Abstract

Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors.

Introduction

Dual energy X-ray absorptiometry (DEXA) is the gold standard for assessing bone mineral density (BMD) and fracture risk in vivo. However, it has limitations in the spine because vertebrae show marked regional variations in BMD that are difficult to detect clinically. This study investigated whether micro-CT can provide improved estimates of BMD that better predict vertebral strength.

The purpose of this study was to evaluate the efficacy of human recombinant osteogenic protein 1 (rhBMP-7) for the treatment of fracture non-unions and to estimate the health economics aspect of its administration.

Twenty-four patients (18 males, mean age 39.1 (range 18-79)) with 25 fracture non-unions were treated with rhBMP-7 in our institution (mean follow-up 15.4 months (range 6-29)). Successful completion of treatment was defined as the achievement of both clinical and radiological union. The cost of each treatment episode was estimated including hospital stay, theatre time, orthopaedic implants, drug administration, investigations, clinic attendances, and physiotherapy treatments. The total cost of all episodes up to the point of receiving BMP-7 and similarly following treatment with BMP-7 were estimated and analysed.

Of the 25 cases, 21 were atrophic (3 associated with bone loss) and 4 were infected non-unions. The mean number of operations performed prior to rhBMP-7 application was 3.4, including autologous bone graft in 9 cases and bone marrow injection in one case. In 21 out of the 25 cases (84%), both clinical and radiological union occurred. Mean hospital stay before and after receiving rhBMP-7 was 26.84 days per fracture and 7.8 days per fracture respectively. Total cost of treatments prior to BMP-7 was £346,117 [£13,844.68 per fracture]. Costs incurred following BMP-7 administration were estimated as £183,460 [£7,338.4 per fracture].

rhBMP-7 was used as a bone stimulating agent with or without conventional bone grafting with a success rate of 84% in this series of patients with persistent fracture non-unions. The average cost of its application was £7,338 [53.0% of the total costs of previous unsuccessful treatment of non –unions, p<0.05). Treating non-union is costly, but the financial burden could be reduced by early rhBMP-7 administration when a complicated or persistent non-union is present or anticipated. Therefore, this study supports the view that rhBMP-7 is a safe and power adjunct to be considered in the surgeon's armamentarium for the management of such difficult cases.

The purpose of the study was to establish an algorithm for the treatment of pathological fractures in children.

Pathological fractures can compromise radiographic and histological diagnosis. The need for histological diagnosis and indications for surgical treatment are not clearly defined.

We reviewed our Centre’s Tumour Registry records of children who presented over the past 7 years with a fracture as the first manifestation of primary bone pathology. There were 23 patients (average age 12 years and 2 months).

There were 9 fractures through simple bone cysts, all treated conservatively initially. All patients were subsequently treated with needle biopsy and bone marrow injection. Three patients suffered refracture and underwent flexible intramedullary nail fixation.

There were 5 cases of fibrous dysplasia. Histological diagnosis was obtained in all cases, followed by prophylactic intramedullary nailing in 3 patients.

There were 2 patients with giant cell tumour, 3 with aneurysmal bone cyst and one with chondroblastoma. Histological diagnosis preceded curettage and grafting in all cases.

Finally, there were 3 patients with Ewing’s sarcoma of the femur. One underwent palliative intramedullary nailing for extensive local disease. The second patient was treated conservatively initially. She subsequently underwent segmental resection and vascularised fibular graft. The third patient underwent internal fixation in another unit for what was considered to be a benign lesion. The histological diagnosis of Ewing’s sarcoma was based on intra-operative specimens. Definitive surgery required wide resection and prosthetic replacement.

We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. All lesions should be appropriately imaged and biopsied if aggressive characteristics are present. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intramedullary nailing or curettage and grafting can follow frozen section under the same anaesthetic.

Purpose: To evaluate efficacy and outcome of embolisation following pelvic ring injuries in patients presented with ongoing hypovolaemic shock.

Methods: Between 2000 and 2003, 200 poly-trauma patients presented in our institutions following pelvic ring injuries. Those with ongoing hypovolaemic shock who were treated within 24h of admission with embolisation were included in this study. Demographics, mechanism of injury, ISS, type of pelvic ring fracture, arterial source of bleeding, hours from injury to embolisation, and outcome were all recorded prospectively.

