Aim: The aim of the study was to investigate the efficacy of the multidetector CT scan in the diagnosis and classification of pelvic and acetabular fractures.

Material and Method: 41 patients, 13 women and 28 men suspect for acetabular or pelvic fracture were examined. Patient’s ranged from 15 to 72 years. Fracture classification was based in that of Letournel and Judet. Examination was performed with a Multidetector CT scanner (Phillips-Brilliance), withnmultiple detectors and thin slices of 2 mm Multilevel and three dimensional reconstructions were performed.

Results: in 15 patients suspects for pelvic or acetabular fracture in plain xray, the CT scan was negative for revealing a fracture. In the rest 26 patients, there were 19 fractures of the anterior column, 4 fractures of the posterior column, 11 acetabular fractures and 7 sacral fractures. All the fractures were detected at the horizontal plane. MPR views were offered additional information for the sacral and acetabular fractures. In 7 patients the fractures diagnosed only after the CT scan was performed. In these patient plain x-rays were negative for fracture. In 6 patients the treatment algorithm was modified, based on CT scans findings

Conclusion: We believe that MDCT is an appropriate as well as an essential method in patients suspects for pelvic or acetabular injuries. MPR and three dimensional reconstructions are very helpful in revealing the personality of the fracture element very important for classification purposes as well as for planning treatment.

Aim: The aim of the study is to evaluate the usefulness of the MDCT scan in the diagnosis of calcaneal fractures and its use in the surgical treatment

Material. 112 calcaneal fractures were examined with a MDCT scan (slices one to two mm, pitch 1.5) with multilevel reconstruction as well as three dimensional reconstruction. The fractures were classified according to Munich classification system. Findings that were evaluated were the involvement of the subtalar joint, the number of fragments of the posterior facet and the extent of displacement.

Results: There were 85 intraartiular fractures and 27 extraarticular. 32 fractures were of type I according to Munich classification system (extraarticular without displacement). 15 fractures were of type II (extraarticular with some displacement). 2 fractures were of type III (intraarticular without displacement). 27 were of type IV (two fragments). 19 were of type V (with free fragments in the joint and 17 were type VI (more than four fragments).

Conclusion: The above mentioned radiological method of evaluating calcaneal fractures offers a quick diagnosis since it can depict the fragments and its displacement very accurately. Furthermore this method permits a very precise preoperative planning for the surgical treatment of these injuries

Aim: The aim of this study is to evaluate the efficacy of the multidetector CT scan in shoulder fractures and to correlate these findings with those of plain x-rays.

Material and Method: A 105 patients with shoulder fracture were examined with a multidetector CT scanner after the acute injury. There were 64 male and 41 female with an average age of 52 yrs (range 16–95 yrs). The examination was performed with a CT PHILIPS BRILLIANCE, and six groups of detectors were used, with thin slices (1.6–2 mm). MPR and three dimensional reconstructions were performed.

Results: The mechanism of injury was fall during walk in 66 patients, fall from a height in 11 patients, and road traffic accident in 28 patients. They were detected 210 fractures at the shoulder region. A 135 fractures were located at the proxd imal end of the humerus, 75 at the scapula, in 95 out of 105 patients. In 10 patients with a comminuted fracture of the upper end of the humerus, the exact number of fragments as well as the precise location of them was not accurately assessed with plain xrays. MDCT control with multilevel anasynthesis and three dimensional reconstruction improved the understanding of the anatomic orientation in complex fractures and fractures–dislocations and in detection of subluxation of the fragments of the shoulder headin four part fractures in two patients.

Conclusion: Our results would orient us for using the MDCT scan in patients with acute shoulder injury, especially in cases with comminuted fractures, because it is better assessed the place, the orientation and the displacement of fragments, which are not easily identified in plain xrays. Furthermore, these reconstructions improve the preoperative planning in those patients

We present a new inflatable self-locking intramedullary nailing system for the treatment of intertrocanteric and subtrochanteric fractures.

Material: We used this system in 63 cases with an average age of 81 yrs. 23 cases were intertrochanteric fractures and 40 cases subtrochanteric. A standard technique of closed reduction was used and the nail was implanted through an entry portal at the tip of the great trochanter.

Results. 38 patients were available for clinical and radiological examination. 13 patients were contacted by telephone and 12 patients could not be reached. The patients were mobilized with the instruction of weight bearing as tolerated. Each fracture was consolidated on average of 8 weeks. In two patients a cut out of the central peg was noted and the system was removed after fracture union. In three patients a mild malalignment was noted but without clinical significance. The mean blood loss was 90 cc and the mean operative time was 36 minutes.

Discussion The features of this system and the advantage of the technique include: fixation along the entire length of the nail, lack of distal interlocking screws, reduced exposure of the surgeon to x-ray and reduced operating time. Our results are very promising and it seems that this system is an innovative, effective, simple and minimally invasive treatment for fractures on the trochanteric region.

