Purpose: To compare the incidence of avascular necrosis, and radiological outcomes between groups treated by closed reduction, open reduction, and open reduction + femoral shortening, under the care of a single surgeon, with open reductions performed through an anterior approach, uninfluenced by the appearance of the ossific nucleus.

Methods: Between Sept 1991 and Dec 2003 we retrospectively studied 66 patients (3 bilateral; 10 males, 53 females) who had undergone reduction under anaesthesia. Of these 34 hips were reduced closed with adductor release (average 0.7 yrs, range 0.2–1.7), 11 reduced open (average age 1.0; 0.4–3.3) and 24 reduced open with femoral shortening (average age 2.4; 0.9–7.8).

Follow up radiographs were graded for the presence of AVN by the Bucholz and Ogden method. Radiological outcome was graded by the Severin score. Average follow up was up to the age of 6.6 years (SD 2.9) for the closed reduction group, open reduction group 8.0 (SD 3.6) and femoral shortening group 9.0 (SD 3.9)

Results:

AVN scores

Closed Reduction (n=34) : Grade 1 : 5.

Conclusions: The group with the highest incidence of AVN & worse Severin grades was the group (average age-1.0) who had open reduction without femoral shortening. The open reduction & shortening group had a higher proportion of good radiological results despite treatment being given at a older age. Concentric closed reduction, where possible, gave the best results.

Significance: Any child presenting with DDH at walking age (over 1) who requires open reduction should also have a femoral shortening. This gives the best chance of avoiding high grade AVN and achieving a good radiological result. Results might improve if open reductions without shortening were discontinued.

Introduction: Road side accidents resulting in polytrauma with an associated fracture of femur is a common pattern of injury in asian countries. We hypothesised that the use of unreamed nailing in the management of such fractures has better outcome than reamed nailing.

Material and Methods: We retrospectively reviewed 116 cases of polytrauma with associated fracture of shaft of femur admitted in our tertiary teaching hospital in North India bewteen Jan 1996 to Dec 2001. The patients were initially resuscitated according to the advanced trauma life support protocol. They were randomally managed by interlocking nail using reamed (n=48) and unreamed (n=68) technique after being haemodynamically stabilized. Five intraoperative parameters were recorded – the surgical time, fluoroscopy time, the intraoperative blood loss, intraoperative oxygen saturation, and any intraoperative complications. The patients were assessed postoperatively for ninety six hours for features of adult respiratory distress syndrome. All patients were clinically and radiologically assessed at 6 weekly intervals till union. The follow-up reassessments were performed by a single surgeon (AG).

Results: There were 80 males, 30 females (6 were bilateral), with an average age of 26 years (range 19 to 64 years). The fractures were closed in 74 and open in 42 (Gustillo Grade 1;n=28, Grade 2;n=9, Grade 3;n=5). 48 were managed by reamed interlock nailing (Group 1) and 68 by unreamed interlock nailing (Group 2). 58 patients had an associated blunt trauma chest, 36 had blunt trauma abdomen, 18 had an associated head injury and 12 had spine injuries. The average surgical time for Group 1 was 118 minutes and for Group 2 was 94 minutes (p=0.014). The average fluorscopy time for Group 1 was 4.30 minutes and for Group 2 was 4.06 minutes. The average intra-operative blood loss for Group 1 was 254 millilitres and for Group 2 was 202 millilitres. The average intraoperative oxygen saturation fall as measured at the time of reaming and nail insertion was 2% in Group 1 and 6% in Group 2. The intraoperative complications were 11 (22.91%) in Group 1 and 18 (26.47%) in Group 2. The features of ARDS were observed in 6 patients in Group 1 (12.5%) and 4 patients in Group 2 (5.88%). The average union time was 25 weeks in Group 1 as compared to 19.4 weeks in Group 2 (p=0.012). The reoperation rate was 6.25% in Group 1 and 11.76% in Group 2.

Discussion: The unreamed interlock nailing is the definitive management of fractures of femur in patients with polytrauma or blunt trauma chest as it requires lesser operative time (and thus exposing the patient to shorter period of anaesthesia), lesser blood loss and lesser fluoroscopy exposure. The incidence of ARDS is significantly lower with unreamed nailing in polytrauma patients. However the union time was significantly longer in unreamed nailing as compared to reamed nailing.

Aim: Complex radial head fractures are often underestimated in their complexity with consequent poor outcomes.

Method: We retrospectively reviewed thirty-two Mason 2 and 3 radial head fractures treated surgically with open reduction and internal fixation by generalist orthopaedic surgeons and trainees over a four-year period. They were clinically, radiologically and functionally assessed for this study. Functional assessment was done using the Mayo elbow performance score (MEPS).

Results: There were fourteen Mason 2 and eighteen Mason 3 radial head fractures. The Mason 2 were fixed by K-wires (n=2), Herbert TM screws (n=5), Acutrack TM screws (n=3), and T-plates (n = 4). The Mason 3 were fixed by Herbert TM screws (n=6), Acutrack TM screws (n=4) and T plates.

Average follow up was 47 months (range 22–65 months). The arc of elbow motion was 1040 (range 680_1400), with an average extension deficit of 230 (range 00–500) and an average flexion deficit of 200 (range 100–400). The average arc of forearm rotation was 1300 (range 00–1400), with an average supination of 660 (range 00–750), and an average pronation of 680 (range 00–800 ). The complications (N=17/32) included superficial skin infection (n=2), transient posterior interosseous nerve palsy (n=4), broken T -plate (n=1), intra-articular placement of a screw (n=1), loose and backed out screw (n=1), non-, union of radial head (n=2). Fixed flexion deformity if elbow (n=4) and mild elbow in stability (n=2). Second surgery was preformed in 18.7 % (n=6/32)(radial head replacement n=1, anterior capsulectomy n=4 and removal of screw n=1).

Conclusion: Radial head trauma surgery is an underestimated source of poor clinical outcomes. Complex radial head fractures should be clinically and radiologically evaluated with the knowledge that they are difficult to accurately and comprehensively assess. The treatment of such fractures may warrant management by a sub-specialist, although this latter conclusion has not been corroborated to date.