Both Bone Forearm Fracture with Complex DRUJ Dislocation: What Are the Odds?

Background Distal radioulnar joint (DRUJ) dislocation can occur as an isolated injury or in association with fracture radius (Galeazzi fracture-dislocation), Essex-Lopresti lesion or, rarely, with fracture of both radius and ulna (termed "Galeazzi type fracture"). DRUJ dislocations can be simple or complex. While simple DRUJ dislocation can be reduced by closed methods once the associated fractures are fixed anatomically, complex dislocation does not reduce by closed means. A complex DRUJ dislocation occurring in a both bone forearm fracture is an extremely unusual pattern of injury. Case Description We describe the clinical presentation, intraop findings, management, and follow-up of two such cases of both bone forearm fracture with complex DRUJ dislocation. In both the cases, the ulnar head was found to be buttonholed through extensor retinaculum between the extensor tendons. Open reduction had to be done via dorsal approach. Timely intervention allowed good results in both the patients. Literature Review Several authors have reported simple DRUJ dislocations in both bone forearm fractures; however, we could come across only three cases of complex DRUJ dislocation in a both bone forearm fracture. A summary of various series and reports on these injuries is presented. Case Relevance Through this case report, we want to highlight this unusual association and emphasize on sequence of fixation, so that this perilous injury pattern is not missed, and favorable outcomes could be obtained through appropriate and timely intervention.

Rare Combination of Distal Tibial Physeal Injury (Salter-Harris Type IV) with Sagittal Plane Fracture of Talus Body: A Case Report.

Introduction: Distal tibial physeal fractures and talus fractures are rare injuries in children and adolescents. Even rare is a combination of these two fractures. Axial compression is an accepted mechanism of injury in talus fractures with position of foot at the point of impact determining the extended patterns. A concomitant medial malleolus fracture suggests a supinated foot at the time of impact. Case Presentation: We report a case of a 13-year-old girl child who sustained a Type IV Salter-Harris injury of distal tibial physis along with a displaced vertical (sagittal) type fracture of the talus body. The uniqueness in our case was that the talar body fracture was a vertical type and that too displaced in the same line along with medial malleolus fragment. Open reduction of both the fractures was done through anteromedial approach followed by minimal fixation with K-wires. Good results were observed at 1 year following the surgery. Conclusion: Injuries of this nature are very uncommon and even more unusual in pediatric age group. This case report emphasizes the importance of having a high suspicion of uncommon fracture patterns in pediatric age group. Early and prompt diagnosis should be made using CT/MRI as a lot of these injuries may go unnoticed on plain radiographs.

Daily v. weekly oral vitamin D3 therapy for nutritional rickets in Indian children: a randomised controlled open-label trial.

The aim of the study was to compare the efficacy of daily v. weekly oral vitamin D3 therapy in radiological healing of nutritional rickets. Children 6 months to 12 years (n 132) diagnosed with nutritional rickets were randomised into three groups (n 44): group A - 2000 IU daily vitamin D3 for 12 weeks, B - 60 000 IU weekly for 3 weeks, C - 60 000 IU weekly for 6 weeks. Serum calcium, phosphorus, 25-hydroxyvitamin D (25(OH)D), parathyroid hormone and X-ray score were estimated at baseline and 12 weeks (endline). The proportion of children who achieved complete radiological healing at endline was compared between three groups by χ2 and delta change in laboratory parameters by ANOVA (parametric data) or Kruskal Wallis test (non-parametric data), respectively. Baseline 25(OH)D ≤ 20 ng/ml was seen in 119 (90·2 %), hyperparathyroidism in 90 (68·8 %) and hypocalcaemia in 96 (72·7 %). A total of 120/132 children completed the study. Complete radiological healing seen in 30 (75 %) in group A, 23 (60·5 %) in group B and 26 (61·9 %) in group C; P = 0·15, with comparable endline X-ray scores; P = 0·31. The median (interquartile range (IQR)) delta X-ray score (baseline-endline) was 7 (4,9), 5 (2·25, 6) and 6 (4,7) in groups A, B and C, respectively; P = 0·019. Median (IQR) 25(OH)D endline levels in groups A, B and C were 50·0 (26·5, 66·5), 42·1 (28·4, 54·4) and 53·5 (33·7, 71·2) ng/ml, respectively; P = 0·045. Radiological scores were comparable at endline among daily and weekly vitamin D groups with greater change from baseline in daily supplemented group.

