Aims. The ulna is an extremely rare location for primary bone tumours of the elbow in paediatrics. Although several reconstruction options are available, the optimal reconstruction method is still unknown due to the rarity of proximal ulna tumours. In this study, we report the outcomes of osteoarticular ulna allograft for the reconstruction of proximal ulna tumours. Methods. Medical profiles of 13 patients, who between March 2004 and November 2021 underwent osteoarticular ulna allograft reconstruction after the resection of the proximal ulna tumour, were retrospectively reviewed. The outcomes were measured clinically by the assessment of elbow range of motion (ROM), stability, and function, and radiologically by the assessment of allograft-host junction union, recurrence, and joint degeneration. The elbow function was assessed objectively by the Musculoskeletal Tumor Society (MSTS) score and subjectively by the Toronto Extremity Salvage Score (TESS) and Mayo Elbow Performance Score (MEPS) questionnaire. Results. The mean follow-up of patients was 60.3 months (SD 28.5). The mean elbow flexion-extension ROM was 95.8° (SD 21). The mean MSTS of the patients was 84.4 (SD 8.2), the mean TESS was 83.8 (SD 6.7), and the mean MEPS was 79.2 (SD 11.5). All the patients had radiological union at the osteotomy site. Symptomatic osteoarthritic change was observed in three patients (23%), one of whom ended up with elbow joint fusion. Two patients (15.4%) had recurrence during the follow-up period. Surgical complications included two allograft fractures, two plate fractures, three medial instabilities, and two infections. Conclusion. Osteoarticular ulna allograft reconstruction provides acceptable functional outcomes. Despite a high rate of complications, it is still a valuable reconstruction method, particularly in skeletally immature patients who need their distal humerus physis for the rest of hand growth. Cite this article: Bone Jt Open 2024;5(9):749–757

Aims. The primary aim of this study was to describe long-term patient-reported outcomes after ulna shortening osteotomy for ulna impaction syndrome. Methods. Overall, 89 patients treated between July 2011 and November 2017 who had previously taken part in a routine outcome evaluation up to 12 months postoperatively were sent an additional questionnaire in February 2021. The primary outcome was the Patient-Rated Wrist and Hand Evaluation (PRWHE) total score. Secondary outcomes included patient satisfaction with treatment results, complications, and subsequent treatment for ulnar-sided wrist pain. Linear mixed models were used to compare preoperative, 12 months, and late follow-up (ranging from four to nine years) PRWHE scores. Results. Long-term outcomes were available in 66 patients (74%) after a mean follow-up of six years (SD 1). The mean PRWHE total score improved from 63 before surgery to 19 at late follow-up (difference in means (Δ) 44; 95% confidence interval (CI) 39 to 50; p = <0.001). Between 12 months and late follow-up, the PRWHE total score also improved (Δ 12; 95% CI 6 to 18; p = < 0.001). At late follow-up, 14/66 of patients (21%) reported a PRWHE total score of zero, whereas this was 3/51 patients (6%) at 12 months (p = 0.039). In all, 58/66 patients (88%) would undergo the same treatment again under similar circumstances. Subsequent treatment (total n = 66; surgical n = 57) for complications or recurrent symptoms were performed in 50/66 patients (76%). The most prevalent type of reoperation was hardware removal in 42/66 (64%), and nonunion occurred in 8/66 (12%). Conclusion. Ulna shortening osteotomy improves patient-reported pain and function that seems to sustain at late follow-up. While satisfaction levels are generally high, reoperations such as hardware removal are common. Cite this article: Bone Jt Open 2022;3(5):375–382