Results: Out of the 200 treated in our institutions 17 (8.5%) underwent angio-embolisation. The mean age of the patients was 37 (14–70) and the mean ISS was 29. Distribution of pelvic ring injuries included: 3LC, 7APC, and 7VS. The mean time from injury to embolisation was 15 hours. 8/17 patients were initially treated with an external fixator. The distribution of arterial injuries was: 7 superior gluteal arteries, 8 internal iliac arteries, 1 obturator artery and 1 internal pudental artery. The mean number of units transfused prior to embolisation was 22 (range 6–50). Mortality rate was 4 (23%) out of 17 embolised patients. Angio-embolisation for pelvic ring injuries occurred in 8.5% of our study population. This study indicates that only a small proportion of patients required embolisation secondary to arterial bleeding. The overall survival rate was in accordance to published international experience.

Conclusion and Significance: Embolisation should be considered as a valid adjunct in some selected group of patients with pelvic fractures where ongoing bleeding refractory to other treatment modalities is present.

We present an evaluation of basic surgical orthopaedic operative training in the last 15 years, using multiple trauma and elective training procedures in orthopaedics. Identifying the influence of competency training and EWTD on Basic Surgical Training. Whilst trying to identify the area’s the MMC should concentrate on to provide a competent trainng programme.

We assessed clinical exposure using 45 Basic Surgical Trainee Logbooks, from posts in 1990 (n=6), 1995 (n=7), 2000 (n=10), and 2004–5 (n=22); and looked at numbers of carpel tunnel decompression, and emergency hip, wrist, and ankle surgeries conducted. As well as the number of external fixators trainees were exposed to. In the 2004–5 group we prospectively assessed competency and knowledge of fracture neck of femur surgery.

From a peak in operative surgery in 1990 numbers have fallen. Today, BST’s participate in 165 emergency hip cases (mean 4.6 procedures per trainee), today, 4.8% (n=8) as primary surgeon. In 1990, and 2000 trainees were primary surgeon in 43.4% (n = 12/32) and 25.2% (n=33/131) respectively.

Trainees are comfortable with closure of skin, subcutaneous and muscular layers but not access; 91% (n=20) required assistance in positioning, and reduction, and recognition of correct alignment. Only 9.1% (n=2) felt competent without senior supervision (mean Orthopaedic BST experience 15.3 months) in hip surgery; whilst none knew of an intra-operative technique to reduce young adult capsular hip fractures. With regards to wrist and ankle fixation the decline has been dramatic decline by 11.1 and 5.9 procedures per trainee. Whilst, the numbers of forearm manipulations peaked in 1990–1995; it has since dropped to less than 5 per trainee in 2005 from 15–16. In 2005, it was also seen that a in a 6 month period a trainee in a typical district general hospital would be lucky to see an external fixator applied (average 0.6 per trainee in 6 month period).

The decline of elective surgery is shown in carpel tunnel decompressions attended. In 1990 9.8 (6–14) were conducted as a primary operator, in 2005, it was 0.5 (0–3). The greatest decline in procedures of 46.3% occurred between 2000, to 2005. A comparison of total operating showed 88.9 (n=79–125) procedures in 6 months were lost between 1990 and 2005; with a 58.6% loss in trauma.

This study suggests deficiency in operative competence today due to reduced opportunities. Thus emphasis should be placed on rota’s being matched to operative exposure, as trainee case numbers have declined sharply particularly in the last 5 years. The MMC should therefore ensure that trainees in the ST1 to 3 years reach their competencies with adequate time in the operating theatre.

The management of pathological fractures in children remains controversial. The indications for surgical treatment are unclear and the need for histological diagnosis before or after definitive treatment is not clearly defined.

We reviewed retrospectively the records of all patients under the age of 16 years who presented over the past 7 years with a fracture as the first manifestation of bone pathology. There were 26 patients (19 boys and 7 girls) of an average age of 12 years and 2 months (range 4.1–15.8 years).

There were 9 cases of fracture through a simple bone cyst, 6 in the humerus and 3 in the femur. In all cases the fracture was treated conservatively initially. Subsequent management included needle biopsy in all, followed by bone marrow injection under the same anaesthetic. The patients suffered a refracture and were treated with flexible intra-medullary nail fixation.

There were 5 cases of fibrous dysplasia, of which 2 in the femur, 2 in the tibia and one in the proximal radius. Histological diagnosis was obtained in all cases prior to definitive treatment. This included a locked intra-medullary nail in one patient and flexible nailing in another two. The remaining two patients are still under observation.

There were 2 patients with giant cell tumour, 3 patients with aneurysmal bone cyst and one patient with chondroblastoma. Histological diagnosis preceded treatment with curettage and grafting in all these cases. There were 6 patients with malignant primary bone tumour, 1 adamantinoma, 2 osteosarcoma, and 3 with Ewings Sarcoma.