Over the past 40 years, the management of displaced fractures of the acetabulum has changed from conservative to operative. We have undertaken a meta-analysis to evaluate the classification, the incidence of complications and the functional outcome of patients who had undergone operative treatment of such injuries.

We analysed a total of 3670 fractures. The most common long-term complication was osteoarthritis which occurred in approximately 20% of the patients. Other late complications, including heterotopic ossification and avascular necrosis of the femoral head, were present in less than 10%. However, only 8% of patients who were treated surgically needed a further operation, usually a hip arthroplasty, and between 75% and 80% of patients gained an excellent or good result at a mean of five years after injury. Factors influencing the functional outcome included the type of fracture and/or dislocation, damage to the femoral head, associated injuries and co-morbidity which can be considered to be non-controllable, and the timing of the operation, the surgical approach, the quality of reduction and local complications which are all controllable. The treatment of these injuries is challenging. Tertiary referrals need to be undertaken as early as possible, since the timing of surgery is of the utmost importance. It is important, at operation, to obtain the most accurate reduction of the fracture which is possible, with a minimal surgical approach, as both are related to improved outcome.

Introduction: Noncontiguous fractures of the tibial diaphysis and ipsilateral ankle is an uncommon entity. The aim of this study is to highlight the unique fracture pattern with emphasis on the necessity for surgical treatment. Material: There were 17 patients with an average age of 42 years, who sustained ipsilateral, noncontiguous fractures of the tibia and ankle. All but two fractures were closed. The level of the tibia fracture included midshaft (two), middle-distal third (ten), distal third (five). Eleven ankle fractures were classified as Weber B, five as Weber C and one Pilon. Two fractures were treated by cast immobilization, eleven with internal fixation of both fractures and four with a combination of internal and external fixation. Seven fractures were treated initially in long leg casts, but each required surgical intervention to control fracture alignment. Results: The average follow up was twenty-three months. The non-operatively treated fractures resulted in a malunion and decreased ankle mobility. Of the cases managed operatively, nine had complete structural and functional recovery; two patients regained 70% of ankle mobility and one developed post-traumatic ankle arthritis. Discussion: The resulted experience from the treatment of these injuries showed their extremely unstable nature. It has been our experience that the nature of the forces acting upon the fragments usually underestimated since reduction of one fracture displaces the other. Furthermore if acceptable reduction is achieved by closed means, progressive slippage of the fragments occurs. We believe that stable fixation of both fractures should be the treatment of choice

Introduction: Primary surgical treatment has been recommended for unstable clavicular fractures if consequences of non-union or malunion have to be avoided. A prospective study was undertaken to evaluate the results of a conservative treatment of very unstable fractures of the middle third of the clavicle, with emphasis to very early mobilization. Material: Patients to be included in the study had to met the following criteria: 1) Fractures of the middle third of the clavicle, severely displaced or comminuted, 2) Closed injuries, 3) No neurovascular complications, 4) No pneumothorax or hae-mothorax and 5) No other injury in the ipsilateral upper extremity. Twenty-three patients with an average age of 24 years included in the study. Each patient evaluated with AP and 45-degree cephalad-tilted views. All patients treated with an arm sling and strongly instructed for early mobilization. All patients were evaluated in a weekly interval and assessed with the American Shoulder and Elbow Surgeonñs shoulder evaluation form. Results: The average follow up was 21.4 months. All fractures were consolidated and all malunited; but no patient had residual symptoms or functional impairment of the limb. On patient developed mild hypesthesia in the ulnar nerve territory. Conclusion: The extremely encouraging results of our study, within the bounds of the above-mentioned follow up, indicate that conservative treatment with very early mobilization may be considered as a valid therapy. However it is a concern the functional result in a longer follow up as well as the cosmetic result.

Purpose: To analyze the long-term functional outcome of vertical shear fractures to other forms of severe pelvic injuries: APC-III, LC-III, and complex acetabular fractures.

Patients and Methods: Out of 561 patients with pelvic ring injuries we identified 31 vertical shear fractures in 29 consecutive patients (4 female). A retrospective chart analysis was performed and the following data was recorded: age, sex, mechanism of injury, associated injuries, Injury Severity Score (ISS), resuscitation requirements, method of stabilization, intensive care unit (ICU) or high dependency unit (HDU) stay, duration of hospital stay, urogenital injuries, neurological injury, systemic complications, time to union and mortality. The same parameters were assessed and analyzed in a control group comprising of 98 patients: 34 patients with APC–III, 32 patients with LC-III and 32 patients with complex (at least bicolumnar) ace-tabular fractures. All patients in the control group were matched for age and sex with the vertical shear fracture group. The mean follow up was 62 months. At final follow up, functional outcome was assessed in all patients using the following generic outcome measurement tools: Euro-Qol 5D (EQ), SF36 v2 (Short form), VAS (Visual analogue score), SMFA (Short musculoskeletal functional assessment) and Majeed score. In addition Merle d’ Aubignæ and Postel scores (Matta modification – 1986) and radiologic degenerative hip scores (Matta 994) were used to assess patients with acetabular fractures.