Aims. The aim of this study was to assess the ability of morphological spinal parameters to predict the outcome of bracing in patients with adolescent idiopathic scoliosis (AIS) and to establish a novel supine correction index (SCI) for guiding bracing treatment. Methods. Patients with AIS to be treated by bracing were prospectively recruited between December 2016 and 2018, and were followed until brace removal. In all, 207 patients with a mean age at recruitment of 12.8 years (SD 1.2) were enrolled. Cobb angles, supine flexibility, and the rate of in-brace correction were measured and used to predict curve progression at the end of follow-up. The SCI was defined as the ratio between correction rate and flexibility. Receiver operating characteristic (ROC) curve analysis was carried out to assess the optimal thresholds for flexibility, correction rate, and SCI in predicting a higher risk of progression, defined by a change in Cobb angle of ≥ 5° or the need for surgery. Results. The baseline Cobb angles were similar (p = 0.374) in patients whose curves progressed (32.7° (SD 10.7)) and in those whose curves remained stable (31.4° (SD 6.1)). High supine flexibility (odds ratio (OR) 0.947 (95% CI 0.910 to 0.984); p = 0.006) and correction rate (OR 0.926 (95% CI 0.890 to 0.964); p < 0.001) predicted a lower incidence of progression after adjusting for Cobb angle, Risser sign, curve type, menarche status, distal radius and ulna grading, and brace compliance. ROC curve analysis identified a cut-off of 18.1% for flexibility (sensitivity 0.682, specificity 0.704) and a cut-off of 28.8% for correction rate (sensitivity 0.773, specificity 0.691) in predicting a lower risk of curve progression. A SCI of greater than 1.21 predicted a lower risk of progression (OR 0.4 (95% CI 0.251 to 0.955); sensitivity 0.583, specificity 0.591; p = 0.036). Conclusion. A higher supine flexibility (18.1%) and correction rate (28.8%), and a SCI of greater than 1.21 predicted a lower risk of progression. These novel parameters can be used as a guide to optimize the outcome of bracing. Cite this article: Bone Joint J 2022;104-B(4):495–503

Purpose: We report three cases of extensive resection of the ulna without reconstruction. Material and methods: For the first two patients, resection was performed for ulnar tumour, on low-grade osteosarcoma and one adamantinoma. In the third patient with a voluminous giant-cell tumour, the distal part of the ulna was resected and used as a graft for arthrodesis after resection of the distal third of the homolateral radius. Resection involved the distal half, three-quarters, and one-third of the ulna in these three patients. Results: At follow-up of 4, 23 and 1 year respectively, wrist motion is normal in the two patients and elbow motion is normal in two out of three. None of the patients experienced wrist pain or ulnar stump pain. Grip force decreased in the two patients who underwent isolated ulnar resection. Discussion: Our observations corroborate reports in the literature leading to the conclusion that reconstruction of the ulna is not justified when one-quarter of the bone can be preserved. The ulna offers an exceptional graft material for reconstruction of the homolateral radius

Purpose of the study: The purpose of using distal metaphyso-epiphyseal osteotomy to shorten the ulna is to reduce healing time compared with diaphyseal shortening and to adapt the osteotomy to the distal radioulnar anatomy and associated conditions by using a variably oblique cut. Material and methods: Oblique metaphyso-eiphyseal osteotomy of the distal ulna was performed in sixteen patients since 2000. Fourteen presented ulnocarpal pain. Among these, eight had associated distal radioulnar pain. Two patients had pain essentially limited to the distal radioulnar area. Radiographically, there was ulnocarpal impingement in fourteen wrists, and signs of early-stage distal radioulnar osteoarthritis in five. Local regional anesthesia was used in thirteen patients who underwent surgery in an outpatient clinic. The dorsoulnar approach was used. The direction of the osteotomy cut depended on the individual condition, and distal radioulnar anatomy and stability. Two headless canulated screws were used for fixation. The elbow and wrist were immobilized for three weeks followed by self-education of pronosupination beginning with a removable orthesis to stabilize the wrist. Results: Outcome was assessed at maximum follow-up of four years. Preoperative pain had totally resolved in fourteen wrists with residual pain at forced pronosupination in two. Wrist motion was not modified in the frontal and sagittal planes. Complete pronosupination range of motion was achieved in thirteen patients, two patients had supination limited to 20° and one had pronation and supination limited to 30°. Force was 90% compared to the opposite side. Bone healing was achieved in all patients, in 3–4 weeks for fourteen wrists and after two months of elbow and wrist immobilization in two. Discussion: Oblique metaphyso-epiphyseal osteotomy of the distal ulna reduced the healing time compared with diaphyseal shortening osteotomies. This technique enables adaptation of the direction and orientation of the ulnar cut to the individual distal radioulnar anatomy. Favorable clinical outcome in patients with early-stage distal radioulnar osteoarthritis has led us to progressively abandon certain indications for distal resection of the ulna and the Sauvé-Kapankji operation

