Introduction

Positive reports from implant designer centres on the use of fibular nails in the complex ankle fractures has resulted in a marked increase in their use nationally. Our aim in this study was to report on the outcomes of the use of all fibular nails in two major trauma centres.

Introduction

Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated a maximum of 25% talar body exposure without malleolar osteotomy. The aim of this study was to investigate the percentage talar body exposure when using the lateral transligamentous approach.

Introduction

The treatment of posterior malleolar fractures is developing. Mason and Molloy (Foot Ankle Int. 2017 Nov;38(11):1229-1235) identified only 49% of posterior malleolar rotational pilon type fractures had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis.

Background

There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. In our previous multicenter study (Powell, BOFAS 2016) we showed that the Olerud-Molander Ankle Score (OMAS) was 79 for unimalleolar fractures and 65 for bi malleolar fractures, however it dropped significantly to 54 in trimalleolar fractures. In creating a treatment guiding classification, we report our results in a system change in management of posterior malleolar fractures in our unit.

Introduction

The dichotomy between surgical repair and conservative management of acute Achilles tendon ruptures has been eliminated through appropriate functional management. The orthoses used within functional management however, remains variable. Functional treatment works on the premise that the ankle/hindfoot is positioned in sufficient equinus to allow for early weight-bearing on a ‘shortened’ Achilles tendon. Our aim in this study was to test if 2 common walking orthoses achieved a satisfactory equinus position of the hindfoot.

Introduction

We performed a longitudinal outcome study involving the operative management of ankle fractures at two university teaching hospitals. This was a retrospective review of the quality of reduction and a prospective study into the functional outcome.

Introduction

Traditional treatment of idiopathic flatfoot in the adult population include calcaneal neck lengthening or fusions. These surgical methods result in abnormal function with significant complication rates. Our prospective study aimed to quantify the functional and radiological outcome of a new technique for spring ligament reconstruction using a hamstring graft, calcaneal osteotomy and medial head of gastrocnemius recession if appropriate.

Introduction

We aimed to retrospectively identify risk factors for delayed / non-union for first metatarsophalangeal joint fusion.

There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. Current ankle classification systems do not account for differences in fracture patterns or injury mechanisms, and as such, the clinical outcomes of these fractures are difficult to interpret. The aim of this study was to analyse our posterior malleolar fractures to better understand the anatomy of the fracture.

In a series of 42 consecutive posterior malleolar, who all underwent CT imaging, we have described anatomically different fracture patterns dictated by the direction of the force and dependent on talus loading. We found 3 separate categories. Type 1 – a rotational injury in an unloaded talus resulted in an extraarticular posterior avulsion of the posterior ligaments. This occurred in 10 patients and was most commonly associated with either a high fibular spiral fracture or a low fibular fracture with Wagstaffe fragment avulsion. The syndesmosis was usually disrupted in these patients. Type 2 – a rotational injury in a loaded talus resulting in a posterolateral articular fracture, of the posterior incisura. This occurred in 16 patients and was most commonly associated with a posterior syndesmosis injury, low fibular spiral fracture and an anterior collicular fracture of the medial malleolus. Type 3 – axially loaded talus in plantarflexion causing a posterior pilon. This occurred in 16 patients and was most commonly associated with a long oblique fracture of the fibular and a Y shape fracture of the medial malleolus. The syndesmosis was usually intact in these patients.

In conclusion, the anatomy of the posterior malleolar should not be underestimated and requires careful consideration during treatment and categorisation in outcome studies to prevent misinterpretation.

The rate of surgical site infection after elective foot and ankle surgery is higher than that after other elective orthopaedic procedures.

Since December 2005, we have prospectively collected data on the rate of post-operative infection for 1737 patients who have undergone elective foot and ankle surgery. In March 2008, additional infection control policies, focused on surgical and environmental risk factors, were introduced in our department.

We saw a 50% reduction in the rate of surgical site infection after the introduction of these measures. We are, however, aware that the observed decrease may not be entirely attributable to these measures alone given the number of factors that predispose to post-operative wound infection.

Cite this article: Bone Joint J 2015;97-B:516–19.

Introduction:

The insertion footprint of the different muscles tendon fascicles of the Achilles Tendon on the calcanium tuberosity has not been described before.