The 3 patients with Ewing’s sarcoma involved the femur. One had extensive local disease and early intra-medullary nailing was performed for palliative reasons. The second patient was treated conservatively initially. Definitive surgery was performed after fracture healing and included segmental resection and vascularised fibular graft. The third patient was initially treated elsewhere. She was thought to have a benign lesion and internal fixation with a screw/plate device was performed. Histology from intra-operative specimens confirmed Ewing’s sarcoma. Definitive surgery required extensive resection and prosthetic replacement.

The 2 patients with osteosarcoma had fracture of proximal humerus and distal femur. The former was treated by forequarter amputation as there was tumour involvement of brachial plexus and remains AWND at 7 years. The latter had resection and EPR of the distal femur.

One patient with adamantinoma underwent segmental resection and reconstruction with VFFG

We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intramedullary nailing or curettage and grafting can follow frozen section under the same anaesthetic.

Firearm injury is a potentially increasing public health problem worldwide. It is increasingly the subject of media and public attention. We aim to analyze the epidemiology, pattern and outcome as experienced.

Data such as age, sex, race, scene and nature of injury, firearm used, alcohol and drug factors, anatomy involved, surgical requirements, transfusion details, ICU/HDU stay, complications, deaths, and outcome were collected from medical notes, WYMAS and Coroners office of all patients who presented with firearm injuries from January 1995 to December 2001. Seventy-eight cases presented to our institution. There were 19 fatalities at the scene of injury. 69 were male. 51 sustained injuries in public places, 20 at their homes and 7 in outdoor areas. Low velocity firearms were involved in 49 cases. 50 were crime related. Alcohol was identified in 34 patients and illicit drugs in 6 cases. 19 cases had bony injury with associated vascular injury in one case. Primary neurological injury was diagnosed in 5 cases. Lower extremities and upper limb injuries accounted for 59% and 26%. 3 had head and neck wounds. 4 patients had thoracic trauma and 5 had abdominal injury. 86% required surgical intervention. 11 patients had a total of 16 complications, the most common being secondary infection. 6% of patients died at the emergency department and 3 after. Chest injuries caused 5 deaths and head wounds caused 3 deaths illustrating criminal intention to cause fatal body harm.

Conclusion: Males in younger age groups are disproportionately affected and the majority were crime- related injuries. Alcohol and other drugs were identified as a significant factor. There has been no significant decrease in the reported cases of firearm injuries or firearm-related deaths after the amendment made in the Firearm Rules in September 1998 (No:1941). The incidence of non-fatal firearm injury is comparable to centres involving similar population.

We have reviewed the patients with vertical shear fractures of the Pelvis and report on our treatment protocol and long-term functional outcome.

Methods: Between January 1993 and January 2002, out of 581 pelvic ring injuries treated in our unit, we identified 31 vertical shear fractures in 29 (4.9%) patients (4 female). Data such as age, sex, aetiology, associated injuries, ISS, resuscitation and transfusion requirements were recorded. ICU/HDU stay, surgical stabilization, urological injuries, systemic complications, neurological injury and mortality were recorded and analysed. Functional outcome was assessed using the following generic tools: EuroQol EQ-5D, SF36v2, SMFA, Majeed score and VAS.

Results: The mean age was 43.5 (16–71). The median ISS was 22 (12–32). Motorcycle accidents were responsible for 27%. Associated injuries included the chest (12 patients), abdomen (8 patients) and extremities (14 patients). Urethral injury was present in 9 and ruptured viscus was identified in 3 patients. Neurologic deficit was present in 9 cases. Posterior ring was stabilized in 3 (0 – 13) days. 6 patients developed systemic complications – ARDS in 4 (12%) patients, sepsis in 2 (6%). The mean follow up was 39 (12–101) months. Functional outcome using the Majeed score revealed that one-third of the patients were fair. SF-36 (physical and mental scores) and EQ 5-score revealed that one-third of the patients were fair. SF-36 (physical and mental scores) and EQ 5-score revealed that one-third of the patients were fair. SF-36 (physical and mental scores) and EQ 5- D revealed a moderate functional outcome. The SMFA and the visual analogue score also revealed similar outcomes.

Conclusion: Prompt resuscitation and early temporarily stabilization of the pelvic ring is essential. Sound reconstruction of the pelvic ring is not always associated with good results, probably due to the extensive pelvic floor trauma seen in this series of patients. Younger individuals seem to have a relatively better outcome when compared to the older age group.

