The condition known as delta phalanx (or longitudinally bracketed epiphysis) is a rare congenital anomaly first described in 1964. The deformity consists of a triangular bone with an epiphysis running along the shortened side of the phalanx in a proximal to distal direction, making longitudinal growth of the digit impossible. Isolated hallux varus congenitus due to a delta phalanx of the proximal phalanges of both great toes is extremely rare: there have been only three such cases reported, two of which were in one family--the only report of a familial occurrence of this deformity. This present report details the occurrence of isolated bilateral hallux varus congenitus in four members of one family, a father and his three eldest children. All three children show bilateral delta phalanx of the proximal phalanges of both great toes. There are associated thumb nail anomalies, but no suggestion of polydactylism

Aims. Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK. Methods. Any patient admitted to hospital with an open fracture between 1 June 2021 and 30 September 2021 was included, excluding phalanges and isolated hand injuries. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture. Demographic details, injury, fracture classification, and patient dispersal were detailed. Results. In total, 1,175 patients (median age 47 years (interquartile range (IQR) 29 to 65), 61.0% male (n = 717)) were admitted across 51 sites. A total of 546 patients (47.1%) were employed, 5.4% (n = 63) were diabetic, and 28.8% (n = 335) were smokers. In total, 29.0% of patients (n = 341) had more than one injury and 4.8% (n = 56) had two or more open fractures, while 51.3% of fractures (n = 637) occurred in the lower leg. Fractures sustained in vehicle incidents and collisions are common (38.8%; n = 455) and typically seen in younger patients. A simple fall (35.0%; n = 410) is common in older people. Overall, 69.8% (n = 786) of patients were admitted directly to an orthoplastic centre, 23.0% (n = 259) were transferred to an orthoplastic centre after initial management elsewhere, and 7.2% were managed outwith specialist units (n = 81). Conclusion. This study describes the epidemiology of open fractures in the UK. For a decade, orthopaedic surgeons have been practicing in a guideline-driven, network system without understanding the patient features, injury characteristics, or dispersal processes of the wider population. This work will inform care pathways as the UK looks to the future of trauma networks and guidelines, and how to optimize care for patients with open fractures. Cite this article: Bone Jt Open 2022;3(10):746–752

Aims. The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK. Method. Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded. Results. Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7). Conclusion. OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry. Cite this article: Bone Joint J 2022;104-B(9):1073–1080

This annotation reviews current concepts on the three most common surgical approaches used for proximal interphalangeal joint arthroplasty: dorsal, volar, and lateral. Advantages and disadvantages of each are highlighted, and the outcomes are discussed.

Cite this article: Bone Joint J 2022;104-B(12):1329–1333.

Aims

The aim of this study was to develop a core outcome set of what to measure in all future clinical research on hand fractures and joint injuries in adults.

Aims

This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England.

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period. All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures. 6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%). Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources

The objective of this study was to investigate how a new customizable light-curable osteosynthesis method (AdFix) compared to traditional metal hardware when loaded in torsion in an ovine phalanx model. Twenty-one ovine proximal phalanges were given a 3mm transverse osteotomy and four 1.5mm cortex screws were inserted bicortically on either side of the gap. The light-curable polymer composite was then applied using the method developed by Hutchinson [1] to create osteosyntheses in two groups, having either a narrow (6mm, N=9) or a wide (10mm, N=9) fixation patch. A final group (N=3) was fixated with conventional metal plates. The constructs were loaded in torsion at a rate of 6°/second until failure or 45° of rotation was reached. Torque and angular displacement were measured, torsional stiffness was calculated as the slope of the Torque-Displacement curve, and maximum torque was queried for each specimen. The torsional stiffnesses of the narrow, wide, and metal plate constructs were 39.1 ± 6.2, 54.4 ± 6.3, and 16.2 ± 3.0 Nmm/° respectively. All groups were statistically different from each other (p<0.001). The maximum torques of the narrow, wide, and metal plate constructs were 424 ± 72, 600 ± 120, and 579 ± 20 Nmm respectively. The narrow constructs were statistically different from the other two (p<0.05), while the wide and metal constructs were not statistically different from each other (p=0.76). This work demonstrated that the torsional performance of the novel solution is comparable to metal fixators. As a measure of the functional range, the torsional stiffness in the AdhFix exceeded that of the metal plate. Furthermore, the wide patches were able to sustain a similar maximum toque as the metal plates. These results suggest AdhFix to be a viable, customizable alternative to metal implants for fracture fixation in the hand

Introduction. Enchondromas located in the phalangeal bones may be more cellular than non-digital locations necessitating clinical and radiological correlation to determine diagnosis. Atypical enchondromas have increased cellularity and atypia relative to simple enchondromas but no evidence of permeation. Chondrosarcomas of the phalanges are thought to have a more indolent course than chondrosarcomas in other locations. The aim of the study was to determine the outcome of atypical enchondromas and grade 1 chondrosarcomas of the phalanges treated surgically. Methods. Data was collected prospectively on patients with a cartilage lesion of the phalanges. Typical enchondromas, grade 2 or 3 chondrosarcomas and patients with Ollier's disease were excluded. Results. There were twenty two cases of atypical enchondroma or grade 1 chondrosarcoma. Ten of the patients were female and twelve male with a mean age of 41. There were fourteen atypical enchondromas and eight grade 1 chondrosarcomas. Sixteen of the lesions were in the hand and six were in the foot. Seventeen tumours, including four cases of grade 1 chondrosarcoma, were treated with extended curettage utilising a high speed burr. Five cases were managed by digital amputation as the degree of bone loss precluded retention of the phalanx. At a mean follow up of 30 months there has been one case of local recurrence occurring in an atypical enchondroma of the foot. There have been no cases of local recurrence in the four cases of grade 1 chondrosarcoma treated by curettage. There have been no cases of distant metastasis. All patients remain under long term clinical review. Discussion. There are few published results on the treatment of atypical enchondromata and low-grade chondrosarcomas of the phalanges. In selected cases extended curettage has a low recurrence rate in the treatment of atypical enchondromata and grade 1 chondrosarcomas of the phalanges

Purpose of the study: Duplication of the thumb is the most common congenital anomaly of the first ray. The characteristic feature of type IV is the diversity of the clinical forms and the presence of certain complex forms particularly difficult to treat (Hung IVD). We propose a new procedure for reconstruction of IVD type thumb duplication. Material and method: This new procedure was used for thumb reconstruction in two boys with type IVD thumb duplication. Mean age at surgery was 10 months. Surgical technique. The future incisions were traced with a central skin resection removing the most hypoplastic nail entirely (generally the radial nail). At the bone level, a longitudinal osteotomy of the proximal phalanges was made over the entire length to remove the central part and obtain a width for the first phalanx comparable to that of the contralateral thumb. An oblique osteotomy was cut in the base of the distal phalanx of the ulnar hemithumb with resection of a radial corner. The same type of osteotomy was performed at the base of the distal phalanx of the radial hemithumb, but with preservation of the radial corner and resection of the rest of the radial thumb. The proximal hemiphalanges were sutured as were the bases of the distal phalanges. This produced automatic realignment and stabilisation of the interphalangeal joint without an ungueal intervention. Results: The three children were reviewed at 24, 18 and 12 months. The Horii score was good in all cases. Discussion: Type IVD duplications of the thumb are difficult to treat and may leave serious sequelae. Our technique is based on the principle of a central resection of the proximal phalanges associated with partial resection of the base of the distal phalanges. This enables realignment and stabilisation of the interphalangeal joint while avoiding the problem of ungueal dystrophy since only one nail is preserved. Our preliminary results are encouraging but must be confirmed with a longer term study

Suture anchors have changed the practice of repair of tendons in modern Orthopaedics. The purpose of the study was to identify the ideal suture anchor length for anchoring flexor digitorum profundus tendon to the distal phalanx. We dissected 395 distal phalanges from 80 embalmed hands. Phalanges from two little fingers and three thumbs were damaged, hence were excluded from the study. We measured the Anteroposterior and Lateral dimensions at three fixed points on the distal phalanges of all 395 fingers using a Vernier’s Callipers with 0.1mm accuracy. The mean value of the Anteroposterior width of the distal phalanx at the insertion of the FDP was found to be 3.4mm for the little finger; 3.9mm for the ring finger; 4.3mm for the middle finger; 4.0mm for the index finger and 5.0mm for the thumb respectively. The commonly available anchors and drill bits were found to be too long when used for anchoring the flexor digitorum profundus tendon in certain distal phalanges. Our findings may be a reason for poor outcome of FDP repair to distal phalanx using suture anchors. New designs for tissue anchors for distal phalanges may be necessary

1. A seven-generation family is described which presented an autosomal dominant hereditary disorder characterised by brachydactyly, hypoplastic nails from the index to the little fingers, normal toe nails, absent middle phalanges in the fingers and lateral four toes, variable degrees of hypoplasia of the distal phalanges in the fingers with normal thumbs and normal big toes. 2. Less frequently syndactyly between middle and ring fingers on the left and narrowing of the proximal phalanges of the ring and little fingers are also found. 3. This disorder seems to represent a new hereditary syndrome

Normal digital flexion relies on flexor tendon pulleys to transmit linear muscular force to angular digital motion. Despite the critical role these pulleys play, there is a growing trend among surgeons to partially sacrifice or “vent” them during flexor tendon repair to improve surgical exposure. Although this new practice is reported to improve outcomes after flexor tendon repair, there is concern for the long-term effects of bowstringing, reduced finger range of motion (ROM) and altered tendon biomechanics. The objective of this study was to examine the effects of the application of a thermoplastic ring, acting as an “external” pulley, on flexor tendon biomechanics and finger ROM. We hypothesized that the application of an external thermoplastic ring would produce a centripetal force over the tendon to reduce bowstringing, improve finger ROM, and restore tendon loads following pulley venting. Twelve digits comprised of the index, long, and ring fingers from four cadaveric specimens were tested using a novel in-vitro active finger motion simulator. Servo-motors were used to generate motion. Loads induced by flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP), and joint range of motion were measured with each sequential sectioning of the A2, A3, and A4 flexor pulley, in comparison to a native healthy finger condition. At each finger condition, A2 and A4 external thermoplastic pulley rings were applied over the proximal phalanx and middle phalanx, respectively, to recreate A2 and A4 function. Results were recorded and analyzed using a one way repeated-measures ANOVA. Following venting of the A2, A3 and A4 pulley, proximal interphalangeal joint (PIPJ) ROM significantly decreased by 17.02 ± 8.42 degrees and distal interphalangeal joint (DIPJ) range of motion decreased by 17.25 ± 8.68 degrees compared to intact pulleys. Application of the external rings restored range of motion to within 8.14 ± 8.17 degrees at the PIPJ and to within 7.72 ± 8.95 degrees at the DIPJ. Similarly, pulley venting resulted in a 36% reduction in FDS load and 50% in FDP load compared to intact pulleys. Following application of the external rings, loads were almost restored to normal at 7% reduction for FDS load and 13% reduction for FDP load. Venting of flexor tendon pulleys significantly alters flexor tendon biomechanics and digit range of motion. The application of thermoplastic rings acting as external pulleys over the proximal and middle phalanges is an effective, inexpensive, non-invasive and reproducible therapeutic method to restore flexor tendon biomechanics and digit range of motion

