Open total talus dislocation without concomitant malleoli fracture: a case report.

BACKGROUND: Total talus dislocation without ankle (malleoli) fracture is a very rare injury with prevalence of only 0.06% of all dislocations and only 2% of talar injuries, and are usually associated with common complications such as infection, avascular necrosis, and posttraumatic arthritis. The treatment usually involves debridement, reduction, stabilization of the ankle joint, and primary or secondary closure of the wound. CASE PRESENTATION: We present the case of a 40-year-old South Asian woman who was involved in an accident. She was rushed to our hospital, whereby subsequent examination revealed an open total talus dislocation with the talus being exposed in its entirety from a contaminated wound in the medial side. Furthermore, radiograph confirmed total talus dislocation without concomitant malleoli fracture. She was immediately taken to the operating theater whereby debridement and immediate reduction was performed under anesthesia, and the ankle was stabilized with external fixator for about 6 weeks. She is now able to bear weight on the affected ankle with minimal tolerable pain and has normal range of motion of the ankle. CONCLUSIONS: Open total talus dislocation without concomitant malleoli fracture is a rare injury. Reduction of the talus in combination with complete wound debridement potentially successfully avoids infection, provides early revascularization preventing avascular necrosis, and preserves the normal ankle anatomy.

Squat and smile assessment in predicting healing of lower limb fractures fixed with a SIGN nail.

BACKGROUND: Irrespective of the treatment method, union is the ultimate goal of any fracture treatment. However, nowadays, rather than the physician-based clinico-radiological methods, the patient-reported outcome measurements assessing their quality of life and function are gaining much popularity. This is specifically true in the part of the world where the patient needs almost complete degree of hip/knee flexion - for social, cultural, religious or occupational reason(s). The ability to squat can assess the mobility and stability of joints and thus the quality of squatting is a proxy reflection of the functional outcome after fixation of lower limb fracture. Thus, we studied to determine the inter-observer and intra-observer reliability of Radiographic Union Score for Tibia (RUST) and Squat and Smile (S & S) test in clinical photograph. We further calculated the sensitivity and specificity of S & S test in predicting healing of lower limb fracture fixed by intramedullary interlocking nail considering RUST as the gold standard. METHODS: This was a retrospective study of prospectively collected data of solid Surgical Implant Generation Network (SIGN) intramedullary interlocking nailing from a single, university-based, high volume tertiary center where 56 consecutive adults with either tibial or femoral shaft fractures fixed with a SIGN nail within one year and not requiring any surgery till minimum of eighteen-month follow-up were included. Cases without either Anterior-Posterior (AP) view and/or Lateral (Lat.) view follow-up x-ray(s) or proper S & S clinical photograph (at least 1.5-year post fixation) were excluded. The x-rays (RUST criteria) and clinical photograph (S & S grading) were scored by two independent and blinded observers each and repeated after 1 month. RESULTS: The overall intra-observer reliability was from 0.773 to 0.825 and inter-observer reliability from 0.635 to 0.757 for RUST scoring which was from 0.687 to 0.785 and from 0.301 to 0.650 respectively for S & S scoring. The sensitivity and specificity of S & S in predicting fracture healing were up to 82.22% and 63.64% respectively. CONCLUSION: The S & S test is reliable to predict the healing of lower limb fracture fixed with an intramedullary nail. The test is more useful to determine healed fractures than to determine non-healed ones. (sensitivity being higher than specificity).

Functional outcome of patients of tibial fracture treated with solid nail (SIGN nail) versus conventional hollow nail - A randomized trial.

BACKGROUND: Trauma related disabilities disproportionately affects low and middle income countries due to lack of resources, skills and optimal implants. Despite adequate animal studies, biomechanical studies, cohort studies and comparison studies we are not aware of any randomized trial to compare the functional outcome of SIGN (Surgical Implant Generation Network, US) solid nailing with a hollow nailing for tibial shaft fracture. METHODS: Sixty patients (≥16 years) of closed and Gustilo grade I traumatic fractures of the leg were randomized into SIGN solid nailing or hollow nailing group. Cases with compromised soft tissue and grossly deformed medullary canal were excluded. Functional outcome and need for resurgery were the primary outcomes while the secondary outcomes were duration of surgery, intraoperative blood loss, overall pain (VAS), radiological union (RUST), surgery related complications (infection, malalignment, shortening, nonunion) and pain/range of motion (ROM) of knee/ankle. All SIGN surgery related data were entered and retrieved online from www.signsurgery.org. RESULT: The demographical parameters were symmetrically distributed between the groups (p > 0.05). 2 cases in SIGN nailing and 4 cases in hollow nailing needed open reduction. The functional outcome, as assessed by blinded physiotherapist using Johner and Wruh criteria, was excellent in 18 (62.06%), good in 6 (20.68%), fair in 3 (10.34%) and poor in 2 (6.89%) for SIGN nail whereas it was 16 (57.14%), 8 (28.57%), 3 (10.71%) and 1 (3.57%) respectively for hollow nail. There was 1 case of implant failure and 1 case of infection. Intraoperative blood loss (397 ± 94.47 ml versus 350 ± 75.43 ml, p = 0.037) and duration of surgery (94.8 ± 14.57 min versus 82.0 ± 12.36 min, p = 0.001) were significantly more in hollow nailing group. At final follow up, overall pain on weight bearing (VAS score) and radiological union (RUST score) were 2.1 and 11.7 for SIGN nailing while they were 2.7 and 11.3 respectively for hollow nailing.(p = 0.41 and 0.45 respectively) The malrotation (p = 1.000), shortening (p = 1.000), varus-valgus angulation (p = 0.511), AP angulation (p = 0.706), ROM ankle (p = 0.239) and ROM knee (p = 0.086) were similar. CONCLUSION: Solid SIGN nailing gives comparable functional outcome as conventional hollow nailing for tibia shaft fracture. For developing world with limited resources, SIGN nail is useful which is supplied freely and is designed to be used without image intensifier and fracture table.

