The treatment of femoral non-union, especially femoral exchanged nailing, has had mixed results in the recent literature. A review of the literature has suggested that exchanged nailing may be the gold standard for the treatment of femoral non-union. Is femoral exchange nailing an acceptable method of treatment of femoral fracture non-union? What is the evidence? In this systematic review we compare four different methods for the treatment of femoral non-union.

English speaking literature from 1970 to 2007 was searched using Pubmed^® and OVID™ databases and a manual reference search to reveal the original research, presenting the results of the treatment of femoral non-union with exchange nailing, plating, external fixation, and isolated bone grafting. Outcome parameters chosen were union rate and speed of union. The baseline variables chosen were age, number of surgeries, infection and the type of non-union.

In total, fifty six case series were identified containing 861 patients treated with exchange nailing (31 studies), 214 patients treated with plating (11 studies), 140 patients treated with external fixation (13 studies), 81 patients treated with bone grafting (4 studies). The average union rate was 89% for exchange nailing, 93% for plating and external fixation and 62% for bone grafting. Speed of union was 7.3 months for exchange nailing, 8.6 months for plating and 9.15 months for external fixation.

Study of baseline variables showed patients to be older in plating and external fixation groups (range 32–44 years, P< 0.001). There were more previous operations performed in the external fixation and plating groups (3 and 1.8 vs. 1.2, P< 0.001), significantly more infected non-unions in the plating and external fixation groups as compared to the exchange nailing group (40% vs. 11.5% P< 0.001) and significantly more atrophic non-unions in the plating and external fixation groups as compared to the exchange nailing group (85% vs. 65%, P< 0.001).

The literature suggests that femoral exchange nailing has an equivalent or poorer outcomes when compared to external fixation and plating in spite of having been performed in potentially less complex cases. Plating of non-union in the literature has a higher rate of associated bone grafting than femoral exchange nailing which may be responsible for marginally better union rate in the external fixation and plating groups.

Isolated bone grafting without revision of fixation does not provide adequate union rate and hence may be of questionable treatment value.

Proximal ulnar fractures may be difficult to treat and may result in chronic instability, non-union heterotrophic ossification, synostosis, stiffness and post-traumatic arthritis. The aim of this study is to study success of treatment in achieving stable reduction and early rehabilitation.

Between December 2003 and January 2007 fifty patients (fifty-one elbows) which had sustained 21.A3 and 21.C3 fractures were identified and retrospectively studied.

There were two broad groups of patients. Young males following high energy injuries (average age=38+/−16) and old females with osteoporotic fractures (average age=65+/−17). Twenty-two patients had associated monteggia and seven patients had trans-olacrenon dislocation. Twenty-three patients had radial sided injury. This included two capitelar fractures, nineteen radial head and neck fractures and one radial shaft fracture. Fortyfive patients were treated with plating and two patients were treated with tension band wiring. Five different plating techniques were used to stabilize the fractures.

Eighteen patients had incongruent reduction. Eighteen patients had complications of the treatment. There were seven cases of non-union, one case of loss of fixation, three cases of heterotrophic ossification, three cases of synostosis, one case of deep infection and five complications resulting from radial head fractures.

There was no relationship between loss of fixation and plating techniques. There was a direct relation between comminution and post fixation incongruence. Heterotrophic ossification was associated with comminution, radial head fracture, monteggia fracture-dislocation and non-union. Radio-ulnar synostosis was associated with comminution of the ulnar fracture.

In conclusion, the main predictor of poor outcome is the comminution of proximal ulnar fracture and the ability to achieve congruous fracture fixation.

We compare the management and outcome of two management stratergies for the perfused but pulseless hand following stabilisation of grade III supracondylar fractures in children.

For this study we looked at 15 patients treated in two centres (all treated by the senior author) between 1995 and 2004. The patients were designated to group I if the pulseless hand had been observed or group II if they underwent immediate exploration. Data collected included time to surgery, neurological deficit, time to return of pulse and subsequent symptoms of forearm claudication. All patients were seen at week 1,3 and followed for at least 6 months post surgery. Radiographs were reviewed to determine the adequacy of reduction of the fracture.

The mean age of patient was 3.8 years. Median time to surgery was 6 hours. 6 children had evidence of anterior interosseus nerve palsy. 12 cases were reduced anatomically, 3 had minimal fracture gap. Of the 8 patients in group I (observation) 2 had secondary exploration and one developed claudication symptoms. All had palpable radial pulse at 3 months.6 of the 7 patients in group II (exploration) were seen to have brachial artery tethering, 2 with median nerve entrapment. 5 of them had subsequent return of radial pulse within 24 hours.