Fractures of metacarpals and phalanges are common in hand injuries. The goal of treatment is the immediate mobilization of the fingers and restoration of the hand anatomy thus avoiding contractures of the metacarpo-phalangeal and phalangophalangeal joints and hand dysfunction. The aim of this study is the comparison between two methods of fixation of these fractures. Between 2000–2007, 74 patients who suffered meta-carpophalangeal fractures were treated by K-wires and 62 patients were treated by mini external fixation. Parameters recorded were the operating time, postoperative range of motion, cost and complications. The surgical time was lesser with the use of K-wires, the operative technique much simple and the cost minimum as compared to mini external fixators. The postoperative range of motion was inferior with the external fixation. However, there was no statistical difference between the two groups. 2 patients with the external fixation and 1 patient with K-wires developed pin-track infection. There were 3 failures of fixation in the external fixator group but no failure occurred with the use of K-wires. The majority of the fractures healed within 6 weeks. K-wires seem to be the ideal method of treatment considering the fractures of metacarpals and phalanges. The use of mini external fixation presents many disadvantages and probably is restricted to the treatment of the open and comminuted hand fractures

1. A review of intra-articular and peri-articular fractures of the phalanges has been carried out, and the late results of such injuries have been examined. 2. These fractures usually unite by bone. 3. The results of conservative treatment by immobilisation are satisfactory in the case of mallet fractures, hyperextension sprain fractures and collateral avulsion fractures of the proximal phalanges. 4. The less satisfactory results after collateral avulsion fractures of the interphalangeal joints and avulsion fractures complicating dislocations are discussed

Introduction: During the design of minimally invasive surgeries (MIS) carried out on the third toe of the foot, it is important to know the position of the nutrient foramen in the third metatarsal shaft and/or proximal phalanx to prevent complications such as avascular necrosis or delays in consolidation further to corrective osteotomies carried out to treat certain conditions that affect the third toe in toe-to-hand surgical transposition. Our aim was to determine the location of the main nutrient foramen of the third metatarsal and/or proximal phalange providing a mathematical method to accurately locate it prior to surgery. Materials and methods: We studied 70 third metatarsals and proximal phalanges of the third toe from surgically amputated lower limbs. We established the position of the nutrient foramen in both normal feet and those with forefoot pathological conditions by means of the nutrient index and the distance from the nutrient foramen to the base and the distal cartilage border and, for the third metatarsal, also to the dorsal aspect. Results: The most frequent location of the nutrient foramen was the middle third of the shaft on the plantar aspect of both bones, and in the majority it was the only location. The distance from the nutrient foramina to each base was significantly correlated with their total length and physiology; we provide the corresponding predictive equations with regression lines. Conclusions: We propose predictive equations of the distance of the NF from the base of both bones based on their total lengths. This distance can be determined by somatic measurement or by means of conventional dorso-plantar x-rays without contrast medium

Introduction: Dorsally angulated metaphyseal fractures of the proximal phalanges usually occur in the middle aged or elderly and are common. Reduction is difficult to maintain with non-operative treatment, due the action of the intrinsic muscles. Most techniques advocated in the literature suggest a transmetacarpal K-wire fixation. We present the results of a simple method of stabilisation using intramedullary K-wires without violating the articular surface. Methods: Over a three-year period, sixty patients with these fractures were treated in this way. A single wire is inserted through the rim of the proximal phalangeal base with MCPJ fully flexed, avoiding transfixion of the collateral ligament. The wire is passed up the medullary canal, across the fracture and up either to subchondral bone or to engage the opposite cortex. The metacar-pophalangeal joints were immobilised with a thermoplastic splint in full flexion and interphalangeal joints mobilised under supervision by the hand therapists. The wire was removed at three weeks. Results: Most patients achieved a full range of movement at 6 weeks follow-up. There were no pin site infections. Conclusion: Dorsally angulated metaphyseal fractures of the proximal phalanges fractures are difficult to treat by non-operative means. If the fracture heals in an angulated position the altered line of pull of the intrinsics will result in loss of flexion at the MCPJ and of power grip. This method is straightforward and gives satisfactory results. It avoids damage to the articular surface of the MCPJ, allows mobilisation of the entire digit and reliably controls the fracture

We treated 35 brachymetatarsal rays of 18 feet in 12 patients by one-stage lengthening with interpositional bone grafts or by gradual lengthening with callotasis combined with shortening of the adjacent metatarsals and phalanges. Definition of the two parabolas which connect the metatarsal heads and the tips of the toes, and recognition of three patterns of metatarsal length, were helpful guides in treatment. In total, 36 excisions of the phalanges and/or the metatarsals were undertaken. The mean shortening was 8 mm. The radiological results were satisfactory. The mean values were as follows: one-stage lengthening, length gain, 1.3 cm; healing index, 1.3 months/cm; percentage increase, 30%; gradual lengthening, length gain, 2.0 cm; healing index, 2.0 months/cm; percentage increase, 50%. Associated shortening of an adjacent bone can avoid the disadvantages of one-stage lengthening which may not achieve target length and can result in neurovascular complications. Reduction of the target length enables the surgeon to carry out one-stage instead of gradual lengthening. It also shortens the length of treatment in the group undergoing callotasis and improves cosmesis

Extensor tendon attachment to the dorsum of the proximal phalanx may fully extend the finger metacarpal phalangeal joint (MPJ). 15 fresh-frozen cadaveric hands were axially loaded in the line of pull to the extensor digitorum comunis of the index, middle, ring and small finger at the level just proximal to the MPJ. We measured force of extension at the MP joint in 3 groups: 1) native specimen, 2) extensor tendon release at the proximal interphalangeal (PIP) joint with release of lumbricals/lateral bands, 3) extensor tendon release at the PIP joint and dorsal proximal phalanx and lumbrical/lateral band release. Degree change of extension was calculated using arctan function with height change of the distal aspect of the proximal phalanx, and the length of the proximal phalanx. We used Student T-test to determine significant decrease in the extension of the phalanges. Extension of all fingers decreased slightly when the extensor tendon were severed at the PIP joint with release of the lateral bands/lumbricals (8deg+/−2deg). After this release, the finger no longer extended. Slight loss of extension was not statistically significant (p >.05) between group 1 and group 2. Groups 1 and 2 were significantly different compared to group 3. In summary, distal extensor tendon transection and release of lateral bands/lumbricals resulted in little change in force and degree of finger extension. The distal insertion of the extensor, released when exposing the PIP joint dorsally, may not need to be repaired to the base of the middle phalanx

The purpose of this prospective clinical study was to identify the true incidence, pattern, and location of the injury and nature of fracture following hand injuries in different paediatric age groups attending a hand unit. Three hundred and sixty children (237 boys and 123 girls) under 16 years of age who presented with hand injuries between 1st April 2000 and 30th September 2000 were included in the study. Bony injuries accounted for 65.5% (236 injuries), 33.3% (120 injuries) were soft tissue injuries. The projected annual incidence rate for skeletal injuries was 418/100,000 children/year. Incidence was low in toddlers (34/100,000), more than doubled in pre-school children (73/100,000) and steeply increased to around 20 fold after the 10th year (663/100,000). Girls had a higher incidence of hand injuries among toddlers and pre-school children. Crushing was the most common cause of hand injury (64%) and most injuries were sustained at home (45%). Toddlers sustained soft tissue injuries predominantly (86%) and older children sustained more bony injuries (77%). Sport was the cause of injures commonly in the older children. There was a higher incidence of fracture in little finger (52%) followed by the thumb (23%). The proximal phalanx was the most frequently fractured bone (67%) among the phalanges. Diaphyseal fractures (46%) were more common in the metacarpal and basal fractures (51%) were common in the phalanges. At discharge more than 80% of the patients felt that they were cured or significantly better. This paper highlights the changing pattern and the different varieties of hand injuries in different paediatric age groups

Aims

The metabolic variations between the cartilage of osteoarthritis (OA) and Kashin-Beck disease (KBD) remain largely unknown. Our study aimed to address this by conducting a comparative analysis of the metabolic profiles present in the cartilage of KBD and OA.

The August 2023 Foot & Ankle Roundup³⁶⁰ looks at: Achilles tendon rupture: surgery or conservative treatment for the high-demand patient?; First ray amputation in diabetic patients; Survival of ankle arthroplasty in the UK; First metatarsophalangeal joint fusion and flat foot correction; Intra-articular corticosteroid injections with or without hyaluronic acid in the management of subtalar osteoarthritis; Factors associated with nonunion of post-traumatic subtalar arthrodesis; The Mayo Prosthetic Joint Infection Risk Score for total ankle arthroplasty.

Aims

In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.

Aims

Previous studies have suggested that selenium as a trace element is involved in bone health, but findings related to the specific effect of selenium on bone health remain inconclusive. Thus, we performed a meta-analysis by including all the relevant studies to elucidate the association between selenium status (dietary intake or serum selenium) and bone health indicators (bone mineral density (BMD), osteoporosis (OP), or fracture).

1. Four cases of epidermal cysts of the terminal phalanges of the fingers are reported. 2. The literature is reviewed and the etiological factors discussed

1. Delta phalanx is a rare congenital abnormality not to be confused with other forms of angular deformity of the phalanges. 2. The deformity needs radical treatment by repeated surgery because there is no tendency to spontaneous correction and growth of the phalanx is prevented by the epiphysial deformity

A minority of cases of osteopetrosis show in addition syndactyly and distal phalangeal anomalies. The seven cases that have been reported with this combination have had an unusual degree of density and thickening of the skull vault, face and mandible, and of the shafts of the metacarpals, metatarsals, proximal phalanges and clavicles. It is submitted that these features constitute a distinct morphological variety of osteopetrosis

1. Rotational deformity of a finger caused by malunion of a phalangeal fracture has been corrected by metacarpal osteotomy. 2. Because of the anatomical arrangement of the metacarpo-phalangeal joint this method gives good control of the distal phalanges. 3. Division through the metacarpal rather than through the phalanx avoids adhesions in the flexor and extensor mechanisms and in the joints of the fingers, allows early mobilisation and is an easier procedure

Open fractures are uncommon in the UK sporting population, however because of their morbidity then are a significant patient group. Currently there is very little in the literature describing the epidemiology of open fracture in sport. We describe the epidemiology of sport related open fractures from one centre's adult patient population. Retrospective analysis of a prospectively collected database recording all sport related open fracture s over a 15 year period in a standard population. Over the 15 year period, there were 85 fractures in 84 patients. The mean age was 29.2 years (range 15–67). 70 (83%) were male and fourteen female (17%). The six most common sports were football (n=19, 22%), rugby (n=9, 11%), cycling (n=8, 9%), hockey (n=8, 9%); horse riding (n=6, 7%) and skiing (n=6, 7%). The top five anatomical locations were fingers phalanges, 35%; tibia-fibula 23%; foreman 14%; ankle 11% and metacarpals 5%. The mean injury severity score was 7.02. Forty five patients were grade 1; 28 patients were grade 2; 8 patients were grade 3a; and 4 were grade 3b according to the Gustilo-Anderson classification system. Seven patients (8%) required plastic surgical intervention for the treatment of these fractures. The types of flaps used were split skin graft (n=4), fasciocutaneous flaps (n=2); and adipofascial flap (n=1). We looked at the epidemiology open fractures secondary to sport in one centre over a 15 year period. Football was the most common sport (22%) and within football, the most common site was the tibia and fibula. In contrast, within the cohort a whole the majority of fractures were upper limb, with the hand being the most common site. Whilst not common in sport, when they are sustained they are frequently occur on muddy sport fields or forest tracks and must be treated appropriately. A good understanding of the range and variety of injuries commonly sustained in different sports is important for clinicians and sports therapists