Non-union of the radius and/or ulna is comparatively common in the treatment of forearm fractures. Bone graft from the iliac crest secured by rigid plate fixation under compression is indicated in non-unions with a bone defect longer than 2 cm. The aim of the study is to compare the results with the current literature. Thirteen patients (female: 1; males: 12), mean age 44 years (23–75 years), were treated in our department between 1993 and 2003. In 10 patients the original injury involved both radius and ulna; in the remaining three only the ulna was affected. All the fractures had been internally fixed, except for a radius fracture. Non-unions involved the ulna in eight cases, the radius in one case and both radius and ulna in four cases. A cortico-cancellous graft was used to fill a defect of the ulna in 11 cases and of the radius in two cases. In the non-unions of both bones only one bone was operated (one radius and three ulna); a different treatment was performed in the other bone. The mean time between the original injury and the indexed procedure was 7 months (3–14 months). The mean bone defect was 4 cm (2–6 cm). A T-shaped cortico-cancellous graft was always used. All the patients were evaluated clinically and radiographically with a mean follow-up of 4 years (1–10 years). Bony union was achieved in all the patients at an average time of 4 months (3–6 months). At the follow-up the mean elbow flexion was 130°, the mean extension lag 4°, the mean pronation 71° and the mean supination 61°. The mean grip strength was 38 kg, 81% of the contralateral side. Cortico-cancellous bone graft from the iliac crest is an effective technique to fill a bone defect of between 2 and 6 cm. Up to this length the mechanical properties of the graft are optimal for a rigid plate fixation under compression; moreover, biological conditions allow ready integration of the graft. Rigid fixation with cortico-cancellous bone graft from the iliac crest is a useful technique for forearm non-unions with a bone defect of between 2 and 6 cm

Aim: The aim of this investigation was to determine how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation. Materials & Methods: Ulna to radial deviation was assessed in 30 normal wrists in 15 normal subjects aged 19 to 32. Movement was measured with a Polhemus Fastrak (TM) magnetic tracking system. The system has translational and rotational measurement accuracies of 1 mm and 1 degree respectively. Subjects placed their palms on a flat wooded stool and had movement sensors attached over their 3rd metacarpal and distal radius. These sensors then recorded movement as the hand moved from full ulna to full radial deviation. Results: The mean range of movement was 47 degrees (SD 8). In full ulna deviation the wrist rotational axis was in the region of the lunate/capitate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 22 mm (SD 14). In 17 wrists the distal displacement was accompanied by mean displacement towards the ulna of 13 mm (SD 8). In 13 wrists the distal displacement was accompanied by a mean displacement towards the radius of 7 mm (SD 5). Conclusion: The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 type of carpal movement. i.e. Column movers and row movers [Craigen & Stanley]

Aim: The carpal bone arrangement can be described as a matrix of two rows and three columns. There a various theories as to how the bones within the matrix move during ulna to radial deviation. One theory suggests that there are two types of wrist movement, namely Row & Column. 1. . The aim of this study was to investigation how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation. Materials and Methods: Ulna to radial deviation was assessed in 50 normal wrists in 25 normal subjects aged 19 to 57. Movement was measured with a Polhemus Fastrak (TM) magnetic tracking system. The system has translational and rotational measurement accuracies of 1 mm and 1 degree respectively. Subjects placed their palms on a flat wooded stool and had movement sensors attached over their 3rd metcarpal and distal radius. These sensors then recorded movement as the hand moved from full ulna to full radial deviation. Results: The mean range of movement was 45 degrees (SD 7). In full ulna deviation the wrist rotational axis was in the region of the lunate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 21 mm (SD 15). In 32 wrists the distal displacement was accompanied by mean displacement towards the ulna of 12 mm (SD 8). In 18 wrists the distal displacement was accompanied by a mean displacement towards the radius of 8 mm (SD 5). Conclusion: The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 types of carpal movement. i.e. Column movers and row movers. 1.

