women over 60 years of age is probably related to the greater carrying angle of the female elbow and to post- menopausal osteoporosis. 18
Distal humeral articularfractures are usually attributed to a fall on to an outstretched hand, 19 and cadaver work 20 has shown that capitellar fractures can be sustained by direct injury in flexion and indirectly through an extended radius, as in falling on an outstretched hand. Both mecha- nisms may produce a coronal shear fracture. Indirect trauma may be associated with a fracture of the radial head, as observed in one-quarter of our series. It is likely that these fractures represent the extreme of a spectrum of injury that includes minor scuffing of the capitellum, often observed with radial head fractures. 21
Arora et al. compared non-operative treatment with volar locking plate fixation of displaced and unstable distal radius fractures. At the twelve-month follow-up examination, the range of motion, the level of pain, and DASH scores were not different between both groups. Patients in the operative treatment group had better grip strength through the entire time period. Radial tilt, radial inclination, and radial shortening were significantly better in the operative treatment group than in the non- operative treatment. However, achieving anatomical reconstruction did not convey any improvement in terms of the range of motion or the ability to perform daily living activities. Complications were significantly higher in the operative treatment group. Arora et al. treated 36 patients with volar locking plate fixation of whom 13 patients had postoperative complications. Five patients had extensor tenosynovitis because of screws that had penetrated the dorsal radial cortex. Four patients had flexor tenosynovitis because of the position of the plate distal to the watershed line of the palmar rim of the distal radius surface. These patients were managed with implant removal. One patient had a rupture of the extensor pollicis longus tendon for which the plate was removed with tendon reconstruction by transfer of the extensor indicis proprius. Carpal tunnel syndrome was observed in one patient and treated by carpal tunnel release and plate removal. Two patients developed type-1 complex regional pain syndrome. 120
Treatment of displaced fractures of the distal radius aims to restore normal anatomy. 16,17 An intra-articular step of more than 2 mm will not be generally accepted when treat- ing these injuries, 18 and recent studies indicate that the crit- ical tolerance may be as low as 1 mm. 19-21 Edwards et al 4 recently reported that arthroscopy may help to identify residual gapping of the articularsurface not detected with fluoroscopy, and another study 5 reported that arthroscopy after fluoroscopic reduction resulted in a modification of the treatment in five of seven patients treated for intra- articularfractures. The identification of the nature and severity of associated soft-tissue lesions is probably the major role of arthroscopy for such fractures. 22-24 For exam- ple, Ruch, Yang and Smith 25 reported that urgent arthro- scopic treatment of acute triangular fibrocartilage complex injuries associated with intra-articular distal radial frac- tures have good results.
After reaching lateral cortical wall, a small cortical window of size 1.5cm X1.5cm is made with straight 10mm osteotome under C-arm control. After that, a small strong lamina spreader (Figure 3) was pushed under the posterior facet to lift the impacted facetal fragment with considerable force but with due care so as to avoid breaking through into the subtalar joint. The articularsurface was visualized and reduced under c arm and checked in both lateral and axial views. Articularsurface was fixed primarily with 1.8mm K- wires. One by one all depressed calcaneal facets are elevated with L shaped
A Schanz pin is then placed through a stab incision in the posteroinferior calcaneal tuberosity from lateral to medial to allow for distraction, provide control of the tuberosity fragment, and aid reduction. After removing any fibrous debris and fat from the sinus tarsi, the lateral wall and the posterior facet fragment are mobilized using a knife or small elevator. Care is taken to avoid significant dissection of the peroneal tendons that are retracted posteriorly as needed. Using fluoroscopy to check alignment and length, two guide pins from a large cannulated screw set are placed from the calcaneal tuberosity
Our functional results are in line with those reported by Lee et al., who obtained good to excellent results at a mean follow-up of 27.2 months when evaluations were per- formed based on the Elbow Assessment Score of the Jap- anese Orthopedical Association in all surgically treated patients. In particular, the mean score was 97.1 points in patients who received screw fixation, 96.3 for those who received Kirshner wire fixation, 94.5 points after tension- band wire fixation, and 93.5 following interosseous suture . When the ROM evaluations were considered, we calculated a mean loss of about 5° for flexion–extension and 2° for pronation–supination. Several studies in the literature evaluated the ROM in patients who had been surgically treated for medial epicondyle fractures. How- ever, different methods of fixation were evaluated at the Fig. 2 Case 2. a X-ray showing a screw tip slightly protruding posteriorly from the bone surface. b Ultrasound examination showing the presence of a hematoma with a partial lesion of the myotendinous junction of the triceps over the protruding screw tip
The goal of any treatment is to maintain or restore the congruity of the articularsurface and restore the length and alignment of the femur and subsequently the function of limb. Although decades ago, conservative management was an option in treating such fractures, presently surgical management clearly gives a better outcome in most scenarios. These are complex injuries which have been treated by different methods. Closed reduction as described by Watson Jones and John Charnley led to stiffness, angular deformities or shortening and needed prolonged confinement to bed. This prompted most surgeons to indulge in more aggressive treatment through open reduction and internal fixation. Surgical fixation allows early mobilization and knee range of motion, better union rates, earlier weight bearing and return to baseline activities.
