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This study was designed to determine which of 3 fixation devices used in wrist arthrodesis provides the greatest immediate stability along 2 axes of movement. Twenty cadaver wrists were mechanically tested. Group 1 consisted of 7 wrists stabilized using a 2.3-mm Steinmann pin. Six wrists from the second group were immobilized with a 9-hole, 3.5-mm AO dynamic compression plate. The third group consisted of 7 wrists stabilized with an 8-hole, short-bend, precontoured low-contact dynamic compression plate. Stiffness and fracture force were determined in both forced flexion and forced pronation. The results showed that the Steinmann pin was the least stable of the 3 constructs in both axes of movement. No differences were observed between the 2 compression plates for either of the 2 axes of movement.

Three methods of internal fixation for MCP arthrodesis of fifteen cadaveric thumbs were used to analyze the biomechanical stability by applying a palmar force, lateral force, and torsion moment. The techniques used included two K-wires 0.045 in parallel (BK), 2 cerclage metallic wires #25 perpendicular to each other (CP), and a 6-holes plate and screws construct from Synthes (PV). The initial rigidity was measured using a Bionix MTS-858. The results after statistical analysis showed: 1) CP was just as rigid as PV for the palmar and lateral tests; 2) CP was, overall, superior to BK in palmar and lateral tests; 3) no difference existed in torsion between the three types of fixation. A comparison was done between the rigidity of the fixation techniques used and the rates of bony nonunion found in the literature. The mean rates of nonunion were reported to be 0-4.0% for the following techniques: CP, tension band wiring (TB), plate and screws, external fixation, compression screw. The rates of nonunion were higher, 7.5-12.5%, for BK, cerclages not perpendicular (CM), bone pegs. According to the results of this biomechanical study and the review of the literature, fixation with BK is the least rigid, and fixation with CP is just as rigid as with PV. The success clinically of CP is yet to be demonstrated. Other studies on the properties of CP for fatigue would be necessary to give a better analysis.

In hand surgery, the k-wires are used frequently and effectively. Several texts mention complications following surgery of the wrist and hand. A safe zone has been described by Steinberg et al., where 40 K-wires were placed in the anatomic snuffbox of 10 cadaveric forearms. The placement of the k-wires were evaluated radiologically and by dissection to examine the underlying structures. A branch of the superficial radial nerve (NRS) was injured in 22% (2/9) of the specimens and the cephalic vein in 33% (3/9). The radial artery was never injured but had a K-wires at least 1 mm away in 22% of the specimens. The anatomy and pattern of distribution of the NRS was studied and compared with the data found in the literature. The NRS emerged between the tendons the muscles of brachioradialis and extensor carpi radialis longus in 9 of 10 specimens, and at a mean distance of 7.8 cm from the radial styloid. The first and second division were at a mean distance proximal to the radial styloid of 4.5 and 3.0 cm, respectively. The mean number of branches of the NRS at the radial styloid was 5.1. Despite a relatively consistent anatomy of the NRS, the anatomic snuffbox remains a complex and dangerous area due to the variability of the nerve's anatomy. An open surgical approach is thus preferred to avoid traumatizing the nerves and vascular structures.

The best type of osteosynthesis for ankle arthrodesis is controversial. Arthrodesis was performed on 21 cadaveric ankles using either the T-plate compression device, crossed cancellous-bone screws or the Charnley external fixator. The instrumented ankles were tested in five degrees of freedom. Internal fixation was more stable. More specifically, the compression T-plate was the most stable, and the Charnley external fixator was the least stable, for all degrees of freedom tested. In addition to the multiple clinical advantages of internal fixation, the results of our study support its use as a method of obtaining the most stable immediate fixation for ankle arthrodesis.

The authors report a rare complication of neurofibromatosis, recurrent rapidly expanding massive subperiosteal hematomas, in the thigh of a 22-year-old woman. The diagnosis was confirmed by plain radiography, ultrasonography and computed tomography. The first two hematomas were drained through a longitudinal lateral incision, tightly closing the periosteum over drains and applying a compression dressing postoperatively. The third hematoma was treated expectantly. Recurrent subperiosteal hematomas may lead to the formation of huge bone cysts and grotesque limb deformity, for which amputation may be the only solution.

