This single-centre prospective randomised trial aimed to assess the superiority of operative fixation compared with non-operative management for adults with an isolated, closed humeral shaft fracture.

70 patients were randomly allocated to either open reduction and internal fixation (51%, n=36/70) or functional bracing (49%, n=34/70). 7 patients did not receive their assigned treatment (operative n=5/32, non-operative n=2/32); results were analysed based upon intention-to-treat. The primary outcome measure was the DASH score at 3 months. Secondary outcomes included treatment complications, union/nonunion, shoulder/elbow range of motion, pain and health-related quality of life (HRQoL).

At 3 months, 66 patients (94%) were available for follow-up; the mean DASH favoured surgery (operative 24.5, non-operative 39.4; p=0.006) and the difference (14.9 points) exceeded the MCID. Surgery was also associated with a superior DASH at 6wks (operative 38.4, non-operative 53.1; p=0.005) but not at 6 months or 1yr. Brace-related dermatitis affected 7 patients (operative 3%, non-operative 18%; OR 7.8, p=0.049) but there were no differences in other complications. 8 patients (11%) developed a nonunion (operative 6%, non-operative 18%; OR 3.8, p=0.140). Surgery was associated with superior early shoulder/elbow range of motion, and pain, EuroQol and SF-12 Mental Component Summary scores. There were no other differences in outcomes between groups.

Surgery confers early advantages over bracing, in terms of upper limb function, shoulder/elbow range of motion, pain and HRQoL. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in patient-reported outcomes at 1yr.

Whilst emergency fasciotomy for acute compartment syndrome (ACS) of the leg is limb and potentially lifesaving, there remains a perception that such surgery may result in excessive morbidity, which may deter surgeons in providing expeditious care. There are limited long-term studies reporting on the morbidity associated with fasciotomy.

A total of 559 patients with a tibial diaphyseal fracture were managed at our centre over a 7-year period (2009–2016). Of these patients, 41 (7.3%) underwent fasciotomies for the treatment of ACS. A matched cohort of 185 patients who did not develop ACS were used as controls. The primary short-term outcome measure was the development of any complication. The primary long-term outcome measure was the patient reported EQ-5D.

There was no significant difference between fasciotomy and non-fasciotomy groups in the overall rate of infection (17% vs 9.2% respectively; p=0.138), deep infection (4.9% vs 3.8%; p=0.668) or non-union (4.9% vs 7.0%; p=1.000). There were 11 (26.8%) patients who required skin grafting of fasciotomy wounds. There were 206 patients (21 ACS) with long-term outcome data at a mean of 5 years (1–9). There was no significant difference between groups in terms of the EQ-5D (p=0.81), Oxford Knee Score (p=0.239) or the Manchester-Oxford Foot Questionnaire (p=0.629). Patient satisfaction on a linear analogue scale was reduced in patients who developed ACS (77 vs 88; p=0.039).

These data suggest that when managed with urgent decompressive fasciotomies, ACS does not appear to have a significant impact on the long-term patient reported outcome, although overall patient satisfaction is reduced.

1. A detailed study of density variations with age in cortical bone samples from different areas of the femoral diaphysis has been carried out.

2. Bone of relatively high density and, conversely, of low density was found to have a spiral pattern along the bone shaft.

3. Moving distally along the femoral shaft there was a transposition of the greatest density from the anterior to the posterior aspect.

4. In the erect body posture the femoral inclination is such that areas of denser bone might be expected to be aligned vertically because of the weight-bearing characteristics of the femur.

5. Most areas of the cortex tended to decrease in density after the age of fifty, the less dense areas changing more than those with an initial high density. Thus, osteoporosis tended not only to maintain but to accentuate the spiral pattern of density distribution by increasing the difference between dense and less dense bone.

6. In the distal region of the diaphysis bone resorption was greatest anteriorly but hardly affected the posterior aspect. A densitometric comparison between these two sites provided a clear indication of the effect of osteoporosis.

The nutrient foramina in seventy-one adult humeri were examined. The foramina were most concentrated in a small area on the medial aspect of the distal half of the middle third of the shaft. Non-union commonly occurs in this same region. The site of the entrance of the nutrient artery to the humerus is predictable with fair reliability. Certain practical applications have been indicated.

