微创内固定技术治疗胫骨远端粉碎骨折

目的介绍应用AO锁定加压接骨板（locking compression plate．LCP）实现微创经皮接骨板（minimally invasive percutaneous plate osteosynthesis．MIPPO）技术围定胫骨远端粉碎骨折的手术方法．探讨其临床疗效。方法2004年5月至2006年10月。应用LCP实现MIPPO技术治疗胫骨远端粉碎骨折13例．男7例．女6例．年龄23～62岁。平均45岁。AO分型43-A2型7例，43-A3型3例．43-B1型1例．43C1型1例。43-C2型1例，其中有3例骨折线延至胫骨中段。关节内骨折。行关节有限切开．坚强内固定；关节外骨折．按MIPPO技术要求间接复位．LCP桥接固定。结果术后摄片测量肢体力线，与健侧对比，内外翻畸形、前后成角均小于等于±5°，无短缩、旋转畸形。采用电话预约门诊定期随访。全部病例随访4～18个月．平均12个月。平均愈合时间14．3周。无复位丢失，无内固定松动、断裂。根据美国足踝矫形外科学会制定的评定标准。从疼痛（40分）、踝关节功能（50分）和骨折对线（10分）方面进行评定。本组评分86～95分。平均92．5分。结论 MIPPO技术利用骨折间接复位技术．避免骨折端不必要的暴露，保护骨折端及其周围的血供。创伤小．固定可靠，有利于骨折的早期愈合及功能康复。对于胫骨远端粉碎骨折。应用LCP实现MIPPO技术固定应成为最佳选择。在X线监视下进行良好的间接复位是手术成功的保证。     

Surgical options for distal radial fractures: indications and limitations

Distal radial fractures are common problems for the orthopedic surgeon, and various surgical treatments have been reported. However, each method has its indications, pitfalls, and limitations. It is important to select the appropriate procedure for the fracture pattern. We studied 115 consecutive patients including 45 patients with distal radial fractures treated with percutaneous pinning, 67 patients treated with external fixation, and 32 patients treated with assisted wrist arthroscopy. Percutaneous pinning was useful in extra-articular fractures and minimally comminuted intra-articular fractures, but was inadequate for patients with severe osteopenia and markedly comminuted intra-articular fractures. External fixation was indicated when intra-articular comminution was present. However, the dorsomedial fragment was often not reduced and maintained by this technique; additional pinning was needed to reduce this fragment. A dynamic-type fixator was feasible for younger patients who required early functional recovery. Arthroscopy provided accurate visualization of the wrist joint and the intra-articular fracture. Received: 18 March 1997     

Distal tibial metaphyseal fractures: the role of fibular fixation

Distal tibial extra-articular fractures are often a result of complex high-energy trauma, which commonly involves associated fibular fractures and soft tissue injury. The goal of tibial fixation is to maximise fracture stability without increasing soft tissue morbidity from surgical intervention. The role of adjunctive fibular fixation in distal tibial metaphyseal fractures has been controversial; although fibular fixation has been shown to improve stability of distal tibial fractures, there has been increased potential for soft tissue-related complications and a delay to tibial fracture healing. Adjunctive fixation of concomitant fibular fractures without associated syndesmotic or ankle pathology is not necessary in surgically stabilised extra-articular metaphyseal fractures of the distal tibia.     

Tibial alignment following intramedullary nailing via three approaches

Purpose

The purpose of this study is to evaluate the incidence of malalignment in patients undergoing IMN for tibial shaft fractures treated with the extra-articular lateral parapatellar, suprapatellar, and infrapatellar approaches.

Methods

A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical centre. Quality of reduction was assessed using the following three parameters: (1) < 10°of angulation in orthogonal radiographic views (2) < 5 mm of displacement between the major fracture fragments (3) < 5 mm of gap between the major fracture fragments. A good reduction was one that met all 3 criteria, an acceptable reduction met 2 criteria, and a bad reduction met one or none of the criteria. All patients treated consecutively for tibial shaft fractures between June 1, 2019 and June 1, 2020 were identified. The final cohort included 57 tibia fractures in 56 patients. Of the 57 tibia fractures, 8 (14%) were proximal third, 32 (56%) were middle third, and 17 (30%) were distal third fractures.

