Myriad protocols exist for isolated Weber B lateral malleolus fractures with a congruent tibiotalar joint on initial radiographs. Stress and weight-bearing radiographs, all at various timepoints, may be employed to identify those injuries that develop significant talar shift but consensus is elusive. This study outlines a safe and reproducible protocol for such injuries, utilising a removable orthosis, immediate weight bearing and standard supine radiographs. A retrospective analysis of a prospective trauma database was analysed to identify patients with an isolated Weber B ankle fracture with adequate presentation radiographs demonstrating a congruent mortise. Patient records and radiographs were evaluated a minimum of 5 years after initial presentation to determine ankle stability, complications, and the burden on outpatient services. Between 2014 and 2016, 657 patients were referred to the specialist trauma clinic from the emergency department. Of the 657, 52 patients had inadequate ED radiographs to determine ankle congruity. At the two-week assessment, 11 of the 52 demonstrated talar shift and required intervention. Therefore 646 patients demonstrated ankle congruity at two weeks after weight bearing. No patient demonstrated talar shift at the six-week assessment. Average number of follow up appointments was 2.4 with 3.5 radiographs. Our new treatment protocol advocates discharge after a single orthopaedic assessment after two weeks of weight bearing. This study supports immediate weight-bearing of Weber B ankle fractures with a congruent mortise in an orthosis. Follow up beyond two weeks is unnecessary and our protocol offers a safe means of significantly reducing the outpatient burden

Aims

The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

Aims

Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

Aims

The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

Dynamometric measurement of the grasp strength is commonly used in wrist assessment. On the other hand measurement of the pronation-supination (PS) strength has been few studied. The longitudinal forearm rotation needs integrity of the two radioulnar joints and of the antebrachial interosseous membrane. The strength developed during PS assesses also trophicity of pronator and supinator muscles. A PS dynamometer (Baseline ®, AREX) is now available for such measurements. The aims of this study were: 1) to study the best way to neutralize the shoulder movements of abduction-adduction, 2) to find the values of PS Strength in a healthy population, and 3) to study correlations between this PS force and several biometric items. A first series of measurements des PS strength was performed thanks to the Baseline dynamometer in 8 people, in association with two devices neutralizing the shoulder movements of abduction-adduction, in repeated campaigns allowed the authors to determine and keep the better one for optimal measurements following campaigns. To assess the normal values of PS Strength in a healthy population, 38 healthy volunteers from both genders and different ages, classified according their age class, from three different forearm position: neutral, from 90 ° of supination and 90 ° of pronation. Finally, statistical analysis looked for correlations between PS strength and some biometric data. Manipulations beginning from a neutral position of forearm were the most reliable. The mean strength within the whole studied sample (76 wrists, 17 male, 21 female) was 10.6 N.m (standard deviation SD 3.26) for the supination and 13.9 N.m (standard deviation 4.19) for the supination. The dominant side exhibited a PS strength superior by 7.5% to that of the non-dominant side. Male gender, the height and weight of the body, forearm circumference displayed positive relationships with PS strength. Mean values of PS strength, measured from a neutral forearm rotation and with the best device to neutralize the shoulder movements, in a healthy population of 38 volunteers, allowed the authors establishing reference values. They will allow precise comparisons between the values found in patients suffering from forearm and/or wrist pathology and the healthy population, taking into account the age, gender and hand dominance

The Essex-Lopresti injury (ELI) of the forearm is a rare and serious condition which is often overlooked, leading to a poor outcome. . The purpose of this retrospective case study was to establish whether early surgery can give good medium-term results. . From a group of 295 patients with a fracture of the radial head, 12 patients were diagnosed with ELI on MRI which confirmed injury to the interosseous membrane (IOM) and ligament (IOL). They were treated by reduction and temporary Kirschner (K)-wire stabilisation of the distal radioulnar joint (DRUJ). In addition, eight patients had a radial head replacement, and two a radial head reconstruction. All patients were examined clinically and radiologically 59 months (25 to 90) after surgery when the mean Mayo Modified Wrist Score (MMWS) was 88.4 (78 to 94), the mean Mayo Elbow Performance Scores (MEPS) 86.7 (77 to 95) and the mean disabilities of arm, shoulder and hand (DASH) score 20.5 (16 to 31): all of these indicate a good outcome. In case of a high index of suspicion for ELI in patients with a radial head fracture, we recommend the following: confirmation of IOM and IOL injury with an early MRI scan; early surgery with reduction and temporary K-wire stabilisation of the DRUJ; preservation of the radial head if at all possible or replacement if not, and functional bracing in supination. This will increase the prospect of a good result, and avoid the complications of a missed diagnosis and the difficulties of late treatment. Cite this article: Bone Joint J 2014;96-B:1385–91

