Abstract. Objectives. Ankle fractures have an incidence of around 90,000 per year in the United Kingdom. They affect younger patients following high energy trauma and, in the elderly, following low energy falls. Younger patients with pre-existing comorbidities including raised BMI or poor bone quality are also at risk of these injuries which impact the bony architecture of the joint and the soft tissues leading to a highly unstable fracture pattern, resulting in dislocation. At present, there is no literature exploring what effect ankle fracture-dislocations have on patients’ quality of life and activities of daily living, with only ankle fractures being explored. Methods. Relevant question formatting was utilised to generate a focused search. This was limited to studies specifically mentioning ankle injuries with a focus on ankle fracture-dislocations. The number of patients, fracture-dislocation type, length of follow up, prognostic factors, complications and outcome measures were recorded. Results. 939 fractures were included within the studies. Eight studies looked at previously validated foot and ankle scores, two primarily focused on the American Orthopaedic Foot and Ankle Society score (AOFAS), three on the Foot and Ankle Outcome Score (FAOS), and one study on the Olerud–Molander Score (OMAS). Patient, injury, and management factors were identified as being associated with poorer clinical outcomes. Conclusions. Not only are age and BMI a risk factor for posttraumatic osteoarthritis but they were also identified as prognostic indicators for functional outcome in this review. Patients sustaining a concurrent fracture-dislocation were found to have poorer clinical outcomes, and the timing and success of reduction further influenced outcomes. This review found that the quality of reduction was directly related to the patients’ functional outcomes post-follow up, and the risk of developing posttraumatic osteoarthritis, which was more frequent in patients sustaining Bosworth fractures, posterior malleolar fractures, and in patients over 35 years old

Lisfranc injuries were previously described as fracture-dislocations of the tarsometatarsal joints. With advancements in modern imaging, subtle Lisfranc injuries are now more frequently recognized, revealing that their true incidence is much higher than previously thought. Injury patterns can vary widely in severity and anatomy. Early diagnosis and treatment are essential to achieve good outcomes. The original classification systems were anatomy-based, and limited as tools for guiding treatment. The current review, using the best available evidence, instead introduces a stability-based classification system, with weightbearing radiographs and CT serving as key diagnostic tools. Stable injuries generally have good outcomes with nonoperative management, most reliably treated with immobilization and non-weightbearing for six weeks. Displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation (ORIF) being the most common approach, with a consensus towards bridge plating. While ORIF generally achieves satisfactory results, its effectiveness can vary, particularly in high-energy injuries. Primary arthrodesis remains niche for the treatment of acute injuries, but may offer benefits such as lower rates of post-traumatic arthritis and hardware removal. Novel fixation techniques, including suture button fixation, aim to provide flexible stabilization, which theoretically could improve midfoot biomechanics and reduce complications. Early findings suggest promising functional outcomes, but further studies are required to validate this method compared with established techniques. Future research should focus on refining stability-based classification systems, validation of weightbearing CT, improving rehabilitation protocols, and optimizing surgical techniques for various injury patterns to ultimately enhance patient outcomes. Cite this article: Bone Joint J 2024;106-B(12):1431–1442

Thirty-three Monteggia fracture-dislocations occurring in patients aged 2 to 15 years were reviewed. A follow-up of 2 to 7 years in 25 patients revealed that 88% had good to excellent results and 12% had results which were fair or poor. Closed reduction was successful in 24 of 28 cases and appeared to be very effective. Open reduction was required only for older children or when treatment was begun late. A mild hyperextension deformity at the elbow noted on follow-up of patients with anterior dislocation of the radial head seemed to support the theory that the injury is caused by hyperextension. A new classification of Monteggia fracture-dislocations in children is proposed

