Finite Element Analysis of Postoperative Stability of Transverse Scaphoid Waist Fracture.

Background and Purpose: Scaphoid waist fractures are often stabilised with compression screws, Kirschner wires (K-wires), or a combination of both. While clinical and bio-mechanical studies evaluating their utility are available, the ideal configuration of implant that would provide adequate stability to permit early use of the hand is debatable. We examined configurations of a single screw, one screw along with a K-wire, and two K-wires used for a transverse scaphoid waist fracture fixation aiming to assess the stability provided by each in the immediate postoperative period. Methods: Computer-aided design (CAD) models of the scaphoid, K-wire, and headless compression screw were created. A transverse fracture was created at the scaphoid waist, and the CAD models of the screw and K-wire were used to fix the fracture in different configurations in a distal to proximal direction. Finite Element Analysis (FEA) was used to examine the strength of configurations when they were subjected to compression and distraction forces. The total maximum deformation (TDef) and factor of safety (FoS) for each configuration were calculated and used as indirect indicators of postoperative stability. Results: When a single screw was used, the configurations with the screw directed posteriorly from either centre or anterior had the best combined TDef and FoS values. For one screw and one K-wire, the configuration with screw and K-wire parallel to each other with the screw located along the long axis in the AP projection and anterior to the K-wire in the lateral projection had the best combined TDef and FoS values. When using two K-wires, configurations with the two wires diverging proximally on the lateral projection had the best combined TDef and FoS values. Conclusions: When fixing a transverse scaphoid waist fracture with a single screw, the screw directed posteriorly from either the centre or anterior aspect of the distal pole has the best stability, a parallel configuration has the best stability when fixing it using a screw and a K-wire, and divergent configuration has the best stability when fixing it with two K-wires only.

Sports-Related Musculoskeletal Injuries in Medical Students.

Background: Little attention is paid to the problem of sports-related injuries in amateur or nonathletes or recreational student athletes. We investigated the prevalence of sports-related musculoskeletal (MSK) injuries in medical students and attempted to identify the risk factors for these injuries. Methods: We conducted a cross-sectional questionnaire-based observational study on medical students of a tertiary care teaching hospital in central India. A total of 500 medical students were approached; the questionnaire consisted of details, such as age, gender, height, weight, predominant sport played or the sport during which they sustained an injury, estimated time spent playing every week, if they had undergone any formal training for the sport, any preexisting MSK condition, details of the injury and the treatment taken, if any, after joining medical school, and duration from getting injured to return to studies and sports. The odds ratio (OR) and logistic regression were calculated for multiple parameters. Statistical significance was set at P ≤ 0.05. Results: Seventy-four of the 402 students who responded reported sustaining a sports-related injury; 33 and 41 students reported injury while playing contact and noncontact sports, respectively. Of these, 58 students reported that they had received formal training in sports. Football, volleyball, cricket, and kabaddi were the sports during which most injuries occurred. The injury rate was 3.7 per 1000 playing or practice hours. Conclusions: Almost one-fifth of the students reported sustaining a sports-related MSK injury after joining medical school. The risk factors identified for these injuries were male gender, participation in team sports, participation in noncontact sports, and lack of adequate preparation or practice.

The use of precontoured plates for midshaft clavicle fractures is not always the best course of treatment.

Plate fixation has become the preferred approach for treating displaced midshaft clavicle fractures. However, plate fixation of the clavicle presents several unique challenges, including its complex bony architecture and its immediate subcutaneous location. In many cases, we have observed that precontoured implants do not conform to the clavicular anatomy, and many patients complain of postoperative implant-related discomfort. A total of 111 clavicles, both left and right sides, were examined to match two commonly used designs of anatomical pre-contoured superior anterior clavicle plates, with and without lateral extension. The anteroposterior (AP) plane congruence of the plate to the underlying bone, the vertical gap between the bone and plate, and the length of the plate that was off the bone either anteriorly and/or posteriorly at both ends of the clavicle were measured. The scoring system was used to determine the fit of the implant on the clavicle as anatomic, good, or poor. We found that the maximum superior bow of the clavicle was lateral to the midline by 30.75 mm and 30.5 mm on the right and left sides, respectively. The magnitude of the bow was 4.28 mm and 4.46 mm on the right and left sides, respectively. We also found that the plate was a poor fit in 75.86% of cases on the left side and 73.5% of cases on the right side. Manipulating the plates during surgery was very difficult in the AP plane.

Mechanism of scaphoid waist fracture: finite element analysis.