The purpose of this study was to evaluate the subjective and objective functional outcome after osteosynthesis of the forearm bone fractures with plates and screws (ORIF) or elastic nailing (CRIF). We evaluated 55 patients (45 men and 10 women) who underwent internal fixation of both forearm bones with CRIF or ORIF, concerning the range of motion of the forearm, wrist and elbow (pronation, supination, flexion and extension), grip strength and a validated outcome measure (DASH score). The mean duration of follow-up was 3 years, and standardized radiographs of the forearm were evaluated. The mean age was 41.6. We used the Student's t test to compare means and chi-square test to compare proportions. The mean (confidence interval 95%) of the DASH scale was 29.6 (22.6 to 36.5), significantly higher (p<0.001) than the normative value in the U.S. (10.1). There was a statistically significant reduction of forearm supination (86.4 vs. 64.6, p<0.001) and grip strength (0.63 vs. 0.48, p<0.001) in relation to the opposite member; grip strength decrease correlated with worse subjective outcome (p<0.02). There were no significant differences between groups undergoing ORIF or CRIF. The risk of nonunion and reintervention was not different between groups (p=0214). Forearm bones fractures are associated with high rates of consolidation and satisfactory mobility of the forearm since we obtain an anatomic reduction of the fracture, as is most easily achieved by plate fixation. However, elastic nailing is a less invasive technique that allows restoring function more quickly with less pain and no increased risk of complications. Given the scant scientific evidence currently available we will require a more comprehensive study to compare the anatomical and functional outcome after ORIF and CRIF

Introduction. Distal radius fractures (DRF) are a common injury in the A&E departments, being a major cause of disability of the upper extremity. The aim of this prospective study is to assess the possible association between objective physical variables such as wrist range of movement (ROM), radiological parameters, and upper extremity disability (measured by the DASH questionnaire), after conservative treatment of DRF. Patients and methods. 44 patients with non-operatively managed DRF were enrolled in a prospective cohort study from July 2007 till September 2009. Inclusion criteria: unilateral DRF in skeletally mature patients, treated non-operatively with closed reduction and cast. Patients who sustained a previous fracture of the wrist, or bilateral wrist fracture, or with dementia, were excluded. After the closed reduction and inmovilization of the fracture in the A&E department we asked the patients to complete the DASH questionnaire, referring to their baseline pre-fracture state. All fractures were classified according to the AO classification. After one year, 36 patients were still available for follow-up purposes. We assesed the following objective physical variables: ROM of both wrists: flexion/extension arc and pronation/supination arch. We recorded the following radiologic parameters: radial angulation, volar angulation and radial shortening. The patient-perceived results were measured by the DASH questionnaire, while pain was measured using the VAS scale. Statistical analysis was performed using the SPSS 15.0. Results. Average follow up: 13,39 months (range 12.3–16.43). Mean age: 62.5 years (18–91). 75% of the fractures were 23A and 24,1% 23B. Average pre-fracture DASH score was 19.6 and 42.1 at the end of follow-up. Radial tilt: 18.18°. Volar tilt: 3,35°. Radial shortening: 5,76mm. ROM for flexion/extension of the involved wrist: 103.6° and non-involved wrist: 131.2°. ROM for pronation/supination involved wrist: 145.7° and non-involved wrist: 173.8°. Post-fracture VAS score: 3.5. We didn't find any significant statistical correlation between the lost of ROM, neither with radiological malaligment nor with patient-perceived outcomes. But we found a significant association between items 24–28 of the DASH (except item 26) questionnaire and the VAS score. Conclusions. The results of the present study show that, conservative treatment of DRF seems to deteriorate the patient self-reported outcomes measured by the DASH questionnaire