To assess the functional outcome of operative and non-operative treatment of distal humeral fractures in the elderly, patients above 75 years of age were studied. Demographic data including associated injuries and co-morbid conditions were recorded. The minimum follow-up was 16 months (range 16–92 months). Elbow function was analysed according to the OTA rating system. Radiographs were monitored for possible predictors of final functional outcome

Out of 125 patients with distal humeral fractures, 29 were above the age of 75 years. The mean age at the time of admission was 84.6 years (range 75–100). One patient was lost to follow-up. In total there were 28 patients with 29 fractures. 5 of these were open fractures. As per the AO classification, there were 8 type A, 8 type B, and 13 type C fractures. 8 patients were treated non-operatively (3 type A, 2 type B, 3 type C) and 21 (5 type A, 6 type B, 10 type C) operatively. An olecranon osteotomy was performed in 12 cases, 2 underwent triceps tongue reflection, and 7 had triceps splitting. Local complications included 4 cases (1 deep and 3 superficial) of infection and 3 non-unions (including one at the olecranon osteotomy). In the non-operative group the mean loss of extension and mean flexion achieved were 34.0 and 70.0 degrees respectively, whereas in the operative group the corresponding values were 23.0 and 107 degrees.

OTA grading revealed 3 excellent, 9 good, 7 fair and 2 poor results in the operated group whereas in the non-operated group there were 0 excellent, 2 good, 3 fair, and 3 poor results. There was direct correlation between loss of anterior tilt of the distal humerus and adverse outcome.

Conclusion: Our study showed that improved functional outcome can be achieved following surgical treatment in these difficult fracture This study supports the view that we need to re-examine the conventional view of ‘bag of bones’ method as blanket treatment and signifies the need for further studies on similar cohorts of patients.

We prospectively studied 29 patients with distal femoral fractures stabilised using the less invasive stabilisation system [LISS]. Four patients were excluded from the final follow up [3 deaths and 1 case of quadriplegia]. The mean age of the remaining 25 patients [9 males] was 60.9 years and the mean follow up 18 months [12–24]. Eleven patients were tertiary referrals from other hospitals [7 cases were referred due to failure of primary fixation]. Overall, there were 12 cases of high-energy trauma [7 open fractures]. According to the AO classification there were 5 Type 33A, 2 Type 33B and 12 Type 33C fractures and 4 Type 32A, 1 Type 32B, 1 Type 32C fractures. Functional assessment was performed using the Modified HSS and the Schatzker and Lambert scores. The average time to union in 22 cases was 3.5 months [range, 2–5]. None of the acute cases required bone grafting with a 100% union rate. There were 3/7 cases of non-union in the salvage group still undergoing treatment. The overall results in the acute cases were good and in the salvage cases fair. While this is a small series of patients, our preliminary data indicate favourable results using the LISS in stabilizing acute distal femoral fractures. However, when the LISS is used as a revision tool despite the concept of preserving the bone biology, the results seem to be less satisfactory. The system appears to be user friendly and no technical difficulties were encountered.

Introduction: Autologous chondrocyte implantation (ACI) is a technique described for treating symptomatic osteochondral defects in the knee. It is contra-indicated, however, in a joint rendered unstable by a ruptured anterior cruciate ligament (ACL). We present our early experience of combined ACL and ACI repair.

Methods: Patients underwent arthroscopic examination and cartilage harvesting of the knee. Chondrocytes were then cultured in plasma and a second operation was undertaken approximately four weeks later to repair the ruptured ACL with hamstring graft and to implant the chondrocytes via formal arthrotomy. Patients then underwent a graduated rehabilitation program and were reviewed at 6 and 12 months. Functional measurements were made using the Bentley functional scale and the modified Cincinnati rating system, with pain measured on a visual analogue scale. All patients also underwent formal clinical examination at each review.

Results: 4 out of the 5 patients reported an improvement in pain as measured on visual analogue scale, with 1 patient reporting no difference. 4 patients had stable knees as determined by negative anterior draw, negative Lachman’s test and negative pivot shift test; one patient showed improvement, but remained pivot shift positive. Improvements in Bentley scores were noted in 3 patients. Cincinnati scores were markedly improved in 3 patients and slightly improved in the remaining 2 patients. The only operative complications were a traction neuropraxia to the saphenous nerve of one patient requiring no treatment and a manipulation under anaesthesia for poor mobilisation in another patient, which was successful in improving range of movement. A further patient required arthroscopic trimming of the cartilage graft which had overgrown; this was also successful.

