IPSILATERAL

FRACTURE
R.

the

From

The

hospital

patients
of

were

patients

records

grouped

of 222

late

one fracture
was fixed.
managed
conservatively.

There
a

is little

subject

Earlier

Liljedahl

(1977)

patients,

have

a means

and

in

past,

we

previous
both

femur

and

1 968

tibia

almost

Olerud

and

H#{246}jer, Gillquist

the

three

30

times

good

number

of

centres,

and

and

results

of

treatment.

knee

has

aimed

received

have

been

in

of the

proximal

the incidence

records

of

of

when

or non-union
occurred
the worst results
found

only

in patients
were those

in the management
Examination
of

is a common

The

left

lower

occurrence

limb

was

injured

was

the

of the
knee

the

and

should

in 1 3 1 patients,

the

right

ninety-one.

ln only
limb;

in

all

one-third
the

ofpatients

remainder

there

were

injury

restricted

associated

to one

injuries

lower

elsewhere.

a.

dual

analyse

the

attention
fully.

fractures

tibia

and

incidence

U)
I.-

fractures

were

also

of the

fractures
of

in the

Most

to shaft

review,

cent

Subsequent

it more
confined

this

to

refracture

per

and

of this

little

to appraise

in

results.

experience

cent

Blake

twenty-one

ofboth

or

the

and
per

risk

(1977)

fixation

reviewed,

Thirty-five

1968;
and

of

pedestrians.
in

in

Ratliff

McBryde

study

were

(Hayes

and

excellent

but

Toronto

osteomyelitis,
was

of ligaments

tibia,

high

patients,

to review

papers
bones,

the

Karlstr#{246}m

obtaining

of the
and

and

non-union,
factor

fractures,

on

and

increasing

out

1973;

rigid

complications
function

or

of

fractures.

disability

Bacon

emphasised

decided

injury

pointed

TIBIA

of treatment.

of delayed
union
personally
examined,

literature

be

permanent

in a prospective

of

We

the method

union

disruption

femur

to

have

of

thirty-one

of

English
of the

Gillquistetal.

Recently,

1974).

as

papers
Moll

1972;

review

in the
appears

and

1 96 1 ; Omer,

fractures,

fractures

which

complications

Winston

University

of the femur

and

A disturbing

of both

of both

ipsilateral

recorded

injury

frequency.

of

delayed

by fixation

management

of ipsilateral

severe

fractures

group.

AND

J. P. WADDELL

Hospital,

of fracture

for

treatment

FEMUR

use of rigid external

fixation
and of cast bracing
is recommended
tibia,
combined
with internal
fixation
of the femoral
fracture.

suggested
that, with
always
be suspected.

the

HUNTER,

of ipsilateral

A 30 per cent incidence

Of sixty-three
patients

conservative

More
fractured

A.

THE

St Michaels

to the type

treated

in patients

following

cases

operation

of the

G.

Service,

according

regardless

osteomyeliti.s

FRASER.

Orthopaedic

required

malunion,

D.

OF

of

the

distal

included.

MATERiAL
The

hospital

fractures

of the

and

I 975.

and

Quebec.

half

the

Males

in Figure

and

reviewed

Robert
South

Gordon

with

from

injuries

at thirteen

were

involved

were

four

aged

simultaneous
received

teaching

times

under

1 . In seventy-eight

hospitals

sixty-four

twenty-five

Fraser,
Australia

Hunter,

MB.,
5042.

as often

ipsilateral
between
within

AGE IN YEARS

I 965

Fig. I

Ontario

years

B.S.,

F.R.C.S.,

Toronto.
Ontario.
Canada.
James
Waddell,
F.R.C.S.(C).

as females,

and

the

range

is shown

involved

and

twenty-five;

cases

a motor-cycle;
than

patients

tibia,

Age

patients

seventy
less

were

femur

222

a motor
of the

old.

car

was

seventy

Forty-two

age

more

motor-cyclists
of

the

patients

than

in

Sixty

were

injuries.

were

thirty-three

F.R.A.C.S.,

Division

of Orthopaedics,

Department

F.R.C.S.(C).

