Trans-articular coronal shear fractures of the distal humerus pose a significant challenge to the surgeon in obtaining an anatomical reduction and rigid fixation and thereby return of good function. A variety of approaches have been described which include the extended lateral and anterolateral approaches and arthroscopically-assisted fixation for non-comminuted fractures. Fixation methods include open or percutaneous cannulated screws and headless compression screws directed either anterior to posterior or posterior to anterior. We describe an illustrated, novel approach to this fracture which is minimally invasive but enables an anatomical reduction to be achieved. A 15 year old male presented with a Bryan and Morrey type 4 fracture as described by McKee involving the left distal humerus. He was placed in a lateral position with the elbow over a support. A posterior longitudinal incision and a 6cm triceps split from the tip of the olecranon was made. The olecranon fossa was exposed and a fenestration made with a 2.5mm drill and nibblers as in the OK (Outerbridge-Kashiwagi) procedure. A bone lever was then passed though the fenestration and used to reduce the capitellar and trochlear fracture fragments into an anatomical position with use of an image intensifier to confirm reduction. The fracture was then fixed with two headless compression screws from posterior to anterior into the capitellar and trochlear fragments (see images). Early mobilisation and rehabilitation were commenced. Follow-up clinical examination and radiographs at six weeks revealed excellent range-of-motion and function with anatomical bony union. We believe that this novel approach to this fracture reduces the amount of soft tissue dissection associated with conventional approaches and their associated risks and also enables earlier return to function with restoration of anatomy.
Management of periprosthetic femoral fractures above a Total Knee Arthroplasty remains a challenge. The different treatment options available include casting for undisplaced fractures, ORIF for a displaced fracture with a well-fixed implant or revision arthroplasty for a very distal fracture and for a fracture with a loose implant. We describe our experience in treating a very distal displaced supracondylar fracture above a well-fixed femoral component in a 68-year-old woman who was recently diagnosed with breast carcinoma and awaiting mastectomy. There was no evidence of metastatic disease. The knee replacement was done 4 years before and the patient did not have any symptoms in the knee prior to the fall. Conventional ORIF with IM nailing or plate osteosynthesis was not possible due to the very distal site of the fracture. We used a custom modified 95 degree angled blade plate in which a slot was cut in the middle of the blade halfway along its length to accommodate the pegs of the femoral component in the distal fragment. The fracture was reduced and fixed with the angled blade plate restoring length, alignment, and providing coronal stability. The patient had a satisfactory union at 3 months without deformity giving a good range of pain free movement in the knee. DCS and 95 degree angled blade plate have been used in the past with mixed results. The lag screw or the blade has to be inserted more proximally to avoid the femoral component and so the distal fixation is often sub optimal. In our case modification of the blade allowed more distal placement providing optimal fixation and avoiding complex revision surgery.
Failure of normal acetabular development is inevitable in congenital dislocation of the hip when it is unrecognised until late infancy or early childhood. Numerous stabilising procedures have been described, one of the first being the shelf operation or acetabuloplasty. This procedure fell into disrepute because the shelf was often located too high or was too small to prevent upward migration of the femoral head. The technique described emphasises the importance of resecting the thickened capsule and exposing the lateral margin of the acetabulum to allow a substantial portion of the outer cortex of the ilium to be turned down both laterally and anteriorly over the femoral head. Twenty cases of acetabuloplasty have been followed up for an average period of nine years. The results have been assessed from the point of view of function, relief of pain, and degree of support of the femoral head as demonstrated radiologically. The shelf operation is a simple and safe procedure, and provided it gives adequate support to the subluxated femoral head it will ensure a stable, mobile joint capable of standing up to reasonable use for many years. If deterioration should occur in later life, total hip replacement may be undertaken more easily than if the joint had been allowed to undergo progressive subluxation.
1. A case of fractured pelvis with massive haemorrhage from the right superior gluteal artery and thrombosis of the right ilio-femoral venous system is reported. 2. The treatment included ligature of the artery and extensive thrombectomy. Ten litres of blood were transfused.
1. Eleven cases of congenital flat foot were studied, five of which are illustrated. 2. Ten of these cases were treated in infancy and followed for at least three years. In two cases the follow-up period was ten years and fifteen years. 3. An essential component of the deformity is equinus of the calcaneus, and treatment consisted of correction of the forefoot deformity by repeated manipulation, followed later by elongation of the calcaneal tendon and capsulotomy of the ankle. 4. The importance of recognising the deformity and beginning treatment in infancy is stressed.
