The femoral head receives blood supply mainly from the deep branch of the medial femoral circumflex artery (MFCA). In previous studies we have performed anatomical dissections of 16 specimens and subsequently visualised the arteries supplying the femoral head in 55 healthy individuals. In this further radiological study we compared the arterial supply of the femoral head in 35 patients (34 men and one woman, mean age 37.1 years (16 to 64)) with a fracture/dislocation of the hip with a historical control group of 55 hips. Using CT angiography, we identified the three main arteries supplying the femoral head: the deep branch and the postero-inferior nutrient artery both arising from the MFCA, and the piriformis branch of the inferior gluteal artery. It was possible to visualise changes in blood flow after fracture/dislocation. Our results suggest that blood flow is present after reduction of the dislocated hip. The deep branch of the MFCA was patent and contrast-enhanced in 32 patients, and the diameter of this branch was significantly larger in the fracture/dislocation group than in the control group (p = 0.022). In a subgroup of ten patients with avascular necrosis (AVN) of the femoral head, we found a contrast-enhanced deep branch of the MFCA in eight hips. Two patients with no blood flow in any of the three main arteries supplying the femoral head developed AVN. Cite this article: Bone Joint J 2013;95-B:1453–7

Introduction. Unstable dorsal fracture/dislocation of PIP joint is a complex injury and difficult to treat. Different treatment methods have been described with varying results. We describe a novel technique to combine fracture fixation with volar plate repair using micro anchor suture. Material and methods. Between July and December 2005, 11 consecutive patients with unstable dorsal PIP joint dislocations underwent open reduction and volar plate repair using our technique. Nine patients had dorsal fracture dislocations and two had open dislocations. All patients were males and their average age was 26 years. All patients were reviewed with the minimum follow up of 12 months. The pain score, range of movements and grip strength were recorded and compared to the normal side. Operative Technique. Volar approach was made using a semi Brunar incision. One or two micro bioabsorbable anchors (Mitek, Ethicon Ltd, UK) were used to stabilise the joint and repair the volar plate. Additional anchor was used to repair the collateral ligament when indicated. Post-operatively the hand was rested in Edinburgh functional splint for 10 days followed by active and assisted range of movements under hand physiotherapist supervision. Results. 10 out 11 patients had excellent pain relief. The average range of movement of the PIP joint was 100 degrees. One patient with neglected PIP joint fracture dislocation for 10 weeks had mild residual pain and stiffness. The mean grip strength was 87% of that of contralateral normal side. All patients returned to their same work as before. 8 out of 9 patients returned to play their regular sports at the same level. All patients were satisfied with the functional outcome. Conclusion. Combined fracture fixation and volar plate repair through anterior approach using micro bioabsorbable anchors appears to be very effective way of treating this otherwise complex unstable fracture/dislocation of PIP joint

AIM: The diagnosis of the posterior dislocation can be missed. Chronic missed locked posterior fracture dislocations of the shoulder raise a difficult problem for treatment especially in young patients. The options for the treatment depend on the size of the humeral defect, the age of the patients and the time from injury to diagnosis. METHOD: Eleven patients with missed locked posterior fracture dislocation of the glenohumeral joint, 25 to 52 years of age were treated with open reduction and transfer of the subscapularis tendon to the defect (modified Mc Laughlin technique). The interval from the injury to diagnosis ranged from 6 weeks to 6 months. Significant pain, prominence of the acromion, posterior bulging and complete loss of external rotation of the shoulder led to the diagnosis that was confirmed by an axillary radiograph and C.T. scan. The humeral head defect was from 20 to 40 per cent of the articular surface. Four patients also had a minimally displaced fracture of the upper humerus. RESULTS: The average length of follow up was 3,5 years. Stability was restored and maintained in all cases. Six patients reported little or no pain. They had almost full range of motion and no functional restriction in the ADL. The remaining five patients had mild pain and slight restriction of movements mainly in external rotation in abduction (elevation 150°, external rotation 25°, internal rotation to L5). These patients had mild functional dysfunction in the ADL. All patients had normal muscle strength and constant score from 60–82. CONCLUSION: Once the diagnosis is established, open reduction and subscapularis tendon transfer reliably decreased patients pain level and significally improved the range of motion and the level of function, restoring stability of the joint. The alternative for older patients or patients with humeral head defect greater than 40% is the use of shoulder prosthesis

