We report a case of an apparent avulsion fracture of the posteromedial margin of the medial plateau of the tibia. This was associated with a tear of the medial meniscus and rupture of the anterior cruciate ligament (ACL). This triad has been previously reported, and the plateau fracture was related to the insertion of the semimembranosus tendon. The detailed investigation of our case and some experiments on cadaver knees showed that the injury was not an avulsion fracture but was produced by varus and external rotation forces on a flexed knee. It was due to the anterior subluxation of the medial tibial plateau after rupture of the ACL.

Abstract. Background. Fracture dislocation of the knee involves disruption of knee ligaments with associated tibial plateau fracture. If these injuries are not evaluated swiftly, can result in a limb-threatening injury. The aim of this study is to look at the clinical outcomes of a single surgeon case series at a major trauma centre. Methods. Prospectively collected data was analysed for a 5-year period. Primary outcome measures used were International Knee Documented Committee (IKDC) score and Knee Injury & Osteoarthritis Outcome Score (KOOS). The secondary outcome measures include Tegner activity scale, knee range of movements and complications. Results. 32 patients were presented with the mean age was 34 years (range 17–74). 14% of patients sustained vascular injury and 19% had common peroneal nerve injury. Priority was given for early total repair/reconstruction with fracture fixation within three weeks where feasible (90% of patients), and if not, a staged approach was adopted. The mean IKDC score was 67 (35–100) & KOOS was 74 (40–100). The mean preoperative Tegner Activity Scale was 6.5 whereas post-operative Tegner Activity Scale was 3.6 The mean flexion achieved postoperative was 115 (90–130). The two common patterns of injuries seen were Anterio-medial rim fractures (52%) with avulsion injuries of posterio-lateral corner structures and posteriomedial plateau fractures with ACL avulsion injuries. The first pattern was commonly associated with vascular and common peroneal nerve injury (90% of patients). Conclusion. To our knowledge, this is the first kind of study to report some fracture patterns that can be associated with particular ligamentous injuries

Abstract. Background. Fracture dislocation of the knee involves disruption of two or more knee ligaments with associated tibial plateau fracture. If these injuries are not evaluated swiftly, can result in a limb-threatening injury. The aim of this study is to look at the clinical outcomes of a single surgeon case series at a major trauma centre. Methods. Prospectively collected data was analysed for a 5-year period. Primary outcome measures used were International Knee Documented Committee(IKDC) score and Knee Injury & Osteoarthritis Outcome Score(KOOS). The secondary outcome measures include Tegner activity scale, knee range of movements & complications. Results. 23 patients were presented with the mean age was 37 years(17–74). 14% of patients sustained vascular injury & 19% had common peroneal nerve injury. Priority was given for early total repair/reconstruction with fracture fixation within 3 weeks where feasible (90% of patients), and if not, a staged approach was adopted. The mean IKDC score was 67 & KOOS was 73. The mean postoperative Tegner Activity Scale was 3.6 with mean flexion of 115(90–130). We observed some patterns of tibial plateau fractures are associated with similar patterns of ligamentous injuries. The anterio-medial rim fractures (52%) were associated with PCL, ACL & avulsion injuries of posterio-lateral corner structures. Most of the neurovascular injuries happened in this group. The other recognisable pattern was posterio-medial fractures, which were associated with ACL avulsion injury. Conclusion. To our knowledge, this is the first kind of study to report some fracture patterns that can be associated with particular ligamentous injuries

Abstract. Objectives. The aim of this study was to test the hypothesis that there are two different mallet injuries; specifically, tendinous ones are primarily low energy avulsion injuries whilst bony ones are primarily high-energy hyper-extension injuries. Methods. We reviewed in detail the demographics, mechanisms of injury, concomitant injuries and the radiological findings of patients presenting with bony and tendinous mallet deformities. The sizes of the bony fragments and angulation of the mallet deformities were measured on the initial radiographs using an established technique. Results. There were 62 tendinous mallet injuries (62 patients). These were mostly low energy injuries in men with a mean age of 57 years affecting primarily the middle and ring fingers. They were rarely associated with other injuries. There were 85 bony mallet injuries (83 patients). These were all high energy injuries also mostly in men with a mean age of 40 years primarily affecting the ring and little fingers. There were two double injuries and seven other concomitant injuries in the patients with bony mallet injuries. The extensor lags were a mean of 300 (range 3–590) for the tendinous injuries and 130 (range 0–380) for the bony injuries (p<0.00001). The fracture fragments were a mean of 51 (range 24–80) %; there was no correlation between fragment size and extensor lag. Conclusions. This study and review of the literature further confirm the substantial differences between tendinous and bony mallet injuries. In particular tendinous mallet injuries are avulsion injuries whilst bony mallet injuries are dorsal impaction fractures; they should be assessed and treated differently. Bony mallet injuries may be multiple and may be associated with other injuries. Low energy mallet deformities do not need radiographs