We report a case of multicentric massive osteolysis. A 52-year-old woman presented with a three-year history of progressive deformities of the hands. She had osteolytic lesions of the metacarpals and metatarsals, and resorption of the terminal phalanges. During follow-up over four years osteolysis spread to affect the ribs, clavicles, mandible, and long bones. There was no family history of any bone disorder and renal function was normal. Death resulted from resorption of the rib cage and post-mortem studies failed to reveal the cause of the osteolysis

EH of bone is a rare vascular neoplasm, subtype of hemangioendothelioma, characterized by mesenchimal cells that have an epithelioid endothelial appearance. There are different kinds of EH: the benign epithelioid hemangioma, and the malignant epithelioid angiosarcoma. This tumors can occurs in soft tissue, lung, liver and bones and often are multicentric. EH generally involve the bone of the spine and lower limb and is very rare in the upper limb and the hands. The main symptom is pain; pathological fracture may occur in aggressive lesions. Radiographically the EH is a ostelytic lesion with variable peripheral sclerosis, cortical destruction and periosteal new bone. Treatment of EH is curettage and local adjuvants in benign lesion, en bloc resection in the low-grade forms and wide or radical surgery in the high-grade forms. Radiation therapy is suggest in inoperable situations. In the present report we describe the clinical features, the oncological treatment and the reconstructive solutions of two cases of EH of the hand treated in the Orthopedic Oncological Center of Gaetano Pini Institute of Milan. Both cases had multiple locations in the carpus, metacarpus and phalanges. The involvement of more joints caused a delayed diagnosis (> 1 year). Exer-esi and reconstruction of several segments of the wrist and hand has led to considerable technical difficulties resolved with the collaboration of the microsurgeon and plastic surgeon

1. A new piece of equipment, the quantitative colour television image analyser, has been introduced as providing a superior method for measuring bone density. 2. This method produces not only a numerical result but also a pattern of density distribution in the form of a seven colour contour map. 3. The changes in twenty rheumatoid hands at an interval of one year have been measured. The metacarpals and proximal phalanges always lose bone, but the metacarpo-phalangeal joint may gain in density if the disease process is far advanced. Some areas can lose 50 per cent of bone in one year

1. Bone changes in the haemoglobinopathies are caused by either (a) chronic haemolysis with marrow hyperplasia, or (b) infarction, when Hb S is present in the red cells in amounts sufficient to allow sickling (and therefore vascular occlusion) in vivo. 2. Marrow hyperplasia produces osteoporosis, widening of the medulla, and thinning of the cortex; it may lead to spontaneous fractures and disturbances of growth. Enlargement of the foramina of the nutrient arteries may be seen especially in the phalanges. Infarcts leading to aseptic necrosis occur in the long bones, and may become infected with Salmonella organisms. The range of radiological lesions caused by these processes is illustrated

The purpose of this study was to retrospectively review the outcomes of percutaneous flexor tenotomies of diabetic claw toes with ulcers or pending ulcers. A retrospective chart review between January 1999 and June 2005 was performed to identify those patients that had undergone a percutaneous flexor tenotomy for diabetic claw toe deformities. Thirty-four toes in fourteen patients were identified. Twenty-four toes had ulcerations at the terminal aspect and three of these had radiographic evidence of osteomyelitis of the terminal phalange. All patients had palpable pulses and good capillary refill. A percutaneous flexor tenotomy was performed in an outpatient clinic on all toes, patients with a rigid flexor contracture at the proximal interphalangeal (PIP) joint underwent an osteoclaysis to correct a portion of the deformity. The average follow-up was thrirteen months, all patients with ulcers healed and there were no significant complications. Those without osteomyelitis healed within an average of three weeks and those with osteomyelitis healed within an average of eight weeks. A Percutaneous flexor tenotomy with osteoclasis of the PIP joint performed in an outpatient clinic is a safe and effective method to off-load the tip of the toe such that ulcer healing can occur. The presence of osteomyelitis is not a contraindication for this technique; however, an increased healing time can be expected

1. Frostbite in a child may be severe enough to destroy the cartilage cells of the epiphysial plate of a digit, and produce clinical deformity. 2. Both the direct effect of the freezing itself and the vascular changes secondary to such frostbite appear to cause necrosis of the growing epiphysis with destruction of the epiphysis and disappearance of the epiphysial line or plate. The disappearance of the epiphysial plate is obvious, but whether the epiphysis itself is actually destroyed and disappears or simply fuses with the metaphysis is a question now being studied. 3. It is suggested that the deformities may be helped by interphalangeal fusion of severely involved joints in the position of function, and phalanges that become angled into varus or valgus may be improved by open wedge osteotomy or epiphysiodesis of the side of the epiphysis still functioning

1. In a series of seventy-one patients with wringer injuries of the hand three basic types of lesion were observed: a) denuding of part of or the entire hand, usually accompanied by avulsion of the distal phalanges; b) small lacerated wounds with wide detachment of surrounding skin and frequent fractures; c) multiple cut injuries of digits or the entire hand with skin avulsions. 2. Treatment was guided by the following principles: a) improvement of blood supply in regions of impaired nourishment; b) stable primary fixation of bones with Kirschner wires; c) primary wound closure through free skin grafting with maximal utilisation of available flaps. 3. Surgical technique as applied in various typical cases is outlined

Introduction. Hand tumors are usually rare and there is not much literature about series of cases. We have studied a series of 110 cases. Hand tumors do consists of both benign and malignant cases. Methods. We studied series of 110 cases at Karnataka Institute of Medical Sciences, Hubli and Mysore Medical College & Research Institute, Mysore. We retrospectively reviewed the records of 110 patients who underwent double ray amputations at our center over few years: few had amputations of the fourth and fifth rays and others amputation of the second and third rays. Mean age at surgery was 34 years (range, 10–45 years), and minimum follow up was 64 months (mean, 98 months; range, 64–136 months). Some patients had high-grade soft tissue sarcomas of the hand, synovial sarcomas, malignant peripheral nerve sheath tumors, and undifferentiated sarcoma. No patients had detectable metastases at surgery. Results. All patients were completely disease-free at latest follow up. One patient was alive with lung metastases detected 32 months after surgery. No patients developed local tumor recurrence. Functional assessment showed a mean Musculoskeletal Tumor Society score of 24 (range, 19–28) and mean grip strength 24% of the contra lateral side (range, 17%–35%). Conclusions. The majority of osseous tumors of the hand are benign. The surgeon who evaluates and treats osseous tumors of the hand has to be familiar with limb anatomy, tumor biology, various presentations of the tumors and the range of treatment possibilities and their limitations. Lesions in the hand more often present earlier in their course than those at other sites, just because they are more likely to superficial and easily noticed. Ganglion cyst is the most frequently encountered comprising 50–70% of benign tumors of hand. Enchondroma was the next common benign bone tumour followed by osteoid osteoma, osteoblastoma, aneurismal bone cyst, giant cell tumor, epidermoid cyst, and osteochondroma. Although malignant neoplasms in the hand that arise from tissues other than the skin are very rare, the hand may be the site of distant breast, lung, kidney, esophagus, or colon adenocarcinoma metastases, most of which have a predilection for the distal phalanges. Malignant tumours of the hand are rare, although there remain many instances in which marginal excisions are performed for unsuspected malignant hand lesions. Suboptimal biopsy incisions and inadvertent contamination during these excisions may result in larger resections or amputations being necessary to ensure complete removal of the tumour with negative margins

Summary Statement. An alternative way to assess three dimensional skin motion artefacts of kinematic models is presented and applied to a novel kinematic foot model. Largest skin motion is measured in the tarsal region. Introduction. Motion capture systems are being used in daily clinical practise for gait analysis. Last decade several kinematic foot models have been presented to gain more insight in joint movement in various foot pathologies. No method is known to directly measure bone movement in a clinical setting. Current golden standard is based on measurement of motion of skin markers and translation to joint kinematics. Rigid body assumptions and skin motion artefacts can seriously influence the outcome of this approach and rigorous validation is required before clinical application is feasible. Validation of kinematic models is currently done via comparison with bone pin studies. However, these studies can only assess major bones in a highly invasive way; another problem is the non-synchronous measurement of skin markers and bone pins. Recently the Glasgow Maastricht kinematic foot model, which comprises all 26 foot segments, has been presented. To validate the model we propose a novel non-invasive method for the assessment of skin motion artefact, involving loaded CT data. Patients & Methods. 25 subjects (healthy and pathological feet) have undertaken CT scans. These CT-scans have been obtained in 1 unloaded and 3 varying loading conditions. CT-slices are 3D reconstructed and segmented. The principal axes of the segmented bones were derived from the surface points of the bones. These principal axes are used to compute bone orientation. Subsequently, coordinate systems of bones in the different loading conditions were matched. Markers were translated and rotated to orientations of their corresponding bones. Maximal distance between markers is calculated per subject to asses the influence of skin motion. Results. Preliminary results of 9 subjects show largest positional differences for markers associated with the cuneiform lateralis (5.7 ± 3.2 mm) and cuneiform intermedium (7.7 ± 3.7 mm). Smallest positional differences are found on the hallux proximalis (0.9 ± 0.34mm). Spatial resolution is too small to accurately calculate orientation of smaller bones, therefor distal phalanges 2–5 are not taken into account in the analysis. Discussion/Conclusion. Skin motion is a major cause of inaccuracy in gait analysis. This is the first study presenting an automated non-invasive method to calculate the 3D orientation of skin markers with respect to the coordinate system of the corresponding bone(s). Largest skin motion is measured in the tarsal region. Future work will be in calculation of the effect of skin motion in the accuracy of joint angle calculation

We performed one-stage lengthening using intercalary autogenous bone graft in 34 metatarsals and seven proximal phalanges in 21 patients with congenitally short metatarsals. At operation, in order to decrease the tension in the surrounding soft tissues, we gradually distracted the osteotomies of the affected bones for 20 to 30 minutes. The patients, all women, were followed up for a mean period of 2.1 years (1 to 6.5). The average gain in length for the 34 metatarsal procedures was 14 mm (6 to 21), equivalent to an increase of 32% (11 to 51), and for the seven proximal phalangeal lengthenings 8 mm (5 to 11), an increase of 54% (47 to 65). There was no evidence of neurovascular impairment. The technique of gradual distraction during operation is simple and effective. It overcomes the disadvantages of one-stage lengthening such as a small gain in length and neurovascular damage