Results: The mean age of all the patients in the study was 43.5 years (16–71) and the median injury severity score was 22 (12–32). Motor vehicle accidents accounted for 79% of the injuries. All patients had their pelvic ring stabilized at least temporarily within 24 hours and all acetabular fractures were reduced and stabilized by 7 days. The mean hospital stay was 26 (9–176) days. Functional outcome was assessed in all patients of the control group and in 28/29 patients of the vertical shear fracture group (1 patient died as a result of a cerebral vascular accident 11 months after injury). In the vertical shear fracture group, 35% of the patients have returned to their previous jobs (49% in control group), 30% have changed their professions (30% in control group) and 25% (14% in control group) have retired from regular work. In the acetabular group, 10 (31%) patients had neurologic injury (6 sciatic, 3 common peroneal, 1 femoral). Of these, 4 were iatrogenic. 6 patients had complete neurologic recovery. Heterotopic ossification was seen in 19 (59%) patients (12 had Brooker Grade 1, four had Grade 2, three had Grade 3). Three patients (9%) with acetabular fractures (all had associated posterior wall fracture) had total hip replacements at 29,40,51months (2 secondary osteoarthritis and 1 osteonecrosis). The clinical outcome (Matta modification-1986 of Merle d’ Aubignæ and Postel scores) of patients in the acetabular fracture group was: 5 excellent (3 THA), 4 good, 13 fair and 10 poor. The radiologic score of degenerative hip disease (Matta 1994) for the acetabular fracture group was: 4 excellent, 8 good, 14 fair and 3 poor.

Conclusion: Patients with vertical shear fractures represent the spectrum of high-energy pelvic disruption. The functional outcome is significantly better in patients with APC III and LC III fractures when compared to vertical shear and complex acetabular fractures thus reflecting the severity of the injury. Secondary osteoarthritis and neurologic injury appear to contribute to the poor outcome of acetabular fractures. Sound reconstruction of the pelvic ring is not always associated with good results probably due to the extensive pelvic floor trauma as seen in this series of patients. Younger individuals seem to have a relatively better outcome when compared to the older age group.

Purpose: Intravasation of intramedullary contents and immune activation under the stimulus of cytokines and other inflammatory mediators released during canal preparation are presumed to be significant factors in the evolution of acute lung injury following stabilization of femoral shaft fractures with intramedullary nailing.

We aimed to quantify the development of acute endo-thelial permeability changes (within 4hours from canal instrumentation) with the reamed (RFN) and unreamed (UFN) nailing technique and assess the effect of coexisting lung contusion.

Materials and methods: A standardized sheep model (n=8 animals/group) was used. In the control groups, a thoracotomy without lung injury was performed prior to canal instrumentation. In the study groups a lung contusion of the right middle and lower lobe was induced. Osteosynthesis of the femur was carried out by the reamed (group RFN; standard Synthes reamer, old version) and unreamed technique (group UFN). Bronchoalveolar lavage was performed in order to assess the extent of lung parenchymal damage (permeability). The amount of protein leakage (determination of protein (Lowry assay) and urea (biochemical test) in BALF and serum) at different time points was analysed. Polymorphonuclear leukocyte activation was quantified by chemi-luminescence. IL-8 and coagulatory disturbances (Protein C) were also measured. All animals were sacrificed four hours following canal instrumentation and histological analysis was performed.

Results: In the control groups both the reamed and the unreamed nailing techniques were associated with a significant increase in pulmonary permeability compared to baseline values, p< 0.05. The experimental lung contusion induced prior to canal instrumentation caused also a significant increase in pulmonary permeability compared to baseline values. However, the subsequent canal instrumentation amplified further, significantly so, the degree of pulmonary permeability only in the reamed group (RFN).Both the activation of leukocytes and IL-8 release were also significantly raised following lung contusion and reamed femoral nailing compared to the UFN group with lung contusion (data not shown). Histological analysis illustrated the presence of fat globules in the pulmonary vasculature.

Conclusion: In a standardised sheep model without chest injury, instrumentation of the femoral canal with the reamed and the unreamed nailing techniques induced a rise in pulmonary permeability changes. In the presence of lung contusion, reamed intramedullary femoral nailing provoked a further increase in pulmonary permeability damage, IL-8 release and leukocyte activation. The findings of this study support the view that reaming of the femoral canal can act as an additional stimulus for adverse outcome in the presence of co-existing chest trauma.

Purpose: To determine the incidence of OA and long-term outcome following complex, Schatzker type 4,5 & 6, tibial plateau fractures.

