplasm. Between 1995 and 2005 66 patients (40 males, 26 females) were submitted to surgical treatment at San Raffaele Hospital, Milano. Most common localizations were femur, humerus, spine, pelvis, metatarsus. We report 3 cases of soft tissue metastases of lower limb. Twenty-five patients had single localization, 10 pathological fracture and in 5 diagnose was bioptical. Surgical treatment was performed with large resection and in 15 patients the lesion was embolized. Twelve patients had local relapse and in 3 we performed a new surgical treatment. We had no infections nor fatal outcome in the post-surgical period

The knowledge of actual extent of the fracture in cases of isolated greater trochanteric fractures has paramount importance in decision-making. MRI has been the most common investigation to detect the intertrochanteric extension. However, to date there is no plain radiographic or MRI criteria to decide which fractures need surgery and which could be managed non-operatively. The aim of our study-was to assess whether the angle and the extent of the greater trochanteric fracture measured on plain radiographs could be used to predict the intertrochanteric extension. We reviewed plain radiographs of 23 patients with isolated greater trochanteric fractures who also had MRI scans. We considered two parameters. extent of fracture in percentage along the intertrochanteric line and. angle of the fracture line. We compared these plain radiographic findings with those of MRI scans and established plain radiographic criteria to predict intertrochanteric extension. Out of 23 patients, MRI scans revealed intertrochanteric extension in eight and they underwent surgical stabilisation. All these eight fractures had a fracture angle of 45° or less and the percentage of fracture extent of > 40%. All the 15 fractures with a fracture angle of > 45° did not show intertrochanteric extension on MRI scan. The mean angle of the fracture in those with MRI proven intertrochanteric extension was 33.5° (range 20°–45°) and in those with no intertrochanteric extension was 55.7° (Range 25°–125°). The mean percentage of length of fracture across the intertrochanteric line was 61.1% (47%–73%) and 39.6% (27%–62%) respectively. We conclude that those isolated greater trochanteric fractures, with a fracture angle of more than 45° are unlikely to have an intertrochanteric extension. Those fractures with an extent of more than 40% and fracture angle less than 45° are likely to show inter trochanteric extension

Introduction: To access efficacy of our protocol for treatment of displaced Gartland type 3 supracondylar fracture humerus in children by giving a small incision medially to identify correct entry point of medial wire and to save the ulnar nerve. This incision is extendable for open reduction if required and have no effect on morbidity. Methods: All Patients with displaced Gartland type 3 supracondylar fractures of humerus admitted from October 1997 to October 2003 were included into this study. They were all treated by closed or open reduction through medial approach and fixed with medial and lateral cross K-wires within 12 hours of admission. Results: There were 43 children with a mean age of 7.2 years at presentation. Follow up time averaged 48 months (range 12–84 months). No patient had iatrogenic ulnar nerve injury. The postoperative mean value of Bauman’s angle in affected elbow was 76.7° with +/− 1.0° and 74.8° with +/− 0.6° on the unaffected elbow. All patients showed satisfactory results according to Flynn’s criteria. Discussion: Cross K-wires give reliable results; a small medial incision is cosmetically more acceptable, provides an excellent view for correct entry point of the wire after visualising ulnar nerve with added advantage of extension if fracture required open reduction

Avoidance of extensor mechanism complications is best obtained by using components with an appropriately designed femoral trochlea and patellar component and where internally rotated components are avoided. Residual valgus deformity may also lead to patellar dislocation or more subtle subluxations, which may manifest as pain along the medial patellar retinaculum. Because rotational abnormalities are difficult to detect on plain x-ray, CT scans are a useful way to diagnose this problem. Peripatellar crepitation may cause symptoms and can be avoided by aggressive peripatellar synovectomy at the time of surgery. In its most severe form, the patellar clunk syndrome, most commonly seen in posterior stabilised knees, arthroscopic debridement of the offending fibrous nodule may be needed. Patellar fracture is best treated on the basis of residual extensor mechanism function. Maintenance of active extension following fracture (with no loss of component fixation) is a good sign that conservative therapy will yield better function than ORIF. Loss of extension indicates that surgery will be required. In this setting restoration of extensor continuity is more important than retention of the patellar component. Patellar tendon avulsion can be avoided by careful attention to the tendon during surgical exposure. Intraoperative repair alone is rarely successful and should be reinforced by semitendonosis, or fascia lata grafting. Late rupture may be treated by this type of grafting alone. But if the patella is necrotic or the failure results in a high riding patella, mechanism transplant is preferred. In this setting attention to fixing the graft in full extension is mandatory to prevent severe extensor lag, as the allograft will stretch out overtime

