Posttraumatic progressive cubitus varus deformity managed by lateral column shortening: A novel surgical technique.

The outward angulation of elbow with supinated forearm is cubitus varus deformity. This deformity is often seen as sequelae of malunited supracondylar fracture of humerus in paediatric age group of 5e8 years. The deformity is usually non-progressive, but in cases of physeal injury or congenital bony bar formation in the medial condyle of humerus, the deformity is progressive and can be grotesque in appearance. Various types of osteotomies are defined for standard non-progressive cubitus varus deformity, while multiple surgeries are required for progressive deformity until skeletal maturity. In this study we described a novel surgical approach and osteotomy of distal humerus in a 5 years old boy having grotesque progressive cubitus varus deformity, achieving good surgical outcome.

Proximal femoral nails compared with reverse distal femoral locking plates in intertrochanteric fractures with a compromised lateral wall; a randomised controlled trial.

PURPOSE: There is no consensus about the best option of internal fixation for unstable intertrochanteric fractures. The aim of the present study was to compare proximal femoral nail (PFN) with contralateral reverse distal femoral locking compression plate (reverse-DFLCP) in the management of unstable intertrochanteric fractures with compromised lateral wall. METHOD: In a randomized controlled study, from November 2011 to October 2012, 40 patients with unstable intertrochanteric fractures with compromised lateral wall (AO 31A 2.2 to 3.3) had osteosynthesis by PFN (n = 20) or reverse-DFLCP (n = 20). Intra-operative variables compared were duration of surgery, blood loss during surgery, fluoroscopy time and surgeons perception of the surgery. Patients were followed up clinically for a minimum of one year. Functional outcome was assessed by Parker Palmer mobility score (PPMS), Harris hip score (HHS), and Short Form-12. Failure was defined as any condition which would necessitate revision surgery with change of implant. RESULTS: Duration of surgery (p = 0.022), blood loss during surgery (p = 0.008) and fluoroscopy time (p = 0.0001) were significantly less in the PFN group than in the reverse-DFLCP group. No significant difference was found in type of reduction, difficulty in reduction and surgeon's perception of surgery. The PFN group had better functional outcome than the reverse-DFLCP group. HHS for the PFN group was 81.53 ± 13.21 and for the reverse-DFLCP group it was 68.43 ± 14.36 (p = 0.018). SF-12 physical (p = 0.002) and mental component (p = 0.007) scores in the PFN group was significantly better than in the reverse-DFLCP group. There was one failure in the PFN group as compared to six in the reverse-DFLCP group (p = 0.036). CONCLUSION: Due to favourable intra-operative variables, better functional outcome and lower failure rates, we conclude that PFN is a better implant than reverse-DFLCP for intertrochanteric fractures with compromised lateral wall.

Walking speeds are lower for short distance and turning locomotion: Experiments and modeling in low-cost prosthesis users.

Preferred walking speed is a widely-used performance measure for people with mobility issues, but is usually measured in straight line walking for fixed distances or durations, and without explicitly accounting for turning. However, daily walking involves walking for bouts of different distances and walking with turning, with prior studies showing that short bouts with at most 10 steps could be 40% of all bouts and turning steps could be 8-50% of all steps. Here, we studied walking in a straight line for short distances (4 m to 23 m) and walking in circles (1 m to 3 m turning radii) in people with transtibial amputation or transfemoral amputation using a passive ankle-foot prosthesis (Jaipur Foot). We found that the study participants' preferred walking speeds are lower for shorter straight-line walking distances and lower for circles of smaller radii, which is analogous to earlier results in subjects without amputation. Using inverse optimization, we estimated the cost of changing speeds and turning such that the observed preferred walking speeds in our experiments minimizes the total cost of walking. The inferred costs of changing speeds and turning were larger for subjects with amputation compared to subjects without amputation in a previous study, specifically, being 4x to 8x larger for the turning cost and being highest for subjects with transfemoral amputation. Such high costs inferred by inverse optimization could potentially include non-energetic costs such as due to joint or interfacial stress or stability concerns, as inverse optimization cannot distinguish such terms from true metabolic cost. These experimental findings and models capturing the experimental trends could inform prosthesis design and rehabilitation therapy to better assist changing speeds and turning tasks. Further, measuring the preferred speed for a range of distances and radii could be a more comprehensive subject-specific measure of walking performance than commonly used straight line walking metrics.