Purpose. A review of the role of external fixators in paediatric trauma at The Royal London Hospital Trauma and Orthopaedic Department. Methods. Retrospective study between 2004 and 2010 reviewing traumatic bone injuries that required initial management with an external fixator. Information was collected through the patients' medical documents and radiographs. Results. In total twenty-seven patients (15 male:12 female, mean age 11, age range 7-15) were initially treated with external fixators over the six year period. The injured bones included 18 tibias, 5 femurs, 2 humeri, 2 radius/ulna, 2 phalanges and 1 wrist. Three patients had two fractures requiring external fixators. Four patients had associated head injuries. Indications included twenty –one open fractures (3 Gustilo type 2, 6 Gustilo type 3A, 12 Gustilo type 3B), seven closed fractures in poly-trauma patients and two closed severely comminuted fractures. Ten fractures were treated with the external fixator as the definitive treatment, fourteen had application of cast following removal of the external fixator and six were converted to internal fixation. Twenty-eight Linear frames were applied (23 Hoffman IIs, 5 Compact Hoffmans) and two circular frames. Mean duration of frame stabilisation was 8 weeks (range 1-16 weeks). Complications included 2 pin site infections successfully treated with antibiotics, 2 patients with hypertrophic scars, 2 leg length discrepancies secondary to bone loss, 2 patients had delayed union and 2 patients had a lower limb deformity requiring intervention, one for adjustment of frame and the other for correction osteotomy with circular frame. Conclusion. The use of external fixators has an important role to play in the management of open fractures and poly-trauma paediatric patients

A 14-year-old girl with a congenitally deformed and shortened right leg and foot is described. The patient could not bear weight on the deformed limb and had to hop on the left leg. The deformed foot faced backwards and had nine toes. The right leg was shorter than the left by 26 centimetres. Radiologically, the lower end of the right femur was ill-developed and there was no knee joint. There were two fibulae and the tibia and the patella were absent. A through-knee disarticulation was done and a prosthesis fitted later. The amputated leg and foot were dissected. Many of the muscles in the leg and foot were duplicated. There were two calcanei, one talus, one navicular, two cuboids and four cuneiforms. Ther were nine metatarsals, and all the toes had three phalanges except for one which had two

Objectives: Nowadays estimating paediatric bone age is done using methods based on standards from the 50’s and 70’s. These methods are often difficult to perform, they require experience in the analysis of multiple bones and are based on subjective measures. Many times, the age calculated stands within a wide range of age interval. We investigate a new method based on AP foot X-rays. Material and Methods: 971 radiographs taken from 220 paediatric patients (0–18 years old) were analyzed. 34 different ratios were designed by measuring ossification centres of the bones of the first and second foot rays. These ratios were statistically studied searching for the relation with variables as gender, laterality, foot pathology and forefoot formulae. Finally, regression lines and curves from each ratio were calculated as well as their correlation with chronological age. Results: The best suited correlations are obtained with the ratios calculated from the epiphysis of the proximal phalange of the first and second toes. With them, multiple regression analysis is able to establish an equation that estimates bone age, with a chronological age correlation of 0,86 for general population, 0,85 for boys and 0,90 for girls (p< 0,01). It is applicable for either feet, and valid for every forefoot formula or pathologic feet. Conclusions: This new method is designed to estimate bone age in children using either plain radiographs or digital images. The method is objective, precise, universal and easy to calculate. It proves a good correlation in children between 1 and 13 years old. It is based on a modern population and adjusted with lineal regression equations to both genders

Malunion of digital fractures can be difficult to correct especially for rotational phalangeal malunion. We describe the simple closed corrective technique. Materials/Methods: Patients whose phalangeal fractures were treated closed (mobilised or POP +/− K wires) and malunited, typically with mal-rotation. The technique is performed under LA. The bone is cut by percutaneous passage of a 1.1 mm K wire multiple times until the bone is fractured. The malunion is corrected and held with one longitudinal 1.1 mm K wire. The osteotomies are supported for 6 weeks in POP/splint and the wire(s) removed. Results: 11 patients with 12 post fracture malunion–All metaphyseal osteotomies healed within 6 weeks with correction of malrotation and no significant angular deformity. The one diaphyseal osteotomy united late healing only partially (inadequately) corrected and requires revision. Apart from the malunion there were no major complications albeit short-term PIP joint stiffness. Conclusion: This is a safe and reliable technique that avoids most of the complications of more challenging open techniques in the phalanges or the compromises of distant techniques e.g. metacarpal correction of phalangeal malrotation. It does however require immobilisation precluding any major simultaneous soft tissue releases. It appears unsuited to diaphyseal correction

Introduction: In clinical practice The Cascade sign is widely used to assess the rotational deformity of the fingers associated with metacarpal and phalangeal fractures. We carried out a scientific study on thirty volunteers to evaluate the validity or otherwise of this standard sign. Material and Methods: Metal pointers were attached to the dorsum of the fingers, flexed at MCP and PIP joints. These pointers represented the mid longitudinal axis of the phalanges. Standardised AP radiographs of the closed fist were taken in all cases with the wrist placed in neutral position, in a custom made jig. The radiographs were assessed by two different observers using Picture Archiving and Communication System, software version VA42B, to determine the convergence of the metal pointers towards the scaphoid tubercle, as described in the cascade sign and Lister method. Statistics: Power of the study was determined with an assumption of a type-2 error of 0.05 and a two sided test. Descriptive statistics and confidence limits were calculated using SPSS 11 software. Results: We observed that the metal pointers did not equivocally converge towards the scaphoid tubercle. The persistent pattern of convergence was within a 2–3cm radius of the scaphoid tubercle. The statistical analysis, two tailed paired t-test of this pattern showed strong association with this latter finding. (p< 0.003). Conclusion: Our study suggests that the cascade sign is sensitive but not specific to access the rotational deformity of the fingers. Radiological there is significant scatter about the scaphoid tubercle

Aim. Assess the oncological and clinical outcomes associated with intralesional curettage, phenol and bone grafting of the lesions. Method. A retrospective study was performed using data from the Leiden University Medical Center. Ninety patients with low grade central chondrosarcoma of long bones and small tubular bones were treated using phenol and ethanol as adjuvant therapy after intralesional curettage. Standard clinical follow-up contained regular visits to the orthopaedic department, physical examination and radiological follow-up with plain X-rays and dynamic Gadolineum-enhanced MRI scans. Results. Between 1994 and 2005 thirty-three males and fifty-seven females with a mean age of 47 years (range 5.6-73.1) were treated in our clinic. Mean follow-up 6.5 years (range 0.2-14.1). Location of chondrosarcoma. Femur (43%), humerus (32%), tibia (10%), fibula (6%), metacarpalia (4%), radius (2%), ulna (1%), phalanx (1%). Average tumour volume of all lesions, including metacarpals and phalanges, was 22 cm3 (range 1-104). With a mean follow up of 6.5 years, 86% of the patients are free of tumour on plain X-ray and dynamic Gd-MRI. Two femoral fractures occurred within 6 weeks after surgery, treated by ORIF. 14% of the patients had re-intervention(s) due to suspected recurrence or residual tumour on dynamic Gd-MRI (7 recurettage, 6 RFA). Histology: Grade I Chondrosarcoma (7), no recurrence (2), non conclusive (4). Overall, there were no cases of metastases. Conclusion. This study presents a large number of patients included, all with same diagnosis and uniform treatment for lowgrade central chondrosarcoma. Periodically clinical and radiological follow-up by dynamic Gd-MRI only showed 8% histological proven recurrences, no upgrading of tumour or occurrence of metastases were seen. Compared to other studies, the complication rates and impairment for the patients are low. Intralesional treatment of low-grade central chondrosarcoma, followed by phenol and ethanol is an effective and safe method with low morbidity for these patients

Enchondromatosis is a non-hereditary disease, characterised by the presence of multiple enchondromas. While Ollier Disease is typified by multiple enchondromas, in Maffucci Syndrome they are combined with haemangioma. Due to the rarity of these diseases, systematic studies on clinical behaviour providing information how to treat patients are lacking. This study intends to answer the following questions: What are predictive factors for developing chondrosarcoma? When is extensive surgery necessary? How often patients die due to dedifferentiation or metastasis?. Twelve institutes in eight countries participated in this descriptive retrospective EMSOS-study. 118 Patients with Ollier Disease and 15 patients with Maffucci Syndrome were included. Unilateral localization of disease was found in 60% of Ollier patients and 40% of patients with Maffucci Syndrome. One of the predictive factors for developing chondrosarcoma is the location of the enchondromas; the risk increases especially when enchondromas are located in the scapula (33%), humerus (18%), pelvis (26%) or femur (15%). For the phalanges, this risk is 14% in the hand and 16% in the feet. The decision whether or not to perform extensive surgery is difficult, especially in patients who suffer multiple chondrosarcomas. Malignant transformation was found in fourty-four patients with Ollier Disease (37%) and eight patients with Maffucci Syndrome (53%). Multiple synchronous or metachronous chondrosarcomas were found in 15 patients. Nine patients died (range 21–54 yrs). Seven of them died disease related due to pulmonary metastasis (2 humerus, 2 pelvis, 3 femur). Two patients died from glioma of the brain. In conclusion, one important predictive factor for developing chondrosarcoma is the location of the enchondromas; interestingly, only patients with chondrosarcoma outside the small bones died of their disease. In this series, no dedifferentiation of chondrosarcoma was seen. A first design flow-chart how to approach chondrosarcoma in patients with Ollier Disease and Maffucci Syndrome is in preparation

Nineteen chondrosarcomas are reported arising in proximal phalanges or metacarpal bones of the hand mainly in elderly patients, predominantly women. The usual clinical presentation was of a progressively painful large tumour, often arising in a dormant lesion near the metacarpo-phalangeal joint. Radiologically most showed some bone expansion with a poorly defined area of destruction and a considerable soft-tissue swelling. Histologically, malignancy was usually obvious, but confusion might arise from the inclusion of bland areas of chondromatous tissue that probably represented the original lesion. Four tumours, initially curetted and grafted, recurred locally and necessitated amputation of the digit or ray. Amputation was the primary treatment for fourteen other tumours and was curative except in one patient who eventually needed amputation through the forearm for a large second recurrence. One tumour was satisfactorily controlled by excision of the affected phalanx. None of these nineteen tumours is known to have metastasised. Correct treatment implies a carefully considered balance between conservation of function and complete removal of all tumour tissue

We retrospectively reviewed 27 patients who underwent an uncemented total Moje ceramic arthroplasty of hallux rigidus. Out of 33 patients who had the above procedure, 27 were available for review. Clinical and functional outcome were assessed using the American orthopaedic foot and ankle society (AOFAS) fore-foot score, and the SF-36 health assessment score. All patients had an antero-posterior and a lateral weight bearing radiograph. The primary pathology was oesteo-arthritis (Hallux Rigidus). All procedures were performed by the senior author or under his supervision. All patients were female with an average age at surgery of 52.6 years (range 45.8–64.7). The average follow up was 39.5 months (range 14–46). The average post-operative AOFAS forefoot score was 80/100 (range 40–100). The average subscore for pain was 29.39/40 (range 10–40). Twenty five patients 92.5% were satisfied with the outcome, and 22 (81%) were able to wear high heel foot wear. The functional outcome as assessed using the SF-36 health score was compatible with an age matched population. The alignments of component were measured in relation to the shaft of the metatarsal and to the proximal phalange. There was no statistical correlation between the alignment and the functional scores. Although, arthrodesis remains the gold standard procedure, total ceramic first MTP joint arthroplasty has a place in the management of some cases of advanced but not end stage hallux rigidus. Careful patient selection is essential to achieve a favourite outcome