Introduction: We hypothesise that disc degeneration is a major cause of segmental instability in elderly spines. Accordingly, we simulated two mechanical features of disc degeneration on cadaveric spines, and measured their effects on spinal movements. Methods: Twenty-one motion segments (T8–9 to L4–5) were obtained from spines aged 48–90yrs. Specimens were loaded rapidly to simulate full spinal bending movements in vivo, while vertebral movements were tracked using an optical MacReflex system. Intradiscal stresses were investigated using “stress profilometry”. Experiments were repeated following compressive creep loading (which reduced disc water content by an amount similar to the aging process) and again following a compressive overload cycle which fractured a vertebral endplate and decompressed the nucleus. MacReflex data were used to quantify the neutral-zone (NZ), the range of motion (ROM), and the range of translational (gliding) movements. Results Creep and endplate fracture both reduced disc height, and generated stress concentrations within the posterior annulus. Both treatments increased NZ, ROM and translational movements in flexion and lateral bending, but not in extension. Endplate fracture markedly increased the “instability index” (NZ/ROM) in flexion. Discussion Disc “degeneration” increased all measures of spinal instability during flexion and lateral bending. Disc decompression in particular created a large NZ in which the spine had negligible resistance to bending. In life, muscle action would prevent the spine “wobbling” within this range of movement. Results in extension suggest impaction between the neural arches. Back pain associated with spinal instability could arise from stress concentrations in the annulus and neural arches, or from abnormal muscle activity

Introduction. Fixation of posterior malleolar fragments associated with ankle fractures aims to stabilise the syndesmosis and prevent posterior subluxation. Haraguchi described 3 types of posterior malleolar fractures, with type 2 being a medial extension injury, these fractures often involve medial and posterior fragments. We describe the techniques and outcomes for a double window posteromedial approach allowing optimal reduction and stabilisation. Methods. A retrospective review was performed at 2 units, Bristol Royal Infirmary and QE Hospitals Birmingham, between August 2014 and April 2016. Inclusion criteria were all patients having this posteromedial approach for closed ankle fracture fixation. Patients were assessed for complications and postoperative ankle function with the Olerud and Molander scoring system. Results. We identified 9 patients treated over an 18 months with average follow up 9 months (range 4–18 months). All had an ankle dislocation reduced on scene or in ED, with 5 having posterior subluxation of the talus on the original films. None were open injuries. All had fixation of a posteromedial malleolar fragment, with 7 requiring a further direct lateral incision. Olerud and Molander ankle function score averaged at 72 (range 60–85) at short term follow up. Discussion. Approaches to the posteromedial fragments have been previously described in 2 ways. One utilises a window just medial to the Achilles tendon taking the neurovascular bundle medially, while the other approaches between tibialis posterior and FDL taking the neurovascular bundle laterally. Neither delivers complete access to an injury that often has sagittal and coronal splits needing individual reduction and fixation. Our approach over the neurovascular bundle allows 2 safe corridors through a single incision facilitating fragment specific fixation of both the medial and posterior components of the injury. Early results suggest this to be a safe and reliable technique to reduce and stabilise complex posteromedial ankle fractures

Aims

Describe a statistical and economic analysis plan for the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) randomized controlled trial.

Purpose: The treatment of extension type II pediatric supracondylar humerus fractures remains controversial. Some argue that closed reduction and cast immobilization is sufficient to treat these fractures, while others advocate closed reduction and pinning. The purpose of this radiographic outcomes study was to determine whether closed reduction and cast immobilization could successfully obtain and maintain appropriate position of extension type II supracondylar humerus fractures. Method: The radiographs of 1017 pediatric patients treated for supracondylar fractures between 1987 and 2007 were retrospectively reviewed. Pre-reduction, immediate post-reduction, and final radiographs of 155 extension type II fractures were measured in order to assess the position and alignment of the fracture fragments. Measurements included the anterior humeral line, humeral-capitellar angle, Baumann’s angle, the Gordon index, and the Griffet index. The latter two indices calculate the rotational instability of the fracture, which can be predictive of reduction loss. Patients were excluded if insufficient radiographs failed to allow complete assessment of the measurement parameters, or if open reduction was required. Results: The average age of the subjects was 5.3 years (range 1–13 years) and had a mean follow-up of 5.3 months. Analysis of the final radiographs demonstrated that in 80% of subjects, the anterior humeral line remained anterior to the mid third segment of the capitellum (radiographic extension deformity), the mean humeral-capitellar angle was 23.8° (range – 11°–50°), the mean Baumann’s angle was 79.4° (range 62°–97°), the mean Gordon index was 4.59%, and 44% of subjects had a Griffet index between 1–3 (potentially indicative of unstable reduction due to malrotation of the fragments, which can allow the development of a cubitus varus deformity). Conclusion: From this radiographic review, a significant proportion of fractures treated with closed reduction and cast immobilization failed to achieve anatomic position and alignment on final x-rays. However, the clinical significance of these results and the potential for long-term re-modeling of these fractures remains unknown

