Treatment of acetabular fractures with quadrilateral plate injury - a comparison of two commonly used methods.

BACKGROUND: Acetabular fractures with quadrilateral plate (QLP) involvement have traditionally been treated by buttress plates applied through an Ilio-inguinal approach. Recently, many surgeons prefer the application of infra-pectineal plates through the modified Stoppa approach for this purpose. Whether one method can be preferred over the other is a matter of investigation. HYPOTHESIS: The research question was whether an infra pectineal plate applied through the modified Stoppa approach for acetabular fractures with QLP involvement would result in an equivalent or better outcome than a buttress plate applied through an ilioinguinal approach. PATIENTS AND METHODS: This was a retrospective study of patients with QLP fractures operated by either of the two methods and who had completed at least one year follow up. Demographic and surgical details and the radiological and clinical outcomes at the last follow-up visit were obtained from patient records. RESULTS: A total of 41 patients were treated with a buttress plate applied through an ilioinguinal approach (group A), and 49 patients were treated with an infra-pectineal plate by the modified Stoppa approach (group B). Duration of surgery and intra-operative blood loss was significantly less in group B patients. Radiological and clinical outcomes were better in group B patients than group A patients. Implant loosening was more frequent in group A patients. Injury to the obturator vessels were more common in group B patients. CONCLUSION: With a comparatively lesser surgical duration and blood loss, better clinical and radiological outcomes at least one year after the surgery, an infra-pectineal plate applied through the modified Stoppa approach can be considered the preferred treatment for most acetabular fractures with QLP involvement. LEVEL OF EVIDENCE: III.

Simultaneous asymmetrical bilateral hip dislocations - A report of three cases with different presentations and management.

BACKGROUND: Simultaneous traumatic dislocation of both the hips in an individual is an uncommon injury. It accounts for only 1-2% of all traumatic hip dislocations. Simultaneous traumatic dislocation of both the hips in opposite directions i.e., anterior dislocation of one hip and posterior of the other is even rarer. These asymmetric dislocations need prompt identification for appropriate management. While their management should proceed in a manner commensurate with the accepted management of isolated dislocations to avoid complications, it is the timely identification which is essential. STUDY DETAILS: Retrospectively the details of three patients with asymmetric bilateral hip dislocations were collected. The article describes the clinical presentation of each patient and the management offered to them. The follow up duration ranged from 15 months to 24 months. RESULTS: In the short term, the outcomes in terms of hip pain, movements at the hips and radiological parameters like absence of arthritic or avascular changes were found to be satisfactory in each patient. CONCLUSION: Early diagnosis and prompt reduction is the essential first step in the appropriate management of these patients to prevent the possible complications. The associated fractures must be managed as per the established principles of trauma care. Long term follow up is essential for identifying if complications like avascular necrosis and secondary osteoarthritis develop after this uncommon injury.

Concomitant ipsilateral acetabular and femoral fractures - an appraisal of outcomes and complications in 34 patients.

Concomitant ipsilateral femoral and acetabular fractures are complex injuries which result from high-velocity trauma. Surgical treatment is the accepted management of such injuries. The objectives of this study were to evaluate the outcomes and study the complications in patients treated for concomitant ipsilateral acetabular and femoral fractures (type 'B' floating hip injuries). This retrospective study was conducted at a tertiary care teaching hospital on patients operated for type B floating hip injuries, who had completed a minimum of one-year follow-up after the surgery and whose complete records were available. Those with floating hip injuries with pelvic fractures were excluded. All patients were operated on the femoral side first, followed by the acetabular side. 34 patients were included ; most of them were young males. A road traffic accident was the most common mode, with a dashboard injury being the most common mechanism of injury. No association between the type of acetabular and femoral fractures was found. The clinical (measured with Harris hip score) and radiological (Matta's method) outcomes at the latest follow-up were excellent or good in >60% cases and had a significant association with the quality of reduction on the post-operative radiographs. Complications were seen in 12 out of the 34 patients. Type B floating hips injuries can be managed well with acceptable short-term results by following a femur first strategy. However, patients must be informed of the possible complications and the probabilities of poorer outcomes when compared to isolated acetabular or femoral fractures.

