Purpose of study:. The presence of an L5 transverse process fracture is reported in many texts to be a marker of pelvis fracture instability. There is paucity of literature to support this view. Available studies have been performed on patients who were already known to have a pelvis fracture. No study has attempted to document the presence of this lesion in the absence of a pelvis fracture. Primary aim: To identify the correlation between the presence of a L5 transverse process fracture and an unstable pelvic ring injury. Secondary aim: To establish whether a L5 transverse process fracture can occur in the absence of a pelvis fracture. Methods:. We conducted a retrospective review of all CT scans performed in patients who presented to a Level 1 Trauma Unit for blunt abdomino-pelvic trauma between January 1, 2012 and August 28, 2013. A total of 203 patients met our inclusion criteria. Results:. Fifty four of these 203 patients (26%) sustained a pelvis fracture. Of these 54 patients 26 (48%) had an unstable fracture pattern according to the AO classification. Five of these 26 patients (19%) had an associated L5 transverse process fracture. Seven (12%) had an L5 transverse process fracture associated with a stable fracture pattern. Three patients (1.4%) had an isolated L5 transverse process fracture in the absence of a pelvis fracture. Conclusion:. This study confirms the association between the presence of a L5 transverse process fracture and an unstable pelvis fracture pattern. This injury is rarely seen in the absence of a pelvis fracture so its presence should alert the treating clinicians to the existence of a pelvis fracture

Aims. Compression and absolute stability are important in intra-articular fractures such as transverse olecranon fractures. This biomechanical study aims to compare tension band wiring (TBW) with plate fixation by measuring compression within the fracture. Methods. A cross-over design and synthetic ulna models were used to reduce variation between samples. Identical transverse fractures were created using a 0.5mm saw blade and cutting jig. A Tekscan(tm) force transducer was calibrated and placed within the fracture gap. Twenty TBW or Acumed(tm) plate fixations were performed according to the recommended technique. Compression was measured while the constructs were static and during simulated elbow range of movement exercises. Dynamic testing was performed using a custom jig reproducing cyclical triceps contraction of 20N and reciprocal brachialis contraction of 10N. Both fixation methods were tested on each sample. Half were randomly allocated to TBW first and half to plating first. Data was recorded using F-scan (v 5.72) and analysed using SPSS(tm) (v 16). Paired T-tests compared overall compression and compression at the articular side of the fracture. Results. The mean overall compression for plating was 819N (+/− 602N 95%CI), TBW overall compression: 77N (+/−19N 95%CI) (P=0.039). Articular side compression for plating: 343N (+/− 276N 95%CI), TBW: 1N (+/− 2N 95%CI). (P=0.038). During simulated movements, overall compression reduced in both groups: TBW -14N (+/−7N) Plating -173N (+/−32N) and no increase in articular side compression was detected in the TBW group. Conclusion. Precontoured plates such as the Acumed(tm) olecranon system can provide significantly greater compression, compared to TBW in transverse olecranon fractures. This was significant for compression over the whole fracture surface and specifically at the articular side of the fracture. Also, in TBW, overall compression reduced and articular side compression remained negligible during simulated triceps contraction, challenging the tension band principle

