Displaced fractures of the radial neck in children can lead to limitation of elbow and forearm movements if left untreated. Several management techniques are available for the treatment of radial neck fractures in children. Open reduction can disturb the blood supply of the soft tissue surrounding the radial head epiphysis and is associated with more complications.

We report our experience of treating 14 children between the age of 4 and 13 years, who had severely displaced radial neck fractures (Judet type 111 and 1V). 12 patients were treated with indirect reduction and fixation using the Elastic Stable Intramedullary Nail (ESIN) technique, (3 with assisted percutaneous K-wire reduction) and 2 had open reduction followed by ESIN fixation of the radial head fragment. This method reduces the need for open reduction and thus the complication rate. Three patients had associated fractures of the same forearm which was also treated surgically at the same time. We routinely immobilised the forearm for two weeks and removed the nail in all cases in an average of 12 weeks. We had no complication with implant removal.

All 14 patients have been followed up for average of 28 months. One patient (7%) developed asymptomatic avascular necrosis (AVN) of the head of radius. Thirteen patients (93%) had excellent result on final review. One patient had neuropraxia of the posterior interosseous nerve which recovered within 6 weeks.

In conclusion we advocate ESIN for the closed reduction and fixation of severely displaced radial neck fractures in children. It remains a useful fixation method even if open reduction is required and allows early mobilisation.

Introduction

To compare the union rates and post-operative mobility of antegrade intramedullary nailing of osteoporotic traumatic supracondylar femoral fractures (AO classification A to C2) with those of plating.

Introduction. IM (Intra Medullary) nail fixation is the standard treatment for diaphyseal femur fractures and also for certain types of proximal and distal femur fractures. Despite the advances in the tribology for the same, cases of failed IM nail fixation continue to be encountered routinely in clinical practice. Common causes are poor alignment or reduction, insufficient fixation and eventual implant fatigue and failure. This study was devised to study such patients presenting to our practice and develop a predictive model for eventual failure. Materials and Methods. 57 patients who presented with failure of IM nail fixation (± infection) between Jan 2011 – Jun 2020 were included in the study and hospital records and imaging reviewed. Those fixed with any other kinds of metalwork were excluded. Classification for failure of IM nails – Type 1: Failure with loss of contact of lag screw threads in the head due to backing out and then rotational instability, Type 2A: Failure of the nail at the nail and lag screw junction, Type 2B: Failure of the screws at the nail lag screw junction, Type 3: Loosening at the distal locking sites with or without infection. X-rays reviewed and causes/site of failure noted. Results. Total patients - 57. Demography - Average age - 58.9 years, 22 Males and 35 females. Eleven patients were noted to have an infection at the fracture site that needed oral or IV antibiotics.16 patients - at least 1 cerclage wire for fracture reduction and fixation + IM Nail. Subtrochanteric fractures (42/57) were the most common to fail. In those fractures with postero-medial comminution, locking of the lag screw in position thus preventing backout can prevent failure. In type 2 failures, preventing varus fixation by early open reduction and temporary fixation with plates and screws can achieve improved results. Those with type 3 failures with periosteal reaction should be considered to be infected until proven otherwise. Conclusions. This classification for failure of IM nails in the femur can be used as a predictive model for failures and allow early recognition and intervention to tackle them