Retrospective review of eighteen patients with sacral fracture dislocations and cauda equina deficits treated with posterior sacral decompression and lumbopelvic fixation. At mean nineteen-month follow-up, all fractures healed without loss of alignment despite immediate full weight-bearing. Fifteen patients (83%) improved neurologically, and ten patients (56%) had full bowel/ bladder recovery. Complications consisted mainly of infection (17%) and asymptomatic rod breakage (33%). This series demonstrates the clinical effectiveness of lumbopelvic fixation, allowing the application to sacral injuries of decompression and fixation principles commonly used in fractures with neurologic deficits that occur in more rostral areas of the spine. To evaluate the results of sacral decompression and lumbopelvic fixation for sacral fracture-dislocations with neurologic deficits. Lumbopelvic fixation provided the stability necessary for full weight-bearing without loss of fracture reduction despite extensive sacral decompression. The functional neurologic improvement in most patients and complete neurologic recovery in all but one patient with intact lumbosacral roots are encouraging. The effectiveness of lumbopelvic fixation facilitates the application of principles of early decompression and stabilization to sacral fracture-dislocations. Sacral fractures healed in all eighteen patients without loss of reduction. Average sacral kyphosis improved from forty-one to twenty-four degrees. Fifteen patients (83%) had normalization or improvement of bowel and bladder deficits, although only ten patients (56%) had improved Gibbons scores. Average Gibbons type improved from four to 2.8 at nineteen-month average follow-up. Rod breakage (33%) and infection (17%) were the most common complications. Recovery of bowel and bladder function was less likely in patients with disruption of any lumbosacral root (36% vs. 86%, p=.066) and complete deficits (47% vs. 100%, p=.241) although the small cohort size precluded statistical significance. Retrospective review of medical records, radiographs, and prospectively collected data of eighteen consecutive patients with sacral fracture-dislocations and cauda equina deficits identified between 1997 and 2002 through institutional databases. Treatment consisted of open reduction, sacral decompression and lumbopelvic fixation. Radiographic and clinical results of treatment were evaluated. Neurologic outcome was measured by Gibbons’ criteria. Please contact author for figures and diagrams

Aim: Displaced intrarticular fractures and fracture-dislocations of the proximal humerus usually need operative treatment. The results of shoulder hemiartroplasty for the treatment of neglected fractures and fracture-dislocations are presented. Material – Method: 9 shoulder hemiartroplasties with modular head was used for the treatment of 5 neglected comminuted fractures and 4 fracture-dislocations of the proximal humerus. They were 5 females and 4 males with a mean age of 58 years, which were followed-up for a mean period of 4 years. The time between the injury and the operation varied from 2 to 8 months. The main indications was pain, loss of shoulder movement in relatively young patients. The tuberosities were found and extensively mobilized. The prosthesis was inserted with cement and the tuberosities were reattached to the shaft. Results: Main follow up was 4 years (2–8). The results were assessed according the modified UCLA score and were found excellent in 2, satisfactory in 4 and poor in z cases. Pain has improved in 7 cases and the mean postoperative elevation was 90? (20?–130?). External and internal rotation was significally improved. 5 patients presented satisfactory muscle strength and were able to perform satisfyingly the daily activities. Constant score rated from 50 to 80. The presence of a dislocation did not affect the final outcome. On the contrary the displacement of the tuberosities was decisive, and it was combined with greater scaring of the soft tissues and greater loss of motion. One patient developed transient palsy of the axillary nerve and another aseptic loosening of the prosthesis 7 years postoperatively. Conclusions: The success of the hemiartroplasty is based on the proper patient selection, the good operative technique and the meticulous postoperative rehabilitation. The retroversion, the height of the prosthesis and the correct balance of the soft tissues are of critical importance in the achievement of a good postoperative result. The tissue scaring, the tuberosities displacement and the rotator cuff lesions create such conditions that place these patients in the limited goal group, as introduced by Neer. The results of this group are considerably inferior to those treated soon after the injury. For this reason if indicated the prosthesis should be used at the first stage and not after the failure of the conservative treatment

1. Seventy-five injuries of the cervical spine are reported. Fifty-three were dislocations and fracture-dislocations involving the third to the seventh segments. 2. The importance of careful examination in all neck injuries is stressed. 3. The injuries are divided into stable and unstable types and the causation of the instability is discussed. 4. Plaster immobilisation for more than six months failed in some patients to prevent recurrence of dislocation. 5. Operative treatment was advised in all cases of dislocation, the spine being wired and grafted with iliac bone. This prevents recurrence and shortens the period of convalescence

1. In the treatment of tarso-metatarsal fracture-dislocations open reduction is advocated whenever closed reduction is found impossible. 2. A technique of operation is described whereby, after reduction, temporary transfixion wires are used to prevent redisplacement

Background: Complex anterior fracture-dislocations of shoulder are rare injuries and little is known about the functional outcomes following operative treatment. The aim of our study was to evaluate the functional outcomes following open reduction and internal fixation for these injuries. Methods: Over a ten and a half year period, we studied thirty-two consecutive patients who presented to shoulder injury clinic at the Royal Infirmary of Edinburgh with an acute Type-I complex anterior fracture-dislocation of the shoulder. The average age of the 19 men and 13 women was 58 years (range 21–81 years). All patients were treated with open reduction and internal fixation and were followed up for at least two years. The functional outcomes were assessed by three scoring systems (Disabilities of the Arm, Shoulder and Hand questionnaire, the Constant questionnaire, and the Short Form-36 general health questionnaire). Results: At two years post injury, the median DASH score was 26 points and the median Constant score was 83.5 points. The range of motion of the shoulder joint showed significant improvement throughout the two year period and degree of forward flexion and abduction continued to show significant improvement at five years. At two years, the mean forward flexion was 162°, mean extension was 152°, mean internal rotation was 109° and mean external rotation was 73°. All but one patient returned to their job at two years. Conclusions: Type I complex anterior fracture-dislocations of the shoulder are rare and occur in the middle age and elderly group of population. Following open reduction and internal fixation, the functional outcomes have been shown to be satisfactory. We recommend that open reduction and internal fixation should be the first choice of treatment in Type-I complex anterior fracture-dislocation of shoulder