The purpose of this study was to review the outcomes and complications of all circular external fixators (frames) used for the management of acute lower limb trauma in our institution over a twenty year period.

We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute lower limb trauma. We identified 68 fractures in 63 patients. There were 11 femoral fractures and 57 tibial fractures. All fractures were classified using the AO Classification system, and most fractures were Type C fractures. We used an Ilizarov frame in 53 patients and a Taylor Spatial Frame in 15 patients. The mean time in frame was 365 days for a femoral fracture and 230 days for a tibial fracture. There were five tibial non-unions giving an overall union rate of 93%. Factors associated with non-union included high energy trauma and cigarette smoking.

The vast majority of lower limb fractures can be treated using ‘conventional’ methods. Complex fractures which are not amenable to open reduction and internal fixation or cast immobilisation can be treated in a frame with excellent results. The paucity of published reports regarding the use of frames for complex trauma reflects the under-utilisation of the technique.

Introduction:

It has been shown that inadequate reduction of the sesamoids can lead to recurrent hallux valgus. It can be difficult however to assess the sesamoid position. We propose a simple method of grading sesamoid position; the sesamoid width ratio. We aim to assess for a difference in ratio between those with and without hallux valgus and subsequent correlation with increased deformity. The new grading system can then be tested for inter-observer reliability.

Introduction:

Inadequate reduction and fixation of ankle fractures leads to poor clinical outcomes although there are no well-established criteria to evaluate the quality of surgical fracture fixation of the ankle. The aim of our study was to validate Pettrone's criteria that can be used in the radiological assessment of the quality of ankle fracture fixation that predict the functional outcome.

Introduction:

Patient reported outcome measures are becoming more popular in their use. Retrospective scoring is not yet a validated method of data collection but one that could greatly decrease the complexity of research projects. We aim to compare preoperative and retrospective scores in order to assess their correlation and accuracy.

When performing scarf osteotomies some surgeons use intraoperative radiography and others do not. Our experience is that when using intraoperative radiography we often change the osteotomy position to improve the correction of the hallux valgus angle and sesamoid position.

We report the results of a single surgeon series of 62 consecutive patients who underwent a scarf osteotomy for hallux valgus. The first 31 patients underwent surgery without the use of intraoperative radiographs and the subsequent 31 patients underwent surgery with the use of intraoperative radiographs, this reflects a change in the surgeons practice. Hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle and sesamoid position using the Hardy Clapham grading system were recorded. All patients had measurements recorded from weight baring radiographs taken pre operatively as well as at 6 and 12 weeks post operatively. Intraoperative measurements were also recorded for all patients in the intraoperative radiography group.

The mean hallux valgus angle preoperatively was 28.5° in the control group and 30.5° in the intraoperative radiography group. The mean hallux valgus angle in the control group at 6 weeks was 12.4° and at 12 weeks was 12.6°. The mean hallux valgus angle in the intraoperative radiography group at 6 weeks was 10.5° and at 12 weeks was 9.8°.

The median sesamoid position pre operatively was 4 for both groups. At 6 and 12 weeks the sesamoid position improved by a median of 1 position in the control group and 2 positions in the intraoperative radiography group (p<0.05).

We recommend that surgeons who do not routinely use intraoperative radiography undertake a trial of this. We have found that the use of intraoperative radiography improves the correction of hallux valgus angle and sesamoid position. These have been shown to increase patient satisfaction and reduce recurrence.

Background

Benefits of day case foot and ankle surgery includes reduced hospital stay, associated cost savings for the hospital, high patient satisfaction and quicker recovery with no increase in complication rates.

In 2007, we set up the preoperative foot and ankle group. Patients were seen three weeks before surgery by a specialist nurse, physiotherapist and a preoperative evaluation is done. The therapist explains the patient's weightbearing status and advices on how to carry this out. Our aim was to reduce inpatient hospital stay and increase our day case procedures.

Introduction

The incidence of osteochondral lesions following ankle fractures varies in the literature between 17-70%. They are commonly associated with chronic pain and swelling in patients diagnosed with such pathology. There is less evidence about the relationship between OCL and the development of post-traumatic osteoarthritis, the most common type of ankle arthritis.