Conservative management remains the gold standard for many fractures of the humeral diaphysis with union rates of over 90% often quoted. Success with closed management however is not universal.

Most of researches related to osteoporosis emphasized on trabecular bone loss. However, cortical bone has a prominent role on bone strength determined by bone quality, such as 2D or 3D geometry and microstructure of bone, not only density.[1] The focal thinning of cortical bone associated with aging in post-menopausal osteoporotic bone in the proximal femur may predispose a hip to fracture.[2, 3] As the trabecular bone is lost with progression of osteoporosis, the remaining cortical bone take more predominant role on bone strength.[4] To date, no effective osteoporotic agent was demonstrated to enhance both cortical geometric change and bone strength. Herein, we investigate the effect of Teriparatide (rhPTH(1–34)) on cortical bone at femoral diaphysis in OVX rat model.

Twenty 12-week-old, female Sprague Dawley rats were used in this study. Bilateral ovariectomies were performed in 16 animals and randomly divided to three groups as control (N=6), OVX (N=6) and treatment group after OVX (OVX+F) by teriparatide (N=8). After twelve weeks of intervention, all rats were euthanized and right femurs and L5 vertebrae were extracted for further tests. All bone specimens were subjected to dual-energy X-ray absorptiometer (DXA) to evaluate areal bone mineral density (aBMD) of L5 vertebrae and femurs, micro-computed tomography (micro-CT) to analyze cortical bone parameters of femoral diaphysis, including cortical cross section area (CSA), cortical thickness and cross-sectional moment of inertia (CSMI). A three-point bending test was applied to determine fracture load of each femurs.

Compare to OVX group, increase of aBMD by 14.6 % at L5 vertebrae and 13.3% at femoral diahpysis in treatment group. The cortical parameters of femoral diaphysis, CSA and cortical thickness, analyzed by micro-CT were significantly increased but the increasing tendency of CSMI did not have significant changes statistically after teriparatide intervention for 3 months duration. The increase of cortical bone strength (OVX vs OVX+F group, 120.72±2.72 vs 137.93±5.02, p < 0.05) at femoral diaphysis after treatment were also noticed.

This study has point out a deeper look at geometric change of cortical bone after teriparatide treatment. This finding imply teirparatide has the ability to change the geometry of cortical bone and increase bone strength at femoral diaphysis.

Humeral diaphysis fractures consist a rather frequent injury. The aim of our study is to evaluate the results of the treatment of humeral diaphysis fractures with the use of an interlocking intramedullary nail.

During the period March 1999 – December 2001, 25 intramedullary nailings were performed in 24 patients with a humeral fracture (16 women and 8 men), aged 26–81 years (Average: 57.1 years) using a Russell-Taylor humeral nail. There were 16 cases of acute humeral fractures, 3 cases of pathologic fractures, and 6 cases of delayed union or non-union. Follow-up ranged from 6 to 36 months (Average: 20 months). Fracture union was recorded, and the results were evaluated according to the scoring system of Neer.

No immediate postoperative complications were recorded. The final result was excellent in 9 cases (36%), good in 12 (48%), unsatisfactory in 3 (12%), while there was one failure (4%), where a reoperation was required. Fracture union was achieved within 4 months in 21 cases (84%), while 2 cases of delayed union and 2 non-unions were recorded.

Interlocking intramedullary nailing offers a dependable solution in the treatment of humeral diaphysis fractures, providing a very satisfactory functional outcome and a high union rate. It offers an excellent option in the treatment of pathologic fractures of the humerus, as well as in severely comminuted fractures and humeral fractures in polytrauma patients.

Tibial shaft fractures co-existing with osteoarthritis can increase the challenges for the orthopedic surgeon. The novel Londhe-Shah technique manages both the problems using one-stage total knee arthroplasty with a long stemmed tibial component which has a good diaphyseal fit. Three osteoarthritis patients with fractures of tibial shaft were treated with this technique and were followed up at 6-weeks, 12-weeks and 1-year (figure 1–3). A complete union of the fractured segment was achieved at follow-up without any adverse events such as infection, damage to the implant, and soft-tissue injury during and after surgery. The American Knee Society Score (AKSS) improved and WOMAC pain and stiffness scores reduced at follow-ups suggesting excellent improvement in functionality and patient satisfaction. One-stage TKR with a long-stem extension of the tibial component to bypass the fracture site mends and stabilises the fracture along with the adverse biomechanics at the fracture site while also correcting the arthritis. The single stage procedure allows early ambulation in six weeks.