Results

We found no significant difference in angulation, displacement, or gapping with respect to surgical approach utilized or location of fracture (proximal or distal tibia fractures) on one-way ANOVA. Quality of reduction was rated as “good” in 48 (84%) of the cases (19 supra, 13 infra, and 16 lateral). Nine reductions (16%) met only two of the three reduction quality criteria and were considered acceptable reductions. These included 2 suprapatellar (1 > 5 mm displacement, 1 > 5 mm gapping), 4 infrapatellar (4 > 5 mm displacement), and 3 lateral extra-articular parapatellar (2 > 5 mm displacement and 1 > 5 mm gapping). No reductions were determined to be bad according the Baumgaertner et al. criteria. There was no significant difference in the rate of combined fibula fractures or the rate of fibular fixation between the three cohorts.

Conclusions

In conclusion, no significant difference was found in fracture reduction angulation, displacement, and gapping in patients treated with an IMN with respect to approach for diaphyseal or metadiaphyseal tibial shaft fractures.

     

AO微创内固定系统在股骨远端及胫骨近端粉碎性骨折的应用

目的探讨应用AO微创内固定系统(lessinvasivestabilizationsystems,LISS)治疗下肢股骨远端与胫骨近端粉碎性骨折的临床效果。方法回顾性分析2003年9月~2005年5月采用LISS治疗14例下肢骨折患者,其中男13例,女1例;车祸伤9例,坠落伤3例,摔倒跌伤2例。开放性骨折5例,闭合性骨折9例。骨折部位包括股骨髁上及髁间粉碎性骨折5例,胫骨上段粉碎性骨折9例。骨折按照AO/OTA分类:股骨骨折中,33C2型3例,33C3型2例;胫骨骨折中,41A2型2例,41A3型2例,41B2型3例,41C2型2例。分别应用股骨远端或胫骨近端LISS行内固定手术。术后对其伤口愈合、术前及术后X线片检查及关节功能恢复情况进行观察。结果患者术后切口均期愈合。均获随访1~20个月,平均11个月。12例骨折均在术后3~5个月愈合,另2例经术后2~3个月观察,效果良好。关节功能根据Johner-Wruhs关节功能评定标准:优10例,良3例,可1例;优良率为93%。11例膝关节屈伸范围达110~130°,2例为100°,1例为80°。结论LISS对股骨远端或胫骨近端粉碎性骨折是一种有效的内固定方法,具有创伤小,固定可靠,临床效果良好等优点。     

AO股骨髁支撑钢板内固定在股骨远端复杂骨折的应用

目的 探讨应用股骨髁支撑钢板内固定治疗股骨远端复杂骨折的方法和临床疗效。方法 回顾分析2001年10月～2004年2月，对23例股骨远端复杂骨折患者进行修复重建，其中男19例，女4例；年龄27～55岁。左侧13例，右侧10例。交通伤16例，高处坠落伤7例。闭合性骨折14例，开放性骨折9例。新鲜骨折21例，陈旧性骨折2例。骨折AO分类：A型关节外骨折6例，C型关节内骨折17例。术前X线片示股骨髁上、髁间粉碎性骨折。患者均行切开复位内固定，对于粉碎性骨折先用克氏针或松质骨螺钉整复股骨内外髁，对齐关节面，外侧置股骨髁支撑钢板固定；对骨缺损较大者行一期植骨，术后行科学合理的康复治疗及随访观察。结果 患者均获随访6～20个月，平均13．7个月。术后14个月X线片示骨折均对位、对线佳。骨折均愈合，愈合时间7～16个月。按Kolmert和Wulff的评价标准，A型6例，优5例，良1例；C型17例，优1l例，良3例，可2例，差1例。结论 采用股骨髁支撑钢板内固定治疗股骨远端复杂骨折，设计合理，操作简便，固定可靠，疗效肯定。     

肱骨远端关节内骨折的手术治疗

目的探讨肱骨远端关节内骨折手术治疗效果。方法14例肱骨远端关节内粉碎性骨折,按AO/ASIF分型,B型2例,C1型8例,C2型3例,C3型1例。采用钢板或克氏针、松质骨螺钉固定4例,“Y”形钢板内固定10例。结果14例均获得随访,随访时间9～20个月。按Aitken和Rorabeck标准进行功能评定:优9例,良3例,可2例。结论治疗肱骨远端关节内骨折应解剖复位、有效固定、早期功能锻炼,手术治疗是比较好的选择。     

