Twenty years ago, at the Annual Conference of the Association of Surgeons of India at Bombay (1964), vertical traction was introduced by the principal author of this paper in his Kini Memorial Oration. But the actual work had begun 5 years earlier at the Calcutta National Medical College Hospital, for treatment of fracture of the femur from trochanteric to the supracondylar levels. An experience of 25 years and detailed follow-up of 200 cases establishes the method as a treatment of choice for femoral shaft fractures, especially in our country, taking into account the cost effectiveness, easy applicability and infrastructural hindrances of fracture management.

Forty cases of fractures of shaft femur in 38 patients were subjected to closed Kuntscher nailing under image intensifier. In 6 cases closed nailing failed for various. Patients were subjected to early weight bearing with or without functional femoral cast brace depending on the rigidity of fixation. Results of follow up ranging from 6 to 18 months showed excellent results in 12 and good results in 20 patients. Two cases died, one due to diffuse carcinomatosis and the other due to anaesthetic complications.

One hundred and three tibial shaft fractures in 100 patients were treated by closed intramedullary nailing without image intensifier. By 12 weeks 91 fractures and while at 18 weeks only 3 had non-union. Four patients needed reoperation for sequestrectomy (2), delayed union (1) and delayed union with broken nail (1).

Ninety three compound fractures of tibia were studied, with respect to their time of presentation. A classification into those presenting within 24 hours, and those presenting later, is helpful, as the later group consists of patients who have inadequate/improper primary care. Most patients could be treated by a through debridement, followed by POP cast immobilisation. Even cases seen early, could seen later than 24 hours, benefit by an immediate, through surgical debridement. Most cases early, could have a primary, or delayed primary, skin cover, using split thickness skin graft or a relaxing incision. Primary internal fixation of compound fractures is to be done after much deliberation and restricted to cases ideally suited. The incidence of delayed or non-union did not depend significantly on the time of presentation. The healing time, however was directly proportional to the degree of initial displacement of the fractures fragments. Incidence of infection, osteomyelitis and poor results, increased with initial delay. Grade III compound fractures with initial displacement of more than 1 diameter, presenting late, stood a good chance of developing osteomyelitis, with poor results.

Results of treatment of 217 cases of compound fractures of forearm bones were studied, in order to determine if primary fixation with intramedullary nails presented any problem. Good results were obtained in 74 per cent of 194 cases treated with primary fixation. The comparable results with conservative management were not encouraging. A through wound debridement and an adequate fixation was essential. Introduction of metal did not increase the incidence of infection. The period of disability was drastically curtailed.

Fortyfive children with femoral neck fracture were studied. Thirty six of them had displaced fractures. Austin Moore’s pinning after reduction was done in 38, S.P. nailing 5 and 2 were treated by hip spica plasters. Avascular necrosis was seen in 16 per cent, non union in 5 per cent and coxavara in 7.5 per cent patients.

Fifty five cases of sub-capital neck of femur between the age of 55 to 90 years treated by replacement with Talwalkar’s prosthesis are presented. Thirty two were old untreated cases of established non-union, 17 were cases which failed to unite with reduction and fixation. Only in 6 cases primary endoprosthetic replacement were done. The cases were followed up from 1 to 6 years. Fair and good results were obtained in 47 cases, poor results in 6 cases died during immediate post operative period. Complications like loosening of the stem and proximal migration of the head were found.

Fourteen patients of intracapsular fracture of neck of femur were treated by intertrochanteric osteotomy with bent Kessel plate. Twelve patients could be followed (average follow up 30.83 weeks). Results were excellent in 2, good in 8 and fair in 2 patient. Majority of patients had a little shortening (upto 2.5 cm) with apparent length almost equal. Fracture united in 7 patients, II had painless hip and 6 could squat and sit cross-legged.

Twenty five patients with fractures of the thoracolumbar spine with paraplegia were treated with segmental spinal instrumentation as a primary procedure which afforded rigid internal fixation of the spine and permitted immediate mobilistion. In 2 patients laminectomy had to be done before definitive instrumentation. There were no serious complications attributable to the surgical procedure in this group of patients.

Sixty cases of fracture patella with rupture of quadriceps mechanism who underwent total patellectomy were followed form 3 to 6 years with an average follow up of 4 years. There were in general gratifying results, except in those cases where was associated femoral articular damage due to direct violence.

An analysis of 55 cases of fracture of patella treated over 4 years period is presented. In 15 transverse fractures open reduction and tension band fixation was done and 14 patients achieved excellent results, and there was very low incidence of extensor lag, quadriceps wasting and quadriceps weakness. In 40 cases of comminuted fractures patellectomy was done. Of this group only 17.5 per cent achieved excellent results while 65 per cent gained good result. Incidence of extensor lag, quadriceps wasting and weakness and loss of flexion was fairly common problem. It was felt that absence of patella has adverse effect quadriceps strength, action and recovery.

One hundred and seven fractures were openly reduced and fixed by tension band wiring. Fractures included were those of patella, olecranon, lateral end of clavicle and dislocation of acromioclavicular joint. Tension band wiring was found to be a good, simple and economical method from point of view of both the surgeon and the patient. Few complication were encountered.

Twenty fractures of olecranon (Including compound and 1 comminuted fractures) were treated by tension band wiring. Three patients had associated fracture of radial head on the same side. All fractures except 2 united within 3 months time while the other 2 united before 6 months. Functional results were good in 15 cases and fair in 5 cases with no poor result. The complications met were superficial infection (4 cases), Inadequate fixation (3 cases) and some stiffness of elbow (3 cases).

