A new technique for closed management of displaced intra-articular fractures of metacarpal and phalangeal head delayed on presentation: report of eight cases.

We present the outcomes of the delayed management of eight displaced intra-articular fractures of the metacarpal and phalangeal heads treated with capsuloligamentotaxis using the Penning mini-external fixator. Closed anatomical reduction with a 2 mm over-distraction was achieved at the time of operation at an average of 20 days after the initial injury. Excellent outcomes in terms of function and pain were obtained at 6 month's follow-up in all cases. This technique is simple, minimally invasive, and effective, with minimal complications.

Single-stage distraction correction for neglected dorsal fracture dislocations of the proximal interphalangeal joint: a report of eight cases.

We present the outcome of treatment of eight chronic neglected dorsal fracture dislocations of the proximal interphalangeal joint treated with a single-stage ligamentous distraction using the Penning mini-external fixator and a closed reduction. The distraction correction and 2 to 3 mm over distraction was performed acutely at the time of operation in all eight cases at an average injury-to-surgery time of 6 weeks. Satisfactory results with an average range of motion of 79 degrees were obtained at an average follow-up of 20 months. This technique is simple, effective and offers the advantage of being minimally invasive. We recommend this single-stage distraction correction technique for the treatment of chronic neglected dorsal dislocations of the proximal interphalangeal joint, which are no more than 10 weeks-old.

Paediatric forearm refractures with retained plates managed with flexible intramedullary nails.

During the past 18 months we have managed four paediatric patients who have sustained forearm refractures associated with retained plates that were used to treat their original fracture. Although this complication is not new, most literature regarding paediatric forearm refracture relates to refractures that occur after closed treatment or after removal of metalwork. We treated the patients in this small series with plate removal and intramedullary stabilisation using elastic stable intramedullary nails (Nancy, Depuy, UK) as opposed to revision plating. Treatment of this complication by this method has not previously been described.

Gradual joint distraction of post-traumatic flexion contracture of the proximal interphalangeal joint by a mini-external fixator.

We present the outcome of the treatment of chronic post-traumatic contractures of the proximal interphalangeal joint by gradual distraction correction using an external fixator. A total of 30 consecutive patients with a mean age of 34 years (17 to 54) had distraction for a mean of 16 days (10 to 22). The fixator was removed after a mean of 29 days (16 to 40). Assessment at a mean of 34 months (18 to 54) after completion of treatment showed that the mean active range of movement had significantly increased by 63 degrees (30 degrees to 90 degrees ; p<0.001). The mean active extension gained was 47 degrees (30 degrees to 75 degrees ). Patients aged less than 40 years fared slightly better with a mean gain in active range of movement of 65 degrees (30 degrees to 90 degrees ) compared with those aged more than 40 years, who had a mean gain in active range of movement of 55 degrees (30 degrees to 70 degrees ) but the difference was not statistically significant (p=0.148). The use of joint distraction to correct chronic flexion contracture of the proximal interphalangeal joint is a minimally-invasive and effective method of treatment.

Distal femoral fractures treated by hinged total knee replacement in elderly patients.

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile. Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low. A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.

Anterior dislocation of the ulnar-humeral joint in a so-called 'pulled elbow'.

We describe an unusual case of a missed anterior dislocation of the elbow joint in a 1 year old girl who presented with a pulled elbow. To our knowledge, this is the first report of anterior dislocation as a result of a pulled elbow in the literature. We would like to highlight the rarity of this presentation and the importance of chronological assessment and management in the accident and emergency department.

The retrograde nail for distal femoral fractures in the elderly: high failure rate of the condyle screw and nut.