Periprosthetic femoral fractures are becoming increasingly common and are a major complication of total hip arthroplasty (THA) and bipolar hemiarthroplasty (BHA). We report a retrospective review of the outcomes of treatment of 11 periprosthetic fractures after femoral revision using a long stem. Eleven female patients with a mean age of 79.2 years (70 to 91 years) were treated for a Vancouver type B1 fracture between 1998 and 2013. The status of the initial arthroplasty was THA in 5 patients and BHA in 6 patients. The original diagnosis was femoral neck fracture in 5 patients, osteoarthritis in 5 patients, and avascular necrosis of femoral head in 1 patient. Seven patients had had a cemented femoral component and 4 had had a cementless femoral component. The mean numbers of previous surgeries were 3.2 times (2 to 5 times). A previous history of fracture in the same femur was found in 7 hips including 5 femoral neck fractures, 3 periprosthetic fractures. The cause of the latest revision surgery was aseptic loosening in 6 hips, periprosthetic fracture in 3 hips, and infection in 2 hips. The average time to fracture after femoral revision using a long stem was 106.5 months (12 to 240 months). The average follow-up was 58.9 months (8 to 180 months). The fracture pattern was a transverse fracture in 6 hips and an oblique fracture in 5 hips. The type B1 fractures were treated with open reduction and internal fixation in 9 hips, 6 of which were reinforced with bone grafts. Seven patients were treated with a locking compression plate and cerclage wiring, and 2 patients were treated with a Dall-Miles system. Two other periprosthetic fractures were treated with femoral revision. One was revised because of stem breakage, and the other was a transverse fracture associated with very poor bone quality, which received a femoral revision with a long stem and a locking compression plate. All fractures except one achieved primary union. This failed case had a bone defect at the fracture site, and revision surgery using a cementless long stem and allografts was successful. These finding suggest that a type B1 fracture after revision using a long stem associated with very poor bone quality or bone loss might be considered as a type B3 fracture, and femoral revision might be the treatment of choice

Background. Stress fractures at tracker after computer navigated total knee replacement are rare. Periprosthetic fracture after Minimally Invasive Plate Osteosynthesis (MIPO) of stress fracture through femoral tracker is unique in orthopaedic literature. We are reporting this unique presentation of periprosthetic fractures after MIPO for stress fracture involving femoral pin site track in computer assisted total knee arthroplasty, treated by reconstruction nail (PFNA). Methods. A 75-year old female, who had computer navigated right total knee replacement, was admitted 6 weeks later with increasing pain over distal thigh for 3 weeks without trauma. Prior to onset of pain, she achieved a range of movements of 0–105 degrees. Perioperative radiographs did not suggest obvious osteoporosis, pre-existent benign or malignant lesion, or fracture. Radiographs demonstrated transverse fracture of distal third of femur through pin site track. We fixed the fracture with 11-hole combihole locking plate by MIPO technique. Eight weeks later, she was readmitted with periprosthetic fracture through screw hole at the tip of MIPO Plate and treated by Reconstruction Nail (PFNA), removal of locking screws and refixation of intermediate segment with unicortical locking screws. Then she was protected with plaster cylinder for 4 weeks and hinged brace for 2 months. Results. Retrograde nail for navigation pin site stress fracture entails intraarticular approach with attendant risks including scatches to prosthesis and joint infection. So we opted to fix by MIPO technique. Periprosthetic fracture at the top of MIPO merits fixation with antegrade nail in conjunction with conversion of screws in the proximal part of the plate to unicortical locking screws. Overlap of at least 3cms offers biomechanical superiority. She made an uneventful recovery and was started on osteoporosis treatment, pending DEXA scan. Conclusion. Reconstruction Nail (PFNA), refixation of intermediate segment with unicortical locking screws constitutes a logical management option for the unique periprosthetic fracture after MIPO of stress fracture involving femoral pin site track in computer assisted total knee replacement

For the management of displaced patellar fractures, surgical fixation using cannulated screws along with anterior tension band wiring is getting popular. Clinical and biomechanical studies have reported that using cannulated screws and a wire instead of the modified tension band with Kirschner wires improves the stability of fractured patellae. However, the biomechanical effect of screw proximity on the fixed construction remains unclear. The aim of this study was to evaluate the mechanical behaviors of the fractured patella fixed with two cannulated screws and tension band at different depths of the patella using finite element method. A patella model with simple transverse fracture [AO 34-C1] was developed; the surgical fixation consisted of two 4.0-mm parallel partial-threaded cannulated screws with a figure-of-eight anterior tension band wiring using a 1.25-mm stainless steel cable. Two different locations, including the screws 5-mm and 10-mm away from the leading edge of the patella, were used. A tension force of 850 N was applied on the patellar apexes at two loading angles (45° and 0° [parallel] to the long axis) to simulate different loading conditions while knee ambulation. The proximal side (base) of the patella was fixed, and the inferior articular surface was defined as a compression-only support in ANSYS to simulate the support from distal femur condyles. Compression-only support enables the articular surfaces of the present patella to only bear compression and no tension forces. Under different loading conditions, the fixed fractured patella yielded higher stability during 0° loading of tension force than during 45° loading. When the screws were parallel placed at the depth of 5 mm away from the patellar surface, the deformation of patellar fragment and maximum gap opening at the fracture site were smaller than those obtained by screws placed at the depth of 10 mm away from the patellar surface. Compared to the superficial screw placement, the deeper placement (10 mm) increased the maximum gap opening at the fracture site by 1.56 times under 45° loading, and 1.58 times under 0° loading. The load on the tension band wire of the 10-mm screw placement was 3.12 times (from 230 to 717 N) higher than that of the 5-mm placement. Under the wire, the contact pressure on the patellar surface was higher with the 10-mm screw placement than the 5-mm screw placement. The peak bone contact pressures with the 10-mm placement were 7.7 times (99.5 to 764 MPa) higher. This is the first numerical study to examine the biomechanical effects of different screw locations on the fixation of a fractured patella using screws and tension band. Based on a higher stability and lower cable tension obtained by the superficial screws placement, the authors recommended the superficial screw placement (5 mm below the leading edge of the patella) rather than the deep screws while fixing the transverse patellar fracture with cannulated screws and cable

