The thalamus is the part of the calcaneus that supports the posterior articular facet and continues forward, becoming thinner towards the groove of the sinus tarsi. The main displacements after fracture depend on 1) a primary fracture line dividing the bone into anterior and posterior fragments, and 2) a semilunar fragment in the thalamic region. In the operation advised the sinus tarsi is exposed and the semilunar fragment is reduced by rotation in the opposite direction and is fixed to the medial fragment (the sustenaculum tali not being displaced) by a transverse Kirschner wire. The two main fragments are fixed by an antero-posterior wire. Plaster is applied and is retained for twelve weeks. Weight-bearing is not permitted for the first four weeks. There were no major complications in fifty-eight operations. The anatomical results were good: restoration of the tuber-joint angle by reduction of the semilunar fragment was maintained. The functional results were very satisfactory: permanent disability was slight or mild

1. Some problems in the early diagnosis and management of congenital dislocation are discussed. 2. In a well-staffed maternity unit one dislocation completely escaped early detection in every 8,000 births over the period 1962 to 1968 inclusive. 3. The complications of early treatment on a Malmö splint are initial failure to obtain reduction, failure to maintain reduction, deformity of the upper femoral epiphysis or metaphysis, and persistent anteversion of the femoral neck. 4. Arthrography suggests that failure of early splintage and deformity of the upper femur are due to attempted reduction in the presence of an inverted limbus. 5. A trial method of treatment of frank displacement in the first year of life has been carried out by combining excision of the inverted limbus with a period in a frog position plaster to correct anteversion. This method avoided changes in the upper femur but failed to correct anteversion in four out of eighteen cases

1. Sixty-eight crush fractures of the articular surface of the lateral tibial condyle have been analysed. 2. Follow-up examination at a minimum of three years after injury was carried out in all cases. 3. The only factors which appeared to influence the results were the extent of the original depression, and if this was severe, the degree of restoration obtained by the treatment. Prolonged plaster fixation was avoided. 4. At review, no patient complained of symptoms which were attributable to damage to ligaments or menisci and no patient had symptoms of late onset. 5. The results suggest that there is nothing to be gained by open reduction if the lateral condyle is depressed by less than 10 millimetres, as conservative treatment gives good results. If the depression is more severe, however, a good result can only be assured if the articular surface is successfully reconstituted, but this is sometimes difficult to achieve. It is not possible to reconstitute the surface by non-operative means

1. The bad reputation of fractures of the scaphoid bone is based on a) past disasters caused by inadequate splintage and premature resort to operation; and b) selection of disabling cases for publication. 2. The results obtained in five series comprising over 1,000 fractures suggest that 95 per cent of adequately studied fractures less than a month old unite if properly treated. 3. Sixty cases of established non-union have provided evidence that disability is almost always the result of further injury and that the disability is usually relieved by a short time in plaster. 4. There is no evidence to support the widely held beliefs that a) union by bone can occur only if the fracture is immobilised throughout the process; and b) union after prolonged immobilisation is due to the immobilisation. 5. A policy of treating the wrist and not merely its radiological appearances is advocated

We have reviewed the outcome of 134 hips in 96 children with Graf type-III or type-IV dysplasia of the hip on ultrasound examination. We treated 28 affected hips in 22 children with the Craig splint, 43 hips in 30 children with the Pavlik harness, and 26 hips in 16 children with the von Rosen splint. A total of 37 affected hips in 28 children was not splinted. All children were less than three months of age at referral. Those treated with the von Rosen splint had a significantly better ultrasound appearance at 12 to 20 weeks of age and fewer radiological abnormalities than those not splinted or treated with the Pavlik harness. In the von Rosen group no hip required further treatment with an abduction plaster or operation compared with ten in the Pavlik harness group, three in the Craig splint group and eight in the group without splintage. Our results suggest that the von Rosen splint is more likely to improve the outcome of neonatal dysplasia of the hip and a definitive, large-scale randomised trial is therefore indicated