Early mobilization of the ankle joint is another advantage of the Ilizarov device. In fractures caused by axial com- pression and no concomitant ligamentous instability, best results can be achieved, if mobilization is started 4-6 weeks postoperatively. Because the bone fragments are held in place by olive wires adjusted to the external fixa- tion and there is not an additional independent internal fixation, intrafragmental microscopic motion is negligible and does not affect healing process. Although the 'in- frame' period is relatively high, especially for those frac- tures where external fixation applied as a neutralizing ele- ment, early mobilization through hinges, compensates the possible disadvantages of prolonged immobilization and enhances cartilage repair. The 4-6 week period until mobilization will start is considered to be sufficient to allow the development of a bone generating potential capable to lead to complete healing of the fracture.
The “fractures” simulated by surgical osteotomy also exhibited cell death preferentially concentrated in regions adjacent to the
“fracture” lines. However, the fractional cell death in these regions was much smaller ( wone-ninth) than that observed in corre- sponding regions in the impaction-fractured porcine joints, or in the above-mentioned human ankle quasi-in-vivo model 7 . This striking difference suggests that the physical stress to which chondrocytes were exposed was very different between these two insult modalities. One possible explanation for this difference is the extreme instantaneous cartilage deformation during a fracture event. During impaction, articular cartilage in the contact area would be highly compressed up until the instant when the cartilage ebone complex fractures, thus building up extremely high cartilage internal pressure. Once the articularsurfacefractures, however, cartilage along fracture lines would abruptly lose but- tressing effects from the adjunct cartilage, resulting high stress gradients, leading to abrupt cartilage deformation that would damage chondrocytes.
bulk production for universal use. Zhiquan et al. 
treated 13 distal third humeral shaft fractures with mini- mally invasive percutaneous osteosynthesis (MIPO).
Fractures were reduced by closed means and fixed with a long narrow 4.5-mm dynamic compression plate intro- duced through two small incisions away from the fracture site. The plate was fixed on the anterior aspect of the humerus under fluoroscopy guidance. The radial nerve was not exposed during this procedure. They reported that the fractures united with a mean healing time of 16.2 weeks, a little longer than the reported time of 9–12 weeks in pos- terior open plating of the humerus. Disadvantages of this approach are that the radial nerve is not visualized directly during the exposure and, biomechanically, the posterior surface of the humerus is considered better for plate application especially of distal-third fractures. Schatzker and Tile listed four reasons for plating the distal humerus posteriorly—the posterior surface of the distal humerus provides a flat surface suitable for plating; placement of the most distal screws from a posterior approach allows direct visualization and avoids the antecubital fossa; posterior placement allows for the plate to extend distally permitting additional screw placement; and the posterior approach provides the option of double plating . Livani et al. 
The specimens were preconditioned by axial loading (0–200 N) through five cycles at the rate of 2 mm/min before formal testing of each model. Specimens were then sub- jected to axial stepwise loading. The load–displacement curve of calcaneus was contin- uously recorded by a transducer. When the load through the material testing machine increased, the calcaneocuboid force would also increase and its value could be read through a monitor (Fig. 1). The maximum value was regcorded as the peak force of cal- caneocuboid joint. The calcaneocuboid peak pressure has been found to successfully assess stability of normal foot, flat foot and corrected flatfoot deformity . Because the contact force through this joint represents the AP mechanical effect, it should be used as an index of the stability in this direction. The reproducibility of the loading pro- cedure was tested by sequentially loading the same specimen three consecutive times while maintaining all other parameters constant. The average value of three tests was used for further statistical analysis. Then, each calcaneus bone was tested 15 times.
Assessment. This was a retrospective study – a comparison of the results, achieved by the same hand surgeon, using the same implants for the same types of fractures, within a peri- od of approximately ten years. The first group of patients was treated without optical visualisation of the joint surface, but the other group with arthroscopically assisted fracture evaluation and fixation. Change of the technique was deter- mined by the improving wrist arthroscopy skills of the sur- geon and growing number of the comminuted distal radius fractures sent to the University clinic from the regional health centres. The results of treatment were assessed with X-ray examinations postero-anterior position in a 10° tilted- view and lateral position in a 20° tilted-view, subjective evaluation using the PRWE score (rating from 0 to 140 with a lower score representing a better result), MASS07 score (rating from 0 to 100 with a lower score representing a bet- ter result), and subjective and objective evaluation using the Gartland and Werley score (rating from 17.5 to 100 with a higher score representing a better result). Grip/pinch/tri- pod-pinch strength and ranges of motion (ROM) were also measured. Wrist mobility was tested using a goniometer, grip strength with Jamar dynamometer, and pinch and three- point strength with a pinch gauge. Scheduled follow-up as- sessments were performed at 1, 3, 6, and 12 months postop- eratively by a hand therapist or by one of the senior ortho- paedic surgeons if the hand therapist was not available.