Background. It is unclear which form of anaesthesia is the most favourable in primary total hip replacement (THR) surgery. A recently published systematic review of modern anaesthesia techniques in primary THR surgery (Macfarlane 2009) was not able to show any convincing benefit of regional or general anaesthesia. One retrospective study that examined anaesthesia and leg length (Sathappan 2008), found an increased incidence of leg length difference > 5 mm in those patients who were operated with regional anaesthesia. Our department used a mini invasive approach in supine as standard procedure in THR. The type of anaesthesia that is chosen is up to the individual anaesthetist. Purpose. We wanted to see if there was any correlation between type of anaesthesia and leg length, total time spent in theatre and recovery room, postoperative hospital stay, blood loss or operating time in primary THR surgery with a mini invasive approach in supine. Materials and Methods. Our study was a retrospective study of 170 primary THR patients. All patients received an uncemented Corail stem and a cemented Marathon cup. Patients with abnormal anatomy, BMI > 46, simultaneous removal of internal fixation or incomplete data were excluded in the analysis. Radiograpic leg length was measured using the inter teardrop line and the lesser trochanter. Results. 99 patients were operated on with spinal anaesthesia and 71 with total intravenous anaesthesia (TIVA). There were 65% women in both groups. Average age was 74 years (32–95) in the spinal anaesthesia group and 67 years (38–93) in the TIVA group. We found no significant difference in the average operating time (spinal 65 min, TIVA 64 min), drop in haemoglobin to the first postoperative day (spinal 16%, TIVA 16%), postoperative hospital stay (Spinal 1.4 days, TIVA 1.4) or in transfusion rate (spinal 1%, TIVA 1.4%). We found a significant difference in the proportion of patients with a leg length difference of more than 7 mm (Spinal 22%, TIVA 6%, p = 0.02) and the average total time spent in theatre and post-operative department (spinal 325 min, TIVA 293 min, p < 001). Discussion. The study is retrospective and is therefore fettered by the limitations inherent in such a study. Our study seems to confirm the earlier findings that the type of anaesthesia can affect leg length in primary THR. It is speculated that spinal anaesthesia has a more unpredictable effect on muscular tension which could explain this

We identified 11 women with a mean age of 74 years (65 to 81) who sustained comminuted distal radial and ulnar fractures and were treated by volar plating and slight shortening of the radius combined with a primary Sauvé-Kapandji procedure. At a mean of 46 months (16 to 58), union of distal radial fractures and arthrodesis of the distal radioulnar joint was seen in all patients. The mean shortening of the radius was 12 mm (5 to 18) compared to the contralateral side. Flexion and extension of the wrist was a mean of 54° and 50°, respectively, and the mean pronation and supination of the forearm was 82° and 86°, respectively. The final mean disabilities of the arm, shoulder and hand score was 26 points. According to the Green and O’Brien rating system, eight patients had an excellent, two a good and one a fair result. The good clinical and radiological results, and the minor complications without the need for further operations related to late ulnar-sided wrist pain, justify this procedure in the elderly patient

Background. Chronic acquired radial head dislocations pose a complex problem in terms of surgical decision making, especially if surgery has already previously failed. There are several underlying causes that should be investigated, including previous trauma resulting in a missed Monteggia fracture. Aim. To review the clinical and radiological outcomes for children up to 18 years of age, with a radial head dislocation treated with circular frame surgery. Method. A retrospective study was designed to identify patients from our departmental database who had undergone circular frame surgery to reduce the radial head during the past 6 years. Results. 20 patients were identified with a mean age of 11 years (3 – 17). Fourteen patients had a diagnosis of missed Monteggia fracture, three patients had Hereditary Multiple Exostoses, one had Nail Patella syndrome, one had Osteogenesis Imperfecta and one had rickets. The average delay between trauma and frame surgery was three years (0 – 7). All patients achieved union of their ulnar or radial osteotomy. The average frame duration was 167 days (61 – 325) and complications included delayed union and residual radial head subluxation. Thirteen patients achieved at least 40 degrees of supination, and 10 patients achieved at least 40 degrees of pronation. Eighteen patients achieved an arc of movement from full extension to at least 110 degrees of flexion. Eleven patients reported their pain level at final follow-up, of which 9 had no pain at all. Conclusion and Discussion. Circular frame surgery was a reliable and consistent method of reducing chronic radial head dislocations and improving function. Radiological appearances of mild residual subluxation of the radial head were clinically well tolerated and generally required no further treatment

Four men who presented with chronic dislocation of the radial head and nonunion or malunion of the ulna were reviewed after open reduction of the radial head and internal fixation of the ulna in attempted overcorrection. Their mean age was 37 years (28 to 46) and the mean interval between injury and reconstruction was nine months (4 to 18). The mean follow-up was 24 months (15 to 36). One patient who had undergone secondary excision of the radial head was also followed up for comparison. The three patients who had followed the treatment protocol had nearly normal flexion, extension and supination and only very occasional pain. All had considerable loss of pronation which did not affect patient satisfaction. Preservation of the radial head in chronic adult Monteggia fractures appears to be a promising mode of treatment

In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant. Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome

Aims

The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining.

