The evidence for treatment of acute complex radial head fractures with radial head replacement (RHR) predominantly comprises short to mid-term follow-up. This study describes the complications and long-term patient reported outcomes following RHR.

From a single-centre trauma database we retrospectively identified 119 patients over a 16-year period who underwent primary RHR for an acute complex radial head fracture. We reviewed electronic records to document post-operative complications, including prosthesis revision and removal. Patients were contacted to confirm complications and long-term patient reported outcomes. The primary outcome measure was the QuickDash (QD).

The mean age at injury was 50 years (16–94) and 63 (53%) were female. Most implants were uncemented ‘loose-fit’ monopolar prostheses; 86% (n=102) were metallic and 14% (n=17) silastic. Thirty patients (25%) required revision surgery (n=3) or prosthesis removal (n=27). Five patients underwent arthrolysis and there were four cases of infection. In the long-term, 80% (80/100; 19 deceased) were contacted at a mean of 12 years (7.5–23.5). The median QD was 6.8 (IQR, 16.8), the median EQ-5D was 0.8 (IQR, 0.6) and the median Oxford Elbow Score was 46 (IQR, 7). Overall satisfaction was high with a mean of 9.4/10 (2–10). There was no significant difference in any outcome measure for those patients requiring revision or removal surgery (all p>0.05).

This is the largest series in the literature documenting the long-term patient reported outcome after RHR. Despite a quarter of patients requiring further surgery, RHR is supported by positive long-term results for the treatment of complex radial head fractures.

The aim of this study was to identify psychosocial factors associated with pain intensity and disability following distal radius fracture (DRF).

We prospectively followed up 216 adult patients with DRF for 9 months. Demographics, injury and treatment details and psychological measures (Hospital Anxiety and Depression Score (HADS), Pain Catastrophising Scale (PCS), Post Traumatic Stress Disorder Checklist – Civilian (PCL-C), Tampa Scale for Kinesiophobia (TSK), Illness Perception Questionnaire Brief (IPQB), General Self-efficacy Scale (GSES) and Recovery Locus of Control (RLOC)) were collected at enrolment. Multivariable linear regression was used to identify factors associated with DASH and Likert pain score.

Ten week DASH was associated with age (β-coefficient (β)= 0.3, p < 0.001), deprivation score (β=0.2, p = 0.014), nerve injury (β=0.1, p = 0.014), HADS depression (β=0.2, p = 0.008), IPQB (β=0.2, p = 0.001) and RLOC (β= −0.1, p = 0.031). Nine month DASH was associated with age (β=0.1, p = 0.04), deprivation score (β=0.4, p = 0.014), number of medical comorbidities (β=0.1, p = 0.034), radial shortening (β=0.1, p = 0.035), HADS depression (β=0.2, p = 0.015) and RLOC (β= −0.1, p = 0.027). Ten week pain score was associated with deprivation score (β=0.1, p = 0.049) and IPQB (β=0.3, p < 0.001). Pain score at 9 months was associated with number of medical comorbidities (β=0.1, p = 0.047).

Psychosocial factors are more strongly associated with pain and disability than injury or treatment characteristics after DRF. Identifying and treating these factors could enhance recovery.

The aim of this prospective randomized controlled trial was to compare patient reported and functional outcomes, complications and costs for displaced olecranon fractures managed with either tension band wire (TBW) or plate fixation. We performed a registered prospective randomized, single blind, single centre trial in 67 patients aged between 16–74 years with an acute isolated displaced fracture of the olecranon. Patients were randomised to either TBW (n=34) or plate fixation (n=33). The primary outcome measure was the Disability Arm Shoulder and Hand (DASH) score at one-year.

The baseline demographic and fracture characteristics of the two groups were overall comparable. The one-year follow-up was 85percnt;. There was a significant improvement in elbow function over the 12 months following injury in both groups (p<0.001). At one-year following surgery the DASH for the TBW group was not statistically different to the plate fixation group (12.8 vs 8.5; p=0.315). There was no significant difference between groups in terms of range of movement, Broberg and Morrey Score, Mayo Elbow Score or the DASH at all assessment points over the one-year following injury (all p≥0.05). Complication rates were significantly higher in the TBW group (63percnt;vs38percnt;; p=0.042), predominantly due to a significantly higher rate of symptomatic metalwork removal (50percnt;vs22percnt;; p=0.021).