The mechanism of scaphoid waist fracture is not completely understood. We used finite element analysis to study the formation of scaphoid waist fractures. Clinical computed tomography scans of 12 wrists were used to create models for finite element analysis. The points of application of load were at different sites along the scaphotrapeziotrapezoid joint distally, and the scaphoid fossa plus the area underlying the radioscaphocapitate ligament was regarded as the fixed proximal support. A fracture was produced at the scaphoid waist in all cases. The location of failure of bone at its anterior or dorsal cortex, either in tension or in compression, was determined by the site of application of the load. The anterior cortex failed in compression when the point of impact was located along the trapezium facet or the entire distal pole, whereas it failed in tension when the point of impact was along the trapezoid facet.

Intraoperative Surgical Wound Contamination May Not Lead to Surgical-Site Infection in Patients Undergoing Clean Orthopaedic Procedures.

Objectives Surgical-site infections (SSIs) can complicate virtually any surgical procedure. While SSI can result from numerous causes, contamination of the surgical field can also contribute to it. Intraoperative bacterial contamination during clean orthopaedic procedures can be detected using perioperative cultures. We hypothesized that perioperative cultures could be used to predict possibility of development of SSI in patients undergoing clean orthopaedic surgeries. Materials and Methods We conducted a prospective cohort study at a tertiary care hospital over a 2-year period. Intraoperative surgical wound lavage fluid and closed suction drain tip obtained in the postoperative period were sent for aerobic culture. All patients were followed up to look for the development of SSI for a period of at least 30 days for those undergoing nonimplant surgery, and 90 days for those with implant surgery. Statistical Analysis Means with standard deviation of the continuous data were calculated. Fisher's exact test and chi-square test were used for the analysis of the categorical variables. Relative risk and odds ratio were calculated to evaluate the association of the parameters under study with SSI. Results A total of 384 patients satisfying the inclusion and exclusion criteria were included. Perioperative cultures detected surgical wound contamination in 39 patients (10.1%). Forty-five patients (11.7%) developed SSI during the follow-up period. Skin commensals constituted 59% of perioperative contaminants and accounted for 20% of the SSIs. The relative risk of developing SSI with perioperative contamination was 0.41 (95% confidence interval: 0.09-1.63). Conclusion Intraoperative surgical-site contaminants could be detected using perioperative cultures. However, these contaminants did not lead to SSI. Timely treatment of perioperative contamination with appropriate antibiotics and local wound care probably helped in the reduction of SSI.

Do Patients of Chronic Low Back Pain have Psychological Comorbidities?

Background Individuals with chronic pain have been reported to have an increased incidence of psychological morbidities. We aimed to examine the prevalence of anxiety, depression, disability, alexithymia, insomnia, and sleep quality in patients having chronic low back pain (LBP) and study their association with the severity of pain and any disability arising from it. Methods This descriptive study was conducted in a tertiary care teaching hospital setting. Fifty adults with nonspecific LBP of > 6-week duration were included. Study instruments employed were patient health questionnaire-9 for depression, generalized anxiety disorder-7 for anxiety, visual analogue scale (VAS) score for pain, Oswestry disability index (ODI) to assess disability, Toronto alexithymia scale-20 for alexithymia, and insomnia severity index and Pittsburgh sleep quality index for insomnia. Descriptive results were expressed as numbers, means, and proportions. Association study between variables was performed using Fisher's exact test. Results Mean ODI score was 31.54% (95% CI, 26.09-36.99); mean VAS score was 6.08 (95% CI, 5.35-6.81). Insomnia of varying severity was found in 29 patients. Sleep quality was reported as good by 23 patients. One patient had alexithymia. There was significant association between the level of disability and depression, anxiety, insomnia, and sleep quality. The severity of pain had significant association with insomnia but the association with anxiety, depression, alexithymia, and sleep quality was not significant. Conclusions Patients with chronic LBP do have associated psychological comorbidities of varying extent. A "patient-centric" approach when treating patients with chronic LBP is necessary, so that appropriate evaluation of psychiatric and psychosocial comorbidities, sleep problems, and quality of life is done as part of their routine management to ensure the desired outcomes.

Current Surgical Antibiotic Prophylaxis Practices: A Survey of Orthopaedic Surgeons in India.