Conclusion: Symptomatic cartilage defects and ACL deficiency may co-exist in many patients and represent a treatment challenge. Our early results suggest that a combined ACL and ACI repair is a viable option in this group of patients and should reduce the anaesthetic and operative risks of a two-stage repair. More patients and longer follow up will be required to fully assess this technique.

Aims: Firearm injury is a potentially increasing public health problem worldwide. It is increasingly the subject of media and public attention. We aim to analyse the epidemiology, pattern and outcome as experienced. Methods: Data such as age, sex, race, scene and nature of injury, þrearm used, alcohol and drug factors, anatomy involved, surgical requirements, transfusion details, ICU/HDU stay, complications, deaths, and outcome were collected from medical notes, WYMAS and Coroners ofþce of all patients who presented with þrearm injuries from Jan 1995 to Dec 2001. Results: 78 cases presented to our institution. There were 19 fatalities at the scene of injury. 69 were male. 51 sustained injuries in public places, 20 at their homes and 7 in outdoor areas. Low velocity þrearms were involved in 49 cases. 50 were crime related. Alcohol was identiþed 34 patients and illicit drugs in 6 cases. 19 cases had bony injury with associated vascular injury in one case. Primary neurological injury was diagnosed in 5 cases. Lower extremities and upper limb injuries accounted for 59% and 26%. 3 had head and neck wounds. 4 patients had thoracic trauma and 5 had abdominal injury. 86% required surgical intervention. 11 patients had a total of 16 complications, the most common being secondary infection. 6% patients died at the emergency department and 3 after. Chest injuries caused 5 deaths and head wounds caused 3 deaths illustrating criminal intention to cause fatal body harm. Conclusions: Males in younger age groups are disproportionately affected and the majority were crime related injuries. Alcohol and other drugs were identiþed as a signiþcant factor. There has been no signiþcant decrease in the reported cases of þrearm injuries or þrearm related deaths after the amendment made in the Firearm Rules in Sep 1998 (No:1941). The incidence of non-fatal þrearm injury is comparable to centers involving similar population.

Aim: We have reviewed the patients treated in our institution with vertical shear fractures of the pelvis and report on our treatment protocol and long term functional outcome. Methods: Between Jan 1993 and Jan 2002 patients with vertical shear fractures were identiþed. Data such as age, sex, aetiology, associated injuries, ISS, resuscitation requirements, transfusion requirements, ICU/HDU stay, treatment, urological injuries, systemic complications, neurological injury and mortality were recorded and analysed. Functional outcome assessment was performed using the following generic tools: Euro-qol 5D (EQ), SF36 v2 (Short form), SMFA, Majeed score and VAS. Results: Out of 380 pelvic ring injuries we identiþed 31 vertical shear fractures in 29 consecutive patients (4 female). The median ISS Score was 22. Motorcycle accidents were responsible for 27%. Injuries were identiþed in the chest (12 patients), abdomen (8 patients) and extremities (14 patients). Urethral injury was present in 9 patients. Ruptured viscus was identiþed in 3 cases. At presentation neurologic deþcit was present in 9 cases. Posterior ring was stabilised in 3(0–13) days. Systemic complications developed in 6 patients Ð ARDS in 4 patients and sepsis in 2 (6%). The mean follow up was 39 months. Functional outcome using the Majeed score revealed that 1/3 of the patients did fair. TheSF-36 v2 analysis, EQ 5-D revealed a moderate functional outcome. The SMFA and the visual analogue score also revealed similar outcomes. Conclusions: Prompt resuscitation and early temporarily stabilisation of the pelvic ring is essential. Sound reconstruction of the pelvic ring is not always associated with good results probably due to the extensive pelvic ßoor trauma as seen in this series of patients. Younger individuals seem to have a relatively better outcome when compared to the older age group.

Purpose: To determine the incidence of OA and long-term outcome following complex, Schatzker type 4,5 & 6, tibial plateau fractures.

Patients and Methods: From Jan 1993 to Dec 2000, 176 consecutive adult patients with tibial plateau fractures were treated in our institution. Among them there were 31 patients (20 male and 11 female) with Schatzker type 4,5 & 6 fractures (17.5%). Details such as the patients’ age, sex, ISS, type of fracture, whether the fracture was open or closed, method of fixation, incidence of delayed union, non-union, the time to union, necessity for additional procedures, complications and hospital stay were recorded and analyzed. Following discharge from the hospital all the patients were followed up in the outpatient fracture clinic having regular clinical and radiological assessment. At final follow up all the patients were recalled in the clinic for clinical assessment. Functional assessment of the patients was performed using the American Knee score. Particular emphasis was to find out the impact of these complex injuries on their employment, their quality of life and the incidence of OA. The mean follow up was 16.8 months (ranges from 6–48 months). The mean time in hospital was 3.5 weeks (range 1–12 weeks).