Purpose. Knowing the morphology of any fracture, including scaphoid fractures, is important in order to determine the fracture stability and the appropriate fixation technique. Scaphoid fractures are classified according to their radiographic appearance, and simple transverse waist fractures are considered the most common. There is no description in the literature of the 3-dimensional morphology of scaphoid fractures. Our hypothesis was that most scaphoid fractures are not perpendicular to its long axis, i.e. they are not simple transverse fractures. Methods. A 3-dimensional analysis was performed of CT scans of acute scaphoid fractures, conducted at two medical centres during a period of 6 years. A total of 124 scans were analysed (Amira Dev 5.3, Visage Imaging Inc). Thirty of the fractures were displaced and virtually reduced. Anatomical landmarks were marked on the distal radius articular surface in order to orient the scaphoid in the wrist. Shape analysis of the scaphoids and a calculation of the best fitted planes to the fractures were carried out implementing principal component analysis. The angles between the scaphoid's first principal axis to the fracture plane, articular plane and to the palmar-dorsal direction were measured. The fractures were analysed both for location (proximal, waist and distal) and for displacement. Results. There were 86 fractures of the waist (76 percent), 13 of the distal third and 25 of the proximal third. The average angle between the first principal axis of the scaphoid and the fracture plane was 52.6 degrees (SD 17) for all fractures, 55.6 degrees (SD 17.2) for the waist fractures, both differing significantly from a right angle (p<0.001). The majority of fractures were found to be horizontal oblique. We found no difference between the angles of the waist fractures which were displaced and those that were not displaced. In contrast, a significant difference was found between the displaced and non-displaced fractures when evaluating the orientation of the scaphoid long axis in relation to the articular plane (139.8 degrees with reduction versus 148.2 without; p=0.036). Conclusions. Most waist fractures were found to be horizontal oblique in relation to the long axis of the scaphoid and not transverse. Although the fracture angle could not explain displacement of the fracture, we found that the orientation of the scaphoid's long axis in relation to the radial articular surface was correlated with fracture displacement. According to these findings, fixation of all fractures along the long axis of the scaphoid should not be the optimal mode of fixation. Optimal fixation of acute scaphoid fractures may call for better analysis of each fracture configuration and the fixation should be guided by this analysis