Introduction. Hip and groin injuries are common in athletes participating in high level sports. Adductor muscle tendon injuries represent a small but important number of these injuries. Avulsion injuries involving tendons attaching to the symphysis pubis have previously been described and can be managed both operatively and non-operatively. The aim is to describe a rare variant of this injury; complete avulsion of the adductor sleeve complex including adductor longus, pectineus and rectus abdominus. A surgical technique is then outlined which promotes a full return to pre-injury level of sporting activity. Patients/Materials & Methods. Fifteen high level athletes with an MRI confirmed acute adductor complex avulsion injury (6–34 days) were identified from the institution's sports injury database over a 10 year period. All underwent surgical repair. The operative procedure comprised anatomical attachment of the avulsed tissues in all cases (plus mesh reinforcement of the inguinal wall in 7 patients). All underwent a standard format of rehabilitation which was then individualised to be sport specific. Results. One patient developed a superficial wound infection which was successfully treated with antibiotics. 12 out of 15 patients complained of transient local numbness which resolved in all cases. All patients (including 7 elite athletes) returned to their previous level of participation in sport. Discussion. Injury to the triad of adductor longus, pectineus and rectus abdominus should be considered in athletes presenting with groin pain following forced adduction. All athletes underwent early surgical exploration, previous studies have shown prolonged symptoms in early conservative management. Adductor tenotomy has shown previously acceptable results but may be less suitable in elite athletes with higher functional demands when operative repair has been shown to be successful. Conclusion. Operative repair of acute sleeve avulsion of the adductor complex in high level athletes, followed by sport specific rehabilitation promotes return to previous level of participation in sport

Aims. Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot. Patients and Methods. We undertook a retrospective review of 285 consecutive patients presenting over an eight- year period with a fracture of the navicular. Five common patterns of injury were identified and classified according to the radiological features. Type 1 fractures are dorsal avulsion injuries related to the capsule of the talonavicular joint. Type 2 fractures are isolated avulsion injuries to the tuberosity of the navicular. Type 3 fractures are a variant of tarsometatarsal fracture/dislocations creating instability of the medial ray. Type 4 fractures involve the body of the navicular with no associated injury to the lateral column and type 5 fractures occur in conjunction with disruption of the midtarsal joint with crushing of the medial or lateral, or both, columns of the foot. Results. In order to test the reliability and reproducibility of this new classification, a cohort of 30 patients with a fracture of the navicular were classified by six independent assessors at two separate times, six months apart. Interobserver reliability and intraobserver reproducibility both had substantial agreement, with kappa values of 0.80 and 0.72, respectively. Conclusion. We propose a logical, all-inclusive, and mutually exclusive classification system for fractures of the navicular that gives associated injuries involving the lateral column due consideration. We have shown that this system is reliable and reproducible and have described the rationale for the subsequent treatment of each type. Cite this article: Bone Joint J 2018;100-B:176–82

Hip and groin injuries are common in athletes who take part in high level sports. Adductor muscle tendon injuries represent a small but important number of these injuries. Avulsion of the tendons attached to the symphysis pubis has previously been described: these can be managed both operatively and non-operatively. We describe an uncommon variant of this injury, namely complete avulsion of the adductor sleeve complex: this includes adductor longus, pectineus and rectus abdominis. We go on to describe a surgical technique which promotes a full return to the pre-injury level of sporting activity. Over a period of ten years, 15 high-level athletes with an MRI-confirmed acute adductor complex avulsion injury (six to 34 days old) underwent surgical repair. The operative procedure consisted of anatomical re-attachment of the avulsed tissues in each case and mesh reinforcement of the posterior inguinal wall in seven patients. All underwent a standardised rehabilitation programme, which was then individualised to be sport-specific. One patient developed a superficial wound infection, which was successfully treated with antibiotics. Of the 15 patients, four complained of transient local numbness which resolved in all cases. All patients (including seven elite athletes) returned to their previous level of participation in sport. Cite this article: Bone Joint J 2015;97-B:1488–92