Division

ofOrthopaedics.

Department

Division

ofOrthopaedics.

distribution.

DepartmentofSurgery,

patients

had

The

chest
and

of Surgery,

ofSurgery,
St Michaels

intracranial
was

the

damage

injured

in

abdomen

Hinders

Hospital,

(including

Medical

Sunnybrook

and

twenty-two

Medical
University

thirty-two

had

patients,
the

Centre,

the

genito-urinary

Bedford

Centre,

Park,

University

ofToronto,

facial

pelvis

in

tract)

in

Adelaide,
of Toronto.

Toronto,

Ontario,

JOINT

SURGERY

Canada.

510

THE

JOURNAL

OF BONE

AND

IPSILATERAL
nineteen.

No

elsewhere

fewer

Classification.
and

The

according

patients)
extended

the

into

plateau

were

of

fractures
knee.

the

knee:

involved;

in Type

(eighteen

patients)

A number

fracture

of

the

Segmental

of the

shaft,

as

fractures

knee

bones

ilb

FEMUR

AND

511

TiBIA

I. Treatment

of the

fractures

in the

first

three

(ten
with

indicated

I (157

weeks

the

of the

lower
knee

tibial

femur;

and

had

also

the

areas

in Figure

shaded
patients

Number
of femora

of treatment

(femur

traction

Number
of tibiae

Plaster

had

1 18

19

1 19

24

Plaster

articular

fracture

by

Skeletal

which
the

an articular

in thirty-three

Method

of either

fractures

patients)

patients)
sides

fractures

Type

extension
had

(thirty-seven

both

occurred

2).

patients)

lla

limbs

THE
Table

damage

to their

(Fig.

without

II (sixty-five

in Type

musculoskeletal
according

the

of both

Type

Ilc

fractures.

had

OF

limb.

classified

involvement

was

in Type

patients
injured

patients

shaft

into

102

to the

to

had

fracture

tibia

than

in addition

FRACTURE

and

incorporated

skeletal

pins

a
2.

twelve.

Intramedullary

nail

65

Plates

19

27

or bolts

12

fixator

twenty-one).
Intramedullary
Screws

nail

External

and

a plate

Amputation

carried

out.

in

Group

(ninety-two

fracture

only

had

been

fixed.

In

patients)
j

both

lively.

fractures

Four

death

had

patients

been

were

or immediate

patients)

Group

one

3 (ninety-nine

managed

excluded

conserva-

because

of

early

amputation.
COMPLICATIONS

Nine
fat

Ila
37

157

IIb
10

lIc
18

failure

features.

compound

One

fractures.

compound

than

fractures

were

late

the

required

high

as

the

of

that

three

had

more

often

and

tibial

Nerve

pattern

established
only
three

of

was

between
managed

three
and
conservatively

fixation

in 44 per

conservative

fixation

means

management

VOL.

complications,

affected

the

diagnosed

the

in

early

Table

were

of

almost

had

been

five

per

cent

according

their

fractures.
of both

No. 4. NOVEMBER

the

1978

developed

malunion

often

than

and

the

gas

refracture,

femur

(Table

Ii).

in
femur

Delayed

complications

in all

222

was

(Table

were
and by

tibia

and

17

18

23

18

13

Refracture

10

syndrome

In fractures

by an

external

by

cent

of

combined

6.4

1 (twenty-

risk

been

Malunion

Osteomyelitis.

incidence

had

Amputation

by

cent.

Group

Tibia

union

Compartment

I); in
changed

managed

to the

Femur

Non-union

tears,

patients

and

Local

as

missed.

were
of

H.

Osteomyelitis

The

fractures

in 25 per

fixation

except
more

in

times

ligamentous

fractures

grouped

in

seven,

patients

(within

weeks.
Femoral
fractures
in 56 per cent of patients
75

patient

in

cases.

in eleven.

was

of the third
week
was
the
management

Tibial

tibia

Eight

occurred

in half

diagnosed

injuries

or external)
of

patients)
60-B,

six

cent.