Ulna Styloid Fractures have been historically dismissed as a relatively benign injury. However recent clinical and biomechanical research has suggested that primary repair of displaced ulna styloid avulsion fractures is advised as a means of stabilizing the radioulnar joint and preventing the disability associated with chronic radioulnar joint instability. Optimum fixation method was examined in this study using a human cadaveric model. A custom jig was designed to allow testing in radial/ulna deviation in varying degrees of wrist flexion and extension. Universal materials testing device was used to apply a maximum load of 150 N. Eight pairs of cadaveric wrists were tested. Constructs tested were 1.6mm K-wire fixation, Tension Band wiring and Screw Fixation. Fracture displacement was measured using a venire micrometer. Results: Displacement on forced radial deviation was maximum in neutral wrist position in all construct configurations. Displacement was minimized in 20 degrees wrist flexion. The optimum fixation method was 2 k-wires with tension band wiring. This study would suggest that the optimum fixation for ulna styloid fractures is a Tension band-wiring construct. If non-operative treatment is used we suggest that the wrist is immobilized in a position of wrist flexion to reduce tension on the ulna carpal ligament and prevent fracture displacement

The aim of this study was to investigate how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation. Fifty normal wrists in 25 subjects were assessed with a Polhemus Fastrak (TM) magnetic tracking system. The subjects, aged 19 to 57, placed their palms on a flat wooded stool. Sensors were attached over their 3rd metcarpal and distal radius. The sensors then recorded movement from ulna to radial deviation. The translational and rotational measurement accuracies were 1 mm and 1 degree respectively. The mean range of movement was 45 degrees (SD 7). In ulna deviation the axis was in the region of the lunate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 21 mm (SD 15). In 32 wrists the distal displacement was accompanied by a mean displacement towards the ulna of 12 mm (SD 8). In 18 wrists the distal displacement was accompanied by a mean displacement towards the radius of 8 mm (SD 5). The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 types of carpal movement proposed by Craigen and Stanley (J. Hand Surg, 20B, 165–170, 1995)

Aims:. 1) To determine the predictive value of a simple stability test in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation. 2) To determine the effect of cast quality as reflected in the skin cast distance (distance between the cast and the skin in the plane of major displacement or angulation) and the cast index (the inside diameter of the cast in the sagittal plane divided by the inside diameter in the coronal plane) on re-displacement rates in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation. Methods: This is a prospective study of 57 children aged 4 to 15 with metaphyseal and Salter-Harris II wrist fractures treated with simple manipulation. Under fluoroscopic imaging, a simple stability test involving moving the hand at the wrist in the dorsopalmar, and radioulnar planes was performed following reduction, and x-ray images were saved. We recorded and compared the displacement and angulation on the initial x-rays, during the test, and at one-and 6-week follow-up. We also recorded the skin-cast distance (SCD), and the cast index (CI). Results: 38 patients had isolated radius fractures and 19 had radius and ulna fractures. Four patients needed remanipulation with K-wire fixation. Multiple regression analysis revealed significant correlation between percentage loss of reduction on testing and subsequent re-displacement (relationship between the two sets of values r = 0.6167, (p< 0.001)). This indicates that instability on testing (seen as a significant percentage loss of reduction) is likely to be associated with some loss of reduction on follow-up. There was a significant relationship between the skin cast distance and the cast index, and loss of reduction on one week follow-up. (p=0.006). Isolated radius fractures had a higher risk of re-displacement than radius and ulna fractures (3.9% and 0.9% respectively; p< 0.05%). Conclusion: Stable reduction on stability testing in wrist fractures in children immobilised in a good cast (reflected in a low SCD, and CI) is associated with a good outcome. Isolated radius and ulna fractures are more likely to re-displace than radius and ulna fractures. There is a relationship between instability and loss of position at the 1-week follow-up. Potentially unstable fractures can be prevented from slipping by a good cast. A stable fracture on our stability test rarely slips. We therefore feel that stability test is a useful adjunct in decision-making