In active patients with an isolated displaced fracture of the olecranon, no difference was found in the patient reported outcome between TBW and plate fixation at one year following surgery. The complication rate is higher following TBW fixation due to a high rate of symptomatic metalwork removal.

We have previously reported that fibular nailing in the elderly is associated with a significantly reduced complication rate and greater cost-effectiveness when compared to ORIF. The aim of this study was to compare the outcomes of fibular nailing to ORIF in patients under the age of 65.

100 patients aged 18 to 64 were randomly allocated between groups. Outcomes assessed over two years post-operatively included: development of wound complications or radiographic arthritis, the accuracy of reduction and patient satisfaction. The mean age was 44, 25% of patients were smokers and 35% had some form of comorbidity of whom three were diabetic. 27 injuries occurred after sport and two after assault the remainder occurred after a simple fall from a standing height.

Superficial wound infections occurred in two patients in each group. Six patients requested removal of the nail, and six patients requested plate and screw removal. Patient reported outcome scores were comparable for the two groups. Two failures of fixation occurred in the fibular nail group; one in a patient with neuropathy. One failure of fixation occurred in the ORIF group. All other patients went on to an anatomical union without complication. Patient satisfaction with the surgical scar was higher after fibular nailing (visual analogue scale mean 0.75, range 0–5) than for ORIF (mean 1.5, range 0–7).

The fibular nail allows accurate reduction and secure fixation of ankle fractures with comparable radiographic and patient-reported outcomes to ORIF at two years and a greater patient satisfaction with the appearance of the surgical scars.

The aim of this study was to report the outcome of radial head replacement for complex fractures of the radial head, and determine any risk factors for prosthesis removal or revision. We identified 119 patients who were managed acutely using primary radial head replacement for an unstable fracture of the radial head over a 15-year period. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded following retrospective clinical record review.

There were 105 (88%) patients with a mean age of 50 yrs (16–93) and 54% (n=57) were female. There were 95 (91%) radial head fractures and 96% were a Mason type 3 or 4 injury. There were 98 associated injuries in 70 patients (67%), with an associated coronoid fracture (n=29, 28%) most frequent. All implants were uncemented monopolar prostheses, with 86% metallic and 14% silastic. At a mean short-term follow-up of 1 year (range, 0.1–5.5; n=87) the mean Broberg and Morrey score was 80 (range, 40–99), with 49.5% achieving an excellent or good outcome. At a final mean review of 6.7 yrs (1.8–17.8), 29 (27%) patients had undergone revision (n=3) or removal (n=26) of the prosthesis. Independent risk factors of prosthesis removal or revision were silastic implant type (p=0.010) and younger age (p=0.015).

This is the largest series in the literature documenting the outcome following radial head replacement for complex fractures of the radial head. We have demonstrated a high rate of removal or revision for all implants, with younger patients and silastic implants independent risk factors.

The aim of this study was to document both the short and long term outcome of isolated displaced olecranon fractures treated with primary non-operative intervention. We identified from our prospective trauma database all patients who were managed non-operatively for a displaced olecranon fracture over a 13-year period. Inclusion criteria included all isolated fractures of the olecranon with >2 mm displacement of the articular surface. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded. The primary short-term outcome measure was the Broberg and Morrey Elbow score. The primary long-term outcome measure was the DASH score.

There were 43 patients in the study cohort with a mean age of 76 yrs (40–98). A low energy fall from standing height accounted for 84% of all injuries, with ≥1 co-morbidities documented in 38 (88%) patients. At a mean of 4 months (range, 1.5–10) following injury the mean Broberg and Morrey score was 83 (48–100), with 72% achieving an excellent or good short-term outcome. Long-term follow-up was available in 53% (n=21) patients, with the remainder deceased. At a mean of six years (2–15) post injury, the mean DASH score was 2.9 (0–33.9), the mean Oxford Elbow Score was 47 (42–48) and overall patient satisfaction was 91% (n=21).

We have reported satisfactory short-term and longer-term outcomes following the non-operative management of isolated displaced olecranon fractures in older lower demand patients. Further work is needed to directly compare operative and non-operative management in this patient group.