A false aneurysm of the superior gluteal artery with compression of the sciatic nerve is reported in an 18-year-old man who was recovering from multiple injuries sustained in a bicycle accident. Rapidly increasing pain and swelling in the leg, with a rapid fall in the hemoglobin level and weakness of dorsiflexion and inversion of the foot were not compatible with the initial diagnosis of abscess. A selective iliac arteriogram revealed the true diagnosis. The gluteal artery was ligated and the false aneurysm oversewn through a posterior, extrapelvic approach. An abdominal, retroperitoneal approach would have been better but was precluded by injuries to the intrapelvic viscera and left-sided colostomy. False aneurysm of the gluteal artery is a life-threatening condition and must be diagnosed early and treated promptly to ensure a successful outcome.

Two hundred and twenty patients with active spinal tuberculosis were seen at the Orthopaedic Centre, Tunis, between 1965 and 1975. Fifty adults and 11 children were paraplegic, this being particularly associated with infection of the mid-thoracic spine and with marked kyphosis. The number of diseased vertebrae ranged up to 7, the average kyphosis measuring 53 degrees and the worst being 140 degrees. Patients had been paralysed for an average of 4 months before seeking treatment. Thirty seven patients were treated by chemotherapy alone and 26 with the addition of anterior decompression and grafting. The selection of treatment was arbitrary. The average follow up was nearly three years. Sixty eight percent of the medical group had complete neurological recovery and 19% partial recovery, against 38% and 31% respectively for the surgical group. Mortality in the medical group was 5% compared with 23% after surgery. Patients in either group who showed no sign of improvement within six months of the beginning of treatment failed to recover. The prognosis was better in children and in patients with partial paraplegia but was not influenced by the duration of paraplegia.

From an anatomical study and clinical review of fractures of the lateral humeral condyle in children, the following conclusions are drawn. The mechanism of injury is a violent varus force with the elbow in extension, the condyle being avulsed by the lateral ligament and the extensor muscles. If the fracture is incomplete, with an intact hinge of pre-osseous cartilage medially, the fragment will not be displaced. If the fracture is complete the fragment may be displaced, and open reduction with internal fixation is mandatory. The results of open reduction more than three weeks after the fracture are no better than those of no treatment at all, and may kill the lateral condylar fragment by damaging its blood supply. The major problem of a neglected fracture is tardy ulnar nerve palsy; to avoid this, immediate anterior transposition of the nerve is recommended, operation for the fracture itself being of no benefit.

Evans and Watson-Jones described different techniques for reconstructing the lateral ligament of the ankle in patients with chronic lateral instability, but long-term results of the two techniques are not clear. This retrospective study compares the results in 20 adults at an average followup of 5 years (range 4 to 8). Preoperatively all patients showed an average talar tilt of 15 degrees more than the normal side. Ten patients had the Evans procedure and ten the Watson-Jones operation. Nineteen patients had good or excellent clinical results with a stable ankle. Radiographic studies showed minimal residual instability which was more marked in plantar flexion than in neutral, but this did not jeopardize the end results. Long-term clinical results of the two operations are similar. However, the Evans technique controlled talar tilt better whereas the Watson-Jones operation was more effective in reducing anteroposterior instability.

1) Twenty-nine children aged 18 months to 7 years with 40 congenitally dislocated hips, were treated between 1964 and 1971. Six hips had a closed reduction, 34 had an open reduction and capsulorrhaphy, and all had an innominate osteotomy. 2) Complications of the treatment included 2 joint infections. Of 11 hips which were unstable post-operatively, more than half were due to errors of the operative technique, and 8 required further surgery. Avascular necrosis of the femoral head occured in 3 hips post-operatively, and another 3 showed irregular ossification of the femoral epiphysis. All 6 hips had had an open reduction, and were mainly in older children who had inadequate pre-operative traction. 18 hips were stiff post-operatively ; 17 had had an open reduction ; Seven of eleven were improved by traction and physiotherapy. 3) The average length of follow-up was 4 years. Although only 70 p. 100 of the hips were clinically satisfactory, 92 p. 100 had excellent or good anatomical results as seen on radiographs.

