We carried out a randomised, controlled trial in 157 patients who had isolated severe Gustilo type-IIIa and type-IIIb fractures of the metaphysis or diaphysis of the leg to determine the prevalence of vascular injuries and the role of vascular repair. All patients had stable vital signs and clinically adequate circulation in their legs before operation. In a control group of 64 patients we performed conventional surgery with systematic debridement and primary stabilisation of the fractures. In the trial group of 93 patients the major vessels and nerves adjoining the compound fracture were routinely explored and repaired when necessary after the initial procedure. Two of the 28 control patients (7.1%) with type-IIIb compound fractures had signs of inadequate circulation after the first operation. Both had major vascular injuries which were demonstrated at a second procedure. In the trial group, major vascular injuries were found in two of 54 patients (3.7%) with type-IIIa and 11 of 39 patients (28.2%) with type-IIIb compound fractures. Compared with the control group the trial group showed improved results at both the immediate and long-term follow-up. Routine exploration and early repair of injured major vessels of the leg in severe compound fractures gave encouraging results

An analysis of 51 type III open tibial fractures treated by external skeletal fixation is presented. The fractures are subdivided according to the classification of Gustilo, Mendoza and Williams (1984) into types IIIa, IIIb and IIIc. The different prognoses of these fracture subtypes is examined. The use of the Hoffmann and Hughes external fixators in the management of type III open tibial fractures is presented and it is suggested that the prognosis is independent of the type of fixator used

Modern principles for the treatment of open fractures include stabilisation of the bone and management of the soft tissues. Wound debridement and irrigation is thought to be the mainstay in reducing the incidence of infection. Although numerous studies on animals and humans have focused on the type of irrigation performed, little is known of the factors which influence irrigation. This paper evaluates the evidence, particularly with regard to additives and the mode of delivery of irrigation fluid. Normal saline should be used and although many antiseptics and antibiotics have been employed, no consensus has been reached as to the ideal additive. Despite the advocates of high-pressure methods highlighting the improved dilutional ability of such techniques, the results are inconclusive and these irrigation systems are not without complications. New systems for debridement are currently being investigated, and an ideal method has yet to be determined

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted

There are a number of classification systems for intracapsular fractures of the proximal femur, but none has been shown to be practical with satisfactory reproducibility and accurate predictive value. We have investigated the AO classification and evaluated intra-and interobserver accuracy and its value in predicting treatment and outcome. We found it to have very poor intra- and interobserver reliability and to be of limited predictive use for the outcome of treatment. A simplified system in which the subdivisions were allocated to one of three groups of undisplaced, displaced and basal fractures was found to be of value. We conclude that this is the only division which is appropriate for these fractures and that the AO system for intracapsular fractures is too complicated and should not be used

We have investigated the anatomy of the proximal part of the ulna to assess its influence on the use of plates in the management of fractures at this site. We examined 54 specimens from cadavers. The mean varus angulation in the proximal third was 17.5° (11° to 23°) and the mean anterior deviation 4.5° (1° to 14°). These variations must be considered when applying plates to the dorsal surface of the ulna for Monteggia-type fractures. A pre-operative radiograph of the contralateral elbow may also be of value

The treatment of fractures of the proximal tibia is complex and makes great demands on the implants used. Our study aimed to identify what levels of primary stability could be achieved with various forms of osteosynthesis in the treatment of diaphyseal fractures of the proximal tibia. Pairs of human tibiae were investigated. An unstable fracture was simulated by creating a defect at the metaphyseal-diaphyseal junction. Six implants were tested in a uniaxial testing device (Instron) using the quasi-static and displacement-controlled modes and the force-displacement curve was recorded. The movements of each fragment and of the implant were recorded video-optically (MacReflex, Qualysis). Axial deviations were evaluated at 300 N. The results show that the nailing systems tolerated the highest forces. The lowest axial deviations in varus and valgus were also found for the nailing systems; the highest axial deviations were recorded for the buttress plate and the less invasive stabilising system (LISS). In terms of rotational displacement the LISS was better than the buttress plate. In summary, it was found that higher loads were better tolerated by centrally placed load carriers than by eccentrically placed ones. In the case of the latter, it appears advantageous to use additive procedures for medial buttressing in the early phase

