Tibial Pilon fractures pose a difficult management problem. For logical fracture treatment, precise understanding of the 3-D anatomy is essential.

We have studied a consecutive series of 126 pilon fractures. Digitised X-rays and CT scans were analysed using a CAD programme.

We have defined six main fragments at the articular surface, their relative frequency and their proportion: Anterior (A) present in 89%, 28% of area. Posterior (P) present in 89%, 40% of area. Medial (M) present in 74%, 29% of area. Anterolateral (AL) present in 34%, 8% of area. Posterolateral (PL) present in 21%, 9% of area. Die-punch (DP) present in 43%, 4% of area.

The primary fracture line varied in orientation from coronal (93%) to sagittal (7%), in contrast to the classic description.

Within those cases where the primary fracture line was coronal we found hitherto undescribed variations in the articular pattern, there being ‘T’, ‘V’, ‘Y’ and pure split fractures with respect to the medial fragment. Fractures which displace into varus show a “T” configuration, those in valgus a “Y” or “V” configuration, (p < 0.001). Fractures with no coronal mal-alignment produce a talo-fibular joint disruption.

Once recognised these different articular patterns require individual techniques for anatomic reduction and fixation.

Optimal treatment of articular fractures is open anatomic reduction and rigid internal fixation. In pilon fractures, this has been associated with unacceptable complication rates.

The cutaneous blood supply of the anterior aspect of the distal tibia is from short direct radial vessels which themselves arise from arteries closely adherent to the deep fascia. On the anteromedial aspect of the leg the deep fascia is fused with the periosteum. We hypothesise that shearing associated with displaced fractures divide these short radial vessels, rendering the skin critically ischaemic. Standard extensile approaches lead to further devitalisation and wound breakdown. It follows that a direct approach onto the fracture line should do minimal extra damage to the blood supply.

Of 97 pilon fractures, 53 have required an open reduction. Median age 43, 39 male. Mechanism of Injury: fall-41, RTA-10, other-two. 19% open (60% IIIB). Time to surgery nine days.

A longitudinal incision with full thickness flaps is based directly over the fracture, not necessarily following internervous planes.

Anatomic reduction was achieved in all cases. There was only one complication of wound breakdown (2%).

This technique affords a safe and reliable approach to the fractured articular surface. Lack of wound breakdown may rely on the use of fine-wire circular frame external fixators for stabilisation of the proximal fracture. Whether this approach will allow plate fixation, remains to be seen.

Os calcis fracture patterns in ten children (mean age 12. 8) with eleven fractures were classified using plain films and CT scans and found to be similar to those in adults.

All except two of the fractures (which were not significantly displaced) were treated with open reduction and internal fixation. In all cases it was possible to achieve anatomic reduction and rigid internal fixation. Eight patients had ‘excellent’ long-term clinical results.

One patient with a court case pending scored ‘good’, and one patient with an ipsilateral talar neck fracture scored ‘fair’. This patient had mildly limited ankle movement; all others had full ankle movement. Six had full subtalar movement, in 2 it was mildly limited and in three it was moderately limited (50–80%). There was no evidence of abnormality of the physes on follow up x-rays. We conclude that operative treatment of these fractures yields optimal results.

Background: Fracture non-union remains a severe clinical problem. The methods of Ilizarov allow a new approach using a tensioned fine wire circular frame to construct cylinders around limb segments that are then manipulated with respect to each other with deformity correction using hinges. Ilizarov introduced the concept of bone formation in distraction. The use of fine wires and non-invasive techniques minimise bone and soft tissue damage.

Method: Two hundred consecutive non-unions treated by the use of an Ilizarov frame were studied prospectively. The first 100 cases to have finished treatment were analysed. The mean time from fracture was 22.8 months (range: six months to 37 years) and the mean number of surgical procedures was four (range: one to 122). Eighty-eight percent affected the tibia. Unifocal compression was also used where bone loss was not a problem.

Results: Ninety-three fractures united. There were two amputations for overwhelming infection, four refractures and one defaulter. Infection, present in 56 cases at presentation was eradicated in all successful cases. Time in the frame for unifocal distraction (n=6) was 6.0 months (2.5-13), for unifocal compression (n=36) was 8.4 months (2.8-20), for bifocal compression distraction (n=33) 10 months (2.9–17.4) and for bifocal excision distraction (n=24) 19 months (6.5–41). Comparing times in frame for tibial bifocal cases, compression/distraction was 9.1 months (2.9–17.4), excision with shortening and relengthening was 15.7 months (6.5–23.6) and excision/transport was 23.5 (12.6–41.5), indicating increasing time required for more radical treatments.

Conclusion: The Ilizarov method provided an excellent technique for the treatment of non-unions. The technique was initially difficult for the surgeon and the patient but, with increasing experience, treatment times were reduced and the frames became progressively more manageable and less painful. In our hands, the Ilizarov frame has become the treatment of choice for all but the simplest non-unions.

We describe a direct method of measuring the tightness of plaster casts. Tightness was measured weekly in 23 consecutive patients with Colles' fractures. Six had objective signs of algodystrophy nine weeks after the fracture. In these patients the plaster cast was significantly tighter during the first three weeks than in patients who did not develop algodystrophy. The complex relationship between these findings is discussed.

