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The current study aims to determine the rate of surgical site infection, causal microorganism, and antibiotic sensitivity pattern in operated upper limb closed fractures at the Aga Khan University Hospital, Karachi. Cases presenting between June 2015 to October 2019, were selected from a single-centre, longitudinal, prospective orthopaedic trauma registry. Infection rate, causal microorganism, and antibiotic sensitivity pattern were determined up to six months after surgery. From among a total of 376 closed fractures, 12 encountered surgical site infection with some having late onset, giving an infection rate of 3% which is 1% higher than the international benchmark. Microorganism culture was performed on 5 (42%) patients out of which 2 (40%) were positive. Frequently used prophylactic antibiotics were first generation Cephalosporin and Co-amoxiclav in 9 (75%) patients, but all other patients required other antibiotic categories. Five patients required implant removal with antibiotic coverage. K-wire insertion required prolonged antibiotic treatment. Most of the cultures were negative in spite of the presence of infection.

Objective: To evaluate the feasibility and effectiveness of percutaneous cannulated screw fixation for the treatment of Day type Ⅱ pelvic crescent fracture., Methods: The clinical data of 14 patients with Day type Ⅱ pelvic crescent fractures underwent closed reduction and percutaneous cannulated screw fixation between January 2009 and July 2016 were retrospectively analysed. There were 9 males and 5 females, aged 17-65 years (mean, 38 years). The causes of injury included traffic accident in 8 cases, falling from height in 3 cases, bruise injury in 3 cases; all were closed fractures. According to Tile classification, there were 8 cases of type B, 6 cases of type C. There were 13 cases combined with fracture of the anterior pelvic ring, including 8 cases of superior and inferior ramus of pubis fracture, 1 case of superior ramus of pubis fracture with symphysis separation, and 4 cases of symphysis separation. The interval of injury and admission was 1- 72 hours (mean, 16 hours), and the interval of injury and operation was 3-8 days (mean, 5 days). After operation, the reduction of fracture was evaluated by the Matta evaluation criteria, the clinical function was assessed by Majeed function assessment., Results: The operation time was 35-95 minutes (mean, 55 minutes), cumulative C-arm fluoroscopy time was 3-8 minutes (mean, 5 minutes), no iatrogenic vascular injury and pelvic organ damage occurred. Postoperative X-ray films at 2 days indicated that 2 cases of vertical shift and 2 cases of mild rotation were not completely corrected. Postoperative CT examination at 3 days indicated that 2 pubic joint screws broke through the obturator bone cortex. None of the pubic ramus screws entered into the acetabulum, but a screw of superior pubic branch broke through the posterior cortical of superior pubic branch, a screw of posterior ilium column broke through the medial bone cortex of the ilium, and no clinical symptom was observed. One patient suffered from wound infection in the pubic symphysis, then healed after 2 weeks of wound drainage, the other wounds healed by first intention. According to Matta criterion for fracture reduction, the results were excellent in 9 cases, good in 4 cases, and fair in 1 case with an excellent and good rate of 92.9%. All patients were followed up 8-24 months (mean, 14 months). All fractures healed at 4 months and restored to the normal walking at 6 months after operation, 3 patients suffered from slight pain in the sacroiliac joints and slight claudication when they were tired or walked for a long time and unnecessary for special treatment. One patient felt pain in the back of the iliac spine when he was lying down. During the follow-up, no screw loosening or other internal fixation failure occurred. At last follow-up, according to Majeed functional evaluation criteria, the results were excellent in 7 cases, good in 5 cases, and fair in 2 cases with an excellent and good rate of 85.7%., Conclusion: The percutaneous cannulated screw fixation is a safe treatment for Day type Ⅱ pelvic crescent fracture, which has a reliable fixation and good effectiveness.

Objective: To investigate the risk factors of wound complications after closed calcaneal fracture operation using a lateral extensive L-shaped incision and to explore the effective interventions to reduce the complications after incision., Methods: Retrospective analysis of clinical data of 285 patients(315 calcaneal fractures) who underwent open reduction and internal fixation by using the lateral extensive L-shaped incision from January 2011 to January 2015. Eighteen factors which might cause the complications of calcaneal incision were compared by univariate analysis, and multiple Logistic regression analysis was performed for factors with statistically significances., Results: Twenty-nine patients(30 calcaneus) had wound complications among all the 285 patients(315 calcaneus) after surgery, including 9 patients with incision redness, swelling, oozing or nonunion;16 patients with skin necrosis or incision rupture, 3 patients with soft tissue superficial infection, and 2 patients with osteomyelitis. Univariate analysis showed that fall height( P =0.017), diabetes ( P =0.026), smoking( P =0.001), and operative time( P =0.003) were correlated with incision complications after surgery. Multivariate analysis showed that diabetes( P =0.029), smoking( P <0.001), and operative time( P =0.018) were risk factors for incision complications after operation., Conclusions: Preoperative smoking cessation, actively control of blood glucose and shortening the operation time by practicing can effectively reduce the incision complication after fracture surgery with the lateral extensive L-shaped incision., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Background: Calcaneal fractures are commonly seen and treated in the emergency department. There are subsets of calcaneal fractures that pose a high risk to the adjacent soft tissue of the heel and can result in full-thickness tissue necrosis., Objective: To identify which calcaneal fractures need to be managed within hours and triaged to the orthopedic team and which can be temporized in a neutral or plantarflexed ankle splint and seen in an outpatient setting., Discussion: Tongue-type calcaneal fractures and tuberosity fractures must be triaged appropriately within the first few hours of presentation to prevent skin compromise. This requires the emergency physician to understand the radiographic morphology of the fracture as well as the clinical signs of skin compromise. Communication with the orthopedic surgery service is essential and splinting in a specific manner is important to stabilize the soft tissue envelope., Conclusion: Recognizing the calcaneal injury pattern and implementing the correct treatment strategy is paramount to having successful patient outcomes. A delay or error in treatment can turn a closed fracture into an open fracture., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To evaluate the effectiveness of the modified intramedullary fixation with two Kirschner wires for extra-articular fracture of the proximal phalangeal base., Methods: Between June 2012 and November 2015, 18 cases (18 fingers) of fresh extra-articular fracture of the proximal phalangeal base were treated, including 16 males and 2 females with an average age of 31 years (range, 21-57 years). The causes included strike injury in 10 cases, fall injury in 4 cases, mechanical injury in 1 case, twist injury in 1 case, crush injury in 1 case, and cutting injury in 1 case. The injured fingers were little finger in 16 cases, ring finger in 1 case, and index finger in 1 case. Of the 18 cases, 17 had closed fractures and 1 had open fracture. X-ray film showed transverse fracture in 14 cases and transverse-oblique fracture in 4 cases. The time between injury and operation was 3 hours to 4 days (mean, 2 days). After anatomical reduction, two Kirschner wires were used for intramedullary fixation. Functional exercises were done at 2 days after operation. The Kirschner wires were removed at 4 weeks after operation., Results: All the wounds healed by first intention. There were no deformation, loosening or breakage of Kirschner wires, and pin tract infection. Postoperative X-ray films showed anatomical reduction of fracture in all cases; no re-displacement happened, and clinical healing was obtained at 4 weeks; bony union was obtained at 8 weeks. All patients were followed up 6-12 months with an average of 8 months. There was no pain in the metacarpophalangeal joint; the range of motion was (88.1±2.3)° at 3 months after operation, showing no significant difference when compared with normal side [(88.8±2.6)°] ( t =1.73, P =0.10). The finger flexion and extension were normal; according to the criteria of total active motion of finger, the results were excellent in all cases., Conclusions: The technique of modified intramedullary fixation with two Kirschner wires for extra-articular fractures of the proximal phalangeal base has the merits of convenient operation, little injury, reliable fixation,and excellent effectiveness. This technique is conducive to the recovery of hand function due to the early functional exercises.

