Purpose of the study: Optimal management of proximal fractures of the humerus remains a subject of debate. We conducted a prospective epidemiological study to identify injuries encountered, determine the reproducibility of reference classifications and their pertinence for therapeutic decision making.

Material and methods: All patients presenting a proximal fracture of the humerus admitted to a teaching hospital from November 2007 to November 2008 were included using a standardised computer form. A CT-scan was obtained if necessary. Fractures were classified by three senior observers (CP, GM, AR) according to the Neer and AO classifications.

Results: Two hundred forty-seven fractures were collected in 75 men (30%) and 172 women (70%), mean age 66 years (18–97). There were 112 fractures on the dominant side (45%). Two patients had vessel injury and one an associated injury of the brachial plexus. One patient had an isolated injury to the axillary nerve. According to the Neer classification which describes 15 types of fractures, there was little or no displacement or 38% of the fractures and 97.5% of the fractures were classified within six groups: little or no displacement, surgical neck, trochiter fracture alone or with anterior dislocation, 3 or 4 fragment fractures. Using the nine subtypes of the AO classification, there were 58 A1, 55 A2, 42 A3, 43 B1, 9 B2, 5 B3, 14 C1, 18 C2 and 3 C3. Groups A and B included 88% of the fractures. Regarding the CT-scan, obtained in 40% of patients, changed the radiographic interpretation in six cases. Interobserver reproducibility was good. Orthopaedic treatment was given for 203 patients (82%). Operations were: fixation of the tuberosities (n=7), anterograde nailing (n=29), hemiarthroplasty (n=6), reversed prosthesis (n=2).

Discussion: This distribution of fractures of the proximal humerus corresponds well with data in the literature. Good quality x-rays can provide adequate classification without a CT-scan for the majority of patients. The classification systems currently used are quite exhaustive although the distribution in the subgroups is not homogeneous.

Purpose of the study: The treatment of thoracolumbar fractures has evolved over the last five years with cementoplasty percutaneous osteosynthesis in addition to the gold standard orthopaedic or surgical treatments. This percutaneous method preserves muscles and maintains reduction to healing. The purpose of this work was to evaluate our results in traumatology patients after five years experience, deducting our current indications.

Material and methods: From February 2004 to February 2009, we included 60 patients with a type A or B2 thoracolumbar fracture free of neurological problems and who had more than 10° kyphosis. Reduction was achieved in hyperlordosis before the percutaneous procedure. In other cases we used open arthrodesis. This was a retrospective analysis of a consecutive monocentre series including 37 men and 23 women, mean age 37 years. The injury was L1 and T12 in the majority. Classification was A1 and A3 for the majority. Osteosynthesis was achieved with an aiming compass and radioscopy. A removable corset was used as needed. Reduction and position of the screws as well as need for a complementary anterior fixation were assessed on the postoperative scan. Clinically, follow-up measured pain and quality of life (VAS and Oswestry), radiographically, vertebral kyphosis.

Results: Mean follow-up was 24 months. At last follow-up, the VAS was 15/100 and the Oswestry 16/100. Material was removed in ten patients. Early in our experience one patient developed neurological problems postoperatively requiring revision surgery. Postoperative vertebral kyphosis was stable at three months and was sustained at two years. Body healing was successful in all cases. There were no cases of material failure.

Discussion: This is a reliable reproducible technique in the hands of a spinal surgeon. Material removal can be proposed about one year after implantation. After the age of 65 years, we favour cementoplasty. For others, we propose a sextant for A1, A2, A3 or B2 fractures with more than 15° vertebral kyphosis. This percutaneous material had major advantages for tumour surgery, for multiple injury patients and for traumatology (especially when a double approach is used).

Conclusion: Percutaneous osteosynthesis of vertebral fractures is now the gold standard for well defined indications. Two therapeutic fundamentals are reduction on the operative table and preservation of the muscle stock. These satisfactory results should be confirmed after removal of the implants.

Purpose: Ankylosing spondylitis and Forestier hyperosteosis produces a fused vertebral column. The fused vertebrae can be considered like a “spine-bone” which has particular features different from those of the mobile spine. The purpose of this retrospective analysis was to investigate the clinical and radiological particularities of the spine-bone in order to reduce the delay to diagnosis.