Patients and Methods: From Jan 1993 to Dec 2000, 176 consecutive adult patients with tibial plateau fractures were treated in our institution. Among them there were 31 patients (20 male and 11 female) with Schatzker type 4,5 & 6 fractures (17.5%). Details such as the patients’ age, sex, ISS, type of fracture, whether the fracture was open or closed, method of fixation, incidence of delayed union, non-union, the time to union, necessity for additional procedures, complications and hospital stay were recorded and analyzed. Following discharge from the hospital all the patients were followed up in the outpatient fracture clinic having regular clinical and radiological assessment. At final follow up all the patients were recalled in the clinic for clinical assessment. Functional assessment of the patients was performed using the American Knee score. Particular emphasis was to find out the impact of these complex injuries on their employment, their quality of life and the incidence of OA. The mean follow up was 16.8 months (ranges from 6–48 months). The mean time in hospital was 3.5 weeks (range 1–12 weeks).

Results: The mean age of the patients was 52 years (range from 25–76 years) and the mean ISS was 18 (6–44). 8 patients had associated injuries (1 had head injury). 24 patients sustained injury secondary to RTA, 6 secondary to fall and 1 secondary to a gun shot injury. 26 fractures were closed and 5 were open (1 Gustilo grade1, 1 grade IIIa and 3 grade IIIb). 29 patients were treated operatively and 2 were managed conservatively. 12 fractures were stabilized initially with AO hybrid frame and cannulated screws, 15 cases were treated with internal fixation (buttress plate), 1 case was treated with double plating and one case was treated with combination of internal fixation and Hoffman external fixator. Intra-operatively a bone graft from iliac crest was used in 7 patients. Soft tissue coverage was required in 4 cases. There were 2 cases of compartment syndrome, 9 cases of superficial infection and 5 cases of deep infection. Overall 10 patients were subjected to a secondary operative procedure following union (5 patients had removal of metal work, one underwent removal of metal work and application of a hemicallotasis device and 4 patients underwent arthroscopy). 7 patients underwent a 3rd procedure (3 had removal of metal work, one had application of a hemicallotasis device, 2 underwent debridement and curettage of the discharging sinus and one patient required a total knee replacement).

There were 6 cases of residual varus deformity (2 with 15 and 4 with 20 degrees) and 3 cases of leg length discrepancy (2.5 cm, 2 and 1.5 cm respectively). All the fractures but 2 progressed to union (one is currently awaiting for a total knee replacement). Functional assessment according to American Knee assessment score was good in 25 cases (80.64%), fair in 4 cases (12.87%) and poor in 2 cases (6.49%). The overall functional score was 93.6%. 9 patients had to do some modifications in their current employment and 7 patients were unable to return to their previous employment. Evidence of radiological OA was present in 18 out of 31 cases (58.6%).

A poor correlation between presence of radiological OA and functional outcome was noted.

Conclusion: 29 (93.5%) patients had a good or fair outcome. Tibial plateau fractures continue to be a cause of morbidity in trauma patients. The incidence of OA in this series of patients was 58.6% but there was no correlation to functional outcome.

Purpose: To determine the epidemiology of femoral fractures in children and their associated injuries. Patients and methods: We reviewed 475 consecutive children admitted over a seven-year period (1992–1999) to a university hospital. Such details were recorded and analysed as – mechanism of injury, ISS, GCS, ICU stay, total hospital stay, operations performed, presence or absence of femoral fracture, complications and mortality.

Results: Out of 475 children admitted, 57 had a femoral fracture (12%). 14 were girls and 43 were boys. The mean age was 5.1 (range 1–14) and the mean ISS was 6.9 (4–36). The mean GCS was 14 (range 5–15).

The commonest cause of injury was a fall from a height 21/57 (37%) followed by road traffic accidents 20/57 (35%), 11 cases were pedestrians. 6 cases were recorded as non-accidental injuries. 8 children underwent operative treatment whereas the rest were treated conservatively. In 36 children the femoral fracture was an isolated injury. The remaining 21 (37%) had 2 or more injuries. The most common associated injury was a head injury of varying severity 10 (50%) followed by fracture tibia 7 (33%) followed by fracture pelvis 4 (19%). Other associated injuries included a splenic laceration, one pancreatic injury, 3 humerus fractures and 3 forearm fractures. None of the children sustained a chest or spinal injury. The mean hospital stay was 22 days (1–67). 4 children were admitted to the intensive care unit (2 had head injuries) and the mean ICU stay was 3 days (2–5). There was no mortality in these series. Two children underwent fasciotomies for tibial compartment syndrome.

Conclusion: The incidence of associated injuries in children with femoral fractures appears to be 35% with head injury being the commonest. The overall prognosis is favourable as seen in these series of patients with nil mortality.

