The case reports of four patients with breakage of the intramedullary nail of the femur are presented. In all four patients the nail broke after consolidation of the fracture of the femoral shaft. All the nails broke at the same place: the junction between the round cross-section and the cloverleaf cross-section

1. A case of flake fracture of the talus progressing to osteochondritis dissecans is reported. 2. The relationship between direct injury and the onset of the lesion is noted. 3. The sequence of events was observed radiographically and clinically for two years from the date of the original injury

The use of a subcortical graft of autogenous iliac bone in patients with delayed union or non-union of fractured tibiae is described together with the results in twenty-nine patients. This procedure when performed early even in the presence of mild sepsis makes it possible to shorten the time of healing without any undue risk

Penetration of the dorsal screw when treating distal radius fractures with volar locking plates is an avoidable complication that causes lesions of the extensor tendon in between 2% and 6% of patients. We examined axial fluoroscopic views of the distal end of the radius to observe small amounts of dorsal screw penetration, and determined the ideal angle of inclination of the x-ray beam to the forearm when making this radiological view. Six volar locking plates were inserted at the wrists of cadavers. The actual screw length was measured under direct vision through a dorsal approach to the distal radius. Axial radiographs were performed for different angles of inclination of the forearm at the elbow. Comparing axial radiological measurements and real screw length, a statistically significant correlation could be demonstrated at an angle of inclination between 5° and 20°. The ideal angle of inclination required to minimise the risk of implanting over-long screws in a dorsal horizon radiological view is 15°. Cite this article: Bone Joint J 2013;95-B:1101–5

Fine-wire accepted as a minimally external fixation is invasive technique, which can provide better outcomes than traditional open methods in the management of complex fractures of the tibial plateau. Available fixators vary in their biomechanical stability, and we believe that a stable beam-loading system is essential for consistently good outcomes. We assessed, prospectively, the clinical, radiological and general health status of 20 of 21 consecutive patients with complex fractures of the tibial plateau who had been treated using a standard protocol, with percutaneous screw fixation and a neutralisation concept with a fine wire beam-loading fixator allowing early weight-bearing. Bony union was achieved in all patients, with 85% having good or excellent results. Full weight-bearing started during the first six weeks in 60% of patients. The general health status assessment correlated well with the knee scores and reflected a satisfactory outcome

We describe a technique of lengthening osteotomy of the fibula for the late treatment of symptomatic malaligned or malunited fractures of the ankle. Good results at two to three years were achieved in five of six cases despite delays of up to four years from the original injury. The method can prevent progressive instability and degenerative arthritis

We report our experience of the use of the Ilizarov technique to treat nine patients with severe compound tibial fractures. The mean defect in bone was 6.3 cm, and four cases were infected. All nine patients had satisfactory union and function without the use of bone grafts or antibiotics. The Ilizarov technique was very satisfactory; there were no major complications

Since 1986 we have treated 15 patients with fractures of the head of the radius limited to one or two fragments (Mason type II) by open reduction and internal fixation with the Fibrin Adhesive System. At a mean follow-up of over two years, all but one of the results were excellent. This method is recommended for the treatment of selected fractures of the radial head followed by early mobilisation

We report three patients in whom a fractured odontoid process was associated with a fracture of the superior articular process of the second cervical vertebra. Although there were no signs of neurological disorder, damage to the C1-C2 joint in all three patients made fusion necessary. Forced lateral flexion is suggested as the possible mechanism of injury

Screw devices used to treat fractures of the femoral neck are usually positioned under image-intensifier control, using anteroposterior and lateral views. The volume projected by these views is over 27% larger than the femoral head; the tips of screws so placed may be outside the femoral head. This can be avoided by placement within the central two-thirds of the head: we have designed a template which can confirm safe placement

1. Dislocation or sublaxation of the inferior radio-ulnar joint in association with fractures of the head of radius is discussed. 2. The incidence of the complication is greater than is generally supposed, and figures are given to support this finding. 3. The subluxation is not always associated with symptoms, and the degree of displacement may not be sufficient to be recognised clinically. 4. The anatomy and mechanism of the displacement have been investigated experimentally, and the results of the experiments are described

We have analysed 31 malunited ankle fractures treated by reconstructive osteotomies. In all cases the malunited fibula has been corrected; this has been combined with other osteotomies and with fixation of ununited fragments as indicated. Our results show that, unless function was severely impaired, reconstruction was always worth while, no matter how long ago the injury had occurred and even if there were already arthritic changes

Asymptomatic cyst-like cortical defects appearing after fractures in children have been occasionally reported. Typically, these defects appear during fracture consolidation, within the newly formed subperiosteal bone, proximal to the fracture line, do not enlarge, and progressively disappear. We have previously shown a fatty density on CT scan within the early cortical defect. We now present two additional cases in which early CT scans appeared to confirm that these transient cortical defects may consist of fat, and probably result from the inclusion of medullary fat within the subperiosteal haematoma

Two patients are described, each with a fracture-dislocation of the hip combined with a fracture of the neck of the same femur. Open reduction combined with internal fixation was performed in both cases. Eight years later one patient had developed avascular necrosis of the femoral head; no signs of avascular necrosis or associated arthritis have appeared in the other patient after four years. A plea is made for considering this more conservative type of operation for these serious injuries before resorting to total hip replacement

We measured the scattered radiation received by theatre staff, using high-sensitivity electronic personal dosimeters, during fixation of extracapsular fractures of the neck of the femur by dynamic hip screw. The dose received was correlated with that received by the patient, and the distance from the source of radiation. A scintillation detector and a water-filled model were used to define a map of the dose rate of scattered radiation in a standard operating theatre during surgery. Beyond two metres from the source of radiation, the scattered dose received was consistently low, while within the operating distance that received by staff was significant for both lateral and posteroanterior (PA) projections. The routine use of lead aprons outside the 2 m zone may be unnecessary. Within that zone it is recommended that lead aprons be worn and that thyroid shields are available for the surgeon and nursing assistants

Sixty closed fractures of the tibia were treated by open reduction and internal fixation with plates and screws. Half the operations were performed with a thigh tourniquet and half without. In the tourniquet group, there were six cases with erythema and induration of the wound; in the other group there were no such complications. Despite negative bacterial cultures, superficial infection of the inflamed wounds was suspected. It is suggested that a tourniquet may predispose tissues to infection, and its use is not recommended during operations for internal fixation of the tibia

We performed a prospective randomised trial on matched groups of patients with displaced tibial shaft fractures to compare conservative treatment with closed intramedullary nailing. The results showed conclusively that intramedullary nailing gave more rapid union with less malunion and shortening. Nailed patients had less time off work with a more predictable and rapid return to full function. We therefore consider that closed intramedullary nailing is the most efficient treatment for displaced fractures of the tibial shaft

At operation for the correction of cubitus varus by removal of a wedge based laterally, the radial nerve fortunately was first explored and found to run through a transverse bony tunnel at the posterior level of a supracondylar fracture sustained eight years previously. After elevation of the bony tunnel and nerve en bloc the osteotomy was completed; neurapraxia of the radial nerve soon recovered. With hindsight, the entrance and exit foramina of the tunnel could be clearly seen in the antero-posterior radiograph taken before the operation

We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients’ quality of life was estimated using the Short Form (SF) 12 score.

A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year.

Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union.

Cite this article: Bone Joint J 2015;97-B:997–1003.