Skeletal injuries following unintentional fall from height.

BACKGROUND: Falls from height are one of the leading causes of death from unintentional injuries. METHODS: We reviewed cases of musculoskeletal trauma due to fall from height, who were treated at a tertiary care hospital in Delhi over a one-year period, with respect to demographic data, site of accident, circumstances and location of fall, approximate height of fall, season, landing surface, details of skeletal and other injuries, and duration of hospital stay. RESULTS: Of 1451 admissions during the period, 138 were injured due to fall from height. Thirty-seven cases were excluded. The mean age of the patients was 31.3 years. The mean height of the fall was 4.54 meters (range: 0.6-12 meters). A total of 126 fractures occurred in 101 patients: 55 in the upper limbs, 50 in the lower limbs, 14 in the spine, and 7 in the pelvis. Associated injuries included head (n = 17), chest (n = 9) and abdominal injuries (n = 6). Ninety patients (89%) needed surgical intervention for fracture management. Eleven (10.8%) of these 101 injuries were fatal. CONCLUSION: Fall from height is a potentially preventable cause of skeletal injuries, as most of the injuries sustained due to fall from height were domestic injuries and occurred due to poor dwelling units.

Rubber band syndrome--high accuracy of clinical diagnosis.

BACKGROUND: Rubber band syndrome is a rare condition seen in younger children in communities where rubber bands are worn around the wrist for decorative purposes. When the band is worn for a long duration, it burrows through the skin and soft tissues resulting in distal edema, loss of function, and even damage to the neurovascular structures. Recognition of this syndrome at the earliest can prevent catastrophic events. METHODS: We report 3 cases of rubber band syndrome. Three children presented with a discharging sinus at the wrist. There was a linear circumferential scar at the wrist in all cases. Plain radiographs showed a circumferential constriction in the soft tissue shadow in all the cases. There was a history of a band tied around the wrist, which had been forgotten by the parents and eventually became embedded in the soft tissues of the wrist. RESULTS: Surgical removal of the buried rubber band was successful in all the cases. Postoperative follow-up over a mean period of 13 months have shown a surprisingly good outcome of hand function in all our patients. CONCLUSIONS: The cardinal features of a linear constricting scar around the wrist in the presence of a discharging sinus should always alert the clinician to the possibility of a forgotten band around the wrist, which might have burrowed into the soft tissues over a period of time. A radiograph of the affected wrist shows a soft tissue constriction at the wrist. A high index of clinical suspicion and the uniformity of symptoms and clinico-radiologic signs enabled us to make a clinical diagnosis of a constriction band (rubber band syndrome), which was proved after a surgical exploration. STUDY DESIGN: Case series. Level of Evidence--Level IV.

Fractures of capitellum: a review of 14 cases treated by open reduction and internal fixation with Herbert screws.

Fourteen patients with displaced fractures of the humeral capitellum were treated by open reduction and internal fixation of the capitellar fragments with Herbert screws. As per Bryan and Morrey classification, there were seven type I fractures, one type II fracture, three type III fractures, and three non-unions. Patient outcomes were evaluated using the Mayo elbow performance score. The follow-up period ranged from three to seven years (mean 4.8 years). All patients had a stable, pain-free elbow with good range of motion at follow-up. There was no evidence of avascular necrosis or degenerative change.

Autogenous non-vascularized fibula for treatment of giant cell tumor of distal end radius.

INTRODUCTION: Giant cell tumor of distal end of radius is treated by wide resection and intralesional procedures with former having better results. The various modalities for the defect created are vascularized/non-vascularized bone graft, osteoarticular allografts and custom-made prosthesis. We report outcome of wide resection and non-vascularized fibular grafting in biopsy-proven giant cell tumors. PATIENTS AND METHODS: Nine patients with mean age of 40 years with Campanacci grade II giant cell tumor of distal radius were managed with radical excision of the tumor and reconstruction with ipsilateral free fibular graft. RESULTS: Mean follow-up time was 56 months. One patient developed recurrence and was treated by amputation. All other patients showed a good union at fibular graft-radius junction. In wrist, average range of motion achieved at last follow-up was 40° of dorsiflexion, 30° of palmar flexion, 45° each of supination and pronation. Major complications encountered included graft fracture (2), wrist subluxation (2), tourniquet palsy (1), aseptic graft resorption (1) and tumor recurrence (1). CONCLUSION: Reconstruction after wide excision by non-vascularized fibular graft is a viable alternative for giant cell tumors of the lower end of radius though it is a challenging procedure and may be accompanied by major complications.

Management of massive posttraumatic bone defects in the lower limb with the Ilizarov technique.