There is a high rate of forearm deformity in patients with hereditary multiple exostoses (HME), and a quarter of patients acquire a dislocated radial head due to disproportionate ulnar shortening. One-hundred and six patients with HME aged 15 years or older were identified from a prospective database. Flexion and extension of the elbow and wrist, and supination and pronation of the forearm was measured. The number of exostoses affecting the proximal and distal radius and ulna were recorded. Proportional ulna length was calculated as a percentage of the patients measured height ([ulna length/height] × 100). More than 70% of patients were affected by exostoses of the forearm, of which the distal radius was the commonest site to be affected (73%). One in seven patients had a dislocated radial head, which was associated with proportional ulna shortening (p<0.001). Both radial head dislocation (p<0.001) and proportional ulna shortening (p<0.001) were confirmed to be independent predictors of forearm motion on multivariable regression analysis. In conjunction with other predictors these could be used to calculate ROM of the forearm. In addition proportional ulna length was also an independent predictor of radial head dislocation (p<0.001). Proportional ulna length could be used as a tool to identify patients at risk of diminished forearm motion and radial head dislocation during childhood, who could be monitored clinically and radiographically, and surgical intervention could be offered before deterioration in function and dislocation of the radial head occurs

Magnetic resonance imaging (MRI) validation of a novel method of assessing Distal Radial Fracture (DRF) reduction using the hypothesised constant relationship between the dorsal radial cortex (DC) and the superior pole of the lunate (SL). MRI scans of 28 normal wrists were examined. Scans included the distal third of the radius to the proximal carpal row. Beginning 5cm proximal to the distal radius articular surface, a line was superimposed upon the DC extending distally through the metaphyseal flare. Lunate height (LH) and distance from the DC line to the SL (DC-SL) were measured at 5-degree rotational increments around the radial shaft central axis to a total of 30 degrees of supination and pronation (S+P). The DC-SL/LH ratio was compared to 0 degrees (anatomical lateral) using the two-tailed paired student t-test. There was no significant difference in DC-SL:LH between 0 degrees of rotation and any 5-degree increment up to 30 degrees of S+P (lowest p=0.075). The DC line lay consistently dorsal to the SL. A constant DC-SL relationship exists with up to 30 degrees of S+P. This reference can be quickly and accurately used to assess DRF reduction in poorly-taken films with malrotation up to 30 degrees from anatomical lateral. Research comparing DC-SL distance with volar tilt to assess DRF reduction is needed

Intro. Distal radial fractures are a commonly encountered fracture & anatomical reduction is the standard. Dorsal angulation is the traditional method of assessment but is inaccurate in rotated lateral xrays. Previously a relationship has been demonstrated between the dorsal cortex (DC) of the radius & the superior pole of the lunate (SL) & its sensitivity for assessing dorsal angulation & translation. Hypothesis. A constant anatomical relationship maintained between the DC and the SL when rotated up to 30 degrees from standard lateral?. Methods. MRI scans of 28 wrists including the distal third of the radius to the proximal carpal row. Beginning 5cm proximal to the distal radius articular surface, a line was superimposed upon the DC extending distally through the metaphysis. Lunate height (LH) & distance from the DC line to the SL (DC-SL) were measured at 5-degree rotational increments around the radial shaft central axis to 30 degrees of supination & pronation (S+P). The DC-SL/LH ratio was compared to 0 degrees (anatomical lateral) using the two-tailed paired student t-test. Results. No significant difference in DC-SL:LH between 0 degrees of rotation and any 5-degree increment up to 30 degrees of S+P (lowest p=0.075). The DC line lay consistently dorsal to the SL. Conclusion. A constant DC-SL relationship is maintained with up to 30 degrees of S+P. This reference can be quickly and accurately used to assess DRF reduction in poorly-taken films with malrotation

Aims

To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.