A total of 45 tibial shaft fractures, all conservatively treated and with union delayed for more than 16 but less than 32 weeks were entered in a double-blind multi-centre trial. The fractures were selected for their liability to delayed union by the presence of moderate or severe displacement, angulation or comminution or a compound lesion with moderate or severe injury to skin and soft tissues. Treatment was by plaster immobilisation in all, with active electromagnetic stimulation units in 20 patients and dummy control units in 25 patients for 12 weeks. Radiographs were assessed blindly and independently by a radiologist and an orthopaedic surgeon. Statistical analysis showed the treatment groups to be comparable except in their age distribution, but age was not found to affect the outcome and the effect of treatment was consistent for each age group. The radiologist's assessment of the active group showed radiological union in five fractures, progress to union in five but no progress to union in 10. In the control group there was union in one fracture and progress towards union in one but no progress in 23. Using Fisher's exact test, the results were very significantly in favour of the active group (p = 0.002). The orthopaedic surgeon's assessment showed union in nine fractures and absence of union in 11 fractures in the active group. There was union in three fractures and absence of union in 22 fractures in the control group. These results were also significantly in favour of the active group (p = 0.02). It was concluded that pulsed electromagnetic fields significantly influence healing in tibial fractures with delayed union

We report a case of fatal pulmonary embolism following a simple ankle fracture in a 17-year-old girl. The diagnosis was confirmed at post-mortem. The risk factors for deep venous thrombosis and pulmonary embolism and their significance in orthopaedic fracture management are discussed

We undertook a simultaneous prospective two-centre study to examine why patients with fractures of the proximal femur experience a delay in undergoing surgery. At centre 1, 23 of 105 patients (22%) suffered an avoidable delay, 18 (78%) because of a lack of theatre capacity while at centre 2, 71 of 130 patients (55%) had an avoidable delay, with 54 (76%) because of this cause. Miscellaneous reasons such as poor ward management, co-existing medical conditions, and lack of equipment were responsible for the remainder of the delays. Without a substantial increase in operating capacity for acute trauma, it will not be possible to comply with guidelines which recommend surgical treatment within 24 hours in elderly and vulnerable patients

1. Thirteen cases of fracture of the lateral process of the talus seen over a period of thirteen months are reported. 2. The mechanism of the injury would appear to be inversion strain of the foot with dorsiflexion of the ankle. 3. The diagnosis would no doubt be made more often if the possibility of this fracture were kept in mind, and if radiographs of good quality were taken with the ankle at 0 degree and the leg rotated inwards 10 to 20 degrees. 4. With regard to treatment, early operation appears to give good results, a single large fragment being reduced accurately and small or comminuted fragments being removed

We performed a retrospective study of the factors affecting the outcome of Weber type-C ankle fractures in 43 patients reviewed at two to nine years after injury. We determined the functional result in relation to the use of a diastasis screw, the accuracy of reduction, the presence of tibiotalar dislocation, and of injury to the medial side of the ankle by medial malleolar fracture or deltoid ligament rupture. We assessed the use of a diastasis screw as appropriate or inappropriate on the basis of an anatomical study performed by Boden et al (1989). The diastasis screw was used unnecessarily in 19 of the 31 patients so treated, but this did not appear to affect the final functional result. The worse functional results were in ankles dislocated at the initial injury, and in those with medial malleolar fractures as opposed to those with deltoid ligament ruptures. The best results were after accurate reduction of the fibula and the syndesmosis, and greater increase in the width of the syndesmosis was associated with a worse result. Our results suggest that an increase of more than 1.5 mm in syndesmosis width is unacceptable. We recommend that when the deltoid ligament is ruptured, a diastasis screw should be used if the fibular fracture is more than 3.5 cm above the top of the syndesmosis. When a medial malleolar fracture has been rigidly repaired a diastasis screw is required if the fibular fracture is more than 15 cm above the syndesmosis