Our previous reports on the pathological anatomy and operative treatment of intra-articular fractures of the calcaneum failed to take account of the fracture pattern anterior to the posterior facet of the subtalar joint. We have reviewed our experience of 63 operative cases and have studied fractures with axial and coronal CT scans reconstructed onto plastic model bones. A constant anterolateral fragment exists, which is displaced by an extended lateral approach to the fracture. If it is unrecognised and unreduced, union in a displaced position may limit hindfoot eversion and disrupt the calcaneocuboid joint. We describe techniques for reduction and fixation of the fragment.

We made a prospective study of the incidence and natural history of algodystrophy and associated changes in bone mineral density in the ankles and feet of 60 consecutive patients who had suffered unilateral fractures of the tibial shaft. At bone union, 18 patients showed signs of algodystrophy. Its development was independent of the type of fracture management and of the severity of injury. Patients with algodystrophy lost significantly more bone mineral than did those without but the degree of this loss was independent of the type of treatment and of the time to fracture union. In most cases the symptoms resolved within six months of fracture union but in four patients they were still present at one year and two of these had not returned to work.

We have studied the radiographic and CT features of 120 displaced intra-articular fractures of the calcaneum in order to define the pathological anatomy. In 96% of cases, the CT scans identified three main fragments: sustentacular, lateral joint and body. The sustentacular fragment was often rotated into varus, the lateral joint fragment into valgus and the body fragment impacted upwards, in varus and displaced laterally. The displacement of these fragments varied according to which of three fracture types was present, as defined by the composition of the fractured lateral wall of the calcaneum. In type 1 it was formed by the lateral joint fragment alone; in type 2 by both body and lateral joint fragments; and in type 3 by the body fragment alone. Fracture fragment displacement differs from that previously described, in that true uniform depression of the lateral joint fragment is rare.

The classification of intra-articular fractures of the calcaneum described in part I is related to an operative approach which allows accurate reduction and stable fixation of the fracture fragments. An extended lateral incision is used to avoid sural nerve damage and problems of soft-tissue healing. In type 3 fractures, access to the lateral joint fragment requires an osteotomy of the lateral wall, but after this the lateral joint fragment can be rotated out of the subtalar joint to allow transcalcaneal reduction of the medial wall. Reduction of the body fragment and lateral joint fragment on to the sustentacular fragment allows the three fragments to be stabilised by a 3.5 mm Y-shaped reconstruction plate. Our early results have been successful in terms of fracture reduction and the restoration of heel shape and joint congruity, but extended follow-up will be necessary to define the indications for this difficult procedure.

We describe the use of intramedullary reconstruction nails in the treatment of 14 patients with pathological subtrochanteric fractures and coexisting metastases in the femoral shaft. After nailing, all patients were free from pain and regained mobility. They were followed up clinically and radiologically until death from the primary disease. There were no mechanical failures even when a less than ideal reduction had been achieved.

The results of 276 cemented revision total hip arthroplasties performed for aseptic failure between 1977 and 1986 have been reviewed. The mean time between revision and review was 75 months (range 30 to 144). Of 220 cases available for review, 159 were assessed clinically and radiographically, and 32 by postal questionnaire. Eighteen hips required further revision, 12 for loosening, two for sepsis, two for persistent pain, and one each for fracture and recurrent dislocation. A further six hips were radiologically and symptomatically loose. Pain was mild or absent in 83%. Over half were able to walk a mile or more; 70% flexed more than 70 degrees; 15% had a flexion deformity, but in only 7% was this more than 10 degrees. The mean Harris hip score was 74. Survival at five years was 95% and at 10 years, 77%.

We report the results of a prospective study of the incidence of algodystrophy following Colles' fracture in 60 patients, using sensitive or quantitative techniques for the assessment of each feature of the syndrome. Nine weeks after fracture, 24 patients had evidence of vasomotor instability, 23 had significant tenderness of the fingers and 23 had lost finger movement. These three abnormalities were significantly associated (p less than 0.001). Swelling was also significantly associated with these three variables. There was no statistical association between the occurrence of algodystrophy and the patient's age or sex, the severity of the fracture, the number of reductions performed or the adequacy of the reduction. We conclude that algodystrophy constitutes a precisely definable and quantifiable syndrome which is more common than has been suspected.

We report nine cases of irreducible congenital dislocation of the knee which were treated by early operation with good results. All were resistant to conservative measures and operation was performed at an average age of nine months. The essential abnormality was a short quadriceps muscle together with subluxation of the hamstring muscles to lie anterior to the axis of knee flexion. The quadriceps tendon was lengthened by VY-plasty and in six cases additional length was gained by proximal mobilisation of the muscle. After operation all the patients were able to walk.

Seven pectoralis major transfers in children suffering from bilateral paralysis of elbow flexion due to arthrogryposis or to trauma are reported. A technique is described in which the muscle is mobilised from the clavicle to allow the tendon of insertion to be attached to the biceps tendon at the elbow. The biceps tendon was found to be present and could be mobilised forwards in all the arthrogrypotic elbows. Subjectively, the results were considered by patients or parents to be very good in six cases and fair in one. Elbow flexion power against gravity and against some resistance was achieved in all patients except one. The overall function was very good in one elbow, good in two, fair in three and poor in only one. The merits of the various procedures described for the restoration of elbow flexion in arthrogryposis are discussed. It is concluded that total pectoralis major transfer by the method described here has given the best results.