Dislodgement of Telescopic Nail from the Epiphysis: A Case Report with an Analysis of Probable Mechanism.

Telescopic nails such as Fassier-Duval (FD) nails have become the standard treatment for stabilizing long bones and correcting deformities in osteogenesis imperfecta (OI). These nails do not require repeat surgery for their replacement when the bones outgrow them. However, they are not completely free from complications. The prohibitive costs of the original implants have led to design modifications being introduced in locally manufactured telescopic nails. While these low-cost devices work well in most cases, they can lead to complications resulting from their design flaws. We present here the complication observed in a locally manufactured telescopic nail with a design similar to the FD nail. The male component of the nail got dislodged from the distal tibial epiphysis, resulting in its proximal migration. We discuss the probable mechanism of this complication and propose possible design changes that can bring down the rates of such incidences.

Can patients with complex acetabular fractures be operated by combined anterior and posterior approaches in a single anesthetic sitting?

INTRODUCTION: While there is a consensus that complex acetabular fractures require anatomical reduction and stable fixation for their management, there is no agreement on the surgical approaches to be used for achieving that goal. Invariably two surgical approaches are needed for management of such fractures. Whether these approaches should be performed in different anesthetic sittings or in the same sitting, sequentially or simultaneously, is debatable. MATERIALS AND METHODS: 41 patients with complex acetabular fractures were operated in floppy lateral position by combined anterior and posterior approaches during the same anesthetic sitting and were followed for a minimum of one year. Patient related parameters as well as the details of their clinical outcome assessed by Merle D' Aubigne (MD'A) score, radiological outcome by Matta's method, Harris Hip score and complications encountered were recorded. Correlations of the clinical outcomes with other parameters were analyzed along with other statistical details. RESULTS: The mean surgical duration was 3.5 h. Anatomical reduction was achieved in 17 patients, congruent reduction in 19 and incongruent reduction in 5 patients. MD'A scores were excellent in 8 cases, good in 18 cases, fair in 5 cases and poor in 10 cases. Radiological outcome was excellent in 5, good in 16, fair in 13 and poor in 7 patients. Statistically significant correlation was noted between the MD'A score with reduction quality, cartilage damage and radiological outcome. Delay in surgery and choice of surgical approach had no correlation with the clinical outcome. CONCLUSION: Combined approaches in the same anesthetic sitting can be used for satisfactory management of complex acetabular fractures. These offer the ease of assessing reduction during surgery, can potentially save time and expenses without unduly affecting the clinical and radiological outcomes and without increasing the rate of complications when compared to approaches performed sequentially.

Can Three Screws and a Fibula be a Viable Treatment for Managing Neglected Femoral Neck Fracture in Trans-Femoral Amputees? - A Report of Two Cases.

Management of neglected femoral neck fracture in a trans-femoral amputee is difficult and challenging. There are limited options available for management of such a fracture. While arthroplasty (hemi or total) can be offered in older individuals, young patients should be offered an attempt of salvage of their native hips. Neglected femoral neck fracture in two young male patients who were trans-femoral amputees was managed by fixation through a Watson-Jones approach. Strategically placed Schanz screws and K-wires were used as joysticks for obtaining reduction and three 6.5mm cannulated screws were placed in a triangular fashion. An augmentation of the fixation was done with free fibula autograft placed in the center of the triangle. Union was achieved in both the cases. Patients were pain-free at the latest follow-up visit. Meticulous clinical and radiological evaluation is mandatory in multiply injured patients to avoid missing fractures. Fixation of neglected femoral neck fractures in young transfemoral amputees with three screws and a fibula can be considered a viable alternative to valgus osteotomy in cases where the stump is small for successful placement of the implant and where implant availability is an issue or the surgeon is comfortable in using screws and fibula for non-unions of femoral neck.