The October 2024 Knee Roundup³⁶⁰ looks at: Managing the unexpected: treatment of intraoperative medial collateral ligament injuries; Identifying subgroups of patients that may benefit from robotic arm-assisted total knee arthroplasty: secondary analysis of data from a randomized controlled trial; Cost-effectiveness of enoxaparin versus aspirin in the prevention of venous thromboembolism after total hip or knee arthroplasty: an analysis from the CRISTAL cluster-randomized trial; Cartilage regeneration and long-term survival in medial knee osteoarthritis patients treated with high tibial osteotomy and osteochondral autologous transfer system; Treatment of chronic and complex meniscal tears with arthroscopic meniscus repair augmented with collagen matrix wrapping: failure rate and functional outcomes; Long-term outcomes of multiligament knee injuries in American football players.

Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes.

Cite this article: Bone Joint J 2023;105-B(12):1244–1251.

Ulnar styloid fractures may contribute to negative outcomes after distal radius fractures due to its association with distal radioulnar (DRUJ)instability and injuries of the triangular fibrocartilaginous (TFCC) complex. This study assesses clinical outcomes of untreated ulnar styloid fractures after internal fixation of distal radius fractures. Patients undergoing operative fixation for distal radius fractures from January 2004 to June 2006 were divided into those with and without ulnar styloid fractures. The two groups were compared in terms of wrist range of motion, ulnar sided wrist pain, extensor carpi ulnaris (ECU) tendinitis, TFCC grind test, and DASH scores. Thirty-one males and 23 females aged 50.9 years(18–88 yrs, SD 16.5) were assessed. At 24 months, the presence of ulnar styloid fractures had no impact on ulnar-sided wrist pain (p=0.331), TFCC grind test(p=0.917) and distal radioulnar joint instability (p=0.957). There was a tendency towards ECU tendinitis (23.8% vs 6.1%, p= 0.058) in patients with ulnar styloid fractures. There was no significant difference in the range of motion and overall DASH scores (8.0 vs 5.9, p=0.474). No association was found between ulnar styloid fractures and DRUJ instability in this study. Ulnar styloid fractures behave like avulsion injuries. In the absence of DRUJ instability, conservative management of ulnar styloid fractures during operative treatment of distal radius fractures do not compromise clinical outcome

Introduction: Paediatric Pelvic fractures are rare and constitute only 1% to 3% of all fractures in children; they are different from other fractures in children due to concomitant injuries that occur immediately. Method: A retrospective analysis was performed in order to review the pattern of paediatric pelvic fractures, indications for surgical treatment and outcome of pelvic fractures in children. In our study we included paediatric patients with significant pelvic fractures, who were treated surgically between 1992 and 2004. We excluded tendon-bone avulsion injuries and acetabular fractures from study. Results: We treated 29 paediatric pelvic fractures in this duration. Mean age was 14.17 (5 to 17) years. All of these patients had procedure under general anaesthetic under care of single consultant. 10 had ORIF of pelvis, 13 had external fixator application, 5 had sacral screw fixation and 6 had examination under anaesthesia. We shall discuss the results in detail in presentation. Discussion: We concluded that although pelvic fractures in children are uncommon but require early diagnosis and management and this should not differ greatly from those in adults

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Can you treat type IIA supracondylar humerus fractures conservatively?; Bone bruising and anterior cruciate ligament injury in paediatrics; Participation and motor abilities after treatment with the Ponseti method; Does fellowship training help with paediatric supracondylar fractures?; Supracondylar elbow fracture management (Supra Man): a national trainee collaborative evaluation of practice; Magnetically controlled growing rods in early-onset scoliosis; Weightbearing restrictions and weight gain in children with Perthes’ disease?; Injuries and child abuse increase during the pandemic over 12,942 emergency admissions.