Aims

This study aimed to answer the following questions: do 3D-printed models lead to a more accurate recognition of the pattern of complex fractures of the elbow?; do 3D-printed models lead to a more reliable recognition of the pattern of these injuries?; and do junior surgeons benefit more from 3D-printed models than senior surgeons?

Crescent fractures are represented by a spectrum of morphological fracture patterns, sharing a common mechanism of injury. We propose three distinct types according to the extent of Sacroiliac (SI) joint involvement and the size of the crescent fragment, which enables a pragmatic choice of surgical approach and stabilisation technique. Crescent fractures are fracture dislocations of the SI joint in which there is variable amount of disruption of the SI ligaments extending proximally as a fracture of the posterior iliac wing. We identified three groups of Crescent fractures according to the extent of SI joint involvement, relationship of the fracture line to the S1 and S2 nerve root foramina on anteroposterior and outlet plain radiograph views, and CT films. Type I involves the less than inferior third of the SI joint with a large posterior iliac fragment left attached to the sacrum. This is best approached anteriorly for stabilisation. Type II has between one-third to two-thirds involvement of the SI joint and is treated according to Helfet's technique. Type III has a very small crescent fragment left attached to the sacrum and the inferior two-thirds of the SI joint is disrupted. This is treated with percutaneous SI screws, but will need anterior open reduction in delayed presentations. Based on this, we treated sixteen patients and followed them for at least two years. There were four Type I, four Type II and eight Type III fractures. Fifteen had anatomical reduction and stabilisation of the SI joint with good functional results. Delayed referral, the presence of significant soft tissue injury posteriorly and infected external fixator pins. From our experience we would like to propose this functional classification of crescent fractures which we find useful in making a choice of surgical approach and stabilisation technique to achieve satisfactory reduction and stabilisation of sacroiliac joint

Background. Evidence concerning the management of dorsal fracture dislocation (DFD) of the proximal interphalangeal joint (PIPJ) in the hand has been limited by small sample size and case heterogeneity within studies. This retrospective case control study examined clinical outcome of this specific subgroup managed by three different methods. Methods. Patients undergoing fixation of unstable DFD of the PIPJ between March 2005 and August 2011 were identified from theatre records. A retrospective review of case-notes and radiographs was undertaken to determine fracture characteristics, fixation methods and clinical outcomes. Results. 21 patients with DFD of the PIPJ were identified with a mean age of 40 years (range 22–65). The majority of patients were male (17/21, 81%) and the mean percentage articular surface involvement of fractures was 41% (Std. Dev. 11.3%). PIPJ DFD's were managed by reduction of the PIPJ and temporary transarticular K-wire fixation (12/21, 57%), hemi-hamate arthroplasty (7/21, 33%), or by open reduction and internal fixation (2/21,10%). PIPJ ROM following hemi-hamate arthroplasty was 65° (range 34–108°) and was greater than K-Wire fixation at 56. o. (range 9–85. o. ) (p = 0.82). Hemi-hamate arthroplasty and K-wire fixation resulted in fixed flexion deformity of 20° (range −12–52°) and 15° (range −6–50°) respectively (p = 0.61). Hand therapy data was available for one case undergoing ORIF with a post-operative ROM of 60° and 30° of fixed flexion. There was poor correlation between articular surface involvement and post-operative range of movement at the PIPJ (Co-efficient −0.16, p = 0.55). Conclusion. We present a relatively large series of outcomes following DFD of the PIPJ. We were unable to demonstrate any difference in post operative clinical outcomes between the fixation methods examined

Aims

The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations.

