Aims

This observational study examines the effect of the COVID-19 pandemic upon the paediatric trauma burden of a district general hospital. We aim to compare the nature and volume of the paediatric trauma during the first 2020 UK lockdown period with the same period in 2019.

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

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

1. Intramedullary nailing in two-level tibial fractures provides the following advantages: it allows walking with full weight-bearing in an average time ofthree to four months; it decreases the rate of non-union ; it decreases the rate of malunion ; it should decrease the rate of infection in closed fractures when compared with other types of internal fixation, due to the technique of blind nailing without exposure of the fracture site. 2. Compound tibia! fractures treated by nailing are still often complicated by infection. Nevertheless, we have not been able to find studies in the literature based on series large enough to permit the conclusion that other methods could lower significantly the infection rate

1. A series of 100 intracapsular fractures of the femoral neck treated with the Charnley compression screw is reported. 2. There were six deaths, and in patients reviewed long enough (seventy-five) there were eleven undisplaced fractures, with successful union in 8l·8 per cent, and sixty-four displaced fractures, with a union rate of 59·6 per cent. 3. If we exclude six failures of operative technique, there remain fifty-eight patients in whom the fracture was judged radiologically to have united in 65·5 per cent. 4. The Charnley compression screw is an effective method of internal fixation in such fractures, and non-union with this method is usually due to causes other than mechanical failure

1. Paraplegia from fracture-dislocation at the thoraco-lumbar junction is a mixed cord and root injury. The root damage can be distinguished from cord damage by neurological examination and by comparison of the neurological level with the fracture level. 2. Even though the cord injury is complete, as it usually is, the roots often escape or recover. 3. Fracture-dislocations can be divided into stable and unstable types. Because of the possibility of root recovery care must be taken to prevent further damage to the roots by manipulation of the spine or during treatment. For this reason unstable fracture-dislocations are fixed internally by plates. 4. Internal fixation also assists in the nursing of the patient. The nursing technique and the care of the bladder are described

A consecutive series is reported of 17 patients who underwent early surgical treatment for acetabular or unstable pelvic fractures associated with ipsilateral fractures of the femur. Treatment included external and internal fixation, and required careful consideration of the surgical approach and the positioning of the patient. The multiple injuries sustained by these patients required simultaneous procedures by several surgical teams. All the femoral fractures were internally fixed at the initial operation and eight patients had primary definitive treatment of all their other fractures as well. In nine patients the definitive treatment of their other fractures was delayed for an average of 11 days. There were no deaths, and no serious infections. The long-term morbidity resulted from the associated injuries and not from the pelvic or femoral fractures

Spines are often stabilised posteriorly by internal fixation and anteriorly by a bone graft. The effect of an autologous bone graft from the iliac crest on implant loads is unknown. We used an internal spinal fixation device with telemetry to measure implant loads for several body positions and activities in nine patients before and after anterior interbody fusion. With the body upright, implant loads were often higher after than before fusion using a bone graft. Distraction of the bridged region led to high implant loads in patients with a fractured vertebra and to marked changes in load in those with degenerative instability. Leaving the lower of the bridged intervertebral discs intact led to only small changes in fixator load after anterior interbody fusion. A bone graft alone does not guarantee a reduction of implant loads

We report a retrospective review of 62 consecutive patients who had a vascularised fibular transfer to reconstruct a large skeletal defect. We were particularly interested in the bone dynamics of the vascularised graft, since fractures occurred in 25% of the cases at an average time of eight months after surgery. Hypertrophy was more common when the limb was mechanically loaded; it was enhanced where the graft was not bypassed by internal fixation. The length of the graft and the use of additional bone graft material had no influence on the incidence of stress fracture or on hypertrophy. We conclude that a vascularised graft should be protected against fatigue fracture during the first year, and that a gradual increase in mechanical loading will enhance remodelling and hypertrophy

1. Nine out of ten patients who undergo McMurray osteotomy may expect lasting relief of pain. Seventy-five per cent should have a satisfactory functional result. It is rare for a patient to be made worse. 2. Osteoarthritis of the hip and ununited fracture of the femoral neck are good reasons for operation; avascular necrosis after fracture is not. 3. Internal fixation shortens the time in plaster and in hospital, and reduces the incidence of stiffness of the knee. 4. The common observation that the joint space may be increased after osteotomy is due often to the altered position of the femoral head. Occasionally there occurs a true increase in joint space, presumably indicating regeneration of articular cartilage, and an accompanying regression in the changes of osteoarthritis