Volar Dislocation of Trapezoid with Coronal Fracture - A Case Report and Review of Literature.

Volar dislocation of the trapezoid is a rare injury and is easily missed. It is more common to have a dorsal dislocation of trapezoid or multiple carpometacarpal joint dislocations. The rare nature of the injury also means that there is little guidance in literature regarding optimal treatment. We are reporting the presentation, management and a 3-year follow-up of this rare injury in a 19-year-old male. Level of Evidence: Level V (Therapeutic).

Osteoblastoma of the Distal Radius.

Osteoblastomas are rare, benign, bone-forming neoplasms that represent less than 1% of all bone tumors and occur mostly in people aged 10 to 30 years. In long bones, the metadiaphyseal region tends to be most commonly affected. However, to the best of our knowledge, only 11 cases have been reported to occur in the distal radius. We present the clinical, radiological, and histopathological findings of an osteoblastoma of the right distal radius in a 42-year-old woman for whom an open excisional biopsy with nidus removal comprised the treatment and produced a good outcome.

Z-Corrective Osteotomy in Malunited Extra-Articular Fractures of Distal Radius.

PURPOSE: We sought to assess clinical, radiological, and functional outcomes following treatment of extra-articular malunions of the distal radius using a multiplanar z-corrective osteotomy. METHODS: Fifteen patients with extra-articular distal radius malunions (13 dorsal and 2 volar) underwent z-corrective osteotomy and volar plate fixation without bone grafting. Correction and maintenance of each deformity was evaluated in terms of various radiographic indices (radial height; volar and radial tilt); osteotomy union; pain (visual analog scale); grip strength; range of motion; Disabilities of the Arm, Shoulder, and Hand scores; and Mayo wrist scores. RESULTS: The mean follow-up was 16.4 months. The mean radial height was corrected from -1.3 mm to 4.9 mm. The mean ulnar variance improved from 4.3 mm to -0.4 mm. The sagittal radial tilt and radial inclination were restored from a mean of -17.9° (dorsal) to 3.3° (volar) and from 12.0° to 17.2°, respectively. The Disabilities of the Arm, Shoulder, and Hand and Mayo wrist scores improved from means of 36 and 56 preoperatively to 24.8 and 73.3, respectively, at 6 months and further to 20.6 and 77.6, respectively, at the last follow-up. There were no nonunions or tendon-related problems. The mean pain score decreased from 4.1 preoperatively to 1.0 at 6 months and 0.8 at the last follow-up. The mean grip strength improved from 5.6 kg preoperatively to 15.6 kg at 6 months and 19.7 kg at the last follow-up. There was a statistically significant improvement in range of motion at the wrist. CONCLUSIONS: The z-osteotomy provides correction of deformity in all 3 planes, along with restoration of radial height. It also maintains a broad area of bone contact between the 2 osteotomized bone fragments, facilitating bony union and eliminating the need for bone grafting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Efficacy of Daily Supplementation of Milk Fortified With Vitamin D2 for Three Months in Healthy School Children: A Randomized Placebo Controlled Trial.