Displaced distal femoral fractures in elderly patients benefit from surgical fixation. We describe the use of a retrograde femoral nail to treat these fractures. The implant has a special condyle screw and nut that allows for manual compression of the fracture when there is an additional inter-condylar split. We present our results when using this implant to treat 16 patients over a 13-month period. The mean patient age was 78 years (range, 65-96 years). All 16 patients were available at the time of final follow up and proceeded to union at an average time of 11 weeks (range, 10-14 weeks). Twenty-six condyle screw and nuts were used. Ten out of 26 condyle screws in 10 out of 16 patients failed by disengaging at a mean time of 10 weeks (range, 8-12 weeks). Our union rate was unaffected by the nut and bolt disengaging. This would suggest that the condylar compression generated by the nut and bolt may not be critical for union.

Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma.

BACKGROUND: Subtrochanteric fractures of the femur that are caused by low-energy trauma are less common than other proximal femoral fractures, but they occur in a similar population of elderly individuals, who are often socially dependent and medically frail. Although a wide range of operative techniques have been used, cephalomedullary nailing theoretically provides the most minimally invasive and biomechanically stable means of treating these complex fractures. The purpose of the present review was to evaluate the functional outcome and perioperative complications associated with the use of a trochanteric-entry cephalomedullary nail to treat all low-energy subtrochanteric fractures that were seen at a single institution. METHODS: Over an eight-year period, we used the long Gamma nail to treat a consecutive series of 302 local patients who had sustained a subtrochanteric fracture during low-energy trauma. The mortality, prevalence of complications, and functional outcome were prospectively assessed during the first year after the injury. Survival analysis was used to assess the rates of reoperation and implant revision during the first year after surgery. RESULTS: At one year, seventy-four (24.5%) of the original 302 patients had died and seventeen (5.6%) had been lost to follow-up. The remaining 211 patients (69.9%) were evaluated with regard to the functional outcome and postoperative complications during the first year after the injury. As with other proximal femoral fractures in the elderly, there was an increased level of social dependence, an increase in the use of walking aids, and a reduction in mobility among survivors. Although eighty-eight (41.7%) of the 211 patients who were evaluated at one year after the injury had some degree of hip discomfort, only two described the pain as severe and disabling. Reoperation for the treatment of implant or fracture-related complications was required in twenty-seven (8.9%) of the 302 patients; however, only eighteen of these patients required nail revision, corresponding with a one-year nail-revision rate of 7.1% (95% confidence interval, 4.0% to 10.2%) on survival analysis. Of the 250 patients who survived for six months after the injury, five (2%) had a nonunion that was confirmed at the time of surgical exploration. Complications related to the proximal lag screw were seen in twelve of the original 302 patients, and a fracture distal to the tip of the nail occurred in five. Although superficial wound infection was relatively common, deep infection occurred in only five of the 302 patients. CONCLUSIONS: Subtrochanteric fractures caused by low-energy trauma are similar to other proximal femoral fractures, with a high mortality rate during the first year after the injury. Trochanteric-entry cephalomedullary nails are associated with an acceptable rate of perioperative complications and favorable functional outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV.

Correction of Madelung's deformity by the Ilizarov technique.

We present our experience with correction of Madelung's deformity by the Ilizarov technique. Seven patients (eight deformities) were treated by osteotomy of the radius with subsequent lengthening and angular correction. They were reviewed at a mean of 30 months (1.5 to 5.5 years). At the time of operation their mean age was 19 years (9 to 44). At follow-up all were free from pain and supination had improved by a mean of 34 degrees and pronation by 9 degrees. Flexion had increased in most cases with a median increase of 15 degrees, but only one patient gained further extension. Radial and ulnar deviation were increased by a mean of 6 degrees and 9 degrees, respectively. Radiographic measurements showed that the mean volar angulation had been reduced from 25 degrees to 11 degrees, ulnar inclination from 45 degrees to 30 degrees and carpal malalignment (volar translation) from 7 to 2 mm. The mean lengthening of the radius was 12 mm (6 to 25). All the patients were satisfied with the functional and cosmetic results.

Chronic flexion contracture of proximal interphalangeal joint treated with the compass hinge external fixator. A consecutive series of 27 cases.