(internal
Patients

seven

end

embolism

embolism

and two for

six weeks)

at follow-up

management

by the
patients

fat

from
Other

complications

TREATMENT
The

clinical

one

and

three

contusion.

pulmonary

two

All local

three

tibial.

injury

involved

(after

of these

patients;
nine

weeksofinjury

knee

later

previously

many

cent)

femoral

and

was

of the
and

per

was

in sixteen

popliteal

popliteal

laxity

incidence

implying

Both

insufficiency.

disruption

in

damage,

patients.

four

lateral

of ligamentous

clearly

patients).

six within

the

(59

(1 09 patients)

occurred

injured,

in six patients,

weeks)

patients

in thirty-eight

of vascular

Ligamentous
incidence

fracture

vessels

cardiac

(2 22 patients).

thirty-two

(61

amputation,

patients;

three

femur

were

complications

fourteen

tibial

to major

arteries

limbs

The

compound

Damage
femoral

and

brain

gangrene.

of fractures

hundred

from
from
included

patients,

Local
Other

one

complications

renal

five

and

twenty-one

Classification

died,

embolism

general

65
Fig.

patients

per

fixator

femora

and

in fractures
cent

of femora

of a patient

1 2 per

cent.

managed

osteomyelitis
in

6.5

per

managed
and

cent

by internal
12.8

developing

Patients

conservatively
developed

in Group

per

cent

osteomyelitis
1 , where

or
per

in 2.5

of

tibiae.

The

fixation

was

of tibiae.

The

in either

was

both

fractures

512

had
rate

R. D.

been
fixed,
had a disastrously
of 30 per cent (Table
iii),

only

one

fracture

fixed

FRASER,

high
whereas

(Group

2)

G.

A.

deep
infection
patients
with

had

a rate

of

higher

or non-union.
The incidence
greatest
in Group

in conservatively

of femora
by fixation

months

Frequency
on bone

without

external

This occurred
in 26 per
was least in Group
1 (15
3 (30 per cent) and was

healing

time

managed

of local

fractures,

14 per

than in those
and 1 1 per

complications

Group
1
27 patients
Per
Osteomyelitis

and

Group

Per

of late

treated
cent of

cent

Per

Average

cent

Per

cent

Malunion

12

Refracture

12

33

35

36

35

Late
bone
(excluding
of implants

occurred
diagnosed

in 8 per cent.
and treated

in the

and

required

removal

late

of internal

malunion
was
and
refracture

A compartment
by fasciotomy

syndrome
was
in three
patients.

almost
identical
Iii). Treatment

operation

for

delayed
requiring

union
or non-union
operation
(bone

further

in Group

operation

in

this

figure

who

was

intramedullary
considered
sports,
was

Hip

commonest

IV.

that
still

Thigh

pain

Knee

-pain

23

-stiffness

I2

1 , whereas

way

However,

representative

of the

exception

(McBryde

reported
patients.
examined
time
almost

we feel
series

that

these

-locking

-pain

-swelling

Ankle-pain

respects.

With

Blake

1974)

previously

series
involved
much
smaller
numbers
All patients
in this review
were
personally
by the senior
author
(R. D. F.). The follow-up

ranged
five

from
years.

two

to twelve

years

with

six
had

femur.
Half of
in relation
to
or markedly
of

13
6
2

be

16

Weakness

Deformity

were

in most

and

hip

or

only
ninety-one
attended
to
sixty-three

the

and

of the

-swelling

Leg

FOLLOW-UP

examined.

varied

Limp

this series,
sixty-three

both

Symptoms
in the
sixty-three
patients
who attended
for
review

-stiffness

in
whom

in

nailing
of the
their activity,
moderately

pain

3.

patients
of

of the
for

symptom

Five

pain

-swelling

Of the
222
were
traceable,

made

to work

of patients.
of

-giving

groups
(Table
the predominant

Group

to return

the

cent

complained

was

was the main complication

grafting,
internal
fixation

was
average

years with an average

of sixteen
1 and Group
2 the average
was

per

amputation

devices);

in all three
treatment
of bone infection
was

reason

both)

(excluding

fixation

for patients

knee

in 37

Amputation
was required
in eight
patients:
two above
the knee, two through
the knee and four below
the knee.
As a result
of these
complications,
35 per cent of
patients

the

reduced
as a result
oftheir
injuries;
this was regardless
the treatment
group
to which
they belonged.

