Abstract

A femoral fracture in an adolescent is a significant injury. It is generally agreed that operative fixation is the treatment of choice and rigid intramedullary nailing is a surgical treatment option. We present on experience of treating adolescent femoral fractures using a lateral entry intramedullary nail.

We reviewed 15 femoral fractures in 13 children who we treated in our unit between 2011 and 2014. Two patients had bilateral fractures (non-simultaneous). Data collected included patient demographics, mechanism of injury, type of fracture, associated injuries, size of nail, time to unite and complications.

The mean age of the patients at time of surgery was 12 years (range 10–15). There were 7 male and 6 female. 10 fractures were caused by a fall whilst 5 were due to road traffic collisions (RTC). 8 fractures involved the middle third, 2 of theses were open fractures and were caused by a RTC. The remaining 7 involved the proximal third of the femur. The mean time to radiological union was 3.4 months (range 2.5–5) in 14 fractures. One patient had a delayed union that required bone grafting and united fully at 7.5 months post injury. The only other complications were a broken proximal locking screw in one patient and an undisplaced femoral neck fracture in another patient. These complications did not compromise the outcome. No patients had infection or developed avascular necroses at the latest follow up.

Intramedullary nailing of adolescent femoral fractures using the lateral entry point is safe and effective

Statement of purpose:

A randomised clinical trial was undertaken to find out if treatment time and failure rate in children treated by the Ponseti method differed between below-knee vs above-knee cast groups.

Introduction

Freiberg's infarction poses a challenge to foot and ankle surgeons. Several surgical and non surgical treatment methods are described. We performed a dorsal closing wedge osteotomy, debridement and microfracture of the metatarsal head. Dorsal closing wedge osteotomy helps in bringing the smooth plantar articular surface of the metatarsal head to articulate with the phalangeal articular cartilage whilst offloading the damaged dorsal articular cartilage. Debridement and Microfracture of the metatarsal head helps in regeneration of the damaged cartilaage via subchondral stem cells.

Introduction

The elbow is the second most common site of non prosthetic joint dislocation. Simple elbow dislocation alone contributes to 11-28% of all elbow injuries. Post-reduction treatment methods include traditional plaster of Paris (POP) immobilisation followed by physiotherapy, sling application followed by early mobilisation and rapid motion. The aim of the study was to evaluate the final outcome and cost-effectiveness of the pop and the sling groups.

Introduction: Freiberg’s infarction poses a challenge to foot and surgeons. Several surgical and non surgical treatment Methods: are described. We performed a dorsal closing wedge osteotomy, debridement and microfracture of the metatarsal head. Dorsal closing wedge osteotomy helps bringing the smooth plantar articular surface of the metatarsal head to articulate with the phalangeal articular cartilage whilst offloading the damaged dorsal articular cartilage. Debridement and Microfracture of the metatarsal head helps in regeneration of the damaged cartilaage

Materials and Methods: Total of 15 patients (12F, 3M) underwent the above surgery between year 2002 and 2008. Mean age was 35yrs (range14–60). All of them had an extraarticular dorsal closing wedge osteotomy fixed with a single screw along with debridement of the joint and mocrofracture of the damaged cartilage. Post operatively heel weight bearing was allowed with a special shoe for 6 weeks. Serial radiological assessments were done to assess healing of the osteotomy and reshaping of metatarsal head. Patients had a mean follow up of 2.5 yrs (Range 1–6). All patients were assessed using subjective patient satisfaction scores (scale 0–10) and AOFAS scores.

Results: 2nd metatarsal was involved in 14 and 3rd in one patient. All the osteotomies healed at a mean period of 10 weeks (range 6–18). The mean patient satisfaction score was 8 (range 5–10). The mean pre and post operative AOFAS scores were 54 and 82. One patient developed post operative haematoma which resolved spontaneously. No other complications noted

Conclusions: A combination of dorsal closing wedge osteotomy, debridement and microfracture is an effective method of treating Freiberg’s disease.

The knowledge of actual extent of the fracture in cases of isolated greater trochanteric fractures has paramount importance in decision-making. MRI has been the most common investigation to detect the intertrochanteric extension. However, to date there is no plain radiographic or MRI criteria to decide which fractures need surgery and which could be managed non-operatively. The aim of our study-was to assess whether the angle and the extent of the greater trochanteric fracture measured on plain radiographs could be used to predict the intertrochanteric extension.

