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

Closed rupture of the middle slip of the extensor hood of a finger is easily missed until the late appearance of a buttonhole deformity. Early diagnosis gives the best chance of satisfactory treatment, but Boyes' test becomes positive only at a late stage. A new test is described in which, from a 90 degree flexed position over the edge of a table, the patient tries to extend the proximal interphalangeal joint of the involved finger against resistance. The absence of extension force at the proximal joint and fixed extension at the distal joint are immediate signs of complete rupture of the central slip. The theoretical basis and the method of performing the test are discussed

1. Rupture of the brachial artery or of one of its divisions in association with elbow injuries is probably more common than a survey of the literature would imply. Three cases of rupture of the brachial artery complicating compound dislocation of the elbow are reported. 2. These cases appear to have a consistent pattern of soft-tissue damage, with avulsion of the common flexor origin, and a varying degree of damage to the biceps and brachialis. The median nerve escaped injury. 3. The method of dealing with the divided vessels does not appear to be of importance in determining the outcome, simple ligation being as satisfactory as attempts at grafting or suture. 4. In no case was there any evidence of Volkmann's contracture. Provided rapid reduction of the dislocation is effected, together with ligation of the vessels, a satisfactory return of the circulation may be expected

We reviewed 21 patients with 22 ruptures of the extensor pollicis longus at a mean of 5.3 years after transfer of the extensor indicis proprius tendon. Of these, 19 with 21 transfers described the result as good, and two as fair. The mean deficit of extension between the operated and unoperated thumbs was 1.4 cm, and the mean flexion deficit 0.6 cm. Pressure gauge measurements showed that the strength of the transfer was 51% of that of the uninjured extensor. The two fair results had an extensor lag of over 1.5 cm. Independent extension of the index was maintained in all patients, none having a discernible lag, but the strength of index extension was reduced to 49% of that of the normal finger. There was no evidence of functional loss. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon is a simple and reliable procedure with few complications. It gives satisfactory long-term extension of the thumb

1. Forty-eight patients with spontaneous rupture of the tendon of the extensor pollicis longus have been studied and the results of forty-four operations by tendon transfer are reported. 2. The etiology and the pathology of the condition are discussed. 3. Transfer of the extensor indicis in general gives a better result than transfer of the extensor carpi radialis longus, but each method has its advantages and disadvantages. 4. The best results are obtained when the suture is done so as to leave the tendon in the fullest degree of tension obtainable

Thirty-three consecutive patients with complete ruptures of the calcaneal tendon were treated by external fixation. The patients were assessed both objectively and subjectively, and the results classified as excellent, good, fair and poor. In 30 patients the result was excellent or good. There were no infections or re-ruptures. Two patients with fair results had sural nerve injury. The only patient with a poor result had Sudeck's atrophy. It is felt that this operation satisfies the need for a new technique which is simple and combines the advantages of both surgical and non-surgical treatment without their major complications

Percutaneous repair of the ruptured tendo Achillis has a low rate of failure and negligible complications with the wound, but the sural nerve may be damaged. We describe a new technique which minimises the risk of injury to this nerve. The repair is carried out using three midline stab incisions over the posterior aspect of the tendon. A No. 1 nylon suture on a 90 mm cutting needle approximates the tendon with two box stitches. The procedure can be carried out under local anaesthesia. We reviewed 27 patients who had a percutaneous repair at a median interval of 35 months after the injury. They returned to work at four weeks and to sport at 16. One developed a minor wound infection and another complex regional pain syndrome type II. There were no injuries to the sural nerve or late reruptures. This technique is simple to undertake and has a low rate of complications

Four patients with pectoralis major ruptures underwent clinical and dynamometric assessment and one patient underwent late surgical repair. The operation is described. Dynamometry proved a useful and objective method of estimating the loss of strength and indicating patients who might benefit from surgical repair

1. Complete rupture of the axillary artery caused by dislocation of the shoulder in a man aged seventy-four is reported. There was severe arteriosclerosis and the simple operation of ligation of the artery was performed with success. There was excellent function of the shoulder and hand on review thirteen years later. 2. Previously recorded cases are reviewed

Ten cases of complete rupture of the collateral ligaments of the metacarpophalangeal finger joints are reported. The nature of this injury, the pre-operative morbidity and the intra-operative pathology are analysed. In all cases surgery was performed with satisfactory results. Operation is indicated for joint stability, grip and pinch strength, pain control and early functional recovery

The stress-tenogram is a radiological technique for the investigation of injuries to the lateral ligament of the ankle, and combines the information previously provided by inversion and anterior stress radiographs, and the peroneal tenogram. It is designed to differentiate between stable and unstable ankles, and between isolated ruptures of the anterior talofibular ligament and combined tears of the anterior talofibular and calcaneofibular ligaments. A high degree of diagnostic accuracy has been confirmed at operative repair in a group of thirty-two patients