Outcome of open reduction and internal fixation of intraarticular calcaneal fracture fixed with locking calcaneal plate.

OBJECTIVE: Debate continues regarding the management of calcaneal fractures, between open reduction and internal fixation and closed treatment. Hence we aim at evaluating the radiological and functional outcomes of open reduction and internal fixation in displaced joint depression type of calcaneal fractures fixed with locking calcaneal plate. METHODS: In this series, 28 patients (26 unilateral and 2 bilateral) with joint depression type of calcaneal fractures as per Essex-Lopresti classification system were operated on with locking calcaneal plate within 3 weeks of injury. Patients were evaluated in terms of associated injuries and X-rays of anteroposterior, lateral and axial views of the calcaneum. CT scan was done to assess the amount of comminution and articular depression. Patients were followed up clinically and radiologically at least for 1 year. Radiological assessment was done by Bohler's angle and Gissane's angle along with measurement of calcaneal height and width. Functional outcome was assessed using the American Orthopaedics Foot and Ankle Society (AOFAS) scale. RESULTS: At average follow-up of 14.5 months, average AOFAS score was 86.3 (range 66 to 97), with 86% having excellent to good results and 2 (7.7%) and 1 (3.7%) having fair and poor results respectively. All patients had stable ankle joint with all having dorsiflexion and plantar flexion more than 30 degrees. Average subtalar range of motion was 17 degrees The mean Bohler's angle, mean Gissane's angle, calcaneal height and width were 25.47 degrees 121.3 degrees 4.32 cm and 3.81 cm respectively at final follow-up. Three patients had flap necrosis at incision site and one had superficial and deep infection. Subtalar arthritis was seen in 5 patients, whereas sural nerve hypoaesthesia in 1 patient. None of the patients had compartment syndrome, heel pad problems, peroneal tendinitis, reflex sympathetic dystropy or implant failure. CONCLUSION: Open reduction and internal fixation with locking calcaneal plate gives sound functional outcome, i.e. restoring anatomically reconstruction of height, width, Bohler's and Gissiane's angles of the calcaneum, and allowing early mobilization.

Hemodynamics and early recovery characteristics of desflurane versus sevoflurane in bariatric surgery.

CONTEXT: Morbidly obese patients are prone for intraoperative hemodynamic disturbances and postoperative airway complications. AIM: Comparison of intraoperative hemodynamics and postoperative recovery characteristics of desflurane versus sevoflurane in morbidly obese patients undergoing laparoscopic bariatric surgery. SETTINGS AND DESIGN: Randomized controlled trial. MATERIALS AND METHODS: After institutional ethics committee approval and written informed consent, 40 morbidly obese patients (BMI > 35 kg/m(2)) were randomized to receive desflurane or sevoflurane as part of a standardized general anesthesia technique. Volatile anesthetic concentration was titrated to maintain electroencephalographic bispectral index score (BIS) in the range of 40-60. Mean arterial pressure (MAP) and heart rate (HR) were recorded preoperatively, at induction and intubation, then at regular intervals. After extubation, early recovery was recorded by time to emergence and orientation to time and place. In post anesthesia care unit, intermediate recovery was assessed by modified Aldrete Score and Digit Symbol Substitution Test (DSST). RESULTS: Intraoperative MAP and HR did not differ between the two groups (P > 0.05). The time to response to painful stimuli, obeying verbal commands and spontaneous eye opening was shorter (P = 0.001) and modified Aldrete Score was higher after desflurane anesthesia than after sevoflurane anesthesia (P = 0.049). DSST also returned towards normal faster after desflurane (28.50 ± 6.30 min vs. 35.0 ± 5.62 min, P = 0.03). CONCLUSIONS: Both desflurane and sevoflurane produce similar hemodynamic changes but the immediate and intermediate recovery was significantly faster after desflurane thus contributing to fast tracking and early discharge of patients.

