High-energy injuries involving the proximal tibia sometimes result in significant soft tissue injuries that may create an incompetent knee extensor mechanism. Reconstruction of the extensor mechanism using the gastrocnemii has been previously described in those patients with tissue loss following either arthroplasty or tumour surgery. In 2009, a single cross-sectional study of eight patients described the technique after trauma, and their outcome at an average of 24 months. Use of a gastrocnemius rotational myoplasty has been described in the literature for six additional cases following trauma.

We present our indications, technique and 5-year results of a separate series of four patients in whom the extensor mechanism of the knee was rendered incompetent after direct tissue loss, or subsequent infection, secondary to trauma. In each case, after stabilisation of the periarticular fracture and control of infection, the medial gastrocnemius was employed both to reconstruct the patellar ligament, and to simultaneously restore soft tissue coverage.

Three out of 4 patients had excellent outcomes, have returned to their previous occupations and participate in regular sport. The overall mean scores were: Oxford knee Score (38.25), Knee Injury and Osteoarthritis Outcome Score (KOOS) (64.5) and Modified Cincinnati Score (68.25). Mean knee ROM was 5–97 degrees. Video for basic gait analysis was recorded.

For those traumatic injuries with the difficult combination of a soft tissue deficit and incompetence of the knee extensor mechanism, we believe the medial gastrocnemius rotational myoplasty provides an excellent reconstructive option to address both of these fundamental problems simultaneously.

Softcast is an attractive alternative to POP for unstable forearm fractures, providing a comfortable, water-resistant splint that can be removed without a plaster saw. Unreinforced Softcast has, however, only been recommended for buckle fractures. A laboratory study was undertaken to compare standardised POP, Softcast and reinforced Softcast splints at clinically relevant endpoints. The load at clinical failure of a 6-wrap Softcast forearm splint was 504N in bending, 202N in kinking, and 11Nm in torsion (equalling 30.4%, 26% and 42.2% of the equivalent values for a circumferential 4-wrap POP). Softcast was however stronger in all modes than a fibreglass-reinforced Softcast splint, such has been recommended for acute fractures. Furthermore, the load to failure in all modes exceeds that which can be exerted by body weight in many paediatric patients. Softcast demonstrated complete recovery of its original shape on unloading, and was 4% lighter than POP. A 6-wrap Softcast splint provides adequate mechanical stability and protection for paediatric patients up to 20kg, not engaged in high-risk activities. The primary risk is not of fracture angulation and loss of position, but temporary indentation of the splint, causing discomfort or pain. Considering its ease of removal, Softcast may be preferable for younger paediatric patients.