Purpose of Study:. To review the outcome of paediatric patients with radius and ulna fractures treated with titanium elastic nails. Description of methods:. Paediatric patients with radius and ulna fractures who fulfilled the criteria for TENS nailing were used. The criteria included failed closed reduction, instability (>15°angulation, >5°rotation) and open fractures. The patients were treated with retrograde TENS nailing of the radius and ulna. The patients were followed up at a paediatric orthopaedic outpatient clinic at 1, 3, 6 and 12 weeks with a final visit at 6 months. Data was collected at every visit looking at range of motion (pronation and supination), clinical and radiological signs of union and complications. Summary of results:. Over a 16 month period, 214 paediatric patients with radius and ulna fractures were seen and managed. Eleven of these patients were treated with TENS nails. The average age of the patient was 8.3 years. The average time to union was 8.5 weeks. The average range of motion at 6 months was pronation of 80°and supination of 73°. Two patients developed a compartment syndrome in the immediate post-operative period and were treated with a fasciotomy and skin grafting. No other complications were noted. Conclusion:. TENS nailing of paediatric radius and ulna fractures in unstable, irreducible and open fractures is a good treatment modality with good, early union of fractures and acceptable range of motion. It provides an excellent alternative to plating these fractures

After a fracture of the distal radius, the bone segments may heal in a suboptimal position. This condition may lead to a reduced hand function, pain and finally osteoarthritis, sometimes requiring corrective surgery. The contralateral unaffected radius is often used as a reference in planning of a corrective osteotomy procedure of a malunited distal radius. In the conventional procedure, radiographs of both the affected radius and the contralateral radius have been used for planning. The 2D nature of radiographs renders them sub-optimal for planning due to overprojection of anatomical structures. Therefore, computer-assisted 3D planning techniques have been developed recently based on CT images of both forearms. The accuracy of using the contralateral forearm for CT based 3D planning the surgery of the affected arm and the optimal strategy for planning have not been studied thoroughly. To estimate the accuracy of the planned repositioning using the contralateral forearm we investigated bilateral symmetry of corresponding radii and ulnae using 3-dimensional imaging techniques. A total of 20 healthy volunteers without previous wrist injury underwent a volumetric computed tomography scan of both forearms. The left radius and ulna were segmented to create virtual 3 dimensional models of these bones. We selected a distal part and a larger proximal part from these bones and matched them with a mirrored CT-image of the contralateral side. This allowed estimation of the accuracy by calculation of relative displacements (Δx, Δy, Δz) and rotations (Δψx, Δψy, Δψz) required to align the left bone with the right bone segments as a reference. We also investigated the relationship between longitudinal length differences in radius and ulna and utilised this relationship to arrive at an optimal planning of the length of the affected radius after surgery. Relative differences in displacement and orientation parameters after planning based on the contralateral radius were (Δx, Δy, Δz): −0.81±1.22 mm, −0.01±0.64 mm, and 2.63±2.03 mm; and (Δψx, Δψy, Δψz): 0.13°±1.00°, −0.60°±1.35°, and 0.53°±5.00°. The same parameters for the ulna were (Δx,Δy, Δz): −0.22±0.82 mm, 0.52±0.99 mm, 2.08±2.33 mm; and (Δψx, Δψy, Δψz): −0.56°±0.96°, −0.71°±1.51°, and −2.61°±5.58°. The results also point out that there is a strong linear relationship between absolute length differences (Δz) of the radius and ulna among the individuals. Since we observed substantial length difference of the longitudinal bone axes of both forearms in healthy individuals, including the length difference of the adjacent forearm bones in the planning turned out to be useful in improving length correction in computer-assisted planning of radius or ulna osteotomies. The improved planning markedly reduces length positioning variability, (from 2.9± 2.1 mm to 1.5 ± 0.6 mm). We expect this approach to be valuable for 3-D planning of a corrective distal radius osteotomy. Awareness of the level of bilateral symmetry is important in reconstructive surgery procedures when the contralateral unaffected side is used as a reference for planning and evaluation. Bilateral asymmetry may introduce length errors into this type of preoperative planning that can be reduced by taking into account the concomitant ulnae asymmetry