Background: Controversy continues with regard to decision making for operative treatment of adolescent clavicle fractures, while the literature continues to support operative treatment for select middle third fractures in adults. The purpose of our study was to evaluate the recent trends in nonoperative and operative management of adolescent clavicle fractures in the United States., Methods: Data were derived from a publicly available database of patients, PearlDiver Patient Records Database. The database was queried for ICD-9 810.02 (closed fracture of shaft of clavicle), with the age restriction of either 10 to 14 or 15 to 19 years old, along with CPT-23500 (closed treatment of clavicular fracture) and CPT-23515 (open treatment of clavicular fracture) from 2007 to 2011. The χ analysis was used to determine statistical significance with regard to procedural volumes, sex, and region. The Student t test was used to compare average charges between groups., Results: A significant increase in the number of adolescent clavicle fractures managed operatively (CPT-23510, ages 10 to 19 y) from 309 in 2007 to 530 in 2011 was observed (P<0.0001). There was a significantly greater increase in operative management of clavicle fractures in the age 15 to 19 subgroup compared with the age 10 to 14 subgroup (P<0.0001). In the operative group, there was a trend toward a higher number of males being managed with operative intervention. The overall average monetary charge for both nonoperatively and operatively managed adolescent clavicle fractures increased significantly in the study period. A statistically significant increase in normalized incidence of operatively managed adolescent clavicle fractures was noted in the midwest, south, and west regions with the greatest increase in west region where the incidence increased over 2-fold (P<0.0001)., Conclusions: Adolescent clavicle fractures seem to be being treated increasingly with open reduction and internal fixation recently, especially in the 15 to 19 age group. Nevertheless, there remains of lack of high-level studies comparing outcomes of operative and conservative treatment specifically for the adolescent population to justify this recent trend., Level of Evidence: Level IV-retrospective database analysis.

Three commonly used murine surgical models of bone healing [closed fracture with intramedullary fixation, distraction osteogenesis (DO), and marrow ablation by reaming] are presented. Detailed surgical protocols for each model are outlined. The nature of the regenerative processes and the types of research questions that may be addressed with these models are briefly outlined. The relative strengths and weaknesses of these models are compared to a number of other surgical models that are used to address similar research questions., (Copyright © 2015 John Wiley & Sons, Inc.)

Fractures are one of the most common large-organ, traumatic injuries in humans, and osteoporosis-related fractures are the fastest growing health care problem of aging. Elective orthopedic surgeries of the bones and joints also represent some of most common forms of elective surgeries performed. Optimal repair of skeletal tissues is necessary for successful outcomes of these many different orthopedic surgical treatments. Research focused on post-natal skeletal repair is therefore of immense clinical importance and of particular relevance in situations in which bone tissue healing is compromised due to the extent of tissue trauma or specific medical co-morbidities. Three commonly used murine surgical models of bone healing, closed fracture with intramedullary fixation, distraction osteogenesis (DO), and marrow ablation by reaming, are presented. The biological aspects of these models are contrasted and the types of research questions that may be addressed with these models are presented., (Copyright © 2015 John Wiley & Sons, Inc.)

Introduction: The aim of the study was to determine predictive risk factors for revision surgery in patients with septic orthopaedic implant removal of the lower leg., Materials and Methods: A total of 196 patients with septic removal of orthopaedic implants after primary trauma of the lower leg between 2008 and 2012 were evaluated. Patients with endoprosthesis infection were excluded from this study., Results: Thirteen patients (22.4 %) had infectious complications with revision surgery. We found 14 patients with soft tissue infections, 10 patients with osteomyelitis, 19 patients with wound-healing problems, 10 patients with pin track infections and two patients with fistulas. High complication rates were associated with severity of the initial trauma, localisation, and the state of union or non-union. Patients with peripheral arterial disease, anaemia and smoking showed a significantly higher risk for revision surgery; whereas patients with diabetes and arterial hypertension did not. A total of 22.6 % had open fractures as an initial trauma. In 76 %, bacteria could be detected. The complication rate was 41.2 % after initial open fractures and 19.6 % after initial closed fractures. A higher grade of soft tissue damage showed no increasing complication rate (p > 0.05)., Conclusions: In this study, complications after septic implant removal of the lower leg were evaluated and risk factors were determined. The awareness of the risks for complications after septic orthopaedic implant removal can lead to a better treatment for patients. Decision-making can be based on scientific results to prevent patients suffering from further severe disease progression.

The authors present a case report and review of the sparse literature of a rare closed degloving injury to the toe, referred to by Flaherty as an "empty toe phenomenon." A 25-year-old man sustained a twisting injury to his left foot when he was involved in a motorcycle accident. The skin was not lacerated around the toe but on physical exam it appeared that part of the toe was empty of its bony contents.