Introduction. Bone transport and distraction osteogenesis have been shown to be an effective treatment for significant bone loss in the tibia. However, traditional methods of transport are often associated with high patient morbidity due to the pain and scarring caused by the external frame components transporting the bone segment. Prolonged time in frame is also common as large sections of regenerate need significant time to consolidate before the external fixator can be removed. Cable transport has had a resurgence with the description of the balanced cable transport system. However, this introduced increasingly complex surgery along with the risk of cable weave fracture. This method also requires frame removal and intramedullary nailing, with a modified nail, to be performed in a single sitting, which raised concern regarding potential deep infection. An alternative to this method is our modified cable transport system with early intramedullary nail fixation. Internal cables reduce pain and scarring of the skin during transport and allow for well controlled transport segment alignment. The cable system is facilitated through an endosteal plate that reduces complications and removes the need for a single-stage frame removal and nailing procedure. Instead, the patients can undergo a pin-site holiday before nailing is performed using a standard tibial nail. Early intramedullary nailing once transport is complete reduces overall time in frame and allows full weight bearing as the regenerate consolidates. We present our case series of patients treated with this modified cable transport technique. Methodolgy. Patients were identified through our limb reconstruction database and clinic notes, operative records and radiographs were reviewed. Since 2019, 8 patients (5 male : 3 female) have undergone bone transport via our modified balanced cable transport technique. Average age at time of transport was 39.6 years (range 21–58 years) with all surgeries performed by the senior author. Patients were followed up until radiological union. We recorded the length of bone transport achieved as well as any problems, obstacles or complications encountered during treatment. We evaluated outcomes of full weight bearing and return to function as well as radiological union. Results. 4/8 bone defects were due to severely comminuted open fractures requiring extensive debridement. All other cases had previously undergone fixation of tibial fractures which had failed due to infection, soft tissue defects or mal-reduction. The mean tibial defect treated with bone transport was 41mm (range 37–78mm). From the start of cable transport to removal of external fixator our patients spent an average of 201 days in frame. 7/8 patients underwent a 2-week pin-site holiday and subsequent insertion of intramedullary nail 2 weeks later. One patient had sufficient bony union to not require further internal fixation after frame removal. 10 problems were identified during treatment. These included 4 superficial infections treated with antibiotics alone and 5 issues with hardware, which could be resolved in the outpatient clinic. 1 patient had their rate of transport slowed due to poor skin quality over the site of the regenerate. 4 obstacles resulted in a return to theatre for additional procedures. 1 patient had a re-do corticotomy and 3 had revision of their internal cable transport constructs due to decoupling or screw pull out. 1 patient had residual ankle joint equinus following treatment which required an Achilles tendon lengthening procedure. Another patient underwent treatment for DVT. There were no deep infections identified and no significant limb length discrepancies or deformities. Conclusions. Overall, we have found that our modified balanced cable transport technique has allowed for successful bone transport for significant defects of the tibia. We have learned from the obstacles encountered during this case series to avoid unnecessary return trips to theatre for our future transport patients. The internal cable system allowed all patients to complete their planned transport without excessive pin tract scarring or pain. Early conversion to intramedullary nail allowed for a shorter time in frame with continued full weight bearing as the regenerate consolidated. No metalwork failure or deformity has occurred in relation to docking site union. All patients have made a good return to pre-operative function during their follow-up period with no evidence of late complications such as deep infection

This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering interventions for treating distal femur fractures in adults; ultrasound and shockwave therapy for acute fractures in adults; and local corticosteroid injection versus placebo for carpal tunnel syndrome.

Purpose of study:. The treatment goals in diaphyseal radius fractures are to regain and maintain length and rotational stability. Open reduction and plating remains the gold standard but carries the inherent problems of soft tissue disruption and periosteal stripping. Intramedullary nailing offers advantages of minimally invasive surgery and minimal soft tissue trauma. The purpose of this study is to describe the results of locked intramedullary nailing for adult gunshot diaphyseal radius fractures. Methods:. A retrospective review of clinical and radiological records was performed on patients with intramedullary nailing of isolated gunshot radius fractures between 2009 and 2013. Results:. Twenty-two nails were inserted in 22 patients, all males with a mean age of 28.9 years (range 19–40). Follow-up was for an average period of 11 weeks (range 6–24). One patient had a median nerve palsy and 2 a posterior interosseous nerve palsy pre-operatively. All operations were performed within 3 to 12 days of the injury. No primary bone grafting was performed. All fractures united with the index procedure. Average time to union was 10 weeks (range 8–24). Fourteen patients (64%) had their radial bow restored and maintained; these patients had minimal comminution in the middle to distal third of the radius. The bow could not be satisfactorily restored in severely comminuted fractures in the proximal third of the radius. Using the Anderson classification outcome was excellent in 14 patients (64%), satisfactory in 6 (27%) and unsatisfactory in 2 (9%). There were no complications associated with the surgery and one patient required nail removal for implant migration. Conclusion:. Intramedullary nail fixation of gunshot radius fractures has shown promising results in our hands with no significant complications. The fracture site and zone of comminution directly influenced our ability to restore radial bow

