Introduction: Noncontiguous fractures of the tibial diaphysis and ipsilateral ankle is an uncommon entity. The aim of this study is to highlight the unique fracture pattern with emphasis on the necessity for surgical treatment. Material: There were 17 patients with an average age of 42 years, who sustained ipsilateral, noncontiguous fractures of the tibia and ankle. All but two fractures were closed. The level of the tibia fracture included midshaft (two), middle-distal third (ten), distal third (five). Eleven ankle fractures were classified as Weber B, five as Weber C and one Pilon. Two fractures were treated by cast immobilization, eleven with internal fixation of both fractures and four with a combination of internal and external fixation. Seven fractures were treated initially in long leg casts, but each required surgical intervention to control fracture alignment. Results: The average follow up was twenty-three months. The non-operatively treated fractures resulted in a malunion and decreased ankle mobility. Of the cases managed operatively, nine had complete structural and functional recovery; two patients regained 70% of ankle mobility and one developed post-traumatic ankle arthritis. Discussion: The resulted experience from the treatment of these injuries showed their extremely unstable nature. It has been our experience that the nature of the forces acting upon the fragments usually underestimated since reduction of one fracture displaces the other. Furthermore if acceptable reduction is achieved by closed means, progressive slippage of the fragments occurs. We believe that stable fixation of both fractures should be the treatment of choice

Aims: This is a retrospective study, comparing prosthesis survivorship, complications and functional results in geriatric patients treated with different types of prosthetic replacement for subcapital fractures of the hip. Methods: In the years 1985–1999, 292 elderly (aged 65–80 years) patients with displaced, nonpathologic sub-capital hip fractures were operated on. Of those, 143 were lost to follow-up; therefore, prospectively collected data of 149 patients were retrospectively reviewed. 54 patients received a unipolar, 48 a bipolar prosthesis and 47 underwent a primary total hip arthroplasty (THA). Mean follow-up was 5.3 years. The patients did not differ in pre-injury characteristics. Analysis of variance was used to compare the three patient groups in terms of early and late complications, need for revision surgery, and functional outcome. Results: A statistically signiþ-cant difference was noted, regarding need for revision surgery, since 5 (9.25%) of the unipolar and 5 (10.4%) of the bipolar prostheses had to be re-operated, compared to 2 (4.25%) from the THA group. Of note, 4 of the revised bipolar prostheses had loose stems. The THA group also proved superior, when recovery of instrumental activities was investigated. Conclusions: Elderly patients, whose biologic age poses high functional demands on them, with a displaced subcapital hip fracture, should receive a total hip arthroplasty. Stem loosening seems more likely, as a mode of failure, in bipolar prostheses, than acetabular erosion.

Introduction: Primary surgical treatment has been recommended for unstable clavicular fractures if consequences of non-union or malunion have to be avoided. A prospective study was undertaken to evaluate the results of a conservative treatment of very unstable fractures of the middle third of the clavicle, with emphasis to very early mobilization. Material: Patients to be included in the study had to met the following criteria: 1) Fractures of the middle third of the clavicle, severely displaced or comminuted, 2) Closed injuries, 3) No neurovascular complications, 4) No pneumothorax or hae-mothorax and 5) No other injury in the ipsilateral upper extremity. Twenty-three patients with an average age of 24 years included in the study. Each patient evaluated with AP and 45-degree cephalad-tilted views. All patients treated with an arm sling and strongly instructed for early mobilization. All patients were evaluated in a weekly interval and assessed with the American Shoulder and Elbow Surgeonñs shoulder evaluation form. Results: The average follow up was 21.4 months. All fractures were consolidated and all malunited; but no patient had residual symptoms or functional impairment of the limb. On patient developed mild hypesthesia in the ulnar nerve territory. Conclusion: The extremely encouraging results of our study, within the bounds of the above-mentioned follow up, indicate that conservative treatment with very early mobilization may be considered as a valid therapy. However it is a concern the functional result in a longer follow up as well as the cosmetic result.

We reviewed 40 patients who underwent V-Y skin flap reconstruction following distal fingertip skin loss.Of the patients 35 were males and 5 females with an average age of 35 years at operation.Surgery was performed as an emergency in all patients.In all cases a single digit was involved.The majority of the injuries were transverse amputations.Mean advancement of the flap was 12 mm.At the follow-up evaluation (mean 2 years),8 patients complained of pain (2 with functional impairment),15 complained of cold intolerance,and 5 had nail deformities.Sensibility of advanced skin was normal in 28 cases,while two-point discrimination averaged 7 mm.This discrimination was virtually identical to contralatertal digits in 25 of the cases.Overall 28 patients were satisfied with their results,while the rest of them were mildly displeased,either with the functional impairment or with the appearance of the involved digits.