经尺骨鹰嘴截骨复位双钢板内固定治疗肱骨远端关节内粉碎骨折

目的　探讨肱骨远端关节内粉碎性骨折的手术疗效。方法　10例肱骨远端关节内粉碎骨折,采用肘关节后侧正中入路,尺骨鹰嘴截骨;骨折复位后,用重建钢板和 1 /3管型钢板分别放置于肱骨远端的后外侧和内侧固定;尺神经常规前置皮下,术后早期功能锻炼。结果　随访 20 ~61个月,骨折全部愈合,骨折愈合时间10~16周。肘关节平均活动度 110. 0°(95°~140°)。Mayo评分良好 9例,可 1例。一过性尺神经麻痹 1例,术后 1个月恢复,无桡神经损伤病例。结论　采用尺骨鹰嘴截骨、关节面解剖复位、双钢板固定和术后早期功能锻炼的方法治疗肱骨远端粉碎性骨折临床疗效良好。     

Mid to distal third tibial shaft fractures caused by gunshots: Characterization and incidence of distal intra-articular extension

IntroductionSpiral tibial shaft fractures are known to have a high rate of distal intra-articular extension; however, the risk of joint involvement caused by gunshots has not been thoroughly evaluated. The purpose of this study was to determine the incidence of intra- articular involvement in tibial shaft fractures caused by gunshots. The secondary purpose of this study was to assess the usefulness of ankle radiographs versus computed tomography (CT) scans in identifying these fractures.Materials and methodsNinety consecutive patients were identified as having a tibia fracture caused by gunshot at a Level-1 trauma center. Forty-four of these patients were fractures of the mid to distal third shaft. Twenty-eight patients had ankle CT scans available for review, and 24 patients had dedicated ankle films. Three orthopaedic surgeons and a radiologist read the radiographs and CT scans. Sensitivity and specificity analysis was performed for the ankle radiographs using ankle CT scans as the gold standard.ResultsSeven of the twenty-eight fractures evaluated with a CT scan proved to have intra-articular involvement (Prevalence: 25%, 95% CI: 11.4%–45.2%). One of the seven intra-articular fractures was not seen on dedicated ankle radiographs (14.3%). The sensitivity of diagnosing an intra-articular extension on ankle radiographs was 0.85, 95%CI: 0.42–0.99. The specificity of diagnosing an intra-articular extension on ankle radiographs was 1.00, 95%CI: 0.81–1.00. Of the seven intra-articular fractures, three required additional treatment to address the intra-articular extension.ConclusionThe incidence of intra-articular involvement for tibial shaft fractures secondary to gunshot is less than that reported for spiral type fractures (11–45% vs. 25–58%). Although radiographs have a high specificity, the sensitivity is lower than expected, with worse outcomes if a fracture is missed. We recommend that a CT scan should be utilized to determine intra-articular extension in the setting of tibial shaft fractures caused by gunshots.     

超声检查在儿童膝关节骨折诊断中的初步应用

目的 评价超声检查在儿童膝关节骨折诊断中的作用.方法 对2015年9月至2019年3月北京大学第四临床医学院北京积水潭医院小儿骨科收治的膝关节骨折患儿27例临床资料进行回顾性分析.其中男18例,女9例;平均年龄7岁4个月(9个月～13岁5个月).所有患儿在伤后2周内接受患侧膝关节X线和MRI检查以及双侧膝关节超声检查....     

Children's Ankle Fractures: Classification and Epidemiology

In an investigation of childhood and adolescence fractures (age groups 0-16) occurring in Malmo during 1950, 1955, 1960, 1965, 1970 and 1975-79, a total of 8682 were found. Four per cent or 373 ankle fractures were classified according to their roentgenological appearance.

Avulsion fractures of the tip of the lateral malleolus were the most frequent, followed by fractures involving the distal fibular physis. Triplane and Tillaux fractures were the third and fourth most common fracture groups. Tillaux fractures were more common in girls (0.01 > P > 0.001). There was no statistically significant difference between the sexes in the other fracture groups or in the whole series. Most injuries were caused by low energy trauma. A foot caught in a bicycle wheel resulted more often in an epiphyseal fracture of the lateral malleolus than any other type of fracture. Otherwise no other etiological factor caused a significant number of cases in any fracture group.

There was a seasonal variation with twice as many fractures during April and September as compared with July and December. The incidence showed a steady increase during growth which ceased after the early teens due to a lower incidence among girls in the age groups 15-16. The incidence increased significantly during the 30 years covered by this study.     

External fixation in comminuted,displaced intra-articular fractures of the distal radius: is it sufficient?