For any figures or tables, please contact the authors directly.

Introduction and Objectives: Periprosthetic fractures are a common phenomenon in revision surgery and following trauma. Treatment strategies range from replacement with a larger stem, metal plates with Dall-Miles wires, and Partridge straps. Our objective is to evaluate the clinical use of Partridge osteosynthesis in periprosthetic femoral fractures.

Materials and Methods: In a period of 6 years (1997–2003), 45 patients presenting with femoral fractures with a hip prosthesis were treated with the Partridge system using nylon material for cerclage and flexible nylon plates (Stryker-Howmedica). Of these, 20 were localised proximal to the tip of the prosthesis (Whittaker Type I), 12 on the tip (Type II), and 13 distal to the tip of the prosthesis (Type III). The study group consisted of 25 females and 20 males, with a mean age of 79.5 years. Mean time between implantation and fracture was 4.5 years. In 78% of the patients (35 of 45), surgery was performed within 48 hours. Open reduction of the fracture was performed, and 6–8 nylon straps were used in most cases. Partridge plates were used in 5 cases. Mean surgical time was 55 minutes, with a mean blood loss volume of 500 milliliters.

Results: There were minor recovery complications in 8 patients (12.6%). There were no deep wound infections. Of the 45 patients, 60% regained their pre-fracture level of function within 6 months. Mean hospital stay duration was 19 days, and 93% of the fractures consolidated with an exuberant callus within the one-year follow-up period. A higher level of care was required by 25% of patients.

Discussion and Conclusions: This simple method of osteosynthesis is indicated for rapid recovery following stabilisation of a periprosthetic femoral fracture. Even with a mobilised prosthesis, the fracture often consolidates with an abundant callus, and the patient is then able to move.

This study was carried out to determine the incidence of shoulder injuries in the ipsilateral shoulder of patients who attended our unit with fractures of the humeral diaphysis.

This was a prospective study. 22 patients with fractures of the humeral diaphysis had an early (within 10 days of injury) MRI scan of the shoulder. The contralateral shoulder was also scanned as an internal control. There were 10 male and 12 female patients. The average age was 45 years. 20 were treated non-operatively, and 2 had retrograde intra-medullary nailing of the humerus. 6 patients in our study had a symmetrical MRI scan. The remaining 16 patients had some acute abnormality evident in the ipsilateral shoulder. 11 patients had a significant subacromial bursitis. 2 of these patients had a tear of the supraspinatus tendon. 1 patient had an undisplaced fracture of the coracoid process. The remaining 4 patients had significant AC joint inflammation, 3 being acute, the 4th being acute-on-chronic.

This study shows a high incidence of asymmetrical MRI scans, indicating a definite shoulder injury sustained at the time of the fracture of the humeral diaphysis. We therefore surmise that shoulder pain and dysfunction post antegrade intra-medullary nailing of the humerus may not be due to iatrogenic causes, but may in fact result from concomitant ipsilateral shoulder injury. To our knowledge, this is the first study demonstrating such an association.

Aims

The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis.

Introduction: We present a prospective comparative study of 200 consecutive patients of closed tibial shaft fractures treated by external fixation using two different fracture reduction methods. Factors affecting fracture healing, including the effect of quality of reduction, was studied.

Methods: The healing time for all these fractures was determined by a combination of clinical, radiological and fracture stiffness measurements. The effect of smoking, AO classification type, associated fractures, initial and final angulation and translation on healing time was evaluated using nonparametric tests and regression analysis.

Results: Healing time was affected most by presence of Compartment syndrome followed by smoking status and final translation at fracture site. Having a compartment syndrome significantly increased fracture healing time (mean 286.7 days versus 139.2 days). There was no difference in healing times between the two different reduction machines. Angulation was found not to affect healing time, but translation did. Both initial and final translation were better using STORM (Staffordshire Orthopaedic Reduction Machine). The amount of axial shortening was also reduced by using STORM.

