Aims

Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making.

We report eight cases of fracture of the cuboid in seven children under four years of age, collected during a two-year period. There was no history of trauma in five of the patients. This fracture is rarely diagnosed and has probably been under-reported. Small children are poor historians and difficult to examine, and early radiographs may be normal or have only subtle abnormalities. Cuboid fracture should be considered in the differential diagnosis of limping toddlers, and a bone scan may be needed to confirm the diagnosis earlier than radiography. These fractures heal completely, without sequelae. Treatment in a short-leg walking cast is recommended, primarily for reasons of comfort

There has been a long-standing debate as to whether medullary or periosteal flow is the dominant vascular supply during the healing of diaphyseal fractures. We used radioactive microspheres to quantify blood flow to the canine tibia two weeks after an osteotomy. There was a significant contribution from the periosteum to the blood supply of healing cortical bone after nutrient artery ligation, with a reversal of flow from a centrifugal to a centripetal direction. Our study has confirmed the qualitative observations of Trueta (1974) regarding the significant recruitment of vessels from surrounding soft tissue during fracture healing. We have not studied the later stages of healing

We describe a method of internal fixation for femoral neck fractures which has been newly developed to reduce the frequency of early complications. Two cannulated screws are inserted in the axis of the femoral neck to reach into the subchondral bone of the femoral head. The screws are inserted over guide pins and the tip of the screw is self-tapping and designed to provide good anchorage in the femoral head. We used this method in 44 consecutive patients in a prospective study with no exclusions, followed for a minimum of 24 months. All fractures healed within 12 months, and there were no cases of early loosening or nonunion. In four cases, late segmental collapse had developed during the mean follow-up period of 30 months

Ten patients with humeral shaft fractures and no clinical or radiographic signs of healing after at least six weeks' immobilisation were treated by flexible intramedullary nailing using a closed retrograde technique. Bone grafting was not performed, and active movement was encouraged after operation. Nine fractures healed; the mean time to union was 10.5 weeks (range 6 to 22 weeks). One patient needed compression plating and bone grafting at 22 weeks, and another required re-operation for distal migration of the rods. There were no infections, nerve palsies or other complications. Stiffness of the shoulder which had developed during early treatment improved after operation

A review of 61 patients with dislocation of the lunate (some with and some without fracture of the scaphoid) showed that the majority had satisfactory results at an average follow-up of three and a half years. Most patients with a simple dislocation had a good or satisfactory result; radiological instability was noted in a quarter of the wrists but was not often associated with symptoms. Two-thirds of the patients with an associated fracture of the scaphoid had a good or satisfactory result. Immediate percutaneous wire fixation of the reduced scaphoid, whether it is fractured or not, is the best way of maintaining normal anatomical relationship while the ligaments and fracture heal; this may further improve the prognosis. In most cases extreme dorsiflexion of the wrist appeared to be the mechanism of injury

Diaphyseal fractures of the tibia in 80 patients were treated by external skeletal fixation using a unilateral frame, either in a fixed mode or in a mode which allowed the application of a small amount of predominantly axial micromovement. Patients were allocated to each regime by random selection. Fracture healing was assessed clinically, radiologically and by measurement of the mechanical stiffness of the fracture. Both clinical and mechanical healing were enhanced in the group subjected to micromovement, compared to those treated with frames in a fixed mode possessing an overall stiffness similar to that of others in common clinical use. The differences in healing time were statistically significant and independently related to the treatment method. There was no difference in complication rates between treatment groups

We present a prospective study of the treatment of 32 unstable Colles’ fractures by external fixation and cancellous grafting with minimal exposure. We inserted an external fixator between the radius and the second metacarpal, and maintained ligamentotaxis for five weeks. In 27 patients the result was good or excellent, but five fractures healed with malunion. All patients made a satisfactory functional recovery. At a mean follow-up of three years (1 to 5) after injury none had pain in the wrist and all were satisfied with the result. The average grip strength was 95% of normal. Seven patients had algodystrophy with mild impairment of finger movements in four. We conclude that the combination of cancellous grafting and external fixation is effective for the treatment of unstable Colles’ fractures

