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BACKGROUND: Locking compression plates have become increasingly popular in orthopaedic surgery. However, the gold standard of treatment for distal fibular fractures remains fixation with a non-locking one-third tubular plate. It has been reported that locking plates in distal fibular fractures are associated with an increased complication rate. HYPOTHESIS: The objective of this study is to assess the complication rates of locking versus non-locking plates in patients who underwent surgical fixation of distal fibular fractures. MATERIALS & METHODS: A retrospective analysis of closed distal fibular fractures that underwent surgical repair over a 2-year period with either a locking or non-locking plate was undertaken, analysing the groups for both wound and overall postoperative complications. RESULTS: A total of 160 patients were treated over 2 years, of which 129 and 31 patients were treated with non-locking and locking plates respectively. There was no significant difference between the non-locking and locking plates overall complication rates (13.5% versus 15.4%, p=0.76) or wound complication rates (3.97% versus 3.85%, p=1.00). DISCUSSION: Distal fibular fractures managed with locking plates do not have a higher complication rate in comparison to those managed with non-locking plates. LEVEL OF EVIDENCE: III (case control study).

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INTRODUCTION: Byler disease (progressive familial intrahepatic cholestasis) is associated metabolic bone disease as a consequence of chronic malabsorption. CASE PRESENTATION: A 33-year-old man with decompensated liver disease secondary to Byler disease was referred to the orthopaedic department with progressive pain over this right proximal tibia. On examination, he had an antalgic gait. Tenderness was localised to the proximal tibia just distal to the tibial tubercle and bilateral foot swelling. Radiographs showed multiple stress fractures characteristic of Looser zones at various stages of healing in both tibia, metatarsals (third, fourth, and fifth on the right side, and second and fourth on the left) and left femur. Bone mineral density was extremely low. Subsequent investigations were consistent with severe osteomalacia due to a combination of vitamin D deficiency and phosphaturia with elevated fibroblast factor 23 (FGF23). A good clinical response was achieved following supplementation with calcium 1000mg and vitamin D 20µg daily. DISCUSSION: Stress fractures are often associated with delay in diagnosis. Our patient presented to the orthopaedic service with multiple Looser zones that had not been previously detected. As expected, there was biochemical evidence of vitamin D deficiency. An unexpected finding was phosphaturia that was associated with marked elevation in FGF23, which has never been reported previously. CONCLUSION: Byler disease may result in Looser zones of osteomalacia due to chronic malabsorption. Renal phosphorus wasting as a consequence of unexplained marked elevation in FGF23 is thought to have contributed to the onset of osteomalacia.

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Ankle fractures are common representing up to 10% of all fractures with an incidence that is rising. Both conservative treatment and operative management of ankle fractures can lead to excellent outcomes. Neurovascular injuries are uncommon but can be a source of significant morbidity and associated poor outcome. The superficial peroneal nerve (SPN) in the lateral approach and the sural nerve in the posterolateral approach are at risk of injury. We report an unexpected finding of a superficial peroneal nerve incarcerated in the fibular fracture site of pronation external rotation type/ Weber-C ankle fracture. To the best of our knowledge we believe this to be the first English language report of an incarcerated SPN at a fibular ankle fracture site.

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The positioning of the patient on the fracture table is critical to the successful reduction and operative fixation of hip fractures which are fixed using the dynamic hip screw system (DHS). There is a standard setup which is commonly used with relative ease. Yet the positioning of patients with amputations either above or below knee of the affected side can pose a significant challenge. We describe a novel positioning technique used on a 51-year old patient with a right above knee amputation who sustained an intertrochanteric extracapsular hip fracture.

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BACKGROUND: Bilateral simultaneous rupture of the quadriceps tendon is a rare entity. They are often associated with degenerative changes of the tendons and predisposing conditions such as diabetes or excessive steroid use. They most commonly tend to occur in patients of 40 years of age or older. MATERIALS AND METHODS: We describe a case of a 67-year-old man with simultaneous rupture of both quadriceps tendons. CONCLUSION: The diagnosis can be difficult and often delayed or missed in the initial examination. We report bilateral quadriceps tendon rupture in a previously healthy patient with good post-operative functional outcome.

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BACKGROUND: Pelvic fractures are usually the result of high-energy trauma and may have associated soft tissue and organ damage resulting in significant morbidity and mortality in these patients. Currently, there is little data from Ireland regarding these injuries. OBJECTIVE: To study the epidemiology of pelvic fractures presenting to a tertiary referral centre in Dublin. METHODS: Patients referred with a pelvic fracture were identified using the Hospital Inpatient Enquiry System (HIPE) from 1998 to 2008. The patient's medical notes were reviewed for demographic data, type and mechanism of fracture and associated injuries. RESULTS: A total of 509 patients were identified over the 10-year period. 466 patients were included in the study. There was a significant male preponderance 76% (n = 354) as compared to females 24% (n = 112). Mean age was 36.5 years (range 16-83). Road traffic accidents (RTA) were the cause in 74% (n = 346) of the cases. CONCLUSION: From our study, the typical patient profile is one of a male in his 30's involved in an RTA requiring acetabular surgery. This is in accordance with previously published international data and highlights the need for specialised units, training in this subspecialty and allocation of resources.

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Spinal epidural abscess is an uncommon entity, the frequency of which is increasing. They occur spontaneously or as a complication of intervention. The classical triad of fever, back pain and neurological symptoms are not always present. High index of suspicion is key to diagnosis. Any delay in diagnosis and treatment can have significant neurological consequences. We present the case of a previously well man with a one month history of back pain resulting from an epidural abscess.

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Skin puckering is a sign that is well associated with certain fractures such as supracondylar humeral fractures in children. To our knowledge, there has been only one clinical report of skin puckering associated with fractured neck of humerus of an adult. This is a second such case of fractured proximal humerus in an adult presenting with skin puckering and the first from the Republic of Ireland. Skin puckering is suggestive of soft tissue interposition and may be an important clinical sign indicating the need for internal fixation.

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BACKGROUND: Metastatic involvement of the penis is most commonly from a primary malignant genitourinary tumour. It is a rare phenomenon usually reflecting disseminated malignancy associated with a poor prognosis. Metastasis to the penis mimicking priapism is extremely rare, particularly in the absence of disseminated disease. MATERIALS AND METHODS: We describe a case of painful priapism caused by a high-grade urothelial malignancy without disseminated disease. CONCLUSION: Life expectancy is estimated at less than 1 year in these patients. Our patient remains in clinical and radiologic remission over 36 months from his original radical surgery.

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INTRODUCTION: Osteopoikilosis is a rare and asymptomatic disease of the bone that is often discovered incidentally on radiography. On a plain radiograph it is manifested by multiple, small, circular or oval shaped radio-dense lesions which are diagnostic for this condition and are often mistaken for metastatic disease. MATERIALS AND METHODS: We present the case of a 24-year-old female patient with osteopoikilosis diagnosed incidentally on radiographs. CONCLUSION: Osteopoikilosis is a benign sclerosing dysplasia of bone of unknown aetiology that requires no specific treatment.

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