Instability of the thumb trapeziometacarpal joint is a major factor in the cause of degenerative disease. Surgically stabilized joint should be subject to less shear forces and hence, will be less likely to develop degenerative changes. The results of volar ligament reconstruction were assessed in 12 patients (8 men- 4 women). The average age at surgery was 35 years. All thumbs were radiographic stage I. All had failed conservative treatment with splinting and anti-inflammatory medication. Operativelly a strip of Flexor Carpi Radialis tendon was used for ligament reconstruction according to the technique described by Eaton, Glickel and Littler. The follow-up period averaged 7 years. At final follow-up 8 thumbs were stage I, 3 were stage II, and one was stage III. Ten patients were at least 90 % satisfied with the results of the surgery and only two had symptomatic thumb basal joint.

Between 1988 and 1998, a total of 12 patients (6 men and six women, of average age 36 years) underwent surgery for schwannoma of the peripheral nerves of the upper extremity. The incidence according to the involved nerve was analyzed and the follow-up results and complications after surgical treatment were reviewed. The median nerve was most frequently involved (6 cases), followed by the ulnar nerve (4 cases) and the radial nerve (2 cases). The average duration of symptoms was 2 years (3 months-8 years). Pain or painful paresthesias were usually the main complains. None of the patients suffered from Recklinhausen’s disease. Magnetic resonance imaging is the preferred exploration technique, particularly useful in case of deep tumor. EMG studies were carried out in all patients. Preservation of nerve continuity is the underlying goal of the therapeutic strategy. Marginal excision was performed in all cases. The tumors were extricable displacing the nerve fiber bundles without penetrating into the bundle itself and it was possible thus to be resected without interrupting the nerve continuity. Postoperatively, 7 patients were pain free, while 5 improved. Neurological deficits were favourably influenced by the operation. Out of 4 patients with motor deficits 3 had complete and 1 had partial recovery. Three out of 6 patients with sensory deficits had complete recovery, 2 remained unchanged, while 1 worsened. One patient developed new motor and another one new sensory deficits. New deficits developed predominantly in patients with large tumorsor longstanding symptoms. There was no reccurence or malignant transformation until the average of 52 months of follow-up.

We reviewed the functional outcome of cominnuted intraarticular fractures of the distal humerus managed with internal fixation with plates and screws. 15 patients (10 men-5 women) were reviewed over a mean of 29 months postoperatively. The age of the patients at operation ranged from 18 to 72 years. Patients were treated within 7 days of injury, using a posterior approach,with or without olecranon osteotomy and with anterior transposition of the ulnar nerve. Bone grafting was used in 7 cases in addition to internal fixation. Postoperative mobilisation was prompt in all patients,who were meticously reviewed for : 1)Function of the upper extremity,with the aid of the scale of DASH (Disabilities of the arm,shoulder and hand), 2)Ulnar nerve (pain, sensitive and movement dissability, functionality), 3)Range of elbow motion, 4) strength of the muscles controlling the elbow, wrist and hand. 5)Post-operative radiographic appearance, 6)Subjective evaluation, 7)Complications. All the patients were satisfied with the outcome of the operation,as well as with the activities which could postoperatively be undertaken. The mean range of motion for elbow (flexion-extension) was 118° in average,while muscle strength for elbow motion was moderately reduced. No case of ulnar neuropathy was observed. On the other hand postoperative complications were considerably frequent, yet they were mild and subsided eventually without further operation.

Introduction: Various surgical techniques existed for the treatment of three and four part proximal humeral fractures with variable outcomes. The aim of this study is to present a technique using small materials, to preserve all the biologic principles of fracture fixation, in the treatment of these challenging injuries.

Material: We perform a study taking as inclusion criteria: 3 and 4 parts proximal, closed, humeral fractures, treated surgically by open reduction and a modular biological internal fixation.

Surgical technique: Through a standard deltopectoral approach the fragments reduced, taking care to preserve the periosteum and manipulate meticulously the soft tissues. All the fractures were fixed with a combined system of Kirschner wires inserted to the proximal fragments, connected by “bone clips” forming a modular construction and fixed to the main distal fragment by AO screws.

Results: 24 patients complied with the inclusion criteria and were followed up a mean of 18 months. All patients achieved a satisfactory result except a fracture-dislocation that developed AVN and was revised into a shoulder arthroplasty and two demented elderly patients with metalware failure that were also revised.

Conclusion: In this first series of non-selected cases the outcome of fracture consolidation is promising. Although this technique is in its embryonary phase of development and the functional results are currently been assessed, the radiological outcomes suggest that the technique described is a valid alternative to the treatment of these fractures if we indicate an osteosynthesis method that combines biology and stability.

Introduction: Noncontiguous fractures of the tibial diaphysis and ipsilateral ankle is an uncommon entity. The aim of this study is to highlight the unique fracture pattern with emphasis on the necessity for surgical treatment.

Material: There were 11 patients with an average age of 40 years, who sustained ipsilateral, noncontiguous fractures of the tibia and ankle. All but one fracture ware closed. The level of the tibia fracture included midshaft (two), middle-distal third (seven), distal third (two). Seven of the ankle fractures were classified as Weber B, three as Weber C and one Pilon. One fracture was treated by cast immobilization, eight with ORIF of both fractures and two with a combination of internal and external fixation. Of the patients treated operatively, five were treated initially in long leg casts, but each required surgical intervention to control fracture alignment.