Evaluation of functional outcome of pilon fractures managed with limited internal fixation and external fixation: A prospective clinical study.

INTRODUCTION: The management of pilon fractures is controversial primarily due to the high rate of complications irrespective of the mode of treatment. Limited internal fixation with external fixation is associated with minimal soft tissue handling. This may reduce the chances of wound dehiscence and infection. This study was designed to evaluate the functional and clinical outcomes in patients treated with limited internal fixation combined with external fixation in pilon fractures. MATERIAL AND METHODS: This study was conducted as a prospective clinical study on 56 skeletally mature patients with closed fractures with poor skin condition, and with open grade 1 and grade 2 distal tibial intra-articular fractures. All patients were treated with combined limited internal fixation and ankle spanning external fixation. RESULTS: All fractures in this series united with an average time period of union of 18.3weeks (ranging from 13 weeks to 30 weeks). There was no non-union in any case. There was malunion in 4 cases, varus malunion (>5 degree) in 2 cases and recurvatum in another 2 cases). Excellent to good functional results were observed in 88% cases based on the modified Ovadia and Beals score. The mean ankle dorsiflexion and planter flexion movements were 10.2±5.3 degrees and 27.4±7.2 degrees respectively. infections occurred in 6 patients which included 4 pin tract infections and 2 superficial wound infection, all 6 healed after removal of pin tract and with oral antibiotics. CONCLUSION: The technique of combined external fixation with internal fixation is safe and effective management option for intra-articular distal tibial fractures.

Sternoclavicular joint tuberculosis: A series of 9 cases.

Tuberculosis (TB) is a chronic disease that may affect any part of the human body. Though the osteoarticular TB is not uncommonly seen, TB of the sternoclavicular joint (SC joint) is an infrequently reported condition. The very fact that many physicians have never seen a single case of SC joint TB in their entire career makes them never think of this condition in cases of chronic swellings of the medial end of clavicle. We are reporting here our experience with nine cases of SC joint TB that were treated by us. Delay in diagnosis in each of the case was a common feature, and they had been treated in line of inflammation elsewhere. Diagnosis was arrived at by clinical, radiological, and microscopic examinations. Six of the reported cases responded well to antitubercular chemotherapy, and in one of the cases, chemotherapy was combined with debridement, which was actually done during biopsy and primarily for tissue diagnosis; in another two cases, immunomodulation therapy for HIV was given along with antitubercular therapy. Tuberculous etiology should be considered for patients presenting with atypical sites of skeletal inflammation, and a high index of suspicion by the treating physician is necessary to make early diagnosis and appropriate treatment.

Cortical blindness along with motor aphasia: An unusual presentation of fat embolism syndrome.

Fat embolism syndrome presented with the classical triad of respiratory manifestations (95%), cerebral effects (60%) and Petechial rash (33%). Focal neurological symptoms in the form of combined bilateral cortical blindness and motor aphasia even prior to respiratory symptoms have been never reported in previous literature. We describe a case of these rare focal neurological symptoms secondary to the fat embolism syndrome in a young adult male following closed femur fracture.

Elbow dislocation with ipsilateral diaphyseal forearm bone fracture: A rare injury report with literature review.

Dislocation of the elbow along with shaft fractures of both bones of the ipsilateral forearm is a rare injury though elbow dislocation or fracture of the forearm bones may occur separately. Such injuries need a concentric reduction of the dislocation and an anatomical fixation of forearm bones for optimal functional outcomes. We report a case of elbow dislocation with fracture of the lateral condyle of the humerus along with fractures of shafts of the radius and ulna in a 44-year-old female. Closed reduction of the elbow and operative stabilization of all fractures were done with good clinical, radiological and functional outcomes in 2 years follow-up period. A significant degree of force is needed to produce a combined dislocation of a joint and fracture of bones around that joint and these complex injuries may be missed if the clinician is not aware of the possibility of such injuries. The fact that the previously reported cases had a posterolateral dislocation while our case had a posteromedial dislocation and a fracture of the lateral humeral condyle as well makes it unique in its presentation and worth reporting. We have also included an up to date literature review on this topic.