Contemporary challenges in clubfoot treatment: A quantitative study among Indian parents.

Purpose: The studies conducted a decade ago showed that the Ponseti method, suffers from many execution-related issues-particularly in low and middle-income countries including poverty, physical distance, lack of transportation etc. The society has undergone many changes, including improvements in literacy, connectivity (both transport and digital), etc., in the last decade. Therefore, this study is designed to identify the contemporary apprehensions, concerns, and challenges of parents seeking CTEV treatment for their child through the Ponseti Method in India. Methods: A descriptive cross-sectional study of 200 parents of the children undergoing treatment at a multi-specialty hospital is carried out using an interview guide. The semi-structured interviews were conducted telephonically and recorded. Results: The statistical analysis shows that a male child is presented late than a female child. The physical distance is associated with child discomfort during the casting and bracing phase, with the travel method affecting the follow-up. The increase in travel time may result in increased casts due to a lack of regular follow-up. Parents' income level is also strongly associated with regularity of follow-up and child discomfort during treatment. Conclusions: The patients traveling long distances in public transport are the most vulnerable group regardless of gender. The children in such cases are more likely to experience discomfort during the casting and bracing phase with a lack of regular follow-up. Expert doctors and brace unavailability in the local area remain vital challenges for the parents.

Automated Closed-Loop Propofol Anesthesia Versus Desflurane Inhalation Anesthesia in Obese Patients Undergoing Bariatric Surgery: A Comparative Randomized Analysis of Recovery Profile.

INTRODUCTION: Precision general anesthesia (GA) techniques that minimize the presence of residual anesthetic and facilitate recovery, are desirable in patients with morbid obesity. Automated administration of propofol total intravenous anesthesia (TIVA), which facilitates precision propofol delivery by factoring in continuous patient input variable (bispectral index) to establish a closed feedback loop system, may help mitigate concerns related to propofol's lipid solubility and adverse accumulation kinetics in patients with morbid obesity. This randomized study evaluated the recovery of patients with morbid obesity undergoing bariatric surgery under propofol TIVA automated by a closed-loop anesthesia delivery system (CLADS) versus desflurane GA. METHODS: Forty patients, randomly allocated to receive propofol TIVA (CLADS group) or desflurane GA (desflurane group), were evaluated for postoperative recovery (early and intermediate) (primary objective); they were evaluated for intraoperative hemodynamics, anesthesia depth consistency, anesthesia delivery performance characteristics, patient satisfaction, and incidence of adverse events (sedation, pain, postoperative nausea, and vomiting) (secondary objective). RESULTS: No difference was found for the time-to-eye-opening (CLADS group: 4.7 [3.0, 6.7] min vs. desflurane group: 5.6 [4.0, 6.9] min, P = 0.576), time-to-tracheal-extubation (CLADS group: 6.7 [4.7, 9.3] min vs. desflurane group: 7.0 [5.8, 9.2] min, P = 0.528), ability-to-shift score from operating room table to the transport bed (CLADS group: 3 [3.0, 3.5] vs. desflurane group: 3 [3.0, 4.0], P = 0.703), and time to achieve a modified Aldrete score 9/10 (CLADS group: 15 [15.0, 37.5] min vs. desflurane group: 15 [15.0, 43.7] min, P = 0.867). CONCLUSION: Automated propofol TIVA as administered by CLADS, which matched desflurane GA with respect to depth of anesthesia consistency and postanesthesia recovery profile, can be explored further as an alternative anesthesia technique in patients with morbid obesity.

Instrumented stabilization in spinal tuberculosis.