Twenty complex tibial deformities due to anterior poliomyelitis in 18 patients were corrected by a modified O’Donoghue osteotomy. This technique allowed correction of the deformity in three planes. This was achieved by widening the rectangular window distally to correct both rotation and valgus and by trimming the anterior edges of the step cuts to correct flexion deformity. An above-knee cast was applied for eight to 13 weeks and the patients followed up for a mean of 3.2 years. One of the 18 patients developed delayed union because of fracture of the medial limb of the step cut. The results showed excellent correction of the three-plane deformity and there was no recurrence. This method of osteotomy is a safe and simple procedure which does not require internal fixation and allows correction of torsional and angular deformity

We treated 49 patients at an average age of 80 years (75 to 90) with distal mostly intraarticular humeral fractures by open reduction. There were 8 class A, 13 class B and 28 class C fractures on Muller's classification. The patients were reviewed at a postoperative average of 18 months. The patients' assessment of the result was very good in 31%, good in 49%, fair in 15% and poor in 5%. The flexion-extension range was very good in 41%, good in 44% and fair in 15%. The incidence of implant failure, pseudarthrosis of the olecranon osteotomy and ulnar nerve lesion was no higher in these elderly patients than in younger patients. Old age is not a contraindication to open reduction and internal fixation; it is important to restore full function

We studied the rate of revision in 84 consecutive total hip replacements performed for failed osteosynthesis of femoral neck fractures and compared it with that for primary arthroplasty for osteoarthritis. The age and sex adjusted risk of prosthetic failure was 2.5 times higher after failure of fixation, but all the excess risk was in patients over 70 years of age. There were radiographic signs of loosening of the femoral component at five to 12 years after secondary arthroplasty in six of 33 survivors. In general, the results of secondary replacement were no worse than those obtained after primary arthroplasty for femoral neck fracture. We consider that internal fixation should be the primary procedure: total hip replacement is a safe secondary procedure when osteosynthesis fails

Hyperphosphatasia, or hereditary bone dysplasia with hyperphosphatasaemia, is a rare genetic disorder which is characterised by failure to transform woven into lamellar bone. Clinical, radiological and histological features establish the diagnosis, fractures, deformities, diffuse sclerosis on radiographs and high serum alkaline phosphatase being characteristic. We report the case of a 27-year-old man with follow-up at the same hospital for 20 years. Attempts at treatment with calcitonin and disocium etidronate (EHDP) failed, but stapling of the growth plates at the knee was successfully performed. Transverse "brittle" fractures of the humerus, lower leg and ribs healed normally, but internal fixation and late bone grafting were required for a subtrochanteric stress fracture of the femur at the age of 24 years. At present the patient has no clinical problems and leads a normal life

Eleven patients with metastases in the cervical spine had operations for severe pain due to a pathological fracture which, in eight of the cases, was unstable. Conservative treatment had either failed or was unsuitable. In the first five patients internal fixation with tension band wires and bone grafts was supported by a halo-brace. The method has evolved to the use of posterior instrumentation with laminar wires from two levels above the lesion to two levels below. Stability is increased by the use of bone cement with or without bone autografts applied to one side of the spine. This technique enables the patient to get up within a few days of operation--a great advantage when life expectancy is limited. The operations were successful in all except one case

The hypothesis provides a theoretical justification for, and re-emphasises the practical importance of, close reduction and strict immobilisation in the treatment of fractures of the neck of the femur. It does not support the view that failure of union is caused by vascular damage at the time of the original injury. Unexpected failure of union after nailing is more likely caused by unrecognised imperfection of reduction and the acknowledged deficiencies of internal fixation. Attempts to improve results by passing the sartorius muscle around the fracture (Adams 1956), or by attaching muscle or joint capsule to the proximal fragment, have failed, because such soft tissues are swept off by the acetabular rim when the hip is flexed or medially rotated. Further work is required, both on the more detailed biochemistry of haemarthroses and on the practical and wider implications of the hypothesis

To assess the stability of the hip after acetabular fracture, dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management. These included roof arcs of 45°, a subchondral CT arc of 10 mm, displacement of less than 50% of the posterior wall, and congruence on the AP and Judet views of the hip. There were three unstable hips which were treated by open reduction and internal fixation. The remaining 38 fractures were treated non-operatively with early mobilisation and delayed weight-bearing. At a mean follow-up of 2.7 years, the results were good or excellent in 91% of the cases. Three fair results were ascribed to the patients’ other injuries. Dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment

Aims

To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years.

We treated 110 fractures of the middle third of the clavicle in 108 patients aged between 14 and 66 years, by fixation with 2 mm Kirschner wires. The wire was introduced, using an air drill and a telescoping guide, from the medial into the lateral fragment. The medial end of the wire which perforated the anterior cortex of the medial fragment was bent backwards to prevent migration into the lung or mediastinum. In cases of nonunion and acute fracture in which a bone gap was present, bone graft was laid around the fracture site after internal fixation. All the fractures united. No wires broke but in three patients one migrated before union was achieved. Twenty-one patients failed to return for removal of the wire; nine of them had radiological evidence of union before they were lost to follow-up