Stress shielding (i.e. reduction in bone strains) in the distal ulna is commonly noted following ulnar head replacement arthroplasty. Optimal design parameters for distal ulnar implants, including the length of the stem, are currently unknown. The purpose of this study was to investigate the effect of stem length on bone strains along the length of the ulna. Strain gauges were applied to each of eight cadaveric ulnae to measure bending loads at six locations along each ulna’s length (approximately 1.5, 2.5, 4.0, 6.0, 8.0, and 13.0cm from the ulnar head). The proximal portion of each bone was secured in a custom-designed jig. A materials testing machine applied loads (5–30N) to the ulnar head while native strains were recorded. The ulnar head was removed and the loading procedure repeated for cemented stainless steel stems 3 and 7cm in length, according to a previously reported technique (Austman et al, CORS 2006). Other stem lengths between 3 and 7cm were tested in 0.5cm intervals with a 20N load applied only. Data were analyzed using a two-way repeated measures ANOVA (á=0.05). In general, distal bone strains increased as stem length decreased (e.g. average microstrains at the second distal-most gauges: 138±13 (7cm), 147±15 (6cm), 159±21 (5cm), 186±40 (4cm), 235±43 (3cm)). The native strains were different from all stem lengths for the four distal-most gauges (p< 0.05). No differences were found between any stem length and the native bone at the two proximal-most gauges. The 3cm stem replicated the native strains more closely than the 7cm, over all applied loads (e.g. average microstrains at the third gauge level for a 25N load: 357±59 (native), 396±74 (3cm), 257±34 (7cm)). No stem length tested matched the native strains at all gauge locations. The 3cm stem results were closer to the native strains than the 7cm stem for all loads at gauges overtop of the stem. Overall, the 3cm stem produced the highest strains, and thus would likely result in less distal ulnar bone resorption after implantation. These results suggest that shorter (approximately 3cm) stems should be considered for distal ulnar implants to potentially reduce stress shielding, although this must be balanced by adequate stem length for fixation

The treatment of relapsing pseudoarthrosis of ulna presents quite a lot of perplexities as regards the surgical strategy to follow which means of synthesis to solve the biomechanical problems (lack of favourable loading stimuli and, on the contrary, presence of unfavourable torsional strengths due to the movement of pronosupination of the forearm),and how to interact in order to favour the restoration of osteogenesis (homologous or autologous bone graft, vascularized or not, bone substitutes, employment of autologous growth factors, of morphogenetic proteins (BMP),and of autologous staminal cells). The authors report about 4 particular cases of relapsing pseudoarthrosis of the ulna previously treated with autologous bone grafts but with no recovery. In order to activate osteogenesis, the authors have employed a graft of autologous bone enriched with platelet derived growth factors + adult mesenchymal stem cells from drawing from the iliac wing. The osteosyntesis has been carried out in 3 cases with endomidollar locked nail and, in one case, with external fixation. All the four cases have reached prompt lasting clinical recovery (following up from 8 to 28 month) and Rx precocious evidence of osteointegration of the grafts independently from the synthesis means. The limited casuistry does not enable us to report any comparable statistical data. The authors think that association of AGF + adult mesenchymal stem cells can be determinant and encouraging and, thanks to the results, they suggest its spreading

Clinical Problem: fractures under tension are common injuries and occur when patients are falling on partial flexed limbs under maximal contraction of the extensor muscles. Typical injuries are patella and olecranon. For these fractures the tension belt osteosyntheses is the mainly used procedure. A high complication rate regarding dislocation, bone healing, pain and functional outcome are reported. This is due to the unstable fixation with the tension belt because of the tendon insertion around the bone fragment witch allow secondary loosening of the tension belt under alternating load. This was found allready 1987 by Brill and Hopf in an experimental study. Materials and Methods: To improve stabilisation a new device was developed: the XS (4,5mm diameter) and the XXS nail (3,5mm) witch is locked with threaded wires and a set screw allows fracture compression inside the nail independend from the soft tissues around. Fiber Wire cerclage transversal around the threaded wire ends allow the fixation of additional frontal plane fragments or marginal fragments. Experimental test were performed in a patella sow-bone models and showed superior to tension bel (patella) and Plate fixation/fibula). On the other side the locked nail system allows percutaaneous osteosynthesis of the whole ulna also in shaft, distal fractures and shortening osteotomies. All clinical cases treated with the XS/XXS nail where recorded prospectively and re-examined after 6–12 months. From may 2000 to march 2002 76 patients with olecranon fractures were evaluated. 85% of the olecranon fracture patients could be re-examined. Most patients where treated immediately or after wound healing without splint. Results: the experimental results shows in all XS nail group no gap after alternating load of 250 and 500N and a rigidity a little higher than that of the not osteotomised patellae. In the tension belt groups in all tested patellae visible gaps of 1 to 3 mm occurred. There was no difference between the single and double XS nail Osteosynthesis. 71.7% of all patients with olecranon fractures showed a very good result according to the Murphy score. In 2 part fractures the rate was even 94.7%. Only in the group of more part fractures in 5.9% fair results were found. No patient showed a poor result. The technical possibilities of XS nail osteosynthesis in ulna shaft, distal fractures and shortening osteotomies are presented. Conclusions: the XS nail is a new device witch allows good anatomical reconstruction and stable fixation with immediate functional therapy in all olecranon and ulna fractures