Results: The average follow up was twenty- three months. The non-operatively treated fracture resulted in a mal-union and a severe loss of ankle mobility. Of the cases managed operatively, seven had complete structural and functional recovery, two patients regained 70% of ankle mobility and one developed ankle arthritis.

Discussion: The resulted experience from the treatment of these injuries shows their extremely unstable nature. It has been our experience that the forces acting upon the fragments usually underestimated since reduction of one fracture displaces the other. Furthermore if acceptable reduction is achieved by closed means, a progressive slippage occurs over the time. We believe that stable fixation of both fractures should be the treatment of choice.

Introduction: The aim of this study is to present a modification of the single tension band technique for the treatment of olecranon fractures, using a double tension band with smaller wires, preserving all the biological parameters for fracture fixation, in an effort to decrease related complications.

Material: Thirty-three patients with olecranon fractures treated with a double tension band fixation. Surgical Technique: Through a posterior approach the fracture is reduced keeping all principles for biologic fixation and stabilized with two parallel small K-wires inserted from the olecranon process and exit through the anterior cortex of the ulna. Then the extensor carpi ulnaris and flexor carpi ulnaris are partly elevated from the ulna and two 1.5-mm transverse drill holes are made through the ulna 3 and 4 cm distal to the fracture. Two 22-gauge wires are passed through the proximal and distal holes, bent into a figure of 8 over the dorsal ulna and simultaneously tightened. The proximal ends of the K-wires are bent and impacted into the olecranon process.

Eleven patients needed supplemental fixation with screws. All patients mobilized the first postop day.

Results: All the fractures consolidated. All patients but two regained full range of motion. No hardware failure was noted except one patient in whom one band was broken but without clinical relevance.

Conclusion: It seems that a double tension band fixation despite the smaller material utilized, provides a very stable construct, permitting early mobilization. Furthermore two bands tensioned independently provide greater compression forces at the fracture site and offer a back up in case that one band fails.

Introduction: Pelvic ring injuries represent a complex injury pattern and sometimes have significant consequences. The aim of this retrospective study is to delineate the indications of surgical treatment with emphasis in the anatomic reconstruction.

Materials and Methods: 85 patients with pelvic ring fracture with or without acetabular fracture reviewed retrospectively. The average patient age was 34 years. Operative treatment was provided to 26 patients. Six isolated acetabular fractures were treated by ORIF. Twenty pelvic ring fractures were treated, by anterior Ex-Fix in five cases, Ex-Fix plus sacroiliac screws in three, anterior reconstruction plate plus sacroiliac screws in two, anterior plate plus sacral bars in three. The remaining seven patients with an additional acetabular fracture treated with anterior plate for the pelvis and plates for the acetabulum.

Results: All the acetabular fractures were anatomically reduced. All fractures consolidated and no patient has developed hip AVN or post-traumatic arthritis. Brooker’s grade III ossifications complicated two patients. Partial neurological deficit of sciatic nerve was seen in three cases of acetabular fractures that improved spontaneously. A case of vertical shearing sacral fracture through the foramina presented with lumbosacral plexus paresis that recovered near normal function in 6 months. Deep infection complicated a case that subsided at 2 weeks on antibiotics and serial surgical debridement.

Conclusions: The strict application on rational criteria and an exquisite surgical technique caring of the soft tissues produce satisfactory outcome of these injuries. The above-described surgical treatment shortens the hospital stay and allows early physiotherapy to restore function.

Introduction: Management of supracondylar fractures above a TKR is a difficult problem, aggravated by the increasing number of arthroplasties carried out and the increase of the ageing population. The aim of this paper is to determine the limb function after treatment of these fractures.

Materials and Methods: We performed a retrospective study of the outcome of the treatment of suprandylar fractures above an ipsilateral TKR. All fractures were classified according to the Lewis & Rorabeck System. Conservative treatment was provided to eight fractures. Osteosynthesis using a Dynamic Condylar Screw (DCS) was performed to five patients. The largest group of twenty patients was treated with a retrograde supracondylar nail. Three patients underwent a revision surgery.

Results: Four out of eight fractures treated conservatively had a satisfactory outcome. All patients treated with a DCS achieved a satisfactory result. Seventy five percent of patients treated with a supracondylar nail gained adequate functional and anatomical result. Revision surgery was satisfactory in all cases.

Conclusion: The above-described fractures are still not very frequent, but represent a high risk of important complications, with potentially disastrous consequences. For those reasons and the poor bone stock in the elderly its management is controversial. The challenge for the surgeon is to achieve the goals of consolidation of the fracture, preservation of a painless TKR, and, restoration of the previous functional status. A complex group of factors, such as fracture pattern, implant status, bone quality and general condition of the patient, need to be assessed.