Purpose: In the younger population there is substantial body of evidence that the outcome is better following open reduction and internal fixation of distal humerus fractures. In the elderly however, there is a need to assess the value of internal fixation of these fractures where osteoporosis is almost a rule than exception and poses considerable challenge to even very experienced trauma surgeon. The purpose of this study therefore was to assess the functional outcome of operative fixation of fractures of the distal humerus in a cohort of elderly patients (aged 75 and above). The reproducibility of four different scoring systems is also evaluated.

Patients and Methods: Between 1996 and 2000 out 125 patients who were treated in our institution, elderly patients above 75 years of age were studied. Demographic data such as age, sex, associated injuries and the pre-admission elbow function were recorded. All the fractures were classified according to the AO/ASIF system. At final follow up elbow function was analyzed using OTA’s rating system and these results were compared using three other scoring systems (Jupiter’s criteria, Aitkin’s and Rorabeck criteria, and the scoring system of Caja et al). Treatment options, surgical or non surgical was based on the medical condition of the patient and the personality of the fracture. Intra-operative details including ulnar nerve transposition, olecranon osteotomy and quality of fixation were recorded and analysed. Serial radiographs were studied in detail for union, loss of reduction, certain prognostic indicators such as anterior tilt of distal humerus, cubitus angle, any articular step, gap, heterotopic ossification and development of degenerative changes. Radiological analysis was correlated with functional outcome. The minimum follow up was 16 months (range 16–92).

Results: Out of 125 patients, 29 (23.2%) were above the age of 75 (5 male). The mean age of the patients was 84.6 years (range 75–100). One patient was lost to follow-up. In total 28 patients were studied with 29 fractures (one bilateral), five open (Gustilo’s grade I). Mechanism of injury included 24 falls and 4 motor vehicle accidents. In seven cases associated injuries (three with ipsilateral upper limb injuries) were noted. Twenty patients (69.8%) had noticeable osteopenia in the x rays. According to the AO/ASIF classification, there were eight type A, eight type B and thirteen type C fractures. Eight patients were treated non-operatively (3 type A, 2 type B, 3 type C) and 21 (5 type A, 6 type B, 10 type C) operatively. The injury-surgery interval ranged from 6hours to 5days. An olecranon osteotomy (chevron type, Jupiter’s technique) was performed in 21 cases, 2 underwent Triceps ‘tongue’ reflection and 7 had triceps splitting. Only one case had anterior transposition of the ulnar nerve and none in the series developed ulnar nerve symptoms. Local complications included one case of deep infection (leading to non-union), three cases of superficial infection treated with antibiotics, 3 non-unions (two affecting the fracture and the other one the site of the olecranon osteotomy). The former patients declined further intervention and the latter patient was asymptomatic. One patient needed removal of olecranon metal ware, one developed olecranon bursitis. Heterotopic ossification was present in one patient with no effect on the elbow function. Overall, the mean loss of extension was 22.5° (range 5–40°) and the mean flexion 98.6° (ranged 40o–132°). In the non-operative group the mean loss of extension and mean flexion achieved were 33.5oand 70.1° respectively whereas in the operative group were 22.7oand 106.6°. OTA grading revealed 3‘excellent’, 9‘good’, 7‘fair’and 2 ‘poor’ results in the operated group whereas in the non-operative group there were no ‘excellent’, 2‘good’, 3‘fair’, 3‘poor’results. It is of note that in the non-operative group there was a 37.5% incidence of poor results significantly higher than the operative group. The number of ‘acceptable’ (excellent + good) results was higher in the surgically treated group (52%) than in the non-surgically treated group (25.0%). The functional outcome was most closely related to anatomical reduction of the fracture (particularly articular step < 2mm) and anterior tilt of the distal humerus and was unaffected by the injury-surgery interval. It was found that the Jupiter score was less rigid for the range of movement but produced similar scores to OTA with less potential inter observer error compared to the two other scoring systems. 18 of the 21(85.7%) the patients had no limitation of rotation.

Conclusion & Significance: This study supports the view that the functional outcome following distal humerus fractures is better with operative treatment in patients above the age of 75. Out of the 4 functional assessment scoring systems evaluated only the OTA and Jupiter gave similar results.

Aim: The purpose of this study was to investigate the validity of exchange intramedullary nailing for the treatment of infected tibial non-union.

Patients and Methods: Between 1994 and 2001 14 (10 male) patients with tibial fractures were treated in our institution with exchange nailing for infected tibial non-union. The mean age of the patients was 34.3 years (range 18–60) and the mean ISS was 17.5 (range 9–57). Road traffic accidents was the causative mechanism in 10 cases. Seven fractures were originally open (grade IIIb). Initial stabilisation was with intramedullary nailing in 7 cases, external fixator in 3, open reduction internal fixation in 2, Ilizarov frame in 1 and POP in 1. All patients had clinical and radiological evidence of non-union and in each case there was clinical and microbiological evidence of intramedullary infection. All the patients subsequently had an exchange intramedullary nail performed together with debridement and antibiotics. The mean time between original nailing and exchange nailing was 28 weeks. At exchange nailing, the old incisions were reopened and the in situ nail was then removed. Following this, the canal was swabbed and then reamed 1½ mm. more than the diameter of the new nail. The swab and reamings were sent for culture and microscopy. The canal was also irrigated with at least 3 litres of normal saline prior to the insertion of the exchange nail. Antibiotics were then continued for a minimal period of 6 weeks, or longer as the clinical situation warranted. Following discharge from the hospital the patients were seen in the outpatient clinics with regular clinical, haematological and radiographic investigations. The average length of follow-up was 24 months following exchange nailing.