Open reduction and internal fixation (ORIF) of ankle fractures is associated with well known complications including wound dehiscence and infection, construct failure and symptomatic metalwork. A technique of intramedullary fibular nailing has been developed that requires only minimal incisions, is biomechanically stronger than ORIF and has low-profile hardware. We hypothesized that fibular nailing would result in a rate of reduction and union comparable to ORIF, with a reduced rate of wound and hardware problems.

100 patients over the age of 65 years with unstable ankle fractures requiring fixation were randomised to undergo fibular nailing or ORIF. Outcome measures assessed over the 12 postoperative months were wound complications, accuracy of reduction, Olerud and Molander score (OMS), and total cost of treatment.

The mean age was 74 years (range 65–93) and 75 patients were women, all had some form of comorbidity. Significantly fewer wound infections occurred in the fibular nail group (p=0.002). Eight patients (16%) in the ORIF group developed lateral-sided wound infections, two of these developed a wound dehiscence requiring further surgical intervention. No infections or wound problems occurred in the fibular nail group and at 1 year patients were significantly happier with the condition of their scar (p=0.02), and had slightly better OMS scores (p=ns). The overall cost of treatment in the fibular nail group was less despite the higher initial cost of the implant.

The fibular nail allows accurate reduction and secure fixation of ankle fractures with a significantly reduced rate of soft-tissue complications when compared with ORIF.

A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports.

A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted. Demographic data were recorded prospectively for each patient with an acute clavicle fractures including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson system.

A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. More than half of simple fall fractures affected the lateral clavicle. The incidence of clavicle fractures has risen over a twenty year period, and a greater proportion of older adults are now affected. Overall, type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing.

We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region.

There are limited recent epidemiological data pertaining to the patterns of skeletal injury around the knee joint in adult patients. Data on fractures of the distal femur, proximal tibia and patella have been individually reported. We aimed to describe the collective epidemiological characteristics of all fractures around the knee.

We conducted a retrospective analysis of a prospectively collected fracture database from an institution serving 545,000 adults. The demographic and injury details for all patients suffering fractures of the distal femur, proximal tibia and patella were analysed. Fractures were classified according to the AO (distal femur, patella) and Schatzker (proximal tibia) systems.

A total of 173 fractures occurred in 170 patients (60% women), representing 6.7% of all lower limb fractures. There were 36 distal femoral fractures, 82 proximal tibial fractures (metaphyseal, plateau or bony avulsions) and 55 patella fractures.

Each fracture type displayed distinct epidemiological characteristics. Injuries of the distal femur occurred in older women. A proportion of tibial plateau fractures occurred in young men following high-energy trauma, but a greater number were encountered by older men and women following low-energy injury. The majority of fractures around the knee were caused by a simple fall from standing, followed by road traffic accidents, and falls from height.

When compared with historical data from our unit, the incidence of fractures around the knee has increased. The median age of affected patients has also risen, and this is particularly true for fractures of the distal femur and tibial plateau.

The epidemiological characteristics of fractures around the knee joint in our adult population are presented. Low-energy trauma in the elderly is likely to constitute an increasing proportion of knee injuries in the future, and this has implications for the provision of trauma services in our region.

Lateral malleolar plating is associated with complication rates of up to 30%. The fibular nail is an alternative fixation technique, requiring a minimal incision and tissue dissection, with the potential to reduce the incidence of complications. We reviewed our results of 105 unstable ankle fractures fixed with the Acumed fibular nail between 2002 and 2010. The mean age was 65 years and 72% of patients had significant systemic medical comorbidities.

A number of different locking screw configurations were assessed over the study period. A proximal blocking screw resulted in satisfactory stability in 93%, single locking screws in 86%, but nailing without locking in only 66%, leading to the development of our current technique. Of the twenty-one patients treated with this technique there have been no significant complications, and only two superficial wound infections. Good fracture reduction was achieved in all of these patients. The mean physical component SF12, Olerud and Molander and Foot and Ankle Outcome scores were 46, 65 and 83 respectively.

The outcomes of unstable ankle fractures managed with the fibular nail are encouraging, with good radiographic and functional outcomes and minimal complications. This technique should be considered in the management of debilitated patients with unstable ankle fractures.

The relationship between advancing patient age, decreasing bone mineral density and increasing distal radial fracture incidence is well established. Biomechanical and clinical work has shown that the radiographic severity of distal radial fractures is greater in patients with poor bone quality. Between 1991 and 2007, the number of elderly Scots (aged 75 years or more) increased by 18%, and population projections predict a further 82% increase by 2035. This study was conducted to investigate the effect of recent changes in the demographics of our population on the pattern and radiographic severity of distal radial fractures encountered at our institution.