Objective: To investigate the effectiveness and biomechanical analysis of 3 fixation methods of screw anterior-posterior fixation (SAPF), screw posterior-anterior fixation (SPAF), and buttress plate fixation (BPF) in treatment of posterior Pilon fractures., Methods: Fifteen fresh-frozen skeleto-ligamentous lower leg specimens were harvested to establish the models of posterior Pilon fracture, and then fracture was fixed with BPF (n = 5), SAPF (n = 5), and SPAF (n = 5). Vertical force was loaded to internal fixation failure in a speed of 1 cm/minute with servohydraulic testing machine. The instantaneous loads of 1 mm and 2 mm steps and the failure modes were recorded. Between May 2008 and December 2011, 56 patients with posterior Pilon fracture were treated with SAPF (SAPF group) in 11 cases, or SPAF (SPAF group) in 26 cases, or BPF (BPF group) in 19 cases. There was no significant difference in age, gender, injury cause, side, disease duration, and complications among groups (P > 0.05). Clinical and radiographic examinations were used to assess the reduction and healing of fracture; the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS) were used to evaluate the functional outcomes., Results: No breaking or bending was observed in all specimens, fixation failure was caused by cancellous bone compression. The instantaneous loads of 1 mm and 2 mm steps were the largest in BPF group, larger in SPAF group, and smallest in SAPF group, showing significant differences among 3 groups (P < 0.05). A total of 47 cases were followed up 16-54 months (9 in SAPF group, 22 in SPAF group, and 16 in BPF group), with a mean time of 35.2 months. Fixation failure was found in 2 cases of SAPF group; the other cases obtain bony union within 3 to 4 months (mean, 3.2 months) with no fixation failure. The AOFAS score was significantly lower in SAPF group than in SPAF and BPF groups (P < 0.05), but no significant difference was found between SPAF and BPF groups (P > 0.05). The VAS score was significantly higher in SAPF group than in SPAF and BPF groups (P < 0.05), but no significant difference was found between SPAF and BPF groups (P > 0.05)., Conclusion: SAPF could not reach enough fixation strength for the posterior Pilon fracture; both SPAF and BPF could reach rigid fixation, and have good effectiveness. And from the biomechanical points, BPF could reach better fixation strength than screw fixations.

Objective: To explore the operative methods and effectiveness of open reduction and internal fixation for Bosworth fracture., Methods: Between January 2005 and January 2012, 6 patients with Bosworth fractures caused by sprain were treated. There were 4 males and 2 females with an average age of 45.8 years (range, 24-73 years). The time from injury to operation was 1-5 days (mean, 1.8 days). They were all closed fractures. According to Lauge-Hansen classification, 6 cases were classified as supination-external rotation type. The surgical treatments included open reduction and internal fixation by plate and screws., Results: Infection occurred in 1 case and was cured after dressing changing; primary healing of incision was obtained in the other 5 cases. Six patients were followed up 15 months on average (range, 12-24 months). The X-ray films showed fracture healing in all cases, with an average healing time of 9.5 weeks (range, 8-13 weeks). No loosening or breaking of internal fixator was observed during follow-up. The average full load-walking time was 12 weeks (range, 10-17 weeks). According to the ankle and hindfoot scale of American Orthopaedic Foot and Ankle Society (AOFAS), the average score was 89.5 (range, 81-94)., Conclusion: For Bosworth fractures, good results can be achieved by early diagnosis, open reduction and internal fixation.

Introduction: In locking intramedullary nails, the most important problem is to put the distal interlocking screw accurately and quickly with minimum radiation exposure. The purpose of this clinical study was to compare the fluoroscopic time and surgical time required for distal locking with either free-hand fluoroscopic guidance or with an electromagnetic navigation system., Materials and Methods: The study comprised 54 patients with 58 fractures of the lower extremity. The patients were divided in two groups: distal locking with freehand fluoroscopic guidance (group I) and distal locking with electromagnetic navigation (group II). The primary outcome in this study was fluoroscopy time. The secondary outcome was the operative time in distal interlocking., Results: In group I, the mean operation time was 108 (81-135) min, the mean time for distal interlocking was 18.35 (9-27) min, the total fluoroscopy time was 47.77 (19-74) s, the mean fluoroscopy time during distal interlocking was 18.29 (2-29) s and the mean attempt at number of distal locking for two screws was 9.96 (2-18) times. In group II, the mean operation time was 80.96 (63-100) min, the mean time for distal interlocking was 7.85 (6.5-10) min, the total fluoroscopy time was 22.59 (15-32) s, the mean fluoroscopy time during distal interlocking was 1.62 (0-2) s and the mean attempt number of distal interlocking was 2 (2-2)., Conclusion: Fluoroscopy time to achieve equivalent precision is significantly reduced with electromagnetism-based surgical navigation compared with free hand fluoroscopic guidance. Also the operative time is significantly reduced with electromagnetic based navigation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: The aim of this study was to compare the outcome of open reduction versus closed reduction of midclavicular fractures using elastic stable intramedullary nailing (ESIN) in both groups., Methods: Titanium elastic nails were used to treat 40 patients undergoing minimally invasive ESIN between December 2006 and July 2009. A total of 19 patients were treated with a closed reduction and 21 patients required open reduction., Results: The Constant Score revealed no significant differences between the two groups (closed 87.4±9.0; open 85.3±7.1) nor did the DASH Score (closed: 5.0±6.5; open 5.8±7.3). The strength measurement of shoulder abduction was consistent in each group: 75.7±22.0 N in the closed reduction group and 74.2±26.0 N in the group with open treatment., Conclusion: There was no difference comparing right- and left-sided injuries and the outcomes were consistent irrespective of the treatment method. When appropriately indicated open and closed intramedullary nailing are very successful modalities of treatment. There were no significant differences in shoulder function after either procedure.

Objective: To explore the method and effectiveness of lateral calcaneal U-shaped incision approach to treat calcaneal fractures involving the talocalcaneal and calcaneocuboid joints., Methods: Between January 2009 and March 2011, 36 cases of calcaneal fractures involving the talocalcaneal and calcaneocuboid joints were treated by the lateral calcaneal U-shaped incision approach and calcaneal anatomical plate fixation. There were 27 males and 9 females with an average age of 38.7 years (range, 19-58 years). According to the Sanders classification criteria, there were 12 cases of type II, 20 cases of type III, and 4 cases of type IV. The Böhler and Gissane angles were (6.21 +/- 10.48) degrees and (89.85 +/- 12.34) degrees, respectively. The average time from injury to surgery was 4.2 days (range, 2-14 days)., Results: Superficial skin flap necrosis and wound exudate occurred in 1 case respectively, which were cured after dressing change; primary healing was obtained in the other cases. All the cases were followed up 12-26 months (mean, 15.2 months). The X-ray films showed that all fractures healed with an average healing time of 10.6 weeks (range, 8-12 weeks). The reduction of articular surface was satisfactory, and the heel height returned to normal. No complication of breakage of internal fixation or traumatic arthritis occurred. The Böhler and Gissane angles were (29.64 +/- 5.33) degrees and (121.75 +/- 6.65) degrees, respectively at 3 months after operation, showing significant differences when compared with the preoperative values (t=43.800, P=0.000; t=33.200, P=0.000). The average time of plate removal was 11.2 months (range, 9-20 months). According to Maryland foot score, the results were excellent in 17 cases, good in 15 cases, and fair in 4 cases; the excellent and good rate was 88.9%., Conclusion: The lateral calcaneal U-shaped incision approach is an effective method to treat calcaneal fractures involving the talocalcaneal and calcaneocuboid joints, which can expose the fracture fully, restore the anatomy of the calcaneal bone, and do early exercise under the condition of rigid internal fixation.