1737 elective foot and ankle cases were prospectively audited from Dec 2005 to end June 2010. All cases were brought back to a specialist nurse dressing clinic between 10 and 17 days post op. Data was collected at the dressing clinic with a standardised proforma on the type of surgery, the state of the wound and any additional management required. Those patients with a pre-existing infection were excluded.

Of the 1737 cases 201 (11.6%) had a minor wound problems such as excessive post op bleeding into the dressings, suture problems, early removal of K wires, delayed wound healing and minor infection. 42 patients required antibiotics (2.4%) 8 patients had a deep wound infection (0.5%) requiring intravenous antibiotics and or further surgery.

There were 1185 forefoot procedures 36 of which developed an infection (3%), overall infections of the mid/hindfoot was 6 (1%).

Practice has changed as a result of the audit (reviewed annually). We have changed our closure techniques (reducing suture problems). For the past 2 years all of our elective foot and ankle patients now go to an ultra clean ward (Joint Replacement Unit) and we have shown a reduction in infection rates by over 50% since. Our infection rate before the JRU was 3.3% with 0.7% deep infection rate (818 procedures) and after the introduction of the JRU our infection rate has ped to 1.6% superficial and 0.3% deep infection p<.001.

This large series prospective study sets a benchmark for infection rates in elective foot and ankle surgery. It also highlights the benefit of a dedicated orthopaedic elective unit with rigorous infection control policy and the need to regularly review our results.

NHS governance demands that services provided are clinically effective and safe. In the current financial climate and threats over public sector spending cuts, services offered by health care providers should also be cost-effective and profitable. Surgical specialties are often perceived as expensive with high implant costs. The aim of this audit was to cost the profit margin for foot/ankle surgery and test the accuracy of coding data collected.

Over 80% of patients with advanced breast cancer will develop bone metastases for which there is no cure. Although thought to involve a complex cascade of cell-cell interactions, the factors controlling the development of bone metastases are still poorly understood. Osteoblasts may have an important role in mediating homing and proliferation of breast cancer cells to the bony environment.

This study aimed to examine the potential role osteoblasts have in the migration of circulating tumour cells to bone and the factors involved in this attraction.

Culture of osteoblasts and MDA-MB-231 breast cancer cells was performed. Breast cancer cell migration in response to osteoblasts was measured using Transwell Migration Inserts. Potential mediators of cell migration were detected using ChemiArray & ELISA assays. A luminometer based Vialight assay was used to measure breast cancer cell proliferation in response to factors secreted by osteoblasts.

There was a 3-4 fold increase of MDA-MB-231 migration in response to osteoblasts. ChemiArray analysis of osteoblast-conditioned medium revealed a range of secreted chemokines including IL-6 & 8, TIMP 1 & 2 and MCP-1. Initially, MCP-1 was quantified at 282 pg/ml, but rose to over 9000 pg/ml when osteoprogenitor cells were differentiated into mature osteoblasts. Inclusion of a monoclonal antibody to MCP-1 in osteoblast-conditioned medium resulted in a significant decrease in breast cancer cell migration to osteoblasts. There was no significant change in proliferation of MDA-MB 231 cells when exposed to osteoblast-conditioned medium.

Osteoblasts are capable of inducing breast cancer cell migration mediated at least in part by chemokine secretion. MCP-1 produced by the osteoblasts was shown to play a central role in mediating homing of the breast cancer cells. Increased understanding of the pathways involved in the development of bone metastases may provide new targets for therapeutic intervention.

Introduction: A learning curve is a recognised phenomenon in surgery. It implies that the frequency of peri-operative adverse events will decrease with the increase in experience of the surgeon. Evidence shows increased instruction and experience in a specific surgical task leads to improved performance. There is conflicting evidence as to whether there is a learning curve for total ankle replacement, and a paucity of evidence for foot and ankle surgery as a whole. Current evidence is centered on perioperative complications, rather than functional outcome.

Aim: To determine whether a learning curve effect is present during the first year of independent practice by measuring patient outcome.

Materials and Methods: 150 patients underwent elective foot or ankle surgery during the first 12 months of a newly appointed consultant’s practice. Preoperative and six month postoperative functional scores were recorded, together with perioperative complications. Two patients died of unrelated causes in the first 12 months. 121 patients (81.8%) were followed up for a minimum of six months by telephone. Functional outcome was assessed with a modified American Orthopaedic Foot and Ankle Society midfoot Score (85 points). Outcome was compared between the first and second six-month periods using the student’s t-test.