Purpose: This study was performed to evaluate the results of intramedullary nailing of distal tibial fractures located within 5 cm of the ankle joint. Materials and Method: From 1990 to 2007, 142 tibial fractures that involved the distal 5 cm of the tibia were treated with reamed intramedullary nailing with use of either two or three distal interlocking screws. Twenty-one tibial fractures were open and were treated primarily with external fixation and then with intramedullary nailing. Seventy patients (49%) were under 20 years old, 85 (59%) were men and traffic accident was the main cause of fracture in 58 (41%) patients. 108 patients were treated with GK nail, 14 patients with modified GK nail and 20 patients with S2 nail. All patients were allowed postoperatively full weight bearing with crutches till the fracture healing. Patients were evaluated clinically and radiographs were reviewed every three weeks till fracture healing. Last follow-up was at two years postoperatively. The functional results were evaluated with the Iowa Ankle-Evaluating System. Results: Acceptable radiographic alignment, defined as < 5° of angulation in any plane, was obtained in 135 patients (95%). No patient had any change in alignment between the immediate postoperative and the final radiographic evaluation. We had no non-unions or failures of the implant. Complications included one superficial infection at the entry point of the nail and one iatrogenic fracture at the time of the intramedullary nailing. The fractures united at an average of 12.5 weeks. The functional outcome was determined at one and two years postoperatively. There was improvement in the Iowa Ankle-Evaluating System scores with time. Conclusion: Intramedullary nailing is an effective alternative for the treatment of distal metaphyseal tibial fractures. Simple articular extension of the fracture is not a contraindication to intramedullary fixation. Functional outcomes improve with time

Displaced supracondylar fractures of the paediatric elbow are a serious, but well described injury. Although complications are common, avascular necrosis (AVN) of the capitellum has not been described or reported before. We describe a case with this complication. A review of the relevant literature is also presented. A three-year-old boy presented to our emergency department with a painful swollen left elbow after a fall. X-ray done in Accident and Emergency, reveal, a displaced, extension type, supracondylar fracture (Gartland Grade III. 1. ). An open reduction (medial approach) was done and the fracture reduced and stabilised with two crossed K wires. The fracture healed in an excellent position. However, at the three-month follow up, the elbow remained stiff with flexion from only 20 to 90 degrees and with very little supination. Eight months after the injury an arthrogram was undertaken which confirmed diagnosis of avascular necrosis of capitellum. No specific treatment for AVN given. Check radiographs showed healing of capitellum with no functional limitations

Proximal juxta-articular leg fractures are often high-energy injuries, involving the tibial articular surface as well as diaphyseal segments. Young, active people are frequently affected, and optimal reduction, effective stabilization, early function and a rapid return to daily-life are the goals of treatment. These fractures are, as well known, difficult to treat, because of the frequent articular involvement, fragment comminution and extension of the fracture rim: if not adequately treated, they might result in mal-union, non-union, articular stiffness and late arthrosis. Mal-union, both angular and rotational, are, in many cases, very difficult lesions to treat, almost always requiring osteotomies, osteointegration and stable fixation: we present our experience in the treatment of these lesions, with the results obtained in 31 cases treated with a minimum of 1 year of follow-up. The same protocol was used in all patients: direct surgical approach to the lesion, removal of any implanted device, careful débridement of the mal-union site (mainly directed to complete interposed fibrous tissue removal), deformity correction, stable internal fixation and osteointegration, whenever necessary, by autologous or homologous bone. We evaluated all cases in terms of patient satisfaction, deformity correction, bone healing and functional recovery: one major complication occurred (nail failure); delayed skin healing was seen in three patients (one requiring re-operation), and one patient there was rupture of a distal locking screw. In conclusion, this method is effective in the treatment of these lesions