Introduction: External fixation has been extensively used to treat the intra-articular fractures of the distal radius and it has several distinct advantages over conventional POP cast and plate fixation. However, the limitation of external fixation to achieve articular congruity in the comminuted intra-articular fractures of the distal radius has been documented in the literature. This could be because external fixation alone does not expand crushed cancellous bone and cannot work without soft tissue hinges. This prospective study was conducted to look at the results of comminuted, displaced intra-articular fractures of the distal radius treated exclusively by external fixation. Materials and methods: A 2-year follow-up of 27 patients with comminuted, displaced intra-articular fractures of distal radius that were treated exclusively by external fixation is presented. The radiological results, functional results and complications were analyzed according to the scoring system given by Jakim et al. Results: Anatomical reduction could not be achieved in 12 patients (44%) and reduction was lost in two patients (7%). Excellent and good results were seen in 59.3%, fair results were seen in 22.2% and poor results were seen in 18.5% of the cases. Outcome scores of patients without articular step were significantly better as compared to the patients with articular step at healing. There was a positive correlation between the restoration of normal anatomy (radiological results) and the functional outcome (r=0.775). Overall nine patients (33%) had complications. Conclusion: We conclude that although the external fixation is reliable in maintaining the reduction in displaced comminuted intra-articular fractures, it is inadequate in restoring articular congruity in many cases. The complications of external fixation are frequent and may be potentially serious in nature.     

Wrist arthroscopy in distal radial fractures using a modified horizontal technique

Wrist arthroscopy has today become an important adjunct in the management of displaced intra-articular distal radial fractures, with reduction of joint incongruencies as well as detection and treatment of associated soft-tissue injuries. However, standard upright arthroscopy makes it difficult to combine arthroscopic-assisted reduction with additional treatment of the often comminuted, extra-articular fracture component. This article describes a modified arthroscopic technique in which the arm is blocked in pronation with the traction horizontally over a handle on a normal hand table, without any other changes in the arthroscopy itself. The author has operated on 17 patients using this horizontal technique in combination with arthroscopic-assisted reductions, closed and open osteosynthesis, and soft-tissue procedures. The horizontal technique allows complete treatment of comminuted, unstable distal radial fractures, intra-articular and extra-articular reduction, and bone grafting, as well as assessment and treatment of associated soft-tissue injuries.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp E5–E5     

Frakturen des distalen Radius

The most prevalent fractures managed by trauma surgeons are those involving the distal radius. The injury occurs in two peaks of prevalence: the first peak around the age of 10 years and the second peak around the age of 60 years. Distal radius fracture management requires sensitive diagnostics and classification. The objectives of treatment are the reconstruction of a pain-free unlimited durable functioning of the wrist and avoidance of typical fracture complications. Non-operative conservative management is generally employed for stable non-displaced fractures of the distal radius with the expectation of a good functional outcome. Unstable comminuted fractures with intra-articular and extra-articular fragment zones are initially set in a closed operation and finally by osteosynthesis. An armament of surgical implants is available for instable fractures requiring fixation. Palmar locked plate osteosynthesis has been established in recent years as the gold standard for operative management of distal radius fractures. Complex Working Group on Osteosynthesis (AO) classification type 3 fractures require extensive preoperative diagnostics to identify and treat typical associated injuries around the wrist.     

Expanding Indications of Primary Arthrodesis in Selected Individuals for Managing Complex Hindfoot Trauma During COVID-19 Pandemic

BackgroundDuring the COVID-19 pandemic, public health measures to encourage social distancing have been implemented, including cancellation of outdoor activities, organized sports, and schools/colleges. Neglected hindfoot fractures have emerged as a consequence with increased frequency. Similarly, complex ankle and pilon fractures that require staged management, prolonged hospital stay, and soft-tissue care have emerged as a potential concern as prolonged exposure to healthcare setting adds to risk of acquiring as well as transmitting COVID-19 infection. The authors present their experience with expanding these indications for hindfoot arthrodesis as they encounter a greater number of neglected ankle and hindfoot trauma.MethodsThis was a retrospective observational study of collected data from the trauma unit of our hospital. Inclusion criteria included all trauma classified by the AO/OTA as occurring at locations 43, and who underwent subtalar and ankle arthrodesis. This included distal tibia, malleolar, talus, and calcaneus fractures. These patients were followed up to at least 6 months till complete fracture union.ResultsA total of 18 patients underwent arthrodesis of either the ankle or subtalar joint between March and October 2020. Mean age of patients undergoing arthrodesis of the hindfoot was 69.2 years (43–84 years). Indications for the procedure included Displaced and comminuted intra-articular distal tibia fractures in elderly (6 patients), Malunited ankle fractures (2 patients), Neglected Ankle fractures managed conservatively (3 patients), Calcaneus fractures (5 patients), and neglected Talus body fracture (2 patients). All patients were followed up to at least 6 months and everyone went onto successful painless union between 3 and 6 months of the arthrodesis procedure without any significant complications.ConclusionIn summary, COVID-19 pandemic has led to a change in paradigm of trauma management and foot and ankle management is no different than other musculoskeletal trauma systems. The authors propose an expansion of indications for hindfoot arthrodesis in managing complex hindfoot trauma in pandemic situation.     