Twenty-seven chronic flexion contractures of the proximal interphalangeal joint were treated with the Compass((R)) hinge external fixator without open surgery. The fixator was removed after a mean of 33 (range, 14-68) days. The mean time from injury to operation was 4 (range, 1-19) years and all patients were reviewed at a mean follow-up of 21 (range, 12-50) months. The mean extension gain was 38 degrees (range, 0-70 degrees), and the mean flexion-extension arc improved by 42 degrees (range, 0-80 degrees). Complications included superficial pin-track infection in 11 cases and pin loosening in four cases.

[Ultrasonographic scanning of patients with severe abdominal injuries]. / UL-scanning af abdomen hos hårdt kvaestede patienter.

INTRODUCTION: The aim of this study was to describe our experiences with ultrasonography (US) of severely traumatised patients, and to show whether it is a safe and fast procedure when screening for intra-abdominal lesions. MATERIAL AND METHODS: In a period from 1996 to 1999, 876 patients were received by the trauma team. The number of patients with an injury severity score (ISS) > 15, was constant during the period. Seventy-five per cent of the patients were men. One hundred and fifty-five patients (18%) died, 111 before US was carried out. RESULTS: Over the four-year period, the number of patients received by the trauma team increased from 150 in 1996 to 365 in 1999. The number of US examinations increased from 61 (1996) till 303 (1999). The number of pathological US scans was constantly about 20 per year, where as the number of pathological CT scans was between ten and 20 per year. The number of patients that went on to explorative laparotomy was between seven and 17 per year and 49 in the whole period. The sensitivity of US to detect abdominal lesions is 0.74 and the specificity 0.97, whereas that to detect free abdominal fluid is 0.88 and the specificity 0.99. DISCUSSION: US of the abdomen is a fast and safe procedure to carry out on the severely traumatised patient. An algorithm for diagnosis is suggested.

The epidemiology of elbow fracture in children: analysis of 355 fractures, with special reference to supracondylar humerus fractures.

We present a study of the pattern of elbow fractures in children under 15 years of age, during a 5-year period, with special reference to supracondylar humerus fractures. The incidence was 308/100 000 per year; 58% of the children had a fracture in the supracondylar area of the humerus. There were 355 elbow fractures, and there were 164 boys (46%) and 191 girls (54%). The mean age for the entire group was 7.9 years (for boys, 7.2 years; for girls, 8.5 years). Of 209 supracondylar fractures (including 5 combination fractures), 134 were type I, 40 were type II, and 35 were type III (as classified by Gartland). Associated temporary nerve injuries involving the median, radial, and ulnar nerves were seen in 15 patients with type III supracondylar fractures. Associated brachial artery injuries were seen in 6 patients, 5 of whom had type III fractures.

Wrist arthrodesis with the AO titanium wrist fusion plate: a consecutive series of 42 cases.

In a 4 year period (1996-1999), 42 total wrist fusions in 25 men and 17 women were performed using the AO/ASIF Titanium wrist fusion plate. The median age of the patients at the time of surgery was 41 (range, 19-72) years. The indication for fusion was post-traumatic arthritis in 29 wrists, Kienböck's disease in eight, rheumatoid arthritis in three, mono-arthritis in one and Volkmann's contracture in one. All patients were reviewed at a median follow-up of 23 (range, 6-50) months. The Buck-Gramcko and Lohmann score for functional evaluation was excellent in 35, good in 5 and satisfactory in 2 patients. We conclude that wrist arthrodesis with the AO/ASIF Titanium wrist fusion plate is an excellent option for treatment of various painful disorders of the wrist.

Metacarpal and phalangeal lengthening by callus distraction.

Twelve metacarpals and two phalanges in 14 patients (nine males and five females) were lengthened between August 1992 and March 1999 by the callus distraction technique using a small external fixator (Orthofix). The indications were traumatic amputation (10 cases), aplasia (three cases) and hypoplasia owing to premature epiphyseal closure of the metacarpal (one case). All patients were reviewed with a median follow-up time of 39 (range, 9-88) months. The median age of the patients was 15 (range, 4-39) years. The median lengthening was 21 (range, 13-34) mm which was a median of 82% (range, 38-162) of the original bone length. The median times for callus distraction and consolidation were 4.5 and 7.5 weeks respectively. All except one patient tolerated the procedure well and were satisfied with the results. Functional improvement was seen in 13 out of 14 patients, but non-union was observed in one patient.