Poor results in treating fractures and dislocations about the elbow may be avoided if the surgeon is aware of the possible injuries, examines good radiographs of both elbows, and treats the injury promptly and appropriately. A displaced fracture of the lateral or medial condyle of the humerus should be suspected if there is a flake fracture of the adjoining metaphysis; open reduction and internal fixation give better results than closed reduction. A shear fracture of the capitulum humeri can only be seen on a lateral radiograph; excision of the fragment, followed by mobilization, is sufficient for a good functional result. Dislocation of the elbow in a child may avulse the medial epicondyle, which sometimes lodges in the joint; it is essential to recognize this and remove the fragment without delay to avoid early degenerative arthritis. An apparently isolated fracture of the ulna should alert the surgeon to the possibility of a dislocation of the radial head; the dislocation and the fracture must be reduced and stabilized to conserve elbow function.

Twenty-three children with fractures of the radial neck were reviewed. Fractures with an angulation of greater than 60 degrees were treated by open reduction and internal fixation with transarticular Kirschner wires through the humerus and the radius. These broke at the joint in two patients, and we now avoid the humerus by using oblique Kirschner wires. Some limitation of movement, especially of forearm rotation, was more common in children with associated lesions of the same elbow and with open reduction. We think that this reflects the severity of the injury rather than the presence of associated lesions or the surgery itself.

Fracture of the medial humeral condyle in children is an epiphyseal injury, and it is probably caused by a valgus force incurred with the elbow extended, the origin of the flexor muscles and medial collateral ligament avulsing and rotating the condyle. The injury is uncommon and is easily misdiagnosed. Four children who were treated within one week of injury were seen more than one year later and had good results. Two patients who were treated late and another who was not treated had poor results. Early diagnosis, accurate reduction, and internal fixation are important to avoid growth disturbance, articular incongruence, and functional disability.

We reviewed the cases of fifteen children who were treated for a Monteggia injury. Transverse and metaphyseal fractures of the ulna were stable after closed reduction, but oblique fractures of the shaft redisplaced and required intramedullary pinning. Five patients who were seen late had open reduction and internal fixation of the fracture. Four of these children had reconstruction or repair of the annular ligament, with excellent results. But in the child in whom the ligament was not repaired the radius subluxated.

Untreated scoliosis affects the quality of life and is a disabling disease in the adult. Most patients can expect back pain, particularly after the age of 30, and one in 4 may be disabled by it. The majority of adults are embarassed by their deformity. Women, in particular, are less likely to marry. Surgical treatment of the adult is difficult and hazardous, and is associated with socioeconomic problems not encountered in the adolescent. Scoliosis should be treated definitively before the end of the period of growth.

"Triggering" of the toes, in which local tendon hypertrophy prevents the smooth movement of the tendon, has been described as a problem more theoretical than real and only three cases have been reported. The authors report a case of partial tethering of the flexor hallucis longus tendon just distal to the medial malleolus in a 28-year-old jogger who had painful triggering of the great toe on plantar flexion of the ankle and great toe. Division of the flexor hallucis longus tendon pulley distal and posterior to the medial malleolus cured the patient.

A 46-year-old man suffered from chondromalacia of the fabella after minor trauma to the back of the knee. The condition was misdiagnosed initially as fasciitis, tendinitis, a Baker's cyst and a herniated lumbar intervertebral disc. Pathognomonic signs were pain behind the lateral femoral condyle on palpation and compression of the fabella and also on passive extension of the knee. Conservative management was unsuccessful. Excision of the fabella gave quick and lasting relief.

Fifteen children with an untreated posterior dislocation of the elbow were seen between 1965 and 1980. Three had a useful range of painless flexion and were not treated by operation. Twelve had a stiff elbow and had an open reduction between three weeks and three years after injury. The triceps was lengthened when it prevented reduction and Kirschner wires were used when necessary to stabilize the elbow. Complications included a transient paralysis of the hand in one patient and myositis ossificans with a rigid elbow in another. The length of follow-up ranged from one to six years. In eleven patients the average range of flexion was increased fourfold, and in all children the elbow had a useful range through 90 degrees of flexion. Eleven children said that the function of the arm was improved. However, four of them had been operated on within six weeks of the accident and might have regained a functional range of movement with a short trial of conservative therapy. We now recommend an interval of conservative treatment for children who are seen three weeks to two months after injury.