In two years we treated four women with ununited stress fractures of their proximal tibial diaphyses. They all had arthritis and valgus deformity. The stress fractures had been treated elsewhere by non-operative means in three patients and by open reduction and internal fixation in one, but had failed to unite. After treatment with a modular total knee prosthesis with a long tibial stem extension, all the fractures united. A modular total knee prosthesis is suitable for the rare and difficult problem of ununited tibial stress fractures in patients with deformed arthritic knees since it corrects the deformity and the adverse biomechanics at the fracture site, stabilises the fracture and treats the arthritis

The late results of tarsometatarsal injuries in 33 patients have been reviewed. The average follow-up period was 15 years (range 11 to 20 years). Methods of treatment included cast immobilisation, and closed or open reduction with or without internal fixation. All patients noted diminishing symptoms after injury and all but six returned to their former occupation. Neither the initial fracture type nor the treatment had any apparent bearing on subsequent function; nor was there any correlation between radiographic assessment of the injury and the patient's symptoms

A new technique for repair of neglected posterior dislocation of the elbow is described, consisting of open reduction with tendon graft stabilisation to create a medial collateral and an intra-articular "cruciate" ligament. This allows flexion-extension exercises to start six days after operation. Eleven cases are reported in which the average range of movement improved from 38 degrees before operation to 105 degrees after a minimum follow-up of two years, with a mean valgus-varus instability of only 13 degrees. One patient had a postoperative infection but all the others were satisfied with the functional result

Distraction fractures of the upper lumbar spine are most often associated with the wearing of seat-belts. Twenty patients with this spinal fracture were reviewed and half of them had intra-abdominal injuries. Eight patients required an exploratory laparotomy. Three distinct patterns of distraction fractures have been identified. Open reduction, local spinal fusion and Harrington instrumentation are recommended for unstable fractures and for those with neurological involvement. Four cases of non-union are included ln the series. Legislation for the compulsory wearing of seat-belts should encompass improvements in design and stricter criteria for installation

Twenty-three patients, aged from 10 to 60 years, underwent open reduction for untreated posterior dislocations of the elbow. The dislocations had been unreduced for periods varying from one month to two years. All patients underwent a standard procedure based on the Speed technique. Complications after operation included one case of gross sepsis and five cases of ulnar neuritis. Most patients gained a useful range of flexion-extension of the elbow. Neither the age of the patient nor the duration of the unreduced dislocation influenced the result

We have compared the sonographic findings of six femoral fractures with soft-tissue interposition which required open reduction with those of a control group of 40 other femoral fractures. Ultrasound assessment before operation showed that the fractured end of the proximal fragment had penetrated the quadriceps muscle anteriorly while the distal fragment lay beneath it. Transverse scans showed less soft-tissue thickness over the end of the proximal fragment in the problem cases. Radiographic image intensification did not provide any additional information. Ultrasound is of value in demonstrating soft-tissue interposition at the fracture site before femoral nailing

The treatment of multifragmentary, intra-articular fractures of the distal humerus is difficult, even in young patients with bone of good quality, but is worse in elderly patients who have varying degrees of osteopenia. We have evaluated the functional outcome of primary total elbow replacement (TER) in the treatment of these fractures in ten elderly patients followed for a minimum of one year. There were no complications in regard to the soft tissues, bone or prosthesis. The mean range of flexion obtained was 125° (110 to 140) and loss of extension was 23.5° (0 to 50). The mean Mayo score was 94 points (80 to 100) and patient satisfaction was high. We feel that TER provides an alternative to open reduction and internal fixation in the management of these complicated fractures in the elderly

The outcome of various types of treatment for femoral fracture in children with head injury was studied retrospectively in 51 patients with 56 fractures. Of these, 36 patients (71 per cent) were in deep coma and scored 5 to 7 on the Glasgow scale. Forty-three children (84 per cent) were eventually able to walk freely. Open reduction and internal fixation proved an attractive solution for femoral fractures in children with head injury who could tolerate general anaesthesia: intramedullary nailing was safe and gave satisfactory results in 16 fractures but infection complicated three of the five fractures which were plated

1. A case, believed to be the fifth on record, of supracondylar fracture with rupture of the brachial artery is described. 2. The relative immunity of the median nerve in these injuries is discussed, with brief reference to a recent case of complete rupture. Only a single previous report of this complication could be found. 3. It is suggested that these injuries are less uncommon than the number reported would indicate. 4. The anatomy of severe displacement is discussed, with special reference to the role of the brachialis. 5. The danger of closed reduction when the relationship of the upper fragment to the neurovascular bundle is in doubt is stressed. 6. The indications for open reduction are given

Aims

Although good clinical outcomes have been reported for monolithic tapered, fluted, titanium stems (TFTS), early results showed high rates of subsidence. Advances in stem design may mitigate these concerns. This study reports on the use of a current monolithic TFTS for a variety of indications.