OBJECTIVE: To evaluate the efficacy of daily supplementation of 200 mL milk fortified with 240 IU of vitamin D2 (ergocalciferol). DESIGN: Double-blind randomized controlled trial. SETTINGS: School-based study in Delhi between October and December, 2019. PARTICIPANTS: 235 healthy children aged 10-14 years. INTERVENTION: Daily supplementation of 200 mL milk fortified with 240 IU of ergocalciferol in intervention group (n=119) and 200 mL of plain milk in control group (n =116) for 3 months. OUTCOME MEASURES: Change in serum 25 hydroxy vitamin D (25(OH)D), parathyroid hormone (PTH), bone formation and resorption markers, and urinary calcium creatinine ratio (U-Ca/CrR). RESULTS: The mean (SD) baseline serum 25(OH) D level in control and fortification groups was 11.9 (3.8) and 11.4 (3.6) ng/mL (P=0.23), respectively. The serum 25(OH)D levels did not increase post-intervention with the dose used for fortification, but were significantly higher in intervention group as compared to control group [10.8 (3.4) vs 6.7 (3.5) ng/mL; P<0.001]. A higher proportion of secondary hyperparathyroidism was observed post-intervention in control (39%) than in intervention group (13.3%); P<0.001. Serum carboxy-terminal telopeptide levels were similar in both groups but the serum procollagen type1 N-terminal propeptide levels were higher in the control than intervention group (P<0.007), following supplementation. CONCLUSIONS: Supplementation of milk fortified with approximately 240 IU vitamin D2 for three months did not achieve sufficient serum 25(OH)D levels in Indian children with vitamin D deficiency during winter.

Management of Orthopaedic Accidental Emergencies Amidst COVID-19 Pandemic: Our Experience in Preparing to Live with Corona.

Introduction: With increasing prevalence of coronavirus cases (including among health care providers), the current advice for orthopaedic surgeons is to favor non-operative management of most injuries and reduce face-to-face follow-up. We present our experience in managing the patients at Government-run non-COVID-19 trauma center in Delhi in an algorithmic form. Our standard operating protocols were mainly based on recommendations of Indian Orthopaedic Association and targeted to provide healthcare at a minimum risk to the treating team as well as other patients admitted to the hospital. Methodology: We describe the inflow, in-hospital management and outflow of patients at our facility during the lockdown period and in the following unlock period (from 23 March to 8 July 2020). Those patients who had absolute indications for surgery were offered surgery, while conservative treatment was more favored in those with relative indications. We also highlight the changes incorporated in OT settings as well as in rehabilitative and follow-up period. Results: Following the described protocol helped us maintain a balance between the safety of patients and our front line workers which was evident by very low COVID-19-positive rate in admitted patients (4.22%) and health care providers (16.67%) in the above-mentioned time period. Conclusions: We need to be prepared to cohabitate with this deadly Novel Coronavirus and adapt our surgical practices according to the need of the hour by minimizing surgical indications and strengthening the training in conservative principles.

Study of Anatomical Variations of 1,2 Intercompartmental Supraretinacular Artery-Based Vascularized Bone Graft in Cadavers.

BACKGROUND: The aim of this study is to describe the anatomy of the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA), including the location of the perforators, number of perforators, and proximal and distal origins of the artery. MATERIALS AND METHODS: The study was done by dissecting both wrists of 11 fresh-frozen cadavers. In each specimen, skin incision and dissections were done in the forearm by the Henry approach. Radial artery was identified and cannulated and dye was injected. The dye consisted of the mixture of polyvinyl chloride and acetone in the ratio of 1:4, to which red-colored resin was added. The artery of interest 1,2 ICSRA was dissected and its anatomical characteristics such as distal origin, proximal origin, number of perforators, and largest perforator were measured. RESULTS: Of the 22 wrists dissected, only in 19 wrists we were able to recognize the perforators. Average number of perforators seen was 3.05 (range 1-5). Average distance of the largest perforator from the radial styloid was 11.79 mm (range 6-19 mm). The average distance of the distal origin of 1,2 ICSRA from the radial styloid was 6.71 mm distal to radial styloid. It ranged from 16 mm distal to styloid process to 6 mm proximal to the styloid process. The average distance of proximal origin of 1,2 ICSRA from the radial styloid was 40.52 mm proximal to the radial styloid (range 25-66 mm). The maximum density of perforators of 2.84 was noticed to be in the region of 6-18 mm from the distal articular margin. CONCLUSION: The distal origin of 1,2 ICSRA in our study was much more distal in comparison to the western population. The detailed anatomy of the 1,2 ICSRA presented in this study may guide in planning and dissection to maximize the vascularity of a pedicled bone graft based on this vessel for the management of scaphoid nonunions and other carpal pathologies.

Functional evaluation of early tendon transfer for thumb opposition in median nerve palsy.