Objective: To analyze the non-operation related risk factors of the wound complications by using lateral extensive L-shaped incision for open reduction and internal fixation of calcaneal fractures., Methods: A retrospective analysis was made on the clinical data of 58 patients with closed calcaneal fractures (63 calcaneus) treated by using lateral intensive L-shaped incision for open reduction and internal fixation between September 2006 and August 2011. There were 52 males (56 calcaneus) and 6 females (7 calcaneus), aged 18 to 64 years (mean, 35 years). The causes of injury included fall injury in 53 cases (58 calcaneus), traffic injury in 5 cases (5 calcaneus). The mean time between injury and operation was 8 days (range, 3-22 days). According to Sanders classification, 4 calcaneus were rated as type II, 31 calcaneus as type III, and 28 calcaneus as type IV. Postoperative complications were observed and graded; 58 patients were divided into complication group (> or = grade 2) and control group (< grade 2). The univariate analysis was used to analyze 18 factors which may lead to wound complications; multi-factor unconditioned logistic regression analysis was done for the factors showing significant difference., Results: According to postoperative wound complications grading, 41 patients (46 calcaneus) were included in the control group, whose incision healed primarily, and 17 patients (17 calcaneus) in the complication group. In 17 patients of the complication group, 14 had skin necrosis or dehiscence, and 3 had superficial infection; they obtained healing after symptomatic treatment. The univariate analysis showed significant differences in combined spinal fracture, diabetes mellitus, and long-term smoking between 2 groups (P < 0.05). The logistic regression analysis revealed that combined spinal fracture was an independent risk factor for wound complications (95% confidence interval: 0.004-0.360, P = 0.004)., Conclusion: Combined spinal fracture is an independent risk factor for wound complications after open reduction and internal fixation of calcaneal fracture using lateral extensive L-shaped incision.

Objective: To investigate the treatment method and effectiveness of fresh closed fracture-dislocation of the midtarsal joint., Methods: Between April 2004 and April 2011, 73 patients (75 feet) with fresh closed fracture-dislocation of the midtarsal joint were treated with closed reduction combined with open reduction and internal fixation. There were 56 males (58 feet) and 17 females (17 feet), aged from 19 to 62 years (mean, 35.8 years). Injuries were caused by falling from height in 35 cases, by sprain in 4 cases, by machine twist in 5 cases, by heavy pound in 9 cases, and by traffic accident in 20 cases. The time from injury to admission ranged from 1 hour and 30 minutes to 48 hours (mean, 4.5 hours). According to Main's classification standard, 6 feet were rated as vertical compression injury, 33 feet as medial displacement injury, 17 feet as lateral displacement injury, 9 feet as flexion injury, and 10 feet as crush injury. Concomitant injuries included midfoot fracture-dislocation (34 feet), scaphoid fracture (6 feet), cuboid bone fracture (18 feet), calcaneal fracture (8 feet), talus fracture (7 feet), tibiotalar joint dislocation (2 feet), subtalar joint dislocation (2 feet), medial malleolus fracture (1 foot), and acute compartment syndrome (3 feet)., Results: Healing of incision by first intention was achieved in 65 cases (67 feet), by second intention in 8 cases (8 feet). Sixty-two cases (62 feet) were followed up from 11 months to 7 years and 11 months (mean, 3 years and 6 months). After operation, feet pain occurred in 26 cases, and stiffness or discomfort of the affected foot in 36 feet when walking. The X-ray examination showed good reduction of fracture-dislocation of the midtarsal joint and concomitant injuries with no re-dislocation or bone nonunion in 59 feet; 3 feet had flatfoot secondary to navicular necrosis, and underwent arthrodesis. The American Orthopaedic Foot and Ankle Society (AOFAS) score was 77-90 (mean, 88.6) at last follow-up., Conclusion: According to the preoperative evaluation of the damage, using the manual reduction combined with internal fixation (mini-plate or hollow screw with Kirschner wire) methods can obtain good effectiveness in the treatment of fracture-dislocation of the midtarsal joint.

Background: Unstable pelvic fractures with associated haemodynamic instability are major contributors of mortality and morbidity after blunt trauma. The pelvic C-clamp is one of the methods for emergency skeletal stabilization for pelvic ring injuries with posterior instability. The application of this device is taught on courses, but it is seldom used. The safety and efficiency of C-clamp application by trained first time users is unknown. We hypothesised that the pelvic C-clamp cannot be safely positioned on a training model after one training session., Methods and Materials: A theoretical and a practical session on the application of the pelvic C-clamp was held within an interval of 11.2±4.4. Twenty-seven participants of various levels of training were assessed on accuracy and efficacy of the application of the pelvic C-clamp was applied to a pelvic model (Pelvic Trainer™)., Results: 70.4% of all participants were able to place both pins inside the safe zone, whilst 81.5% of all pins were positioned safe. 18.5% were considered to be in unsafe position. The distance to optimal target point was 9.6±7.8mm on the left (injured) hemipelvis and 8.7±7.8mm on the right (uninjured). The time needed for assembly was 99.7±39.7s, for placement it averaged at 133.9±74s., Conclusions: The majority of pins were placed into the safe zone on a training model within 4 min after one training session. 18.5% dangerous pin placement within 11 days of the training requires careful consideration (risk/benefit) in the context of a critically injured dying patient., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The articular surface of the posterior facet may be extremely difficult to reduce anatomically in a tongue-type calcaneal fracture because the fragment tends to translate when attempting the rotational component of the reduction. A new osteotomy that converts the tongue into a joint depression fragment to permit an accurate articular surface reduction is described to assist in realignment. This technique has been used successfully by the author in more than 30 fractures, and the results are reported herein. Surgeons faced with this dilemma may use the maneuver to solve a difficult problem.

Injuries to the tarsometatarsal joint are infrequent and the presentation varies. The radiologic evaluation can be difficult, and injuries are missed initially in up to one third of cases. A 60-year-old female sports instructor presented to the emergency department with a Lisfranc fracture dislocation of the foot as result of an indirect trauma. The patient attended to a hospital the day she sustained the injury, where the Lisfranc fracture was missed. At our hospital, the patient underwent immediate restoration of the dislocation. Because of swelling, internal fixation was applied 2 weeks later. Postoperatively, the patient was mobilized in a non-weight-bearing plaster cast for 6 weeks, continued by progressive weight-bearing in a walker. The fixation screws were removed 3 months after surgery. Lisfranc fractures are rare injuries and can be missed at first sight. Careful clinical examination and radiographs in 3 different planes are required to identify the injury. Computed tomography might be helpful when the findings from the above-mentioned examinations are inconclusive. Operative treatment, including anatomic reduction and fixation, is required in almost all cases to achieve the best satisfactory result. Long-term complications include secondary arthritis and foot deformities, which can be treated by foot ortheses or arthrodesis., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the efficacies of treating intra-calcaneal fractures with bone grafting., Methods: From January 2005 to October 2011, a total of 182 calcaneal patients underwent operations for closed fractures. There were 159 males and 23 females with an average age of 41.2 years old. The fractures were of the following types: left calcaneal (n = 68), right calcaneal (n = 86) and bilateral (n = 28). According to the Sander's classification, there were type II (n = 27), type III (n = 109) and type IV (n = 46). And they were divided into bone graft (n = 94) and non-bone graft (n = 88) groups. All of them underwent a profiled plate fixation via a lateral approach. No external fixation was necessary and early ankle functional exercises started postoperatively. They handled partial weight-bearing at Week 6 and full weight-bearing at Week 12. Their outcomes were assessed by the American Orthopedic Foot and Ankle Society ankle-hindfoot scale (AOFAS) while classification comparison affected the prognosis (P < 0.05)., Results: The follow-ups of 10 patients were lost at Month 3. And 172 cases were followed up for an average period of 14.2 months (range: 9 - 16). The average healing duration was 12 weeks (range: 6 - 15). None of follow-up cases had any complication, such as vascular and nerve injury and osteomyelitis. Twenty-nine cases in the non-bone graft group had articular cave-in after weight bearing. And 21 cases were associated with subtalar arthritis. And in the bone graft group, there was no articular cave-in and only 1 case was associated with subtalar arthritis. The outcomes of bone graft and non-graft groups were as follows: excellent (n = 68), good (n = 20), fair (n = 5) and poor (n = 1) vs. excellent (n = 44), good (n = 26), fair (n = 7) and poor (n = 9). The rate of excellent and good was 87.9%. And the post-operative AOFAS scores had statistical differences between 2 groups (P < 0.05)., Conclusion: Bone grafting is important for improving the therapeutic efficacies for intra-calcaneal fractures.

Purpose of the Study: The aim of this prospective study was to evaluate the clinical and radiographic results in a group of patients with calcaneal fractures treated by means of minimally invasive, arthroscopically-assited osteosynthesis., Material and Methods: A total of 175 calcaneal fractures in 154 patients were treated surgically at the Trauma Centre of Masaryk Hospital between January 2006 and August 2010. Twenty-six patients were enrolled in this prospective study. They had a total of 30 calcaneal fractures, of which 28 were managed by minimally invasive, arthroscopically-assisted osteosynthesis. The patient's records included demographic data, relevant medical history, fracture type by Sander's classification, associated injuries, time to surgery, length of surgery, post-operative quality of reduction, Böhler's angle before and after surgery, healing complications, hospitalisation time, follow-up period, bone union, functional outcome in Rowe score and hardware removal. The patients underwent minimally invasive osteosynthesis under arthroscopic and radiographic guidance. For this procedure, patients with Sanders type IIa and IIb fractures were predominantly indicated. The group also included patients older than 60 years, smokers, patients addicted to alcohol, a diabetic patient, a dialysed patient and a patient with chronic lower-limb lymphoedema., Results: The patient group included 21 men with 25 fractures (83.5%) and five women with five fractures (16.5%). Nine men (42.9%) were heavy smokers; three men (14.3%) and one woman (20 %) were addicted to alcohol. All fractures were closed and, according to the Sanders system, were classified as follows: 16 fractures as type IIa (57.1%); eight fractures as IIb (28.6%); two fractures as IIIab (7.1%) and one IIIac and IIIbc (3.6% respectively). Six patients (23.1%) sustained bilateral fractures of the lower-limb. In the post-operative period, no disturbance of soft tissue healing and no superficial or deep wound infection were observed. The outcome of fracture reduction assessed by CT examination was excellent in 24 fractures (85.6%), satisfactory in one (3.6%) and poor in one fracture (3.6%). The mean Böhler's angle was +7.2 degrees pre-operatively and +35.4 degrees post-operatively. In all patients bone union was achieved within 3 months; hardware was removed in 19 fractures (67.9%). Functional outcomes according to the Rowe score were very good in 18 (69.2%), good in four (15.4%) and satisfactory in four (15.4%) patients. There were no poor results. The mean Rowe score for the whole patient group was 86 points., Discussion: The demographic data are in agreement with the recent literature data. However, most studies have not included smokers and people addicted to alcohol, therefore, no comparison can be made. The comparison with studies on ORIF-treated fractures is also difficult, because our study included a higher number of less severe fracture types. The surgical technique is demanding and was, at the beginning, associated with intra-operative errors. The post-operative values of Böhler's angle are comparable to the results of ORIF techniques, but this does not mean that this technique could substitute the use of ORIF in complex fractures. The absence of any soft- or bone-tissue healing problems is a very good result, considering the number of risk factors in our patient group. The good functional outcomes according to the Rowe score can be attributed to a higher proportion of less complex fractures in the group., Conclusions: In our group of patients with predominantly less severe types of calcaneal fractures, the quality of post-operative fracture reduction, as a result of minimally invasive, arthroscopically-assisted osteosynthesis, appeared to be comparable with open techniques. The observed complete bone healing and absence of soft-tissue problems could present a surgical option to treatment nihilism in patients contraindicated for ORIF techniques.

Background: Intramedullary pin and plate fixation for midshaft clavicular fractures both have their proponents, but little comparative data are available. We performed a retrospective comparison of these 2 techniques., Materials and Methods: A retrospective review was performed on 40 consecutive patients with closed, simple, or wedge-type midshaft clavicular fractures that were identified from a prospectively collected orthopedic trauma database. Eight patients were excluded due to incomplete follow-up. Intramedullary pins were used in 18 patients and plates in 14; of these, 7 plates were placed superiorly, 6 anteriorly, and 1 inferiorly. Treatment method was determined by preference of the treating surgeon., Results: Among the patients treated with intramedullary pin fixation, all 18 fractures healed, and each underwent a planned procedure for pin removal. Complications included 1 intraoperative pin breakage, 1 superficial wound infection, 2 prominent symptomatic pins, and 1 transient brachial plexopathy. Among the patients treated with plating, delayed union occurred in 1, and refractures occurred in 2 (1 required a second procedure). Three patients underwent plate removal for symptomatic hardware. No patients in either group had significant loss of shoulder motion., Conclusion: Intramedullary pin fixation for acute, simple, or wedge-type midshaft clavicular fractures provides a safe and predictable alternative to plate and screw fixation., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Trans-scaphoid perilunate fracture dislocations (TSPLD) are uncommon injuries and constitute about 3% of all carpal injuries. Up to 25% of these high energy trauma cases go undiagnosed. Presented are 43 (3 female, 40 male) consecutive patients treated for dorsal TSPLD, all were closed fractures. Patients were between 17 and 66 years old. Twenty male patients were injured in active duty military service. Surgical treatment was made with a volar approach using titanium cannulated headless compression screws (3.2 mm) placed via a guide wire. Repositioning the dislocated carpus is then conducted using 3 temporary fixation Kirschner wires (1.6 mm). The patient had a volar short arm splint for 4 weeks, then given an orthosis. Triple fixation Kirschner wires were removed 6-8 weeks postoperatively. Mean followup period was 29 months (range 20-38). The average Mayo wrist score for all 43 patients is 87 (good) (range 65-99). All patients returned to their previous employment.

Purpose/background: Therapy of metacarpal neck fractures depending on radiographically measured palmar angulation is discussed controversially in the literature. Some authors describe normal hand function of malunited metacarpal neck fractures with a palmar angulation up to 70°; others define 30° as the uppermost limit to maintain normal hand function. However, the methods of measuring palmar angulation are not clearly defined. Here, we present a new method to measure palmar angulation using ultrasound. The aim of this prospective study is to compare the radiographic methods of measuring palmar angulation with the ultrasound method., Patients/material and Method: 20 patients with a neck fracture of the metacarpals IV or V were treated either conservatively or operatively. 2 weeks after trauma or operation, an x-ray was performed. 2 examiners measured the palmar angulation on the oblique and lateral projections using 2 different methods (medullary canal and dorsal cortex methods). At the same time, the 2 examiners performed measurements of palmar angulation using ultrasound. The measurements obtained with the different methods as well as by the 2 examiners at 2 different terms were compared. Intra- and interobserver reliability of each method was calculated, and for the ultrasound method a test for accuracy of the measured angles was performed., Results: Depending on the method of radiographic measurement and different x-ray projections, an average of up to 20.3° higher angles were determined as compared with the ultrasound method. The average deviation in angles measured within and between the 2 examiners was lower for the ultrasound method than for the radiographic methods, corresponding to a higher degree of intra- and interobserver reliability., Conclusion: The ultrasound method for measuring palmar angulation in metacarpal neck fractures is simple, and appears to be more precise in comparison to radiographic methods. An exactly lateral projection of the fractured metacarpal bone can be imaged without superposition and exposure to radiation. The question arises whether previous studies that suggested normal hand function with palmar angulation up to 70° might have been based on too high angle-readings due to the use of radiographic methods., (© Georg Thieme Verlag KG Stuttgart · New York.)

Pelvic fractures account for 4-5% of all fracturated patients, and they occur in 4-5% of polytraumatized patients. In the most of the cases, they are consequent to high-energy trauma with a high percentage of lesions of other organs (cerebral, thoracic, and abdominal lesions. The most of the patients (80%) who die are dying within the first hours after trauma for a massive hemorrhagic shock. When the pelvic fracture and the patient's hemodynamic conditions are both unstable, osteosynthesis of the fracture is mandatory. Fracture stabilization should be performed within the first hour after trauma (as soon as possible), and it should be considered as part of the resuscitation procedure. We usually make an urgent stabilization of pelvic fracture with an anterior external fixator technique. We have revised all unstable pelvic fractures treated in our department (Orthopaedic Clinic Pisa University) from 2000 up to the 2005 to determine a correct treatment protocol for these lesions. Pelvic stabilization, reducing the pelvic volume and bleeding from the stumps of fracture, determines the arrest of the hemorrhage, as evidenced by the sharp decline in the number of transfusions in postoperative period. In these cases, there is an absolute indication for an urgent pelvic stabilization. Pelvic stabilization, whether temporary or permanent, allows to control the bleeding because it (1) leads to a reduction in the volume pelvis with a containment on the retro-peritoneal hematoma (2) reduces bleeding from the fracture fragments (3) reduces motility fracture promoting the blood clotting. The stabilization of the pelvis also makes it easier to manage the patient and his mobilization for the implementation of subsequent investigations. In our experience, external fixator accounts for its characteristics the gold standard approach for the urgent stabilization of these lesions, and, for most of them, it can be used as the definitive treatment. External fixation is a quick and easy procedure for pelvic fractures stabilization for surgeons with experience with this technique.

Malleolar fractures are rarely associated with lesions of the adjacent tendons or neurovascular structures. The association of ankle fractures with Achilles tendon rupture is even more infrequent, although both of these injuries are very common in and of themselves. To our knowledge, fracture of the lateral malleolus in association with an acute rupture of the ipsilateral calcaneus tendon has not been previously described. In this article, we describe a female patient who sustained an acute rupture of the Achilles tendon in conjunction with fracture of the ipsilateral lateral malleolus., (Copyright © 2010 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the rate of postoperative infection (POI) for internal fixation repaired equine long bone fractures and arthrodeses and identify associated risk factors., Study Design: Case series., Animals: Horses (n=192) with fracture repair of the third metacarpal and metatarsal bones, radius, ulna, humerus, tibia, and femur, or arthrodesis with internal fixation., Methods: Medical records (1990-2006) were reviewed for signalment, anatomic location, fracture classification and method of repair, technique and surgical duration, bacterial species isolated, postoperative care, onset of POI, and outcome., Results: Of 192 horses (171 [89%] closed, 21 [11%] open fractures), 157 (82%) were discharged from the hospital. Infection occurred in 53 (28% horses), of which 31 (59%) were discharged. Repairs without POI were 7.25 times more likely to be discharged from the hospital. Closed fractures were 4.23 times more likely to remain uninfected and 4.59 times more likely to be discharged from the hospital compared with open fractures. Closed reduction and internal fixation was associated with a 2.5-fold reduction in rate of POI and a 5.9 times greater chance for discharge from the hospital compared with open reduction and internal fixation. Females had a strong trend for increased POI when compared with colts and stallion but not geldings., Conclusions: Overall rate of POI was 28%. Fracture classification, method of repair, gender, and surgical duration were significant risk factors.

Volar perilunate dislocations of the wrist are rare. An unusual case of volar perilunate dislocation in the presence of an ununited scaphoid in a skeletally immature patient is presented.

Background and Purpose: Recent meta-analyses have suggested similar wound infection rates when using single- or multiple-dose antibiotic prophylaxis in the operative management of closed long bone fractures. In order to assist clinicians in choosing the optimal prophylaxis strategy, we performed a cost-effectiveness analysis comparing single- and multiple-dose prophylaxis., Methods: A cost-effectiveness analysis comparing the two prophylactic strategies was performed using time horizons of 60 days and 1 year. Infection probabilities, costs, and quality-adjusted life days (QALD) for each strategy were estimated from the literature. All costs were reported in 2007 US dollars. A base case analysis was performed for the surgical treatment of a closed ankle fracture. Sensitivity analysis was performed for all variables, including probabilistic sensitivity analysis using Monte Carlo simulation., Results: Single-dose prophylaxis results in lower cost and a similar amount of quality-adjusted life days gained. The single-dose strategy had an average cost of $2,576 for an average gain of 272 QALD. Multiple doses had an average cost of $2,596 for 272 QALD gained. These results are sensitive to the incidence of surgical site infection and deep wound infection for the single-dose treatment arm. Probabilistic sensitivity analysis using all model variables also demonstrated preference for the single-dose strategy., Interpretation: Assuming similar infection rates between the prophylactic groups, our results suggest that single-dose prophylaxis is slightly more cost-effective than multiple-dose regimens for the treatment of closed fractures. Extensive sensitivity analysis demonstrates these results to be stable using published meta-analysis infection rates.

Interleukine (IL-1alpha, IL-4) blood levels and lipid peroxidation--antioxidant agents were assessed in 98 patients with fractures of long tubular bones. Using the data, an algorithm was worked out, which permits prediction of septic complications with a high level of accuracy.

Objective: To analyze the reasons on complications of treatment with elastic nail in children's long bone fracture., Methods: Sixty-six cases (75 parts of long bone fratures) were treated by elastic nail including 49 male and 17 female. The age ranged from 3 to 17 years, mean 7.8 years. There were 35 femur fractures (2 cases were hibateral), 20 tibia and fibula fractures (12 cases were tibia fractures), 8 radial fractures (1 case was ulna fracture) and 3 humerus fractures. The cases included 4 open fractures and 62 closed fractures. All cases were fresh fractures, no multi-segmental fractures. Three cases associated with brain and chest injuries. These cases were treated by open or closed reduction and internal fixaion with elastic nail. A cast or brace had been used after operation for a month. Following-up included the function of the joint,the bottom of the nail and the callus. Complications were timely recorded., Results: All the patients were followed-up for 12 to 29 months, averaged 17 months. The cases occurrenced compilications including 2 cases of nonunion, 2 of new fracture, 1 of displacment, 4 of joint dysfunction, 3 of irritation of the bottom of the nail and 1 malunion., Conclusion: Strict indication, well design,canonical operation is a good way to avoid compliacations. At the same time,early treatment can reduce the sequela.

Closed multiple metacarpal fractures are uncommon. They are usually associated with significant soft tissue swelling. Early stable fixation and functional rehabilitation optimises outcome. We present a review of 19 patients with 43 metacarpal fractures treated by early open reduction and internal fixation with 2 mm plates. Eighteen patients recovered a full range of motion, while one patient was lost to follow-up. Implant removal on account of extensor irritation was required in only two metacarpals in two patients. Plating of multiple closed metacarpal fractures is a safe, reliable and consistently reproducible treatment method.

Objective: To investigate the outcome of manipulative reduction and splint fixation for treatment of middle and lower fractures of ulnar and radius., Methods: Sixty-eight patients with lower segment fractures of ulnar and radius included 46 male and 22 female, aged from 1 to 26 years. The course was from 10 min to 1 week. There were 39 cases in right and 29 in left; 45 in inferior segment and 23 in middle segment. All cases were closed fractures. According to fracture displacement, different methods of manipulation and splint or plaster splint fixation were used to reduction and fixation., Results: Sixty-eight patient were followed-up for 0.5 to 1 year (mean 8 months), the fractures were all healing. According to the effective evaluation criteria, the results were excellent in 57 cases, good in 11. X-ray film showed anatomic reduction in 38 cases, similar to anatomic reduction in 20, functional reduction in 10., Conclusions: Manipulative reduction and splint fixation for the treatment of the ulnar and radial bone fractures is a method of simple, minimally invasive, effective and functional advantages of quick recovery.

Objective: To discuss feasibility of minimal-invasive surgical treatment of the pelvis fractures., Methods: Twenty-six patients with pelvis fractures were treated by micro-surgical treatment. There were 15 male and 11 female with an average age of 40 years ranging from 20 to 62 years. All patients were closed fractures, 17 patients were hemi-pelvis fractures, 9 patients were bilateral-pelvis fractures. The fracture type of posterior ring of pelvis as follows:8 patients were sacro-iliac joint dislocation, 12 patients were vertical section fractures in the outboard of the sacrum. The fracture type of anterior ring of pelvis as follows: 9 patients were hemi-fracture of rami ossis pubisi or hemi-fracture of rami ischi, 7 patients were bilateral-fracture of rami ossis pubisi or bilateral-fracture of rami ischii, 6 patients were separation of symphysis pubis. Six patients accompanied with shock. Anterior ring of pelvis was fixation by lag screw via superior ramus of pubis and pubic symphysis; Posterior ring of pelvis was fixation by lag screw via sacroiliac joint or intrasacral rod via ilium. X-ray films and multi-slice spiral CT of pelvis was obtained in order to understand exterior and inner details about pelvis fractures. Adopt orientation in body and inducted by C-arm digital subtracting X-ray system when operating., Results: Blood loss was about 10 to 50 ml (mean 30 ml). Operation time was 30 to 50 minutes. Time of fracture union was 8 to 12 weeks (mean 11 weeks). Wound infection, ununion of fracture and nerve injuries had not been found., Conclusion: Minimally invasive operation has the merit of short operation time, fine effect, soon recovering and few complication.

