The attachment of the plantar aponeurosis to the proximal phalanx of the toe, through the plantar plate (PP), forms the main flexor of the toe during gait by the reversed windlass mechanism. Disruption of the plantar plate is a common cause of pain, instability and toe deformity. Surgical techniques have recently been described to repair tears but long term results are awaited. This study aims to review the results of a technique designed to reconstruct and reinforce the failed plantar plate and restore the reversed windlass. Through a dorsal extra-articular approach the EDL tendon of the affected toe is used to restore the mechanical link between the proximal phalanx and the plantar aponeurosis on the plantar aspect of the joint. 42 PP reconstructions in 39 patients (36 female) aged 44–72 were undertaken, most frequently on the 2nd toe. 25 required correction of hallux valgus and four had undergone this previously. Follow up was 2–81 months.Introduction
Methods
To evaluate the efficacy of elastic stable intramedullary nailing (ESIN) for the treatment of forearm fractures in children and adolescents. Between June 2002 and August 2007, 28 patients (19 boys – 9 girls) with 28 forearm fractures were treated with ESIN in our department. The mean age was 12.88 years (range 10.9–4.82). Both forearm bones were affected in all cases. 13 patients were treated by intra-medullary splinting immediate after the accident whilst 15 children were operated after failure of conservative treatment and fracture redisplacement. The radius was nailed in a retrograde fashion in all cases. On the other hand antegrade nailing of the ulna was performed in 18 cases whilst retrograde nailing in 5 patients. In 8 cases closed reduction was possible whilst a small incision at the fracture site was necessary in 20 children. In all cases an above-elbow cast was applied for 5 – 6 weeks postoperatively. The healing process was determined on the basis of two-projection radiographs. At the latest follow-up elbow and forearm motion were also assessed. Mean follow-up was 16 months (range, 7 – 28). With the exception of one case all fractures healed within 9 weeks. No case of infection, cross-union or non-union occurred. At the latest follow-up all children presented with complete restoration of elbow movement but three of them had a deficit of pronation of 15–20 degrees. In those cases where an open reduction was required the results were the same as in other cases. Based on our results, retrograde, of both bones, nailing is recommended for the treatment of all displaced forearm fractures in children older than 7 years-old. Proper preoperative curving of the nails offers increased stability maintaining the anatomic relation of the forearm bones.