Unacceptable
of patients,

cent

the

From

weight-bearing

six months.

to eight
Group

Table

complications.
in 8 per

fracture;
over

taken

operation
removal
and

amputation)

Other
problem

Pain
present

undergone
the patients
work
or

26

or
30

iV).
was

26

15

Delayed
non-union

was

months.
before

an estimate

each

tibia

three
time

eleven
months,
while
Group
3 patients
took an average
of twenty-one
months
to return
to work.
Nine patients
had
to change
their
occupation
and
five were
still
unemployed
at the time of review.

patients

11

support,
for

time

of

of the

from two weeks

months;
in both

12

30

average

The most common

symptoms
at the time of review
involved
the knee in 50 per cent and the ankle
in 25 per
cent; 25 per cent of patients
complained
of a limp (Table

99 patients

and
The

cent

The
time
taken
for patients
to
aids varied
from two weeks
to seven

recollection

femur

operations

Group

92 patients

cent

an

patients

and 2 1 per cent of tibiae,

(1 0 per cent of femora

III.

with

3)

tibiae).
Table

J. P. WADDELL

Subjective
findings.
become
mobile
with

1 1 per

cent,
and conservatively
managed
patients
(Group
had an 8 per cent incidence
of bone
infection.
Delayed
union
cent of patients.
per cent),
and

HUNTER,

an average

one
of

of

Objective
findings.
The main findings
on examination
are listed in Tables
V and VI. Despite
the high incidence
of clinical
deformity
(27 per cent),
only
one patient
complained
of this, and her deformity
was largely
due to
loss of soft tissue
in the calf rather
than to angulation
at
the

site

of the

fracture.
THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

IPSILATERAL
Table

V.

Clinical

findings

in the

sixty-three

FRACTURE

patients

OF

reviewed

THE

FEMUR

best

in Group

Type
Group
1
1 1 patients
Per

Group
2
28 patients

cent

Obvious
clinical
deformity

Per

Group
3
24 patients

cent

18

Per

29

Per

36

of the

Full

movement

which

38

11

29

Stiff ankle

35

45

29

24

17

11

27

29

38

32

29

43

30

joint

joint

(less
compared

with

all

Clinical
findings
in fifty-seven
for review.
except
those
with
femur
and tibia)

patients
articular

(all who
fractures

Per
Clinical

Group
2
26 patients

cent

deformity

Per

VII.

were

of knees

fully

at the

joints

of

mobile
ankle

and

stiffness

was

immobilisation

fully

mobile

time

(Table

Vil).

Average
duration
of plaster
immobilisation
(months)

Knee

joint

AnJ

Subtalar

5.2

7.8

7.1

1.5

4.5

4.8

attended
of both

Group
3
23 patients

cent

range

range

of

made

average

which

Significant
Group
1
8 patients

20
and

normal

degrees

that

three

a longer

joints

by

in plaster

were

At

Mobile
VI.

more

ankle

the

90

with

Stiffjoint

Table

When

of patients,

by half

than

comparisons

Table

the
cent

of immobilisation

joints.
with

V).
was

cent.

was
similar

than

trend

of

in 32 per

subtalar

stiffened

associated

39

43

found

per

duration
had

knees;

22

36

Less than
90
degrees
of knee
movement

subtalar

in 30

subtalar

Instability
knee

Stiff

42

3 (Table
this

dorsiflexion

was

of the

more

movement)

Shortening
(more
than
1 inch)

knee

43

of

restriction

in Group
excluded

Vi).