Introduction and Aims: The purpose of our study was to assess the efficacy of double osteotomy of the radius and ulna for correction of Madelung’s deformity. Made-lung’s deformity is a congenital alteration of the growth of the ulnar portion of the distal radius resulting in pain, decreased function of the wrist and hand and serious aesthetic disturbances. Method: Four wrists in four patients with a mean age of 18.3 years were treated for symptomatic increased ulnar and volar inclination of the distal articular surface of the radius. All patients complained of wrist pain. In addition, two of them were dissatisfied with the aesthetic appearance of their wrist and the restricted range of movement. A double osteotomy of the radius and ulna was performed. The ulna was stabilised with a six-hole semi-tubular plate and the radius with a titanium T-plate. Results: At one-year follow-up: pain relief and cosmetic appearance were satisfactory in all patients. Grip strength improved by 5.3 pounds. Average flexion improved from 63 to 67 degrees and pronation from 59 to 66 degrees. Abduction increased from three to six degrees and adduction from 16 to 21 degrees. Realignment of the wrist was shown radiographically by a change of ulnar inclination and volar inclination of the radius from 35.5 to 24 degrees and 15.5 to 10.5 degrees respectively. There was no evidence of recurrence of the deformity in any of the four wrists. Conclusion: The initial results with the double osteotomy of the radius and ulna for Madelung’s deformity are promising but need longer follow-up

Methicillin– resistant Staphylococcus aureus (MRSA) infected gap non –union of long bones fractures is a challenge to manage. Treatment options are limited such a Ilizarov bone transport, vascularized bone free transfer etc. These techniques have complications and require expertise. We present a rare case with MRSA infected nonunion and bone defect 5cm of ulna which was managed with the induced membrane formation. A 33-years old male presented to outpatient department, 2 months after internal fixation on both left bone forearm fractures (Gustillo I). There was pus discharge from the operative site of ulna. Culture results: MRSA, C-Reactive Protein (CRP): 2,58 (0–5), Erythrocyte Sedimentation Rate (ESR): 42 (0–20). Intravenous (iv) Teicoplanin and Rifampicin were administrated and after one month no topic symptoms and CRP- ESR were normal. One month later he had again actively draining sinus (CRP: 1,47 ESR:22). The implant (ulna) was removed and a gap 5 cm was created at the fracture site (necrotic-infected bone debrided), which was filled by cemented spacer (Tobramycin and vancomycin). An external fixator was applied to ulna. Radius was not involved. Post op. iv the same antibiotics for 4 weeks. At the end of 8 weeks, the spacer was removed and the gap was filled with autologous cancellous bone graft (iliac crest). After 5 months the patient was reviewed. No any clinical and functional problems. Radiographics and CT-images were showed osseous consolidation. This technique (called as ‘Masquelet’) gives promising result in the management of infected long bone defects in upper extremity