The epidemiology of two distinct series of patients (1991–93; 2007–08) suffering distal radial fractures was compared. The patient and radiographic fracture characteristics known to be predictive of fracture instability and severity were compared using the MacKenney formulae, and a subgroup analysis of distal radial fragility fractures was performed.

The life expectancy of our catchment population has improved since 1991, and we have encountered a larger number of distal radial fractures occurring in older, more active and functionally independent patients. We identified an increase in the proportion of AO type B fractures, particularly in the oldest patient groups. The radiographic severity of distal radial fractures, especially low energy metaphyseal injuries, has increased.

If the current trend in population demographics continues, it seems likely that orthopaedic surgeons will encounter an increasing number of severe distal radial fractures deemed unsuitable for treatment by closed methods.

The aim of this study was to document our experience of acute forearm compartment syndrome, and to determine the risk factors for requiring split skin grafting (SSG) and developing complications post fasciotomy. We identified from our trauma database all patients who underwent fasciotomy for an acute forearm compartment syndrome over a 22-year period. Diagnosis was made using clinical signs and/or compartment pressure monitoring. Demographic data, aetiology, management, wound closure, complications and subsequent surgeries were recorded. Outcome measures were the use of SSG and the development of complications following forearm fasciotomy.

90 patients were identified with a mean age of 33 yrs (range, 13–81 yrs) and a significant male predominance (n=82, p<0.001). A fracture of one or both of the forearm bones was seen in 62 (69%) patients, with soft tissue injuries causative in 28 (31%). The median time to fasciotomy was 12hrs (2–72). Delayed wound closure was achieved in 38 (42%) patients, with 52 (58%) undergoing SSG. Risk factors for requiring a SSG were younger age and a crush injury (both p<0.05). Complications occurred in 29 (32%) patients at mean follow-up of 11 (3–60) months. Risk factors for developing complications were a delay in fasciotomy of >6 hrs (p=0.018), with pre-operative motor symptoms approaching significance (p=0.068).

Forearm compartment syndrome requiring fasciotomy predominantly affects males and can occur following either a fracture or soft tissue injury. Age is an important predictor of undergoing SSG for wound closure. Complications occur in a third of patients and are associated with an increasing delay in the time to fasciotomy.

Techniques for fixation of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities.

Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and AAOS Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

Distal radius fractures are common, yet the long-term functional outcome of these patients is unknown. This study investigated the long-term functional outcomes after distal radius fracture (DRF) in adult patients 16–23 years following injury. Secondary aims were to establish morbidity, mortality and function related to pattern of injury and patient demographics.

Background

A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures.

This study describes the long term clinical and patient reported outcomes following simple dislocation of the elbow.

We identified all adult patients treated at our trauma centre for a simple dislocation of the elbow over 10 years. 140 patients were identified and 110 (79%) patients were reviewed at a mean of 88 (95% CI 80–96) months after injury. This included clinical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, an Oxford Elbow questionnaire and a patient satisfaction questionnaire.

Patients reported long-term residual deficits in range of movement. The mean DASH score was 6.5 (95% CI 4 to 9). The mean Oxford Elbow score was 43.5 (95% CI 42.2 to 44.8). The mean satisfaction score was 85.6 (95% CI 82.2 to 89). Sixty-two patients (56%) reported persistent subjective stiffness of the elbow. Nine (8%) reported subjective instability and 68 (62%) complained of continued pain. The DASH, Oxford Elbow and satisfaction scores all showed good correlation with absolute range of movement in the injured elbow. After multivariate analysis, a larger elbow flexion contracture and female gender were both independent predictors of worse DASH scores. Poorer Oxford Elbow scores and overall satisfaction ratings were predicted by reduced flexion-extension arc of movement.

Patients report good long term functional outcomes after simple dislocations of the elbow. These are not entirely benign injuries. There is a high rate of residual pain and stiffness. Functional instability is less common and does not often limit activities.

Introduction

This study investigates the epidemiology of proximal radial fractures and potential links to social deprivation.