Results: The mean age of the patients was 52 years (range from 25–76 years) and the mean ISS was 18 (6–44). 8 patients had associated injuries (1 had head injury). 24 patients sustained injury secondary to RTA, 6 secondary to fall and 1 secondary to a gun shot injury. 26 fractures were closed and 5 were open (1 Gustilo grade1, 1 grade IIIa and 3 grade IIIb). 29 patients were treated operatively and 2 were managed conservatively. 12 fractures were stabilized initially with AO hybrid frame and cannulated screws, 15 cases were treated with internal fixation (buttress plate), 1 case was treated with double plating and one case was treated with combination of internal fixation and Hoffman external fixator. Intra-operatively a bone graft from iliac crest was used in 7 patients. Soft tissue coverage was required in 4 cases. There were 2 cases of compartment syndrome, 9 cases of superficial infection and 5 cases of deep infection. Overall 10 patients were subjected to a secondary operative procedure following union (5 patients had removal of metal work, one underwent removal of metal work and application of a hemicallotasis device and 4 patients underwent arthroscopy). 7 patients underwent a 3rd procedure (3 had removal of metal work, one had application of a hemicallotasis device, 2 underwent debridement and curettage of the discharging sinus and one patient required a total knee replacement).

There were 6 cases of residual varus deformity (2 with 15 and 4 with 20 degrees) and 3 cases of leg length discrepancy (2.5 cm, 2 and 1.5 cm respectively). All the fractures but 2 progressed to union (one is currently awaiting for a total knee replacement). Functional assessment according to American Knee assessment score was good in 25 cases (80.64%), fair in 4 cases (12.87%) and poor in 2 cases (6.49%). The overall functional score was 93.6%. 9 patients had to do some modifications in their current employment and 7 patients were unable to return to their previous employment. Evidence of radiological OA was present in 18 out of 31 cases (58.6%).

A poor correlation between presence of radiological OA and functional outcome was noted.

Conclusion: 29 (93.5%) patients had a good or fair outcome. Tibial plateau fractures continue to be a cause of morbidity in trauma patients. The incidence of OA in this series of patients was 58.6% but there was no correlation to functional outcome.

Purpose: In the younger population there is substantial body of evidence that the outcome is better following open reduction and internal fixation of distal humerus fractures. In the elderly however, there is a need to assess the value of internal fixation of these fractures where osteoporosis is almost a rule than exception and poses considerable challenge to even very experienced trauma surgeon. The purpose of this study therefore was to assess the functional outcome of operative fixation of fractures of the distal humerus in a cohort of elderly patients (aged 75 and above). The reproducibility of four different scoring systems is also evaluated.

Patients and Methods: Between 1996 and 2000 out 125 patients who were treated in our institution, elderly patients above 75 years of age were studied. Demographic data such as age, sex, associated injuries and the pre-admission elbow function were recorded. All the fractures were classified according to the AO/ASIF system. At final follow up elbow function was analyzed using OTA’s rating system and these results were compared using three other scoring systems (Jupiter’s criteria, Aitkin’s and Rorabeck criteria, and the scoring system of Caja et al). Treatment options, surgical or non surgical was based on the medical condition of the patient and the personality of the fracture. Intra-operative details including ulnar nerve transposition, olecranon osteotomy and quality of fixation were recorded and analysed. Serial radiographs were studied in detail for union, loss of reduction, certain prognostic indicators such as anterior tilt of distal humerus, cubitus angle, any articular step, gap, heterotopic ossification and development of degenerative changes. Radiological analysis was correlated with functional outcome. The minimum follow up was 16 months (range 16–92).