There are multiple options for the treatment of these fractures with their associated merits and demerits. Anatomical restoration of the articularsurface in cases of peri-articularfractures and good fracture alignment and adequate compression in osteoporotic fractures along with secure fixation of both proximal and distal fragments are the key to achieve good functional outcome in these fractures to prevent early secondary osteoarthritis.
operatively by manual testing after completion of the surgery in all cases. We reduced radioulnar joint injury for 11 patients (45.8%) by using medial K-wire, and if the joint was still instable, the transfixing wire through DRUJ was retained for 6 weeks. The external fixator frames were removed after 6 to 8 weeks for all patients; however K-wires were not removed until complete consolidation of the fractures occurred. Wrist joint mobilization was allowed after removal of the ex- ternal fixator frame, regardless of the removal of the wire or its retention until 2 weeks. Group II: The patients of this group were treated by ORIF using distal volar radial locked plate. After reduction, K-wires were placed through the radial styloid provisionally, if required. An anterior locking plate was then positioned.
Several authors have consequently used indirect reduc- tion and application of fine wire circular frames to treat intra-articular calcaneal fractures with poor skin condition.
Emara et al.  treated 12 patients with Sanders type III fractures and poor skin condition. The technique used was an open reduction of the articularsurface of the subtalar and calcaneocuboid joints. Using a fine wire fixator and distraction completed the reduction. A measure of the function of patients was achieved using the AOFAS and compared to the function of 20 patients with Sanders type III fracture and adequate skin condition who had been treated with ORIF. At a mean of 20 months, both groups had similar functional and radiographic outcomes. The ORIF group had higher postoperative complications, with peroneal tendinosis, hardware penetration into the subtalar joint, superficial wound infection, and superficial sensory nerve injury that subsided ten months after the surgery.
supply of the fractured bones. The LISS is an internal fixator taking advantage of locked full- length metaphyseal screws, and a combined plate allowing for compression fixation and/or locked internal fixation (21) . LISS could be considered the first plate that was specifically designed and instrumented for application using a minimally invasive sub-muscular approach as it has its own insertion handle which facilitated the introduction of the implant sub- muscularly and at the same time acts as a drill guide for accurate insertion of the screws through separate small stab wounds.
After pre-anaesthetic checkup and fitness, the patients were planned for surgery with preoperative planning for fixation for each individual patient. All patients were operated in lateral decubitus position with the injured limb freely mobile over a roll, in flexion. Tourniquet was applied as proximally on the arm as and when required. Posterior midline skin incision curving laterally at the olecranon area and ending in midline was used. The ulnar nerve was identified and retracted immediately away from operative site. The anconeus was elevated from the olecranon. Non-articular area of the olecranon identified usually 2 cm from the apex of olecranon by distracting the joint. A chevron osteotomy was then performed with a thin saw blade upto the anterior cortex. The osteotomy was completed using a thin osteotome. The fracture was exposed by stripping of triceps from the metaphyses as and when required and reduced to anatomic position, paying special attention to the articularsurface.
Open Reduction and Internal Fixation with Lateral Calcaneal Locking plate
Surgery was performed in lateral position either in general or regional anaesthesia by extensile lateral approach in all patients. The land marks are lateral malleolus, calcaneo-cuboid joint and base of fifth metatarsal. Incision made in a right angled fashion with the vertical line starting 4cm above the lateral malleoli between fibula and tendoachilles and extended downward till the junction of dorsal and plantar skin. The horizontal line is extended distally up to the base of fifth metatarsal. The incision is carried straight down to the bone at its angle and then developed to allow a single, thick flap to be lifted from the periosteal surface. A “no touch” technique is employed by retracting the flap with K wires in the talus and cuboid. Reduction aided by periosteal elevator or osteotome.
Only one superficial infection occurred 6 days post-surgery, and it was resolved by cutting several intense sutures im- mediately, extending the administration of 1.5 g cefuroxime sodium twice a day for 5 days and changing dressings more frequently. One screw breakage was found in a patient at the last follow-up, which may be due to walking with weight-bearing earlier than we proposed. No gap > 3 mm or step-off > 2 mm of the subtalar joint and no paresthesia were found in all limbs. No soft tissue reaction was found in all feet at the final follow-up.
Anesthesia was obtained by axillary nerve block. In all patients, a volar approach to the distal radius was per- formed. A longitudinal incision along the flexor radialis carpi was made. The radial artery was preserved and dislocated radially. The pronator quadratus was released using an ‘‘L’’ incision from the radial insertion. After exposure of the volar margin of the distal radius, the distal portion of the DVR Ò plate (Hand Innovation) was held against the distal radius with K-wires. At this stage fluoroscopy was necessary to identify the correct posi- tioning of the plate on the volar surface of the radius and for planning the level of the osteotomy. The plate was then removed after marking the position of the plate