We have reviewed our experience of four iatrogenic femoral neck fractures in 315 consecutive closed intramedullary nailings with the AO/ASIF universal femoral nail. The average neck-shaft angle in the bones that fractured was 139.3 degrees +/- 1.2 degrees SD (136 to 141); in the whole series the average neck-shaft angle was 125.3 degrees +/- 8.6 degrees and only 11 had angles of more than 135 degrees. The upper ends of the nails in the four which fractured were 17 mm, 5 mm, 3 mm, and 1 mm below the tip of the greater trochanter. In the seven patients with neck-shaft angles greater than 135 degrees but with no fracture, none of the nails had been inserted beyond the tip of the greater trochanter. We nailed six cadaver femora to simulate the forces produced by intramedullary nailing. Despite deep insertion, only one of the six sustained a neck fracture. This specimen had a radiographic neck-shaft angle of 140 degrees against an average of 127.3 degrees +/- 4.0 degrees for the other five. We believe that the medial prong of the AO insertion jig, with its medial overhang of 2 to 3 mm, may impinge on the superior aspect of a valgus femoral neck during final impaction, causing a neck fracture. This may be avoided by leaving the end of the nail above the tip of the trochanter in such cases

A consecutive series of 150 patients with clavicular fractures is presented. In 81% detailed information regarding the mechanism of the injury was available and, of these, 94% had fractured their clavicle from a direct blow on the shoulder; only 6% had fallen on the outstretched hand. This finding, at variance with commonly held views regarding the mechanism of this injury, was further investigated by biomechanical analysis of the forces involved in clavicular fractures. The biomechanical model supported the clinical findings

Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (> 95%). The arthrodesis failed because of avascular necrosis of the talus in only three patients (17.6%), who developed grossly unstable, ulcerated hindfeet, and required below-knee amputation

It has been shown that raised intracapsular pressure causes avascular necrosis of the femoral head in experimental animals, but the relevance of this to clinical fractures of the femoral neck is controversial. We have studied 19 patients with intracapsular fractures of the femoral neck by pressure measurement and by ultrasonography to demonstrate capsular distension. The intra-articular pressure in Garden Grade I and II fractures averaged 66.4 mmHg with a maximum of 145 mmHg. In 10 Garden Grade III and IV fractures the average pressure was 28 mmHg with a maximum of 65 mmHg. Most of the recorded intracapsular pressures were high enough to have caused possible vascular embarrassment, and it is suggested that early decompression of the haemarthrosis should be considered

Type-I fractures of the lateral tibial plateau were simulated by osteotomy in 18 pairs of unembalmed cadaver tibiae. One fracture of each pair was fixed with two lag screws whereas the contralateral site was stabilised with three lag screws, or two lag screws plus an antiglide screw. The lateral plateau was displaced downwards using a servohydraulic materials testing machine and the resulting force and articular surface gap were recorded. Yield load was defined as the maximum load needed to create a 2.0 mm articular offset at the fracture line. The yield loads of the three-lag-screw (307 ± 240 N) and antiglide constructs (342 ± 249 N) were not significantly different from their two-screw control constructs (231 ± 227 and 289 ± 245 N, respectively). We concluded that adding an antiglide screw or a third lag screw did not provide any biomechanical advantage in stabilising these fractures

A clinical, radiological and histopathological study of femoral heads from 125 patients with fracture of the neck of the femur and from 30 cadavers was carried out to identify various risk factors. The findings showed that the Singh index was unreliable as a radiological indicator of the bone content of the femoral heads; that the bone content of the femoral head in patients sustaining a fracture of the femoral neck did not differ from that of the controls; that osteomalacia was not found in any of the heads examined; and that the distribution of trabecular microfractures did not support the hypothesis that fracture of the neck was the result of progressive fatigue. It was concluded that the single most important factor leading to fracture in this Australian population was injury caused by falls and that such injury was frequently associated with other disease processes

Fifty-three ununited fractures with a median time since injury of 28 months were treated by electrical stimulation using pulsing electromagnetic fields. Union was achieved in 38 cases (71.7 per cent) in a median time of six months. For ununited fractures of the tibia the success rate was higher at 86.7 per cent. Previous or active sepsis, the presence of plates or nails, the age of the patient or the time since the injury did not affect the results. Analysis of the failures suggests that inadequate immobilisation, a fracture gap of more than five millimetres or the presence of a screw in the fracture gap was responsible. In four patients no cause of failure could be determined

Sixteen consecutive patients with tibial plateau fractures were investigated by standard radiography, biplanar tomography and computerised axial tomograms (CT scans). It was found that CT scanning proved most helpful for classifying the type of fracture, for evaluating the degree of comminution, and for measuring displacement. Moreover, because a single position was maintained throughout the investigation, the patients felt less discomfort than during other assessment procedures. For these reasons CT scanning is recommended for evaluating this type of fracture