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Our study demonstrates that missed injuries can occur at any stage of the management of patients with major trauma. Repeated assessments, both clinical and radiologic, are mandatory to diminish the problem. In initial assessment, one still has to treat the greatest threat to life before complete diagnosis of all injuries, but alertness to evolving injuries must remain throughout the patient's stay in hospital.

BackgroundA variety of methods has been described to stabilise periprosthetic fractures around total knee arthroplasty (TKA). Our report offers a review of the actual strategies in the reduction and fixation of these fractures. Surgical treatment should be based on the following four steps:Diagnostics: By taking the patients' history together with an X-ray of the knee and femur, the fracture is analysed. It is crucial to define whether any losening of the prosthesis had occurred. In selected cases, CT-scan may add important information on the stability of the implant.Classification and planning: For most fractures around the distal femur, the Rorabeck classification is used while fractures around the proximal tibia are best classified according to the Felix classification. Additionally the Orthopaedic Trauma Association (OTA) may be helpful in the planning process for reduction and fixation.Surgigal technique: In fractures around a stable implant (Rorabeck type I and II; Felix type A and C), it is favourable to use plates and retrograde nails (in Rorabeck I or II with an open box of a TKA). For reduction, three methods are available: (a) the open technique (with direct or indirect reduction); (b) the mini open technique (direct reduction of the fracture by cerclage or lag screw and percutaneous plate fixation in OTA type 32 or 33-A1) and (c) the minimally invasive technique (indirect reduction and percutaneous fixation in all other OTA types). Fractures with a loose prosthesis (Rorabeck III and Felix B) are best stabilised by hinged revision arthroplasty.Rehabilitation: It is of great importance for the aged patient to be mobilised out of bed early. In most of the cases, partial weight bearing has to be performed by the aid of frames during the first 6 weeks after surgery. In a well-fixed revision prosthesis with a cemented stem, early full weight bearing might be allowed.ConclusionStandardised less invasive procedures to treat periprosthetic fractures present a valuable alternative to open techniques. The main advantages are lower rates of oft tissue complications and implant failures following less invasive techniques of long plate application. Polyaxial locking systems allow for stable plate fixation around intramedullary implants.

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There are few long-term follow-up reports concerning the treatment of thumb duplication. We reviewed the treatment of 19 of 74 patients treated at our institution between 1956 and 2002. The average follow-up was 22 (range, 7 years to 35 years) years. Satisfactory function was achieved in 18 thumbs and cosmesis in 12 thumbs. Six thumbs were cold-intolerant at this late follow-up. Pinch strength was similar to the contralateral normal thumbs. Collateral ligament repair did not significantly contribute to joint stability. An objective method of postoperative evaluation showed good results in five, fair results in 12 and poor results in two thumbs.