Material and results: Forty-eight spinebone fractures were observed over a 17-year period by one practitioner. Twenty of the patients (mean age 62 years) had ankylosing spondylitis and 28 (mean age 81 years) had hyperosteosis. All of the patients were men. Twenty-five were victims of falls, eleven victims of traffic accidents, and six victims of sports accidents (all with ankylosing spondylitis). No notion of trauma could be identified for six patients. Sixteen fractures were diagnosed within 1 to 28 days. Forty-four patients had cord injury including 16 cases which developed secondarily. Four types of fracture were identified:

- type I = anterior opening fracture: 30 patients,

Fractures diagnosed late were four anterior opening fractures, eight “rasp line” fractures, and four “sawbone” fractures. A CT scan was obtained in all cases and an MRI in 30. Three compressive spinal extradural haematomas were diagnosed. Thirty-two patients died, 31 patients with spinal injuries due to decubitus-related complications and one by rupture of an aneurysm of the aorta.

Discussion: This series illustrates several points. Fracture without trauma is frequent. Diagnosis is made late. Fractures gone undiagnosed lead to neurological complications or nonunion. Diagnosis of “rasp line” fractures cannot be made on standard x-rays, leading us to order a scanner and/or an MRI in all patients with a painful ankylosed spine even if the standard x-ray does not show any fracture. Neurological and extradural haematoma are serious complications. Mortality is high in these debilitated patients. Knowledge of these exceptional fractures of the vertebral column is necessary to improve diagnosis and prognosis.

Purpose: The purpose of this work was to study arterial blood supply to the coxal bone in order to minimise the risk of postsurgical necrosis during acetabular osteosynthesis. Necrosis of the coxal bone is a rare but well-known complication of acetabular fracture surgery.

Material and methods: Ten fresh cadavers were dissected after intra-arterial injection of coloured resin. All collaterals feeding the bone were described and counted. An arterial map was drawn.

Results: The acetabulum is supplied by four main arterial sources: 1) the ischion artery, a collateral of the pudendal artery, which supplies the posterior and lateral part of the acetabulum; 2) the artery of the roof of the acetabulum, a collateral of the superior gluteal artery, supplies the upper and lateral part of the acetabulum: 3) branches of the anterior and posterior division of the obturator artery which supply the upper part and the rim of the obturated foramen and the anteroinferior and posteroinferior parts of the acetabulum; 4) branches issuing from the obturator artery supply the quadrilateral surface.

Discussion: The Kocher approach can easily injure the ischion artery. The wide lateral approach described by Letournel and the triradiate approach described by Mears can injure the ischion artery and the artery of the roof of the acetabulum. Theoretically, the risk of bony necrosis would be greater if an endopelvic approach is associated due to the risk of injury to the endopelvic arteries issuing from the obturator artery. The anterior approach to the acetabulum appears to carry the less risk of ischemia, theoretically, than the other approaches to the acetabulum.

Purpose: We report the operative technique and preliminary results for percutaneous osteosynthesis in the supine position with computed tomography guidance for acetabular fractures without joint displacement.

Material and methods: This prospective study conducted in a single unit included a consecutive non-randomised series of 55 patients who underwent surgery for an unstable pelvic injury between June 1996 and December 2000 under computed tomography guidance. In ten cases, the radiographic and computed tomographic analysis demonstrated a coronal fracture of one of the columns without joint displacement accessible for anteroposterior screw fixation. There were eight men and two women, mean age 35 years.

Surgery: the ten patients were operated on in the supine position, in the scanner room under the same aseptic conditions as in the operation room. The reference computed tomography slice was the Corse slice. The femoral vasculo-nervous bundle was identified. A threaded guide wire was inserted perpendicuallary to the fracture line, anteriorly to posteriorly (Cap Corse technique). A perforated screw with a 7.3 mm diameter was used to fix the fracture. Minimal post-surgical surveillance was 48 hours. Weight bearing was not authorised for six weeks to three months. Al patients were followed prospectively, and mean follow-up ws 16 months (12–36).

Results: Traction was lifted immediately after surgery in all cases. All the patients got up the day after surgery. Mean hospital stay was less than five days postoperatively in all cases. There were no complications (vascular, neurologic, infectious) and no secondary displacement. At last follow-up, he Postel Merle d’Aubigné score was 18 for eight patients, 16 for one and 14 for one. Two patients showed radiographic signs of degenerative hip disease.

Discussion: This percutaneous osteosynthesis method using computed tomographic guidance is reliable (100% well positioned screws) and avoids the need for traction in bed. Morbidity is low (no complications). Even though these eight patients did not present clinical and radiographic signs of osteoarthritis, this technique did not avoid the risk of degenerative hip disease in two patients.

Conclusion: An alternative to traction, percutaneous osteo-synthesis with computed tomographic guidance performed in the supine position for acetabular fractures is a cost-effective procedure.