Open reduction and internal fixation was employed in the treatment of 25 severely displaced fractures and fracture-dislocations of the proximal humerus. Our aims were accurate reduction and stable fixation to allow early mobilisation and to achieve full functional recovery. In 15 fractures an AO T-plate was used and in 10 a bent semitubular plate was employed as a blade plate. Excellent or satisfactory results were obtained in all six patients with two-part fractures involving the surgical neck; in four of the five patients with three-part fractures involving the surgical neck and tuberosities; in nine of the 11 patients with fracture-dislocation; and in two of the three patients with split fractures of the humeral head. Overall results were good or satisfactory in 21 of the 25 cases. Unsatisfactory results were associated with rotator cuff damage

Sixty-six patients are presented who have had a total hip replacement by the Charnley low-friction technique after injuries of the hip, the majority of which were fracture-dislocations. The clinical results of the arthroplasties in this relatively young group of patients are shown to be very good. The selection of young patients for total hip replacement arthroplasty is discussed

Four patients with lumbosacral fracture-dislocation are presented. The common mechanism of injury was hyperflexion with compression. A rotational element may be implicated in single facet dislocation. Although lumbosacral fracture-dislocations can be managed conservatively, the best method of treatment is open reduction and bone grafting as soon after injury as possible. Only this will ensure complete correction of the deformity and prevent later deterioration

We treated 36 patients with unilateral facet dislocations or fracture-dislocations of the cervical spine at the Mayo Clinic between 1975 and 1986. Adequate records were available for 34: ten patients were treated by open reduction and posterior fusion, and 24 by nonoperative management. Of these, 19 had halo traction followed by halo-thoracic immobilisation, four had a simple cervicothoracic orthosis, and one received no active treatment. Anatomical reduction was achieved more frequently in the operative group (60% compared with 25%). Nonoperative treatment was more likely to result in cervical translation on flexion/extension lateral radiographs, and in significant symptoms. Only 36% of the patients treated by halo traction achieved anatomical alignment; in 25% halo traction failed to achieve or maintain any degree of reduction. During halo-thoracic immobilisation, half of the patients lost some degree of reduction and patient satisfaction with the appliance was low. Open reduction and internal fixation of unilateral facet injuries gave better results. 6

This paper reports a prospective study of 72 consecutive patients with fractures or fracture-dislocations of the upper end of the humerus, treated during 1981. Most were elderly and treatment was conservative. Of the 72 patients 64 were followed up for a period of six months. Observations were made on the type of fracture, the speed and pattern of recovery of shoulder movements, on the time of commencement of physiotherapy, and on its duration. We found that with conservative treatment alone, 94% of our patients had good or satisfactory results at six months from injury. The criteria for manipulation are discussed and the literature is reviewed

A particular pattern of complex instability of the elbow is “the terrible triad”, in which elbow dislocation is associated with fractures of the coronoid and radial head. Other frequent patterns are the variant of Monteggia lesions (Bado II) described by Jupiter which is characterized by ulnar fracture associated with fracture-dislocation of proximal radius, and the articular fracture of the distal humerus associated with elbow dislocation. The goal of treatment is to restore the primary stabilizers of the elbow such as the coronoid process, olecranon and both collateral ligaments by internal fixation and reconstruction of the ligaments. If elbow stability obtained at operation is unsatisfactory or internal fixation not enough stable, there an indication for applying a dynamic external fixator (DEF). The latter allows:. the articular congruence to be maintained and the ligaments to heal in adequate tension and position,. internal fixation and ligaments reconstruction to be protected, and. immediate joint motion to be carried out. From 2005 to 2008, we treated surgically 31 patients with complex instability of the elbow. DEF was applied in 38% of cases, namely 3 terrible triads, 5 fracture-dislocations of Monteggia and 4 articular fractures of the humerus associated with elbow dislocation. The mean age of patients was 44 years (range 30–74). All patients underwent ORIF, reconstruction of ligaments and dynamic external fixation. The OptiROM elbow fixator was used In 2 patients, the Orthofix fixator in 1 and the DJD fixator in 9. In all cases, active elbow motion was allowed without restrictions from the second postoperative day. Indomethacin was consistently administered for 5 weeks to prevent heterotopic ossifications. The DEF was removed after 6 weeks. The mean follow-up was 25 months (range 5–44 months). At last follow-up, the clinical results, evaluated according to the MEPS, were excellent in 10 patients (83%), who had had a fast recovery of range of motion (ROM). The elbow was painless in all patients and stable in all but 1. Moderate osteoarthrosis was found in 60% of cases. Complications included: 1 elbow stiffness, 1 pseudarthrosis of capitulum humeri and trochlea, 1 transitory radial nerve palsy, and 1 superficial pin tract infection. In conclusion, DEF is a helpful tool for treatment of complex elbow instability, particularly when stable internal fixation cannot be obtained or instability persists after ligaments reconstruction. However, DEF increases morbidity, and implies a longer operative time and prolonged exposure to radiation

