Introduction: Vascular injuries associated with limb bone fractures are relatively uncommon.

Aim: To determine the mechanisms of injury and evaluate the outcome of combined orthopaedic and vascular injuries.

Method: A retrospective review of all patients with vascular injury associated with limb bone fractures between January 1992 and July 2006 was performed. Data collected included demographic details, clinical presentation, assessment, management and outcome.

Results: Of 22,340 fractures treated during the 14 years period 36 patients sustained a vascular injury that required surgical intervention. Of those, 18 patients (50%) had a concomitant fractures or other orthopaedic injury this group form the basis of the audit. The median age was 31.1 (range 3–80) years, and 66% were male.

Road traffic accidents accounted for 12 injuries (66%), other accidents 4(22%), iatrogenic injury 1(6%), and 1 gunshot injury (6%). Four patients had an associated nerve injury with varying severity. Skeletal fixation preceded vascular repair in most of the cases. Peroperative arterial shunting was not used in any patient. The primary vascular procedures included end-to-end anastamosis 2(11%), bypass grafting 1(6%), interposition vein grafts 8(43%), vein patch 1(6%), direct arterial repair 2(11%), ligation 2(11%), primary amputation 1(6%), reposition of normal course of artery 1(6%).

During a 17 months follow-up period, the upper and lower limb preservation rate was 100 and 89%, respectively. Nine patients (50%) were symptom free; three patients (16.6%) had a neurological deficit.

Conclusion: Vascular injury is uncommon in the orthopaedic patients. High suspicion and early intervention is essential to optimise outcome and function.

Introduction: Although the application of low-energy Extracorporeal shock waves application (ESWA) to treat musculoskeletal disorders is controversial, there has been some limited, short-term evidence of its effectiveness for the treatment of chronic plantar fasciitis. Objective: The aim of this prospective study is to explore the effect of Extracorporal shock waves in patients with chronic planter faciitis. Methodology & results: In this prospective study 70 heels in 62 patients with chronic planter faciitis in whom conventional conservative treatment consisting of nonsteroidal anti-inßammatory drugs, heel cup, orthoses and/or shoe modiþcations, local steroid injections have failed, were treated with low energy ESWA. Standard radiographs of the affected heels were obtained before ESWA to document the existence of a calcaneal heel spur. Pre and post therapy subjective and objective scoring systems are being used to know the functional outcome (SF36 Health Survey score, Short Form McGill Pain Questionaire, American Orthopaedic foot and ankle society Hindfoot Scale, Visual analogue Pain score). Patients were reviewed at 6 and 12 weeks post treatment. At followup pain was decreased by 70% to 90% on the visual analog scale (VAS) and the comfortable walking time had increased signiþcantly. There were no reported side effects. Conclusion: This study indicates that in patients with chronic plantar fasciitis, the ESWA.provide a good pain relief and a satisfactory clinical outcome

Introduction: Fractures of the distal radius are amongst the most commonly encountered injuries in orthopaedic trauma. Treatment options include closed manipulation, percutaneous fixing using K wires and external fixation. Restoration of the volar tilt and radial length are proven to have a positive correlation with a good functional outcome.

A randomised prospective study has been performed to compare the effectiveness of percutaneous stabilisation using K wires inserted in the traditional transcortical fashion with K wires inserted using a novel intramedullary spring loaded technique. The treatments were compared for their ability to restore normal anatomy, carpal alignment and function of the hand after unstable fractures of the distal radius.

Patients and Methods: Between October 2001 and February 2002, 46 patients with unstable fractures of the distal radius were entered into the study. There were 37 females and 9 males, mean age of 58 years (range 17–87). Fractures were classified using the AO system. Patients were randomly allocated using closed envelopes into one of two groups. All fractures were reduced, and three 1.6mm K wires were inserted using one of two techniques. Group I (24 pts) had the wires engaged into the opposite cortex and driven down the medullary canal (spring-loaded). All patients were followed up for a minimum of 6 weeks. Radiological and functional evaluation was performed.

Results: Immediate post operative radiographs showed a mean dorsal angle of –3° in Group I (ie 3 degrees volar tilt) and –7.5° in Group II. Restoration of radial length was similar in both groups. By 6 weeks, the mean dorsal angle for Group I was −1.9°, and –10.6° in Group II. The mean loss of radial length was similar in both groups (1.2mm in Group I; 1.3mm in Group II). Functional outcome was assessed using the Wrist Function Score², and was similar in both groups at 6 weeks. There were 2 early fixation failures, both in Group I, and both class C3 fractures (AO).

Conclusion: ‘Spring loaded’ percutaneous K wiring of distal radius fractures results a significantly superior restoration of volar tilt post operatively and at 6 weeks when compared against the transcortical technique. The ‘spring’ translates into a dynamic force reducing the fracture. We estimate that these radiological results will result in a superior functional outcome in the longer term.

The study was designed to determine the incidence and to quantify the risk factors of permanently decreased bone mineral density (BMD) of the Lumbar spine and Femoral neck following tibial shaft fractures.

42 consecutive adults treated for isolated tibial shaft fractures at our institution between January 1984 and June 1985 formed the subjects of this study. Mechanism and type of injury, method of treatment, length of immobilisation and weight bearing status and healing time were determined from the patient records. A questionnaire including history of smoking, alcohol consumption, medications, other fractures, medical conditions like thyroid/parathyroid disorders, convulsions, and renal disorders was administered. Bone mineral density of lumbar 1–4 vertebrae and both hips was assessed using DEXA scanning. T and Z scores were generated. Statistical analysis was performed using the Chi square test to test the significance of association of osteopenia/osteoporosis (Z score < -1) with a previous tibial shaft fracture and calculating the odds ratio (OR) and 95% confidence interval (CI) to quantify the suspected risk factors.

The incidence of significant loss of BMD of the ipsilateral femur and/or lumbar spine was found to be 33%. A statistically significant association (p< 0.001) between a history of tibial shaft fracture and permanent loss of BMD was noted. The following risk factors were found to be statistically significant; Smoking (OR 22, 95% CI=4–> 40, p< 0.001), Alcohol more than 20 units/week (OR 11, 95% CI 2.2–54,p< 0.005), Open fracture (OR 17, 95% CI=2.9–> 40, p< 0.001), Non-weight bearing more than 12 weeks (OR 15, 95% CI 2.9–> 40, p< 0.005), and delayed union defined as healing time more than 6 months (OR 15, 95% CI 1.54–> 40, p < 0.05).

Permanent regional osteopaenia/osteoporosis occurs in a significant proportion of tibial shaft fracture patients. Modern fracture management should include identifying ‘at risk’ patients and appropriate management to prevent fragility fractures.