Femoral head fractures i.e. Pipkin fractures are uncommon injuries and there are very few large series in literature with reported outcomes. There remain many controversies regarding diagnosis and management. This study, which is the largest single surgeon experience, is an attempt to get answers to some of these controversies.

This series is an analysis of 51 patients with femoral head fractures. There were 44 males and seven females. The right side was involved in 36 and left in 16 patients. According to Pipkin classification these were 13 Pipkin-I, 27 Pipkin-11, three Pipkin-111 and eight Pipkin-IV fractures. Thirty-two patients were managed by surgical intervention. The surgical approach was posterior in Pipkin-I and in seven cases of Pipkin-II fractures. Another eight Pipkin II cases were managed surgically by anterior Smith-Peterson approach while another eight fractures were accessed by posterior approach with flip osteotomy. The Pipkin III and IV cases were managed using surgical approaches that varied depending on the pattern of associated acetabular injury. The fractured fragment, if small, was excised and, if large, was re-fixed using small fragment partially threaded cancellous screw. Follow-up of two to eight years was available in 39 cases.

Using Thompson and Epstein criteria, 26 patients were rated as having good results, eight fair and five poor results. Early osteoarthritic changes were seen in five patients, avascular necrosis of the femoral head in three patients and one patient had re-fracture in same hip during an epileptic fit with subsequent fixation problems. Of four patients with sciatic nerve injury, two had persisting motor deficit. There was one case of heterotopic ossification.

Most Pipkin-I fractures can be managed by closed reduction, Pipkin-II fractures usually require ORIF. The best results have been obtained by a Smith-Peterson approach if the hip has already been reduced, but posterior approach with flip osteotomy offers the best exposure if the hip is still unreduced. Pipkin III patients need hip replacement if presentation is late, while ORIF gives acceptable outcome in Pipkin IV fractures.

We present a case of a 14 year old who sustained an isolated injury to her foot while horse riding. X-rays demonstrated a medial and plantar dislocation at the level of the talo-navicular and calcaneo-cuboid joint, with associated fractures of the cuboid and navicular. This was treated initially with open reduction and fixation with kirschner wires as the injury was grossly unstable and reduction difficult to maintain with casting alone. CT scan was then performed prior which confirmed satisfactory reduction of the dislocation and fixation with the k wires so these were left in situ and the navicular fracture reduced and fixed with a barouk screw.

The Chopart joint was first described by French surgeon Francois Chopart as the talo-navicular and calcaneo-cuboid joints were a practical level for amputation. Injury here is a rare but missed in 40% at presentation. Pure dislocation occurs in 10–25% with most having concomitant fractures. The Chopart joint has critical role in balance and stability in normal gait. Early recognition allows prompt reduction and fixation of these injuries which has been associated with a better outcome. However these are severe injuries and patients should be counselled on potential long term functional impairment even with optimal management.

Introduction

We aim to assess whether radiographic characteristics of the greater tuberosity fragment can predict rotator cuff tears inpatients with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity.

Dislocation and carpal fracture-dislocation are a rare injury, interesting capsula and ligaments, with a variable damage of the vascularization. Classification is difficult for the complexity on this lesion.

The aim of our work is to underline how the best final clinical result is achieved after an immediate treatment of reduction and stabilization of bone injury.

We considered two groups:

A: 13 patients, who have been observed since 1991 until 1998:

B: Another group is at short term is since July 2002 until 2005 and is in 20 patients with 21 wrists 1 is bilateral.

Finally we think that is necessary, to avoid the instability and pseudoartrosis on the scaphoid, to treat all the transcapholunate dislocation with open reduction and stabilisation, as agreed with literature.

Dislocation and carpal fracture-dislocation are a rare injury, interesting capsula and ligaments, with a variable damage of the vascularization. Classification is difficult for the complexity on this lesion.