There is evidence that fractures heal more rapidly in patients with head injury. We measured the circulating level of interleukin-6 (IL-6) and its soluble receptor (sIL-6R) and soluble glycoprotein 130 (sgp130) in serum from patients who had sustained a head injury with and without fracture and compared these with levels found in control subjects. Within 12 hours of injury the serum level of IL-6 was significantly higher in patients with head injury and fracture compared with the control group. Levels of IL-6 were also significantly higher in patients with head injury and fracture compared with fracture only. While there was no significant difference in circulating levels of sIL-6R in the initial samples they were increased one week after surgery in patients with head injury and fracture and with head injury only. In addition, reduced levels of sgp130 in patients with head injury with and without fracture indicated a possible reduction of the inhibitory effect of this protein on the activity of IL-6. Our study suggests that IL-6 may be involved in altered healing of a fracture after head injury

From 1987 to 1993 we treated 33 patients with 29 phalangeal and seven metacarpal fractures by external fixation using a mini-Hoffmann device. There were 27 open and 25 comminuted fractures. In 12 patients one or more tendons was involved. The mean follow-up was 4.4 years. Complications occurred in ten fractures; two required repositioning of the fixator. All the fractures healed. The functional results after metacarpal fractures were better than those after phalangeal fractures and fractures of the middle phalanx had better recovery than those of the proximal phalanx. Twenty-eight of the 33 patients were satisfied with their result. External fixation proved to be a suitable technique for stabilising unstable, open fractures with severe soft-tissue injuries

There is evidence to suggest that fractures heal more rapidly in patients with a head injury as a result of systemic factors released from the site of this injury. We have measured the circulating level of insulin-like growth factor-1 (IGF-1) and IGF binding protein-3 (IGFBP-3) in serum because of their known involvement in the stimulation of the activity of osteoblasts and the healing of fractures. The serum level of IGF-1 was significantly lower in patients with both head injury and fracture and fracture only compared with that in healthy volunteers (p < 0.01 and p < 0.02, respectively). The level of IGFBP-3 was also significantly lower in patients with both head injury and fracture (p < 0.01). Our findings showed, however, that the level of IGF-1 and IGFBP-3 varied from week to week in both the patients and healthy control subjects. These results indicate that the levels of circulating IGF-1 and IGFBP-3 are unlikely to be responsible for the altered healing of fractures seen in conjunction with head injury

We report 60 benign bone tumours treated by resection and curettage followed by the implantation of calcium hydroxyapatite ceramic (CHA). After follow-up of six to 60 months (average 36), no patient had local recurrence of the tumour or any adverse effects from the implants. In almost all cases radiography showed that the CHA was well-incorporated into the host bone, with new bone formation in and around the CHA. Corrective remodelling of deformed bone and normal fracture healing suggested that there was normal bone turnover in the presence of the CHA. Histology of biopsies from seven patients showed bone ingrowth into the pore structure of CHA in the central zone of some defects by one year after implantation. CHA appears to be a useful substitute for bone graft in the treatment of some benign tumours

The Medoff sliding plate (MSP) is a new device used to treat intertrochanteric and subtrochanteric fractures. There are three options for sliding; either along the shaft or the neck of the femur, or a combination of both. In a prospective series of 108 consecutive displaced intertrochanteric fractures we used combined dynamic compression. The patients were followed clinically and radiologically for one year. All fractures healed during the follow-up period. The only postoperative technical failure was one lag-screw penetration. Combined compression of the MSP gives increased dynamic capacity which reduces the risk of complications. The low rate of technical failure in our series compares favourably with that of the sliding hip screw or the Gamma nail but randomised trials comparing the MSP with other hip screw systems are necessary to find the true role of the MSP with its various sliding modes

In a prospective study, 170 impacted femoral neck fractures were treated by early mobilisation and weight-bearing. The overall mortality at one year was 16%. In the 167 patients who were followed up until fracture healing or secondary instability, 143 fractures (86%) united. Instability occurred only in patients over 70 years of age, and in younger patients with a short life expectancy. Stepwise logistic regression analysis indicated that poor general health and old age (over 70 years) were risk factors. None of the other variables, such as the Garden index, Pauwels' type, and time to full weight-bearing had any influence on the development of secondary instability. Delayed operation after secondary instability caused no increase in mortality, nonunion or avascular necrosis. Functional treatment of all patients with impacted femoral neck fractures seems therefore to be justified