Results: Out of 125 patients, 29 (23.2%) were above the age of 75 (5 male). The mean age of the patients was 84.6 years (range 75–100). One patient was lost to follow-up. In total 28 patients were studied with 29 fractures (one bilateral), five open (Gustilo’s grade I). Mechanism of injury included 24 falls and 4 motor vehicle accidents. In seven cases associated injuries (three with ipsilateral upper limb injuries) were noted. Twenty patients (69.8%) had noticeable osteopenia in the x rays. According to the AO/ASIF classification, there were eight type A, eight type B and thirteen type C fractures. Eight patients were treated non-operatively (3 type A, 2 type B, 3 type C) and 21 (5 type A, 6 type B, 10 type C) operatively. The injury-surgery interval ranged from 6hours to 5days. An olecranon osteotomy (chevron type, Jupiter’s technique) was performed in 21 cases, 2 underwent Triceps ‘tongue’ reflection and 7 had triceps splitting. Only one case had anterior transposition of the ulnar nerve and none in the series developed ulnar nerve symptoms. Local complications included one case of deep infection (leading to non-union), three cases of superficial infection treated with antibiotics, 3 non-unions (two affecting the fracture and the other one the site of the olecranon osteotomy). The former patients declined further intervention and the latter patient was asymptomatic. One patient needed removal of olecranon metal ware, one developed olecranon bursitis. Heterotopic ossification was present in one patient with no effect on the elbow function. Overall, the mean loss of extension was 22.5° (range 5–40°) and the mean flexion 98.6° (ranged 40o–132°). In the non-operative group the mean loss of extension and mean flexion achieved were 33.5oand 70.1° respectively whereas in the operative group were 22.7oand 106.6°. OTA grading revealed 3‘excellent’, 9‘good’, 7‘fair’and 2 ‘poor’ results in the operated group whereas in the non-operative group there were no ‘excellent’, 2‘good’, 3‘fair’, 3‘poor’results. It is of note that in the non-operative group there was a 37.5% incidence of poor results significantly higher than the operative group. The number of ‘acceptable’ (excellent + good) results was higher in the surgically treated group (52%) than in the non-surgically treated group (25.0%). The functional outcome was most closely related to anatomical reduction of the fracture (particularly articular step < 2mm) and anterior tilt of the distal humerus and was unaffected by the injury-surgery interval. It was found that the Jupiter score was less rigid for the range of movement but produced similar scores to OTA with less potential inter observer error compared to the two other scoring systems. 18 of the 21(85.7%) the patients had no limitation of rotation.

Conclusion & Significance: This study supports the view that the functional outcome following distal humerus fractures is better with operative treatment in patients above the age of 75. Out of the 4 functional assessment scoring systems evaluated only the OTA and Jupiter gave similar results.

Aim: The purpose of this study was to investigate the validity of exchange intramedullary nailing for the treatment of infected tibial non-union.

Patients and Methods: Between 1994 and 2001 14 (10 male) patients with tibial fractures were treated in our institution with exchange nailing for infected tibial non-union. The mean age of the patients was 34.3 years (range 18–60) and the mean ISS was 17.5 (range 9–57). Road traffic accidents was the causative mechanism in 10 cases. Seven fractures were originally open (grade IIIb). Initial stabilisation was with intramedullary nailing in 7 cases, external fixator in 3, open reduction internal fixation in 2, Ilizarov frame in 1 and POP in 1. All patients had clinical and radiological evidence of non-union and in each case there was clinical and microbiological evidence of intramedullary infection. All the patients subsequently had an exchange intramedullary nail performed together with debridement and antibiotics. The mean time between original nailing and exchange nailing was 28 weeks. At exchange nailing, the old incisions were reopened and the in situ nail was then removed. Following this, the canal was swabbed and then reamed 1½ mm. more than the diameter of the new nail. The swab and reamings were sent for culture and microscopy. The canal was also irrigated with at least 3 litres of normal saline prior to the insertion of the exchange nail. Antibiotics were then continued for a minimal period of 6 weeks, or longer as the clinical situation warranted. Following discharge from the hospital the patients were seen in the outpatient clinics with regular clinical, haematological and radiographic investigations. The average length of follow-up was 24 months following exchange nailing.

Results: There were 7 positive cultures of MRSA, 4 of staph. aureus and in 3 cases multiple bacteria were grown from the samples. No further treatment was required following exchange nailing in 5 (35.7%) cases out of 14. 4 patients required further soft tissue debridement and a free flap to secure union within a week of the exchange nailing procedure. Of the remaining 5 patients, 1 required dynamisation to encourage union; another required incision and drainage of peri-fracture abscess and proceeded to union uneventfully; the third patient needed iliac crest bone grafting which eventually resulted in union. The penultimate patient had numerous operations after the exchange nailing before finally uniting with bone morphogenic protein. Unfortunately the last patient developed overwhelming sepsis which necessitated below knee amputation. Overall, the mean time to union was 11.3 months (4–24).

Conclusion: In this series of patients the success rate of exchange nailing for septic tibial pseudarthrosis was 78.5% (11/14). However, some of the patients, especially those originally sustaining open fractures required additional procedures to secure union. We believe that exchange tibial nailing remains an effective method of treatment in the presence of deep bone sepsis.

Purpose: To document the incidence of neurological lesions and functional outcome following displaced acetabular fractures.