We retrospectively reviewed 27 patients who underwent an uncemented total Moje ceramic arthroplasty of hallux rigidus. Out of 33 patients who had the above procedure, 27 were available for review. Clinical and functional outcome were assessed using the American orthopaedic foot and ankle society (AOFAS) fore-foot score, and the SF-36 health assessment score. All patients had an anteroposterior and a lateral weight bearing radiograph. The primary pathology was oesteo-arthritis (Hallux Rigidus). All procedures were performed by the senior author or under his supervision. All patients were female with an average age at surgery of 52.6 years (range 45.8–64.7). The average follow up was 39.5 months (range 14–46). The average post-operative AOFAS forefoot score was 80/100 (range 40–100). The average subscore for pain was 29.39/40 (range 10–40). Twenty five patients 92.5% were satisfied with the outcome, and 22 (81%) were able to wear high heel foot wear. The functional outcome as assessed using the SF-36 health score was compatible with an age matched population. The alignments of component were measured in relation to the shaft of the metatarsal and to the proximal phalange. There was no statistical correlation between the alignment and the functional scores. Although, arthrodesis remains the gold standard procedure, total ceramic first MTP joint arthroplasty has a place in the management of some cases of advanced but not end stage hallux rigidus. Careful patient selection is essential to achieve a favourite outcome

Aims: Thirty-three patients with condylar fractures of the middle and proximal phalanges were treated with internal fixation using self-tapping titanium lag screws. The results were studied prospectively and prognostic factors identified. Methods: The age range was 14–45 (mean 26 years). Five patients presented at more than five weeks post injury. Four patients had bicondylar fractures. The surgical technique, which utilises a lateral approach, is outlined. All surgery was performed by the senior author (DS), semi-electively, within five days of presentation. Patients were seen in the 4th postoperative day for mobilisation and protective splintage. Results: The results were satisfactory in the majority of cases. 21 patients had achieved a full range of movement when reviewed at six weeks and further eight at 12 weeks. The remainder were left with a flexion contracture of 10–35 degrees (mean 26). All patients achieved full flexion. All fractures healed and there was no loss of fixation. Conclusions: Internal fixation using a single lag screw through a lateral approach restores joint congruity, facilitates union and provides fixation stable enough to allow early mobilisation. Bicondylar and proximal phalangeal fractures had a poorer prognosis. Fractures presenting even at eight weeks can be taken down and reduced. Delay in fixation does not appear to influence the long-term outcome

Eight children developed osteochondroma (OS) at a mean of 88 months, after hematopoietic stem cell transplantation (HSCT). The mean age at HSCT was 56 months (12-84). This represents a cumulative incidence of 20% among patients less than 18 years of age transplanted from 1981 to 1997. These eight patients underwent allogeneic (n=2) of autologous (n=6) transplantation for either acute leukemia (n=6) or neuroblastoma (n=2) after a conditioning regimen including total body irradiation (n=7) or a combination of Busulfan and Cyclophosphamide.Multiple OS were indentified in seven patients and a solitary OS in one. Locations included: clavicle (2), ribs (2), superior iliac epiphysis (1), metaphy-sis of the distal femur (2), distal (2) and proximal (1) tibia, proximal humerus (1), distal radii (3), scapula (3), proximal metaphysis of the proximal phalanges of the fingers (2) and parietal bone (1). OS were asymptomatic in four children. Eight lesions in five patients were resected and all were benign. No recurrence occured.Four children received growth hormone before diagnosis of OS, but there was no clinical, radiological or histological difference between those who did not. Univariate analysis showed an increased rate associated only with autolo-gous HSCT, with a 31,7% probability of a new OS et 12 years after HSCT.Ostoechondroma should be added to the other adverse effects of HSCT in children

Introduction and Objectives: The technique modified by Regnauld makes it possible to correct the MTP angle and the DASA, shorten the first phalange preserving the MTP joint, and its articular congruence and functionality. Assessment of results at 2 years follow-up of 147 cases treated with this technique. Materials and Methods: Causes: Hallux Valgus 111; Hallux Rigidus 36. Sex: Women 114, men 33. mean age 70 years. Associated surgery: Proximal chevron-type osteotomy of the first MTT: 23; Scarft-type diaphyseal osteotomy: 1; osteotomy of the base of the first MTT: 11; double osteotomy: 5; subcapital Weils-type osteotomy: 15. Preoperative AOFAS test score 39.6. Mean follow-up 2.3 years. Pre and postoperative measurement of metatarsophalangeal angles. Postoperative assessment at 1 month, 6 m, 1 year and 2 years with X-ray, AOFAS scale. Results: Postoperative assessment using the AOFAS scale: < 1 month: 65, < 6 months: 78, < 1 year: 89, < 2 year: 82. AOFAS scale at 2 years: Moderate pain 2%. Narrow shoes 11%. Moderate MTP restriction 35%. Severe MTP restriction 2%. Infrequent mobility with severe IP restriction 9%. Asymptomatic malalignment 5%. Subjective assessment: Very satisfied 25%. Satisfied 68%. Not very satisfied 5% (occasional pain). Unsatisfied 2% (daily pain). The evolution of the values of the MTP angle were: preoperative MTP angle 34.7°, MTP angle 4 weeks postoperatively 8.1°, MTP angle at 1 year 14.7°, MTP angle at 2 years18.1°. Discussion and Conclusions: Satisfactory results (93%). This technique corrects the MTP angle, preserves the MTF joint and makes it possible to associate with it other surgical techniques to modify the intermetatarsal angle. By preserving the MTP joint we prevent early evolution of hallux rigidus. Very little loss of MTP correction at 2 years (10°), with no clinical correlation

Introduction and Aims: The hypothesis that ‘utilisation of gradual distraction and soft tissue correction by external fixation improves outcomes in hand and wrist deformity’ was analysed in 29 extremities in 24 patients, to define the indications for gradual soft tissue correction of congenital and acquired deformity and distraction osteogenesis in hypoplastic digits. Method: This retrospective review of 29 extremities in 24 patients evaluated the role of monolateral external fixators with uniplanar (n=20) and multiplanar (n=9) correction capability (Orthofix, International). Evaluation included an assessment of complications, patient satisfaction, functional outcome, and impact on health-related quality of life. Results: The devices were successfully used to correct radial longitudinal deficiency of the radius (radial club hand) (n=9); digital hypoplasia (n=15) and wrist flexion contracture secondary to spasticity (n=5). There were no significant complications related to the devices. Pin track irritation and drainage occurred in two of 108 pins. One pin became loose and needed to be replaced, and one fixator required two intraoperative adjustments. Multiplanar fixators used for correction of radial club hands and wrist flexion contracture improved soft tissue position in allowing secondary bony procedures and/or tendon transfers. Distraction osteogenesis of metacarpals and phalanges (included seven previously transferred extraperiostial toe phalanges) was successful with an average lengthening of 2.1 centimetres. Conclusion: Gradual distraction and soft tissue correction improves outcomes in congential and acquired hand and wrist deformity in children and adolescents. Mono-lateral fixation devices allow correction with hinges or gears, enhance correction of complex deformity, and is well tolerated by patients and caregivers

Material: This work presents the treatment of 114 patients (125 feet), aged 9 – 53 years for:. - 82 short feet due to congenital metatarsal hypoplasia,. - 3 first toe stumps (P1),. - 32 post-trauma and post-surgery cases including two after resection of the metatarsal heads. The cosmetic defect was the principal complaint in most patients (95 women), as well as complications related to wearing shoes. Pain in the forefoot resulted from biomechanical conflicts between the toes and the metatarals. Methods: An oblique or transverse osteotomy for lengthening was performed on the base of the metatarsals and the phalanges. An external fixator, with modifications, was used. Pins were driven through the joints during the osteosynthesis to prevent dislocations. Traction was started three to five days after surgery at the rate of 0.5–1 mm/24 hr. Partial weight bearing on the operated limb was recommended. The external fixator was dismounted progressively with ablation of the pins allowing complete rehabilitation of the toes and walking exercises. These measured favour formation of regenerated bone and remodelling into hard bone, shortening treatment which was 45 ± 6 days in the study group. Results: Outcome was followed for 1 – 3.5 years. The desired lengthening of the forefoot (1.5 – 5 cm was achieved in all feet. All feet were pain free and the cosmetic result and foot bearing on the floor was improved. The patients were satisfied, with no complaints, and walked with full weight bearing without complementary prostheses and wearing ordinary shoes. Discussion: This experience in lengthening short tubular bones of the feet confirms the efficacy of the techniques used which provided good cosmetic and anatomo-functional results with one treatment

It has been known for well over a century that the corresponding ossification centres of the hand tend to appear before those of the foot (Mall 1906), although even now the range of variability remains poorly defined. Presumably a similar asynchrony also obtains for chondrification, although precise timing is more difficult here than for ossification. Accordingly, it is tempting with respect to this syndrome to relate fusions restricted to the phalanges of the hand and to the tarsal bones to the action of a gene which during a very limited period of development exerts an effect on those small bones of the hand and foot which are in a very specific stage of development. But since there are other inherited abnormalities of the skeleton, such as brachydactyly, where homologous bones are involved, it is clear that at the descriptive level gene action can either appear to be "stage-specific" or "homologue-specific." There are also mutations affecting the axial skeleton such as the type of polydactyly of the foot described by Neel and Rusk (1963) which appear to be neither "stage" nor "homologue" specific, involving only the foot. Finally then, there are syndromes, such as Lawrence-Moon-Biedl-Bardot, in which involvement of the hands and feet (polydactyly) is associated with such other apparently completely unrelated defects as retinitis pigmentosa and hypogonadism. While it is tempting to try to construct theoretical patterns and systems of developmental processes on the basis of results such as these, it is clear that the ultimate understanding of how genes can appear to act in so many ways almost certainly depends on the identification of a genetically controlled, qualitative or quantitative biochemical lesion. With the current parallel developments in biochemical and developmental genetics, new insights into these enigmas will surely be forthcoming in the relatively near future

Aims

Although chondrosarcomas (CSs) display true malignant features, including local recurrence (LR) and metastases, their behaviour in the hands and feet is thought to differ from that in other parts of the axial and appendicular skeleton by having a lower metastatic potential. The purpose of this study was to investigate the disease-specific and surgical factors that affect the local and systemic prognosis of CS of the hands and feet.

