A prospective comparison between external fixation and plates for treatment of midshaft nonunions of the clavicle.

BACKGROUND AND AIMS: Several surgical techniques have been used to treat clavicular nonunions. The aim with this prospective study was to compare treatment of symptomatic midshaft clavicular nonunions with either external fixation or plating. PATIENTS AND METHODS: The study included two consecutive series where the first 11 patients (8 men and 3 women) were treated with external fixation (EF) while the following 13 patients (5 men and 8 women) were treated with internal fixation using a 3.5 mm reconstruction plate (RP). All patients had autologous cancellous bone graft. After on average 8.6 years (EF) and 5.4 years (RP), respectively, an independent observer evaluated the patients. RESULTS: In the EF-group 8/11 healed within 12 months while 3/11 healed after reoperation with a reconstruction plate and new bone grafting at 6-9 months. In the RP-group 12/13 healed within six months while 1/13 healed after two additional bone transplants. There was no hardware breakage. The healing time for the RP group was significant shorter when compared with the EF group even if the fractures that did not heal after the first operation were excluded. In 4 patients the plate was removed following healing. There was no significant difference in functional outcome between groups at follow up. CONCLUSION: The reconstruction plate was a better alternative than external fixation due to faster and more reliable healing. Patients commonly considered the external frame cumbersome.

Classification of ankle fractures: the Lauge-Hansen or AO system?

Lauge-Hansen's system of classification of ankle fractures has been of pioneering importance and when correctly employed has improved the results of conservative treatment. Weber's classification scheme introduced by AO is simpler and more suited for surgical than nonoperative therapy. Both systems have deficiencies. Moreover, both are based on partly divergent concepts of the causative mechanisms of ankle fractures.

Operative treatment of ankle fracture-dislocations. A follow-up study of 306/321 consecutive cases.

In a prospective study of 321 consecutive cases of dislocation ankle fractures, operatively treated according to the AO (ASIF) principles, 306 cases (95%) were followed up two to six years after surgery. The infection rate was 1.8% with no septic arthritis. The clinical results were "excellent and good" in 82%, "acceptable" in 8%, and "poor" in 10%. Posttraumatic arthritis occurred in 14% and was significantly more common among middle-aged women. There was a strong correlation between the degree of arthritis and the clinical result. A computer analysis (AID) revealed that the most decisive factors influencing the clinical result were the type of fracture, the accuracy of the reduction, and the sex of the patient. Exact reduction, rigid internal fixation, early postoperative joint exercises, and subsequent full weight-bearing in a below-the-knee walking plaster are essential for a good end result of fracture-dislocations of the ankle joint.

Measurement of the motion range in the loaded ankle.

In an easily practicable method of measuring the motion range in the ankle under load, the patient is asked to put his foot on a 30-cm-high stool and then lean forward as much as possible without lifting his heel from the supporting stool. In this position the knee is flexed and the greater part of the body weight is on the examined foot. Dorsal extension is then measured with a protractor as the angle between the support line of the foot and the long axis of the leg. The loaded plantar flexion is measured in the same position but with the heel raised as much as possible. In a study of 317 healthy ankles, this method was found to give greater and more reproducible values than measuring on unloaded ankles in sitting or supine positions. Measurements of the loaded dorsal extension were also made on radiographs of 66 healthy ankles. The mean value was 32.5 degrees; the mean talar forward tilt was 5.0 degrees. In normal daily life, at least 10 degrees are required; for performing athletics and sports activities, a loaded dorsal extension range of 20 degrees-30 degrees is necessary.

Skiing injuries in children: lower leg fractures.

A study was made of 113 children who sustained a lower leg fracture during downhill skiing. The age distribution showed a peak between 4 and 7 years in both sexes, and boys had another peak in their teens. Three of four patients were beginners. To a large extent, they had had their bindings adjusted in ski shops. Three of four bindings did not release at the time of the accident. Spiral fractures in the shaft or distal metaphysis of the tibia predominated (73%); the incidence of concomitant fibular fracture was low. The degree of malalignment was generally small. The results of treatment, which was generally conservative, were good, 7% of the patients having minor sequelae 1-3 years after the accident. To reduce the risks in children's downhill skiing, the following measures seem important: intensified training during the beginner stage; increased supervision by parents and in ski schools; development of children's release bindings and testing methods; and adequate instruction of personnel in ski shops.

Skiing safety in children: adjustment and reliability of the bindings.

One-hundred children were picked at random from ski lift queues and were questioned as regards their skiing ability, experience, and ski equipment. Around 40% of the skiers had not made any adjustment and/or setting of the bindings. The lateral toe release and recentering forces were recorded. We found, irrespective of to which reference system our results were correlated, a very low percentage of bindings with acceptable setting, lower than has been reported for adults. Sixty percent of the bindings did not have any space between the sole of the boot and the slip plate. After correction of the space, the lateral toe release torque decreased significantly. Only 20% of the bindings displayed a recentering force. Our results indicate the need for several improvements regarding children's release bindings, including factors such as mechanical function, adjustment, and testing. The IAS reference system is recommended as the best of the existing reference systems.

Skiing injuries in children and adults: a comparative study from an 8-year period.

The investigation is a retrospective analysis of 2756 skiing injuries from two centers in a Swedish skiing area during the years 1972 to, and including, 1979. The relative frequency of lower extremity injuries successively diminished, while a corresponding increase of upper extremity injuries was found. The relative frequency of ankle and foot injuries declined, while the frequency of knee injuries did not change, knee injuries still being the most common skiing injury. The relative frequency of fractures of the lower leg showed a statistically significant decrease, but, in children, constituted 16% of all injuries at the end of the investigation period. Further studies, with special regard to the children's prerequisites, seem to be necessary to define the desired characteristics of an optimally functioning safety binding for children.

Release and retention in Alpine ski bindings.

Six different designs of alpine ski bindings were semistatically tested in a MTS machine, and measurements of release forces were performed at the toe and at the heel, perpendicularly, and at 30 degrees backward and 30 degrees forward from the normal of the ski, respectively. In the conventional, two-part bindings examined, there was no difference between the forces acting in perpendicular and oblique planes. The release resistance in oblique directions was lower than the retention force perpendicularly to the ski in two binding designs with a spring-loaded, moveable toe unit (Besser, "Jack" prototype). A low release resistance obliquely forward is important for the prevention of injury to the lower extremity when a skier falls forward. On analysis of the injury-preventing properties of a release binding, consideration should also be paid to release resistance in oblique planes.

Thumb injuries in downhill skiing.

Thumb injuries are next to knee injuries the most common injury in downhill skiing today. In this material they constituted 17% of all skiing injuries. Three-fourths of the thumb injuries were lesions of the ulnar collateral ligament of the metacarpophalangeal joint. Compared to a control population consisting of 1619 randomly chosen uninjured skiers, we found that no type of ski pole handle in common use today eliminated the risk of thumb injury, but the injury frequency was higher when using a ski pole with a big plate on the top of the handle. It was, however, of no importance how the skier gripped the ski pole in relation to the strap. It is suggested that the skier during a fall holds on to the ski pole until the very last moment before the hand hits the ground. The ski pole handle then remains in the hand and constitutes the hypomochlium that forces the thumb into abduction and extension, which causes the typical ulnar collateral ligament injury.