Aims: To evaluate the results of our preliminary experience with the retrograde nailing for distal femoral fractures. Methods: During the period 1997 Ð 2000, 39 patients with 43 fractures of the distal femur, treated with retrograde intramedullary nail. There were 10 periprosthetic, 2 nonunions after previous failed þxation and 1 pathological fracture. 12 fractures were extra-articular, 18 had intra-articular extension and 2 fractures were open Type II according to Gustillo classiþcation. The mechanism of injury was road trafþc accident in 15 cases, with 9 of those being polytrauma patients, simple fall in and 1 spontaneous fracture. Results: Union was achieved in 11,3 weeks average time. There were 2 mal-unions and 1 nonunion needed reoperation. From the rest of the patients there were 4 with an excellent functional score, 19 good and 2 fair results. There were one superþcial infection, treated conservatively. In one patient the metalwork removal was necessary because he complained of pain from the distal interlocking screws. Conclusions: Retrograde intramedullary nailing, appears to be a reliable technique to treat fractures of the distal femur. It is accompanied by a high union rate and a low infection rate. It offers the advantage of little soft tissue impairment and adequate stability necessary for the fracture healing. Blood loss is usually small and therefore the method is suitable for fracture treatment in elderly and polytrauma patients. The accuracy of the reduction remains a question, because there is no precise method to test it intraoperatively

Introduction: Traumatic and iatropathic nerve injuries complicate 6–16% of paediatric supracondylar extension fractures of the humerus. The majority recover spontaneously. This retrospective review of lesions referred to our tertiary unit determined the incidence of surgical intervention. Methods: Between 1997–2002, 37 neuropathies (32 fractures) in 19 males and 13 females (mean age 7.9yrs) were referred for further management. 8 fractures were Gartland grade 2 and 24 grade 3. All fractures were closed. Two were originally treated non-operatively, 20 by closed reduction and percutaneous pinning and 10 by open reduction and internal fixation. Results: The ulnar nerve was most frequently injured (19, 51.4%), followed by median (10, 27%) and radial (8, 21.6%) nerve palsies. 14 (37.8%) neuropathies were fracture-related but 23 (62.2%) were treatment-related. 10 patients (31.3%) required operative exploration. Three (9.4%) were listed for surgery but cancelled due to nerve recovery. Nerve grafting using either the forearm medial cutaneous nerve or the superficial radial nerve was necessary in 4 of 10 operated cases. 26 patients (81.3%) had excellent outcomes, 5 (15.6%) good and 1 (3.1%) fair. Discussion: In contrast to current literature suggesting that 86 to 100% of supracondylar associated neuropathies recover spontaneously within 2 to 3 months, surgical exploration was required in over 30% of cases

Introduction: Isolated greater trochanter fractures gained clinical importance because of the possibility of their inter-trochanteric extension. Aim: To assess whether the direction and the extent of the fracture measured on plain radiographs could be used to predict the inter-trochanteric extension. Materials and Methods: We reviewed plain radiographs and MRI scans of 24 patients who sustained isolated greater trochanter fractures between year 2003 and 2006. We considered two parameters. extent of fracture in percentage along the intertrochanteric line. angle of the fracture line. Both these parameters were measured on a plain anteroposterior radiograph. To measure the length of fracture we have drawn a straight line along the medial border of femoral shaft extending proximally in to the pelvis. Then we measured the distance between the most superior point of the fracture line on the lateral cortex and the midpoint of lesser trochanter on the first line. Then we measured the length of the fracture starting from the most superior point on the lateral cortex. We estimated the percentage of this fracture length in relation to line. To estimate the angle, again we have drawn a straight line along the medial border of femoral shaft extending proximally in to the pelvis. We have drawn another line in the direction of fracture staring from most superior point of fracture on the lateral cortex joining the first line. We measured the angle between these two lines (Fig 2). We used our Hospital PACS system to measure the angles and the length of the fracture. Results: Out of 24 isolated greater trochanteric fractures as diagnosed by plain radiographs, MRI scans revealed intertrochanteric extension in nine (37.5%). On the plain anteroposterior radiograph, the mean angle of the fracture in those with MRI proven intertrochanteric extension was 34º (range 20º–45º). In those with no intertrochanteric extension on MRI scan, the mean angle was 55º (Range 25º–125º). The mean percentage of length of fracture across the intertrochanteric line was 62% (47%–73%) and 40% (27%–62%) respectively. All the fractures with MRI proven intertrochanteric extension had a fracture angle of < 45º and the percentage of fracture length of > 40%. All the 15 fractures with fracture angle more than 45º did not show intertrochanteric extension on MRI scan. Conclusions: We conclude that those isolated greater trochanteric fractures, with fracture angle of more than 45 º are unlikely to have an intertrochanteric extension. These patients could be mobilised without further MRI scans. Those fractures which fulfil the plain radiographic criteria of extension of more than 40% and fracture angle between 20º–40º are likely to show inter trochanteric extension. These patients need further clinical assessment and MRI scans to confirm the intertrochanteric extension