BACKGROUND: Surgical antibiotic prophylaxis (SAP) has become the standard of care in orthopaedic surgery. Inappropriate usage of antibiotics (dosage, strength, and/or administration time and duration) can inadvertently result in superadded infections and antimicrobial resistance. The purpose of this study was to document and analyse the prescription patterns for SAP, and to investigate the factors associated with divergence from standard guidelines. METHODS: We conducted an online cross-sectional questionnaire-based study to collect information about the SAP practices of the members of the Indian Orthopaedic Association (IOA) using Google forms. A link to the questionnaire was sent by e-mails. RESULTS: The overall response rate was 5.73%. While 97.3% respondents practised SAP routinely, the practice was not aligned with standard guidelines' recommendations. There was heterogeneity in the use of SAP in terms of choice of antibiotic(s), number of co-prescribed drugs, single- versus multiple-dose regimens, and the duration of therapy. The prescription practice patterns showed that orthopaedic surgeons almost always used broad-spectrum antibiotics for long durations, regardless of the type of surgery. CONCLUSION: While Orthopaedic surgeons in India are practicing SAP, the pattern of antibiotic usage is heterogeneous. Variations were noted in the choice of antibiotics for different types of surgeries, time of administration, duration of usage in the postoperative period as well as co-prescriptions. This study highlights the urgent need for a comprehensive, rational, and robust national SAP policy for orthopaedic surgeries.

Neck pain among undergraduate medical students in a premier institute of central India: A cross-sectional study of prevalence and associated factors.

CONTEXT: Competitive exams conducted for undergraduate and postgraduate medical courses in India are tough. The undergraduate course is additionally taxing to the students' health. Lack of physical activity, the stress of studies, and universal adoption of different gadgets make the undergraduate medical students prone to develop musculoskeletal pain-related issues. AIMS: This study aimed to evaluate the prevalence of neck pain and the associated factors including gadget use among undergraduate medical students of a premier medical college in central India. SETTINGS AND DESIGN: All undergraduate medical students including the interns of our institute were enrolled for this cross-sectional study. METHODS AND MATERIALS: A self-explanatory internet-based questionnaire prepared using Kobo Toolbox was circulated via WhatsApp and email by the class representative of each batch of students. The responses obtained were analyzed using Statistical Package for the Social Sciences (SPSS). STATISTICAL ANALYSIS USED: Proportions and means were calculated. Chi-square test and univariable logistic regression analysis were used. RESULTS: Three hundred thirty-one valid responses out of 423 responses were analyzed. In total, 58.3% of 331 students suffered from neck pain within the last one year. Students in the 3rd and 4th year had 2.9 times higher odds of current neck pain in comparison to 1st-year students. History of neck pain before joining the course was associated with a higher risk of having current neck pain. Self-perceived aggravation of pain from gadget use had significantly higher odds of contributing to the current episode of neck pain. CONCLUSIONS: Neck pain is not uncommon among undergraduate medical students. History of previous neck pain including that during schooling makes a student prone for the current episode of pain. Academic stress, smartphone and laptop use tend to aggravate the pain in those who have neck pain.

Glomus tumor of the fingertips: A frequently missed diagnosis.

BACKGROUND: Glomus tumors present as painful lesions, most commonly in the fingertips. These can present to outpatient clinics of multiple specialties. MATERIALS AND METHODS: Retrospective review was performed of 37 patients diagnosed as having glomus tumor in the thumb or fingertips over a 10-year period. The data collected included demographics, presenting symptoms, duration, previous treatment history, physical examination, treatment, and recurrence. The data were presented by means of descriptive statistics. RESULTS: The mean duration of symptoms before presentation was 3.8 years (range 2 to 12 years). The mean age at presentation was 38 years (range 16 to 62 years), and female to male ratio was 21:16. Twenty-two patients had left-hand involvement; thumb 8, index finger 5, middle finger 5, ring finger 14, and little finger 5. Clinical and radiological assessments were made preoperatively. At presentation, 18 cases had nail changes, whereas 19 had no obvious nail changes - out of these, 4 had pulp involvement. The lesion involved the subungual region in 33 cases. The mean size of the lesion was 3.8 mm (range 2 to 10 mm). Thirty-six patients were found to have histopathologically proven glomus tumors, whereas in one no specific lesion was found on histopathological examination; this patient returned with recurrence of symptoms at 2-month follow-up. There was no other patient experienced recurrence of symptoms. CONCLUSION: Early diagnosis of glomus tumors is important to avoid lengthy treatment delays, chronic pain, disuse syndromes, and psychiatric misdiagnoses.

Musculoskeletal disorders and associated risk factors in coaching students: A cross-sectional study.