The Kramer osteotomy for hallux valgus deformity was described in 1990 and has been performed by the senior author in our unit since 1999. The procedure involves a wedge excision of bone and lateral displacement of the first metatarsal head. The osteotomy is splinted by a K-wire passed medially to the phalanges and metatarsal head into the metatarsal diaphysis. During the period October 1999 to December 2001 this procedure was performed on 26 feet in 24 patients. Case notes were reviewed retrospectively to assess the subjective outcome following the operation. Patients were invited to attend a follow up clinic to assess the outcome using the Hallux Metatarsal-Interphalangeal Scale (HMIS) of the American Orthopaedic Foot and Ankle Society and weight bearing radiographs of the foot. Twelve patients (13 feet) were seen at this follow up. Discharge from hospital was on the day following surgery in 20/24 patients with three days maximum stay. K-wires and plaster boots were left in situ for 41 days on average (30–50 days range). From the case notes, using absence of hallux pain, deformity, hallux stiffness and footwear problems as outcome measures, 20 feet (77%) had a good outcome, five feet (19%) had a fair outcome and one foot (4%) had a poor outcome. At the follow up clinic at a mean time from operation of 134 weeks (range 56–153 weeks), the average HMIS score was 86/100 (Range 60–100) with 77% scoring 85 or more out of 100. Average postoperative intermetatarsal, hallux valgus and distal metatarsal articular angles were 6.9, 15.8 and 11 degrees respectively. Other than six cases of minor infection of skin, treated empirically with antibiotics, no other complications were seen. All patients were happy they had received this treatment. In conclusion the Kramer osteotomy is a technically simple operation which gives good results with few complications

In this report we present the results of the primary suture of the flexor tendons in zone II, in 198 patients who were operated in our department between 1998 and the first months of 2001. 142 were male from 16 to 65 years old and 56 were female between 14 to 60 years old. Children below 14 years old are not included in this report. The majority of patients in this review reported an accident during dancing and late night activities. Patients with complex injuries such as fractures of phalanges, phalangeal dislocations and extensive soft tissue laceration were excluded. The majority of the patients operated immediately within the first 48 hours and only 28 patients (14, 5%) were operated with a delay ranging between 1 – 5 weeks. The suturing technique was variable in all cases. A Bruner (zig-zag) incision was utilized to facilitate. The tendon was sutured using a standard Kleinert technique and 4.0 nylon sutures as supportive sutures, 5.0 nylon sutures were used to suture the epitendon in a continuous fashion. A dorsal splint holding the wrist in 40° of flexion and the MP joints in 70° of flexion and PIPs and DIPs in extension was used postoperatively. Early mobilization was initiated (shortly after surgery, 3 – 4 days) and lasted 4 weeks. After this period the patient underwent a program of full active motion for an additional 4 weeks. They finally allowed to perform freely after a 12-week postoperative period. We used the Kleinert score to evaluate the surgical results. According to this score results were found to be: Excellent in 80 patients (40%), good in 60 pts (30%), fair in 22 (12%) and poor in 16 pts (8%). Despite the satisfactory overall results we observed a high incidence of tendon ruptures (10%) in 20 patients and this may be related to poor follow up and rehabilitation conditions. No other complications (infection, hematoma formation, and skin slough) were observed in these patients

Introduction: Osteomyelitis and septic arthritis (SA) below the elbow are severe conditions affecting the function and viability of the hand. Factors predisposing to these conditions and parameters affecting prognosis are emphasized. Material and Methods: In a 4 years period, 16 patients with SA (4) or osteomyelitis (12) were treated in a University Orthopaedic Department providing care to a rural population of 1.000.000, Nine had history of trauma in unhygienic environment, 3 had immunodeficiency and in 4 osteomyelitis was iatrogenic [previous fixation of fractures (3) and vein catheterization (1)]. SA was located in the wrist (2) and thumb joints (2) and osteomyelitis involved the radius (3), ulna (1), metacarpals (3) and phalanges (5). Ten patients received oral antibiotics in other centers. The mean delay from onset of symptoms to referral to our center was 22 days. Apart of antibiotics administration, surgical treatment included debridement and irrigation for SA and excision of necrotic bone, stabilization (external fixators), use of antibiotic beads and secondary bridging with bone graft for osteomyelitis. Additional procedures (amputations, arthrodesis) were also required in some cases. Results: Cultures were positive in 9 of 16 cases [Staph. aureus (5) and enterobacter cloacae (3)]. Patients underwent multiple procedures (mean: 3.8) and 4 underwent amputation of a digit (2) and hand (2) due to the rapid extension of infection threatening and finally taking the lives of 2 elderly and immunosuppressed patients. Mean follow-up period of the 12 surviving and non-amputated patients was 18 months. Union was accomplished in all cases. Functional results were excellent or very good in 10 of 12 patients and good in 2 patients. All patients were satisfied and returned to their previous occupations. Conclusions: Osteomyelitis and SA below the elbow was frequent in population living in unhygienic environment or working with soil. All cases received medical treatment with delay. Immunosuppressing conditions favored the extension of infection and threatened patients lives. Delay in treatment in combination to immunosuppression resulted to significant morbidity. Early treatment including surgical drainage, thorough debridement and antibiotic administration is necessary for elimination of skeletal infection and salvage of the hand and patients life

We report preliminary results from the first, multicenter prospective study designed to define the incidence of symptomatic (Venous Thromboembolism) VTE in patients with isolated leg fractures distal to the knee. Eight hundred and twenty-six enrolled patients have completed three months of follow up. By three months, only seven patients had sustained a symptomatic VTE with no fatal PE. Symptomatic and fatal VTE were infrequent complications after isolated leg fractures distal to the knee without thromboprophylaxis. Routine thromboprophylaxis may not be warranted in isolated leg fractures distal to the knee. To report results from the first, multicenter prospective study designed to define the incidence of symptomatic Venous Thromboembolism (VTE) in patients with isolated leg fractures distal to the knee. Symptomatic and fatal VTE are infrequent complications after isolated leg fractures distal to the knee without thromboprophylaxis. Routine thromboprophylaxis may not be warranted in isolated leg fractures distal to the knee. From August 2002 to April 2004, one thousand eight hundred and eight consecutive patients with isolated leg fractures distal to the knee were screened for entry at five hospitals in Ontario. Patients with major trauma, active cancer and previous VTE were excluded. Thromboprophylaxis was not allowed. Patients were followed prospectively for three months, with telephone calls at fourteen days, six weeks and three months. Suspected DVT and PE were investigated in a standardized manner. Eight hundred and twenty-six enrolled patients have completed three months of follow up. The mean age was forty-five years (range sixteen to ninety-three) and 59.5% of this cohort was female. 99% of these fractures were unilateral and 97% were closed. Fractures included: fibula (38%), metatarsal (29%), phalanges (13%), calcaneus, talus or tarsal (10%), tibia (10%) and patella (7%). Only 11% of fractures were surgically treated. 88% of fractures received a cast or splint for a mean duration of 41+/− 20 days. Complete follow-up was available for 97.5% of this cohort. By three months only seven patients had sustained a symptomatic VTE (2 proximal DVT, 3 calf DVT, 2 PE) with no fatal PE-an incidence of 0.9% (95% CI 0.3 to 1.8%). Funding: This study was funded by a research grant from Pharmacia

Fourteen cases of pigmented villonodular synovitis (PVNS) of the foot and ankle (between January 1957 and December 1999) accrued from Scottish bone tumor registry are presented with an average follow-up of 4.6 years aimed to analyse the clinical, radiological and histopathological features in order to investigate the clinical behaviour of PVNS in the foot and ankle, and to determine the factors influencing recurrence. The mean age was 26.4 years (range, 8 to 52 years). There were eight females and six males. The mean delay in presentation was 10.3 months. The anatomical sites were foot phalanges (n=2), tarso-metatarsal area (n=3) and hindfoot (n=9). Hindfoot cases comprised of 6 extra-articular soft tissue swelling around the ankle, two affecting the ankle joint and one involving the subtalar joint. There were eight (57.1%) cases presented with painless lump, five (35.7%) patients with painful lumps and one case with a lump associated with toe deformity. The clinical suspicion were ganglion, gout, soft tissue swelling (? tumour) and exostosis. Peri-articular tissue invasion and cortical infiltration was found in one third on plain films. CT scan showed multiple lytic lesions and MRI scan findings were consistent with extensive low signal soft tissue hypertrophy and bone erosion, two of which were suspected with synovial sarcoma. Excision of the lump was done in 4 cases with a complete recovery. Foot phalangeal PVNS were treated with toe amputation through metatarsophalangeal joint and no cases had recurrence of the lesion. There were two recurrences affecting the ankle and the subtalar joint. Recurrent ankle PVNS was treated with re-exploration, open synovectomy, curettage of talar cyst and autogenous bone grafting. The second recurrent case involving subtalar joint was treated with re-excision and curettage. Both recurred cases were primarily treated with intralesional excision for their diffuse variety. There were no recurrences in the nodular variety. Complete recovery was achieved in 85.7% case (12/14). A high index of suspicion for PVNS should be observed for cases presenting with a painless or painful mass in the foot and ankle region. Complete recovery can be achieved in the majority by complete excision. Toe amputation may be considered for foot phalangeal PVNS

Giant Cell Tumour of the Tendon Sheath is a benign tumour of synovial origin most frequently affecting the upper limb. Up to 11% exhibit radiographic evidence of cortical erosion and intra-osseous expansion. In the upper limb recurrence rates of between 10–50% following excision have been reported. However, GCT-TS is rarely described in the foot and ankle and its behaviour is ill understood. 17 cases of this rarely described tumour in the foot and ankle are presented, describing their clinical presentation, histopathology, treatment and outcome. Analysis of all cases of histopathologically proven GCT-TS of the foot and ankle from the Oxford Tumour Registry, was conducted between the periods of January 1984 to December 1999. 22 cases were identified of which 17 cases had adequate records to allow analysis of patient demographics, duration of symptoms, preoperative investigations, presumed diagnosis, precise site of origin, post operative complications and recurrence rates. The mean age of presentation was 28 (8–53). 10 cases were female and 7 male. 76% cases occurred in the foot, all of which arose adjacent to the phalanges or heads of the metatarsals. 14% occurred in relation to the ankle or sub-talar joint. 82% presented with a painless swelling. The duration of symptoms ranged from 6 months to 8 years. Only one patient complained of sensory symptoms. Pre-operative investigations included radiographs in 64% with 3 cases having an additional MRI scan. The MRI scans of GCT-TS have characteristic changes on T1 and T2 images. The presumed preoperative diagnosis was incorrect in 82%. 36% of radiographs taken showed changes including cortical erosion and speckled calcification. A local excision was performed in 15 cases, an amputation in one and a wide local excision in one case only. There have been no recurrences during the follow up period of between 1–12 years. GCT-TS of foot and ankle is rare and is commonly misdiagnosed. Despite only a local excision being performed in more than 80% of this series there were no recurrences. Plain radiographs may show cortical erosion or speckled calcification in up to 36% and MRI is helpful in further defining the anatomy of the lesion, allowing planned excision and reducing the risk of recurrence