Introduction

The optimal treatment of elderly patients with unstable ankle fractures is a widely contested and as yet unresolved issue. Whereas the AO technique of anatomical reduction and plate fixation has been shown to give good functional results it is associated with a wound complication rate of up to 40%. This has led some surgeons to believe the risks of operative intervention are too great.

The fibula nail is an intra-medullary device with the benefit of requiring minimal soft-tissue dissection. It provides lateral column support over a greater area than the standard plate.

The study aims were to assess the clinical and radiographic outcome of a cohort of patients managed with the Fibula Nail (Acumed).

Aim: To investigate factors that influence outcomes one year after distal radial fractures To investigate how deformity (radiologically), functional outcome and patient satisfaction affect one another.

Background: Identifying the factors that influence outcome in DRF is important in anticipating and treating patients with potentially correctable factors that may affect recovery. Previous studies have looked at different sub-sets of the DRF group most often with patient reported outcomes. We have reviewed a large consecutive group of DRF looking at which factors influenced the outcomes.

Methods: Data on 640 distal radial fractures was prospectively recorded over a 24 month period. The database was reviewed and validated. Mechanism of injury, hand dominance and occupation were noted. Initial, post reduction, one week, 6 week and one year x-rays were taken. The volar and dorsal shortening, tilt and angulation were recorded. Any operative intervention or complication was noted.

At one year follow up functional testing was performed including range of movement. This tested for grip strength, multiple postional strengths and a functional score looking at activities of daily living.

Results: Prediction of functional outcome was significantly associated with age, volar communition, dorsal angulation and pain. The grip strength after a distal radial fracture is significantly stronger in dominant side fractures compared with non dominant, in younger patients and those without dorsal communition.

We also showed that fractures that are most likely to malunite show a significantly poorer functional outcome and weaker grip strength.

Conclusion: This study identifies factors that predict the functional outcome in Distal Radial fractures. Although many assumptions are made that certain fractures lead to poorer results this has rarely been shown in such a large, diverse group of DRFs.

In an age where patients and practitioners strive to ever increasing levels of knowledge this study allows us to counsel patients in their likely functional outcomes more accurately.

Introduction: We present the world’s largest current series of open distal radial fractures (ODRF), aiming to describe the epidemiology and outcomes of these injuries.

Methods: Patients with ODRF treated at the Edinburgh Orthopaedic Trauma unit between 1990 and 2009 were identified from computer records. All patients aged over 13 with juxta-articular and metaphyseal fractures were included – diaphyseal injuries were excluded. The following information was retrieved from notes and radiographs: patient demographics; co-morbidities; mechanism of injury; AO classification; other injuries; time to A& E treatment; time until surgery; antibiotic use; Gustillo and Anderson (GA) grade; surgical treatment; complications; further surgery; functional outcome.

Results: 201 patients were included. The average age was 65.5 years, 75% were female. 69% resulted from simple falls, 15% falls from height, 6% sporting injuries and 9% from road traffic accidents. 73 % were GA-1, 26% were GA-2, 1% GA-3. The commonest fracture pattern was AO 23-C2. 41% underwent definitive debridement within 6 hours, 46% in 6 to 24 hours, 13% waited longer. 30% were treated by ORIF, 38% with non-bridging fixator, 29% by bridging fixator and 3% by MUA and plaster. 43% of wounds were closed primarily, 47% were left open, 8% required delayed closure, 2% required skin grafting. Follow-up averaged 16.5 weeks. 14% suffered superficial infections, 1.3% suffered deep infection. Predictors of infection included primary closure and the use of an external fixator. Functional outcome was variable.

Discussion: Most open distal radial fractures occur in elderly women after a simple fall. Serious infection rates are low.

The purpose of this prospective study was to determine the predictive factors and hence optimal management of closed uncomplicated proximal radial fractures. We examined all patients presenting to our unit over an 18-month period with isolated closed proximal radial fractures. 237 consecutive patients were included. Demographic data, physical examination, radiographs, treatment and complications were recorded. Patients were reviewed at 2, 6, 12, 26 and 52 weeks post injury. Outcome was determined via functional assessment and Mayo Elbow Score (MES). Data were analysed using SPSS.