Intramedullary nailing versus proximal plating in the management of closed extra-articular proximal tibial fracture: a randomized controlled trial.

BACKGROUND: Extra-articular proximal tibial fractures account for 5-11 % of all tibial shaft fractures. In recent years, closed reduction and minimally invasive plating and multidirectional locked intramedullary nailing have both become widely used treatment modalities for proximal and distal tibial metaphyseal fractures. This study was performed to compare plating and nailing options in proximal tibia extra-articular fractures. MATERIALS AND METHODS: This randomized prospective clinical study was conducted on 58 skeletally mature patients with a closed extra-articular fracture of the proximal tibia treated with minimally invasive proximal tibial plating (PTP) or intramedullary nailing (IMN) by trained surgeons at a tertiary trauma center. RESULTS: Postoperative hospital stay (p = 0.035), time to full weight-bearing, and union time (p = 0.004) were significantly less in the IMN group than in the PTP group, but there was no clear advantage of either technique in terms of operative time (p = 0.082), infection rate (p = 0.738), range of motion of the knee (p = 0.462), or degrees of malunion and nonunion. CONCLUSION: Both implants have shown promising results in extra-articular proximal tibial fractures, and provide rigid fixation that prevents secondary fracture collapse. LEVEL OF EVIDENCE: Level 2, randomized controlled trial.

Bilateral central acetabular fracture dislocation in a young patient due to seizure activity: a case report and review of the literature.

Various musculoskeletal injuries are well known complications of epilepsy either because of direct trauma or because of unbalanced forceful muscle contraction. We report a case of non-traumatic bilateral central acetabular fracture dislocation due to seizure activity induced by neurocysticercosis of the brain, which was managed conservatively and obtained reasonable good outcome. This case highlights the importance of proper evaluation in young non-osteoporotic patients who have experienced an epileptic attack without any previous history. It is also imperative to mention that these patients should be thoroughly examined neurologically to find out the exact etiology and should be treated accordingly to prevent future seizure activity.

Multicentric spinal tuberculosis with sternoclavicular joint involvement: a rare presentation.

Background. Tuberculosis is a chronic disease which may have varied presentations. Though pulmonary tuberculosis is the commonest, extrapulmonary tuberculosis involving skeletal system is often seen. Individuals with poor nourishment and immunological status are especially susceptible for disseminated and multicentric tuberculosis. Case Report. We here present a case of tuberculosis involving multiple anatomical locations in an immune-competent patient which was diagnosed with radiological studies and confirmed with histological examination. Patient was put on multidrug antitubercular therapy and responded well to the treatment with improvement in clinical and radiological picture. Clinical Relevance. This report of a rare case makes us aware of the varied presentations which tuberculosis can present with. It should be kept as a differential diagnosis in patients with cough and fever but not responding to conventional treatment. This is even more important in countries with poor socioeconomic conditions.

Iatrogenic brachial artery injury during anterolateral plating of humeral shaft fracture.

There are several well defined indications for surgical management of humeral shaft fractures. Operative procedures on the humerus are associated with their own complications. Iatrogenic brachial artery injury as a complication of humeral shaft plating has not been reported previously. We report a case of a 48 years old female, who received operation at a district hospital and was referred to us when the surgeon could not palpate the pulse. CT angiogram showed that there was segmental non-opacification of the brachial artery. There was distal reformation and the thrombosis was decided to be managed conservatively. We believe that the arterial injury was a result of improper surgical technique and the segmental block might be due to improper use of plate holding forceps. This case report makes us aware of a rare complication of operative management of humeral shaft fractures and that basic principles of surgery must be always followed to prevent such injuries.