Spinal tuberculosis (TB) produces neurological complications and grotesque spinal deformity, which in children increases even with treatment and after achieving healing. Long-standing, severe deformity leads to painful costo-pelvic impingement, respiratory distress, risk of developing late-onset paraplegia and consequent reduction in quality and longevity of life. The treatment objective is to avoid the sequelae of neural complications and achieve the healed status with a near-normal spine. In TB, the spine may become unstable if all three columns are diseased. Pathological fracture/dislocation of a diseased vertebral body may occur secondary to mechanical insult. Surgical decompression adds further instability, as part of the diseased vertebral body is excised. The insertion of a metallic implant is to provide mechanical stability and the use of an implant in tubercular infection is safe. Indications for instrumented stabilisation can be categorised as: (a) pan vertebral disease, in which all three columns are diseased; (b) long-segment disease, in which after surgical decompression a bone graft >5 cm is inserted with instrumentation to prevent graft-related complications and consequent progression of kyphosis and neural complications and (c) when surgical correction of a kyphosis is performed when both anterior decompression and posterior column shortening is required. The implant choice should be individualised according to the case. Pedicle screw fixation in kyphus correction in healed disease is a most suitable implant. Hartshill sublaminar wiring stabilisation in active disease is a suitable implant to stabilise the spine, taking purchase against healthy posterior complex of the vertebral body to save a segment.

Magnetic resonance evaluation of tubercular lesion in spine.

PURPOSE: Information on Magnetic Resonance (MR) features of active and healed lesions in tuberculosis (TB) spine are lacking. We evaluated MRI findings in active and healed proven TB spine to establish the diagnostic features. MATERIALS AND METHOD: Forty-nine consecutive spinal TB patients (20 male; 29 female) diagnosed clinicoradiologically and/or on histopathology, Fine Needle Aspiration Cytology (FNAC), bacteriology, or Polymerase Chain Reaction (PCR) were enrolled. Pretreatment MR scans were reviewed for diagnostic features, and eight-month follow-up MR scans were reviewed for healing changes. RESULTS: Cervical spine (n = 6), dorsal spine (n = 14), and lumbar spine (n = 29) were affected. Fourteen had paraplegia. Mean vertebrae involved were 2.61 on X-ray with a total of 128 vertebrae (VB) and 3.2 on MRI (range, 2-15) with 161 VB. The lesions were more extensive on MRI (34.7%) than appreciated on X-ray. The disc was preserved partially or fully in 88.2% of instances. End plate erosions (159/161 VB), lost VB height (94/161), exudative lesion (158/161), granular lesion (3/161), pre and paravertebral collections (49/49 cases), marrow oedema (161/161), discitis (98%), epidural involvement (107/161), epidural spread (100/161), and subligamentous spread (156/161) were observed. Canal encroachment (10-90%) was seen in 37 cases. Mean motor and sensory scores with greater than 50% canal encroachment were 87/100 and 156/168, respectively. Cord oedema was observed in 11 cases (eight with neural deficit and three cases without). Cord atrophy was seen in one case each before and after treatment. A total of 83% of patients had a combination of paravertebral collections, marrow oedema, subligamentous and epidural extension, endplate erosions and discitis. On healing (n = 20), complete resolution of marrow oedema and collections, fatty replacement of bone marrow and resolution of cord signal intensity were observed. CONCLUSION: The marrow oedema, preservation of disc space, subligamentous extension of abscess, septate paravertebral abscess, epidural extension, endplate erosions and discitis were consistently observed in 83% cases of TB spine on MRI.

Evaluation of Hearing Loss in Congenital Hypothyroid Children at a Tertiary Care Hospital in Central India.

