1. A case of femoral artery occlusion after fracture of the femur occurring several days after internal fixation with a medullary nail is described. 2. Arterial reconstruction was undertaken seventeen days after the internal fixation, twenty-seven days after the injury, with restoration of flow and recovery of the limb

We have studied the effect of shortening of the femoral neck and varus collapse on the functional capacity and quality of life of patients who had undergone fixation of an isolated intracapsular fracture of the hip with cancellous screws. After screening 660 patients at four university medical centres, 70 patients with a mean age of 71 years (20 to 90) met the inclusion criteria. Overall, 66% (46 of 70) of the fractures healed with > 5 mm of shortening and 39% (27 of 70) with > 5° of varus. Patients with severe shortening of the femoral neck had significantly lower short form-36 questionnaire (SF-36) physical functioning scores (no/mild (< 5 mm) vs severe shortening (> 10 mm); 74 vs 42 points, p < 0.001). A similar effect was noted with moderate shortening, suggesting a gradient effect (no/mild (< 5 mm) vs moderate shortening (5 to 10 mm); 74 vs 53 points, p = 0.011). Varus collapse correlated moderately with the occurrence of shortening (r = 0.66, p < 0.001). Shortening also resulted in a significantly lower EuroQol questionnaire (EQ5D) index scores (p = 0.05). In a regression analysis shortening of the femoral neck was the only significant variable predictive of a low SF-36 physical functioning score (p < 0.001)

Cadaveric experiments in 10 knees were used to study the strength of two methods of internal fixation for a fractured patella. A modified AO tension band technique was compared with the combination of cerclage wiring and a tension band used at Pyrford. The repairs were stressed to failure; the combination of cerclage and tension band wiring proved to be significantly stronger and is recommended

We have reviewed 34 children who had been treated by open reduction through a medial incision and transarticular pinning for a severely displaced supracondylar fracture of the humerus. Follow-up ranging from nine months to 20 years showed that 27 of 34 elbows (79%) had excellent or good results, with satisfactory resolution of neurovascular problems and no complications due to the method of treatment

The development of genu valgum in a child after a fracture of the upper metaphysis of the tibia with a medial gap is due to the interposition of a flap of fibrous tissue consisting of pes anserinus and periosteum avulsed from the lower fragment. The ensuing biomechanical disturbance induces bowing of the shaft and asymmetrical growth at both ends of the bone. Four cases of established deformity are reported, together with two cases of fresh fracture successfully treated by surgical clearance of the fibrous tissue from the gap

We randomised 50 patients with ankle fractures of Weber types B and C and a ruptured deltoid ligament treated by open reduction and internal fixation to two treatment groups to examine the influence of the repair of a ruptured deltoid ligament. No differences were found except for a longer duration of surgery in the repair group. Our findings suggest that a ruptured deltoid ligament can be left unexplored without any effect either on early mobilisation or on the long-term result

The clinical characteristics of sleeve fractures of the patella are described and the methods of treatment are reviewed. Attention is drawn to the fact that the diagnosis may be missed because the distal bony fragment may be so small as not to be detectable by radiography. This is important because a large fragment of articular cartilage also separates. The best result was obtained from reconstitution of the extensor apparatus by internal fixation of the patellar fracture with repair of the quadriceps expansion

We have compared the results and complications after closed and open reduction with internal fixation in young adults with displaced intracapsular fractures (Garden grades III and IV) of the neck of the femur. We also studied the risk factors which influenced nonunion and the development of avascular necrosis (AVN). A total of 102 patients aged between 15 and 50 years was randomised to receive either closed or open reduction. Both groups were compared for age, gender, time to surgery and posterior comminution as well as for union and complications. Using univariate and multivariate analysis the factors influencing nonunion and AVN were assessed. Of the 102 patients, 92 were available for review. There was no significant difference between the groups in terms of union (p = 0.93) and AVN at two years (p = 0.85). Posterior comminution, poor reduction and improper placement of the screws were the major factors contributing to nonunion. The overall incidence of AVN was 16.3% (15 of 92 patients) and it was not influenced by these factors. A delay of more than 48 hours before surgery did not influence the rate of union or the development of AVN when compared with operation within 48 hours of injury

We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients’ quality of life was estimated using the Short Form (SF) 12 score.

A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year.

Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union.

Cite this article: Bone Joint J 2015;97-B:997–1003.