Results: Eighty procedures were undertaken during the first six months compared to 70 in the second. Total ankle replacements were only undertaken in the latter period. Otherwise there was no statistical difference in the caseload. One wound infection occurred during each period and other perioperative complications were equivalent. Functional improvement was greater in the group from the second 6 months (+23.86 v’s +18.69). This difference did not reach statistical significance (p = 0.061).

Discussion and Conclusion: There is a trend, approaching significance, towards a learning curve during a foot and ankle consultant surgeon’s first year of practice. Collating data from other new consultants may demonstrate a learning curve with statistical significance.

Introduction: Osteoporosis is a skeletal disorder characterised by decreased bone mineral density (BMD) and a subsequent increased risk of fragility fractures. This disease is commonly associated with postmenopausal females with an increasing incidence into later life, over 50% of females over 80 have osteoporosis. At the opposite spectrum of life, decreased BMD is traditionally associated with the female athletic triad, with hormonal imbalance leading to skeletal insufficiency. Considered a “silent disease” until a fracture occurs, as orthopaedic surgeons we must be able to identify those at risk of osteoporosis and refer promptly for dual energy x-ray absorptiometry (DEXA) scanning to prevent future fragility fractures in this specific patient cohort.

Methods: We carried out an epidemiological analysis of all female patients under the age of 30 referred for DEXA scanning in a university teaching hospital over a 3 year period. We analysed mode of referral, risk factors, T-score and subsequent fractures with an aim to highlight an underestimated level of osteopenia/osteoporosis in the younger patient.

Results: We identified 102 patients eligible for our study, with a mean age of 25.34 (Range- 17–29). As per the World Health Organisation (WHO) osteopenia was defined as osteopenia as a T-Score between −1 and −2.5, with osteoporosis below −2.5. The mean T score of these patients was −1.037 (range −3.2 to 2.4). Medical teams initiated the majority of referrals (77%), followed by General Practitioners (17%), Gynaecologists (4%), Paediatricians (1%) and Surgeons(1%). Risk factors included excess steroid use for medical conditions (41%), decreased body mass index (BMI) (27%), ceoliac disease (12%) and radiological evidence of osteopenia (7%). 34% of these patients had suffered a fall with 12% of patients suffering from a fragility fracture.

Conclusion: We identified a definite cohort of young female patients who had a mean T-score within the levels for osteopenia. Over one third had suffered a fall and 12% had suffered a fragility fracture despite a young age. With ever increasing patient numbers in both fracture and orthopaedic clinics and increased pressure on resources, it is imperative that we still take thorough histories to identify those young female patients that are at risk of osteoporosis. With appropriate follow up and investigations, they can be started on necessary treatment and prevent subsequent fragility fractures, the incidence of which appears to be underestimated.

Scarf osteotomy is a commonly performed method of hallux valgus correction. Release of deforming lateral soft tissue structures is an integral part of this correction. The aim of this study was to determine if there was any difference in the correction achieved by dorsal and transarticular releases as part of a scarf osteotomy.

This radiological study was performed at a single institution. One surgeon utilised the dorsal first web approach for the distal soft tissue release and one the transarticular approach. There were 23 patients in each group. The same post-operative regime was used on both sets of patients. Data was collected on hallux valgus angle (HVA), intermetatarsal angle (IMA) and AFS sesamoid scoring.

The pre-operative deformity as measured by hallux valgus angle and intermetatarsal angle where similar for both groups (p= 0.25, 0.79 respectively) with a significant difference in severity of AFS scoring in the dorsal group (p < 0.001). Patients who underwent a dorsal approach release had a mean improvement in IMA of 5.46 degrees compared to 3.86 in the transarticular group. The HVA improved by 17.92 degrees in the dorsal group compared to 8.08 in the transarticular group. Both these results were statistically significant (p= < 0.01,< 0.002 respectively). There was a statistically significant difference in number of patients returning to within normal limits of the HVA (p= < 0.05); 18 patients returned to a normal hallux valgus angle after undergoing the dorsal approach compared to 9 patients in the transarticular group.

Our study shows that when performing a distal soft tissue release in conjunction with a scarf osteotomy for correction of hallux valgus, a dorsal first web approach is significantly better at correcting the HVA as compared to a transarticular approach. We would, therefore, recommend the use of a dorsal approach when performing this surgery.