Hearing loss has long been associated with congenital hypothyroidism and, if not noticed and treated early, may result in delayed language acquisition and difficulties in comprehension. In light of the implications of congenital hypothyroidism and its associated hearing loss, we decided to conduct this study. The aim of this study was to identify the prevalence of hearing loss in congenital hypothyroidism and its relation to the severity of the disease and age of initiation of treatment. This study was conducted from July 2016 to June 2021 at a tertiary care hospital in Bhopal. The hearing status of congenital hypothyroid children and matched controls was assessed by pure tone audiometry or free field audiometry and, in selected cases, with brainstem evoked response audiometry. Eight children (25%) with congenital hypothyroidism had hearing loss, compared to one (3.12%) in the control group (p < 0.05). No statistically significant difference has been found in the gender, mean age of diagnosis, mean age of initiation of levothyroxine treatment, mean screening FT4 levels, and mean screening TSH levels between congenital hypothyroid children with and without hearing loss. Due to the high prevalence of hearing loss in congenital hypothyroidism and its impact on language and cognitive development, it is critical to create awareness among healthcare professionals that children diagnosed with congenital hypothyroidism must undergo audiological evaluation at the time of diagnosis and periodically thereafter. Alternatively, children with unexplained hearing loss must be screened for congenital hypothyroidism.

Study of Cell Viability and Etiology of Contamination in Decalcified Bone Allograft: A Pilot Study.

BACKGROUND: Bone allografts can elicit immune responses which is correlated with the presence of Human Leukocyte Antigen (HLA) and cellular DNA. It also has risk of causing occult infection arising out of contamination during its processing and storage. The presence of immunogenic materials like cells, cellular remnants and DNA in a decalcified bone allograft during different phases of processing has never been studied. Present study was conducted to explore- the cell viability using routine Hematoxylin and Eosin, presence of DNA using Feulgen staining and etiology of contamination in decalcified bone allograft during procurement, demineralization and ethanol preservation. METHODS: The harvested bones from patients undergoing hemireplacement/THR/TKR were processed to prepare decalcified bone allografts. The samples during procurement (A), HCL treatment (B) and ethanol preservation (C) were sent for histopathological analysis (number of osteocytes in the maximum density field under 40x and the cells demonstrating presence of DNA on feulgen stain) and microbiological assessment (aerobic/anaerobic/fungal cultures). RESULTS: Histopathological study demonstrated the presence of osteocytes and other cells like bone marrow, adipocytes, endothelial cells in the decal bone allograft. The average number of osteocytes gradually decreased from 55.47, 9.6, 0.86 in sample A, B, C, respectively. Feulgen staining confirmed the presence of DNA in osteocytes and other cells which decreased both qualitatively and quantitatively in subsequent stages of processing. Rate of contamination demonstrated at the procurement was 6.67% (Staphylococcus aureus). After treatment with HCl (demineralisation), 7.14% of non-contaminated allografts were found contaminated (Staphylococcus epidermidis). None of the remaining 13 non-contaminated allografts showed contamination after storage in ethanol. Overall 13% of the patients had positive cultures on microbiological assessment. CONCLUSION: The population of osteocytes in the harvested bone reduced significantly after processing with HCl and ethanol preservation. Presence of DNA, demonstrated by using Feulgen staining, was observed in bone marrow cells, adipocytes along with osteocytes which showed quantitative reduction on processing. Hence, antigenicity, conferred by cells and their DNA, reduced significantly after processing of decal bone. Contamination rate of banked decalcified allograft was 13%. Thus, culture and sensitivity tests should be carried out at each step of processing of decal bone allograft.

Neglected reverse Essex-Lopresti injury with ulnar nerve compression.

A 45 year old woman was diagnosed as having anteromedial radial head dislocation and distal radius fracture five months after her injury on right forearm. The radial head dislocation led to ulnar nerve compression. She had severe restriction of her elbow movements. She was treated with arthrolysis, decompression of the ulnar nerve and radial head resection. The reverse Essex Lopresti injury and radial head dislocation compressing the ulnar nerve has not been reported in English language literature to the best of our knowledge. A mechanism is proposed for the injury. In acute presentations, restoration of both the radioulnar joints should be done and neglected nature of such injury leads to suboptimal outcomes.

Monteggia fracture dislocation equivalents--analysis of eighteen cases treated by open reduction and internal fixation.