or more

The
18

worst
were

Restriction

27

29

1 and

patients

degrees

cent

513

TIBIA

(Table

Average

or
Radiological
angulation
(more
than
10 degrees)

Iic

obvious

cent

AND

Per

restriction

of movement

present
in
intramedullary

in five

cent

tightness

26

23

pain
was
undergone

patients
of

six

the

the

patients,
nailing

foot

toe

was

flexors

at

the

hip

with

five of whom
of the femur.
small

and

had

wasted.

attributed

to

with

ischaemic

damage.
Radiological
(more
than

deformity
10 degrees)

42

Assessment

43

ofresults.

described
Full

movement

of the

Less
knee

than
90 degrees
movement

knee

50

31

were

of
0

by

18

graded

as

(Table

VIII).

three

patients,

considered
and

There

was

more

than

little

as 5 degrees

obvious

1 0 degrees
in

one

sometimes

Shortening

time
the

one

increase

third

side,

was

of these

patients
complained
had marked
laxity.

was

Group

clinical

and

60-B,

knee,

in 39

per

as compared
cent

laxity

was

marked.

of giving

way

of the

No. 4, NOVEMBER

1978

three

results

two

with

of patients.

Only
knee;

in

three

of

whom

of results
(1977)

Group

per

patients
were

in

cent

and

in 36

poor

in only
were

acceptable

poor.

cent

cent

had

Group

per

the

cent

of

2 (including

per

cent

of Group
1 , 1 1 per

of Group

of Group

their

using

30

of Group
in 23

in 1 0 per

2 and

Assessment
and Olerud

Fifteen

achieved

results)

or

achieved

thirty

were

patients

acceptable

2.

results,

were

occurred

of Group

VIII.

Group

for assessment
(1977),

were

1 , in 36 per

excellent
results

amputees,

Table

in
results

in Group

3. Poor

results

good

the

incidence
of shortening
due to bone loss at the

3. The

fractures

criteria

three

treated

of Karlstr#{246}m

Group

Total

Excellent

Good

15

Acceptable

15

30

Poor

15*

all three

A full range of movement

at the knee was found
in
only 24 per cent of patients,
and restriction
to less than
90 degrees
in 1 1 per cent.
Recovery
of movement
was
VOL.

Good

cent

all

Olerud
good,

Excellent

fifteen

the criteria

and

excellent,

to have

patients
the

was

limb.

of

as

limb
by one
inch
(2.5
in 22 per cent of patients

of the

present

the

clinically

incidence

The high
primarily

laxity

valgus

undeformed

least

was

While

deformity

in

of

of patients.

radiological

of the lower
or more occurred

of injury.
Ligamentous
other

cent

in a clinically

amputees).
1 patients

of angulation

in tibial
gross

had
the
deformity.

centimetres)

evidence

in 38 per

patient,

seen

1 patients
radiological

(excluding
in Group

radiological

Using

Karlstr#{246}m

63
*This

figure

includes

the

three

amputees

514

R. D.

conservatively,

were

not

method
of treatment
have influenced
the

included

of the
necessity

FRASER,

in this

G.

grouping

fracture
was not
for amputation.

A.

HUNTER,

as the

thought

to

fracture

of the

injury

which

is often

to the

head,

chest,

This

review

multiple

has

associated

not

importance

light

of

nine

clinical

fat

embolism

injuries

pose
limbs

the

amputation.
and

vascular

per

operation

(after

non-union,

six

graded

results

are
of

same

of

excellent,
with

our

around
found
excellent

or

advocated
internal
fixation
found

smaller

series
(1977).

their

59

also

in

twelve

in

in the

(1977)
with

shaft

tion

fixation,

series

by

in Group

1 patients

as the

incidence

best

of twelve

of

limbs

only

three

by

why
from

our

those

all;

it leads

alarming
high

infection

and tibia
as compared

2 (1 1 per

findings

cent)

rate

had
and

in our
(30

per

review
cent)

both
been
fixed
with
the infection
Group

3 (8 per

cent).

of both

of our

the management
internal
fixation

by

at

complicathe

two

was

the

knee

at

The
follow-up

patients
knee,

the

contributing
account.