Introduction: Compromised by pre-existing medical co-morbidities, weakened by the second hit of surgery, elderly patients with hip fractures are amongst the most challenging cases to manage appropriately in the acute hospital setting.

Aim: To document the frequency and outcome of post operative medical complications in elderly patients following surgery for hip and proximal femoral fractures.

Methods: Retrospective analysis of acute admissions to a University teaching hospital with hip and pertrochanteric fractures over an 18 month period. Medical records and radiographs were reviewed for details relating to location of fracture, in-patient morbidity, mortality and length of stay. In-patient fracture referrals and patients under 65 years of age were excluded.

Results: From a total of 438 fracture fixation procedures or prosthetic replacements, 368 patients were eligible for analysis. The mean age of patients was 83.6 years. The mean length of stay was 14.2 days.

142 patients experienced significant postoperative morbidity consisting of 24 myocardial infarctions, 46 respiratory tract infections, 33 urinary tract infections, 3 cerebral vascular accidents and 36 exacerbations of congestive cardiac failure. There was no correlation between morbidity and location or type of fracture. The mean age (86.1 yrs) and length of stay (26 days) was greater in the morbidity group (p< 0.05). The overall post operative in-patient mortality rate was 9%, rising to 50% in those who suffered a myocardial infarction and 33% in those with exacerbations of congestive cardiac failure.

Conclusion: This study reinforces the poor prognosis conferred by a hip fracture on the elderly patient both in terms of morbidity and mortality. As the population ages and life expectancy increases, health services will come under ever more pressure to cater for the expansion in numbers of hip fracture patients. Greater resources and dedicated professional medical staff are required in order that the best possible care and outcome may be achieved for these patients

Aim: An epidemiological analysis of spontaneous community acquired septic arthritis cases in an elderly population at a university teaching hospital

Method: We studied confirmed cases of spontaneous septic arthritis in the over 65 population. Patients with prosthetic joint infections were excluded from the study. We analysed data relating to initial presenting complaint and clinical examination, haematological and microbio-logical tests along with ultimate patient outcome.

Results: There were 7 confirmed cases of spontaneous septic arthritis in over 65 population in the last 6 months (2 hips, 5 knees). The mean age was 72.14 (range 65–82) with a mean length of stay of 49 days. Those with septic arthritis of the knee presented with swelling, pain and immobility. Hip cases presented with pain and immobility. All patients were systemically well at time of presentation, with no other foci of infection detected after septic screening. All patients had aspirate and arthroscopic/arthrotomy confirmed infection. Staphylococcus Aureus was isolated from 6 joint aspirations and Pseaudomonas Auruginosa from one patient. Complications of treatment included acute renal failure, cardio/respiratory failure, disseminated infection and death (1 case).

Conclusion: Septic arthritis must be considered as a differential diagnosis in all patients with joint pain, swelling and immobility. This diagnosis is not confined to the paediatric population. A backround of degenerative disease and the occult presentation in the elderly may delay diagnosis. Sepsis must be considered in the elderly with joint pathology, with treatment initiated in a prompt and aggressive manner to prevent the sequelae that ensues.

Introduction: Gait analysis studies of patients following ankle arthrodesis have demonstrated a functional gait, largely due to tarsal hypermobility compensating for lost tibio-talar motion. We present a prospective radiographic study comparing the pre and post-operative range of motion of the foot following ankle arthrodesis. In this study, we introduce a radiographic technique using reliable anatomic landmarks to measure sagittal range of motion of the foot after ankle arthrodesis.

Materials and Methods: Between 2002 and 2007, we performed 154 arthrodesis procedures of the ankle. Patients were suitable for inclusion in this study if an isolated arthrodesis of the ankle was performed for post traumatic arthritis with a minimum of 1 year follow-up without any additional hindfoot operations. Preoperative and post-operative passive plantar flexion and dorsiflexion radiographs were obtained in a standardized fashion. Anatomic landmarks were then used to measure and compare tibio-talar, mid-tarsal, and subtalar movement.