Fracture of the tibia with additional injury of the ankle joint. A frequent and undervalued combination

Summary There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6 %) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Typ B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20,7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13,6 % of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.      

Fracture of the tibia with additional injury of the ankle joint. A frequent and undervalued combination Eine h?ufige, aber wenig beachtete Kombination

There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6 %) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Typ B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20,7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13,6 % of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.     

Ilizarov external fixation for severely comminuted supracondylar and intercondylar fractures of the distal femur

Our aim was to determine the clinical effectiveness and safety of Ilizarov external fixation for the acute treatment of severely comminuted extra-articular and intercondylar fractures of the distal femur. A total of 14 consecutive patients with complex fractures was treated. There were three type-A3, two type-C2 and nine type-C3 fractures according to the AO/ASIF system. The mean follow-up was 14 months. Most fractures (13) united primarily at a mean of 16 weeks. One patient with a type-IIIA open fracture had infection and nonunion. The mean range of flexion of the knee at the final follow-up was 105 degrees (35 to 130). We conclude that, in the treatment of comminuted fractures of the distal femur, the Ilizarov fixator is safe and effective in providing stability and allowing early rehabilitation.     

Complex fractures, do we operate on enough to gain and maintain experience?

Complex fractures are generally assumed by our profession to require adequate training and continuing practice to treat optimally. The quantity of complex fractures treated in individual hospitals and by or under the care of individual orthopaedic consultants may have implications regarding the quality of care for particular patients and also for the training of specialist registrars.A complex fracture was defined as a comminuted peri- or intra-articular fracture or segmental shaft fracture: fractures acknowledged at specialist fracture courses and by special trauma surgeons to require particular training and experience to treat optimally. The AO classification was used: most fractures were in AO groups B and C [M.E. Muller, S. Narazian, P. Koch, J. Schatzker, The Comprehensive Classification of Longbones, Springer, Berlin, 1990]. Theatre records were used to identify all operated orthopaedic trauma cases over a period of 1 year in one District General Hospital (DGH) and one University Hospital, each serving populations of over 300000 and for 6 months in one DGH (population approximately 300000). Radiographs and hospital records were reviewed by two orthopaedic surgeons and the number and type of complex fractures documented as defined above. In hospital A, 69 complex fracture operations were carried out under the care of six consultants in 12 months. In hospital B, 24 complex fractures were treated by five consultants over a 6-month period and in hospital C, 127 complex fractures were treated by 10 consultants over a 12-month period. Some consultants (different consultants for different fracture regions) did not operate on any complex fracture of the proximal, mid, or distal humerus; proximal, mid, or distal radius or ulna; proximal, mid, or distal femur; proximal, mid, or distal tibia; calcaneum; peri-prosthetic; Lisfranc; or talus fracture during the specific time period. Some consultants only treated one or two such fractures. Where two surgeons had developed an area of special interest and cross-referral were encouraged individual surgeons were operating on up to 25 complex cases in their area of interest.This audit has shown that individual complex fractures present infrequently to particular hospitals and surgeons. This finding raises questions about the optimal management of such fractures: are we maintaining a sufficient level of expertise, or should there be more cross-referrals to surgeons with a specific interest either in trauma or in a particular anatomical region?     

Attritional flexor tendon ruptures after a malunited intra-articular fracture of the distal radius

Rupture of the flexor tendon following Colles fracture is uncommon. In all reported cases it occurred as a complication of an extra-articular, displaced fracture of the distal radius. We report a case in which flexor tendon rupture occurred 30 years after a comminuted intra-articular fracture of the distal end of the radius. There have been no reports of delayed flexor tendon rupture after an intra-articular fracture of the distal radius in young adults.