A group of 40 patients with unstable knees due to a combination of a meniscal tear with a rupture of the anterior cruciate ligament was studied to assess the effects of treatment by meniscectomy alone. The results were assessed both subjectively and objectively, but emphasis was placed on the symptoms rather than the physical signs of instability. Meniscectomy alone cured the symptoms of instability in 22 of the patients and a further eight required no further surgical treatment; bucket-handle tears were associated with a good result and posterior-horn tears with a poor result. The remaining 10 patients later underwent an additional procedure to reconstruct the ligament because of persisting symptoms. It was concluded that in patients with this combined lesion the torn meniscus should be dealt with first. In young patients with a posterior-horn tear it would be justifiable to perform a ligamentous reconstruction at the same time as the meniscectomy

1. A case of bilateral spontaneous and simultaneous rupture of the quadriceps tendons is described. 2. The underlying cause was found to be gouty affection of the tendons. 3. So far as is known, a similar case has not previously been recorded

A total of 60 children and adolescents with rupture of the anterior cruciate ligament (ACL) was seen between 1980 and 1990. Observation of the 23 patients who were treated conservatively revealed that the natural history of the injury resulted in severe instability and poor function of the knee. Associated meniscal tears were present in 15 knees. Three osteochondral fractures occurred and osteoarthritic changes developed in ten knees. In 1990 therefore we introduced reconstruction of the ACL with a four-strand hamstring graft using an anatomical placement with transphyseal tunnels and anchorage well away from the growth plate. Over a period of nine years, 47 knees underwent reconstruction. The mean follow-up was 49 months (12 to 96). No child suffered physeal damage or leg-length discrepancy. The results were satisfactory in 77% and there was little difference between patients treated before the adolescent growth spurt and those treated during or after this time. These results, however, were not as good as those seen in adults during the same period

After a severe ankle sprain the incidence of residual complaints, particularly on the medial side of the joint, is high. We studied a consecutive series of 30 patients who had operative repair of acute ruptures of lateral ligaments. During operation, arthroscopy revealed a fresh injury to the articular cartilage in 20 ankles, in 19 at the tip and/or anterior distal part of the medial malleolus as well as on the opposite medial facet of the talus. In six patients, a loose piece of articular cartilage was found. We conclude that in patients with a rupture of one or more of the lateral ankle ligaments after an inversion injury, an impingement occurs between the medial malleolus and the medial facet of the talus. Patients with a lesion of the lateral ankle ligament caused by a high-velocity injury (a faulty landing during jumping or running) had a higher incidence of macroscopic cartilage damage (p < 0.01), medially-located pressure pain (p = 0.06) and medially-located complaints at one-year follow-up (p = 0.02) than those with a low-velocity injury (a stumble)

Consecutive patients with a confirmed rupture of at least one of the lateral ligaments of the ankle were randomly assigned to receive either operative or functional treatment. They were evaluated at a median of 8 years (6 to 11). In total, 370 patients were included. Follow-up was available for 317 (86%). Fewer patients allocated to operative treatment reported residual pain compared with those who had been allocated to functional treatment (16% versus 25%, RR 0.64, CI 041 to 1.0). Fewer surgically-treated patients reported symptoms of giving way (20% versus 32%, RR 0.62, CI 0.42 to 0.92) and recurrent sprains (22% versus 34%, RR 0.66, CI 0.45 to 0.94). The anterior drawer test was less frequently positive in surgically-treated patients (30% versus 54%, RR 0.54, CI 0.41 to 0.72). The median Povacz score was significantly higher in the operative group (26 versus 22, p < 0.001). Compared with functional treatment, operative treatment gives a better long-term outcome in terms of residual pain, recurrent sprains and stability

Aims

To determine whether the findings from a landmark Canadian trial assessing the optimal management of acute rupture of the Achilles tendon influenced the practice patterns of orthopaedic surgeons in Ontario, Canada.

Major ruptures of the rotator cuff were repaired in 89 patients over a six-year period, using an approach through the split deltoid muscle and the bed of the excised outer centimetre of the clavicle. Review of these patients showed that poor results were associated with larger cuff defects, with more pre-operative steroid injections and with pre-operative weakness of the deltoid muscle. A randomised prospective study showed that repair followed by splinting in abduction gave no better results than repair followed by resting the arm at the side. Excision of the coraco-acromial ligament was associated with worse results than leaving its divided halves in situ. Follow-up showed that the results continued to improve for two years after operation; their quality was maintained in patients less than 60 years old, but in those over 60 there was deterioration with time

Aims

The aim of the study was to analyze the results of primary tendon reinsertion in acute and chronic distal triceps tendon ruptures (DTTRs) in the general population.

Rupture of the tendons of both peroneus longus and peroneus brevis results in considerable disability. We have performed transfer of flexor digitorum longus (FDL) to peroneus brevis in two patients with lateral instability of the hindfoot due to chronic transverse tears of both tendons for which end-to-end repair was not possible. Both patients had excellent function when reviewed after eight and six years, respectively, with no symptoms. CT showed a normal appearance of the FDL in both patients, but the peroneal muscles looked abnormal. Transfer of the FDL provides a reliable solution to lateral instability of the hindfoot resulting from loss of function of both peronei