We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients' age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 vs 2.12 minutes, p < 0.001, and 97.9 vs 81.2 minutes, p < 0.001, respectively).After one year, all the fractures had united. Patients who had intramedullary nailing had a higher mean pain score (40 = no pain, 0 = severe pain), [corrected] but better function, alignment and total American Orthopaedic Foot and Ankle surgery scores, although the differences were not statistically significant (p = 0.234, p = 0.157, p = 0.897, p = 0.177 respectively). Three (6.8%) patients in the intramedullary nailing group and six (14.6%) in the locked compression plate group showed delayed wound healing, and 37 (84.1%) in the former group and 38 (92.7%) in the latter group expressed a wish to have the implant removed. We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures.

Case reports have described postoperative paraplegia from failure to identify and decompress all stenotic segments of OLF. This study demonstrated that OLF is not uncommon, and that some 15% of the lesions are noncontinuous, and therefore could be missed. The authors recommend that for patients undergoing surgical decompression for 1 level of OLF, the whole spine should be routinely screened for other stenotic segments. Failure to do so could result in paraplegia from the nondecompressed levels.

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Heterotopic ossification (HO) and avascular necrosis (AVN) have been identified as post-traumatic complications of femoral head fractures and may lead to a restriction in hip function and permanent disability. The question of which surgical approach is the best for the femoral head fracture and its relationship with HO and AVN remains controversial. We conducted a systematic review in which all published studies were evaluated. We performed a literature search in MEDLINE, PubMed, EMBASE, MD Consult, and the Cochrane Controlled Trial Register from 1980 to April 2009. We found ten appropriate studies, describing 176 patients. A lower percentage of patients treated with a trochanteric flip approach was reported with HO than patients treated with anterior or posterior approach (33.3% versus 42.1% and 36.9%, respectively), although the difference was not statistically significant. The incidence of AVN was highest in the posterior approach group (16.9%), and subsequently with the trochanteric flip approach (12.5%) and the anterior group (7.9%). The investigators concluded that the use of the anterior approach may result in a higher risk for HO and the posterior approach may result in a higher risk for AVN. A new, posterior-based approach of trochanteric flip seems to be a better approach for femoral head fractures. A further case-control study would be appropriate to confirm the findings in our systematic review.

SummaryPosterior dislocation of the shoulder (PSD) is a rare injury; the diagnosis is often missed on initial examination. We present a systematic review of the current literature and discuss the key of the diagnosis of PSD. We searched the MEDLINE, PubMed, EMBASE, MD Consult, and the Cochrane Controlled Trial Register databases for the articles according to our eligibility criteria. Finally, 53 articles were included in our systematic review. There were 242 shoulders in 205 patients. In total, in the initial assessment with anteroposterior radiographs in 166 cases, only 19 (11.4%) cases confirmed the right diagnosis. When anteroposterior combined with axillary or Y view radiographs or computed tomography were present as the initial assessments in 36 cases, the diagnoses were made correctly and timely (100%). When axillary or Y view radiographs or computed tomography were taken subsequently, the diagnosis was confirmed in all 205 patients.