We reviewed retrospectively 45 patients (46 procedures) with bladder exstrophy treated by bilateral oblique pelvic osteotomy in conjunction with genitourinary repair.

The operative technique and post-operative management with or without external fixation are described. A total of 21 patients attended a special follow-up clinic and 24 were interviewed by telephone. The mean follow-up time was 57 months (24 to 108).

Of the 45 patients, 42 reported no pain or functional disability, although six had a waddling gait and two had marked external rotation of the hip. Complications included three cases of infection and loosening of the external fixator requiring early removal with no deleterious effect. Mid-line closure failed in one neonate managed in plaster. This patient underwent a successful revision procedure several months later using repeat osteotomies and external fixation.

The percentage pubic approximation was measured on anteroposterior radiographs pre-operatively, post-operatively and at final follow-up. The mean approximation was 37% (12% to 76%). It varied markedly with age and was better when external fixation was used. The wide range reflects the inability of the anterior segment to develop naturally in spite of close approximation at operation.

We conclude that bilateral oblique pelvic osteotomy with or without external fixation is useful in the management of difficult primary closure in bladder exstrophy, failed primary closure and secondary reconstruction.

We reviewed prospectively, after skeletal maturity, a series of 24 patients (25 hips) with severe acute-on-chronic slipped capital femoral epiphysis which had been treated by subcapital cuneiform osteotomy. Patients were followed up for a mean of 8 years, 3 months (2 years, 5 months to 16 years, 4 months). Bedrest with ‘slings and springs’ had been used for a mean of 22 days (19 to 35) in 22 patients, and bedrest alone in two, before definitive surgery. The Iowa hip score, the Harris hip score and Boyer’s radiological classification for degenerative disease were used.

The mean Iowa hip score at follow-up was 93.7 (69 to 100) and the mean Harris hip score 95.6 (78 to 100). Degenerative joint changes were graded as 0 in 19 hips, grade 1 in four and grade 2 in two. The rate of avascular necrosis was 12% (3 of 25) and the rate of chondrolysis was 16% (4 of 25). We conclude that after a period of bed rest with slings and springs for three weeks to gain stability, subcapital cuneiform osteotomy for severe acute-on-chronic slipped capital femoral epiphysis is a satisfactory method of treatment with an acceptable rate of complication.

The literature on fracture repair has been reviewed. The traditional concepts of delayed and nonunion have been examined in terms of the phased and balanced anabolic and catabolic responses in bone repair. The role of medical manipulation of these inter-related responses in the fracture healing have been considered.

The sternoclavicular joint is vulnerable to the same disease processes as other synovial joints, the most common of which are instability from injury, osteoarthritis, infection and rheumatoid disease. Patients may also present with other conditions, which are unique to the joint, or are manifestations of a systemic disease process. The surgeon should be aware of these possibilities when assessing a patient with a painful, swollen sternoclavicular joint.

The objective of this retrospective study was to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults and to determine prognostic factors for functional outcome. Of 63 adult patients who sustained a Monteggia fracture in a ten-year period, 47 were available for follow-up after a mean time of 8.4 years (5 to 14). According to the Broberg and Morrey elbow scale, 22 patients (47%) had excellent, 12 (26%) good, nine (19%) fair and four (8%) poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The mean Broberg and Morrey score was 87.2 (45 to 100) and the mean DASH score was 17.4 (0 to 70). There was a significant correlation between the two scores (p = 0.01). The following factors were found to be correlated with a poor clinical outcome: Bado type II fracture, Jupiter type IIa fracture, fracture of the radial head, coronoid fracture, and complications requiring further surgery.

Bado type II Monteggia fractures, and within this group, Jupiter type IIa fractures, are frequently associated with fractures of the radial head and the coronoid process, and should be considered as negative prognostic factors for functional long-term outcome. Patients with these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery.

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome.

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age.

Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres.