Introduction
The incidence of pseudoarthrosis of the long bones is 7%. Some of the causes that increase the risk of nonunion are obesity, comminution of the focus and open fractures.

Goals
To present a case of failure in osteosynthesis of a femur fracture with implant rupture, evaluating patient characteristics and resolution of said complication through multimodal surgery.

Material and methods
Case of a patient with a history of type 2 DM and grade 3 obesity is presented. Male suffered a distal femur fracture treated by osteosynthesis with a condylar plate and cerclages. At 5 months of evolution, a rupture of the plate and absence of fracture consolidation were observed on CT. Surgery was indicated to remove previous osteosynthesis material and perform a new osteosynthesis. To do this, the femoral medullary canal was reamed, the focus of the fracture was decorticated and a retrograde femur nail was implanted, placing a crest bone graft in the bone defect. In addition, a condylar femur plate was implanted with monocortical screws in the area superimposed on the nail and a screw in the femoral neck. Finally, samples were taken to rule out infection.

Results
At 6 months, the patient presented knee mobility of 0-90 degrees and an absence of complications. On radiographic control, a fracture callus was observed.

Conclusions
Surgery for surgical complications, such as pseudoarthrosis, are complex surgeries that may be treated in multiple ways but always taking into account the cause of the failure of previous surgery.

Introduction: Calcaneal tuberosity fractures account for 1-3% of calcaneal fractures; they are more common in females in the seventh decade of life. The most commonly associated injury mechanisms are foot trauma while in plantar flexion or vigorous contraction of the soleus and gastrocnemius muscles. Treatment varies according to the avulsion fracture pattern, but minimal soft tissue dissection is crucial. Case Presentation: We present a case of a 67-year-old female patient observed in the emergency room with left foot trauma. She had a history of Osteoporosis and High Blood Pressure. Imaging revealed a fracture avulsion of the calcaneal tuberosity (Beavis type I). The insertion of the achilles tendon was preserved, causing superior displacement of the posterior fracture fragment. Osteosynthesis was performed with two cannulated cancellous screws with 2 washers, and achilles tendon reinforcement through a minimal invasive posterior incision. Postoperatively the patient was kept immobilized with a posterior splint for six weeks without load, starting physiotherapy at 8 weeks. No complications were reported; 3 months postoperatively the patient presented without pain or limitations, with an American Orthopedic Foot & Ankle score of 97% Conclusion: There are few guidelines for addressing this type of fracture or research on its etiology and vulnerability factors given its rarity. Osteoporosis has been proposed as a common entity in calcaneal avulsion fractures. Surgical treatment assumes a central position in the treatment; the complications are mainly related to soft tissues damage by the fracture itself or soft tissue dissection. Minimally invasive approaches assume fulcrum importance.

Introduction: Acute carpal tunnel syndrome (ACTS) is characterized by sudden onset of pain and dysesthesias in the median nerve distribution. It is a surgical emergency and is usually caused by trauma, so atraumatic ACTS is considered a rare entity. Case Presentation: A 52-year-old right dominant male presented to the emergency room with a warm mass on the volar aspect of the wrist with associated increasing pain, hand weakness and numbness in the sensory distribution of the median nerve of the left hand, over the course of 24 hours. He had a history of gouty arthritis, with tophi in multiple articulations. Radiographic images were normal. Given the patient’s history and the clinical findings, we considered the diagnosis of an acute carpal tunnel syndrome secondary to a gout crisis. The patient was admitted for urgent carpal tunnel decompression. A longitudinal volar incision was made, and the transverse carpal ligament was divided. A liquefied chalk colored substance infiltrated the carpal tunnel, with associated extensive tenosynovitis. Complete excision of intratendinous tophi was performed, achieving further complete decompression of the median nerve. The excised substance was sent for histology study, confirming the presence of gout crystals. Microbial cultures were negative. The patient recovered complete normal painless motion at one-year follow-up, returning to his labor without limitations. A strict dietary plan and medication were instituted, with no recurrence so far. Conclusion: ACTS due to gout is a rare entity and surgery should not be delayed. Further medical treatment and diet are essential.

There is a lack of understanding of risk factors and postoperative outcomes of syndesmotic injuries with singular versus multi-part fractures. A retrospective analysis was done between 2008 and 2016, utilizing the American College of Surgeons National Surgical Improvement Program database. Patients with open reduction and internal fixation of isolated lateral malleolus fractures, bimalleolar fractures, or trimalleolar fractures were identified. A total of 2045 patients underwent syndesmotic fixation. Subjects with bimalleolar or trimalleolar fractures were more likely than those with unimalleolar fractures to be Caucasian (Odds Ratio [OR]=1.5 and 1.9), female (OR=1.8 and 2.9), above 65 years of age (OR=1.6 and 1.9) or have an American Society of Anesthesiologists (ASA) grade III (OR=1.5 and 1.4) (all, p≤0.028). Patients with a unimalleolar fracture were more likely than those with bimalleolar or trimalleolar fracture to be male (OR=1.8 and 2.9), African American (OR=1.5 and 1.8), under the age of 30 (OR=1.4 and 1.8), or present with an ASA grade I (OR=1.6 and 2.0) (all, p≤0.004). Subjects with bimalleolar or trimalleolar fractures were more likely than those with unimalleolar fractures to have lengthier hospital stays (OR=1.8 and 2.1), while patients with trimalleolar fractures were more likely than those with unimalleolar fractures to have hypoalbuminemia (OR=2.3), develop a complication (OR=2.2) or an open wound (OR=1.9), or to be readmitted (OR=2.2) (all, p≤0.036). Comorbidity rates and adverse postoperative outcomes significantly increase as the number-part fractures increased in syndesmotic fixation patients. Risk factors also vary across fracture severity.

There is a lack of understanding of risk factors and postoperative outcomes of syndesmotic injuries with singular versus multi-part fractures. A retrospective analysis was done between 2008 and 2016, utilizing the American College of Surgeons National Surgical Improvement Program database. Patients with open reduction and internal fixation of isolated lateral malleolus fractures, bimalleolar fractures, or trimalleolar fractures were identified. A total of 2045 patients underwent syndesmotic fixation. Subjects with bimalleolar or trimalleolar fractures were more likely than those with unimalleolar fractures to be Caucasian (Odds Ratio [OR]=1.5 and 1.9), female (OR=1.8 and 2.9), above 65 years of age (OR=1.6 and 1.9) or have an American Society of Anesthesiologists (ASA) grade III (OR=1.5 and 1.4) (all, P≤0.028). Patients with a unimalleolar fracture were more likely than those with bimalleolar or trimalleolar fracture to be male (OR=1.8 and 2.9), African American (OR=1.5 and 1.8), under the age of 30 (OR=1.4 and 1.8), or present with an ASA grade I (OR=1.6 and 2.0) (all, P≤0.004). Subjects with bimalleolar or trimalleolar fractures were more likely than those with unimalleolar fractures to have lengthier hospital stays (OR=1.8 and 2.1), while patients with trimalleolar fractures were more likely than those with unimalleolar fractures to have hypoalbuminemia (OR=2.3), develop a complication (OR=2.2) or an open wound (OR=1.9), or to be readmitted (OR=2.2) (all, P≤0.036). Comorbidity rates and adverse postoperative outcomes significantly increase as the number-part fractures increased in syndesmotic fixation patients. Risk factors also vary across fracture severity.

Introduction: The management of limb-length discrepancy secondary to traumatic bone loss poses an unique challenge for surgeons. The Ilizarov technique is popular, but is associated with long external fixator time and many complications. This retrospective study assessed outcomes of post-traumatic femoral defects managed by monorail external fixation over an intramedullary nail. Methods: Six patients were included from October 2015 to May 2019 with post-traumatic femoral defects, that underwent treatment with Monorail fixator-assisted intramedullary nailing. Mean follow-up time was 232.83weeks. Five were open fractures (Gustilo-Anderson type 3A:n=4, 3B:n=1), one had closed fracture. Average bone defect size was 8cm. Primary outcomes were lengthening index, consolidation time and index, external fixator index. Secondary outcomes were time to full weight bearing(FWB), time to union, complications. Patient reported outcome measures including EQ-5D-5L, SF-36, Oxford knee scores(OKS), Oxford hip scores(OHS) were recorded after recovery. Results: Average consolidation time and index were 9.45months and 1.27months/cm, respectively. Mean lengthening and external fixator index were 21.9days/cm and 26.6days/cm, respectively. On average, patients achieved FWB and union 53.50 weeks and 72 weeks after bone transport initiation, respectively. Two patients had docking site hypertrophic non-union, treated by reamed intramedullary exchange nailing. Two patients had osteomyelitis. EQ-5D-5L and SF-36 scores were compared to UK population norms (p=0.102,p=0.170, respectively). Average OKS was 33.8 and OHS was 39.3. Conclusion: Monorail external fixation over an intramedullary nail is an effective option for post-traumatic femoral defects, reducing external fixator time, lowering complication rate, returning patients’ quality of life to a level comparable with the normal population.

INTRODUCTION: Distal radioulnar joint (DRUJ) is a di-arthrodial trochoid synovial joint involved in pronation-supination and stabilizes the wrist. Poor outcomes after distal radius surgery are due to untreated/unrecognized DRUJ injuries. As per current literature, little evidence supports the efficacy of immobilizing the unstable DRUJ. MATERIALS & METHODS: We carried out a prospective study in a tertiary center. We randomized 60 patients in two comparison groups of 30 each- DRUJ fixed in neutral position using k-wires for 6weeks and DRUJ not fixed. Patients in both groups were followed up for a period of 12months at serial intervals. Evaluation was done using parameters: grip strength, range of wrist motion, supination, pronation, Sarmiento improved Gartland-Werley scoring system (GW score) and serial radiographs RESULTS: AO-OTA Class C and Frykman’s Class VII and VIII were the predominant class in both the groups. In 1.5 and 3 months follow-up, the fixed group had significantly better grip strengths, VAS scores and range of motion. At the 6 and 12 months follow-up, no statistically significant difference was noted. At final follow-up, all 30 patients in the fixed group had excellent outcomes (GW score 0-2). In not fixed group, 28 patients had excellent and 2 had good outcomes (GW score 3-6). No major complications were noted. CONCLUSION: We conclude, fixing the DRUJ in distal radius fractures with an unstable DRUJ operated with volar locking plate has no benefit in functional and radiological outcomes in the long term although it may help early recovery of range of motion and pain.

Scapular fractures are rare injuries due to the thick muscular coverage and represent less than 0.5% of all fractures. They are mostly managed with closed treatment. Some with significant displacement have poor long-term outcomes for the shoulder and the upper extremity as a whole if treated with closed techniques. These fractures are often associated with other injuries, which are sometimes life-threatening. Clinical case of a glenoid fracture with scapular body extension, documented with images of surgery and radiological study. Male, 44 years-old, presented to the emergency room complaining with left shoulder pain and impaired function after a fall upon left shoulder in a motorcycle accident. No neurovascular impairment. No associated injuries. X-ray and CT revealed a glenoid fracture (glenopolar angle < 22º) with scapular body extension (Ideberg Va). Surgery was performed 2 weeks later – open reduction and fixation of the glenoid fragment with 2 3.5mm lag screws through a modified Judet approach. The body fragments were not significantly displaced. Immobilization in a sling for 3 weeks. He had elbow extension weakness, with complete recovery after rehab at 2 months post-op. 4 months after surgery, he has no pain, full range of motion, no infraspinatus hypotrophy, and signs of fracture consolidation with good joint congruity. Open reduction and internal fixation of displaced scapular fractures is a safe and effective treatment option that results in a reliable union rate and good-to-excellent functional outcome. The main risk of surgery is the neurological injury – suprascapular and axillary nerves.

Summary: We report the case of a false equivalent of Galeazzi in children. This lesion is characterized by epiphyseal detachment of the distal end of the ulna instead of the distal radioulnar dislocation. A 16-year-old boy was injured after falling from his own height. The radiograph showed a fracture of the lower ¼ of the radial shaft with posterior angulation, associated with stage 2 Salter and Harris epiphyseal detachment of the distal end of the ulna. An attempt at reduction under general anesthesia was not possible. An open pit reduction was imposed. On exploration, the periosteum was torn and interposed in the fracture site, preventing reduction. The lifting of the obstacle allowed reduction and stabilization was maintained by axial racking-in for the ulna and cross-racking for the radius. We will continue monitoring to prevent growth disturbances at the distal end of the ulna.

Introduction :Tibial shaft fractures are extremely common in orthopaedic practice and there is no unanimous method for their treatment .However , there is an increasing trend towards intramedullary nailing . This study evaluates the outcome of osteosynthesis of closed tibial shaft fractures using Eggers slotted plate and screws. Methods: 200 consecutive adult patients with closed unilateral tibia shaft fracture were treated by open reduction and internal fixation with Eggers plate in Bhattyacharyya orthopaedics and related research centre between May 2014 to May 2016 and were followed up clinico-radiologically for 24 months in terms of pain or tenderness at fracture site , limb length discrepancy , angular or rotational deformity, infection , wound complications, signs of union and implant failure. All patients were operated without using image intensifier.Results : 49.05% patients had fracture involving middle third of tibia and rests were equally distributed between proximal and distal third shaft fractures . 118(59%) patients had achieved union in less than 3 months of time whereas for 74 (37%) patients fracture took upto 5 months to unite. There were 4 cases of delayed union and 2 cases of nonunion and they had significant fracture comminution. 2 patients had infected nonunion. They were all treated with ring fixator. No patients had significant wound breakdown ,shortening or deformity.Conclusion: Eggers plate has excellent outcome in osteosynthesis of selected tibia fractures and obviates the need for intraoperative C-Arm .It is a cheaper and quicker alternative to intra medullary nail especially in developing countries.

Introduction: In the last decades, the surgical treatment of distal radius fractures with volar locked plates has increased in popularity. The presence of implants can predispose to re-fracture. The replacement of peri-implant fractures can be more challenging and associated with various complications.
Case description: The authors report the case of a 64-year-old woman, with history of left distal radius fracture, surgically treated, who presented to the Emergency Department after low-energy trauma to the left wrist. She had a radius fracture, immediately proximal to the plate, and a distal ulnar open fracture, Gustillo and Anderson type II, without neurovascular deficits. Fracture osteotaxis was performed and, 4 days later, the patient underwent definitive treatment with radius anatomical volar plate and ulnar lateral plate. Although the same surgical material was requested, as it was an older version, there were no compatibility of keys, which made it difficult to extract and prolonged the surgical time.
Discussion: Peri-implant fractures of the wrist are very rare, but will probably increase in the future, due to the use of radial volar plates. The presence of an osteoporotic bone and the stress point created at the proximal end of the plate may be at the origin of these fractures. Additionally, this case also warns of potential complications associated with extraction of osteosynthesis material.
Conclusion: Because of the constant evolution of orthopaedic material, the appearance of new fracture patterns and complications in the extraction of the older material are challenges that surgeons will have to continually overcome.

Introduction: The ability to accurately measure post-operative functional outcomes after orthopaedic trauma is a challenging problem. Patient Reported Outcome Measures (PROMs) are widely used for this purpose. Wearable Activity Monitors (WAMs) have been increasingly used to monitor orthopaedic trauma patients during all phases of treatment. The objective of this systematic review was to identify the uses of WAMs in orthopaedic trauma.
Methods: We performed a search in PubMed and Embase for human clinical studies published in the English language between 2010-2019 involving fracture management and making use of WAMs. Papers were reviewed by multiple investigators. Descriptive statistics of variables of interest were used to analyze the data.
Results: A total of 137 papers were available for final analysis. There was a trend of increasing number of WAM publications each year, with the majority of the studies being small (10-50 subjects) case series. Accelerometry followed by plantar pressure measurement WAMs were the most commonly employed technologies. The most common location for WAM placement was insoles, followed by the waist. Hip fractures were the most commonly studied, followed by fragility fractures, then ankle, “lower extremity” and tibia fractures. The rehabilitation phase following surgery was the most common time period studied.
Conclusions: Wearables are emerging in the orthopaedic literature and in evaluating outcomes. Wearable technology can effectively help direct and measure recovery based on the individual patient’s needs, though optimal implementation of this technology has yet to be established.

Virtual fracture clinic is an established way of assessment and normally guided by a senior physio-therapist and a Consultant go through a set of Xrays and decide on management which is execut-ed.As a gold standard practice it should be led by consultant but in our unit registrars also join in for the virtual fracture clinic consultations

.We did an audit cycle to check if it is equally effective and if implemented changes improve practice outcomes.

Out of 604 patients seen,61% pts referred to physical fracture clinic,24% pts discharge13% pts re-ferred to physiotherapy,1% pts referred to GP. Rate of discharge varies between Consultants 57% to 32% which is significant variation (p<0.5) and varies between consultant and registrar (p<0.5).Significant(p<0.05)number of patients with safe discharge were brought back for face to face consultation but this number reduced significantly in follow up audit.
Proportion of patients reviewed in consultant-led VFC has increased (61% to 69%), 11% fewer to face to faceclinic when VFC led by a consultant, There issignificant variation in interconsultant out-come and recall rates. A&E staff training significantly (p<0.05)improved recall outcome.
This audit helped inform the development of a digital VFC pathway integrated between ED and fracture clinic and has been particularly effective in COVID setup. The implemented changes based on first audit has proven as effective measures.

Abstract:Dislocation of the acromioclavicular joint is a common injury with a number of surgical interventions being described for its treatment.Among the different techniques developed, the LockDown synthetic implant(previously called the Nottingham Surgilig) is a synthetic ligament which has been increasingly used in the ACJ reconstruction with encouraging results.

Objective: To assess the post operative results in patients who underwent acromioclavicular joint reconstruction using the LockDown system as well as measuring the radiographic appearance in the post operative radiograph.Patients with a minimum 2year follow up were included in the study.

Methods: A retrospective case series evaluating 30 patients undergoing ACJ reconstruction with the LockDown system with at least two years of follow up.The clinical assessment was conducted before and after the operation using the Oxford shoulder score and the visual analogue pain score.Types of complications(infection rate, implant failure, bone osteolysis) as well as the radiographic appearance were also noted.

Results: The patients who underwent a Lockdown synthetic implant reconstruction for an acromioclavicular joint dislocation, improved from
24.67±2.35 to 46.8±2.35, p<0.001 in the 2year follow up appointment.According to the Visual Analogue Scale, the pain was reduced significantly from 6.87±0.33 to 1.11±0.22, p<0.001.Complications occurred in 6.6% of the patients, with 2 cases of superficial wound infections.

Conclusion: Patients who underwent a LockDown synthetic implant reconstruction had a significant improvement in their quality of life.From our case series, its widely use is totally justified, making the Lockdown system a valuable tool in the management of acromioclavicular joint dislocations.

Background: The use of electric scooters (e-scooters) has dramatically increased as they become an attractive alternative for public transportation in busy metropolitan areas worldwide. Despite their benefits, e-scooters challenge the
health-care system with poorly understood forms of injuries, mainly orthopaedic fractures. Methods: A total of 3,331 e-scooter-related admissions were retrospectively collected between May 2017 and February 2020 in a level-I trauma center. These admissions were analyzed for demographic variables, orthopaedic fracture diagnosis, associated injuries, and surgical treatment. Results: A total of 716 fractures were diagnosed in 563 patients, with 46.4% of the patients requiring hospitalization. Of 492 upper-limb fractures, 89.2% occurred in a rider fall mechanism; and of 210 lower-limb fractures, 15.7% occurred in rider-vehicle collisions. Fifty-nine percent of long bone fractures were complex fragmentary and/or intra-articular fractures. Orthopaedic surgeons recommended that 225 fractures undergo surgical treatment. The
most common upper-limb fracture was AO/OTA class 2R1A, with open reduction and internal fixation of the distal part of
the radius being the most common upper-limb procedure (n=58). The most common lower-limb fracture was AO/OTA
class 41C, with open reduction and internal fixation of the proximal part of the tibia being the most common procedure (n=28). A total of 22 patients (3.9%) required reoperation within 1 year.
Conclusions: This investigation provides unique information on demographic characteristics, patterns, and treatment of
orthopaedic fractures secondary to the high-energy mechanism of e-scooter injuries. These new in-depth data are
important for health-care system preparedness with regard to management and resource allocation to treat these
challenging injuries.

Acute limb compartment syndrome is a limb threatening emergency that requires prompt recognition and treatment. It consists on an increase in the interstitial pressure of an osseofascial compartment, leading to decreased capillary perfusion and micro vascular compromise. Consequences can range from muscle necrosis, limb amputation or even death.  Diagnosis is most commonly made after repeated examination and, if necessary, on intracompartmental pressure measurement. The most common causes of acute compartmente syndrome are fracture or a blunt force. A stab injury as a cause of an acute compartment syndrome is a rare event. The autors report a case of an acute compartment syndrome of the forearm, as a result of a 1 cm stab lesion with an X-Acto knife. On time diagnosis and prompt fasciotomy of the forearm lead to satisfactory outcomes and limb salvage.

Introduction: Artisanal coated intramedullary standard nails with a layer of antibiotic cement were used in osteosynthesis of the long bones of the lower limbs that had septic non-unions: case report series. Obtaining alignment was easy and reaming also improved consolidation and healing.
Methods: We treated 12 cases with tibial and femoral septic non-union operated between 2011-2019. Four cases had severe malalignment (10 degrees-30 degrees). After debridement and reaming of the bone in excess by 4 mm thicker than the desired nail diameter, we performed the synthesis with cemented nails. We manually coated the intramedullary standard nails with a layer of specific antibiotic cement, inserting a nail into a cement prefilled sterile tube. In 10 cases we were able to locked the crafted nail.
Results: Healing of the non-union was achieved in all cases and restoration of alignment was obtained in 11 cases. The shortening was required in 4 cases with an average of 1.5 cm, but in one case the elongation with the equalization of lower limbs was obtained. In 4 cases we have added hydroxyl apatite locally preloaded with Tobramycin. Clinical and laboratory criteria confirmed the absence of sepsis. There was no need for a reoperaton.
Conclusions: Good results have been obtained with this cement-antibiotic coated crafted nails in septic diaphyseal non-union of the tibia and femur. The one-step surgery managed to solve the non-union, septic, and malalignment. Our experience is limited, but in the future, it could be a valuable method.

Purpose of study

We present the technique and results of IM Nailing for 4 part proximal humeral fracture-fixation in accordance with AO principles.


Method

Retrospective case series of 14 patients with 4 part proximal humerus fracture between 2013-2015. Two patients had dislocation of humeral head along with the fracture. They were treated with Stryker T2 proximal humeral nail by one operating surgeon.

Beach chair position, deltopectoral approach is used. Entry point in head is made by multiple holes by 2mm K wire. T2 proximal humeral nail is inserted. The nail is fixed in the shaft. The repair of tuberosities to shaft with 2 transverse and 3 figure of eight sutures. The proximal locking bolts are inserted and used to compress greater tuberosities . The anteroposterior bolt compresses lesser tuberosity. The tuberosities are further repaired around the bolt.

Results

The average age was 62 years and follow up was 11 months. All patients but one has shown healing of tuberosities. Average oxford shoulder score at final follow up was 38 (range 32-42). There was no post operative infection. There was mild varus collapse in one patient. One patient needed removal of superolateral bolt.
Average range of motion was: Forward flexion- 100 degrees, Abduction- 90 degrees, Internal rotation- lower lumbar spine and External rotation- 20 degrees.

Conclusion

Potential benefits include the ability to compress tuberosity fragments perpendicular to the fracture line leading to good healing, higher stiffness values in bending and torsional load, biomechanical advantages of a shorter lever arm.

Introduction:The molecule Teriparatide has a positive bone forming effect and has proved its role in healing of vertebral fractures and in treating osteoporosis over the last 15 years.Aim: To establish the healing effect of teriparatide in delayed union of meta-diaphyseal fractures in long bones. Many meta diaphyseal fractures in long bones tend to go into delayed and non union in old age. To prove its role in augmenting fracture healing and hence avoid a second procedure like a bone grafting. Method: A series of 20 long bone fractures including proximal femur, distal femur, proximal tibia, distal tibia were included in this study. Tereparatide therapy was started after signs of delayed union or non union appeared.Patients were reviewed on a monthly basis both clinically and radiologically.Results:All patients were reviewed on a monthly basis clinically and radiologically.All fractures healed by 12 to 16 weeks of teriparatide therapy.We had no untoward incidents in the study population. Conclusion: Teriparatide therapy has a definite role in the healing of delayed and non union of long bone fractures. It helps to avoid a second procedure like bone grafting in a significant number of patients.

Introduction: To evaluate retrospectively the complications of the surgical treatment of displaced acetabular fractures. Methods: Between 2011 and 2018 a number of 108 patient with displaced acetabular fractures were treated. The group comprised 94 male and 14 female with the average age of 44.2 years. According to the Letournel classification 29 posterior wall fractures (26.8%), 8 posterior column fractures (7.4%), 26 transverse fractures (24%), 13 posterior column and posterior wall fractures (12%), 25 transverse and posterior wall fractures (23.1%) and 7 T-shaped fractures (6.5%) were noted. Results: Intraoperative complicatons were vascular injuries (5 cases) and damage to the static nerve (2 cases). Quality of reduction (Matta's criteria) shows anatomical reduction in 60 cases (55.5%), imperfect in 31 cases (28.7%) and poor in 17 cases (15.7%). Neurological injury represented by peroneal nerve palsies occurred in 6 patients (5.5%). Acute infection was noted in one case. Two year clinical results (available for 92 patients) were excellent in 38 cases (41.3%), good in 38 cases (41.3%), fair in 10 cases (10.9%) and poor in 6 cases (6.5%). There was a statistically significant correlation between quality of reduction and clinical results. Heterotopic ossifications were recorded in 31 cases (33.6), osteonecrosis of the femoral head was recorded in 9 cases (9.9.%) and arthrosis in 9 cases (9.9.%). Hip arthroplasty was the final solution for 14 patients (15.2%). Conclusions: Despite the relatively large number of complications, surgery treatment for acetabular fractures offers better results than conservative treatment, in which the complication rate is much higher.

Objectives
Define medical-related causes for operative delay in hip fractures beyond 36 hours from diagnosis against National anaesthetic safety guidelines for the preoperative management of these fractures.

Methods
A retrospective review of 249 hip fracture patients admitted to our hospital between May 2018 and March 2019. Patients, breached 36 hours due to medical causes, with isolated closed proximal hip fractures were included.

Results
74% patients were operated within 36 hours meeting the best practice tariff, 20% were delayed beyond 36 hours and the remaining 6% were managed non operatively as medically unfit, amongst half died whilst admission. Out of the 49 patients who breeched, 64% were because of medical reasons whilst 36% were because of non-medical causes as theatre or surgeon availability. The medical causes for delay were distributed as follows 32% needed for medical optimisation for deranged laboratory investigation or chest infection, 40% awaited cardiology review or Echocardiography as requested by the anaesthetist, finally, 28% were delayed to allow time for oral anticoagulants to be cleared from their systems after the stoppage.
Nearly 25% of this couldn't be justified when challenged against the local and anaesthetic guidelines.
we advised each hospital should revise their policies and evaluate the delayed patients especially regarding managing pre-existing oral anti-coagulant stoppage, cut-off points for different electrolytes and Echocardiography indication in order to avoid undue delay of management of neck of femur patients

Introduction: The coronavirus pandemic has placed the world, but especially, the medical profession in an unprecedented situation. Each city has experienced a major burden in their resources and infrastructures. This change made hospital administrations adapt and change the way of providing Health Care. Countries in lockdown are expected to have less major trauma, but, despite that fact, accidents and injuries still occur. Surgical procedures have become restricted to urgent or emergency cases, such as trauma or infections. Methods: We collected the data, in our hospital, Hospital Senhora da Oliveira, Guimarães, concerning only trauma patients with surgical treatment need, in the covid era (March 2020-March 2021) and compared it with the previous period (March 2019-March 2020), trying to categorize them in terms of type of acident, part of the body injured, severity of the injury, sex and age of the patient. Results: Every medical specialty developed protocols within the local context to cope with the crisis. We aim to provide a general picture and a commentary on the evolving situation in our orthopaedic department. Also, we wanted to acknowledge what has changed regarding the emergent surgeries. We tried to shed some light in the real causes behind these changes and if the delay in admission time, due to fear of Covid, had any role on the worsening of patient’s prognosis.

Introduction: Temporary transarticular stabilization, using Steinmann pins or Kirshner wires, has been an option for treating unstable fracture-dislocations in the upper extremities in adults and children. A migrated wire or pin can have dire consequences, prompt recognition and immediate retrieval of the implant is paramount to avert these complications. Although uncommon , intrathoracic migration is a serious complication that demands immediate removal.
Case presentation: We present a case of a 55 years-old man that underwent surgery (open reduction and internal fixation) for a proximal humerus fracture/dislocation and transarticular stabilization, using a Steinmann pin, due to maintained posterior instability. An asymptomatic intrathoracic migration of the Steinmann pin was diagnosed 2 weeks post-operative. The Steinman wire was successfully retrieved via a deltopectoral approach.
Conclusion: The migration of pins and wires can occur with severe complications (including death). They should be used cautiously and followed both clinically and radiographically, until all the wires are removed. A migrated pin into the lung can be a challenging case for physicians especially in postoperative period.

Introduction: Primary hemiarthroplasty is a proposed surgical treatment for unstable intertrochanteric fractures in the elderly to overcome the disadvantage of protected weight-bearing following fixation with acceptable functional results. Objective: To evaluate the functional outcome of unstable intertrochanteric fractures with primary cemented hemiarthroplasty in severely osteoporotic elderly patients. Methods: From 2015-2019, 50 patients were operated on according to inclusion criteria and results were analyzed prospectively. According to Evan’s Classification, only type 3 and above were included. The Harris Hip Score (HHS), time duration of the surgery, intraoperative blood loss, postoperative time to full weight bear, complications were analyzed. Results: Follow-up evaluations were performed at 6 weeks, 6, 9, and 12 months, and every year thereafter (mean 1.5 years). The average duration of surgery was 81.36 min, with a mean blood loss of 361.03 ml. All patients were full-weight bearing with a walker on an average of 3.2 days. Excellent to fair results were obtained at final follow-up in 45(90%) cases and in 5 (10%), the results were poor. Average HHS improved from 69.7 (poor) at 6 months to 80.1(good) at final follow-up. However, 8 patients (16%) developed complications in terms of greater trochanter non-union, breakage of cerclage wires, superficial infections, and peri-prosthetic fractures. Conclusion: For severe osteoporotic elderly with unstable fractures, hemiarthroplasty is an effective surgical alternative to internal fixation to reduce the complications of recumbency and nil-weight bearing. The procedure offers the best chance to the patient for faster mobilization, improves the quality of life, and gives a long-term solution.

Introduction: Olecranon osteotomy can be used for intra-articular exposure in complex fractures of the distal humerus; however, it may result in complications. Methods: We retrospectively evaluated the results and complications of the fractures treated using this technique in our institution. Results: From 2009 to 2018, we used olecranon osteotomy in 25 cases. The osteotomy was fixed through different methods, according to surgeon preference: tension band wiring in 56%, a canulated screw in 44% and locking plate in 4% Hardware removal due to patient intolerance was performed in 4 cases (2 cannulated screw and 2 tension band wiring). In 2 patients with cannulated screws, revision surgery was needed – 1 for delayed union and another for screw pull-out. One was reviewed using a locking plate and the other using tension band wiring; both lead to union of the osteotomy. One patient had dysesthesia in the ulnar nerve territory; however, there were no motor changes and the electromyography was normal. All patients achieved union of the osteotomy (considering the 2 cases which needed revision). Average range of motion was 18-114º. Discussion: This study has shown the importance of adequate fixation of the osteotomy - in our series tension band wiring had better results. The most common complication was hardware intolerance. Functional range of motion was achieved in most cases. Conclusion: Olecranon osteotomy should be considered for better exposure in complex distal humerus fractures. Although there are complications, most of them seem to be manageable, with good results.

Introduction: Humeral trochlea fractures are usually associated with elbow dislocations or capitellar fractures. Isolated trochlea fractures in adults are a surgical rarity as compared to its capitellar counterpart. Laugier was the first to provide an original description of the fracture in 1853, and as a result it is often referred to as Laugier’s fracture. To our knowledge, there are only 15 cases reported in the literature concerning isolated trochlea fractures.
Case Report: We report a clinical case of a male patient, 15 years-old, that presented to the emergency department after falling from height and landing on his outstretched hand. He presented with severe pain at the elbow, swelling and functional incapacity. The radiographic study demonstrated an isolated trochlea fracture, with severe displacement. We decided for surgical treatment with open reduction and internal fixation with 2 cannulated screws, 3.0 mm.
Outcome: After 1 year of follow-up, the patient had an excellent outcome, with full range of motion including full pronosupination, no signs of instability and a Mayo Elbow score of 100.
Conclusion: The trochlea rarely fractures in isolation and the reasons for such are numerous. It has no muscular or ligamentous attachments and the ulnohumeral joint is not subject to shear forces that occur at the radiocapitellar joint. The treatment mainstay of displaced trochlear fractures is surgical stabilization. Open reduction and stable internal fixation combined with early motion exercises can achieve optimal results.

Objectives:
To compare the functional outcome of Deltopectoral and Deltoid-Split approach in proximal humerus fracture managed with locking plate fixation.

Methodology:
This randomized controlled trial (RCT) was conducted for a duration of 2 years, i.e. from 15th March 2018 to 15th March 2020. All patients with isolated proximal humerus fracture (Neer’s type II and III) belonging to either gender aged between 20 to 50 years were included in the study. Patients were randomly divided into 2 groups; A and B. Group A was managed with Deltopectoral approach while those in group B underwent fixation using Deltoid-split approach. Functional outcome was assessed using Quick- Disabilities of Arm, Shoulder and Hand (DASH) score at 1 year follow-up. Data was analyzed using SPSS version 23.

Results:
A total of 60 patients were included in the study. Mean age was 41±3.4 years. Functional outcome in terms of Quick-DASH was significantly better in group A (13 versus 24, p<0.01).

Conclusion:
Deltopectoral approach has better functional outcome at 1 year in proximal humerus fracture as compared to the Deltoid-split approach.

Objectives: After some surgeries with ZipTight fixation for patients with acute acromioclavicular dislocation or distal clavicle fracture with disruption of the coracoclavicular ligament, some patients showed loss of reduction in the acromioclavicular joint or fracture fragment. To prevent that, we started temporary Kirschner wire (K-wire) fixation. In this study, we evaluated the efficacy of temporary K-wire fixation between the clavicle and acromion of the scapula. Methods: Fourteen patients with acute acromioclavicular dislocation (six patients with Rockwood’s classification type 3, seven with type 4, and one with type 5) and three patients with distal clavicle fracture with disruption of the coracoclavicular ligament (all patients with AO classification 15.3A) were treated. One ZipTight suture was inserted between the clavicle and coracoid process of the scapula after reduction and fixed by using K-wires in all patients. The K-wire was left in three patients for 43 (range, 31–53) days after surgery and was removed during surgery in 14 patients. Results:
The average follow-up period was 7.4 months. The average coracoclavicular distance was measured before surgery, just after surgery, and at final follow-up. Subsequently, the amount of postoperative collection loss was evaluated. The amounts were 1.0 (0–2) and 3.2 (0–10) in the patients with and without a temporary left K-wire, respectively. Conclusion:
Our results suggest that coracoclavicular ligament reconstruction with ZipTight and temporary K-wire fixation prevented re-dislocation of the acromioclavicular joint or the fracture fragment and could be a useful treatment procedure.

Introduction: Distal biceps tendon rupture is an uncommon injury for which surgical repair is typically recommended. Whilst functional outcomes are typically good irrespective of time to surgery, delayed repair can result in increased complications. Our aim was to determine patient satisfaction & post-operative complication rates following distal biceps tendon repair and compare those repaired acutely with those whose repair was delayed. Method: Single-centre, multi-surgeon retrospective review of all distal biceps tendon repairs between April 2014 and April 2018. Data were collected on mechanism and laterality of injury, hand dominance, surgical timing & technique, and post-operative complications. Telephone interviews were conducted to determine patient satisfaction, utilising the Oxford Elbow Score (OES) and Quick Disabilities of Arm, Shoulder and Hand (QDASH) outcome measures. Results: 29 patients identified (100% male), average age 40. 24 patients repaired within three weeks of injury. Three minor post-operative complications reported, all in acute repair group. 24 patients were available for telephone follow-up. Average follow-up period was 46 months. Average OES was 46 (range: 26 – 48), and average Q-DASH was 3.2 (range: 0 – 45.5). When comparing acute and delayed surgical repair, there was no significant difference in either OES (p= 0.51) or Q-DASH (p= 0.88), nor in post-operative complication rates (p= 1). Conclusion: Patient satisfaction following distal biceps tendon repair remains high and complication rates are low, irrespective of time to surgery, even beyond three years post-operatively. To our knowledge this is the longest follow up period yet comparing acute and delayed repair.

Aims: This study aimed to evaluate the clinical outcomes of well-fixed periprosthetic tibial fractures after TKA.
Patients and methods: The medical records of patients who presented with Felix type 2A periprosthetic tibial fractures after TKA were retrospectively obtained from 5 institutions. Data on injury mechanism, fracture pattern , and surgical method were recorded. Functional outcomes including range of motion (ROM) and Knee Society Score (KSS) at postoperative 1 year were reviewed. Radiologic findings included union time and mechanical proximal tibial angle (MPTA) at the last radiologic follow-up.
Results: Eighteen patients (average age, 73.9 years) were included. The fractures resulted from high-energy (11 cases) and low-energy (7 cases) injuries. Two cases involved open fractures. Anatomical locking plates were used in all cases: single plate (4 cases) and dual plates (14 cases). The average number of proximal screws was 7.1 (range, 4-9). All patients achieved bone union at an average of 18.6 weeks without secondary intervention. No infection occurred; however, 1 patient with skin necrosis required local flap. Implant removal was performed in 5 cases: 1 case, skin defect and 4 cases, discomfort due to plate prominence. The average ROM and KSS were 120.3° and 85.9, respectively. The mean MPTA was 87.8°; the MPTA was higher in the single-plate group (94.0° vs. 88.1°, p=0.013). The malalignment rate was higher in the single-plate group (p=0.043).
Conclusion: Felix type 2A periprosthetic tibial fractures treated with minimally invasive osteosynthesis showed excellent clinical outcomes, and tibial alignment was well maintained in the dual-plate group.

Due to increasing number of high-energy traumatic events, the incidence of complex and compound fractures are also in the rise. Such fractures are often exposed to various environmental contaminants, inadequate debridement and sometimes erroneous decision making leading to cases of infected nonunions. Eradication of infection in such cases and achieving union may sometimes pose serious challenge to orthopaedic surgeons. Presence of comminution, bone gap or deformity can seriously complicate the situation. No definite surgical technique has been found to be full proof in dealing with these infected nonunion cases. In this scenario the limb reconstruction system (LRS) fixator is emerging as a useful option for infected nonunions with deformity or gap nonunion. Fifty one cases of infected nonunions involving tibia (n=37), femur (n=13) and humerus (n=1) were treated by LRS fixators after debridement of the infected nonunion site. Flap cover procedure was done as per necessity. Bone gaps and limb length discrepancies were dealt with bone transport or limb lengthening by the LRS instrument. Weight-bearing and removal of fixator was decided according to the radiological evidence of healing. All the nonunion sites except 1 and all the regeneration sites healed uneventfully, although the union time was varied (range, 21-52 weeks). Commonest complication was pin-tract infection and pain. The mean lower extremity functional score (LEFS) was 60.3 out of 80. LRS fixator is an excellent tool for management of infected nonunions which is easy to apply, comfortable for the patient with minimum complications and predictable as well as reproducible outcomes.

The published literature on the treatment, results and complications of distal femur fractures in the elderly is limited, however they seem to be associated with significant mortality.
The objective was to describe an elderly population with fractures of the distal femur, to report the mortality rate in the first year and factors associated with it.
Retrospective study of patients with age ≥65 years and with distal femur fractures treated at our institution, between August 2011 and April 2018.
78 patients were identified and 3 were excluded. The majority (90.7%) were female. The median age was 81 years old. The Charlson Comorbidity Index had a median of 5. According to the classification of the American Society of Anesthesiologists, 77.6% of patients undergoing surgery were ASA III or IV. The most frequent fractures were supracondylar fractures (48%).
Surgical treatment was performed in 78.7% of the cases (osteosynthesis with plate and screws in 45.8%, endomedular nailing in 50.8% and fixation with screws in 1.7%).
The mortality rate at 1 year follow-up was 14.7%.
In univariate analysis, age and Charlson's Comorbidity Index were associated with mortality in the first year, with an odds ratio (OR) of 1.131 [confidence interval (CI) 1.017-1.257] and 1.354 (CI 1.061-1.728) respectively. No association was found between ASA classification, type of fracture, treatment modality, surgical technique and time to surgery with mortality.
Fractures of the distal femur in the elderly are associated with significant mortality. However, the factors associated with this mortality are not completely established.

The elbow is one of the most commonly affected joints in pediatric traumatology, although fractures of the capitellum humeri are rarely reported, due to the late ossification (around age 14) of its ossification centre. The most common cause is a fall on an outstretched arm, usually from standing height, and patients present with elbows in a semi-flexed position. A 14 years-old male patient with Down syndrome presents himself at the emergency service after falling on the school's playground. The fall was not observed. He keeps the right elbow in a semi-flexed position and refuses active elbow motion. No visible swelling. Physical examination was severely hindered by the patient's lack of cooperation. Lateral and face radiographs of the elbow point to a possible lateral condyle/capitellum fracture, and oblique radiographs confirmed a displaced type 1 capitellum fracture. The child was taken to the operating room and open reduction (through an anconeus approach) and internal fixation with headless screws was performed. Vascular status was normal before and after surgery. Capitellum fractures are rare fractures associated with a common injury mechanism. There is a lack of consensus regarding optional management. Utmost attention by attending orthopaedists is necessary to avoid misdiagnosis and complications.

Background: The “terrible triad” injury it’s a rare condition that combines elbow dislocation, radial head and coronoid fractures. The definition of “terrible” regards the increased elbow instability and the associated complications, such as soft-tissue disruptions. Although selected terrible triad injuries can be managed non-operatively, the majority of injuries are treated with surgery repair to allow early elbow motion.
Case Presentation: The authors present a case of a 57-year-old female with an accidental fall and direct trauma of her left elbow. An initial evaluation was performed with an X-ray. She was diagnosed with posterior dislocation of the elbow with a radial head fracture and a coronoid fracture. A CT scan was performed for surgery planning. The operative treatment is often complex and in this particular case, despite the pre-operative plan, intraoperatively it was realized that the fragment was too small to accomplish reconstruction of the coronoid process. However, it was possible to use part of the radial head to “reconstruct/replace” the coronoid and fix it with a Herbert screw.
Clinical Outcomes: Eigth months after the surgery, the patient has 110 degrees of flexion, a limitation of 10 degrees in extension, and no limitation at prono/supination.
Discussion: Complex elbow dislocations are injuries with not only a significant risk of long-term disability but also challenging to operate. The aim of surgical fixation is to stabilize the elbow to allow early mobilization. In this clinical case, surgeons want to flag that, despite pre-operative studies recurring to CT scans, procedures don’t always go as planned.

Aims: To establish the incidence and nature of injuries seen in patients following mobility scooter accidents. Methods: Data was analysed from the Trauma Audit and Research Network (TARN) database for patients who had suffered from injuries related to mobility scooters between the ages of 20 to 99 years from February 2014 to November 2020 in NHS England. Patient demographics, injury mechanism and pattern and mortality rate were analysed. Results: 1504 patients were identified (61.3% male). The mean age was 73.3 (20.1 to 99.8) years. The mean Injury Severity Score (ISS) was 12.3 (1 to 59). Severe trauma (ISS ≥16) was seen in 29.4% of patients. Higher Abbreviated Injury Scale (AIS) scores were seen in patients who sustained injuries to the extremities (mean AIS 1.41). The mean length of stay in hospital was 17 days. Overall, mortality following injury was 10.6%. The majority (74.8%) of patients dying from their injuries were aged 75 years or over. Conclusion: As the population ages, injury characteristics of those with major trauma changes. Mobility scooter use is prevalent amongst older people and we provide a detailed analysis of injuries sustained with their use across a national database. Extremity trauma predominates and the length of stay and hence the resource use inherent is considerable. These injuries particularly affect the ‘most old’ and carry a considerable mortality burden.

Background: A randomized clinical trial (RCT) compared outcomes of intramedullary nailing (IMN) versus external fixation (EF) for open tibial fractures in Tanzania and found no difference in reoperation, though questions about late infection and union remained after one year. The purpose is to ascertain any differences in outcomes with longer-term follow-up. Methods: The RCT included adults with acute open tibial shaft fractures who were randomly assigned to statically locked, hand-reamed IMN or uniplanar EF. These patients were re-evaluated three to five years after treatment. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Secondary outcomes included quality of life, function, and radiographic alignment and healing. Results: Of the 240 RCT patients, 126 (52.5%) patients (67 managed with IMN and 59 managed with EF) died or returned for follow-up at a mean of 4.0 years (range 2.9 – 5.1 years). There were no significant differences in demographic or injury characteristics between those with and without longer-term follow-up. Thirty-two composite primary events occurred with rates of 23.9% and 27.1% in the IMN and EF groups, respectively (relative risk [RR] = 0.88, 95% confidence interval (CI) 0.48-1.60) with no significant differences in event type. Persistent complications were present at long-term follow-up in 25% of patients who sustained a primary event. Secondary outcomes were similar between groups. Conclusion: While no differences in primary events were detected at a mean of 4 years, fracture-related infection and nonunion complicate management of these injuries in nearly a quarter of patients.

Purpose
Our study aims to assess the burden of periprosthetic fractures at a large district general hospital over 10 years, describe patient, fracture characteristics and explore the challenges of current infrastructure for their management.

Methods
Retrospective data from January 2011 to December 2020. We recorded patient demographics, primary arthroplasty procedure, fracture classification, mode of periprosthetic fracture management, time period between primary operation and fracture, morbidity and mortality.

Results
229 Periprosthetic fractures. Number of fractures in 2020 was triple to 2011. Mean age 78.6 years (range 33-100), with 151 females. Two-thirds of the patients were ASA grade 3 or above. 62.89% about Total Hip Arthroplasties (THA), 30.6% about Total Knee arthroplasties (TKA). 11 post hip hemiarthroplasty, Unicondylar knee arthroplasty, Reverse Shoulder Arthroplasty, Shoulder hemiarthroplasty and Total Elbow arthroplasty were 1 case each. 60% of THA’s were cemented and 85% of TKA’s were cruciate retaining. Majority of the fractures were IV.3.B2 (30.6%), followed by IV.3.B1 (17.9%) and V.3.B1 (15.7%). Mean time to surgery was 6.06 days (range 1-24). 75% of the fractures were managed locally. 36.25% of the fractures treated with open reduction and internal fixation, 32.75% managed non-operatively, 27% underwent revision. 93.89% patients had a favourable outcome. Cumulative mortality risk at 30 days was 2.18%, 1 year 23.58% and 5 years 38.87%.

Conclusion
The burden of Periprosthetic fractures is increasing. With high mortality and morbidity risks, a robust multidisciplinary team approach alongside an efficient higher specialist centre referral system is recommended. Our model demonstrates the importance of a well-established clinical system.

Oral Anticoagulation – method of treatment or prophylaxis, routinely used in elderly and frail patients, when an underlying heart disease or condition needs constant control. Low energy, minor trauma – direct hit or twist, might induce deep sub fascial bleeding, often unrecognised and undertreated or not treated at all. Extensive area of the muscles cuffs and subcutaneous tissue might get involved, leading to skin necrosis, often secondarily macerated and infected. Aggressive surgical debridement is necessary, but here lies the problem – the defects left are large and difficult to cover primarily, hence NPD are often utilised. The treatment is long, expensive and often necessitating grafting.

Background & Objectives: Per-trochanteric femoral fractures are of intense interest globally. In the management of per-trochanteric fractures, intramedullary (IM) devices have proven advantage over extramedullary devices. The aim of our study was to compare functional outcome between proximal femoral nail (PFN) and proximal femoral nail anti-rotation (PFNA) using modified Harris Hip Score and amount of blood loss, duration of surgery, complications & time to union. Materials and Methods: A total of 100 patients with per-trochanteric fractures fulfilling inclusion and exclusion criteria, were randomized into 2 groups to undergo fixation with either standard PFN (n=50) or PFNA (n=50). They were compared in terms of demography, per-operative variables and postoperative parameters including functional evaluation till 6 months postoperatively. Result: Background demographic variables were comparable between the groups. Operative duration of surgery, amount of blood loss and number of fluoroscopic images were significantly lower in PFNA group as compared to PFN group. Complications like infection, time to union, cut out/z-effect didn’t differ significantly between the 2 groups. Post op functional recovery as evaluated by pain and modified Harris hip scores were similar in both groups. Conclusions: PFNA significantly reduces the operative time, amount of blood loss and fluoroscopic imaging as compared to PFN. However PFNA offers no significant benefits over PFN in terms of functional recovery or complications. Keywords: Proximal femoral nail anti-rotation(PFN-A), Proximal femoral nail(PFN), Per-trochanteric fracture

Introduction:
Paediatric avulsion fractures of the pelvis and hip joint are rare injuries most commonly associated with a rapid muscle contraction
of the respected apophysis, which is the weakest component of the growing skeleton. The chosen therapy option can be either conservative or surgical.

Methods:
We present a cohort of 69 patients treated for an apophyseal avulsion fracture of the anterior superior / inferior iliac spine, the lesser and greater trochanters iliac crest and the ischial tubercle. We compare the treatment outcomes, treatment time, need for immobilisation, and complications of conservative vs. surgical treatment.

Results:
The mean time to mobilisation was 24.5 days in the conservative and 8.5 days in the surgical group of patients. In the group of surgically
treated patients, healing signs were observed as early as in week 6. As of month 4, no difference was observed between the groups in terms of the clinical and radiological outcomes.

Conclusions:
The treatment outcomes of both methods are comparable in the long term. Surgery is indicated in dislocations exceeding 1 cm. Faster
recovery and return to sports activities is the main advantage of the surgical treatment method. Disadvantages include the necessity of general anaesthesia as well as the risk of infection and the need of the osteosynthetic material removal. The choice of the treatment method remains individual depending on the type of injury and habitual practice of the centre.

Introduction: Jeffery type fracture in children is rare. However, when associated fractures go unrecognized, physical impairment may develop. The purpose of this study was to evaluate outcomes of treatment for Jeffery type fracture in children and discuss the diagnosis and treatment.
Materials and Methods: A total of 6 patients (male: 3, female: 3). All treatment was performed in one institution from 2010 to 2020. Average age at injury: 8.2 yrs. (3-12 yrs.). Mechanism of injury: falling onto an outstretched hand in all patients. Average F/U period: 3.1 yrs. (4 mos. – 10 yrs.).
Results: Bone union was achieved in all patients. Cast or splint fixation was applied for an average of 4.3 wks. postoperatively. Average ROM (E/F) at final F/U: 0 - /140.8 °(140- 145°). Average carrying angle: 171.2 °(159- 179°). No valgus instability with symptom and no complications.
Discussion: Pediatric fractures may be difficult to diagnose. In two of our patients, although medial epicondyle fracture (MEF) before the appearance of epiphyseal nucleus and greenstick fracture of the olecranon had gone unrecognized until the appearance of callus formation, fortunately, favorable results were achieved in both cases. However, unrecognized MEF might lead to painful pseudarthrosis or tardy ulnar nerve palsy, and unrecognized radial neck fracture may cause restricted forearm rotation. These results suggest that if identifying a fracture around the elbow, the presence of other associated injuries should be suspected and tested for using modalities such as ultrasound, MRI, and arthrography.

Introduction. Floating knee injury (FKI) is considered a high-energy fracture of the ipsilateral femur and tibia. This study aims to evaluate a series of patients with floating knee injuries, isolated or in the context of polytrauma, focusing on complications and fracture management. Methods: Retrospective review FKI cases treated since January 2012 in our institution, with a minimum 12 months of follow-up. Data include associated injuries and the management protocol. Complications were defined as early and late. Results: Out of 1002 lower extremity fractures, 45 were FKI. The mean age was 37.8 years. Motorcycle accident (46.6%) was the principal injury mechanism. 55 % of patients were considered polytraumatized, although a higher 82% were managed with external fixation on admission. 64.5% of tibial fractures and 24.6% of femoral fractures were open. Complications were: fracture-related infection (FRI) of the tibia (20%), FRI of the femur (9%), symptomatic hardware (11%), and late amputation (8.8%). Delayed union or nonunion occurred in 6.5% overall. No statistically significant difference in the incidence or type of complications between polytrauma and non-polytrauma patients was found. The preferred method for definitive fixation was intramedullary nailing (IMN) for the tibia and femur (all retrograde in the latter). As surgical expertise has increased, it has been indicated for periarticular fractures as well. Conclusion: Floating knee injuries have a high prevalence of early and late, systemic and limb-related complications. These are comparable for polytrauma or isolated injuries. Tibial and retrograde femoral IMN has been our preferred method for definitive fixation.

introduction: Nonunion of long bone fractures has become a common problem in orthopedic practice. Non union of a fracture can occur both in conservative as well as in operative treatment . Infected non-union of long bones not only a source of functional disability but also it can lead to various economic and social hardship. Infected non-union can result from various etiologies, commonest being, open fractures, previous surgical procedures or as squeal to osteomyelitis of bone. Case series: We present a series of 04 cases of non union tibia in patients managed with LRS fixator. All the patients are having good functional outcome. All patients had open fracture for which they were managed. One patient had compound grade 1 proximal tibia fracture whose wound was managed first and then internal fixation was done with platting. For other 03 patients due to compound tibia fracture external fixation of Tibia was done as primary procedure, wound was debrided antibiotics given and skin grafting for 2 patients and flap cover for 1 patient was done. After the wound has healed the non union of tibia was managed with LRS fixator which showed good outcome discussion: Distraction osteogenesis and bone transport can be considered to be the gold standard for infected gap non-union of the tibia as it simultaneously solves the problem of the bone gap, infection (radical debridement without fear of bone gap), deformity correction, early weight bearing and concomitant soft tissue expansion. this case series shows good outcome in all the 4 patients.

Introduction: A 81 year old female patient was admitted to Salisbury District Hospital with an interprosthetic fracture of the left femur in August 2020. She underwent previous bilateral hip replacements and left total knee replacements. Her management is presented to share the learning and reflect on the experience. Methods: This lady mobilises with a walking aid, non-smoker and has history of Diabetes Mellitus, Rheumatoid Arthritis, on oral steroids and bilateral leg ulcers. She underwent open reduction and internal fixation with a long distal femoral locking plate. Unfortunately she developed wound infection for which she underwent repeated washouts. About eight weeks from the initial fixation, she underwent revision fixation using the antibiotics beads with a new locking plate and soft tissue cover using gastrocnemius flap. Results: Eventually the wound healed except a small area but the fracture failed to heal. She was on appropriate antibiotics as per the microbiology culture results. This lady was managing with the pain from the limb and was not willing to undergo any further surgery due to the associated risks for persistent non-union of the interprosthetic femur fracture. Conclusion: Currently this patient was managed in the care home with no plans for any further treatment. A closed primary internal fixation using MIPO technique would have reduced the risk of postoperative wound breakdown and infection. Patient could be counselled initially about the high risk of infection including the loss of the limb prior to surgery in view of the associated significant comorbidities and risks.

Purpose: The management of elbow fracture-dislocations is challenging, traditional treatment options for persistent instability include plaster, trans-articular fixation and external fixator. The internal joint stabiliser (IJS) (Skeletal Dynamics, Miami, FL) has recently been advocated as an alternative and this systematic review aims to analyse the ability of the IJS to maintain radiographic joint reduction and the associated complication profile. Methods: A systematic review of the literature was conducted in accordance with the PRISMA guidelines using the online databases Medline and EMBASE. The review was prospectively registered on the PROSPERO database (CRD42020187670). Clinical studies reporting the maintenance of joint reduction after the use of IJS in patients with acute or chronic elbow instability were included. Results: 5 studies were identified that met the inclusion criteria (n=65). Four studies were case series and one was a case report. Only two patients across the studies had ongoing radiological instability (3%) and both were associated with coronoid insufficiency. The mean flexion-extension arc ranged from 106° to 135° and pronation-supination arc ranged from 138° to 151°. The mean DASH scores ranged from 16 to 37.3 and the mean Broberg and Morrey Functional score from 68.2 to 93. Complication rates in the case series ranged from 21% to 40%, the commonest complications were heterotopic ossification, neuropathy and infections. Conclusion: Initial reports into the use of the Internal Joint Stabiliser for elbow instability have shown a low incidence of residual radiological joint incongruency. However, the complication rate associated with the procedure is relatively high.

Introduction: On-calls are an integral part of the working life of doctors. Details of admissions and ward referrals for review on the post-take ward round are collected. However, patients that have been discharged are not captured. Significant issues arise due to time lag from referral to review. Frequent re-referrals of patients seen by previous on-call team causes further delays. When complaints arise, it is difficult to ascertain the patient flow process when a patient has not been admitted. Aim: A Quality Improvement Project to improve capture of on-call workload and change practice to improve patient care. Method: A proforma was designed to be used by the on-call team to collect the following details: Date, on-call team members, all referrals and sources of patient referral, time referred, time seen, Senior review and Outcome. Results: Mean daily referrals 36 (25-67), mean time to review 60 minutes (5-120), documented admissions 30% (10-23). Source of referral ED 46%, other departments 32%, T&O ward or clinic patients 10%, General practitioners 11%, out of area 1%. Conclusion: 70% of on-call workload was not captured if assessing hospital admissions alone. This project allowed us to appreciate the pressures faced by on-call SHO. Based on the findings, we have now instituted an additional ward cover doctor everyday from 8am to 5pm to improve patient care by reducing delays in assessments. This allowed the on-call doctor augmented with an additional twilight SHO from 2pm to 10pm deal with referrals from ED and other departments reducing delays in patient care.

Objective: This retrospective study compares two techniques of fixation of mid shaft clavicle fractures; nail fixation vs. plate fixation. We compared titanium elastic nail (TEN) fixation with plate fixation in patients with uncomplicated midshaft clavicle fractures.

Methods: 84 patients were included in our study; 35 in the nail fixation group and 49 in the plate fixation group. We compared the 12-month post-operative shoulder function and scar assessment. Primary outcome was measured by the DASH score and POSAS score. Secondary outcome was measured by Constant score, surgery complications, implant removal, hospitalization days, size and quality of the scar.

Results: There was no significant difference in DASH and Constant scores between the two groups. However, the nail group leads in the POSAS (12 (12-12) 25 (17-30) p<0.001) and in all scar parameters (size, scar influence). There were no significant differences in the complications despite implant removal where more removals were noted in the nail group (16 (44.4%) 4 (8.3%) p <0.001).

Conclusions: Fixation of uncomplicated midshaft clavicle fractures with nail provides better cosmetic results and scar quality than fixation with plate, and presents no significant differences in functional ability or complications.

Introduction:
According to the literature, 5–10% of polytraumatized patients suffer from injuries to urogenital organs. Nevertheless, a thorough investigation of the correlation of injuries to the urogenital tract and spinal as well as pelvic fractures is missing so far. The aim of this retrospective analysis was therefore to assess the relevance of urogenital organ injury in the multiple injured patient.
Methods:
All severely injured patients with an ISS≥16 who were admitted to the emergency room of a German university hospital between 2016-2020 were retrospectively scanned for fractures to the thoracic/ lumbar spine or the pelvic girdle. Apart from demographic data the trauma-mechanism, injuries, length of hospital-stay, surgeries, laboratory results and urological treatment were analyzed.
Results:
215 patients with an average ISS of 33 (Range:17-75) were identified. 31 patients (14,4%) had urogenital injuries with an average AIS-score of 2,26 (Range:1-5).
It was striking that the severity of the injury to the pelvic girdle correlated directly to the presence of urogenital injuries (p<0,05), while there was no correlation to spinal injuries. Additionally most urogenital injuries resulted from motorbike-accidents (p<0,02) and 90% of these patients were male.
Furthermore the GFR and Creatinin-Clearance at admission was significantly lower in patients with urogenital injuries (p<0,05), but did not differ 3 and 7 days after admission.
There was no difference in the length of stay in the ICU or the general ward or death rates.
Discussion:
Especially male patients with fractures of the pelvic girdle due to motorbike-accidents will profit from early diagnosis and treatment.

Background: Femur fractures are largely managed with intramedullary devices in today’s era. It has been long known that femur has an anatomical bow in the sagittal plane. Intramedullary devices have been devised with an anterior bow which varies amongst various manufacturers. Intramedullary devices tend to impinge on the anterior cortex beyond the isthmus and the asymmetrical bow of intramedullary nails can lead to posterior cortical opening at the fracture site. We hypothesized intramedullary devices have a larger radius of curvature (ROC) compared to the anatomical bow of the femur and thus more anatomical nails should be used. Methods: Radiographic data of seventy-seven normal femur scans done in patients for their trauma related indications were loaded in the Mimics 21.0 software (Materialise, Leuven, Belgium). A centreline was created using the software. In the sagittal plane, a best fit circle was created involving a major part of the centreline and ROC was calculated. Results: We found the average ROC of our data was 1069mm with a standard deviation of 290mm. We also found that the femur length (indirect parameter for height) shares no correlation (r=0.11) with the ROC (p value 0.3). Conclusions: The usual ROC of intramedullary nails are commonly >1300mm which is much higher than the ROC we have identified from our data. Thus, we conclude that implants with smaller ROC in the range of 1100mm are needed which will lead to better implant placement in the canal and avoid complications of anterior cortex impingement and prevent fracture gap widening.

Introduction: Open lower limb fractures are associated with high rates of morbidity and mortality when inadequately treated. Open fracture management is a priority for quality improvement because consequences of infection can be devastating for the patient, there is a high volume of patients with open fractures, and there is good evidence available to inform standards.

Methods: Care of patients admitted in 2019 with open fractures was evaluated against British Orthopaedic Association Standards for Trauma and Orthopaedics. A retrospective audit where patients were identified using the Trauma Audit and Research Network Database was performed. The sample size was 32 patients.

Results: Photographs of open fracture wounds were taken and kept in the patient’s records in 2 patients (6%).

Conclusion: There is poor compliance with guidance for open fracture management with respect to photography of open fracture wounds.

Implications: Conventional photography has been the almost exclusive mode for capturing and displaying medical images, involving copies of images being stored in patient notes. We have facilitated the introduction of an all-digital system that permits electronic capture, storage and retrieval of medical images. Key benefits include: images can be taken via any mobile device, images are automatically uploaded centrally and deleted from the mobile device, patients can be consented digitally, images are accessible via the intranet, images can be viewed from multiple workstations, and images will be stored and backed up centrally.

Background: Crush injuries in road traffic accidents, leading to amputations. In past, such amputated stumps with circumferential skin loss have been managed by either cutting the stump shorter or applying a split skin graft. Both ways are associated with many disadvantages and complications. Cutting the stump shorter leads to difficulty in prosthesis fitting, a heavier and bigger prosthesis, that causes more energy expenditure. Split skin grafts at stumps are associated with recurrent ulcerations and wounds. Such SSG is also insensate.
Case Presentation: A young male patient, 22year age having a run over the injury in road traffic accident, resulted in an open fracture of the tibia with soft tissue loss up to mid-thigh. He developed gangrene of the right tibia and ended in an above-knee amputation. The skin of the thigh was to be excised at a much higher level up to groin. Thus a circumferential skin loss of about 24-25 (9-10cm length was created. This circumferential skin loss was managed with lengthening of the skin by this new technique “Altaf technique “.
We used a ring attached to our locally developed external fixator (Naseer-Awais External Fixator) and fitted it at the margins of the skin with wires to lengthen it. Thus we were able to lengthen this 25 cm skin loss in less than 2 months.
Discussion/Conclusion: Lengthening of bones with soft tissues is regularly practiced in orthopedic surgery using the Ilizarov method, which is based on the principle of tissue growth under tension. In literature skin stretching devices

Introduction:We present an alternative to external fixation in bone transport.This new system is based on magnetic technology, the main indication of which is the treatment of bone defects of up to 10 cm in the tibia and femur.Methods:The case presented is that of a 54-year-old man with septic nonunion of the middle third of the tibial diaphysis, sequela of a grade 2 open fracture which required multiple interventions (as a result of a traffic accident that had occurred 25 years before).After a first surgical intervention, the infection and soft tissue defects were resolved.A second intervention was then carried out, treating a residual 8 cm defect by means of bone transport with a magnetic endomedullary nail system.During the postoperative period, at his home, the patient carried out the transport, with the aid of an external remote control, performing a 0.17 mm distraction three times a day.Results:After a follow-up of more than 18 months, the patient presented an adequate evolution, with minimal complications and favorable radiologic control.Compared to external fixation, the method used in this patient appears to have fewer complications,as it is an endomedullary technique, with less pain and less risk of infection. Furthermore, the technique is relatively simple for the surgeon and the distraction process comfortable and simple for the patient.Conclusions:The new endomedullary bone transport system is another tool available to the surgeon in the treatment of large bone defects,allowing complex cases to be resolved,minimizing the complications derived from external fixation and with better tolerance for the patient.

Patella fracture is one of the common fractures in the lower limb. It can be an isolated fracture or in association with adjacent long bones fracture. Patella forms an integral part of the knee extensor mechanism. It keeps the knee biomechanics aligned, maintaining the active extensor functioning for independent ambulation. Thus, active management of fracture in the patella need not be neglected and utmost priority ought to be determined towards the preservation of this important biomechanical pivotal structure. In the majority, commonly displaced transverse, two-part, patella fractures are managed with tension band wiring (TBW) using K wires or cannulated screws. Though, the principle of fixation remained the same, various innovations and modifications have been added to this conventional method of fixation of the patella fracture. Patella fractures with comminution or more than two major fragments, added technical challenges in their fixation, especially using the conventional tension band wiring method. However, if the principle of TBW when followed and applied properly can result in favorable outcomes. Recently, patella locking plates have been designed to tackle this challenge which allows multiple locking screws along the perimetry of the patella, thus maintaining the reduction and allow early rehabilitation compared to the conventional methods. This case report highlights the merits of the patella locking plate in a case of failed TBW in a patella fracture.

Open elbow dislocations represent a rare variant of elbow dislocations. It is associated with severe trauma, neurovascular injuries, and a high rate of complications and revision surgery. There is limited knowledge regarding treatment and functional outcomes. We present an unusual case of open and simple elbow dislocation with excellent functional outcomes. A 42-year-old female patient presented in the emergency department after falling onto an extended elbow while walking. She referred immediate pain and severe deformity with anterior exposure and loss of motion. On admission there was an anterior wound of about 4 centimeters associated with paresthesias of the hand, without vascular alteration although the neurovascular bundle was visible. Radiographs and CT-angiography revealed a simple posterolateral elbow dislocation with vascular integrity. Surgical exploration was immediately undertaken. The area of exposure was abundantly washed with saline solution. After reduction, the integrity of the vasculonervous bundle was verified. Primary repair of the anterior capsule and internal ligament complex was performed. Clinically, the joint was stable and full passive motion was present. The patient was discharged after a protocol of antibiotherapy, without complaints of sensitivity and with a posterior splint for 3 weeks. Recovery was uneventful with the patient following a typical recovery that would be expected after a closed posterior elbow dislocation. At 6 months the mobility arc was 5-140º, with no limitation of pronosupination or instability. Although an elbow dislocation is an unfortunate accident, this patient was lucky because the hyperextension trauma was not excessive enough to damage the vasculonervous bundle.

Abstract: Bilateral patellar tendon rupture is an extremely rare injury in children and adolescents. Predisposing factors include repetitive microtrauma, systemic metabolic or rheumatic diseases, and corticosteroid or fluoroquinolone usage. Bilateral pure spontaneous rupture without any predisposing factors is exceedingly rare and accounts for only a small percentage of the reports in the literature. We presented a 14-year-old male patient who had been previously followed-up with the diagnosis of Osgood-Schlatter disease and operated for bilateral rupture. We applied primary repair to the anatomical locations with U staples and suture anchors. At the end of the fifth-year follow-up, the patient had no symptoms and achieved full range of motion in both knees without terminal extension lag. Bilateral patellar tendon rupture is considered a severe injury and necessitates early diagnosis and surgical intervention. Structural alterations resulting from inflammation and tendon degeneration due to existing Osgood-Schlatter disease can be a causative factor for bilateral patellar tendon rupture in adolescents. Key Words: Patellar tendon, rupture, Osgood-Schlatter disease, bilateral, adolescent.

Introduction: Congenital pseudarthrosis (CTP) is a spectrum of medical disorders characterized by by a spontaneous fracture that heals poorly with routine treatment. The true etiology of congenital pseudarthrosis of the tibia is not fully understood, but it is associated with neurofibromatosis. Treatment of congenital pseudarthrosis in the adult is controversial among different surgeons. Case Presentation : A 25-year-old male known to have congenital pseudarthrosis and neurofibromatosis type 1 . He underwent for " Sofield-Millar Procedure " of the left leg with rush rod due to cystic changes age of four years in 1997 . Two years from the follow up , patient came to the clinic and they found the rush rod was getting shorter and it was palpable under the skin and it was revised to longer rod. He was presented to our emergency department with history of fall down on the left leg . Patient denied any history of loss of consciousness . Computed tomography of the left showed the fracture line was reaching the site of rod with extension . Due to extensive bowing of the left leg .The Implant was removed and the fracture was fixed by intramedullary nail and bone morphogenetic protein 7 was added to the fixation for bone healing . Instructions was given to the patient for non-weight bearing of the left limb for 2 months . Six months postoperatively , patient came to the clinic mobilized on the left lower limb with full range of motion and without any restrictions.

Proximal humerus(PH) fractures are commonly occurring fracture. Unstable three- or four-part fracture patterns are associated with higher complications. The aim of this study is to evaluate the functional and radiological outcome of PH fractures managed operatively with ORIF using PHILOS plating augmented with fibular strut autograft. We evaluated 18 patients with closed unstable PH fractures. All patients sustained 3 or 4 part closed fracture were classified according to Resch and AO classification and medial metaphyseal comminution was present, ORIF with locking plate was performed with fibula autograft to support medial calcar/defect. Radiological outcome was assessed by NSA graded according to Paavolainen classification and loss of humeral head height (HHH). Functional outcome was assessed by shoulder ROM, UCLA and ASES score. Radiological union at the fracture site was achieved in all at 8 months (range 6 to 12), ROM were mean flexion of 123.89, internal rotation 65.94 and abduction of 115 degrees. The average NSA was in the range of 120-130 degrees and none of the patients showed loss in the HHH of more than 4 mm. Functional outcome assessed by ASES score (Mean 89.44) and UCLA score (Mean 29.61) suggested fair to good results. Among complications, screw perforation and infection were seen in two patients. No patients had shown varus collapse and avascular necrosis. In unstable proximal humerus fractures, PHILOS plate augmented with fibular strut autograft provides a very stable construct. In unstable situation with calcar comminution, the fibular graft support reduces the complications related to PHILOS plate fixation significantly.

Introduction: Management of intertrochanteric fractures poses challenges in terms of obtaining stable fixation and good postoperative outcomes especially unstable ones in osteoporotic population. There is a paucity of clinical data comparing the Proximal Femoral Nail Anti-rotation Asia(PFNAII) implant and Proximal Femoral Nail(PFN) with respect to their ability resist deforming forces throughout the twelve month follow up period. Methods: Patients presenting with unstable intertrochanteric fractures were included and randomly treated with either PFN or PFNAII. Postoperative radiographs were assessed for tip-apex distance, Cleveland index, actual neck shaft angle (eliminating the hip rotational misjudgement) and quality of reduction. Comparison of functional outcomes was done using the modified Harris Hip Score(mHHS) and New mobility score(NMS). Results: Out of 100 patients, 50 were treated with PFN and 50 with PFNAII. The average mHHS was 79.70 in PFN group and 80.82 in PFNAII at end of follow up. 58% patients of PFN group and 78% patients of PFNA II group were able to maintain actual neck shaft angle(aNSA) obtained intraoperatively during the follow up(p= 0.032). 8(16%) patients in PFN and 4(8%) patients in PFNAII groups had implant related complications. 44 patients from PFN group and 47 patients from PFNAII group retained the same Cleveland index throughout the follow up period. Conclusion: PFNAII has statistically significant better ability to retain aNSA. It was also found to be technically more forgiving in terms of suboptimal placement of blade/screw. No statically significant difference was noted in terms of functional outcome and complications in our comparative study groups.

Introduction: Operative fixation of intra articular fractures of the distal humerus requires adequate exposure. The trans olecranon approach is commonly used approach. The olecranon osteotomy has potential complications related to prominence/migration of hardware, displacement/non-union of osteotomy and triceps weakness. Triceps reflecting anconeus pedicle [TRAP] approach avoids the olecranon osteotomy without compromising the operative exposure. We present outcome of fixation of displaced intra-articular distal humerus fractures with the use of TRAP approach. Materials and Methods: We reviewed the functional and radiological results of 98 consecutive patients with intercondylar fractures of the humerus treated by open reduction internal fixation with both medial and lateral column plating through TRAP approach between 2006 and 2017. There were 76 males and 22 females and the average age was 32 ± 4.5 years. Results: At a minimum follow-up of 12 months (average 14 ± 2 months) 87 (87.5%) patients had good triceps strength. The average range of motion was 118.4 ± 7 degrees (range 80 o -130 o). The average time to union was 3.2 ± 1.6 months (range two to six months). No patient had triceps rupture, implant failure, neurovascular deficit or non-union. Six patients needed removal of the implant because of subcutaneous prominence, 2 patients had elbow stiffness, one patient had implant failure. Conclusion: The TRAP approach provides good visualization for fixation of intercondylar fractures of the humerus, without any noticeable untoward effect on triceps strength and postoperative rehabilitation; and one can avoid iatrogenic fracture of the olecranon and its associated complications.

Methods – An Ambispective study done from december 2015 to december 2018 at tertiary centre. A total of 55 knees in 50 patients were included (41 females and 9 males). All cases were randomly allocated into 2 groups: group 1 – IMIL Nail with CC Screws and group 2 - DFLCP. Group 1 IMIL Nail with CC Screws consist of 16 knees and group 2 DFLCP included 39 knees in 34 patients. All patients gave informed consent for participation in the study. Intraoperative assessment of transepicondylar axis was done by palpating the most prominent point on lateral epicondyle and sulcus on medial epicondyle and passing a k wire through it. Confirmation was done under image intensifier C arm with epicondylar view. Postoperative assessment was done using radiographs, range of motion and knee score. Results – The mean degree of ROM in group 2 was around 117° ± 2.0° and 102° ± 3.0° in group 1, both of which were within normal limit. The difference in two groups was not statistically significant. There was no postoperative infection. Post operative fat necrosis was seen in 1 patient which required exploration, debridement and secondary suturing. Conclusion – No functional, clinical and statistical difference was observed in between 2 groups. Though DFLCP group gave slightly better outcome.Key words – Supracondylar femur fracture with intercondylar extension. No conflict of interest

Background: With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. Methods: A retrospective cohort analysis of 58 patients. 34 SP tibial nails over 3 years versus 24 IP tibial nails over a similar time frame. We compared; radiation exposure, patient positioning time (PPT), non-union rate and follow-up time. Knee pain in the SP group was evaluated, utilising the Hospital for Special Surgery (HSS) Knee injury and Osteoarthritis outcome score (KOOS). Results:58 patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78cGy (range 11.60 to 156.01cGy) vs 121.09cGy (range 58.01 to 18.03cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow-up was 5.5 months vs 11 months in the IP and SP group respectively. Mean KOOS was 7 (range 0 to 22) at 6 months for the SP group. Conclusion: The semi extended position (SP group) leads to reduced radiation exposure because of ease of imaging. All Patients in SP group showed improved outcomes, with shorter follow-up and fracture union . The KOOS revealed SP nail patients had minimal pain and good knee function. This study establishes a management and PROMs baseline for ongoing evaluation of SP nails.

Aims
COVID-19 remains the major focus of healthcare provision. Managing orthopaedic emergencies effectively, while at the same time protecting patients and staff, remains a challenge. We explore how the UK lockdown affected the rate, distribution, and type of orthopaedic emergency department(ED) presentations, using the same period in 2019 as a reference. This article discusses considerations for the ED and trauma wards to help to maintain the safety of patients and healthcare providers with an emphasis on more remote geography.

Methods
The study was conducted from 23March2020 to 5May2020 during the full lockdown period(2020 group) and compared to the same time frame in 2019(2019 group). Included are all patients who attended the ED at Raigmore Hospital during this period from both the local area and tertiary referral from throughout the UK Highlands.

Results
Orthopaedic presentations in 2020 and 2019 were 736(37.2%) and 1,729(36.2%) respectively, representing a57.4% reduction. During the lockdown,43.6%of operations were major procedures and 56.4%were minor procedures, representing a significant proportional shift.

Conclusion
During the COVID-19 lockdown period there was a significant reduction in ED attendances and orthopaedic presentations compared to 2019. We also observed that there was a proportional increase in fractures in elderly patients and in minor injuries requiring surgery. These represented the majority of the orthopaedic workload during the lockdown period of 2020. Given this shift towards smaller surgical procedures, we suggest that access to a minor operating theatre in or close to ED would be desirable in the event of a second wave or future crisis.

Background: This study aims to estimate the risk of acquiring medical complication or death from COVID-19 infection in patients who were admitted for orthopaedic trauma surgery during the peak and plateau of pandemic. Unlike other recently published studies, where patient-cohort included a more morbid group and cancer surgeries, we report on a group of patients who had limb surgery and were more akin to elective orthopaedic surgery. Methods: The study included 214 patients who underwent orthopaedic trauma surgeries in the hospital between 12th March and 12th May-2020 when the pandemic was on the rise in the United Kingdom. Data was collected on demographic profile including comorbidities, ASA grade, COVID-19 testing, type of procedures and any readmissions, complications or mortality due to COVID-19. Results: There were 7.9% readmissions and 52.9% of it was for respiratory complications. Only one patient had positive COVID-19 test during readmission. 30-day mortality for trauma surgeries was 0% if hip fractures were excluded and 2.8% in all patients. All the mortalities were for proximal femur fracture surgeries and between ASA Grade 3 and 4 or in patients above the age of 70 years. Conclusion: This study suggests that presence of COVID-19 virus in the community and hospital did not adversely affect the outcome of orthopaedic trauma surgeries or lead to excess mortality or readmissions in patients undergoing limb trauma surgery. The findings also support resumption of elective orthopaedic surgeries with appropriate risk stratification, patient optimization and with adequate infrastructural support amidst the recovery phase of the pandemic.

Background: Surgical management of Ruptures of the pectoralis major tendon varies depending on the chronicity and surgeon preferences. Direct repair is usually chosen in acute cases, however in chronic cases it may be necessary to use other techniques. Case Presentation: Male, 41 years old, surf teacher. Suffered a rupture of pectoralis major tendon while surfing. He went to the emergency room 2 weeks after the accident. Clinically he presented with hematoma on the anterior surface of the shoulder, pain and decrease range of motion specially in elevation and internal rotation of the left arm. MRI confirms complete avulsion of the pectoralis major tendon. With a retraction of 3.5 cm medial to its insertion. Surgical technique: Distal half of a deltopectoral approach was performed. A blunt dissection was used to free the muscle and tendon from the chest wall and subcutaneous tissue. The footprint area was prepared creating an area of bleeding bone along the lateral border of the bicipital groove. Three anchors were placed and high resistance sutures for pectoralis major tendon fixation. Pulling the sutures reduced the tendon tightly to the footprint. Clinical Outcomes: Clinical follow-up at 4 weeks shows a good evolution. 3 months after surgery, the patient was pain-free, with complete range of motion and started again activities. Discussion: Direct repair with high resistance sutures anchors of a two - week pectoralis major rupture can have good clinical outcome, low risk of complications, and a good return to pre-operative level of recreational activity.

Fractures of the proximal tibial epiphysis are rare constituting 0.5-3% of all epiphyseal injuries. The growth arrest following these injuries gives rise to various angular deformities. Management of subsequent fractures of these injuries poses a particulary difficult challenge. We present a rare case of such a fracture in a 17 year old with a previous malunited proximal tibial salter and Harris Type V physeal injury who was treated conservatively with cast application at the time of initial injury. Patient was assessed with CT and MRI scan which showed bicondylar fracture of proximal tibia with metaphyseal separtion with noted anterior slope of the articular surface due to previous growth arrest and intact intra-articular structures. Patient was treated with open reduction with the aid of external fixator device with Schanz pin in each hemicondyle of proximal tibia. Fracture site reduction along with slope correction was achieved with osteotomes and distraction device and anterolateral and posteromedial plate fixation was carried out along with bone grafting. Post fixation satisfactory correction of recurvatum of the knee was noted. At 3 and 6 month follow up patient was noted to have achieved full range of the movement of the knee and was mobilising full weight bearing after achieving complete union. Our Aim with this case report is to demonstrate this rare proximal tibial injury and further illustrate Ex Fix assisted differential anterior correction and to demonstrate fragment specific fixation of medial and lateral hemiplateu.

Nonunion of the femur is unpredictable and the presence of infection makes for a poor prognosis and increases morbidity. Knowledge of the mechanisms of bone consolidation is crucial.
It is acknowledged today that this depends on three essential factors:the mesenchymal cells, the inducting proteins and osteoconduction.The allograft which introduces these three factors, but in unknown quantities, remains one of the referenced solutions in the management of nonunion.
This Study includes a young patient, treated over 2014-2016, for septic nonunion of the femur, according to a standardised technique implemented in two stages; first healing of the infection and stabilisation, followed by bone reconstruction after a precautionary period.The minimum duration of antibiotic treatment was 8 weeks.The principal objective of the medico-surgical management over a two year period was defined as the healing of the infection and radiological assessment of bone consolidation with the lower limb intact. There were four surgical interventions with our reconstruction technique, involving compacted graft fragments followed by the arrest of sepsis then followed by consolidation.We had to use the scanner to refine the radiological analysis of cortical continuity.It was thought that the problem of diaphyseal nonunion was addressed by the arrival of bone inductors but the published results are disappointing to a greater or lesser degree.Because of that, thanks to our results, fragmented allografts remain for us the solution which brings the three essential factors to the consolidation linked to a rigorous management of the treatment which is necessary more than ever .

Background: Tension band wiring supposedly is most commonly used technique for displaced patella fractures, but is not effective in comminuted fractures and osteoporotic bones. It often leads to loosening of wires, dislocation of fracture, hardware problem and failure of osteosynthesis resulting in knee stiffness and post-traumatic osteoarthritis. The aim of the study is to evaluate clinical outcome in patients with acute patella fractures(<3 week) treated with unidirectional angle fixed low profile titanium patella locking plate. Materials and Methods : Twenty patients who presented with displaced patella fractures, aged between 18-70 years were included in the study. All fractures were reduced and fixed with Unidirectional Angle Fixed stable low profile titanium patella locking plate. Knee Range of motion and Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL) was used to evaluate the outcome. Results: We were able to achieve union in 19 out of 20 patients. One patient with comminuted patella fracture had failure of fixation, which was revised. Mean Flexion at Final follow up was 124°(110°-130°) and none of the patients had extensor lag. Final radiograph revealed complete union in all patients.Conclusion: This technique offers an option of fixation in comminuted patella fracture and in osteoporotic individuals. It provides mechanical stability for fracture fixation resulting in anatomical reduction, good functional outcome, lower incidence of symptomatic implant or failure of osteosynthesis.

Introduction:There have been many techniques in problem solvingso-called disaster injuries of extremities, especially the lower leg. No general guidelines exist, except for main postulates in general surgery. The main problem remains a critical bone defect that can be accompaniedby a soft tissue defect. General approach is to debride dead tissue (soft tissue and bone), prevent an infection and provide a stable fixation leading to healing. Method:In our case we had a male patient with a crush injury of the lower leg. Initial treatment plan was made after the admission and diagnostic procedures. A thorough cleaning was followed by debriding of dead tissue. Then a primary plate fixation of comminuted distal fibula and an ex fix (a delta frame) was put in place. A bone defect of distal tibia was filled with a PMMA bone spacer mixed with garamycin. First, the soft tissue defect was solved by a local lobe and partial thickness skin transplantation. Second, a definitive stabilization was achieved by a locked anterolateral distal tibia plate. An induced membrane developed and auto and allograft bone marrow was put inside it. The patient went through the physical therapy procedures during the following six months with partial weight bearing and crutches. Every two months the radiological evaluation was made. Result:The treatment led to a good radiological consolidation of distal tibia and the complete healing of soft tissue. Conclusion:As conclusion, the Masquelet technique proved to be a good treatment option in treatment of complex injuries of extremities.

Introduction: With the recent launch, by the United Kingdom Government (UK), of a campaign aimed at promoting cycling uptake, the use of cycles in the country is likely to increase. This study aims to characterise cycling related injuries sustained in Cambridgeshire, the region with the highest rates of cycling in the UK. Methods: A retrospective review of cycling related trauma admissions between January 2012 - June 2020 was performed. Our centre's electronic record system was used to collect data including: age, gender, injury mechanism,injured body regions, incident date, helmet use, Glasgow coma scale (GCS), length of stay and 30-day mortality. Comparison was made between different injury mechanisms: 'fall from cycle', 'cyclist versus vehicle' and 'cycle v cycle'. Results: A total of 606 cycling-related trauma cases were identified, with 52 excluded due to insufficient data. 'Fall from cycle' was he most common mechanism (53.4%). The ‘cyclist v vehicle’ group was associated with a significantly lower GCS, higher Injury Severity score (ISS) and longer hospital stay than the other two groups. Patients wearing a helmet during the accident showed a significantly reduced risk of head injury, lower ISS and higher GCS. A significantly increased age was seen in helmet wearers, compared to non-wearers. Discussion: With a likely increase in cycling uptake, it is crucial that effective accident prevention interventions are implemented. Our findings may be used to guide such interventions. A holistic strategy involving road infrastructure changes, driver and cyclist education and helmet promotion campaigns targeting the younger generation could be employed.

Multifocal femur fractures involve the diaphysis and both the proximal and distal meta-epiphyseal ends of the femur. These fractures are extremely rare occurring in 0.43% of femoral fractures and are challenging to treat due to the different fracture configurations present in one bone and the limited array of implants that could address each fracture component adequately. We present 2 cases of multifocal femoral fractures that were treated successfully through an individualized approach. The first case is a 58-year-old male that was treated at 4 weeks post-injury with lag screw fixation of the distal articular fracture, antegrade intramedullary nailing of the subtrochanter and shaft, and plating of the distal femur. The second case is a 55-year-old male with a 5-week-old injury wherein the femoral neck fracture and the shaft were fixed using a dynamic condylar screw with a 14-hole side plate and the distal fracture was fixed by plating on the medial side through a minimally invasive approach. Follow-up showed stable osteosynthesis with evidence of clinical and radiographic union without postoperative complications. Delayed treatment of multifocal fractures of the femur requires thorough preoperative planning in order to ensure bony union and early mobilization and to prevent catastrophic outcomes. Four questions can be asked as guide in the surgical treatment of these complicated fractures: 1) How many implants to use? 2) which combinations of implant to use? 3) which fracture to fix first? and 4) which method of reduction to use?

Introduction: Fractures of the distal metaphysis of the tibia can be nailed if a sufficient amount of bone is available distal to the fracture site to insert two or three locking screws. However, fractures in this region operated with nail fixation provide less stability as a result of metaphyseal flare, which reduces the contact between the nail and the endosteal surface. Objective: The purpose of this retrospective study was to assess the union and complications associated with distal third tibial fractures which were operated with reamed tibia nail with two versus three distal locking screws. Methods: The study was carried out between 2017-2019 in which fifty-seven patients were included the study. In 25 patients 2 distal screws were inserted and in 32 patients 3 distal screws. Patients were followed up to the tibial fracture union (5–12 months with a mean of 7 months). Results: Our results showed, 4% of delayed-unions in distal third fractures with two distal screws compared to 3.12% who had three distal screws. This is statistically insignificant (p>0.01). None of the patients developed non-union nor had screw breakage and residual ankle or knee pain. Conclusion: Our study showed that there was no statistically significant difference in the delayed union, non-union, and complications in distal third tibia fractures operated with tibia nailing when two or three distal locking screw was used. Therefore, we conclude that two distal locking screws are a necessity and three being a luxury. The increased distal locking screws do not influence the fracture union.

Introduction: The glenohumeral joint is the joint with the highest rate of dislocation. Bone impaction and greater tuberosity fractures are frequent complications. Neurovascular injuries are less frequent.
Case description: The authors report the case of a 77-year-old man, with history of cognitive impairment and bilateral shoulder dislocation at different times, who presented to the Emergency Department with acute left shoulder pain and deformity, without associated neurovascular deficits. Bilateral shoulder dislocation was identified through imaging. Closed reduction of the left shoulder dislocation was performed, which resulted in the immediate formation of a haematoma in the axillary region. Radial pulses were present bilaterally. Computed tomography angiography showed reduction of the dislocation and two collections contiguous to the distal third of the axillary artery, suggestive of pseudoaneurysm. The patient underwent endovascular treatment with placement of a metallic stent in the axillary artery. He was asymptomatic at a 5-week re-evaluation, recovering the previous range of motion.
Discussion: Axillary artery injury is a rare complication of anterior shoulder dislocation, with higher incidence in the elderly, especially with history of recurrent shoulder dislocation. The triad of shoulder dislocation, formation of axillary haematoma and decrease or absence of ipsilateral peripheral pulses is considered pathognomonic of an axillary artery injury. However, these signs may develop late or not at all.
Conclusion: Injury to the axillary artery after anterior shoulder dislocation is a rare but potentially serious complication. It is mandatory to always consider the possibility of a vascular injury, both before and after the reduction of the dislocation.

Background: Children are prone to unintentional injuries and various scoring systems have been used to triage these injuries. The aim of this study is to determine the associations between paediatric trauma score (PTS), revised trauma score (RTS) and the length of hospital stay as an indicator of injury severity. Method: This is a descriptive cross-sectional study conducted in University of Calabar Teaching Hospital, Calabar and National Orthopaedic Hospital, Enugu from February 2018 to March 2020. A total of 212 patients were included in the study. A structured questionnaire was used to collect personal, injury-specific and treatment-specific data. The relationship between PTS, RTS, and the length of hospital stay was evaluated using the one-way ANOVA. Results: Majority129 (60%) of the injured children were males. Majority of the injuries were due to falls from heights (54%). The mean PTS was 5.36±1.9, while the mean RTS was 7.10±0.9. The Pearson’s Product Momentum Correlation Coefficient shows that there was weak but statistically significant correlation between the paediatric trauma score and the revised trauma score (r=0.22, P=0.02). The one-way ANOVA showed a statistically significant decrease in the revised trauma score with an increasing duration of hospital admission (F-statistic=6.654, df=3, p=0.000). The paediatric trauma score showed a less obvious decrease with no trend. Conclusion: In this study the RTS showed an inverse obvious relationship with the length of hospital stay. Key Words: Paediatric Trauma, Paediatric Trauma Score, Revised Trauma Score, Duration of hospital stay, Injury severity

Background: Extensive composite extremity defects remain a challenge in reconstructive surgery. In this study, we used combined transfer composed of the vascularized fibula flap and a perforator flap to reconstruct extensive composite extremity defects.Patients and Methods: From January 2004 to December 2018, 14 male patients aged 9 to 55 years with extensive composite extremity defects (large soft-tissue and long bone defect) underwent reconstructive surgery in our institution. The combined transfer surgery was consisted of the vascularized fibula bone flap and a perforator flap, such as anterolateral thigh flap, deep inferior epigastric perforator flap, or thoracodorsal artery perforator flap. Results: All fourteen patients were treated successfully using the combined transfer method. The dimensions of the different perforator flaps ranged from 13 × 6 cm2 to 26 × 11 cm2, and the size of the skin paddle of the fibular osteocutaneous flap ranged from 9 × 3 cm2 to 21× 7 cm2. The mean length of the fibular graft was 16.2 cm. No serious donor site complications were observed. Only one patient developed venous congestion and was salvaged. Though all patients had bony unions (mean time of 8.9 months), two developed a stress fracture of the transferred free fibula. Conclusion: We were able to minimize donor site morbidity and avoid amputation in these patients using combined transfer technique Our results show the combined transfer of perforator flap and vascularized fibula flap with or without a skin paddle is a feasible reconstruction option for the treatment of the extensive composite extremity defects.

Purpose:
The aim of this study was 1/ to analyze safety a efficiency of MAGNEZIX pins and screws fixation of osteochondral fragments of the knee joint in pediatric patients and 2/ to report clinical and radiological outcomes at short-term follow-up (FU).
Methods:
12 patients (5 girls, 7 boys) were included in the study. Inclusion criteria were 1 / age < 18 years; 2 / unstable or dislocated OCL caused by Indry or due to osteochondritis dissecans, classified according to ICRS; 3 / refixation with MAGNEZIX implants; 4 / minimum FU 12 months. X-rays were taken 1 day, 6 weeks, 3, 6 and 12 months after surgery, MRI scans were performed 12 months after surgery.
Results:
Mean age at surgery was 13.3 ± 1.6 years. Mean time of operation was 72.4 min. ± 24.1. A total of 25 screws were used in 11 patients, mean 2.4 ± 1 per patient, 4 pins were used in 1 patient. In 2 patients the fixation was combined with fibrin glue. The mean FU was 14.2 ± 3.3 months. No intraoperative complications occurred. All patients showed full recovery of function and showed no signs of pain 6 months after surgery. Complete radiographic healing occurred in 12 cases. Mild radiolucent zones were observed around the implants in the range of 6 weeks - 3 months.
Conclusion:
Fixation of osteochondral fragments by MAGNEZIX screws and pins during short-term FU provides sufficient stability and leads to uncomplicated healing.
Key Words:
MAGNEZIX, biodegradable implants, osteochondral fracture, osteochondritis dissecans

Background: Acetabular fractures occur in 1-15% of the paediatric population and fewer still sustain triradiate cartilage (TRC) injury. The literature surrounding the recognition and management of TRC fracture is scarce with no consensus on the most appropriate treatment. We present a case of 12-year-old boy with a TRC fracture and ischial tuberosity hamstring avulsion fracture. The aim of this paper is to outline the merit in conservative management in a 12-year-old boy presenting with dual hip pathology and a review of the literature.
Methods: A PubMed and Ovid database search using the term “Triradiate cartilage” and one of the following terms: “Fracture,” “Injury” or “Trauma” was performed to identify TRC injury case reports.
Results: There are 38 reported cases of TRC fractures with the majority being polytraumatic injuries (n=30). In 14/38 cases, (1 SH II, 7 SH V and 6 not stated) the diagnosis of TRC injury was made at a later stage after the initial presentation. 5 cases were managed operatively at initial presentation and 33 managed non-operatively. There were 16 reported cases of progression to acetabular dysplasia in the non-operatively managed cases, of which 8 patients (1 SH V and 7 not stated) required surgical intervention in the form of osteotomies or joint replacement.
Conclusion: TRC fractures are rare and consequently present a challenge in diagnosing and treating them. Conservative treatment is an option; patients do need long term follow-up to find complications related to growth arrest. Surgical treatment should be considered in young patients with incongruent joints.

Background: Open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), requiring prompt surgical intervention for optimal outcomes. However, few studies have examined delays to surgery for these injuries in low-resource settings. Methods: This is an unplanned secondary analysis of patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Patients with diaphyseal open tibia fractures were analyzed for risk factors for delayed hospital presentation, time from injury to treatment hospital, and time to surgical treatment using multivariable models. Results: A total of 249 patients met inclusion criteria. Only 12% of patients used an ambulance, 40% were delayed ≥2 hours in first hospital presentation, and 75% experienced an interfacility referral. After adjustment for injury severity, having insurance was associated with decreased risk of delayed hospital presentation (OR 0.47, p=0.043). Interfacility referrals (+3.52 hrs, p=0.043), rural injury location (+14.49 hrs vs urban, p<0.001), and multifragmentary fractures (+5.92 hrs vs simple, p=0.014) were associated with slower times to treatment hospital admission. Younger age (+0.82 hrs per 10 yrs, p=0.026), pre-primary or no education (+5.14 hrs vs college, p=0.013), household size ≥8 people (+4.12 hrs vs single, p=0.017), and ≥8 financial dependents (+5.56 hrs vs single, p=0.016) were associated with delay from hospital admission to surgery. Conclusions: Prehospital network and socioeconomic characteristics are significantly associated with delays to open tibia fracture care in Tanzania. Fewer interfacility referrals and surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs.

Background: The management of isolated radial neck and head fractures is controversial. Plate fixation and tripod fixation are two commonly employed techniques but risk damage to soft tissues as well as implant related complications. Intramedullary fixation is commonly used in paediatric cases and reduces the potential drawbacks of open fixation. The aim of this systematic review was to analyse outcomes of intramedullary fixation in adults in terms of function, union and complication rates. Methods: A systematic review of the literature was conducted in accordance with the PRISMA guidelines using the online databases Medline and EMBASE. The review was registered on the PROSPERO database. Studies were appraised using the Methodological index for non-randomised studies (MINORS) tool. Results: Seven studies were deemed eligible for inclusion (n=55). Mean ages of patients ranged from 31.3 to 44.2 years and mean follow up ranged from 9 to 86 months. The Mayo Elbow Performance score (MEPs) was reported in five case series (mean scores 81.8 -97.9) and the prevalence of excellent results ranged from 71% and 83%. Although 100% of fractures united, the pooled complication rate was 24% (range 0-50%). The commonest complications were elbow stiffness (7%), superficial radial nerve neuropraxia (7%) malunion (5%) and AVN (1.8%). No study reported any patients requiring revision surgery. Discussion: Intramedullary fixation for radial head and neck fractures appears to provide a reliable alternative treatment options in terms of union, range of motion and functional outcomes. Further robust trials direct comparing against open fixation techniques are required.

A 78-year-old lady presented to the Emergency department following mechanical fall, resulting in multi-fragmentary displaced fracture to the dominant right proximal humerus. Examination revealed cold pulseless hand with delayed capillary refill. CT angiography of the right upper limb showed distal axillary artery non-opacification due to compression by fracture fragments without any blushing. Vascular surgeons in the tertiary centre hospital were contacted for their opinion. However, 4 hours had elapsed since injury and the nearest tertiary hospital being 1.5 hours away, referring the patient to that centre would result in further delay and increased cold ischaemia time. Therefore, it was advised that surgery be undertaken at the DGH, to open reduce the fracture and take pressure off the vessels. Fracture was exposed using the Deltopectoral approach and pressure taken off the vasculature. As the humeral head was osteoporotic and multi-fragmentary, she underwent reverse geometry shoulder replacement. Although radial pulse was not palpable at the end of the surgery, vascularity improved significantly with warm and pink peripheries. At the end of 2-year follow up, she had good range of shoulder movements with oxford shoulder score of 58/60 and normal radial pulse.

Background: Anatomic fracture reduction is one of the cornerstones of AO Principles for fracture fixation. Comminuted fractures are often difficult to reduce and often require a combination of K wires, clamps, screws or plates. While very useful, these devices can often interfere with placement of the definitive fixation device (plate/nail/frame). Sliding knot sutures can be a useful tool to maintain fracture reduction. The Nice knot is a double sutured sliding knot described by Boileau et al. We describe the use of Nice knot to assist fracture reduction and allows unfettered access to definitive fixation. Technique: Initial approach and dissection of fracture fragments is per injury configuration and surgeon preference. Once the fragments have been identified, any two adjacent fragments can be held reduced with a K wire or a clamp. A looped PDS suture is passed around the fracture and tied with a Nice knot. The stability of the reduction was confirmed on radiographs. The process is repeated until the entire fracture is reduced. Once satisfactory reduction has been achieved, the fracture can be definitively fixed. Discussion: We’ve illustrated this technique in ankle and clavicle fractures with clinical photographs and radiographs. The authors have also used it for femoral and humeral shaft fractures, demonstrating applicability to different fracture configurations. We believe this technique lends itself well to diaphyseal long bone fractures and is a useful adjunct to fracture reduction and fixation. Other sliding knot sutures could be potentially used in the same manner.

Introduction: Acute median nerve compression in the carpal tunnel is a rare condition. It is a surgical emergency that requires urgent decompression. This case describes a case of an acute carpal tunnel syndrome associated with a fracture of the 5th metacarpal neck. Case Presentation: Male patient, 59 years old, victim of a fall from height with left hand trauma. Observed in the emergency department, with edema of the wrist and hand, referring pain during passive and active mobilization, without paresthesia or hypoesthesia. Radiologically, a SNAC grade III lesion of the wrist and a fracture of 5th metacarpal neck were present. The patient was under surveillance and starts with sudden severe pain and increased paresthesia. It was decided to submit the patient to an emergent surgery with section of the transverse ligament and release of the median nerve. It was possible to observe an abundant hematoma in the carpal tunnel and drainage was performed. Discussion: There are occasional reports of acute carpal tunnel syndrome after fracture and dislocation of the carpal bones and fractures or dislocation of the 2nd and 3rd metacarpal bones. Thus, even small fractures in the hand can be associated with extensive bleeding that spreads and causes acute carpal tunnel syndrome. In the case described here, probably, the degenerative changes in the wrist contributed to the development of acute carpal tunnel syndrome after minor trauma. It shows the importance of investigating the function of the median nerve even in cases with apparent minor injuries.