Purpose. Knowing the morphology of any fracture, including scaphoid fractures, is important in order to determine the fracture stability and the appropriate fixation technique. Scaphoid fractures are classified according to their radiographic appearance, and simple transverse waist fractures are considered the most common. There is no description in the literature of the 3-dimensional morphology of scaphoid fractures. Our hypothesis was that most scaphoid fractures are not perpendicular to its long axis, i.e. they are not simple transverse fractures. Methods. A 3-dimensional analysis was performed of CT scans of acute scaphoid fractures, conducted at two medical centers during a period of 6 years. A total of 124 scans were analysed (Amira Dev 5.3, Visage Imaging Inc). Thirty of the fractures were displaced and virtually reduced. Anatomical landmarks were marked on the distal radius articular surface in order to orient the scaphoid in the wrist. Shape analysis of the scaphoids and a calculation of the best fitted planes to the fractures were carried out implementing principal component analysis. The angles between the scaphoid's first principal axis to the fracture plane, articular plane and to the palmar-dorsal direction were measured. The fractures were analysed both for location (proximal, waist and distal) and for displacement. Results. There were 86 fractures of the waist (76 percent), 13 of the distal third and 25 of the proximal third. The average angle between the first principal axis of the scaphoid and the fracture plane was 52.6 degrees (SD 17) for all fractures, 55.6 degrees (SD 17.2) for the waist fractures, both differing significantly from a right angle (p<0.001). The majority of fractures were found to be horizontal oblique. We found no difference between the angles of the waist fractures which were displaced and those that were not displaced. In contrast, a significant difference was found between the displaced and non-displaced fractures when evaluating the orientation of the scaphoid long axis in relation to the articular plane (139.8 degrees with reduction versus 148.2 without; p=0.036). Conclusions. Most waist fractures were found to be horizontal oblique in relation to the long axis of the scaphoid and not transverse. Although the fracture angle could not explain displacement of the fracture, we found that the orientation of the scaphoid's long axis in relation to the radial articular surface was correlated with fracture displacement. According to these findings, fixation of all fractures along the long axis of the scaphoid should not be the optimal mode of fixation. Optimal fixation of acute scaphoid fractures may call for better analysis of each fracture configuration and the fixation should be guided by this analysis

As the incidence of total hip arthroplasty (THA) rises, an increasing prevalence of peri-prosthetic femur fractures has been reported. This is likely due to the growing population with arthroplasties, increasing patient survival and a more active life-style following arthroplasty. It is the 3rd most common reason for THA reoperation (9.5%) and 5th most common reason for revision (5% with fracture risk after primary THA reported at 0.4%-1.1% and after revision at 2.1%-4%). High quality radiographs are usually sufficient to classify the fracture and plan treatment. Important issues in treatment include stem fixation status and fracture location relative to the stem. Additional comorbidities will also influence treatment choices, of which the most critical is the presence of infection and the quality of bone stock. The most commonly studied, and reported classification system is the Vancouver. Type A are peri-trochanteric fractures with AL at the lesser and AG at the greater trochanter. B fractures are those around the stem with B1 fractures having a well-fixed stem, B2 a loose stem with adequate bone stock, and B3 representing loose stem and inadequate bone stock. C fractures are distal to the stem. Type A) Trochanteric Fractures: These are usually associated with lysis. Displaced fractures can be managed adequately with cerclage fixation and cancellous allograft to fill osteolytic defects. Undisplaced fractures usually heal well with symptomatic treatment. Type B) Fractures Around the Stem: The B1 type has a well-fixed component and is usually treated with extramedullary fixation plus graft. Contemporary plates have been designed specifically for these fractures. Strut allograft may be used to provide a more rigid construct. Spiral and long oblique fractures can be cerclaged while short oblique or transverse fractures require fixation anterior and lateral with cable plates and cortical strut grafts. Screws can be used distal to the implant, and cables used proximally. The B2 type has a loose prosthesis but otherwise good bone stock. In this setting, the fracture line may be extended on the lateral cortex of the femur as an extended osteotomy to provide easy access for cement removal. These fractures can be managed with an extensively coated stem if rotational stability can be obtained in the distal segment. If rotational stability over a 4 cm scratch interference fit of the stem isn't possible, then a fluted tapered modular stem should be used. Strut allografts improve initial stability. The B3 type has both a loose prosthesis and poor bone stock and in the younger patient restoration of bone stock should be a priority. Bulk femoral grafts may be needed. The elderly or low functional demand patient may be treated with a proximal femoral replacement. Because of soft-tissue deficiencies, a constrained acetabular liner may be needed to prevent instability. Type C) Fractures Distal to the Stem: These usually accompany a stable stem and many fixation devices are available. Locking plates have become most popular and should be secured with cerclage wires proximally around the component with screws distally. Retrograde nails may be employed if there is adequate bone distal to the stem tip and above the fracture