BACKGROUND: There is paucity of literature on early tendon transfer in surgical rehabilitation of hands with median nerve injuries. Since the single most important functional deficit in median nerve palsy is the loss of thumb opposition, we evaluated the results of early tendon transfer in restoration of thumb opposition. METHODS: This prospective study involved 10 cases of isolated median nerve paralysis (axonotmesis or neurotmesis) that underwent early tendon transfer for restoration of thumb opposition. A pre- and post-operative evaluation in terms of power and precision grip strength and range of opposition of thumb was done. Median nerve exploration was performed in 4 cases and was supplemented by a tendon transfer for thumb opposition. The extensor indicis proprius (EIP) opponensplasty was performed in nine out of ten cases. In one case where the patient had scarring over the EIP tendon, palmaris longus (PL) opponensplasty was performed. RESULTS: The median age at injury was 29 years (range; 8 years-57 years). Minimum period of follow-up was 6 months. Six patients who underwent EIP transfer had excellent opposition while 3 had good opposition. The patient, in whom PL opponensplasty was done, had an excellent opposition. The median time for return to work was 2.75 months.There was significant improvement in the power grip and all three types of precision grip at 6 months follow-up. The percentage deficit in the affected hand compared to the normal hand was significantly reduced. There was no case of tendon pull out in our study, nor did any of our patients have an extensor lag following EIP transfer. CONCLUSION: Early tendon transfer has a unique role in the management of median nerve palsy hand and we suggest this procedure should be considered in both high and low lesions.

Late extensor pollicis longus rupture following plate fixation in Galeazzi fracture dislocation.

Late rupture of extensor pollicis longus (EPL) tendon after Galeazzi fracture dislocation fixation is an unknown entity though it is a well-established complication following distal radius fractures. We report the case of a 55-year old male who presented with late EPL tendon rupture 4 months following internal fixation of Galeazzi fracture dislocation with a Locking Compression Plate (LCP). He was managed with extensor indicis proprius (EIP) transfer to restore thumb extension. At 4 years followup, functional result of the transfer was good. We identify possible pitfalls with this particular patient and discuss how to avoid them in future.

Pseudoaneurysm of the anterior tibial artery: A rare complication of proximal tibial steinman pin insertion.

An anterior tibial artery pseudoaneurysm is a rare and unexpected complication of Steinmann pin insertion. We describe the case of an 18-year-old boy, who sustained such an injury to the anterior tibial artery during this procedure. Diagnosis was confirmed on a magnetic resonance (MR) angiogram. Aneurysmal sac excision with lateral repair of the vessel wall was performed. Postoperatively, a good flow was documented on a follow-up MR angiogram. This case highlights a major and unexpected complication of a so-called minor procedure. Too posterior a pin placement in the proximal tibia should be avoided to prevent such injuries.

Trans-scaphoid transcapitate transhamate fracture of the wrist: case report.

We describe a new pattern of upper limb injury: a combination of fractures of both radius and ulna, with a rare type of trans-scaphoid transcapitate transhamate greater arc injury of the wrist and fractures of metacarpals, managed successfully.

Dupatta (scarf): a unique cause of cervical spine injury in females.

INTRODUCTION: Dupatta (scarf) is a part of the traditional dress for females in the Indian subcontinent. Working near machinery, riding a motorcycle or cyclerickshaw, can result in entanglement of dupatta in moving parts of machinery and subsequent cervical spine injury. It is seen most commonly in rural areas, with farmyard equipment. MATERIAL AND METHODS: A retrospective study was performed between January 2004 and January 2006, on all the patients presenting with cervical spine injury secondary to dupatta entanglement in machinery. They were assessed for mode, level of injury, neurological status, associated complications, radiological picture and clinical outcome. RESULTS: There were 12 such cases of cervical spine injury. The most common cause of injury was a threshing machine. All cases except one had quadriplegia (ASIA grade A) with bladder and bowel involvement. There was loss of consciousness in nine patients. Three patients expired. There was no neurological recovery in any patient. CONCLUSION: Dupatta is a unique cause of cervical spine injury in females, especially in rural areas. Easy methods of prevention may be helpful in preventing such injuries.