[Discoid lateral meniscus. The importance of MRI scanning for the diagnosis]. / Diskoid lateral menisk. MR-scannings betydning for diagnostik.

This article reports a case of a complete discoid lateral meniscus with an anteriomedial cleavage tear in a 4-year-old boy diagnosed by MRI. The patient underwent arthroscopy with findings of a torn complete discoid lateral meniscus. As the peripheral rim of the meniscus was stable, a partial meniscectomy with reshaping was done. At follow-up two years postoperatively, the patient had recovered uneventfully.

A prospective comparison of wedge matrix resection with nail matrix phenolization for the treatment of ingrown toenail.

In a prospective study, 110 patients with ingrown toenails were operated on, 55 with wedge matrix resection (WMR) and 55 with nail matrix phenolization (NMP). The patients were randomized on the basis of their address. All patients were reviewed by questionnaire 4 weeks postoperatively to establish the degree of pain, time of pain relief, walking and working ability, and the presence of infection. Furthermore, they were examined clinically at a median follow-up time of 11 months postoperatively to evaluate recurrence rate, rate of spicula formation, and patient satisfaction with regard to cosmesis and symptom relief. The data were tested for statistical significance using the chi-square test and Mann-Whitney rank sum test. The recurrence rate of ingrown toenail for the WMR group was 5.5% (3 patients) with a spicula rate of 36% (20 patients) and a reoperation rate of 20% (9 patients). In the NMP group, there were no recurrences (p = n.s.), the spicula rate was 7.3% (4 patients) (p < .005) and no patients were reoperated on (p < .016). Patient satisfaction with less pain and earlier pain relief was greatest in the NMP group. These results indicate that nail matrix phenolization is an efficient therapy for ingrown toenails and may be preferable to nail wedge resection.

Madelung deformity treated with Ilizarov technique: a report of two cases.

Two children with painful and progressive Madelung deformities were treated by osteotomy of the radius and subsequent angular correction and bone lengthening using the Ilizarov technique. Both children were radiologically improved and free of pain at follow-up.

Bone and joint tuberculosis in Denmark: increase due to immigration.

We studied the epidemiology of bone and joint tuberculosis (TB) in Denmark during the period 1993-1997, using data in the national Danish TB register. We found 95 cases, accounting for 4% of all tuberculosis cases and 15% of extrapulmonary cases, giving a mean annual incidence of 0.4 per 10(5) in the period. 26 cases were found among native Danes (3-8 cases per year) with a median age of 66 (10-92) years and giving a mean annual incidence of 0.1 per 10(5). Among immigrants, an increasing number of cases of bone and joint TB were diagnosed, increasing from 5 in 1993 to 28 in 1997, giving a total of 69 cases with a mean age of 35 (11-75) years and a mean annual incidence of 4 per 10(5) in the period. The spine was affected in half of the cases. 28 patients had active TB elsewhere in the same period. In most patients, there were no predisposing or risk factors for disease except for ethnicity. Compared to a study of bone and joint TB in Denmark in the 1980s, the total incidence is the same, but there has been a shift in patients from old Danes to young immigrants. The increasing number of bone and joint TB cases among immigrants is due to recent immigration of Somalian refugees, who have a high incidence of TB and a high proportion of extrapulmonary TB. The diagnosis was often delayed several months or years. This study shows that attention must be paid to this condition, particularly in young patients from an endemic immigrant population.

Traumatic duodenal rupture in a soccer player.

Traumatic duodenal rupture resulting from blunt trauma during soccer is an extremely rare occurrence. A case report of this unusual condition is presented together with a review of the literature.