Comparison of clinic-radiological outcome of cross pinning versus lateral pinning for displaced supracondylar fracture of humerus in children: A randomized controlled trial.

INTRODUCTION: Supracondylar fracture of humerus (SFH) is frequently encountered in the immature skeleton, [1] predominantly in the non-dominant extremity. AIM: This study compared the clinic-radiological outcome between cross pinning with lateral pinning for fixation of displaced supracondylar fracture of humerus in children. MATERIALS AND METHODS: All eligible patients were randomized into two groups, group I for lateral pinning and group II for cross pinning. Before passing medial pin in group II a stab incision was given to visualise the medial epicondyle. Patients were followed up on 3 weeks, 6 weeks and 3 months. Final outcome was measured in terms of clinic-radiological union, Baumann angle, loss of reduction, stability of fracture fixation, incidence of iatrogenic nerve injury and Flynn's score. Results: There were 37 patients in group I and 40 in group II. Both groups were comparable in terms of demographic details. At the final outcome there were no difference in between the groups in terms of all radiological and clinical outcome. Two patients of group I developed delay ulnar neuritis, which resolve completely in subsequent follow-up. CONCLUSION: Both techniques provide stable fixation, union and good functional outcome without iatrogenic ulnar nerve injury provided that small incision sufficient enough to identify the medial epicondyle is given with passing of medial pin.

Comparison of Functional and Radiological Outcomes of Olecranon Fractures Treated with Tension Band Wiring with Kirschner Wires to Transcortical Screw Fixation-A Randomised Controlled Study.

AIM: To compare the clinical and radiological outcomes of fixation of olecranon fractures by a transcortical screw with conventional tension band wiring (TBW) using a Kirschner wire (K-wire). MATERIALS AND METHODS: This is a non-blinded randomised controlled trial comprising two groups (n = 30 each) with Mayo type A olecranon fractures fixed with either TBW or transcortical cancellous screws (CCS). Outcomes included the Mayo elbow performance index (MEPI), time to union, range of motion (ROM), and rates of complication among these two groups. RESULTS: Most of the patients showed excellent scoring as per MEPI in both the groups at 6 weeks (90% in TBW group and 76.7% in CCS group) and were not significant (p = 0.719). Signs of the radiological union were noted in 80% of the cases at 6 weeks and complete at 6 months. Hardware-related complications (8.3% symptomatic hardware and 6.7% implant back-out), infection, and mean ROM were similar between the two groups (elbow flexion was 142.33 ± 24.67° in TBW group and 143.1 ± 10.19° in transcortical screw group, p = 0.246) at the end of the study. CONCLUSION: There were no statistically significant differences in the clinical-radiological outcomes and complications fixing the non-comminuted olecranon fractures with either transcortical screw or TBW. CLINICAL SIGNIFICANCE: Transcortical screw fixation is an acceptable alternative to TBW for non-comminuted olecranon fractures in terms of union and functional outcome. HOW TO CITE THIS ARTICLE: Sinha S, Maharjan R, Khanal GP, et al. Comparison of Functional and Radiological Outcomes of Olecranon Fractures Treated with Tension Band Wiring with Kirschner Wires to Transcortical Screw Fixation-A Randomised Controlled Study. Strategies Trauma Limb Reconstr 2020;15(3):131-137.

Giant pseudoaneurysm of subclavian artery after blunt chest trauma.

Subclavian artery (SCA) pseudoaneurysm after blunt chest trauma is rare and its delayed presentation months after the SCA injury is even rarer. Herein we discuss a case of SCA pseudoaneurysm in a 74-year-old man who presented to us 5 months after blunt chest trauma. He had been managed conservatively for the fracture of first rib and clavicle until presentation to our hospital. He had uncontrolled hypertension and a rapidly increasing large painful swelling (10 by 8 cm) in left clavicular region along with purplish discoloration of the overlying skin. The diagnosis was confirmed after computed tomography angiography and the patient was successfully treated with surgical evacuation of clots, primary repair of the rent in the SCA, and plating of clavicular fracture.