The capacity for physiotherapy to improve the outcome after fracture of the distal radius is unproven. We carried out a randomised controlled trial on 96 patients, comparing conventional physiotherapy with a regime of home exercises. The function of the upper limb was assessed at the time of removal of the plaster cast and at three and six months after injury. Factors which may predict poor outcome in these patients were sought. Grip strength and hand function did not significantly differ between the two groups. Flexion and extension of the wrist were the only movements to improve with physiotherapy at six months (p = 0.001). Predictors of poor functional outcome were malunion and impaired function before the fracture. These patients presented with pain, decreased rotation of the forearm and low functional scores at six weeks. Our study has shown that home exercises are adequate rehabilitation after uncomplicated fracture of the distal radius, and routine referral for a course of physiotherapy should be discouraged. The role of physiotherapy in patients at high risk of a poor outcome requires further investigation

We present the results of a prospective trial of osteotomy of the metatarsal neck for hallux valgus in 31 feet of 23 women, using a new stapling device with no plaster splintage and early weight-bearing. Surgery was performed for pain (29 feet) and difficulty with footwear (nine feet). The average time for return to light work was 3.3 weeks, and to full work 8.3 weeks after operation. Seventeen patients had full recovery within three months and 21 of the 23 patients had complete relief of pain. Shoes were more comfortable in 17 feet and 9 patients could wear narrower shoes. Only two patients were unsatisfied with the appearance of the foot. All the osteotomies united, and the average hallux valgus angle was improved on radiographs from 35 degrees to 23 degrees. The mean first metatarsal angle was reduced from 16 degrees to 11 degrees. The new technique allows more accurate surgery and easier postoperative management

The factors during and after operation which influence the development of a solid and stable posterior spinal fusion have been evaluated in 406 patients with scoliosis. The patients were managed in three different ways and all pseudarthroses were accurately detected by exploring the spines six months after the attempted fusion. The incidence of pseudarthroses was significantly lowered from 25 per cent in Group I to 3.8 per cent in Group III by the application of Harrington instrumentation and the use of large amounts of autogenous iliac bone grafts in addition to an interfacetal fusion. Early mobilisation 7 to 10 days after operation and a return to normal activities in a well-moulded underarm plaster jacket did not have a detrimental effect on the development of the fusion or the early maintenance of correction. Those spines with supplementary bone grafts stabilised more rapidly and had better maintenance of correction with only minimal loss after removal of all external support at 10 months

We studied prospectively 30 patients who had a Mitchell’s osteotomy secured by either a suture followed by immobilisation in a plaster boot for six weeks, or by a cortical screw with early mobilisation. The mean time for return to social activities after fixation by a screw was 2.9 weeks and to work 4.9 weeks, which was significantly earlier than those who had stabilisation by a suture (5.7 and 8.7 weeks, respectively; p < 0.001). Use of a screw also produced a higher degree of patient satisfaction at six weeks, and an earlier return to wearing normal footwear. The improvement in forefoot scores was significantly greater after fixation by a screw at six weeks (p = 0.036) and three months (p = 0.024). At one year, two screws had been removed because of pain at the site of the screw head. Internal fixation of Mitchell’s osteotomy by a screw allows the safe early mobilisation of patients and reduces the time required for convalescence

Over 200 high-velocity missile injuries treated in a low-technology environment were audited under the aegis of the International Committee of the Red Cross Hospitals in Afghanistan and Northern Kenya. Femoral fractures were treated either by traction or external fixation using a uniaxial frame. The results showed that patients treated by external fixation remained in hospital longer than those treated on traction. The positional outcome was identical in both groups. In tibial fractures the external fixator was only of extra benefit in those of the lower third when compared with simple plaster slabs unless more complex procedures such as flaps or vascular repair were to be performed. In complex humeral fractures, external fixation resulted in long stays in hospital and a large number of interventions when compared with simple treatment in a sling. We conclude therefore that in an environment where facilities are limited and surgeons have only general experience very careful initial wound excision is the most important factor determining outcome. The application of complex holding techniques was generally inappropriate