BACKGROUND: Coaching institutes attract students aspiring for admission to professional courses and jobs. Physical stress during coaching includes poor study posture and sitting on chairs improperly in overcrowded classes for prolonged periods. Many students attending the coaching institutes report to outpatient clinics of multiple specialties with musculoskeletal disorders (MSD). MATERIALS AND METHODS: We carried out a cross-sectional study of 500 coaching students. We ascertained the 12-month MSD (period prevalence) and last 7-day MSD (point prevalence) using the Nordic Musculoskeletal Questionnaire. The duration of attending classes, hours of daily study, and duration of sitting continuously at a stretch were also enquired. RESULTS: A total of 488 responses were retrieved. Males and females accounted for 63.9% and 36.1%, respectively. The respondents' mean age was 18.6 ± 1.06 years; mean body mass index was 21.4; mean duration of attending classes was 15.6 ± 7.66 months; mean hours of daily study were 4.78 ± 1.71 hours; mean duration of sitting continuously at a stretch was 2.2 hours. The overall prevalence of MSD was 87.1%. The mean frequency of MSD per participant was 2.6. Most participants reported pain in the neck region and lower back (43%), followed by ankle/foot (36%), followed by upper back (32%), followed by shoulder (28%); knee, elbow, and wrist/hand were lesser than 20%, while hip/thigh pain was the least common symptom (8%). CONCLUSION: This study serves to sensitize the medical community to this largely under-reported problem in young individuals who are in the phase of life preparing for their future career while inadvertently risking their long-term health in the process.

Surgical Implications of Innervation Pattern of the Triceps Muscle: A Cadaveric Study.

The innervation pattern of triceps is complex and not fully comprehended. Anomalous innervations of triceps have been described by various authors. We have attempted to delineate the nerve supply of the triceps and documented the anomalous innervations of its different heads. The brachial plexus and its major branches (in the region of the axilla and arm) and triceps were dissected in 36 embalmed cadaver upper limbs. Long head received one branch from radial nerve in 31 (86%) specimens. Four (11%) specimens received two branches including one that had dual innervation from the radial and axillary nerves, and one (3%) specimen had exclusive innervation from a branch of the axillary nerve. Medial head received two branches arising from the radial nerve in 34 (94%) specimens. One (3%) specimen received three branches from the radial nerve whereas one (3%) had dual supply from the radial and ulnar nerves. Lateral head received multiple branches exclusively from the radial nerve, ranging from 2 to 5, in all (100%) specimens. Knowledge of the variations in innervation of the triceps would not only help the surgeon to avoid inadvertent injury to any of the nerve branches but also offers new options for nerve and free functional muscle transfers.

Predebridement wound culture in open fractures does not predict postoperative wound infection: A pilot study.

BACKGROUND: There is confusion in the current literature regarding the value of obtaining predebridement wound cultures in the management of open fractures with several studies reporting contrasting results. We undertook a pilot study to determine the initial bacterial flora of open fractures in our environment and determine the correlation between subsequent wound infection if any, and the initial bacterial flora. MATERIALS AND METHODS: Initial/predebridement wound swabs were obtained for 32 patients with open fractures. Patients underwent a debridement of the open wound and preliminary stabilization of fracture in the operating room within 24 h. Postdebridement wound cultures were obtained at 48 h and repeated subsequently, if indicated, during the follow-up period. The antibiotic therapy was modified based on the culture reports. RESULTS: Initial wound swab culture showed bacterial contamination in 18 patients (56%); 14 patients (44%) developed an infection in the immediate postoperative period or during follow-up. Age, gender, co-morbid medical condition, delay in presentation, and grade of open fracture were not found to be predictors of postoperative infection. No patient had an infection with the same organism, which was present in the initial culture. CONCLUSION: The findings of this study suggest that the initial flora are not the infecting organisms in the open fracture wounds, and predebridement wound cultures have no value in predicting postdebridement wound infection.

Open Fracture of the Forearm Bones due to Horse Bite.

INTRODUCTION: Fractures have been described mainly following falling accidents in horse-related injuries. Horse bites are uncommon accidents. We present a case of open fracture of the forearm due to horse bite. CASE REPORT: A 35-year-old male farm-worker presented to the emergency room with alleged history of horse bite to the right forearm about 2 hours prior to presentation while feeding the horse. There was deformity of the forearm with multiple puncture wounds, deep abrasions and small lacerations on the distal-third of the forearm. Copious irrigation with normal saline was done and he was administered anti-tetanus and postexposure rabies prophylaxis. Prophylactic antibiotic therapy was commenced. Radiographs revealed fracture of radius and ulna in the mid-shaft region. He underwent emergency wound debridement, and the ulna was stabilised with an intra-medullary square nail. Seventy-two hours later, he underwent re-debridement and conversion osteosynthesis. He had an uneventful recovery and at three-month follow-up, the fractures had healed radiographically in anatomic alignment. At two-year follow-up, he is doing well, is pain free and has a normal range of motion compared to the contralateral side. CONCLUSION: Horse bites behave as compound fractures however rabies prophylaxis will be needed and careful observation is needed. Early radical debridement, preliminary skeletal stabilisation, re-debridement and conversion osteosynthesis to plate, and antibiotic prophylaxis were the key to the successful management of our patient.