OBJECTIVE: Monteggia fracture dislocation equivalent, though already described by Bado, is still an unclassified entity. We aimed to retrospectively analyze 18 cases of Monteggia variants and discuss the injury mechanisms, management, and outcome along with a review of the literature. METHODS: A retrospective record of Monteggia fracture dislocation (2003-2008) was reviewed from medical record department of our institute. Classic Monteggia fracture dislocation, children below 12 years or adults over 50 years, as well as open grade II and III cases were excluded from this study. Monteggia variant inclusion criteria included fracture of the proximal ulna together with a fracture of the radial head or neck and skeletal maturity. Totally 26 patients were identified with Monteggia variants and 18 were available for follow-up, including 11 males and 7 females with the mean age of 35 years. The ulna fracture was treated by compression plating along with tension band wiring. Radial head/neck was reconstructed in 12 patients while excised in 6 patients. RESULTS: Follow-up ranged from 1-4 years, mean 2.6 years. Patients were assessed clinicoradiologically. Mayo Elbow Performance Score was employed to assess the outcomes. At final follow-up, the results were excellent in 10 patients, good in 4, fair in 2 and poor in 2. Mean range of motion of the elbow was 20 degree 116 degree, 50 degree and 55 degree for extension, flexion, pronation and supination, respectively. Two patients had complications in the form of heterotopic ossification and stiffness of the elbow. One nonunion ulna, primarily treated by tension band wiring, was managed by refixation with locking reconstruction plate and bone grafting. Bone grafting was only required in this patient for nonunion. Another patient had implants removed on his request. The results in our series closely correlated with extent of intraarticular damage, coronoid fracture and comminuted fractures. CONCLUSIONS: Monteggia fracture dislocation equivalents are rare injuries and pre-surgery recognition by radiographs and 3-D CT helps make optimal plan. The poor results usually relate to intraarticular damage, coronoid fractures and comminution of the ulna and radial head fractures.

Nonunion of coronal shear fracture of femoral condyle.

Isolated coronal fractures of femoral condyle are rare in adults and nonunion of Hoffa fracture is reported only a few times in the literature. We analyzed six cases of nonunion of Hoffa fractures over a period of three years. Three patients were treated conservatively and three patients had fixation failures. Delay of presentation was 2 months to one year. Treatment protocol consisted of open reduction, excision of pseudoarthrosis, bone grafting and internal fixation along with knee arthrolysis. Union was achieved in all patients at mean 16 weeks. The treatment of nonunion of Hoffa fractures requires careful preoperative planning and meticulous surgical technique. The literature regarding the controversies in fracture management and surgical technique are reviewed.

Covid-19 Pandemic: Resumption of Orthopedic Care and Medical Education.

Covid-19 is a respiratory disease caused by coronavirus 2 (SARS-CoV-2) first identified in Wuhan, China (December 2019). The disease rapidly crossed the barrier of countries, continents and spread globally. Non-pharmaceutical measures such as social distancing, face mask, frequent hand washing and use of sanitizer remained the best available option to prevent the spread of disease. OPD, IPD admissions, elective O. Ts were curtailed. Orthopedic care was only limited to emergency and semi-urgent procedures like necrotizing fasciitis, open fracture, and compartment syndrome. These measures were taken to preserve infrastructure and manpower to manage covid-19 pandemic. The children were thought to have a low susceptibility to covid-19 as compared to an adult. Deferring the patient during pandemic has led to high orthopedic disease burden, morbidity and disease-related sequelae, hence elective care must be resumed with modified hospital infrastructure. Resumption of elective/emergent orthopedic care should be slow, phasic and strategic, much similar to unlocking. Cases must be stratified depending on covid status and severity. Dedicated O.Ts with neutral/negative pressure and HEPA filter for covid positive and suspected patients are to be used. All symptomatic and suspected patients should be investigated for covid-19 by RT-PCR, blood counts and CT scan. Regional anaesthesia should be preferred to General anaesthesia. Power drill/saw/burr/pulse lavage should be minimized to avoid aerosol generation. Postoperatively continuous surveillance and monitoring to be done for covid related symptoms. Medical institutes rapidly shifted to the online mode of education. Blended learning (virtual & physical) and imparting skills have to be continued in post covid phase with equitable distribution of teaching hours to students of different years.