We reviewed plain radiographs of 23 patients with isolated greater trochanteric fractures who also had MRI scans. We considered two parameters

extent of fracture in percentage along the intertrochanteric line and

Out of 23 patients, MRI scans revealed intertrochanteric extension in eight and they underwent surgical stabilisation. All these eight fractures had a fracture angle of 45° or less and the percentage of fracture extent of > 40%. All the 15 fractures with a fracture angle of > 45° did not show intertrochanteric extension on MRI scan. The mean angle of the fracture in those with MRI proven intertrochanteric extension was 33.5° (range 20°–45°) and in those with no intertrochanteric extension was 55.7° (Range 25°–125°). The mean percentage of length of fracture across the intertrochanteric line was 61.1% (47%–73%) and 39.6% (27%–62%) respectively.

We conclude that those isolated greater trochanteric fractures, with a fracture angle of more than 45° are unlikely to have an intertrochanteric extension. Those fractures with an extent of more than 40% and fracture angle less than 45° are likely to show inter trochanteric extension.

Introduction: Achilles tendinopathy (AT) is the most common over use syndrome of the lower limb. One of the simple operations performed for this condition is “Multiple longitudinal tenotomies”. This can be performed by either percutaneous or open methods. We compared the outcome of percutaneous versus open method of multiple longitudinal tenotomies for this condition.

Methods and materials: It is a retrospective study of patients operated for AT in our hospital from 1997 to 2008. Total of 43 patients. Twenty had percutaneous and 23 had open tenotomies. All of them had a trial of non-operative treatment prior to surgery, in the form of analgesia, physiotherapy, heel inserts, and ultrasound therapy. Data was collected from patient records and by telephonic questionnaire of the patients. Data collected includes pre and postoperative pain scores on a scale of 0–10, duration of symptoms, patient satisfaction scores (0–10) and complications. This questionnaire also included limitation to walk, run, going up/down the stairs, work and sporting activities.

Results: In the percutaneous group the mean pre and postoperative pain scores were 8.79 and 2.07 (p value 0.000). In the open group the values were 8.65 and 1.75 (p value 0.000). The mean satisfaction scores in the percutaneous and open groups were 8.25 (range 3–10) and 8.14(range2–10) respectively. The patient satisfaction scores were not significantly different between the two groups (p value 0.942). In the percutaneous group there was one recurrence and in one patient there was no symptomatic relief. In the open group there were 2 superficial infections, which settled with antibiotics and a wound breakdown, which in addition required debridement and eventually healed by secondary intension.

Conclusions: Both percutaneous and open methods of longitudinal tenotomies resulted in significant symptomatic relief and good patient satisfaction scores. Although the outcomes of both groups were comparable the percutanous method has an added advantage of less complications and simplicity of the procedure.

Introduction: Isolated greater trochanter fractures gained clinical importance because of the possibility of their inter-trochanteric extension.

Aim: To assess whether the direction and the extent of the fracture measured on plain radiographs could be used to predict the inter-trochanteric extension.

Materials and Methods: We reviewed plain radiographs and MRI scans of 24 patients who sustained isolated greater trochanter fractures between year 2003 and 2006. We considered two parameters

extent of fracture in percentage along the intertrochanteric line

Both these parameters were measured on a plain anteroposterior radiograph. To measure the length of fracture we have drawn a straight line along the medial border of femoral shaft extending proximally in to the pelvis. Then we measured the distance between the most superior point of the fracture line on the lateral cortex and the midpoint of lesser trochanter on the first line. Then we measured the length of the fracture starting from the most superior point on the lateral cortex. We estimated the percentage of this fracture length in relation to line.

To estimate the angle, again we have drawn a straight line along the medial border of femoral shaft extending proximally in to the pelvis. We have drawn another line in the direction of fracture staring from most superior point of fracture on the lateral cortex joining the first line. We measured the angle between these two lines (Fig 2). We used our Hospital PACS system to measure the angles and the length of the fracture.