Distal radius and ulna fractures are a common paediatric injury. Displaced or angulated fractures require manipulation under anaesthetic (MUA) with or without Kirchner (K) wire fixation to improve alignment and avoid malunion. After treatment a proportion redisplace requiring further surgical management. This study aimed to investigate whether the risk of redisplacement could be reduced by introducing surgical treatment guidelines to ascertain whether MUA alone or the addition of K wire fixation was required. A cohort of 51 paediatric forearm fractures managed either with an MUA alone or MUA and K wire fixation was analysed to determine fracture redisplacement rates and factors which predisposed to displacement. Guidelines for optimal management were developed based on these findings and published literature and implemented for the management of 36 further children. A 16% post-operative redisplacement rate was observed within the first cohort. Redisplacement was predicted if an ‘optimal reduction’ of less than 5° of angulation and/or 10% of translation was not achieved and no K wire fixation utilised. Adoption of the new guidelines resulted in a significantly reduced redisplacement rate of 6%. Implementation of departmental guidelines have reduced redisplacement rates of children's forearm fractures at Great Western Hospital

Number one in frequency of all fractures in children is the distal forearm fracture. The most common green-stick fracture with minor or no dislocation is treated by short or long arm cast. Depending on the age 4 or six weeks of immobilization is sufficient. Displaced fractures of the distal radius and ulna are treated by closed reduction under general anaesthesia or lighter forms of analgesia. Reduction is followed by fixation in the “Schede position” (flexion, ulnar abduction) with obligatory change of cast after 10–14 days. Healing can be expected after 6 weeks. As an alternative percutaneous pinning of the reduced fracture allows immobilization in a short arm cast and without the the unpleasant flexion and ulnar abduction (. Voto et al 1990. , . Mani et al 1993. , . Gibbons et al 1994. , Choi et al 1959). There is currently a prospective randomised study running organized by Mr Clarke from Southampton, to the advantages and disadvantages after use of pins or abstaining from them apparent risks. For midshaft forearm fractures closed reduction and long arm cast immobilisation had been treatment of choice in the past. Remanipulation under anaesthesia because of lack of retention of both bone fractures have been common. Concerns came up mainly in the age group above 10 years with a high rate of unsatisfactory results (. Kay et al 1986. ). Plate fixation of both bones is a difficult procedure and causes damage to the interosseous membrane and can enhance rotatory deficits. In addition ugly scars are not unusual. Intramedullary nails seemed advantageous. (. Amit et al 1985. ). J.L. Morote and the Spanish school of Sevilla were the first to use a minimal invasive method of reduction and K-wire fixation of midshaft and proximal forearm fractures. (Perez-Sicilia et al 1977). The French group in Nancy and Metz had the some years later and developed their elastic stable intramedullary system for forearm fractures . Metaizeau 1988. , . Lascombes et al. 1990. ). A high rate of excellent outcomes and hardly any complications were observed. Intramedullary fixation with elastic stable nails even permits immediate motion (. Verstreken et al 1988. ). The surgical technique of Morote using blunt-ended 1,6 to 1,8 mm K-wires is described in “Operative Technique in Orthopaedics and Trauma” (. Parsch 1990. ) The results were confirmed by Kaye Wilkins (1996), . Luhmann et al 1998. , and . Richter et al 1998. An unacceptable high rate of complications was seen in groups, who used pins, which were not buried, who removed pins to early and before consolidation or who had fixed only one bone (. Cullen et al 1998. , . Shoemaker et al 1999. ). We recommend the intramedullary system for all displaced forearm fractures of children above 6 years until closure of the growth plate.(. Parsch 1990. ). The learning curve is short, the time of surgery an average of 40 minutes. The radiation exposure can be limited by the use of short impulse image intensifier. There is virtually no blood loss. With the learning curve more than 80 % can be fixed by closed means. Open reduction might be necessary in adolescents, or in delayed fracture care. Postoperative immobilisation is a plaster shell or brace is used for 2 weeks, this is not obligatory. Postoperative infections have not been observed after this minimal invasive method. Skin irritations can be avoided by complete bending of the K-wire ends. In unacceptable malunion after conservative treatment closed or open realignment of the fractures followed by intramedullary Morote pinning is the treatment of choice. Refractures may happen with wires in place shortly or a long time after removal of the hardware. They are not associated to the system, but rather to the fact that some children are subject to repeated falls, liable to break an arm. Acute Monteggia fractures have the radial head reduced conservatively, usually under general anaesthesia. (. Bado 1967. ). The ulnar fracture is reduced and than fixed by intramedullary K-wires (. Fowles et al 1983. ). In late reconstruction of Monteggia lesions we prefer plate fixation of ulna osteotomy