Conclusion: Healing time is affected by translation at fracture site, which is a factor under the control of the surgeon. The second reduction method using STORM, helps achieve better reduction.

Aim: To evaluate outcomes in humeral shaft fractures treated non-operatively and to identify possible causes for non-union.

Methods: Patients were identified through a manual search of the operating theatre register and all plaster room forms for the period 1/1/02 – 31/12/05. Patient files and radiographs were then examined for factors that might influence rate of non-union.

Results: 45 fractures were identified in 44 patients. 28 of these were treated conservatively with a hanging cast and functional brace. Of these, 11(39.6%) went onto non-union requiring ORIF + bone grafting.

There was a strong correlation between the length of time spent in the hanging cast and a high rate of non-union. The average length of time spent in cast for the non-union group was 48 days as opposed to 30.9days in the group that went onto unite (p=0.0601)

There was a statistically significant correlation between non-union and the radiographic degree of distraction at the time of first application of hanging cast (p=0.016) and also at the six week check (p=0.001).

Other factors associated with a poor outcome were the degree of varus angulation at presentation (p=0.0078), male sex, right humerus, dominant side, older age group, high energy injury, NSAID use, significant co-morbidities and associated injuries.

Conclusions: Our results compares unfavorably with Sarmiento who quotes a non-union rate of 2.5% in patients who are treated on average only 9 days in hanging cast. Our high rate of non-union is associated with a high degree of distraction at time of first application of hanging cast and an extended period of time spent in cast.

We would like to present this case series of 10 adolescent patients with displaced, closed diaphyseal tibial fractures managed using the Taylor Spatial Frame.

Management options for these injuries include non-operative treatment, antegrade nailing, flexible nailing systems, plating and external circular fixation. External circular fixation allows anatomical reduction avoiding potential complications such as growth arrest associated with antegrade nailing and retained metal work with plating. Flexible nailing system and cast immobilisation are unreliable for precise anatomical reduction. With limited evidence as to the extent of post-traumatic deformity that is acceptable, combined with the limited remodeling potential that this patient group possess, the precision of percutaneous fixation with the Taylor Spatial Frame system has clear advantages.

This is a retrospective analysis of 10 adolescent patients with a mean age of 14.5 years (range 13 to 16 years). Data collected includes fracture configuration, deformity both pre and post operatively compared to post frame removal, length of time in frame and complications. The data was gathered using the patient case notes and the Picture Archiving and Communications System. The mean time in frame was 15.5 weeks (range 11 to 22 weeks). One non-union in a cigarette smoker was successfully managed with a second Taylor Spatial Frame episode.

Our conclusion was that with careful patient selection the Taylor Spatial Frame allows successful treatment of closed tibial fractures in adolescents, avoiding complications such as growth arrest and post-traumatic deformity as well as avoiding retained metalwork.

We evaluated the clinical outcome of IM nailing for the treatment of femoral shaft pseudarthrosis in patients who had multiple failed plate osteosyntheses. From January 2000 untill April 2001, 20 (19 male-1 female, mean age 28) patients were treated because of femoral shaft non-union in our institution. All patients had two or more failed plate osteosyntheses. There were no septic non-unions in this group. Eight patients had an established non-union on an average of nine months post-op and the remaining eleven had radiological and clinical evidence of implant failure. There was no segmental bone loss, hi all patients the implants were removed and nailing was performed. Extensive periosteal stripping, bone necrosis and soft-tissue scaring were constant findings in all patients. Twelve patients received interlocking nails. Eight femurs were grafted with iliac crest bone graft. All patients were followed by serial x-rays until union.

There were no postoperative complications. All pseudarthroses were healed within an average of 9.7 months (8–12). Non-unions which received bone graft (eight out of twenty) in day one, were healed faster than those which didn’t. There were no re-operations among these patients. Among the remaining ten patients five were grafted five to six months postoperatively and three had had nail dynamization.

IM nailing for femoral shaft non-unions after multiple failed plate osteosyntheses is a safe and effective method of treatment. Autologous bone graft reduces healing time and re-operation rate.