We conducted a prospective review of patients treated specifically for phalangeal fractures over a period of 6 months. Data was sourced from patient records, Emergency Dept records and theatre records. X-rays were reviewed by the senior authors using the AGFA IMPAX Web1000 v5.1 System. A total of 654 patients presented to our hospital during the study. Of these, 257 (39%) patients were referred to the plastics and hand surgical team on-call. Remaining 397 (61%) patients were seen and treated at the local accident and emergency. Our review identified a patient group of 75 out of 654 (11.5%) patients who required operation. Mechanism of injury: Direct impact: n=60 (80%), Hyperextension n=11 (15%), Hyper-flexion injury n=4 (5%). Mode of injury: sports related, commonly rugby or football: 23 (31%) patients, crush injury 13 (17%), road traffic accident 10 (13%), punching either wall or a fellow human being in 10 (13%), fall 8 (11%), circular saw related injury in 8 (11%). The average patient age for a phalangeal fracture was 37.3 years. 47 (63%) patients were in the age group 20–40 years. The mean age for a phalangeal fracture in males was 35.9 (16–75) years and 42.2 (23–70) years in females. The gender distribution of these patients reveals that 58/75 (77%) patients were males. This indicates that males were at an increased relative risk of 3.4 for sustaining a hand fractures than females. The fractures were studied with respect to their complexity, digit(s) involved, phalanx and the site on the phalanx, pattern of fracture and finally the involvement of the MCP or the IP joints. Our study revealed that fifty-two (69%) of the fractures were closed while twenty-three (31%) were open. Injuries to the distal phalanges accounted for the most of the open fractures (15/23, 67%). The little finger and the ring finger were the common fingers to be involved. The fractures were treated with various standard techniques of operative fixation. Postoperatively patients were mobilised as soon as possible and fitted with a removable thermoplastic splint to allow daily active and passive exercises. Hand therapists followed unit protocol including at least one visit per week, with follow up for four to six weeks. Final review was undertaken by a clinician in a dedicated Hand clinic six weeks post fixation. Our work provides data on incidence and demographic distribution of phalangeal injuries presenting acutely to an NHS Trust covering a population area of 500,000. In our trust it is standard protocol for all such injuries to be reviewed by the Hand team to institute optimal hand therapy for patients. The study enabled us to develop a patient care pathway which will improve both patient and resource management

There is little data regarding the epidemiology of childhood injury in Ireland. This is difficult to obtain retrospectively. The aim of this study was to prospectively evaluate paediatric trauma referrals to our department, describe their epidemiology, and identify potentially preventable injuries in children. Our unit at the National Childrens Hospital is located in a growing suburban area in South Dublin. Injury surveillance was conducted on orthopaedic referrals by distributing a form to parents of children attending fracture clinics or admitted acutely for surgery. Parents were asked for demographic information, and a brief description of the injury in terms of location, mechanism and circumstance of injury. Diagnosis was completed by the attending doctor and data was transferred to a computerised database. We analyzed data from the 397 referrals in the first month of this study. The mean age of injury was 9.1 years and the male: female ratio was 1.3:1. The peak hour of injury was 7 – 8 pm. Only 33% of injuries occured during the weekend. 62% of injuries were due to falls, usually form the standing position. The most common location for injury was in or about the home (39%), and other notable locations were school (16%) and sportsfield (14%). 61% of falls greater than 1 metre occurred at home, mostly from walls and childrens slides. 20% of injuries occurred while participating in organized sport, including Gaelic football, soccer and hurling. Injuries occuring during unsupervised sport were more likely to need surgery. Domestic ‘bouncing castles’ and trampolines, increasingly popular in our area, were a notable cause of significant trauma to the upper limb. 7% of injuries occurred by falling from a bicycle, but vehicular road traffic accident was an uncommon cause of injury. 263 children had confirmed fractures, other injuries consisting largely of sprains to the ankle, elbow and wrist. Predictably, the bones most commonly fractured were the radius (41%), phalanges (15%) and humerus (11%). 20% of fractures needed operative management, mostly forearm manipulation under anaesthesia. 63% of operative cases were performed outside of normal working hours. Several countries utilise injury surveillance as a means of development and evaluation of injury prevention strategies. In our initial study, basic surveillance has outlined local characteristics of chilhood trauma, and some trends were noted. In particular, we suggest home injuries need further attention in out catchment area

Aims

The purpose of this study is to examine the adductus impact on the second metatarsal by the nonosteotomy nonarthrodesis syndesmosis procedure for the hallux valgus deformity correction, and how it would affect the mechanical function of the forefoot in walking. For correcting the metatarsus primus varus deformity of hallux valgus feet, the syndesmosis procedure binds first metatarsal to the second metatarsal with intermetatarsal cerclage sutures.

Aims

Tenosynovial giant cell tumour (TGCT) is one of the most common soft-tissue tumours of the foot and ankle and can behave in a locally aggressive manner. Tumour control can be difficult, despite the various methods of treatment available. Since treatment guidelines are lacking, the aim of this study was to review the multidisciplinary management by presenting the largest series of TGCT of the foot and ankle to date from two specialized sarcoma centres.

Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees.

Cite this article: Bone Joint J 2021;103-B(3):430–439.

Aims

Our aim was to develop and validate nomograms that would predict the cumulative incidence of sarcoma-specific death (CISSD) and disease progression (CIDP) in patients with localized high-grade primary central and dedifferentiated chondrosarcoma.

Aims

Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP.

Introduction: Recent in vivo studies of flexor tendon midsubstance healing have indicated that during the first 10 days after injury and repair there is no increase in ultimate tensile force. In contrast, there is an increase of approximately 170% in the rigidity (stiffness) of the repair site and a decrease of more than 45% in the repair-site strain at 20 N force. The basis for the increase in rigidity during the early stages of tendon healing is not known, but may be due to either biological or mechanical factors. In particular, cyclic loading of the tendon repair site during post-operative rehabilitation may have a mechanical conditioning effect that increases the stiffness of the repair site independent of repair-site healing. Our objective was to determine whether or not cyclic loading of repaired flexor tendons causes an in increase in repair-site rigidity and whether or not this increase depends on the level of applied force. We simulated 10 days of passive motion rehabilitation by applying 6000 loading cycles to repaired flexor tendons ex vivo at force levels generated during passive motion rehabilitation. We then evaluated the tensile mechanical properties. We hypothesized that cyclic loading causes an increase in repair-site rigidity and a decrease in repair-site strain. Materials and Methods Forty-eight flexor digitorum profundus (FDP) tendons with attached distal phalanges were obtained from twelve hindlimbs of six adult mongrel dogs. Specimens were randomly assigned to one of three groups: control (no loading), low-force (5 N) cyclic loading or high force (17 N) cyclic loading. Tendons were transected in Zone II, 4 cm proximal to the insertion site. They were repaired using a four-strand modified Kessler technique with double-stranded 4-0 Supramid suture (S. Jackson) supplemented with a running peripheral suture of 6-0 Prolene (Ethicon). For cyclic loading, the distal phalanx and proximal tendon stump were placed in custom clamps attached to a materials testing machine (Instron 8500R). Tendons in the low-force and high-force groups were loaded for 6000 cycles at 2 Hz from 0.5 N to peak forces of 5 and 17 N, respectively. The force levels were chosen to match the peak tendon forces that were measured in vivo for low- and high-force passive motion rehabilitation protocols of the canine forelimb; 6000 cycles were used to simulate the number of cycles applied during a 10-day period of rehabilitation (600 cycles/day). Specimens in the control group were sham loaded for an equivalent period of time (50 minutes). After cyclic loading, specimens were allowed to recover for 1 hour and then tested to failure in tension. From plots of force versus repair-site strain we determined ultimate (maximum) force (N), repair-site rigidity (N/[mm/mm]) and repair-site strain (%) at 20 N force. One-way analysis of variance was used to determine the effect of loading on tensile properties. Results: Specimens subjected to high-force cyclic loading had significantly increased rigidity compared to specimens in the low-force and control groups. Rigidity in the high-force group was increased by 100% compared to control. Similarly, repair-site strain at 20 N was decreased by 50% in the high-force group compared to control group. Ultimate force was increased in the high force group compared to control (p = 0.02; Table), but the magnitude of the increase was only 13%. There were no significant differences between the low-force and control groups (p > 0.05). Discussion: Based on our findings, we conclude: 1) Repair-site rigidity is increased by 100% and repair-site strain decreased by 50% following 6000 cycles of high-force (17 N) loading. In contrast, ultimate force is changed only slightly (13%) by high-force loading. 2) Mechanical conditioning of the repair site by repetitive forces applied during rehabilitation may have a consequence that has not been noted previously, i.e. it leads to increases in rigidity and decreases in strain. This effect may explain in part the changes in tensile properties observed after only 10 days of healing in vivo. 3) The lack of effect of low-force (5 N) loading on repair-site rigidity and strain is in contrast to the previous in vivo findings in which rigidity increased in the low-force rehabilitation group. This discrepancy suggests that the observed in vivo changes can not be explained entirely by mechanical conditioning effects. 4) Therefore, both biological and mechanical factors are likely to play an important role in the rapid changes in repair-site mechanical properties that occur following flexor tendon injury and repair

Aims

The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery.

Fractures in patients aged ≥ 65 years constitute an increasing burden on health and social care and are associated with a high morbidity and mortality. There is little accurate information about the epidemiology of fractures in the elderly. We have analysed prospectively collected data on 4786 in- and out-patients who presented with a fracture over two one-year periods. Analysis shows that there are six patterns of the incidence of fractures in patients aged ≥ 65 years. In males six types of fracture increase in incidence after the age of 65 years and 11 types increase in females aged over 65 years. Five types of fracture decrease in incidence after the age of 65 years. Multiple fractures increase in incidence in both males and females aged ≥ 65 years, as do fractures related to falls.

Analysis of the incidence of fractures, together with life expectancy, shows that the probability of males and females aged ≥ 65 years having a fracture during the rest of their life is 18.5% and 52.0%, respectively. The equivalent figures for males and females aged ≥ 80 years are 13.3% and 34.8%, respectively.

Cite this article: Bone Joint J 2014;96-B:366–72.

Aims

To determine whether an early return to sport in professional Australian Rules Football players after fixation of a non-thumb metacarpal fracture was safe and effective.

We analysed the clinical and radiological outcomes of a new surgical technique for the treatment of heterozygote post-axial metatarsal-type foot synpolydactyly with HOX-D13 genetic mutations with a mean follow-up of 30.9 months (24 to 42). A total of 57 feet in 36 patients (mean age 6.8 years (2 to 16)) were treated with this new technique, which transfers the distal part of the duplicated fourth metatarsal to the proximal part of the fifth metatarsal. Clinical and radiological assessments were undertaken pre- and post-operatively and any complications were recorded. Final outcomes were evaluated according to the methods described by Phelps and Grogan. Forefoot width was reduced and the lengths of the all reconstructed toes were maintained after surgery. Union was achieved for all the metatarsal osteotomies without any angular deformities. Outcomes at the final assessment were excellent in 51 feet (89%) and good in six (11%). This newly described surgical technique provides for painless, comfortable shoe-wearing after a single, easy-to-perform operation with good clinical, radiological and functional outcomes.

Cite this article: Bone Joint J 2013;95-B:929–34.

Paediatric fractures are common and can cause significant morbidity. Socioeconomic deprivation is associated with an increased incidence of fractures in both adults and children, but little is known about the epidemiology of paediatric fractures. In this study we investigated the effect of social deprivation on the epidemiology of paediatric fractures.

We compiled a prospective database of all fractures in children aged < 16 years presenting to the study centre. Demographics, type of fracture, mode of injury and postcode were recorded. Socioeconomic status quintiles were assigned for each child using the Scottish Index for Multiple Deprivation (SIMD).

We found a correlation between increasing deprivation and the incidence of fractures (r = 1.00, p < 0.001). In the most deprived group the incidence was 2420/100 000/yr, which diminished to 1775/100 000/yr in the least deprived group.