Results: Out of 24 isolated greater trochanteric fractures as diagnosed by plain radiographs, MRI scans revealed intertrochanteric extension in nine (37.5%). On the plain anteroposterior radiograph, the mean angle of the fracture in those with MRI proven intertrochanteric extension was 34º (range 20º–45º). In those with no intertrochanteric extension on MRI scan, the mean angle was 55º (Range 25º–125º). The mean percentage of length of fracture across the intertrochanteric line was 62% (47%–73%) and 40% (27%–62%) respectively. All the fractures with MRI proven intertrochanteric extension had a fracture angle of < 45º and the percentage of fracture length of > 40%. All the 15 fractures with fracture angle more than 45º did not show intertrochanteric extension on MRI scan

Conclusions: We conclude that those isolated greater trochanteric fractures, with fracture angle of more than 45 º are unlikely to have an intertrochanteric extension. These patients could be mobilised without further MRI scans. Those fractures which fulfil the plain radiographic criteria of extension of more than 40% and fracture angle between 20º–40º are likely to show inter trochanteric extension. These patients need further clinical assessment and MRI scans to confirm the intertrochanteric extension.

Introduction: Fracture classification systems help in communication, treatment planning, assessing prognosis and form standards to report treatment results. The ideal classification system should be reliable, reproducible, all-inclusive, mutually exclusive, logical and clinically useful. The aim of our study was to assess the inter observer reliability and intra observer variability for the AO, Schatzker and Hohl and Moore classification systems.

Materials and Methods: We randomly selected fifty sets of radiographs of tibial plateau fractures occurred between 2000 and 2005. Exclusion criteria: Only one available view, inadequate films. Four orthopaedic surgeons at various level of experience i.e. one senior senior house officer, two registrars and a trauma consultant classified the fractures. Radiographs were blinded and each time the radiographs were presented to the observers in a different order. Radiographs were viewed at two separate sittings 8 weeks apart. The data was analysed using kappa statistics through SPSS version 14. The Kappa co-efficients were interpreted according to Landis and Koch grading. (< 0.00=poor; 0.0–0.2=slight, 0.21–0.4=fair, 0.41–0.60=moderate, 0.61–0.8=substanti al,> 0.8=excellent)

Results: For the AO classification the mean kappa co-efficients for inter-observer and intra-observer reliability were 0.36 (0.33–0.39) and 0.83(0.61–1.00) respectively. For the Schatzker classification the mean kappa co-efficients for inter-observer and intra-observer reliability were 0.47(0.45–0.49) and 0.90(0.75–1.00) respectively. For the Hohl& Moore classification mean kappa values for inter-observer and intra-observer variability were 0.14 and 0.81(0.59–1.00) respectively. According to Landis and Koch grading, AO classification is fair in terms of interobserver reliability, the Schatzker classification is moderate and the Hohl& Moore is slight.

Conclusions: None of the three systems fulfils the criteria for an ideal classification system. However, the Schatzker classification system was found to be superior. The Hohl& Moore system was least reliable of all. Hence, we recommend usage of Schatzker classification system in tibial plateau fractures both in clinical practice and clinical studies until a superior classification system evolves.

Introduction- Proximal humeral fractures remain a challenging problem. Most authors agree that anatomical reduction and stable fixation are essential to allow early range of motion. A variety of techniques have been described such as threaded pins, tension band wiring, screws, nails, plates and primary prosthesis. Locking plates score over other implants by the virtue of providing greater angular stability and better biomechanical properties. The Aim of the Study is to evaluate the functional outcome of PHILOS plate Osteosynthesis of displaced proximal humeral fractures.

Materials and Methods- A retrospective study of 50 patients treated with PHILOS plating for the 2 part, 3part and 4 part proximal humeral fractures with a minimum follow up of 1 year. All the patients were assessed in clinic by Constant Murley and ASES scoring systems. X-ray evaluation was done for fracture healing, AVN, mal-union, non-union, collapse of head, screw penetration and impingement of plate.

Results- Total of 50 acute displaced fractures of proximal humerus treated with PHILOS plating between 2003–2005 were assessed. Mean age was 64 years (15–86) Male to female ratio was 12:38, dominant to non-dominant ratio was 32:18. According to Neer’s classification 16 fractures were 2 part, 24 fractures were 3 part and 10fractures were 4 part. The overall mean Constant score was 73.4(range20–100) and ASES score was 71.7(range 25–98). Under 60 years of age the mean Constant and ASES scores were 83.5 and 83, over 60 years of age scores were 63.1 and 60.4 respectively. The complications include two deep infections which needed excision arthroplasty, one malunion, one subacromial impingement which needed plate removal after fracture healing. No mechanical failure, no non-union, no ANV was noted.

Conclusions- PHILOS plate Osteosynthesis is a reliable method of treating complex proximal humeral fractures. It provides good mechanical stability and allows rapid mobilization with out compromising fracture healing.