Both our own experience with antegrade nailing of the humerus and reports in the literature have made us aware of some of the drawbacks of this technique. Invasion of the intact shoulder is associated with damage to the rotator cuff and possible ectopic calcification, resulting in subacromial impingement. The ‘blind’ percutaneous placement of the top locking screw may endanger the axillary nerve and/or the bicipital tendon.

From 1990 to 2000 we performed 144 retrograde nailings, 41 of which were lost to follow-up. For two years we followed up the remaining 103 patients, 71 men and 32 women, who had sustained 83 closed and 20 compound fractures, 14 of which were caused by gunshots. There were 89 recent fractures and 14 cases of nonunion, nine of them the outcome of non-surgical management. Seidel interlocking nails were used in 92 patients and Russell-Taylor in 11. Reaming was invariably done, first to prevent jamming of the nail and fracture propagation, secondly to create endosteal bone transport (equivalent to bone grafting), and thirdly to contribute to bone morphogenetic protein release.

The results were encouraging. In fresh fractures callus was present after 5 to 8 weeks and in nonunions after 10 to 14 weeks. In 10 patients, iatrogenic periportal uni-cortical fractures occurred. These healed at the same pace as the original fracture and did not affect the functional recovery. There were no vascular complications. One patient developed transient radial nerve paresis, but there was no permanent neurological damage. No sepsis developed in previously uninfected fractures. Shoulder and elbow function remained normal.

We describe the outcome of tibial diaphyseal fractures in the elderly (≥ 65 years of age). We prospectively followed 233 fractures in 225 elderly patients over a minimum ten-year period. Demographic and descriptive data were acquired from a prospective trauma database. Mortality status was obtained from the General Register Office database for Scotland. Diaphyseal fractures of the tibia in the elderly occurred predominantly in women (73%) and after a fall (61%). During the study period the incidence of these fractures decreased, nearly halving in number. The 120-day and one-year unadjusted mortality rates were 17% and 27%, respectively, and were significantly greater in patients with an open fracture (p < 0.001). The overall standardised mortality ratio (SMR) was significantly increased (SMR 4.4, p < 0.001) relative to the population at risk, and was greatest for elderly women (SMR 8.1, p < 0.001). These frailer patients had more severe injuries, with an increased rate of open fractures (30%), and suffered a greater rate of nonunion (10%).

Tibial diaphyseal fractures in the elderly are most common in women after a fall, are more likely to be open than in the rest of the population, and are associated with a high incidence of nonunion and mortality.

Cite this article: Bone Joint J 2013;95-B:1255–62.

Introduction and Aims: To review the existing classifications in characterising the pathologic morphology of congenital lower limb deficiencies (CLLLD) and their usefulness in planning limb reconstruction. Method: Ninety-five patients undergoing limb reconstruction were classified using existing classifications. Predominantly femoral deficiencies were classified using Aitken, Amstutz, Hamanishi, Gillespie and Torode, Fixsen and Lloyd-Roberts, Kalamchi, and Pappas systems and fibular deficiencies were classified using Coventry and Johnston, Achterman and Kalamchi, and Birch systems. Results: All patients with predominant deficiency of one segment (femoral or fibular) also had associated shortening of the other segment in the same limb. Acetabular dysplasia, knee instability due to cruciate insufficiency and lateral femoral condylar hypoplasia were found in both femoral and fibular deficiencies. None of the existing classification systems were able to represent the complete pathologic morphology in any given patient. Due consideration of alignment, joint stability and length discrepancy of affected limb as a whole at the planning stage of reconstruction could not be ascertained using these classification systems. Instead, it was useful to characterise the morphology of the involved limb using the following method:. Acetabulum: Dysplastic/Non-dysplastic. Ball (Head of femur): Present/Absent. Cervix (Neck of femur): Pseudoarthrosis and neck-shaft angle. Diaphysis of femur: Length/deformity. Knee: Cruciates. Fibula and Tibia: Length/deformity. Ankle: Normal/Ball and socket/valgus. Heel: Tarsal coalition/deformity. Ray: Number of rays in the foot. Conclusion: Existing classifications do not represent the complete morphology of the entire involved lower limb in CLLLD and therefore a systematic method of characterising the morphology of the lower limb is more useful in planning limb reconstruction