There were 156 (66%) radial head fractures and 81 (34%) radial neck fractures. 225 (95%) patients were treated non-operatively in a collar and cuff for one week followed by physiotherapy. 12 (5%) patients required primary surgical intervention due to either a mechanical block to forearm rotation (n=4) or a significant degree of radiographic comminution and/or displacement (n=8). Of the 201 patients who attended follow-up, 183 (91%) patients achieved excellent or good functional results measured on the MES. 155 (78%) patients achieved this by six weeks, with an average flexion arc of 125 degrees. Of the 12 patients treated operatively, the average MES at six weeks was fair (60). Regression analysis showed that increasing age, the AO-OTA fracture classification (B2.3, C2.3), radiographic displacement and operative treatment were significant predictors of a fair or poor outcome at six weeks.

The majority of isolated proximal radial fractures can be treated non-operatively with early mobilization, achieving excellent or good results within 6 weeks. Age, fracture classification, radiographic displacement and treatment choice are important factors that determine speed of recovery.

Purpose: External fixation is a popular treatment method of unstable distal radius fractures. There has been much debate and confusion however regarding the use of bridging versus non-bridging fixation. The aim of this study is to define the indications for bridging and non-bridging external fixation in the treatment of unstable distal radius fractures. The study also endeavours to evaluate the complications and pitfalls associated with this treatment and to determine if non-expert surgeons can reproduce successful outcomes.

Methods: Between January 1995 and December 2000, 641 patients with fractures of the distal radius were treated at our institution with external fixation. The fractures were treated either by bridging or non-bridging external fixation. Demographic data was collected prospectively for these patients including their hospital number, date of birth, gender, age at injury, mode of injury, type of external fixator and whether the fracture was an open or closed injury. Further information was collected retrospectively from review of case notes and x-rays and included AO classification, status of the operating surgeon, duration of fixation, and complications.

Results: Patients treated with bridging external fixation had significantly more mal unions in terms of dorsal angulation and shortening. The non-bridging fixators were better able to maintain and in some cases improve on the immediate post external fixation measurements. Minor pin tract infections were more common in the non-bridging group.

Conclusions: Non-bridging external fixation is the treatment of choice for unstable fractures of the distal radius with sufficient space for the placement of pins in the distal fragment. A predictable outcome with low complication rate can be expected.

Distal radial fractures account for 17% of all fractures treated, with peaks in the bimodal distribution corresponding to young and senior patients. External fixation is one of the best techniques to allow quick patient recovery and is necessary for complex fractures, such as that of the distal radius. However, the safe removal time for these frames remains unclear. A conservative approach commonly leaves the external fixator in place for six weeks, which may be unnecessarily prolonged and lead to increased complications. The aim of this work is to develop a technique to quantify, objectively, a safe removal time for these frames. Studies have been conducted on external fixation of tibial fractures, however there are differences that do not allow transfer of these studies to the external fixation of distal radial fractures. These differences include configuration of the fixation frame, bone and fracture geometries, and the application and transfer of the load to the bone. In this work, the dynamic transfer of the load between the fractured bone and the fixator is investigated. An instrumented grip and a measuring device have been developed to monitor the axial force and displacement when the patient applies a load. Using measurements collected by the instrument and data specifying the frame geometry, a finite element model is used to calculate the load carried by the fixator and by the bone, and the rigidity of the new callus is determined. Plotting the rigidity on semi-logarithmic scale the healing rate can be established. This technique has been successfully verified in a laboratory simplified structure representative of bone fracture. The rigidity of several intra-gap materials has been estimated experimentally using the technique, and the results compared to the real value of the material. These measurements do not interfere in any way with the patient treatment and they can be collected from the first day after the operation. The technique has been tested on 14 volunteer patients and the increase in callus rigidity can be detected by measurements during treatment using the technique described. A randomised prospective study has been initiated to validate this technique and investigate the healing process. A positive outcome would enable the rigidity of the new callus bone and the healing rate to be monitored during clinical assessment. Any healing delay or non-union could be promptly detected, improving the quality of the treatment.

The detection and treatment of acute compartment syndrome following trauma is critical if contractures, delayed fracture healing and possible amputations are to be avoided. The current standard for monitoring relies on invasive compartment pressure measurements. These require an additional procedure and cause discomfort to the patient. This prospective clinical study investigates the relationship between the intra-compartmental pressure and soft tissue oxygenation (%StO₂) measured non-invasively by near-infrared spectroscopy (NIRS) in patients at risk of acute compartment syndrome.