Results: There were 48 patients who met the inclusion criteria for this study. Preoperatively, the mean measured motion was as follows: total sagittal motion 35o, tibio-talar motion18o, mid-tarsal (transverse tarsal + naviculo cuneiform + tarsometatarsal joints) motion 12o (34% of pre-op sagittal arc), subtalar motion 5.5o (15% of pre-op sagittal arc), and mid-tarsal + subtalar motion 17.5o (49% of pre-operative sagittal motion). These changed post operatively to a mean motion as follows: total sagittal motion 18.5o, (52% of preoperative sagittal motion), mid-tarsal motion 10o (28% of pre-op sagittal arc), subtalar motion 10.5o (27% of pre-op sagittal arc), and mid-tarsal + subtalar motion 20.5o (54% of pre-operative sagittal motion).

Discussion: This study presents an accurate and reproducible means of measuring the sagittal plane range of motion of the hindfoot and ankle, and documents the presence of increased motion in the subtalar and talonavicular joints after ankle arthrodesis.

Ankle arthrodesis is a common operation with published fusion rates ranging from 62–100%. The literature documents the difficulties of obtaining arthrodesis in certain patients for example with neuroarthropathy, but the risk of non union related to deformity, bone quality, bone defects and systemic disease has not previously been reported.

Between 2002 and 2006 we performed an ankle arthrodesis in 154 patients, and analyzed these patients retrospectively to delineate categories of risk factors for achieving arthrodesis. From this analysis we devised a preoperative radiographic scoring system to grade complexity of pre-operative ankle arthrodesis. The scoring system is based upon 5 categories; size and plane of deformity, presence and size of bone defects, presence and area of avascular necrosis, site of previous fracture in post-traumatic arthritis and predisposing condition causing the arthritis. Each category has potential scores of 1–5, apart from the latter which is scored up to 6, with higher scores being more severe. The grade of complexity is derived from a cumulative score from all 5 categories.

Statistical analysis revealed good intra and inter- observer correlation. Multivariate regression analysis demonstrated that this scoring system correlates with the techniques used for arthrodesis as well as outcome. This study demonstrated that if the method of arthrodesis is altered according to the relative risk of non –union then there is no significant difference in outcome between patients of high and low risk for non-union

We present a new scoring system for severity of pre-operative condition in ankle arthrodesis patients and introduce an algorithm for surgical correction based upon this pre-operative scoring system. The surgical techniques for the arthrodesis are presented, ranging from simple screw fixation to more complex bone grafting techniques, bone stimulation and alternative methods of fixation.

Distal tibial physeal fractures are the second most common growth plate injury and the most common cause of growth arrest and deformity. This study assesses the accuracy of pre-operative planning for placement of the screws in these fractures using either standard radiographs or CT scans.

We studied 62 consecutive physeal fractures over a period of four years. An outline of a single cut of the CT scan was used for each patient. An ideal position for the screw was determined as being perpendicular to and at the midpoint of the fracture. The difference in entry point and direction of the screw between the ideal and the observers’ assessments were compared using the paired Student’s t-test. There was a statistically significant improvement (p < 0.0001) in the accuracy of the point of insertion and the direction of the screw on the pre-operative plan when CT scans were used rather than plain radiographs.

We would, therefore, recommend that CT scans are routinely used in the pre-operative assessment and treatment of distal tibial physeal fractures.

Introduction; Distal tibial physeal fractures are the commonest cause of growth arrest and deformity secondary to failure to achieve and maintain an accurate reduction. Our study compared assessment of displacement and screw placement using X-ray alone compared to CT scans. Methods; 62 consecutive fractures over a 4 year period were used. Displacement was measured on 18 Salter Harris III and IV fractures by 7 surgeons separately using X-rays alone. These measurements were compared to those made from the CT scans. Screw placement was drawn onto tracings of outlines of of single cuts of CT scans by 4 surgeons seperately for all 62 fractures using X-rays alone. This was repeated one week later using the CT scans. Ideal screw placement was considered to perpendicularly bisect the fracture line. Differences between the ideal and observer measurements were analysed using the paired t-test. Results; The surgeons were incorrect in determining whether there was more or less than 2mm of displacement in 33.3 Ð 50% of cases (mean = 38.9%) . There was a statistically signiþcant difference (p < 0.0001) in accuracy of screw insertion point and direction between using X-rays and Ct scans for all surgeons and fracture types. Conclusions; We recommend that CT scans are essential for accurate pre-operative assessment of distal tibial physeal fractures.