Objective: To review the existing classifications in characterizing the pathological morphology of congenital lower limb deficiencies and their usefulness in planning limb reconstruction. Methods: Ninety-five patients undergoing limb reconstruction were classified using existing classifications. Predominantly femoral deficiencies were classified using Aitken,Amstutz,Hamanishi,Gillespie andTorode,Fixsen and Lloyd-Roberts, Kalamchi, and Pappas systems and fibular deficiencies were classified using Coventry and Johnston, Achterman and Kalamchi, and Birch systems. Results: All patients with predominantly femoral deficiencies also had associated shortening of ipsilateral tibia and fibula. Similarly, most patients with predominantly fibular deficiencies also had some associated shortening ipsilateral femur. Acetabular dysplasia, knee instability due to cruciate insufficiency and lateral femoral condylar hypoplasia were found in both femoral and fibular deficiencies. None of the existing classification systems were able to represent the complete pathologic morphology in any given patient. Due consideration of alignment, joint stability and length discrepancy of affected limb as a whole at the planning stage of reconstruction could not be ascertained using these classification systems. Instead, it was useful to characterize the morphology of the involved limb using the following method:. Acetabulum: Dysplastic/ Non-dysplastic (AC index, Sharp’s angle, CE angle). Ball (Head of femur): Present/Absent. Cervix (Neck of femur): Presence of pseudoarthrosis & neck-shaft angle. Diaphysis of femur: Length / deformity. Knee: Presence of cruciates, patellar and femoral con-dylar hypoplasia. Fibula and Tibia: Presence/ absence, length and deformity. Ankle: Normal/Ball and socket/ valgus. Heel: Presence of tarsal coalition and deformity (valgus, equinus). Ray: Number of rays present in the foot. Conclusion: Congenital longitudinal lower limb deficiency is a spectrum of disorder involving the entire lower limb. Existing classifications do not represent the complete morphology of the entire involved lower limb and therefore a systematic method of characterizing the morphology of the lower limb is more useful in planning limb reconstruction

To describe the treatment and morbidity of lower limb (LL) football fractures in regard to returning to football in a known UK population at all skill levels. All football fractures during 2007–2008 sustained by the Lothian population were prospectively collected with the diagnosis being confirmed by the senior author when patients attended the only adult orthopaedic service in Lothian. Patients living outside the region were excluded from the study. Patients were contacted in August 2010 to ascertain their progress in return to football. There were 424 fractures in 414 patients. 366 fractures (86%) in 357 patients (86%) were followed up with a mean interval of 30 months (range 24–36 months). Of these 32% were sustained in the LL. 88% of LL injuries returned to football compared to 85% of upper limb (UL) fractures (p=0.4). 60% of LL patients were treated as outpatients. 35% were operated on −26% had ORIF and 9% IM Nailing. The most common LL fractures were Ankle 38%, Tibial Diaphysis 14%, 5th Metatarsal 11%, Fibula 9% and Great Toe 7%. Only one of the fractures was an open injury - Gustillo Class 1 2nd Phallanx Foot. Three of the 12 patients who underwent IM nailing required fasciotomy. One patient in the operative cohort developed a significant infection. The mean time for return to football for conservative treatment was 17 weeks (range 3–104 weeks), and for operative treatment 41 weeks (range 10–104 weeks). 91% of patients treated conservatively returned to football, compared to 84% of the operative cohort (p=0.3). 43% of patients had ongoing symptoms from their injury. 9% of the operative cohort required removal of metal work or further operative intervention. 83% of patients returned to the same level of football or higher following injury. Patients under 30 were 1.4 times more likely to return to sport than those over 30 (p<0.05). We have previously demonstrated that football is the most common cause of sporting fracture(1), yet little is known about patient outcome following fractures. LL fractures are less common than UL fractures, and there is no difference in the proportion of patients returning to football following LL fractures and UL fractures. Over half of LL fractures are treated as outpatients and the incidence of open fractures is very low. There is no significant difference between the operative and conservative groups in their return to football. In the over 30 age group, sustaining a fracture may act as a catalyst to quit football. This may explain the higher non-return rate compared to the under 30 age group. 43% of patients perceive that they have ongoing problems with their fracture over 24 months post-injury reflecting the considerable morbidity of football-related fractures