we

cent

25 per

in

Stiffness

associated

of

should
fracture

that

in

tibia,
together
combination
and

the

did

poorly

too

small

of both

in this
to

series.

make

at follow-up

The

definite
though

were
and

of patients

with
allows

knee.

fractures

referred

ankle

(25

complained

per
of a

laxity
of the knee
five times as high

at
as

rupture
diagnosed
at the
only
a small
number
of
of giving
ligamentous

always
be thought
of the femur
and

knee,

more
THE

more

or of cast-bracing

of patients)
cent

union

way of the
laxity
in

osteoarthritis
must
be taken
into
that the possibility
of ligamentous

of the

with

the

to delayed

articular

complained
effects
of

to early
suggest

wound

opera-

recommend

of ligamentous
cent)
was almost

at follow-up
long-term

disruption
ipsilateral

and

patient

symptoms
per

incidence
(39 per

We

prolonged

risks

regarding
their management,
should
be applied.

(50

one

more
meticulous

fixation

was

common

knee

rate

Iic)

follow-up

as high

only

is to be attempted,

with

(Type

times

clearly
be good
enough
for
without
risk of infection.
far worse
than no fixation
at

findings,

the

deep

were
of both

are fixed there is

theatre
staff. The

the

fractures

of

than

the

where

to a less

of one or .both
fractures
ligamentous
integrity
can

in patients

Despite

additional

the incidence
of ligamentous
outset
(8 per cent).
While

results

internally
rates

and

to

patients

were
He

field

external

mobilisation

number

both

three

of the fractured
of the femur;
this

in general,

that

results

series

fractures
and the

infection

of rigid

of the

1968;

1977)

better

almost

perhaps

to a high

use is made

The

number
in

of

requiring
treatment

(Ratliff

Olerud

2 patients

operative
conditions
must
rigid fixation
to be achieved
inadequate
fixation
is often

cent of patients);
limp.

managed

a large

lead

and

to the

treated
good

cent)
of the

papers

was

operative
time

were

fractures.

conservatively.
review
were

explains
differ

results

rate

feature

which
has not previously
of bone infection
(30 per

in Group

recommendations
similar
principles

described.

femur
1),

cent)

sides

bones,

grading

both

hospitals

probably

for

per

in our

1), a finding
The incidence

of

of the
tibia
by intramedullary

of

with

end-results

most

disastrously

Group

in eleven

teaching

This
and

just

The
whose
(Group

fixation

compared

different
rate

study
of both

stabilisation
means,
followed

internal

results

of surgeons.

fourteen

prospective

fractures

eleven
patients
treated
The patients
in this present

thirteen

of

cent

and the incidence

of late operations
in patients
treated
by fixation

or non-union.
in view

femur
at seven
to fourteen
days.
They
functional
results
were achieved
in most

with

internal

or

poor.

fractures

out

of their
patients
though
their
criteria
not defined.
Ratliff
(1968)
reported
that the
good

the

good

included

per

disturbing

previous

(Group
reported.

contamination
tion.
if fixation

cent

cent

from

bones
been

Of

per

Using

15 per

Another

management.
rate

operating

These

cent

is apparent

infection

early

a!.

of the
excellent

found

large number
of patients
(35
bone
operations
regardless

change

only
shaft
fractures.
They
of both
bones
resulted
in

results

immediate
or external

obtained

per

1 were
better
than
proportion
of poor

to a 30

was the
secondary

or

(thirty-one

per

and

series

28

48

due

fracture
was fixed. When
both
more
demand
on the surgeon
late

end-results.