Results: There were 7 positive cultures of MRSA, 4 of staph. aureus and in 3 cases multiple bacteria were grown from the samples. No further treatment was required following exchange nailing in 5 (35.7%) cases out of 14. 4 patients required further soft tissue debridement and a free flap to secure union within a week of the exchange nailing procedure. Of the remaining 5 patients, 1 required dynamisation to encourage union; another required incision and drainage of peri-fracture abscess and proceeded to union uneventfully; the third patient needed iliac crest bone grafting which eventually resulted in union. The penultimate patient had numerous operations after the exchange nailing before finally uniting with bone morphogenic protein. Unfortunately the last patient developed overwhelming sepsis which necessitated below knee amputation. Overall, the mean time to union was 11.3 months (4–24).

Conclusion: In this series of patients the success rate of exchange nailing for septic tibial pseudarthrosis was 78.5% (11/14). However, some of the patients, especially those originally sustaining open fractures required additional procedures to secure union. We believe that exchange tibial nailing remains an effective method of treatment in the presence of deep bone sepsis.

Introduction: Injuries to the urinary tract are a well known complication in patients with pelvic trauma. A severe urological injury frequently results in adverse long term outcome and prolonged disability. We present a review of the results of management of urological injury and the impact on final outcome in patients with pelvic fractures.

Patients: Out of 554 patients admitted to our center with pelvic fracture, 39 with injury to the urinary tract were identified – 8 females and 31 males (study group). The mean age of the patients was 30.9 yrs (range 15 to 71 yrs) and the mean ISS was 12.9 (range 9 to 22). Two patients had a skin wound communicating with fracture hematoma. Seven (18 %) had upper tract injury, 6 (15.4 %) had extraperitoneal bladder rupture, 9 (23.1 %) had intraperitoneal rupture, 3 (7.6 %) had bladder neck injury and 14 (35.9 %) had urethral injury. The mechanism and type of injury, initial management, timing of urological intervention, orthopaedic procedure complications and long term result in terms of incontinence, stricture and sexual dysfunction were assessed. All patients were assessed based on Orthopaedic, urological and the Euroqol (EQ5D) generic health questionnaire and compared to age and sex matched control group of 47 patients with similar pelvic injuries and ISS but no urological injury. The mean follow up period was 2.3 years.

Results: Upper urinary tract injuries: All were managed nonoperatively and had a uniformly good outcome except one patient who had a traumatic renal vein thrombosis and required nephrectomy. Three had acetabular fractures (one ant column and 2 both column fractures) and 4 had pelvic ring injuries (2 AP, 2 LC). Six were operated with av. time delay between injury and surgery being 7.1 days. We consider the urological injury related to the general trauma rather than the specific pelvic injury. Lower tract injuries: 14 out of 15 patients with bladder rupture had a repair of bladder within 24 hours of arrival at our center. One with a small extra-peritoneal tear was managed nonoperatively. Seven had LC injury, 6 had ARC and 2 had acetabular fractures (both column). One of the acetabulum fractures was managed by fixation and bladder repair on the day of arrival and the other had secondary congruence, which was not operated. Pelvic ring injuries were managed by internal and/or external fixation as appropriate. The average time delay between injury and surgery was 1.8 days. One patient with AP2 fracture died after 3 weeks due to severity of associated visceral injuries. Three patients reported failure of erection. All three patients with bladder neck injury had an APC fracture. Two were managed by immediate repair (day 1 and day 2) and had normal continence. One repair was delayed due to delay in transfer and was done on the 4th day. He developed faecal and urinary incontinence and loss of sexual function. Thirteen males had urethral injury – average age 37 yrs (range 19 to 70 years). Five had APC and five LC pelvic ring injuries, three had acetabular fractures. Three patients had a primary urethrostomy for a gap defect and two of these developed erectile dysfunction. Two were referred late to our center and were managed by continent urinary diversion. The rest had a catheter railroaded to maintain alignment of the two urethral ends and delayed repair was done for three patients. One patient in this group had sexual dysfunction while 5 developed a stricture. The only female patient with urethral injury had an open tilt fracture associated with urethral tear.

The control group had 7 acetabular fractures, 19 AP compression, 17 lateral compression injuries and 4 vertical shear injuries. Four were managed nonoperatively. None of these had an open fracture. The average time delay between injury and surgery was 2.2 days.