The aim of our work is to underline how the best final clinical result is achieved after an immediate treatment of reduction and stabilization of bone injury.

We considered two groups:

A: 8 patients, who have been observed since july ’93 until 1996 ; all the patients were men who had work or car accidents, with outstretched upper extremity. The ages of the patients ranged from 19 to 34 years.. All patients were followed for an average of 8 years

1 is bilateral

3 wrists reoperated for lacking initial reduction or for the general initial condition

Assesment of the patients includeds clinical rating and roentgenografich analysis. The clinical scoring included pain, functional status, range of motion and grip strength.

Among the various classifications, we took into account the one proposed by Allieu, based on the radio-lunate ligament, consequently this classification offers an important prognostic factor.

In one of our cases there was assocciated a fracture of the radial stiloid, and in other one a posterior dislocation of the elbow.

We treated all the patients with a volar approach, the stabilitation of the carpus and scaphoid was achieved utilizing K wires in four cases, microscrew in two patients for scaphoid’s fracture and in other one the Herbert screw in the A group

In the B recent group we used in all cases K wiring, and herbert screw in 8 wrists, microscrews in one , and internal capsulodesis in the 2 last for perilunate isolated dislocation

The initial failing of reduction is due to an unstable reduction in very injured patient ( we use only k wire for the navicular)

10 patients in the second B group have been treated by the same first Author

After surgery treatment, the wrist was immobilizated in a splint for 6 weeks, then a careful mobilitation was started.

Finally we think that is necessary, to avoid the instability and pseudoartrosis on the scaphoid, to treat all the transcapho-lunate dislocation with open reduction and stabilitation, as agreed with literature.

To devise an operative approach to the management of acute posterior fracture-dislocation of the shoulder which restores or retains normal proximal humeral anatomy and allows the early restoration of a complete, stable range of motion.

Since 1996 we have treated four male patients (five shoulders) aged between 19 and 54 years at the time of first dislocation with autogenous iliac grafting of the anterior humeral head defect for acute and acuteon-chronic posterior dislocation of the shoulder. Two patients had epilepsy: one of these patients had bilateral dislocations. Two patients had motorbike RTAs. The deltopectoral approach with vertical division of the subscapularis tendon was used in all cases. The defects comprised 20– 25% of the volume of the humeral head at the equator after preparation for grafting. Grafts were fixed with compression screws. The subscapularis tendon was repaired anatomically. Active-assisted rehabilitation was started immediately, restricting external rotation to the neutral position for six weeks, thereafter allowing full rotation and elevation as comfort allowed.

The patient with bilateral dislocations died of unrelated causes 18 months after surgery. He was reported to have had no further dislocations, complete pain free functional use of both shoulders and no complications of the procedure. The remaining three patients were reviewed at a minimum of 20 months after surgery (average 35 months). All grafts had incorporated. There was no graft collapse or boundary arthrosis. The absolute Constant scores were 85.1, 90.9, and 89.2; the subjective shoulder scores were 98%, 90%, and 99%; the Oxford rating scale for pain scores were 14 out of 60, 13 out of 60, and 14 out of 60; and the Oxford rating scale for instability scores were 14 out of 60, 15 out of 60 and 15 out of 60. There were no redislocations, or complications of the procedures.

Posterior stability appears more dependant on surface arc of contact than on capsular integrity, in contrast to the anteriorly unstable shoulder. Restoration of the articular surface arc of contact by segmental autogenous grafting retains normal humeral anatomy, allows normal motion with excellent cuff function, and a return to normal daily activities. The procedure has been shown to be safe at a minimum of 20 months.

Fracture-dislocations of the tarsometatarsal (Lisfranc) joints are frequently overlooked or misdiagnosed at initial presentation. This is a comparative cohort study over a period of five years comparing primary open reduction and internal fixation in 22 patients (23 feet) with secondary corrective arthrodesis in 22 patients (22 feet) who presented with painful malunion at a mean of 22 months (1.5 to 45) after injury. In the first group primary treatment by open reduction and internal fixation for eight weeks with Kirschner-wires or screws was undertaken, in the second group treatment was by secondary corrective arthrodesis. There was one deep infection in the first group. In the delayed group there was one complete and one partial nonunion.