Twenty personnel from armed forces who sustained injuries of the talus were studied. Closed reduction succeded in 4 of them, in rest of the 13 cases open reduction and internal fixation was done. All the cases had excellent to good results.

Four cases of neglected ruptured tendo-achillis have been treated by a new type of repair using the tendon of plantaris in a criss-cross manner to effect repair. In 2 cases V-Y plasty has been done to effect approximation. No metallic non-absorbable suture has been used.

Thirty two patients, aged between 7 and 60 years were treated for neglected posterior dislocation of the elbow. The dislocation had been unreduced for a period ranging from 3 weeks to 2 years. Twenty three patients were treated by open reduction and 9 were treated by physiotherapy alone. Elbow fixed in more than 100 degrees extension were taken for open reduction, while those fixed in less than 100 degrees extension were treated by early mobilization and physiotherapy. Most of the patients eventually gained a stable elbow with a useful range of movements, irrespective of the duration of the unreduced dislocation. The major complications encountered in the series were one case each of subluxation and ankylosis of the elbow joint. Heterotopic calcification was seen in several cases, but this did not adversely affect the function of the joint. This method of treating neglected dislocations of the elbow gives a stable, yet functional elbow joint, and is recommended for use in developing countries.

Aetiological factors of cubitus deformity associated with supracondylar fracture of humerus were investigated in a cadaceric elbow model. Supracondylar fracture was ‘created’ by hand saw cutting the bone just proximal to the coronold and olecranon fossa. The mounted specimen was subjected to varying degress of medio-lateral displacements, medio-lateral axial rotations, mediolateral tilts, in isolation and in various combinations. It is concluded that it is the combination of medial angulation and medical rotation that is responsible for cubitus varus deformity.

Forty cases of Monteggia fracture-dislocation treated between 1973 to 84 were analysed at follow up. It was common in children as well as in young adults, 85 per cent were males. According to the Bado’s classification type I (anterior Monteggia) was the most common (60 per cent). Early cases were best treated by closed reduction. To forestall redisplacement of radial head, a re-check x-ray after 3 weeks was considered helpful. In early malunion of ulna open reduction and internal fixation, and in non union bone grafting should be done in addition. Oblique osteotomy of ulna with internal fixation was done in old cases in children where radial head had overgrown. Old dislocation of radial head in children was treated by open reduction with or without fixation to lateral condyle by Kirschner wire. In adults in old cases head redius was excised whereas in comparatively early cases head was reduced by closed or open reduction with or without fixation to lateral condyle with Krischner wire. Average period of follow up 21/2 years (6 to 72 months). Eighty per cent had either excellent or good results, 10 per cent were satisfactory and 10 per cent were poor.

We treated 52 fractures of the humeral shaft during 1983-84 using functional cast brace made of high density polythene. The initial management was in the from immobilisation in ‘U’ Salb which was converted to the cast brace at the end of second week in the majority of cases of the 52 fractures. Out of these 44 were closed and 8 were open. Neither group posed any particular problem in management. Average healing time was 7.26 weeks in 98 per cent of the cases. The fractures healed with abundant callus and functionally the patient had good mobility of the adjacent joints. We emphasise the advantages of this procedures because of its simplicity, economy and negligible morbidity.

Fifty fresh cases of Colles’ fracture were randomly divided into 2 groups. Group I was treated by closed reduction and percutaneous fixation of the distal fragment of radius to the proximal one. Group II was treated by conventional closed reduction. Both the groups had plaster cast for 6 weeks. No clinical deformity was present in 60 per cent and 24 per cent of patients in group I and II respectively. Functionally in group I the results were excellent in 60 per cent, good in 16 per cent, fair in 20 per cent and poor in 4 per cent whereas in group II the results were excellent in 20 per cent, good in 32 per cent, fair in 28 per cent and poor in 20 per cent cases. Percutaneous fixation by Kirschner wires is a worthwhile procedure for better cosmetic and functional results.

Three cases of carpometacarpal dislocation are reported. Two patients had dislocation of the fifth metacarpal and one had combined dislocation of the second and third metacarpals. In 2 cases which were diagnosed early, closed reduction was successful and the functional results were excellent. In one case, the dislocation was diagnosed three weeks after injury, but open reduction could not be performed because the patient refused and the functional results after conservative treatment were poor.

Eleven cases of dorsal dislocation of metacarpophalangeal joints were studied. It was observed that the interposition of the volar fibrocartilaglnous plate was the most important single factor in causing irreducibility of dislocated metacarpophalangeal joints. The long flexor tendon and lumbrical muscle did not hinder reduction after longitudinal division of the volar plate.

A new surgical exposure to the front of the shoulder joint and the anterior surface of neck of scapula through an axillary approach is descried. It is a simple approach through the intermuscular planes and requires no blood transfusion for operations such as osteotomy of neck of scapula, curettage of lesions over neck of limited operations on shoulder joint.

Fifteen patients aged 11 to 83 years, who previously had paralytic poliomyelitis, were treated for fractures of the long bones. Six of the patients were Nigerians, one an Asian and 8 were British. All the fractures united within normal bone healing time. Twelve fractures occurred in the paralyses limb (80 per cent) and the poliomyelitis contributed to the fall in all cases under review. Two patients had operative treatment, but the rest were treated conservatively with satisfactory results.