The most deprived children were more likely to suffer a fracture as a result of a fall (odds ratio (OR) = 1.5, p < 0.0001), blunt trauma (OR = 1.5, p = 0.026) or a road traffic accident (OR = 2.7, p < 0.0001) than the least deprived.

These findings have important implications for public health and preventative measures.

Cite this article: Bone Joint J 2015;97-B:240–5.

Aims

We report the use of the distal radius and ulna (DRU) classification for the prediction of peak growth (PG) and growth cessation (GC) in 777 patients with idiopathic scoliosis. We compare this classification with other commonly used parameters of maturity.

Objectives

To determine the pattern of mutations of the WISP3 gene in clinically identified progressive pseudorheumatoid dysplasia (PPD) in an Indian population.

A relationship between social deprivation and the incidence of fracture in adolescents has not previously been shown. We have used a complete fracture database to identify adolescents who sustained fractures in 2000. The 2001 Scottish census was used to obtain age-specific population and deprivation data according to the Carstairs score. Regression analysis determined the relationship between the incidence of fractures and social deprivation.

We analysed 1574 adolescents with fractures (1083 male, 491 female). The incidence of fractures in this group was 21.8 per thousand (31.0 male, 13.1 female). Social deprivation predicted the incidence in adolescent males and females. The incidence of fractures of the proximal upper limb and distal radius in females was overwhelmingly influenced by socioeconomic factors. Males of 15 to 20 years of age were more likely to sustain fractures of the hand and carpus if they lived in economically depressed neighbourhoods.

A prospective series of 32 cases with tuberculosis of the hand and wrist is presented. The mean age of the patients was 23.9 years (3 to 65), 12 had bony disease and 20 primarily soft-tissue involvement. The metacarpal of the little finger was the most commonly involved bone. Pain and swelling were the usual presenting features and discharging sinuses were seen in three cases.

All patients were given anti-tubercular chemotherapy with four drugs. Operative treatment in the form of open or arthroscopic debridement, or incision and drainage of abscesses, was performed in those cases where no response was seen after eight weeks of ATT. Hand function was evaluated by the modified score of Green and O’Brien. The mean was 58.3 (25 to 80) before treatment and 90.5 (80 to 95) at the end. The mean follow-up was for 22.4 months (6 to 43). Conservative treatment was successful in 24 patients (75%). Eight who did not respond to chemotherapy within eight weeks required surgery.

Although tuberculosis of hand has a varied presentation, the majority of lesions respond to conservative treatment.

Giant cell tumours (GCTs) of the small bones of the hands and feet are rare. Small case series have been published but there is no consensus about ideal treatment. We performed a systematic review, initially screening 775 titles, and included 12 papers comprising 91 patients with GCT of the small bones of the hands and feet. The rate of recurrence across these publications was found to be 72% (18 of 25) in those treated with isolated curettage, 13% (2 of 15) in those treated with curettage plus adjuvants, 15% (6 of 41) in those treated by resection and 10% (1 of 10) in those treated by amputation.

We then retrospectively analysed 30 patients treated for GCT of the small bones of the hands and feet between 1987 and 2010 in five specialised centres. The primary treatment was curettage in six, curettage with adjuvants (phenol or liquid nitrogen with or without polymethylmethacrylate (PMMA)) in 18 and resection in six. We evaluated the rate of complications and recurrence as well as the factors that influenced their functional outcome.

At a mean follow-up of 7.9 years (2 to 26) the rate of recurrence was 50% (n = 3) in those patients treated with isolated curettage, 22% (n = 4) in those treated with curettage plus adjuvants and 17% (n = 1) in those treated with resection (p = 0.404). The only complication was pain in one patient, which resolved after surgical removal of remnants of PMMA. We could not identify any individual factors associated with a higher rate of complications or recurrence. The mean post-operative Musculoskeletal Tumor Society scores were slightly higher after intra-lesional treatment including isolated curettage and curettage plus adjuvants (29 (20 to 30)) compared with resection (25 (15 to 30)) (p = 0.091). Repeated curettage with adjuvants eventually resulted in the cure for all patients and is therefore a reasonable treatment for both primary and recurrent GCT of the small bones of the hands and feet.

Cite this article: Bone Joint J 2013;95-B:838–45.

The management of children’s fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Cite this article: Bone Joint J 2015; 97-B:442–8.

The December 2014 Oncology Roundup³⁶⁰ looks at: metaphyseal and diaphyseal osteosarcoma subtly different beasts; sports and endoprosthetic reconstruction of the knee; is curettage without tissue diagnosis sensible in cartilaginous tumours?; autoclaved autograft in bone tumour reconstruction; vascularised graft a step too far in bone defects?; interdigitated neoadjuvant chemoradiotherapy in high-grade sarcoma; predicting life expectancy in patients with painful metastasis; and osteolytic lesions of the hands and feet.

In this case report a four-year-old girl with ulnar dimelia is described. She had six digits without mirror symmetry in her right hand. The first pre-axial digit was excised and true pollicisation performed for the second pre-axial digit. The arterial anatomy was abnormal but there was not symmetrical development of the arterial tree.

We hypothesised that the use of pulsed electromagnetic field (PEMF) bone growth stimulation in acute scaphoid fractures would significantly shorten the time to union and reduce the number of nonunions in a randomised, double-blind, placebo-controlled multicentre trial. A total of 102 patients (78 male, 24 female; mean age 35 years (18 to 77)) from five different medical centres with a unilateral undisplaced acute scaphoid fracture were randomly allocated to PEMF (n = 51) or placebo (n = 51) and assessed with regard to functional and radiological outcomes (multiplanar reconstructed CT scans) at 6, 9, 12, 24 and 52 weeks. The overall time to clinical and radiological healing did not differ significantly between the active PEMF group and the placebo group. We concluded that the addition of PEMF bone growth stimulation to the conservative treatment of acute scaphoid fractures does not accelerate bone healing.

Cite this article: Bone Joint J 2014; 96-B:1070–6.

Proximal osteotomies for forefoot deformity in patients with rheumatoid arthritis have hitherto not been described. We evaluated combination joint-preserving surgery involving three different proximal osteotomies for such deformities. A total of 30 patients (39 feet) with a mean age of 55.6 years (45 to 67) underwent combined first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of the second to fourth metatarsals and a fifth-ray osteotomy.

The mean follow-up was 36 months (24 to 68). The mean foot function index scores for pain, disability and activity subscales were 18, 23, and 16 respectively. The mean Japanese Society for Surgery of the Foot score improved significantly from 52.2 (41 to 68) to 89.6 (78 to 97). Post-operatively, 14 patients had forefoot stiffness, but had no disability. Most patients reported highly satisfactory walking ability. Residual deformity and callosities were absent. The mean hallux valgus and intermetatarsal angles decreased from 47.0° (20° to 67°) to 9.0° (2° to 23°) and from 14.1° (9° to 20°) to 4.6° (1° to 10°), respectively. Four patients had further surgery including removal of hardware in three and a fifth-ray osteotomy in one.

With good peri-operative medical management of rheumatoid arthritis, surgical repositioning of the metatarsophalangeal joint by metatarsal shortening and consequent relaxing of surrounding soft tissues can be successful. In early to intermediate stages of the disease, it can be performed in preference to joint-sacrificing procedures.

We carried out a retrospective study to assess the clinical results of lengthening the fourth metatarsal in brachymetatarsia in 153 feet of 106 patients (100 female, six males) using three different surgical techniques. In one group lengthening was performed by one-stage intercalary bone grafting secured by an intramedullary Kirschner-wire (45 feet, 35 patients). In the second group lengthening was obtained gradually using a mini-external fixator after performing an osteotomy with a saw (59 feet, 39 patients) and in the third group lengthening was achieved in a gradual manner using a mini-external fixator after undertaking an osteotomy using osteotome through pre-drilled holes (49 feet, 32 patients). The mean age of the patients was 26.3 years (13 to 48). Pre-operatively, the fourth ray of the bone-graft group was longer than that of other two groups (p < 0.000). The clinical outcome was compared in the three groups. The mean follow-up was 22 months (7 to 55).

At final follow-up, the mean lengthening in the bone-graft group was 13.9 mm (3.5 to 23.0, 27.1%) which was less than that obtained in the saw group with a mean of 17.8 mm (7.0 to 33.0, 29.9%) and in the pre-drilled osteotome group with a mean of 16.8 mm (6.5 to 28.0, 29.4%, p = 0.001). However, the mean time required for retention of the fixation in the bone-graft group was the shortest of the three groups. Patients were dissatisfied with the result for five feet (11.1%) in the bone-graft group, eight (13.6%) in the saw group and none in the pre-drilled osteotomy group (p < 0.000). The saw group included eight feet with failure of bone formation after surgery. Additional operations were performed in 20 feet because of stiffness (n = 7, all groups), failure of bone formation (n = 4, saw group), skin maceration (n = 4, bone-graft group), malunion (n = 4, bone-graft and saw groups) and breakage of the external fixator (n = 1, saw group).

We conclude that the gradual lengthening by distraction osteogenesis after osteotomy using an osteotome produces the most reliable results for the treatment of fourth brachymetatarsia.

Fractures of the proximal interphalangeal joint include a wide spectrum of injuries, from stable avulsion fractures to complex fracture-dislocations. Stability of the joint is paramount in determining the appropriate treatment, which should aim to facilitate early mobilisation and restoration of function.

The use of pulsed electromagnetic fields (PEMF) to stimulate bone growth has been recommended as an alternative to the surgical treatment of ununited scaphoid fractures, but has never been examined in acute fractures. We hypothesised that the use of PEMF in acute scaphoid fractures would accelerate the time to union by 30% in a randomised, double-blind, placebo-controlled, multicentre trial. A total of 53 patients in three different medical centres with a unilateral undisplaced acute scaphoid fracture were randomly assigned to receive either treatment with PEMF (n = 24) or a placebo (n = 29). The clinical and radiological outcomes were assessed at four, six, nine, 12, 24 and 52 weeks.

A log-rank analysis showed that neither time to clinical and radiological union nor the functional outcome differed significantly between the groups. The clinical assessment of union indicated that at six weeks tenderness in the anatomic snuffbox (p = 0.03) as well as tenderness on longitudinal compression of the scaphoid (p = 0.008) differed significantly in favour of the placebo group.

We conclude that stimulation of bone growth by PEMF has no additional value in the conservative treatment of acute scaphoid fractures.

We describe 22 cases of bizarre parosteal osteochondromatous proliferation, or Nora’s lesion. These are surface-based osteocartilaginous lesions typically affecting the hands and feet. All patients were identified from the records of a regional bone tumour unit and were treated between 1985 and 2009. Nine lesions involved the metacarpals, seven the metatarsals, one originated from a sesamoid bone of the foot and five from long bones (radius, ulna, tibia, and femur in two). The mean age of the patients was 31.8 years (6 to 66), with 14 men and eight women. Diagnosis was based on the radiological and histological features. The initial surgical treatment was excision in 21 cases and amputation of a toe in one. The mean follow-up was for 32 months (12 to 162). Recurrence occurred in six patients (27.3%), with a mean time to recurrence of 49 months (10 to 120). Two of the eight patients with complete resection margins developed a recurrence (25.0%), compared with four of 14 with a marginal or incomplete resection (28.6%).

Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.