Purpose of the study:. To determine the outcomes of cases converted from an external fixator to an internal fixation device in the management of limb reconstructions and deformity corrections. Method:. A retrospective review of 18 patients, that underwent a conversion procedure to internal fixation following long term external fixation use, was done. This comprised 24 limbs. Inclusion criteria: All cases of long term external fixator use converted to internal fixation over a 5 year period. Average external fixation time, pin site care, conversion timing, surgical device used as well as outcome were documented. Results:. The mean treatment time in an external fixator was 185 days (61–370). The reasons for conversion included patient dissatisfaction, pin tract sepsis and a refracture. The conversion procedures included 8 intramedullary nail fixations and 16 plate and screw fixations. An acute conversion was identified as an internal fixation that was done in the same sitting as external fixator removal. A delayed conversion was any internal stabilisation that was done thereafter. In total, the complication rate associated with conversion to internal fixation following long term external fixation was 25%, mainly due to persistent non-union or sepsis. In the 8 conversions to intramedullary nails, 7 were acute: 4 had good outcomes with sepsis free union being achieved. 3 had poorer outcomes with a non-union and 2 amputations being documented. The single delayed nailing achieved union. In the 16 conversions to plate fixation, 13 achieved union. 10 were acute conversions and 3 were delayed. The remaining 3 that developed complications included 2 acute conversions with septic non-unions and a single delayed conversion which resulted in sepsis. Conclusion:. Conversion of an external fixator to an internal fixator in a non-acute reconstructive setting has a 75% success rate. In the acute conversion group (19 cases), plate and screw fixation had a superior outcome. In the delayed conversion group (5 cases), intramedullary fixation was favoured

Hind foot Charcot deformity is a disastrous complication of diabetic neuropathy and can lead to instability, ulceration and amputation. The treatment of these patients is controversial. Internal stabilisation and external fixation have demonstrated variable results of limb salvage and some authorities thus advise patients to undergo elective amputation. We report a series of 9 diabetic patients with severe hind foot deformity complicated by ulceration in 5/9, who underwent acute corrective internal fixation with successful correction of deformity, healing of ulceration in 4/5 patients and limb salvage in all cases. Conservative measures such as total contact casting were tried in 5 patients had predominant varus deformity, 2 with valgus deformity and 2 with unstable ankle joints. 5 patients had developed secondary ulceration. All patients underwent corrective hind foot fusion with tibio-talo-calcaneal arthrodesis using a retrograde intramedullary nail fixation and screws and bone grafting. One patient also with fixed planovalgus deformity of the foot underwent a corrective midfoot reconstruction. Patients were followed up in a diabetic/orthopaedic multidisciplinary foot clinic and were treated with total contact casting. (Mean follow up time was 15.6 ±6.9months) In all patients the deformity was corrected with successful realignment to achieve a plantigrade foot. Healing of the secondary ulcers was achieved in 4/5 cases and limb salvage was achieved in all cases. Three patients underwent further surgical procedure to promote bone fusion. One patient required removal of a significantly displaced fixation screw. Two patients had postoperative wound infections which that were treated with initially intravenous antibiotic therapy and then negative pressure wound therapy. In conclusion, internal fixation for severe hind foot deformity together with close follow up in a multidisciplinary diabetic/orthopaedic foot clinic can be successful in diabetic patients with advanced Charcot osteoarthropathy and secondary ulceration