We found no significant difference between the study and the control group in the outcome on comparing patients with upper tract and bladder injuries but the urethral injury group had a poorer result in all 5 parameters of the EQ5D.

Conclusions: Upper tract and bladder injuries in the context of pelvic trauma can be successfully managed as described, they do not add significant morbidity compared to the control group. In contrast urethral injuries significantly affected the outcome after pelvic fracture in terms of general health and return to normal function. Early management with primary alignment at the time of pelvic stabilisation and a delayed repair if required produced good results. A high index of suspicion and routine retrograde urethrograms would reduce risk of missed or iatrogenic injury. A team approach is required to achieve optimum results.

Introduction: Noncontiguous fractures of the tibial diaphysis and ipsilateral ankle is an uncommon entity. The aim of this study is to highlight the unique fracture pattern with emphasis on the necessity for surgical treatment.

Material: There were 11 patients with an average age of 40 years, who sustained ipsilateral, noncontiguous fractures of the tibia and ankle. All but one fracture ware closed. The level of the tibia fracture included midshaft (two), middle-distal third (seven), distal third (two). Seven of the ankle fractures were classified as Weber B, three as Weber C and one Pilon. One fracture was treated by cast immobilization, eight with ORIF of both fractures and two with a combination of internal and external fixation. Of the patients treated operatively, five were treated initially in long leg casts, but each required surgical intervention to control fracture alignment.

Results: The average follow up was twenty- three months. The non-operatively treated fracture resulted in a mal-union and a severe loss of ankle mobility. Of the cases managed operatively, seven had complete structural and functional recovery, two patients regained 70% of ankle mobility and one developed ankle arthritis.

Discussion: The resulted experience from the treatment of these injuries shows their extremely unstable nature. It has been our experience that the forces acting upon the fragments usually underestimated since reduction of one fracture displaces the other. Furthermore if acceptable reduction is achieved by closed means, a progressive slippage occurs over the time. We believe that stable fixation of both fractures should be the treatment of choice.

Introduction: Knee dislocations are uncommon injuries with most series reporting only few cases over a period of many years. The association of knee dislocations with femoral shaft fractures is exceedingly rare and further complicates the management of this injury. We describe four patients managed at our tertiary care trauma center and evaluate the outcome.

Patients and Methods: Out of 187 femoral fractures treated in our institution over a period of 6 years (1994–1999), 4 patients with 5 femoral fractures and ipsilateral knee dislocations were identified. All four patients (2 female) were in early twenties and involved in high energy road traffic accidents. One woman had bilateral knee dislocation with fractures of both femora and tibiae. None of these four patients had head, chest or major visceral injury. No patient had neurovascular damage or compartment syndrome. All were managed by immediate relocation of the knee, angiography, locked intramedullary nailing of femur and post-operative bracing of the knee for six weeks – either by external fixator or hinged brace. Following discharge from the hospital they were followed up regularly in the fracture clinic. Secondary reconstructive procedures were planned depending on the severity of injury and patient demands. The minimum follow up was two years.

Results: Four of five femoral fractures united within expected time scale. One with nonunion had exchange nailing twice and is presently under follow up. Out of the five knees, four underwent a secondary reconstructive procedure. One patient had an open dislocation of the knee with loss of quadriceps tendon, part of patella and patellar tendon, which was reconstructed with Leeds-Keio ligament strips and a free flap. One other patient required an ACL reconstruction two years after injury and finally had a stable painless knee. The lady with bilateral injury had reconstruction of both PCL 2 years after injury. At the final follow up seven years later, there was residual PCL laxity in one knee and she was mobile with one stick. At final follow up all the patients were assessed by the American knee score.

Conclusion: Femur fractures with knee dislocations are orthopaedic emergencies. These injuries should be treated by immediate relocation of the knee, stabilization of the femoral fracture and ensuring normal distal circulation. In our patients, we have braced the knee initially and symptomatic instability was later on managed by appropriate ligament reconstruction procedures. Cross instability may require application of bridging external fixator to facilitate knee ligament healing. Two patients in this series had a good outcome with stable painless knees. The treatment has to be individualized in each situation to achieve an optimum result.

Purpose: To document the incidence of neurological lesions and functional outcome following displaced acetabular fractures.