In this prospective study of 18 hips we compared the efficacy of ultrasound with CT in determining the position of the femoral head in a spica cast after closed or open reduction in children with developmental dysplasia of the hip. Ultrasound was performed through the perineal opening of the cast. With a transinguinal approach, the superior ramus of the pubis, the acetabulum, the femoral head and the femoral neck can be depicted in one plane. The CT and ultrasound images were blinded and reviewed by two of the authors. Ultrasound was inconclusive in the first two reductions since the perineal opening was too small to see all the landmarks in one plane. In the following 16 reductions the landmarks were well defined and interpretation of the CT and ultrasound was similar. The perineal opening in the spica cast should be made in such a way that the ultrasound probe can be positioned in the groin so that the landmarks can be shown in one plane

In a randomised prospective trial 98 elderly women with trochanteric fractures of the femur were treated with either a 135 degrees Jewett nail-plate or a 135 degrees Dynamic hip screw. The results at six weeks, three months and six months were statistically analysed. There were no significant differences in the two groups with regard to pain, length of hospital stay, morbidity or mortality. Although operative difficulties and open reduction were more common with the Dynamic hip screw, at the end of six months more patients in this group were mobile and there was significant radiological evidence of better compression without loss of fixation

Twenty-six patients with femoral neck fractures were treated by open reduction, cancellous screw fixation and free fibular grafting. The patients were between 14 and 50 years of age. There were 16 old and 10 fresh fractures. Four patients had radiological signs of avascular necrosis before the treatment was instituted. Bony union was achieved in all patients except one, where the failure occurred because of a technical error. The patients were followed up for at least two years. No new case of avascular necrosis was detected after treatment, and there was clinical and radiological improvement in all four patients with pre-operative avascular necrosis

Thirty-three Monteggia fracture-dislocations occurring in patients aged 2 to 15 years were reviewed. A follow-up of 2 to 7 years in 25 patients revealed that 88% had good to excellent results and 12% had results which were fair or poor. Closed reduction was successful in 24 of 28 cases and appeared to be very effective. Open reduction was required only for older children or when treatment was begun late. A mild hyperextension deformity at the elbow noted on follow-up of patients with anterior dislocation of the radial head seemed to support the theory that the injury is caused by hyperextension. A new classification of Monteggia fracture-dislocations in children is proposed

There were 22 patients with cerebral palsy aged six to 17 years who underwent an acetabuloplasty as part of an open reduction of the hip. In 11 patients a paediatric cell saver was used to collect autologous blood which was re-infused per-operatively. This group was compared to a cohort of 11 patients undergoing similar operations in whom only banked homologous blood was transfused. On average, 432 ml of autologous blood was re-infused compared to 909 ml of homologous blood (p < 0.01), representing 19.6% and 47% of the total blood volume, respectively (p < 0.002). Two units of homologous blood were transfused in the cell saver group compared with 20 units in the control group (p < 0.001). When using a paediatric cell saver, homologous blood transfusion was avoided in 82% of patients and there were no complications

One hundred consecutive closed fractures of the adult tibial shaft treated by closed methods were surveyed prospectively in order to observe their natural history. The fractures were analysed with regards to speed of healing and the influence of age, sex, causal force, radiological morphology and concurrent fibular fracture. At 20 weeks 19 fractures had not yet united, but 15 of these had united by 30 weeks with conservative treatment alone. The remaining four cases were operated upon because no further progress in healing was anticipated. These findings suggest that, with regard to healing, open reduction and internal fixation is rarely justified in closed adult tibial shaft fractures

Fifty-six patients with displaced malleolar fractures had open reduction and fixation of the fracture fragments using, by random selection, either biodegradable implants or metal AO plates and screws. The cylindrical biodegradable implants were made of polylactide-glycolide copolymer (polyglactin 910). The complications, radiographic results and functional recovery were studied prospectively. After follow-up of at least one year, no significant differences emerged in the complication rate or in the results of treatment between the two methods of fixation. Because of the advantage of avoiding the need to remove metal fixation after union, we now use biodegradable internal fixation routinely to treat displaced malleolar fractures

Fractures of the distal end of the radius should be treated on the same principles as other fractures involving joints. Displaced articular fractures require open reduction to allow anatomical reconstruction of both the radiocarpal and the radio-ulnar joints. For extra-articular fractures with severe comminution and shortening this enables the radial length to be re-established achieving radio-ulnar congruency. Stable internal fixation can be achieved with two 2.0 AO titanium plates placed on each of the ‘lateral’ and the ‘intermediate’ columns of the wrist at an angle of 50° to 70°. This gives good stability despite the tiny dimensions of the plates, and allows early function. We report a series of 20 fractures treated by this method of internal fixation with satisfactory results in all

Posterior dislocation of the acromioclavicular joint with the lateral end of the clavicle locked behind the acromion has only rarely been described. This paper present such a case diagnosed two weeks after the shoulder was injured in an accident. The clavicle was locked behind the articular surface of the acromion, restricting the movement of the shoulder and causing considerable pain. Anteroposterior radiographs showed a high-riding clavicle but no gap in the joint, but the axial view showed the dislocation. At operation the coracoclavicular ligaments were found overstretched but not ruptured. As reduction of the acromioclavicular joint was not possible, the lateral end of the clavicle was resected. Although the result was perfect, we consider the correct treatment should be early closed or open reduction of the acromioclavicular joint