We describe a new technique for examining the infant hip using ultrasound. Both hips are imaged simultaneously via an anterior approach. The examination can be done with the hip either extended or flexed and abducted. The method has three advantages: 1) since both hips are imaged simultaneously, lines can be drawn to assist in determining the relationship between the femoral head and the pelvis; 2) proximal, anteroposterior and lateral displacement of the femoral head can all be demonstrated; 3) the method is applicable to the infant in a harness or a plaster cast to demonstrate maintenance of reduction of a dislocated hip. The usual direction of dislocation of the femoral head was anterior and lateral. Proximal migration was also observed in cases with more severe dislocation. In flexion, the dislocated head of the femur often moved posterior to the acetabulum. Of 1276 hips, in 638 infants aged from three weeks to one year, 49 showed congenital dislocation. The accuracy of our anterior method of sonography in diagnosing congenital dislocation of the hip compared well with the method of Graf and with radiography

This is a study of children who first attended as infants with either progressive infantile idiopathic scoliosis or congenital scoliosis. All had a pattern of scoliosis in which early and damaging deterioration is inevitable. The infants were treated from before the age of three, initially by plaster casts and then a Milwaukee brace, followed at about the age of ten by correction and fusion. The cases were then observed to the end of growth or near that point. In the main study there were twelve cases, six of progressive infantile idiopathic scoliosis and six of congenital scoliosis, which were followed through this long period. Only one of the twelve had a curve worse at the end of growth compared with the initial radiograph as an infant; this one curve had increased only 16 degrees in almost as many years. Although small, the series does show that it is nearly always possible to control even the most serious scoliosis in an infant, if it is tackled early and unremittingly. There are supportive studies of children who have partially completed this regime, and interim results in a newer group of children with spina bifida and scoliosis

1. Fifty dislocations and fracture-dislocations of the pelvis have been reviewed. 2. Complications were unusual. Two patients with rupture of the bladder died; two with rupture of the urethra survived. Of eight patients with retroperitoneal haemorrhage four died; the treatment advised is controlled blood transfusion maintaining a blood-pressure of not more than 100 mm. 3. Two types of pelvic disruption should be distinguished: 1) pubic injury with sacro-iliac dislocation; 2) pubic injury with fracture near the sacro-iliac joint. The first is twice as common as the second. 4. In each type, displacement is maintained by extension of the hip and outward roll of the limb. This may be controlled by the Watson-Jones plaster method but the pelvic sling technique is preferred and was used in all cases in this series. 5. The prognosis in fracture-dislocations is very good; nearly all patients went back to heavy work. 6. The prognosis in sacro-iliac dislocations is not so good; only half the patients went back to heavy work and there was often persistent sacro-iliac pain. Sacro-iliac arthrodesis is advised in those cases

1. After limb injuries with loss of skin and subcutaneous tissue, full-thickness skin flaps afford the most satisfactory cover. It is particularly important to replace unstable and scarred skin before attempting bone reconstruction and similar operations. 2. In the leg and foot, full-thickness skin cover is conveniently obtained by the cross-leg flap technique. The blood supply of such flaps is considered and the technique of operation is described. Free excision of avascular scar tissue is essential. 3. "Delayed transfer" of the flap is advisable unless conditions are favourable; two methods are considered. 4. Immobilisation in plaster is the most satisfactory method of fixation of the limbs after attachment of the flap. Muscle exercises are performed throughout the period of treatment in order to minimise joint stiffness and shorten convalescence. 5. The cross-leg flap technique should not usually be used in children, young women, or the aged and mentally infirm. Contra-indications include arthritis of the knee and hip joints because there is danger of joint stiffness. 6. Vascular complications of cross-leg skin grafting are discussed

MicroRNAs (miRNAs) are a class of small non-coding RNAs that have emerged as potential predictive, prognostic, and therapeutic biomarkers, relevant to many pathophysiological conditions including limb immobilization, osteoarthritis, sarcopenia, and cachexia. Impaired musculoskeletal homeostasis leads to distinct muscle atrophies. Understanding miRNA involvement in the molecular mechanisms underpinning conditions such as muscle wasting may be critical to developing new strategies to improve patient management. MicroRNAs are powerful post-transcriptional regulators of gene expression in muscle and, importantly, are also detectable in the circulation. MicroRNAs are established modulators of muscle satellite stem cell activation, proliferation, and differentiation, however, there have been limited human studies that investigate miRNAs in muscle wasting. This narrative review summarizes the current knowledge as to the role of miRNAs in the skeletal muscle differentiation and atrophy, synthesizing the findings of published data.

