[Physiological and Pathological Development of calcaneal apophysis in Children]. / Klinische Pathologie der Fersenbeinapophyse im Wachstumsalter.

BACKGROUND: The apophysis of the calcaneal bone forms an insertional region for the strong plantarflexors with the Achillis tendon and serves as an origin for the plantar aponeurosis and the short intrinsic foot muscles. Both components create a tendinous sling whithin which the apophysis acts as a pivot, which functions when it runs a straight course and its tension is adequate. This mechanism results in combined tractional and compressional forces which work together with the ground reaction forces during gait as molding elements of the calcaneous bone. Every longer lasting change in the magnitude and distribution of these forces can be followed by structural adaptations especially during the growth period. Furthermore the calcaneal apophysis functions as a connecting link between the ankle and thigh bones on one side and the mid- and forefoot region on the other side. When studying the causal relationships which influence the apophyseal growth and shape intrinsic and extrinsic components must be distinguished. CLINICAL DIAGNOSTICS: Every analysis of calcaneal pathologies should use clinical and instrumented diagnostics. Any classification must separate between bony and soft tissue elements and consider structural and functional influences in three planes. If an exact classification can be established an individual hypothesis must be formulated out of which therapeutic measures can be developed. THERAPY: Treatment must focus on the pathologic changes of shape as well as on functional aspects. A thorough knowledge of the normal development and function of the calcaneal apophysis serves as a basis for further understanding and treating pathologic changes of this hitherto only sparsely investigated functional region.

Influence of type of management of transverse sacral fractures on neurological outcome. A case series and review of literature.

STUDY DESIGN: A retrospective study with review of literature. OBJECTIVES: (1) To report the management and outcome of a series of six cases of transverse sacral fractures. (2) To review the literature and see the influence of the type of treatment on the neurological outcome, in particular, of the bladder and bowel and to identify the possible factors determining this outcome. SETTING: Regional spinal injury Unit, Southport, UK. METHODS: Six patients with transverse sacral fractures were identified and their case notes were reviewed. The follow-up period was 4 to 17 years. A review of literature was carried out and publications that reported the outcome of function of bowel and urinary bladder were considered for the study. RESULTS: Five of our six patients had cauda equina syndrome. Five cases were managed conservatively and one case surgically. Bladder and bowel function did not improve in three out of five cases. A review of English literature identified 18 (60 cases) of the 25 publications mentioning the outcome of bladder and bowel function. Of these, 47 cases were managed surgically, with the improvement of bladder and bowel function in 34 cases. Rest of the 13 cases were treated conservatively, with the improvement of bladder and bowel function in 10 cases. CONCLUSION: There is no statistical evidence of benefit of either surgical or conservative management on the outcome of bladder and bowel function. Presence of a severe angulation, displacement of fracture and neurotomesis dictate poor prognosis.

National survey in the United Kingdom of prophylaxis of deep vein thrombosis for patients with fracture of the neck of the femur.

Thromboprophylaxis continues to be a contentious issue because of a lack of clear answers to pertinent questions. Hence, a survey is helpful in identifying current practices. A national survey in the UK in January 2004 investigated the use of thromboprophylaxis following fracture of the neck of the femur. Responses from 723/1648 (44%) orthopaedic consultants to a postal questionnaire showed that 623 (86%) regularly undertook trauma surgery and 625 (87%) had protocols for prophylaxis of deep venous thrombosis. In all, 555 (89%) consultants followed these protocols routinely and, of these, 276 (50%) regularly used both chemical and mechanical prophylaxis, 235 (42%) used chemoprophylaxis only and 44 (8%) used mechanical prophylaxis only. Among consultants using chemoprophylaxis, 238 (46%) used low-molecular-weight heparin, 148 (30%) used aspirin, 75 (15%) used low-molecular-weight heparin and aspirin, 35 (6%) used unfractionated heparin and 15 (3%) used warfarin. However, 68 (11%) did not use any thromboprophylaxis at all for patients with fractured neck of the femur.

Orthopaedic injuries following falls by hospital in-patients.

BACKGROUND: Falls are one of the most frequent episodes on the hospital wards. OBJECTIVE: To identify orthopaedic injuries sustained by in-patients falling on the hospital wards and to find out what treatment these required along with the additional time and cost that this incurred. METHODS: A retrospective analysis of 900 incident forms and case records was undertaken for a 3-year period. Fractures and other soft-tissue injuries sustained and time, place, and mode of injury were noted. Type of fractures sustained and specific treatment required including operative procedure needed were studied. The cost of each treatment and the total cost in terms of time and money were calculated. RESULTS: We identified 42 patients with orthopaedic injuries; 53% of the falls were recorded on medical wards. A poor pre-fall mobility was an important factor in over 80% of the cases, and a variety of medical conditions pre-existed in the elderly ill patients. Eighteen patients (42%) sustained hip fractures, of whom 15 patients (36%) required surgical treatment. There were 9 deaths in total, 5 of them occurred in patients with hip fractures. The cost of treating the injuries amounted to about GBP 70,000. An additional hospital stay of 56 weeks in total was needed, most patients requiring between 1 and 5 weeks of additional stay. CONCLUSIONS: Falls in elderly in-patients can result in a variety of skeletal injuries. These may require major operative procedures and result in significant morbidity and can prove fatal. The treatment of these injuries is a substantial added expenditure to the trust.

Bilateral simultaneous extensor mechanism disruption following simultaneous bilateral total knee replacement.

Extensor disruptions of the knee following the total knee replacements are uncommon. We describe a case of postoperative bilateral simultaneous extensor mechanism disruption following simultaneous bilateral total knee replacement. On both sides, the patient sustained open wounds. The extensor mechanism was successfully repaired on both sides, but the outcome is less than satisfactory.

A hidden injury.

Transverse sacral fractures associated with cauda equina syndrome are uncommon lesions and often missed at the time of presentation. This case report highlights the benign presentation and the unpleasant outcome of such an injury.