In each group 20 patients were available for follow-up at a mean of 36 months (24 to 89) after operation. The mean American Orthopaedic Foot and Ankle Society midfoot score was 81.4 (62 to 100) after primary treatment and 71.8 (35 to 88) after corrective arthrodesis (t-test; p = 0.031).

We conclude that primary treatment by open reduction and internal fixation of tarsometatarsal fracture-dislocations leads to improved functional results, earlier return to work and greater patient satisfaction than secondary corrective arthrodesis, which remains a useful salvage procedure providing significant relief of pain and improvement in function.

Purpose: The management of Dorsal Fracture Dislocations of the PIP joint is challenging, especially for the unstable ones. Complications are common and often lead to functional disability. Many treatment methods have been described in the past, illustrating that no optimal solution has been found. In the Hemi-Hamate autograft technique, introduced by Hastings in 1999, a reconstruction of the volar lip joint surface and stabilization of the joint is achieved. This autograft can be seen as a model of a non vascularised bone-cartilage composite graft. The purpose of the present retrospective study was to evaluate the long term results of the hemi-hamate autograft technique in unstable PIP fracture-dorsal dislocations with special reference to posttraumatic degenerative arthritis common in non vascularized joint transfers.

Materials and Methods: We report the results of 9 patients operated between November 2002 and March 2008 and with a minimum follow up of 26 months. The mean follow-up time was 56 months. There were 6 men and 3 women with a mean age at operation of 45 years (23–66). All fractures were unstable with comminution of the volar lip. In 3 patients the dominant hand was involved. The middle finger was injured in 4 patients, the ring finger in 4 and the little finger in 1 patient. All patients were treated with the operation technique described by Hastings and reanalyzed by Williams. The volar base of middle phalanx was debrided and reconstructed by a pre-sized autograft harvested from the dorsal side of the homolateral hamatum, and fixed with mini screws. A standard rehabilitation program was used postoperatively. Clinical (ROM, grip strength), radiographic and subjective outcomes (VAS) were examined in all patients.

Results: At the last follow up, the injured finger had an average active ROM at the MCP joints of 97o (90o–115o) at the PIP 69 o (45 o –95 o) and at the DIP 59 o (30 o –90 o). The extension lag in the PIP joints were mean 10 o (0 o –30 o). Grip strength of the injured hand was mean 89% of the uninjured contralateral side. On radiographs, severe arthritis in the treated PIP was found in 2 of 9 patients. Another 2 patients had degenerative arthritis in several PIP. The average subjective score of patient’s satisfaction was 85 (20–100) in a scale 0–100 (100 best).

Conclusions: The Hemi-Hamate autograft technique is a technically demanding operation but an alternative to arthrodesis or primary joint arthroplasty in the treatment of Fracture-Dorsal Dislocations of PIP joint. Our results are good and comparable to previously reported results (Williams 2001). Some deterioration will occur regarding joint osteoarthritis but a high degree of subjective patient satisfaction was found. Further studies and methods to decrease the osteoarthritis would be preferential.