The advent of Elastic Stable Intramedullary Nailing has revolutionised the conservative treatment of long human bone fractures in children (Metaizeau, 1988; Metaizeau et al., 2004). Unfortunately, failures still occur due to excessive bending and fatigue (Linhart et al., 1999; Lascombes et al., 2006), bone refracture or nail failure (Bråten et al., 1993; Weinberg et al., 2003). Ideally, during surgery, nail insertion into the diaphyseal medullary canal should not interrupt or injure cartilage growth; nails should provide an improved rigidity and fracture stabilisation. This study aims at comparing deflections and stiffnesses of nail-bone assemblies: standard cylindrically-shaped nails (MI) vs. new cylindrical nails (MII) with a flattened face across the entire length allowing more inertia and a curved tip allowing better penetration into the cancellous bone of the metaphysis (Figure 1). MII exhibits a section with two parameters: a diameter C providing nail stiffness and a height C' providing practical dimension when both nails are crossed at the isthmus of the diaphysis: C/C' is set to 1.25 for all MII nails. A CT scan of a patient aged 22 years was used to segment a 3D model of a 471mm-long right femur model. The medullary canal diameters at the isthmus are 10.8mm and 11.4mm in the ML and AP direction, respectively. Titanium-made CAD models of MI (Ø=4mm) and MII (flat face: Ø=5mm) were pre-curved to maintain their flat face and carefully placed and positioned according to surgeon's instructions. Both nails were inserted via lateral holes in the distal femur with their extremities either bumping against the cortex or lying in the trabecular bone. Transverse and comminuted fractures were simulated (Figure 1). For each assembly, a Finite Element (FE) tetrahedral mesh was generated (∼100181 nodes and 424398 elements). Grey-scale levels were used to assign heterogeneous material properties to the bone (E=6850 ρ. 1.49. (Morgan et al., 2003)). Two modes of loading were considered: 4-point bending (varus and recurvatum: F. max. =6000N) and internal torsion (M. max. =70kNmm). This led to the simulation of 15 FE models, including a reference intact femur. Results show that in valgus, for the transverse (comminuted) fracture, the mean displacement of the assembly decreased by around 50%: from 15.24mm (27.49mm) to 8.15mm (13.85mm) for MI and MII, respectively, compared to 3.59mm for the intact bone. The assembly stiffness increased by 87% and 99% for transverse and comminuted fracture, respectively (Table 1). Similar trends were found in recurvatum with higher increases in assembly stiffness of 170% and 143% for transverse and comminuted fracture, respectively (Table 1). In torsion, for the transverse (comminuted) fracture, the measured angle of rotation decreased from: 0.43rad (0.66rad) to 0.22rad (0.43rad) for MI and MII, respectively, compared to 0.09rad for the intact bone. This corresponded to an increase of 95% and 55% in assembly stiffness for transverse and comminuted fracture, respectively. In conclusion, using the 5mm-diameter new nails (MII) for the same intramedullar space, during either bending or torsion, assemblies were always stiffer than when using standard cylindrical nails

Fracture of the acetabulum can lead to degenerative arthritis of the hip, avascular necrosis of the femoral head, or both. Total hip arthroplasty is a common form of surgical treatment when significant joint changes and pain are present. Ten patients with fracture acetabulum were treated in this study using metal on metal total hip arthoplasty. The initial fracture was posterior wall fracture in one patient, posterior column fracture in one patient, transverse fracture in 2 patients, fracture dislocation in 3 patients and fracture posterior wall and column in 3 patients. The indications of arthroplasty were secondry osteoarthritis after internal fixation or after conservative management or collapse of the femoral head. Arthroplasty was done after an average period of 1.8 years (range from 1 to 4 years). After a follow up period ranged from 3 to 7 years with a mean of 4.6 years, the Harris hip score was improved from a mean of 51 (range 20 to 65) to a mean of 92.5 (range 90 to 95). Infection occurred in one case and two stages revision was done. Another case developed loosening of the acetabular component and was revised using cementless cup fixed with screws and bone graft. Metal on metal THR after acetabular fracture are relatively uncomplicated and lead to a good outcome despite the difficulties faced during the procedure