The levels of the active metabolites of vitamin D were measured in the callus and in the epiphyseal growth plate of chicks given radioactive cholecalciferol during fracture healing. Those levels were correlated with the histological findings. Three groups of chicks were studied: a control group with no fracture, chicks with fractures fixed by Kirschner wire, and chicks with unfixed fractures. A significant increase in the levels of the active metabolites was found in the callus during the first few days after fracture. The levels of 25-hydroxycholecalciferol [25(OH)D3] and of 24,25-dihydroxycholecalciferol [24,25(OH)2D3] were higher when there was no fixation, while those of 1,25-dihydroxycholecalciferol [1,25(OH)2D3] were higher after fixation. The concentrations of these metabolites in the proximal epiphysis of the tibia were similar to those found in the callus. Based on these findings it is suggested that the active metabolites of vitamin D are directly involved in the process of fracture repair

Experimentally produced fractures in long bones studied by light and electron microscopic histochemistry were found to heal by a process of enchondral calcification. There was intense proliferation in the cells of the cambium layer of the periosteum, with differentiation to chondroblasts and osteoblasts, suggesting that this layer was the primary tissue responsible for development of the callus. Cytoplasmic processes of the hypertrophic chondrocytes appeared to bud and produce matrix vesicles. Alkaline phosphatase activity was detected along the plasma membrane of the hypertrophic chondrocytes and around the matrix vesicles, before any signs of mineral deposition. Calcification took place by deposition of hydroxyapatite crystals in and around these matrix vesicles which frequently showed alkaline phosphatase activity. It is suggested that there is a close functional association between alkaline phosphatase activity and calcification in the process of fracture healing, which is another type of enchondral calcification mediated by matrix vesicles

Of 290 Ugandan children and adolescents with proven Burkitt's lymphoma 11 had lesions in the long bones or the pelvis. These started in the medulla as small osteolytic foci which coalesced and penetrated the cortex causing subperiosteal new bone formation in layers or spicules, and giving rise to large soft-tissue masses. Common sites were the femoral and tibial diaphyses and the metaphyses around the knee. Five were in the epiphyses. Other sites were the pelvis, humerus and ulna. One patient had a lymphomatous synovial effusion of the knee. In the lower limbs the lesions were often bilateral and symmetrical. Five patients had pathological fractures. Radiologically the lesions mimicked Ewing's sarcoma, osteosarcoma, osteomyelitis, acute leukaemia, syphilis and yaws, but clinically they were relatively painless, an important differential diagnostic feature. In the five patients with sustained remissions after chemotherapy the lesions and fractures healed well and the growth plates were undamaged

In the assessment of fracture healing by monitoring stiffness with vibrational analysis or instrumented external fixators, it has been assumed that there is a workable correlation between stiffness and strength. We used four-point bending tests to study time-related changes in stiffness and strength in healing tibial fractures in sheep. We aimed to test the validity of the measurement of stiffness to assess fracture strength. At each duration of healing examined, we found marked variations in stiffness and strength. Stiffness was shown to be load-dependent: measurements at higher loads reflected ultimate strength more accurately. There was a biphasic relationship between stiffness and strength: at first there was a strong correlation regardless of loading conditions, but in the second phase, which included the period of ‘clinical healing’, stiffness and strength were not significantly correlated. We conclude that the monitoring of stiffness is useful primarily in assessing progress towards union but is inherently limited as an assessment of strength at the time of clinical union. Any interpretation of stiffness must take into account the load conditions

Aims

It is increasingly appreciated that coordinated regulation of angiogenesis and osteogenesis is needed for bone formation. How this regulation is achieved during peri-implant bone healing, such as osseointegration, is largely unclear. This study examined the relationship between angiogenesis and osteogenesis in a unique model of osseointegration of a mouse tibial implant by pharmacologically blocking the vascular endothelial growth factor (VEGF) pathway.