Abstract: Monteggia fracture dislocation in an uncommon injury in children. In the less severe injuries, with minimum angulation of the ulnar fracture, the radial head dislocation is frequently missed. The treatment of these late recognised injuries (more than one month) remains controversial, with frequent complications and high failure rates reported in literature. We have devised a new operative technique which has proved so far to be very successful and reliable. The procedure can be recommended only for children who have no major intra-articular injury, no epiphyseal damage and only mild adaptive changes of the radial head. It is also contraindicated if there is significant overgrowth of the radius as well as secondary changes in the proximal and distal radioulnar joints. The parents are warned of possible complications and residual loss of some movements. Under general anaesthesia, a curved longitudinal incision is made centred over the ulnar deformity extending proximally to the lateral epicondyle. The essence of the operation is the oblique ulnar metaphyseal osteotomy. The cut is made starting proximal medial to distal lateral. The osteotomy recreates the instability allowing open reduction of the radial head. It also allows for ulnar lengthening by the sliding of the osteotomised surfaces with graft interposition if necessary. The radial head is approached between the anconeus and wrist extensors, through the same exposure. The annular ligament is dividend and radial head reduced into its anatomical position. The ulna is securely fixed in the angulated position using a one third tubular plate. Finally, after checking the stability of the radial head in all forearm movements, the annular ligament is repaired. An above elbow cast is applied with forearm in supination and elbow in 90 degrees of flexion. The cast is worn for six weeks, with weekly check radiographs. Active use of the arms is encouraged after this with follow up at increasing intervals. The follow up of our cases has shown that the ulnar angulation completely remodels, with normal development of the radial head. A functional range of forearm rotation and full flexion/extension at the elbow are regained with time. We have not noted any residual subluxation/dislocations in our cases

Anterior elbow dislocations often occur as a fracture-dislocation in which the distal humerus is driven through the olecranon, causing either a simple oblique fracture of the olecranon or a complex, comminuted fracture of the proximal ulna. The purpose of this study was to characterise the morphology and to evaluate the surgical treatment of this injury.

Thirteen patients (8 women and 5 men) with a mean age of 42 years were included in this study. Four patients had a simple, oblique fracture of the olecranon and 9 a complex, comminuted fracture of the proximal ulna. Six patients had an associated fracture of the coronoid process which was detached as a large fragment and 7 an additional fracture of the radial head. In all cases the collateral ligaments were found intact. All fractures were treated by open reduction and internal fixation through a midline dorsal approach. Simple fractures of the olecranon were treated with tension-band wiring while comminuted fractures were fixed with a plate and screws. Fractures of the coronoid process were stabilised by interfragmentary screws or small plates. The concomitant radial head fractures were treated by excision of small fragments, internal fixation or radial head replacement.

The average follow up was 71 months. According to the functional scale of Broberg and Morrey, the results were excellent in 8 patients, good in 2, and poor in 3. Mild arthritis was observed in one patient.

Transolecranon fracture –dislocation of the elbow is often misidentified as an anterior Monteggia lesion or a simple fracture of the olecranon. Differential diagnosis between these lesions is imperative. Consequently, anatomical restoration of the trochlear notch in cases of transolecranon fracture –dislocations can be achieved leading to good long-term results.

Thoracolumbar junction of the spinal column is the common site of spinal trauma and is often complicated by neurological dysfunction. From 1997 to 2000, there were 12 patients surgically stabilized. 8 of them were victims of major trauma while the rest was after a trivial fall in osteoporotic spine. Lengthen of follow-up ranged from 6 to 42 months.

Ages of the patients in the major trauma group were from 22 to 65. Except the one who had anterior approach because of multiple level lesions, all fractures after major trauma were initially relocated and stabilized posteriorly. Subsequent anterior procedures were necessary in three of them because of significant residual spinal canal stenosis. All except one had satisfactory lower limb function on follow up. Two patients who were paralysed on admission were able to walk independently and 4 others had improved by at least one Frankel grade. Return of neurological function was usually observed within the first week after the procedure. Residual sphincter dysfunction was however, a common problem.

The management of four osteoporotic spinal fractures in thoracolumbar junction was more unpredictable. Patients were from 66 to 92 years old. Anterior decompression was often performed because of the presence of retropulsed fragment. Although some improvement of lower limb function could be achieved, rehabilitation in three of them was complicated by loss of reduction or failure of the implant.

Recovery of the neurological function in the lower limbs was found to have no correlation with the amount of stenosis of the spinal canal. Most of the damage occurred probably at the time of injury. The sphincter control was most difficult to rehabilitate after an insult to the conus medullaris.