Neglected isolated fracture of the trochlea humeri.

A 15 years old girl was found to have isolated trochlea fracture 10 weeks after an injury caused by a fall on her left elbow. Movement of the elbow was severely restricted. Radiographs showed a half moon-shaped and anterosuperiorly displaced osteochondral fragment. Medial approach capsulotomy of the elbow and excision of the intraarticular adhesions were done to expose the isolated trochlea fracture. Headless screws were used for fixation, combined with bone grafting. The follow-up showed union and excellent functional recovery of the elbow. Isolated trochlea fracture in adults is rare and usually associated with capitellar fractures and/or elbow dislocations. A neglected trochlea fracture is rarely reported in the English language literature to the best of our knowledge. Recognition of isolated trochlea fracture is vital to apprehend the pathomechanics of the injury and to devise a suitable treatment approach.

Osteochondroma of the talus: three varying cases.

Osteochondroma of the talus is a rare entity that can cause pain, swelling, restriction of movements, synovitis and tarsal tunnel syndrome (TTS). We present three such cases with varying presentation. Case 1 presented with synovitis of the ankle along with a bifocal origin of the talar osteochondroma. Case 2 presented with TTS as a result of compression of the posterior tibial nerve. Case 3 presented with deformity of the foot. In all the three cases, the mass was excised en bloc and histologically proven to be osteochondroma. In case 3, the ankle joint was reconstructed with plate, bone graft and arthrodesis of the inferior tibiofibular joint. All the three cases had good clinical outcomes.

Teaching Ear Examination Skill to Undergraduate Students Using Check List.

For examination of ear, proper illumination is a pre requisite. Diseases related to ear may lead to altered sense of hearing and may affect normal balance system. If students are taught to examine ear using a check list, they may perform better. To teach ear examination to undergraduate students using a check list. Total 50 undergraduate students of M.B.B.S. attending E.N.T. clinic in Chirayu Medical College and Hospital were included in the study. They were given enrolment no. 1 to 50 and were divided into two groups. Group 1, enroll. no. 1 to 25 and group 2, enroll. no. 26 to 50. Group 1 was taught using check list and the Group 2 was taught without use of checklist. Both the groups were evaluated using check list. The group B students were again taught, using check list and were again evaluated using check list. Use of check list showed that there was statistically significant improvement in learning by students using check list in group 1 students compared to group 2 students who were taught without use of check list. The group 2 students also had improvement on evaluation, after they were taught using check list. Study suggests that use of check list for ear examination skill to undergraduate students has significant role and students learn better than when taught without use of checklist. Inclusion of checklist for teaching ear examination to undergraduate students may be considered.

Hypoglossal Nerve Palsy as a Rare Complication of C1-C2 Pott's Spine.

Reporting a rare scenario of hypoglossal nerve palsy in craniovertebral tuberculosis. Two patients presented in outpatient department with chief complaints of pain in neck, restricted neck movements, gait changes, difficulty in speech and weakness in all the extremities. On the basis of clinicoradiological correlation, the patients were diagnosedwithtuberculosis of C1-C2 spine. They were started on antituberculosis therapy Category 1. The patients improved clinically and there was no worsening of symptoms, but they noticed tongue deviation and hypotrophy on one side of the tongue. C1-C2 tuberculosis along with cranial nerve palsy, especially hypoglossal nerve is one of the rarest presentations. Hypoglossal nerve arises from the medulla, exits through hypoglossal canal in the base of the skull and traverses neck to supply tongue musculature. Prevertebral fascia extends from superior mediastinum to base of the skull. Abscess in this area can cause either actual compression of the hypoglossal canal or C1 and base of the skull dissociation which can lead to compression of the canal.