Horse riding is a common pursuit and is more dangerous than believed. Most injuries of the hand and wrist are caused by falls, as in other sports. However, exclusive to riding are injuries sustained whilst leading a horse. Avulsion injuries are well recognised but little has been reported on phalangeal fractures in this situation. We report on seven cases that required hospitalisation in our hand unit, for injuries from horses over a two year period. Six of these patients sustained multi-fragmented spiral periarticular fractures involving the middle and proximal phalanx and one a horse bit. We will discuss in detail the mechanism of their injuries, the surgery undertaken, their post-operative rehabilitation and overall outcome. Furthermore we review the recommended horse handling technique and contrast it with the mechanism of injury in our cases. In our experience the fractures seen were unstable, comminuted and needed internal fixation. One patient developed a delayed union and three post-operative stiffness. Our results suggest that fractures whilst leading horses are more complex than recognised, usually need surgery and often have a relatively poor outcome. All of these cases were largely preventable and could be attributed to incorrect horse leading technique

Aims

Avulsion of the proximal hamstring tendon origin can result in significant functional impairment, with surgical re-attachment of the tendons becoming an increasingly recognized treatment. The aim of this study was to assess the outcomes of surgical management of proximal hamstring tendon avulsions, and to compare the results between acute and chronic repairs, as well as between partial and complete injuries.

Complex hand injuries are those which involve more than one functionally significant anatomic structure of the hand (i.e vessels, nerves, tendons, bones). The epidemiologic and management characteristics of these injuries, encountered in a specialized center covering an urban and agricultural population, were recorded and studied. Between 1997 and 2002 the Orthopaedic Department of the University of Ioannina surgically treated 211 complex hand injuries in 190 patients with a mean age of 35 year (range 2.5–73). The majority of patients were male (89%). The incidence of these injuries was low at the extremes of the age distribution (children and adults over 60 years old). The greatest incidence was in the 15–30 year old age group. The mechanism of the injury was found to be clean cut trauma in 31% and avulsion or crushing in 69%; with the later being frequent agricultural injuries. Fifty-nine per cent of the injuries were viable, while 41% where non-viable (complete amputation in 63% and incomplete in 37%). Of the non viable injuries 66% eventually underwent stump configuration. Primary repair of only one anatomical structure was performed in 58%, most commonly osteosynthesis and tendon suturing. In 42% primary repair of more than one structure was performed, most commonly osteosynthesis and tendonorrhaphy in avulsion injuries and neuroraphy combined with tendonorrhaphy in clean cut injuries. Complex hand injuries are frequently seen in young male adults and the most common mechanism of injury is avulsion-crushing. Most of them are work-related accidents, so prevention should focus on adherence to safety guidelines. Management of such injuries requires special surgical techniques and expertise, necessary for staged reconstruction

Fractures about the radial or ulnar aspects of the base of the proximal phalanx or the metacarpal head represent collateral ligament avulsion injuries. Unlike such injuries in the metacarpophalangeal joint of the thumb these injuries are rare and have received scant attention in the literature. The results of open reduction and internal fixation, highlighting the surgical approach and technique, of collateral ligament avulsion fractures about the metacar-pophalangeal joints of the fingers are presented. Over a five year period sixteen patients presented to the hand injury service with the above injury. Thirteen of these fractures occurred at the base of the proximal phalanx. Fourteen were acute injuries and two non-unions. These fractures affected a predominantly young population (average age 24 years) and the majority were sustained during sporting activities. All were treated by ORIF except for one in which the patient declined operative treatment. Metacarpal head fractures are assessed through a standard dorsal approach but as the collateral ligament inserts into the volar - lateral aspect of the proximal phalangeal base access to this fracture is best achieved via a volar approach to the digit. Fractures were stabilized with a single interfragmentary screw. Surgical fixation gave satisfactory results in fourteen cases. All these patients had a full range of finger movement within 3 weeks. One patient developed symptoms suggestive of RSD. At 3 months review all fractures treated by ORIF had united. The patient who declined surgical treatment developed a symptomatic non-union. Conservative treatment of these unstable fractures leads to non-union. The surgical anatomy dictates the surgical approach, with fractures at the proximal phalangeal base best accessed via a volar approach. ORIF restores joint surface congruity, establishes union and provides stable fixation to allow early mobilisation and return to normal activities

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management.

Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury.

This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients.

Cite this article: Bone Joint J 2020;102-B(10):1281–1288.