The radius has a sagittal and coronal bow. Fractures are often treated with volar anterior plating. However, the sagittal bow is often overlooked when plating. This study looks at radial morphology and the effect of plating the proximal radius, with straight plates then contoured plates bowed in the sagittal plane. We report our findings and their effect on forearm rotation. Morphology was investigated using fourteen radii. Attention was made to the proximal shaft of the radius and its sagittal bow, from this 6, 7 and 8 hole plates were contoured to fit this bow. A simple transverse fracture was then made at the apex of this bow. Supination and pronation was then compared when plating with a straight plate and a contoured plate. Ten cadavers had the ulna plating at the same level. The effect on rotation of fractures plated in the distal third shaft was also measured. A significant reduction in rotation was found, when a proximal radius fracture was plated with straight plate compared to a contoured plate: 10.8, 12.8, 21.7 degrees (p<0.05 for 6, 7, 8 hole plates). Forearm rotation was decreased further when a longer plate was used. Ulna or distal shaft plating did not reduce rotation. This study has shown a significant sagittal bow of the proximal shaft of the radius. Plating this with contoured plates in the sagittal plane improves rotation when compared to straight plates. Additional ulna plating is not a source of reduced forearm rotation

Fractures of the proximal femur at the level of the lesser trochanter (reversed and transverse fracture lines, Evans classification type II, AO classification A3 fractures) are known to have an increased risk of fixation failure. 58 patients with such a fracture were randomised to have the fracture fixed with either an intramedullary nail (220 mm Targon PF nail) or a sliding hip screw (SHS). The mean age of the patients was 82 and 11% were male. All patients were followed up for one year by a research nurse blinded to the treatment groups. Mean length of surgery was 50 minutes for the nail versus 52 minutes for the SHS. There were no differences between groups in the need for blood transfusion. Operative complications tended to be less for the nail group (1/27 versus 5/26). Mean hospital stay was 18 days for the nail group versus 29 days for those treated with the SHS. The only fracture healing complications were one case of cut-out in the SHS group and two cut-outs in the nail group, two of which required revision surgery. During follow-up those patients treated with the nail reported a tendency to lower pain scores than those treated with the SHS (p=0.04 at two months). This difference persisted even at one year from injury. Mortality and regain of mobility was similar between groups. These results indicate that for these difficult fractures types both types of fixation produce comparable outcomes

Emerging evidence has linked the long-term use of alendronate (fosamax) with subtrochanteric insufficiency fractures. However, findings to date have been anecdotal. The aims of this study were to determine the incidence of subtrochanteric insufficiency fractures and identify whether they were more prevalent following the introduction of alendronate in Australia. All patients that presented between January 2007 and February 2009 with low- energy subtrochanteric fracture were identified. Similar data were collected between January 1995 and February 1997 as this was immediately prior to introduction of alendronate in Australia. The radiographs were examined for failure due to pre- existing insufficiency fracture. Characteristic findings were a transverse fracture line on the tension side of the femur with lateral cortical thickening immediately adjacent to the fracture. Relevant details from the history were recorded. We also separately identified all patients that presented between 2007 and 2009 with a proximal femoral fracture and determined the proportion taking alendronate. One hundred and seventeen patients with low-energy subtrochanteric fracture were included. Seventy-nine patients presented between 2007 and 2009 and 38 presented between 1995 and 1997. Forty-one of the 79 (52%) patients were identified as having radiograph findings suggestive of underlying insufficiency fracture, whilst none were identified prior to the introduction of alendronate. Of the 41 patients with subtrochanteric insufficiency fracture, 40 (98%) had been taking alendronate and one had been taking risedronate. Twenty-nine of the 41 (71%) complained of prodromal pain in the affected femur. Eighteen of the 41 (44%) demonstrated subtrochanteric insufficiency changes on the contralateral side and 9 of 41 (22%) sustained spontaneous non-traumatic fracture during activities of daily living. Of the 38 patients without insufficiency changes, 12 (32%) had been taking alendronate. Alendronate use was therefore strongly suggestive of insufficiency fracture (sensitivity = 98%, specificity = 84%, PPV = 77%, NPV = 99%, LR+ = 6). The mean duration of alendronate use in those with insufficiency fracture was 7.1 years (95% CI, 6.6-7.6 years). The mean duration in those without was 3.2 years (95% CI, 2.6-3.8 years, P<0.0001). Three hundred and ninety eight patients presented with a low-energy proximal femur fracture between 2007 and 2009. Of these, only 52 (13%, P<0.0001) were taking alendronate. This is the largest study in the literature on subtrochanteric insufficiency fractures and alendronate therapy. Confirming recent reports, alendronate use was strongly suggestive of subtrochanteric insufficiency fracture. Our findings provide the most compelling evidence to date of the potential long-term sequelae of alendronate but more research is needed before definitive conclusions can be made

