Purpose of the study: Percutaneous screw fixation is widely used for the treatment of non-displaced fresh fractures of the carpal scaphoid. This screw fixation can be achieved either via a volar approach (retrograde insertion) or via a dorsal approach (antegrade insertion). The purpose of our study was to define the best approach as a function of the orientation of the fracture line (types B1 or B2 in the Herbert classification).

Material and methods: We used 12 upper limbs. For each wrist we obtained three scanner images: in maximal flexion, in the neutral position, and in maximal extension. For each scanner image, the parasagittal slice corresponding to the ideal plane for screw position was identified by digital reconstruction. On each slice, the type B1 and B2 fractures were modellised, as was the displacement of the corresponding screws introduced via the volar incision (S1) or the dorsal incision (S2). Each virtual screw was positioned as perpendicular as possible to the fracture line. For each slice corresponding to a given wrist position, we measured the angles between the fracture line (B1, B2) and the screws (S1, S2), giving four angles V1 (S1-B1), V2 (S1-B1), D1 (S2-B1), D2 (S2-B2). Thus the angle closest to 90° was considered the most satisfactory.

Results: For B2 fractures, the position of the virtual screw perpendicular to the fracture line was possible via both the volar and the dorsal incision. For B1 fractures, it was impossible to position the screw perpendicular to the fracture line, but the dorsal approach with the wrist in maximal flexion gave the best position.

Conclusion: For B2 fractures, the dorsal and volar approach allow optimal screw insertion so the choice of the incision depends on the surgeon’s experience. For B1 fractures, we recommend the dorsal approach.

Purpose of the study: Kyphoplasty was introduced to reinforce the anterior column in osteoporotic vertebral fractures. It can be used for non-osteoporotic fractures. The purpose of this work was to report the clinical and radiographic results of kyphoplasty for non-ostoporotic vertebral fractures.

Material and methods: From December 2005 to August 2008, we followed prospectively 21 patients (12 M, 9 F) mean age 45 years (16–58) treated for thoracolumbar fractures by kyphoplasty in order to reinforce the anterior column. There were 23 fractures (T11 = 2, T12 = 5, L1 = 8, L2 = 4, L3 = 4) Magerl: A1 = 6, A3.1 = 7, A3.2 = 1, B1 = 2, B2 = 7. All patients were assessed preoperatively, postoperatively, and at last follow-up with a visual analogue scale (VAS) and the EIFEL function score. The sagittal CT scans passing through the pedicles and the midline were used to measure: the height of the anterior and posterior walls of the fractured vertebra and the supra and infra vertebrae as well as the kyphosis angle.

Results: Thirteen fractures were treated by kyphoplasty alone; seven by kyphoplasty combined with percutaneous osteosynthesis; three by kyphoplasty combined with open osteosynthesis with decompression because of preoperative neurological deficits. Mean follow-up was 13 months (6–28). There were no postoperative neurological or infectious complications. At last follow-up, the mean VAS was 1.25 (05) and the mean EIFEL 4 (0–12). Preoperatively, mean compression was 40.9% (6.2–81.4) for the anterior column and 16.7% (0–60.2) for the posterior column. Postoperatively the respective values were 22.8% (5.1–69.3) and 12.3% (−12 to 72.6) for a mean correction of 46.2% for the anterior column and 14.3% for the posterior column. At last follow-up, compression was respectively 26.1% and 7.9%. The vertebral kyphosis was 16.3 (6–16.3) preoperatively and 9.1 (3–4) postoperatively (mean correction 8.7). At last follow-up, vertebral kyphosis was 9.1 (1.7–28.3).

Discussion: Kyphoplasty allows satisfactory restoration of vertebral height without loosing short-term correction. For us, kyphoplasty should be associated with posterior fixation in patients with posterior injury. For neurological lesions, kyphoplasty associated with decompression and posterior fixation avoid the need for complementary anterior procedures.

Purpose of the study: Different posterior osteosynthesis techniques have been described for the treatment of unstable injury of the pelvic girdle. Bi-iliac fixation using threaded rods or plate-screw fixation has been proposed. The purpose of this work was to describe a modification of the posterior osteosynthesis using instrumentation designed for the spinal column.

Material and methods: From January 2006 to October 2008, four patients (three men, one woman, mean age 24 years, range 18–34) underwent surgery in our unit for unstable fractures of the pelvis with a trans-sacral posterior fracture line (AO classification C1.3–4). Two patients presented neurological signs including one by head trauma with hemiplegia. Two patients had an anterior fixation with an external fixator and another an anterior plate fixation. The operation was conducted via a posterior midline incision. After reduction of the fracture, the osteosynthesis was achieved with two poly-axial screws inserted in each of the iliac wings and connected by two rods and one or two cross connectors.

Results: Mean follow-up was 7.5 months (range 5–17). None of the patients developed infectious, neurological or mechanical complications postoperatively. Complete pain-free weight-bearing and walking were achieved in patients at three months. None of the patients had a horizontal or vertical misalignment callus measuring more than 5 mm. Screw analysis showed that three screws penetrated the sacroiliac joint in the first patient of the series with no clinical consequence.

Discussion: This posterior fixation technique for unstable fractures of the pelvis appears to be reliable and reproducible for type C fractures in combination with anterior fixation. It uses standard instrumentation for spinal osteosynthesis. A study with a larger population and longer follow-up is needed.

Purpose of the study: High-energy varus or valgus ankle trauma causes severe injury to the capsule and ligaments. We describe a presentation associating massive tears of the lateral/medial collateral ligaments with a transversal wound of the corresponding malleolus. This wound results from excessive tension on the skin cause by the major varus/valgus. We have defined this injury as an open and severe ankle sprain (OSAS).

Material and method: This was a retrospective analysis. We search the databases of three participating centres using the corresponding diagnostic and therapeutic codes from January 2005 to January 2009. The identified files were screened to select patients with OSAS.

Results: There were 11 cases of OSAS. Eight involved the lateral side of the ankle and three the medial side. Mean age was 41 years (range 21–45). All patients were victims of a high-energy trauma (five motorcycle accidents) and four patients had fallen from a high point. Associated injuries were tendon section (n=3), section of the deep fibular nerve (n=2), and section of the anterior tibial artery (n=1). Pneumarthrosis was the only visible anomaly on the plain x-rays of seven ankles. Diagnosis was confirmed preoperatively in all cases clinically with varus-valgus stress manoeuvres.

Conclusion: OSAS is a rare misleading injury. Confusion with a common wound is possible. The risk is to miss acute instability and thus its treatment. The diagnosis should be proposed for all transversal wounds without contusion over the malleolus with normal x-rays.