Patients and Methods: Prospective review of patients who underwent stabilisation of acetabular fractures in a University Hospital trauma centre. From December 1994 to November 2000 136 patients were identified with acetabular fractures. The open reduction and internal fixation of the acetabular fixation was performed by standard operative techniques. The time from the initial injury to the operation ranged from 24 hours to I4days. Patients with sciatic nerve injuries were prospectively followed up and long-term outcome recorded. Weakness or absence of dorsiflexion or plantar flexion was graded according to the standard Medical Research Council. Abnormalities of sensation, including absent or diminished sensation to light touch and pinprick as well as dysesthesia or hyperesthesia of the dorsal and plantar aspects of the foot were recorded. None of the patients had an injury of the spinal cord. Intra-operative monitoring was performed in most cases, and routine electromyography and nerve -conduction studies were done post-operatively and at least on one more occasion to record the level and severity of the lesion and to monitor progress of recovery. All the patients were followed up clinically in the trauma clinics and functional improvement was routinely assessed. The mean follow up of the patients was 3.4 years (range 1.5–6 years).

Results: Out of 136 patients who underwent stabilisation of acetabular fractures there were 27 (19.8 %) cases of neurological lesions. In 12 cases the femoral head was dislocated posteriorly. Twenty were men and eight were woman. The mean age was 33.8 (range 16–66). 15 patients had associated injuries. The mean ISS was 12.6 (range 9–34). At initial presentation there were 13 patients with a complete dropped foot lesion, 10 patients with foot weakness and 4 patients with burning pain and altered sensation over the dorsum of the foot. Intra-operative monitoring was performed in 16 cases. All the patients had EMG studies for neurophysiological assessment of the lesion. EMG studies revealed sciatic nerve lesions in all the cases but in nine patients with a dropped foot there was evidence of a proximal (sciatic) and distal (neck of fibula) lesion, “double crush syndrome”. Only in 3 of these cases there was documentation of an ipsilateral knee injury. In two patients there was deterioration of foot function after surgery due to iatrogenic damage. At final follow-up, clinical examination and associated EMG studies revealed full recovery in 5 cases with initial muscle weakness (mean time 4.2 years (2–5)) and complete resolution of sensory symptoms (burning pain and hyposthesia) in 4 cases (mean time 3 years (2–4)). There was improvement of functional capacity (motor and sensory) in two cases with initially complete drop foot and in 4 cases with muscle foot weakness (mean time 3.6 years (range 2–6). In 11 of the cases with dropped foot (all nine with “double crush”) at presentation, there was no improvement in function, (mean time 3.9 years (range 2–6).

Conclusion: Acetabulum fractures associated with sciatic nerve injuries continue to be a significant cause of long-term morbidity in trauma patients. In cases where there is evidence of “double crush lesions” the prospect of functional recovery is low as seen in this group of patients. Single lesions appear to be associated with a more favourable prognosis.

Purpose: To determine any relation between scapular fracture, severity of chest injury and mortality in patients with multiple injuries.

Patients and Methods: We reviewed 621 consecutive patients admitted over a five year period (1995–1999) with multiple injuries. All had an associated chest injury. Such details were recorded and analyzed as – mechanism of injury, ISS, AIS for chest, GCS, ICU stay, total hospital stay, operations performed, presence or absence of scapular fracture, complications and mortality. Patients with chest injury but without scapula fracture formed the control group of the study.

Results: Out of 621 patients with multiple injuries (mean ISS 27.5), 79 (17 women) (12.72%) – group 1 were identified with scapular fractures. 542 (122 women) patients with chest injury but no scapular fracture formed the control group – group 2. The mean age of group 1 was 42 years versus 40 years of group 1 and the mean ISS was 27.12 (SD 15.13) and 28. 41 (SD 14.21) in group 1 and group 2 respectively (p value > 0.05). In group 1 the chest AIS was 3.46 (SD 1.10) and 3.18 (SD 1.06) in group 2 (p value < 0.05).The most common associated chest injury in group 1 was pneumothorax (28%) followed by pulmonary contusion (15.2%) whereas in group 2 it was likewise pneumothorax (20%) followed by pulmonary contusion (21%). There were 8 (10.1%) flail segments in the scapula group, versus 50 flail segments (9%) in the non scapula group. In group 1 there was an incidence of 3.8 % associated thoracic vertebral fractures compared to 8.3% in group 2. 2.6 % of patients in group 1 had major vessel injury or cardiac laceration as compared to 3 % in group 2. There were 4 brachial plexus injuries in group 1 (5.1%) versus nil in group 2. In group 1, 32 (40.5%) patients had sustained associated abdominal injuries mean AIS 3.1 versus 190 (34.6%) in group 2 with a mean AIS of 2.9. In the scapula group there were 31 clavicle fractures, 12 humerus fractures and 4 shoulder dislocations. In the non-scapula group there were 137 clavicle fractures, 93 fractures of the humerus and 2 shoulder dislocations. The mean hospital stay in both groups was 22 days (range 5–153). In group 1 the mortality rate was 11.4% (9 patients) mean ISS 48 (range 24–75) versus 25% (136 patients) mean ISS 41.3 (range 17–75) in group 2.

Conclusion: Patients with scapular fractures were found to have a higher chest and abdominal AIS. Overall, the scapular fracture was not associated with higher ISS or higher mortality and does not correlate with a poorer outcome.