Introduction. This is the first study to illustrate spinal fracture distribution and the impact of different injury mechanisms on the spinal column during contemporary warfare. Methods. A retrospective analysis of Computed Tomography (CT) spinal images entered onto the Centre for Defence Imaging (CDI) database, 2005-2009. Isolated spinous and transverse process fractures were excluded to allow focus on cases with implications for immediate management and prospective disability burden. Fractures were classified by anatomical level and stability with validated systems. Clinical data regarding mechanism of injury and associated non-spinal injuries for each patient were recorded. Statistical analysis was performed using Fisher's Exact test. Results. 57 cases (128 fractures) were analysed. Ballistic (79%) and non-ballistic (21%) mechanisms contribute to vertebral fracture and spinal instability at all regions of the spinal column. There is a low incidence of cervical spine fracture, with these injuries predominantly occurring due to gunshot wounding. There is a high incidence of lumbar spine fractures which are significantly more likely to be caused by explosive devices than gunshot wounds (p<0.05). 66% of thoracolumbar spine fractures caused by explosive devices were unstable, the majority being of a burst configuration. Associated non-spinal injuries occurred in 60% of patients. There is a strong relationship between spinal injuries caused by explosive devices and lower limb fractures. Conclusion. Explosive devices account for significant injury to both combatants and civilians in current conflict. Injuries to the spine by explosions account for greater numbers, associated morbidity and increasing complexity than other means of injury

Purpose. The coronoid process is an integral component for elbow stability. In the setting of a comminuted coronoid fracture, where repair is not possible, a prosthetic device may be beneficial in restoring elbow stability. The hypothesis of this in-vitro biomechanical study was that an anatomic coronoid prosthesis would restore stability to the coronoid deficient elbow. Method. A metal coronoid prosthesis was designed and developed based on CT-derived images adjusted for cartilage thickness. The kinematics and stability of eight fresh-frozen male cadaveric arms (mean age 77.4 years, range 69–92 years) were quantified in the intact state; after collateral ligament sectioning and repair (control state); after a simulated 40% transverse coronoid fracture; and after implantation of a coronoid prosthesis. Elbow flexion was simulated passively with the arm oriented in the varus position and the forearm in pronation. Varus-valgus angulation (VV) and internal-external rotation (IE) of the ulna relative to the humerus were quantified with an electromagnetic tracking system (Flock of Birds, Ascension Technologies, Burlington, VT, static accuracy: 1.8mm position, 0.5 orientation). Results. No significant difference was found between the intact elbow and the native coronoid control state with collateral ligament repair (mean standard deviation) (VV=0.13.1, p=0.9; IE=0.82.59, p=0.4). A significant decrease in stability was observed following the 40% coronoid fracture (VV=5.73.4, p<0.01; IE=10.93.35, p<0.001). Following coronoid hemi-arthroplasty, no significant difference in stability was found between the coronoid prosthesis and the control state (VV=0.22.7, p=1.0; IE=1.33.0, p=0.8). Conclusion. An anatomic coronoid prosthesis restores the stability of the coronoid deficient elbow similar to the intact state. Further studies are needed to determine the optimum fixation method of this device and to determine the range of sizes which would be required for the successful commercialization of this device for patient use. Clinical trials will be required to confirm the favourable findings of this in-vitro investigation