Adults with acute tibial or radial diaphyseal fractures were recruited on admission to the orthopaedic trauma unit. Non-invasive and invasive monitoring over anterior tibial or volar forearm compartments was carried out from admission and continued post-operatively. The differential pressure (ΔDP) was calculated as the compartment pressure subtracted from the diastolic blood pressure. The threshold for fasciotomy was a ΔDP < 30mmHg. StO₂ values were simultaneously recorded from the contralateral (uninjured) limb at the same site. All patients had the difference between the StO₂ value on the injured and uninjured sides calculated (‘StO₂ difference’).

Sixty patients with tibial fractures and 5 patients with forearm fractures were recruited. The mean age was 39 years (S.D.18 years). Fourteen patients underwent a four-compartment lower leg fasciotomy determined by a ΔDP < 30mmHg.

We have observed that the difference in StO₂ between limbs (measured non-invasively) was significantly lower in patients undergoing a fasciotomy. This suggests that NIRS is able to detect a change in oxygenation of the soft tissues in trauma patients developing an acute compartment syndrome. We are optimistic that near-infrared spectroscopy (NIRS) will be a reliable new non-invasive technique for detection of an acute compartment syndrome.

We reviewed the results of the treatment of 30 tibial fractures with minor to severe bone loss in 29 patients by early soft-tissue and bony debridement followed by primary locked intramedullary nailing. Subsequent definitive closure was obtained within the first 48 hours usually with a soft-tissue flap, and followed by bone-grafting procedures which were delayed for six to eight weeks after the primary surgery. The time to fracture union and the eventual functional outcome were related to the severity and extent of bone loss. Twenty-nine fractures were soundly united at a mean of 53.4 weeks, with delayed amputation in only one patient. Poor functional outcome and the occurrence of complications were usually due to a departure from the standard protocol for primary management. We conclude that the protocol produces satisfactory results in the management of these difficult fractures, and that intramedullary nailing offers considerable practical advantages over other methods of primary bone stabilisation.

We describe a new technique for open reduction, bone grafting and fixation with a single Kirschner wire of unstable fractures of the distal radius. Of the 83 patients treated by this technique, most had regained volar tilt when seen at an average of 13 months after injury. Malunion was seen in 18 patients due either to poor placement of the graft and Kirschner wire or because of both volar and dorsal comminution. Assessment of hand and wrist function showed an average recovery of 63% of mass grip strength with an excellent return of specialised grip strength and range of movement. The advantages of this technique over closed methods include the ability to regain the volar tilt of the distal radius and to achieve reduction at any time before union of the fracture.

Exchange nailing for failure of union after primary intramedullary nailing of the tibia is widely used but the indications and effectiveness have not been reported in detail. We have reviewed 33 cases of uninfected nonunion of the tibia treated by exchange nailing. This technique was successful without open bone grafting in all closed fractures and in open fractures of Gustilo types I, II and IIIa. The requirement for open bone grafting was reduced in type-IIIb fractures, but exchange nailing failed in type-IIIb fractures with significant bone loss. For these we recommend early open bone grafting. The most common complication was wound infection, seen more often than after primary nailing. We discuss our protocol for the use and timing of exchange nailing of all grades and types of tibial fracture.

We reviewed a series of 79 distal radial fractures with volar displacement which had been fixed internally using a buttress plate. The fractures were classified using the Frykman and AO systems; 59% were intraarticular. Complications occurred in 40.5% of cases; malunion was most frequent (28%). Functional recovery in patients with malunion was significantly worse than in those with good anatomical restoration (p < 0.001). The AO and Frykman classifications and the degree of restoration of volar tilt were predictive of outcome.

In two hospitals, 115 consecutive open femoral shaft fractures were treated by meticulous wound excision and early locked (97) or unlocked (18) intramedullary nailing. All the fractures united; union was delayed in four, three of which required bone grafting. The average range of knee flexion at follow-up was 134 degrees (60 to 148). Five patients had a final range of less than 120 degrees, but three of these improved after manipulation under general anaesthesia. Three patients developed staphylococcal infections and required further surgical treatment. All eventually healed.