Cite this article: Bone Joint Res 2020;9(11):798–807.

Between 1988 and 1995, we studied 91 club feet from a series of 120 recalcitrant feet in 86 patients requiring surgical treatment. There were 48 boys and 20 girls. The mean age at operation was 8.9 months. Surgery consisted of an initial plantar medial release followed two weeks later by a posterolateral release. This strategy was adopted specifically to address the problems of wound healing associated with single-stage surgery and to ascertain the rate of relapse after a two-stage procedure. Immobilisation in plaster was used for three months followed by night splintage. The feet were classified preoperatively and prospectively into four grades according to the system suggested by Dimeglio et al. Grade-1 feet were postural and did not require surgery. All wounds were closed primarily. One superficial wound infection occurred in a grade-4 foot and there were no cases of wound breakdown. The rate of relapse was 20.4% in grade-3 and 65.4% in grade-4 feet. Two-stage surgery for the treatment of club foot seems to be effective in the reduction of wound problems but does not appear to give significantly better results in terms of relapse when performed for more severe deformities

1. The method of treatment of a mallet finger deformity by immobilisation in a plaster in the position of hyperextension of the distal interphalangeal joint and flexion of the proximal interphalangeal joint is, on the whole, unsatisfactory because the splint is difficult to apply, it may need to be changed frequently, and it is sometimes complicated by pressure sores. 2. In many cases the deformity is still present after six weeks of adequate immobilisation, but gradual improvement from the contraction of fibrous tissue occurs for up to six months. Therefore an assessment of the results of any method of treatment should be made only after an interval of at least six months. 3. The subjective end results at the end of six months are satisfactory whether or not there has been efficient immobilisation in hyperextension. Few patients have any disability and only rarely is this sufficient to cause interference with normal activities. A high proportion of patients show slight persistent deformity and limitation of movement, and this is seemingly uninfluenced appreciably by the type or duration of treatment. 4. The only treatment necessary for most cases of mallet finger is the application of elastic adhesive strapping or a straight spatula splint in order to relieve the initial discomfort from the injury

We treated 50 patients with fractures of the waist of the scaphoid in a below-elbow plaster cast for up to 13 weeks. Displacement of the fragments was assessed independently by two observers using MRI and radiographs performed within two weeks of injury. The MRI assessments showed that only the measurement of sagittal translation of the fragments and an overall assessment of displacement had satisfactory inter- and intra-observer reproducibility and revealed that nine of the 50 fractures were displaced. Only three of the 49 fractures with adequate follow-up failed to unite, and all were displaced with more than 1 mm of translation in the sagittal plane. If the MRI assessment of displacement of the fracture was used as the measurement of choice, assessment of displacement on the initial scaphoid series of radiographs showed a sensitivity of between 33% and 47% and a positive predictive value of between 27% and 86%. Neither observer was able correctly to identify more than 33% to 47% of the displaced fractures from the plain radiographs. Although the overall assessment of displacement and gapping and translation in the coronal plane on the plain radiographs influenced the rate of union, none of these parameters identified all three fractures which failed to unite. We conclude that the assessment of displacement of scaphoid fractures on MRI can probably be used to assess the likelihood of union although the small number of nonunions limits the power of the study. In contrast, the assessment of displacement on routine radiography is inaccurate and of less value in predicting union

Aims

The treatment of tibial aplasia is controversial. Amputation represents the gold standard with good functional results, but is frequently refused by the families. In these patients, treatment with reconstructive limb salvage can be considered. Due to the complexity of the deformity, this remains challenging and should be staged. The present study evaluated the role of femoro-pedal distraction using a circular external fixator in reconstructive treatment of tibial aplasia. The purpose of femoro-pedal distraction is to realign the limb and achieve soft tissue lengthening to allow subsequent reconstructive surgery.