1. Three cases of injury to the femoro-popliteal artery complicating fracture of the femoral shaft are described. 2. In all three cases restoration of peripheral circulation by arterial repair carried out within ten hours of injury succeeded in saving the limb from permanent damage. 3. The importance of adequate resuscitation, early diagnosis and early adequate surgical intervention is stressed. 4. The mechanism of injury and the clinical features of help in early diagnosis are discussed. 5. The place of internal fixation of the femoral fragments is discussed and its advantages and disadvantages are compared with those of treatment by skeletal or skin traction

We report the use of elastic stable intramedullary nailing (ESIN) in 123 fractures of the femoral shaft in children. Flexible rods are introduced through the distal metaphyseal area, and the aim is to develop bridging callus. Early weight-bearing is possible and is recommended. There was one case of bone infection and no delayed union. Complications were minimal, the most common being minor skin ulceration caused by the ends of the rods. A surprising feature was the low incidence of growth changes, with a mean lengthening of only 1.2 mm after an average follow-up of 22 months. Compared with conservative treatment, ESIN obviates the need for prolonged bed rest and is thus particularly advantageous for treating children

A protocol for the treatment of fractures of the middle third of the femur by the early application of a hip spica has been evaluated in 191 children aged 10 years or less. Children without other injuries spent only a few days in hospital for the application and later removal of the spica. At all ages, anterior angulation of less than 20 degrees and valgus angulation of less than 15 degrees were accepted at the one-week review. Acceptance of shortening varied with the age of the child and the stage of treatment, but was 10% or less of the femoral length at the time of spica removal. At late review leg-length discrepancy was rare and clinically insignificant. This method of treatment was simple and effective. It dramatically reduced the cost of care and freed a number of children's hospital beds

In a prospective randomised study, the Hansson pin technique for internal fixation of fractures of the femoral neck was compared with the Uppsala screw technique. The series consisted of 115 consecutive patients, 97 women and 18 men, with a mean age of 80 years. There were 56 patients treated with Hansson pins and 59 with Uppsala screws. After one year 22 patients had died, eight in the Hansson pin group and 14 in the Uppsala screw group (p = 0.28). Twenty-four complications had occurred, 18 in the Hansson pin group and six in the Uppsala screw group (p = 0.008). After exclusion of those with complications, the patients in the Hansson pin group had significantly more pain, less mobility, and a smaller proportion were living in their own homes

Thirty-one patients have been reviewed four and a half to thirteen years after total excision of the patella for fracture. This operation did not give the uniformly excellent results previously reported by some authors. The type of incision used was unimportant in the long term. Immobilisation in plaster-of-Paris for any period between one and eight weeks after operation had no adverse effect on the long-term results. There was no correlation between the amount of calcification or ectopic bone formation found in the patellar tendon and the degree of function or discomfort in the joint. There was no evidence that osteoarthritis is an inevitable sequel to patellectomy in man. Maximal recovery of knee function may take up to three years after patellectomy. In this series 22% of patients had excellent results, 39% good results and 39% poor results, according to defined criteria. The implications of these findings are discussed

Using a dynamic biomechanical model of malunion of the shoulder, we have determined the change in deltoid force required for abduction with various combinations of superior and posterior displacement of fractures of the greater tuberosity of the humerus. We tested eight fresh human cadaver shoulders in a dynamic shoulder-testing apparatus during cycles of glenohumeral abduction from 0° to 90°. The greater tuberosities were osteotomised and stabilised to represent malunion with combinations of superior and posterior displacements of 1 cm and less. The peak force was measured for each displacement in each specimen and statistically compared with values of no displacement using a repeated-measures analysis of variance. The abduction force was significantly increased by 16% (p = 0.006) and 27% (p = 0.0001) by superior displacements of 0.5 cm and 1 cm, respectively, while combined superior and posterior displacement of 1 cm gave an increase in force of 29% (p = 0.001). While treatment criteria for acceptable residual displacement of the greater tuberosity are widely used, there is little information on the direct biomechanical effects of displacement on shoulder mechanics. Although the results of conservative treatment are influenced by a number of factors, including associated injuries, rehabilitation and the pre-existing function of the shoulder, our data suggest that small amounts of residual displacement may alter the balance of forces required to elevate the arm at the glenohumeral joint

Dislocation is the most frequent serious complication following total hip replacement for subcapital femoral fracture. We report a prospective study, using matched groups, which compared the range of hip movement following hip replacement for arthritis and for fracture. The range of movement was significantly greater in the fracture group. We suggest that this is a predisposing factor for dislocation

External fixation of the first metacarpal was used in Rolando's fracture to counter the forces that cause shortening and articular incongruity. Satisfactory reduction was achieved and maintained in five patients

We describe a patient in whom an initially intact sciatic nerve became rapidly encased in heterotopic bone formed in the abductor compartment after reconstruction of the posterior wall of the acetabulum following fracture. Prompt excision and neural release followed by irradiation and administration of indometacin resulted in a full neurological recovery and no recurrence 27 months later

1. Five cases of greenstick fracture of the upper end of the ulna with dislocation of the radio-humeral joint are described. 2. Although the direction of angulation of the fracture and the corresponding displacement of the upper end of the radius may be lateral, medial or anterior, it is suggested that all five cases form a group in which the mechanism of injury is essentially the same. This mechanism is considered to be a fall on the outstretched hand with the forearm held in supination. 3. The complications of the injury are described