There is concern about the incidence and serious nature of infection after intramedullary nailing of the tibia, especially for open injuries. We have reviewed 459 patients with tibial fractures treated by primary reamed nailing. The incidence of infection was 1.8% in closed and Gustilo type I open fractures, 3.8% in type II, and 9.5% in type III fractures (5.5% in type IIIa, 12.5% in type IIIb). These incidences appear to be acceptable in comparison with other published results. We describe the different modes of presentation of infection in these cases, and suggest a protocol for its management, which has been generally successful in our series.

We report the results of locked Seidel nailing for 30 fractures of the humerus. There were frequent technical difficulties at operation especially with the locking mechanisms. Protrusion of the nail above the greater tuberosity occurred in 12 cases, usually due to inadequate locking, and resulted in shoulder pain and poor function. Poor shoulder function was also seen in five patients with no nail protrusion, presumably because of local rotator cuff damage during insertion. Our results suggest that considerable modifications are required to the nail, and possibly to its site of insertion, before its use can be advocated.

We report the use of Grosse-Kempf reamed intramedullary nailing in the treatment of 41 Gustilo type II and III open tibial fractures. The union times and infection rates were similar to those previously reported for similar fractures treated by external skeletal fixation, but the incidence of malunion was less and fewer required bone grafting. The role of exchange nailing is discussed and a treatment protocol is presented for the management of delayed union and nonunion.

An analysis of 51 type III open tibial fractures treated by external skeletal fixation is presented. The fractures are subdivided according to the classification of Gustilo, Mendoza and Williams (1984) into types IIIa, IIIb and IIIc. The different prognoses of these fracture subtypes is examined. The use of the Hoffmann and Hughes external fixators in the management of type III open tibial fractures is presented and it is suggested that the prognosis is independent of the type of fixator used.

We present the results of using the Grosse-Kempf interlocking nail in the management of 125 closed and type I open tibial fractures. The mean time to union was 16.7 weeks and no fracture required bone grafting. Mobilisation of the patient and the range of joint movement were better than with other methods of treating tibial fractures. There was a 1.6% incidence of infection; 40.8% of patients had knee pain and 26.4% needed to have the nail removed. Other complaints were minor. We suggest that closed intramedullary nailing with an interlocking nail system is an excellent method of treating closed and type I open tibial fractures.

Intracompartmental pressures of 66 patients with 67 tibial fractures treated by intramedullary nailing were monitored. There was no difference in the pressures recorded between the different Tscherne fracture types, between open and closed fractures, between low energy and high energy injuries or between fractures dealt with early and those not treated until more than 24 hours after injury. The overall incidence of acute compartment syndrome was 1.5%. No patient developed any sequelae of compartment syndrome. We conclude that intramedullary nailing does not increase the incidence of acute compartment syndrome in tibial fractures and that delay does not reduce the risk of raised compartment pressures.

Thirty patients who had sustained a Colles' fracture at least four years previously were examined functionally and radiographically. Seventeen had a good radiological result and 13 were considered to have malunion. Functionally the displaced group performed significantly worse than the undisplaced group. We conclude that malunion of a Colles' fracture results in a weak, deformed, stiff and probably painful wrist.

Three cases are reported in which an osteosarcoma developed in relation to an enchondroma in a long bone. Two of the cases were in the proximal femur whilst one occurred in the proximal humerus, both recognised sites for old calcified enchondromas or "cartilage rests". The ages of the patients at presentation were 55, 63 and 84 years and all were women. Two patients died with pulmonary metastases within six months of the onset of clinical symptoms. Despite their intimate relationship to the enchondromas, none of the osteosarcomas could be shown histologically to have arisen from tumour cartilage. It appears probable that these are cases in which independently arising tumours have merged to form a so-called "collision" tumour, but the possibility that they could have been derived by dedifferentiation of a previously benign neoplasm cannot be discounted.

The value of remanipulating a Colles' fracture which has redisplaced after primary reduction was assessed in 50 patients. In those over 60 years old, remanipulation failed to achieve a lasting improvement in position, while the majority of those under 60 years maintained a significant improvement in dorsal angulation. It is concluded that the elderly patient does not benefit from this procedure.

A method of stabilising spondylolisthesis using Dwyer instrumentation is described and the results in seven patients are presented. The operation is straightforward, has few complications and also succeeds in reducing the angle of slip.

Two cases of aneurysmal bone cyst in the pelvis which healed spontaneously are described. Spontaneous regression of aneurysmal bone cysts has not previously been well documented. Our experience with these two cases suggests that radical intervention is not always necessary.