Ten patients, who underwent treatment for complex fracture-dislocation of the proximal interphalangeal joint of finger and one patient for that of the interphalangeal joint of thumb with a modified pins and rubbers traction system, were reviewed to evaluate the clinical and functional results. Two patients had open fracture-dislocation, 5 had pilon fractures and 4 had fracture-dislocations. The system was modified to avoid rotation of the pins in the bone during joint mobilization, thus minimizing the risk of osteolysis due to friction of pins over the bone. Michigan hand scoring system was used for subjective assessment and range of motion at proximal and distal interphalangeal joints and grip strength for objective assessment. Average follow-up was 18 months (range 3 months to 28 months). The average normalised Michigan hand score was 86. Based on Michigan scores, overall hand function was rated excellent in 8 patients, good in 2 and poor in 1. Eight patients have returned to their original jobs. The average arc of flexion in the proximal interphalangeal joint was 85 degrees and in the distal interphalangeal joint it was 47 degrees. The average grip strength was 95 percent of the uninvolved side. Two patients developed minor pin site infection, which did not necessitate pin removal or any alteration in the treatment regime. There have been no cases of osteolysis, osteitis or osteomyelitis. This modification of pins and rubbers traction system has given very acceptable results with a low complication rate. It is light, cheap, effective and easy to apply

Aims

Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries.

We present six patients with chronic dislocation of the elbow who were treated by primary semiconstrained total elbow arthroplasty. All were women with a mean age of 65 years (51 to 76), the mean interval between dislocation and surgery was 17 weeks (5 to 52) and the mean follow-up 58 months (24 to 123).

The most dramatic improvement was in function. The mean American Shoulder and Elbow Surgeon score was 5.2 times better (p < 0.001) and the mean total range of movement increased from 33° to 121° (p < 0.001) after operation. Three patients developed wear of polyethylene. One required revision for a periprosthetic fracture, and another required a bushing exchange.

Primary semiconstrained elbow arthroplasty provides significant, predictable functional improvement. Potential solutions for wear of polyethylene include a different operative technique or design of implant. Despite the high incidence of such wear, total elbow arthroplasty should be considered as a viable treatment option for chronic dislocation of the elbow in elderly patients.

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury).

Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries.

A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated.

1. Ten consecutive cases of acute atlanto-axial fracture dislocation were treated by posterior C.1-C.2 fusion.

2. In eight cases there was significant redislocation warranting further therapy.

3. Operative fusion together with prolonged firm immobilisation are recommended only after a trial of conservative therapy.

1. Fifty-nine patients with various inter-carpal dislocations have been reviewed.

2. In this series trans-scapho-perilunar fracture-dislocation was the commonest injury. Early cases can be reduced by closed manipulation but in late cases operative reduction is usually advisable. When the injury is more than three months old, arthrodesis of the wrist joint is indicated.

3. When trans-scapho-perilunar fracture-dislocation was complicated by avascular necrosis of the proximal scaphoid fragment, the results in a small series treated by early excision were approximately equal to those treated by continued immobilisation. The results of grafting the scaphoid were poor.

4. Dislocations of the lunate seen within ten days of injury could usually be reduced with good results; no such case developed Kienböck's disease within the period of review. In late cases excision gave satisfactory results.

5. Forward dislocation of the lunate with half the scaphoid gave good results when manual reduction succeeded, but the results of excision of fragments were less satisfactory.

6. There was one case of forward dislocation of the lunate together with the distal half of the scaphoid.

7. Subluxation of the scaphoid is disclose in antero-posterior radiographs by a typical gap between it and the lunate bone. The subluxation may become recurrent and present a characteristic syndrome.

8. Other rare dislocations of the carpal bones are described.