Objective: To investigate the operative treatment of displaced intra-articular calcaneal fractures (DIACFs) using a combination of small lateral incision approach and internal fixation and allograft bone transplantation., Methods: From January 2005 to December 2007, 28 patients with 34 DIACFs were treated with open reduction, allograft bone transplantation and internal fixation through a small lateral incision approach. Of them, there were 18 males and 10 females, aged 16-65 years. The disease course was 2 hours to 18 days. According to Sanders classification, there were 18 cases of type II fractures, 10 cases of type III fractures and 6 cases of type IV fractures., Results: 22 patients with 28 DIACFs were followed up 18.5 months (13-28 months). The wound of 26 feet achieved primary healing, the acute rejection was found in 2 patients and developed wound complications. Both patients underwent further surgery prior wound healing. After the internal fixation were removed, fractures was fixed with external fixator, closed continuous irrigation and drainage was employed. In the meantime, both patients received antibiotics and incisional dressing change. As a result, one achieved primary healing, the other developed delayed healing. The preoperative X-ray film showed that Böhler angle was (6.19 +/- 9.66) degrees and Gissane angle was (103.04 +/- 15.03) degrees; the postoperative X-ray film demonstrated that Böhler angle was (34.51 +/- 5.89) degrees and Gissane angle was (112.18 +/- 10.50) degrees; showing statistically significant differences (P < 0.05). The internal fixation of 12 patients (14 DIACFs) were removed at 6 -10 months after operation, Böhler angle was (32.81 +/- 5.10) degrees and Gissane angle was (110.81 +/- 9.98) degrees. When compared with preoperative X-ray film, statistically significant differences (P < 0.05) was found, but there was no statistically significant differences (P > 0.05) when compared with normal X-ray film. According to the American Orthopedic Foot and Ankle Society evaluation system for ankle-hind foot, 3 feet scored 60-70 points, 10 feet 70-80 points, 12 feet 80-90 points and 3 feet 90-100 points., Conclusion: Allograft bone transplantation is an option for management of DIACFs, because it enables satisfactory reconstruction of bone defects, allows met anatomic reduction and functional recovery, maintaining restoration of calcaneal height and anatomic reduction of the posterior facet.

Fractures of the scaphoid waist that fail to heal tend to collapse into a flexed posture. The so-called "humpback deformity" of the bone is accompanied by collapse of the proximal carpal row with dorsal tilt of the lunate. It is possible to restore scaphoid height and carpal alignment by insertion of a tricortical wedge of graft from the iliac crest. In this article, we demonstrate the surgical technique of volar wedge grafting for scaphoid nonunion.

Background: The current study examined the outcomes of operative treatment of unstable ankle fractures in patients at least 80 years old at the time of injury., Methods: Of 2,682 patients who presented for treatment of ankle fractures, 17 patients met the study criteria. These patients had open reduction and internal fixation after sustaining 15 closed and two open unstable ankle fractures. There were 11 type B fractures and six type C fractures by the Danis-Weber classification, and 12 supination-external rotation and five pronation-external rotation fractures by the Laugen-Hansen classification systems., Results: When noncompliant patients who developed complications were removed from analysis, the fixation failure and deep infection rates were 0% each., Conclusions: These results highlight the importance of patient compliance and non-weightbearing status in the treatment of ankle fractures in patients over 80 years.

Appropriate care of pediatric polytrauma patients requires the knowledge and expertise of a variety of subspecialists. Though most of pediatric polytrauma patients survive, long-term sequelae are common. The most common causes of long-term functional deficits after pediatric polytrauma involve injuries to the central nervous and musculoskeletal systems. Orthopaedic care of polytrauma patients is important to facilitate early mobilization and care of these children, as well as to minimize late impairment.

As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient-, injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis. The patients were reviewed until clinical and radiological evidence of union at a mean of 13.3 months (4 to 60). Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 2.38 times for highly comminuted fractures, by 3.14 times when nail dynamisation was applied, and by 1.65 times when the locking screws failed. In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was > or = 3 mm.

Redisplacement of unstable forearm fractures in plaster is common and may be the result of a number of factors. Little attention has been paid to the influence of immobilisation with the elbow extended versus flexed. We prospectively treated 111 consecutive children from two centres with closed forearm fractures by closed reduction and casting with the elbow either extended (60) in China or flexed (51) in Israel. We compared the outcome of the two groups. There was no statistically significant difference in the distribution of the age of the patients, the site of fracture or the amount of angulation and displacement between the groups. During the first two weeks after reduction, redisplacement occurred in no child immobilised with the elbow extended and nine of 51 children (17.6%) immobilised with the elbow flexed. Immobilisation of unstable forearm fractures with the elbow extended appears to be a safe and effective method of maintaining reduction.

Although pioneers such as Leriche in 1921 [5] and Judet et al in 1954 [4] introduced screw or plate fixation of the broken calcaneus, surgical treatment using open anatomical reduction and stable internal osteosynthesis only commenced at the start of the 1980s. This treatment was made possible by the introduction of new imaging methods such as CT which allowed better detection of the fracture pathology and provided the basis for new surgical strategies. Since the start of the 1990s, various anatomically shaped steel and titanium calcaneal plates have been available. The Foot and Ankle Expert Group of the AO Foundation together with Synthes USA developed an anatomically shaped interlocking calcaneal plate, which has been available in steel since 2002, and a titaniummolybdenum(15%) alloy version (Mathys) since November 2003. The latter is now being tested clinically in our unit.

Operative treatment of intra-articular calcaneal fractures with anatomical reduction and early mobilisation has lead to a considerable improvement of the functional results of these severe injuries over the recent two decades. New tendencies like modified approaches tailored according to the vascular anatomy, arthroscopic control of joint reduction in conjunction with open or percutaneous procedures, early flap coverage for severe open fractures or closed fractures with full thickness skin necrosis, the use of interlocking plates that further minimises the need of bone grafting and subtalar arthrolysis at the time of hardware removal for fibrous overgrowth have the potential for further improvement of the outcome. The observation from several comparative studies that operative treatment leads to superior results in displaced intra-articular calcaneal fractures has been qualified in a recent prospective, randomised multicentre trial. This paper presents and the authors' experience with the demanding operative treatment of these fractures together with new developments aiming at improving the clinical results.

Background: Sternal fractures are uncommon injuries observed in the direct impact of the sternum against the steering wheel in car accidents with the likelihood of associated thoracic injuries., Objectives: To present our experience in the management of blunt sternal fractures., Location: Hospital de Urgencias de Córdoba., Materials and Methods: Patients with blunt sternal fracture were included over a one year period. After an anterior chest x-ray suggested a clinical problem, lateral x-ray of the sternum was performed for the fracture diagnosis. CT scan, ECG, serum CPK and an echocardiogram were used to evaluate the associated trauma. The indications for fixation were bony deformity, intractable pain and thoracic instability., Results: Of eight patients with sternal fractures, 5 were caused by road accidents and the others by a direct blow in the chest. Five patients suffered associated injuries. One patient presented cardiac contusion but did not require treatment. Fixation was performed on 4 patients. No surgical complications were observed., Conclusions: Sternal fracture should be suspected in patients with anterior chest trauma from road accidents. A lateral x-ray of the sternum is useful in fracture evaluation. Possible associated thoracic Injuries need to be necessarily evaluated. Osteosintesis should be performed on patients with bony deformity and severe pain, while for stable, not displaced or conminuted fractures, pain relief should be performed.