Patients and Methods: Prospective review of patients who underwent stabilisation of acetabular fractures in a University Hospital trauma centre. From December 1994 to November 2000 136 patients were identified with acetabular fractures. The open reduction and internal fixation of the acetabular fixation was performed by standard operative techniques. The time from the initial injury to the operation ranged from 24 hours to I4days. Patients with sciatic nerve injuries were prospectively followed up and long-term outcome recorded. Weakness or absence of dorsiflexion or plantar flexion was graded according to the standard Medical Research Council. Abnormalities of sensation, including absent or diminished sensation to light touch and pinprick as well as dysesthesia or hyperesthesia of the dorsal and plantar aspects of the foot were recorded. None of the patients had an injury of the spinal cord. Intra-operative monitoring was performed in most cases, and routine electromyography and nerve -conduction studies were done post-operatively and at least on one more occasion to record the level and severity of the lesion and to monitor progress of recovery. All the patients were followed up clinically in the trauma clinics and functional improvement was routinely assessed. The mean follow up of the patients was 3.4 years (range 1.5–6 years).

Results: Out of 136 patients who underwent stabilisation of acetabular fractures there were 27 (19.8 %) cases of neurological lesions. In 12 cases the femoral head was dislocated posteriorly. Twenty were men and eight were woman. The mean age was 33.8 (range 16–66). 15 patients had associated injuries. The mean ISS was 12.6 (range 9–34). At initial presentation there were 13 patients with a complete dropped foot lesion, 10 patients with foot weakness and 4 patients with burning pain and altered sensation over the dorsum of the foot. Intra-operative monitoring was performed in 16 cases. All the patients had EMG studies for neurophysiological assessment of the lesion. EMG studies revealed sciatic nerve lesions in all the cases but in nine patients with a dropped foot there was evidence of a proximal (sciatic) and distal (neck of fibula) lesion, “double crush syndrome”. Only in 3 of these cases there was documentation of an ipsilateral knee injury. In two patients there was deterioration of foot function after surgery due to iatrogenic damage. At final follow-up, clinical examination and associated EMG studies revealed full recovery in 5 cases with initial muscle weakness (mean time 4.2 years (2–5)) and complete resolution of sensory symptoms (burning pain and hyposthesia) in 4 cases (mean time 3 years (2–4)). There was improvement of functional capacity (motor and sensory) in two cases with initially complete drop foot and in 4 cases with muscle foot weakness (mean time 3.6 years (range 2–6). In 11 of the cases with dropped foot (all nine with “double crush”) at presentation, there was no improvement in function, (mean time 3.9 years (range 2–6).

Conclusion: Acetabulum fractures associated with sciatic nerve injuries continue to be a significant cause of long-term morbidity in trauma patients. In cases where there is evidence of “double crush lesions” the prospect of functional recovery is low as seen in this group of patients. Single lesions appear to be associated with a more favourable prognosis.

The purpose of this study was to investigate the validity of exchange intramedullary nailing for the treatment of infected tibial non-union.

14 (10 male) patients with tibial fractures were treated in our institution with exchange nailing for infected tibial non-union. The mean age of the patients was 34.3 years (range 18–60) and the mean ISS was 17.5 (range 9–57). Seven fractures were originally open (grade IIIb). All patients had clinical and radiological evidence of non-union and in each case there was clinical and microbiological evidence of intramedullary infection. Following initial stabilisation, all the patients subsequently had an exchange intramedullary nail performed together with debridement and antibiotics. The mean time between original nailing and exchange nailing was 28 weeks. Antibiotics were then continued for a minimal period of 6 weeks, or longer as the clinical situation warranted. The average length of follow-up was 24 months following exchange nailing.

There were 7 positive cultures of MRSA, 4 of staph. aureus and in 3 cases multiple bacteria were grown from the samples. No further treatment was required following exchange nailing in 5/14 (35.7%) cases. 4 patients required further soft tissue debridement and a free flap to secure union. Of the remaining 5 patients, 1 required dynamisation, another required incision and drainage of peri-fracture abscess, the third patient needed iliac crest bone grafting which eventually resulted in union. The penultimate patient had numerous operations after the exchange nailing before finally uniting with bone morphogenic protein. Unfortunately the last patient developed overwhelming sepsis which necessitated below knee amputation. Overall, the mean time to union was 11.3 months (4–24).

In this series of patients the success rate of exchange nailing for septic tibial pseudarthrosis was 78.5% (11/14). We believe that exchange tibial nailing remains an effective method of treatment in the presence of deep bone sepsis.