Satisfactory radiological reductionof the fracture does-not exclude vessel or nerve entrapment. We would advocate early exploration of the artery if the pulse does not return within 24 hours.

Purpose: To identify the risk of metastases at the time of diagnosis in patients with soft tissue sarcomas and to estimate the cost effectiveness of identifying these.

Methods: A retrospective database review was used to identify all new soft tissue sarcoma patients referred to our unit and to find those identified to have metastases at diagnosis. Data of tumour size, depth, grade, age, type of tumours, Chest x-ray (CXR)/CT chest results were available in all patients. We estimated the efficacy of CXR in identifying metastases and the costs of various staging strategies.

Patients: 1170 with newly diagnosed STS in 7.5 years (1996–2004) were included.

Results: The incidence of metastases at diagnosis was 10% (116 patients), 8.25% (96 patients) had lung metastases and 20 had metastases elsewhere. The risk of having lung metastases at diagnosis was 11.8% in high grade tumours, 6.95% in intermediate grade and 1.2% in low grade tumours. The risk increased almost linearly with size at presentation and was higher in deep tumours and older patients. CXR alone detected 2/3 of all lung metastases. The positive predictive value of the CXR was 93.7%, the negative predictive value was 96.7%, the sensitivity 62.5% and the specificity 99.6%.

The accuracy was 96.9%. CT overestimated metastases in 4%.

Discussion: We recommend that all patients with a newly diagnosed STS should have a CXR and only those with an abnormality or who have large, deep high grade tumours should have a CT chest. This strategy will save £7500 per 100 new patients with STS and will detect 93% of all chest metastases, missing 1 patient with metastases per 166 patients.

Limb preserving surgery following segmental resection of the distal end of the radius and its articular surface presents a major challenge. We have studied 11 consecutive patients with aggressive tumours located in the distal radius that required segmental resection of the distal radius and its articular surface to evaluate the clinical and functional outcome of reconstruction of such defects.

The mean age at the time of diagnosis was 33 years (7–60). Follow up ranged from 12 to 306 months (median 56). Histological diagnosis was osteosarcoma in 4 patients, chondrosarcoma in 2, giant cell tumour in 5 and meta-static carcinoma in 1 patient. Four patients received chemotherapy. The length of excised bone ranged from 6 to 14cm. Reconstruction was performed with non-vascularised proximal fibula strut graft in 6 patients, ulna transposition in 3 and custom made endoprosthesis in 2 patients. The wrist joint was arthrodesed in 5 patients.

At the time of review 2 patients had died of disease, one was alive with disease and 8 were alive and free of disease. Non-union of the graft occurred in one patient, reflex sympathetic dystrophy in 2 and prosthetic dislocation in one. One patient had local recurrence. Four patients required further surgery including one patient who needed an amputation for severe reflex sympathetic dystrophy, one graft revision for non-union, one secondary wrist arthrodesis and one closed reduction of dislocated endoprosthesis. Patients without arthrodesis often had clinical and radiological signs of wrist instability. The majority of the patients achieved satisfactory function with little or no discomfort and ability to perform activities of daily living.

We conclude that limb salvage surgery is worthwhile in patients with resectable tumours of the distal radius.

Large benign lytic lesions of the proximal femur present a significant risk of pathological fractures. We report our experience of treating 9 consecutive patients with such defects treated with curettage and fibula strut grafting without supplementary osteosynthesis to evaluate the outcome of this type of reconstruction..

The mean age at the time of diagnosis was 13 years (8–21). Follow up ranged from 2 to 215 months (median 15). Histological diagnosis was fibrous dysplasia in 10 patients and unicameral cyst in 2. All the patients were at risk of pathological fracture. None of the patients developed pathological fracture after surgery and the lesions consolidated fully within one year. Local recurrence occurred in one patient (8%). Minor donor site complications occurred four patients.

All the patients were able to fully weight usually within 3 months of surgery.

At the time of review all but one patient were completely asymptomatic and fully weight bearing. The only symptomatic patient was the patient with local recurrence which has recently been treated.

We conclude that fibula strut graft is a good method of reconstruction of cystic defects in the proximal femut. It prevents pathological fracture, allows mechanical reinforcement of the lesion and delivers biological tissue allowing early consolidation of the defect.