Olerud

acceptable

patients

twenty-one

good,

poor

had

if

malunion.

the

and
not
fixation

good

or
or

the

union

at follow-up

had

they

cent

knee
rigid

patients.
H#{246}jer et

of

ultimately

delayed

largely

or non-union.

unacceptable

Half

disappointing.

and

grading

review

the
that

of

required

for

cent
to

26 per

are

patients

excellent

24 per

Karlstr#{246}m

system

limb.

cent),

union

conservative

in the

injury

examined

inferior

patients)

the

Neurovascular

refracture

as

and

of

per

in Group
had a high

delayed

it

cases

to the

review
all

weeks)

patients

were

series.

vascular

of

osteomyelitis,

acceptable,

As

cent

sixty-three

cent

by

made

management

threat

(36

results
3, which

H#{246}jeret a!. 1977;

Karlstr#{246}m
and
fixation
of both
bones
can give

of these

twenty-one

this

is to be avoided.
results
of this

Thirty-five

of
the

the over-all
in Group

system.

be

WADDELL

group.

injuries

immediate
assessment
of
appropriate
treatment
are essential

status

amputation
The

major

must

local

is a serious

resuscitation

aspect
in

main

other

the

and

complicated

required

the

this

deaths

tibia

musculoskeletal

mention

of

the

the

and

discussed
but

and
with

viscera

injuries,

prime

femur

this,
those
results

DiSCUSSION
ipsilateral

J. P.

is usually
be accurately
ankle

prolonged

JOURNAL

OF

and

of in patients
with
tibia.
Stabilisation
necessary
tested.
subtalar

joints

immobilisation
BONE

AND

before

JOINT

was

than
SURGERY

IPSILATERAL

these

when

the

benefit

the

patients

joints

were

ofearly
in this

Our thanks
are
to he reviewed.
financial
help.

mobile;

this

mobilisation
series

due to the
We would

finding

ofjoints.

were

under

FRACTURE

emphasises
More

THE

FEMUR

age;

than

twenty-five

surgeons
throughout
the
like to thank
Professor

OF

half

years

teaching
centres
Ian Macnab
for

stiffness

handicap

of

AND

of the
to

of Ontario
his support

knee

these

expectations

515

TIBIA

or

young

are

ankle

can

patients,

be

an

whose

enormous

demands

and

high.

and Quebec,
who helped
of this project,
and the

in this survey
by allowing
Canadian
Orthopaedic

their patients
Foundation
for

REFERENCES
Giliquist,
J., Reiger,
A., Sj#{243}dahl, R.,
Scandinavica,
139, I 67- 1 72.
Hayes.
41,

J. T. (1961)
1379-1388.
H.,

HOjer,

Gillquist,

Multiple
J.,

Karlstr#{243}m, G.,

and

McBryde,
56-A,

, Jun.,

Omer,

A. M.
1309.

M.

E.

Obstetris,

VOL.

and

A. H. C. (1968)

Winston,

60-B,

No.

Liljedahl,
Blake,

Bylund,

in the
S..O.

S. (1977)

(1977)

ipsilateral

R. (1 974)

The

P.

same

(1973)

Multiple

extremity:

some

Combined
fracture

fractures
of the

floating

The

ofthe
results

985-991.

4. NOVEMBER

1978

shaft

ofthe

of conservative

femur

femur

fractures
problems
of the
and

knec-ipsilateral

J. H., and Bacon,

W. L. (1 968) Combined
Hospital
from
1961
to 1967. Journal
of
Fractures

( 1 972)
134,

fractures

Olerud,

G. E., Jun.,
Moll,
at Brooke
General

Ratliff,

and

and

and

treatment

tibia

fractures
Trauma,

in the same

of fractures

of

a single

in their
femoral

tibia.
fractures

limb.
of the

and

tibial

and

Proceedings
and

in the
and

femur

and

tibia

ofT/ic

Clinics

same

Joint

tibia.

in a single

tibia

problem.

Surgical

shafts

ofBone

of the

femur

A therapeutic

management.

Journal

ofthe
femur
8, 1026-1041.

leg.

Journal

extremity.

same

of

Analytical
ofMedicine,

limb.

Surgery,

America,

8, 206-2

12.

240-243.

59-A,
ofBone

Chirurgica

North

injury,

Surgery,

RoyalSociety

in the

limb.

Arta

and

Joint

study
61,
Gynecology

Surgery,

of cases
906-908.
and