Massive bone defects have been treated by various methods with variable success rates. The Ilizarov technique has been advocated as a preferred method for treatment of large segmental defects. Twenty five patients with massive post traumatic bone defects of the lower limb (22 tibiae, 3 femurs) were treated using Ilizarov's technique. After radiological evaluation, the patients were subjected to bone transport. Bifocal osteosynthesis was performed in all except those needing >12 cm of bone transport. Distraction was started between day 4 and 7 at the rate of 1 mm per day in four increments. All were males with a mean gap of 8.9 cm (range: 5-17 cm), mean age of 28.24 years (16-40) and having undergone a mean of 2.6 previous surgeries. Mean time in Ilizarov frame was 8.8 months and external fixator index was 0.98 months. Mean duration of follow-up after frame removal was 23.5 months. Union was achieved in 23 (92%) cases. Bone grafting was required in 9 (36%) According to ASAMI criteria, bone results were excellent in 13, good in 1, and poor in 11 patients. Functional results were excellent in 6 patients, good in 9, fair in 4, and poor in 6 patients. A total of 72 complications occurred (2.88 complications per patient). Union was achieved in all except two patients. The Ilizarov external fixator offers a limb salvage solution even in large bone defects but the surgeon should set realistic goals both for himself and his patients while offering this method of treatment.

Bone mineral density in young Indian adults with traumatic proximal femoral fractures. A case control study.

There is scarcity of data on osteoporosis in India for the age group of 20-40 years when peak bone mass is achieved. This study aimed to assess bone mineral density (BMD) in patients in this age group with traumatic proximal femoral fractures, and to compare it with age matched controls. Thirty patients aged 20 to 40 years with traumatic proximal femoral fractures and 30 healthy volunteers within the same age group were included in the study. Radiographs of the pelvis were taken to determine the Singh index, and DEXA scan of the unaffected hip was done to assess BMD. Fracture cases were compared with controls for significant difference in BMD. The male to female ratio of the study was 2:1. Based on Singh's index, 60% of fracture cases and 20% of controls were osteoporotic. T scores by DEXA revealed that 24 patients with fracture and 22 controls had osteopenia or osteoporosis. There was a significant difference in the Singh index between the two groups and no significant difference in BMD assessed by DEXA scan. No agreement was found between BMD determined by DEXA and Singh's index. The study points that our population fails to attain an adequate peak bone mass. It also questions the applicability of Western data to Indian population. The findings also indicate that Singh's Index cannot substitute DEXA for diagnosis of osteoporosis.

Wooden foreign body in the forearm--presentation after eight years.

We report herein a case in which symptoms appeared eight years after the apparent trauma, which had been forgotten. Surgery yielded a wooden foreign body in the forearm. A 10-year-old boy presented with a six-week history of pain followed by swelling in his left forearm occurring after a trivial blunt trauma, with occasional bouts of fever. There was an oval swelling (7 cm x 3 cm) on the posterolateral aspect of the upper third of the left forearm. Tenderness, increased local temperature and elicitable fluctuation, with no scars or wounds (signs of trauma), were noted. Radiographs of the forearm revealed a soft tissue swelling but no fracture, periosteal reaction or other bony lesion. Aspiration of the swelling yielded purulent material (gram stain negative). The abscess was drained and exploration of the cavity revealed a 14 mm long slender wooden foreign body embedded in granulation tissue. On retrospective enquiry, the family reported that the child had sustained a penetrative injury eight years before after falling on a broomstick. Presence of a foreign body must be kept in mind while investigating a suspicious swelling on the extremities. A thorough history and careful imaging are the keys to diagnosis.

Gender-specific high-flexion knee prosthesis in Indian women: a prospective randomised study.

PURPOSE: To compare outcomes in Indian women who underwent total knee arthroplasty (TKA) using the standard Legacy Posterior Stabilised (LPS) versus the gender-specific LPS high-flexion knee prosthesis. METHODS: 100 women (200 knees) aged 60 to 80 years with an arc of flexion of ≥90º underwent simultaneous sequential TKA for primary osteoarthritis of both knees. They were randomised to receive the standard NexGen LPS prosthesis (n=50) or the gender-specific NexGen LPS High-Flex prosthesis (n=50). Both knees in each patient received the same prosthesis. The resected bone from the posterior femoral condyle was 2 mm greater when the gender-specific prosthesis was used. Patients were followed up at 3, 6, 12, and 24 months. Range of motion, Knee Society score, and Hospital for Special Surgery score were evaluated pre- and post-operatively by a single assessor. RESULTS: The mean follow-up duration was 2.1 (range, 1.6-2.5) years. Respectively for the standard and gender-specific groups, the mean range of motion was 111º and 112º preoperatively and 120º and 123º at the latest follow-up. The gender-specific group gained approximately 3º more in range of motion (p=0.007). The Knee Society score and the Hospital for Special Surgery score between groups were not significantly different pre- and post-operatively. CONCLUSION: The perceived advantage of a gender-specific prosthesis over a standard prosthesis did not translate into better clinical and functional outcome scores.

Minimally invasive plate osteosynthesis using a locking compression plate for diaphyseal humeral fractures.

PURPOSE: To assess outcomes of minimally invasive plate osteosynthesis (MIPO) using a locking compression plate (LCP) for 42 humeral shaft fractures. METHODS. 28 men and 14 women aged 18 to 68 (mean, 34; median, 29) years underwent closed reduction and MIPO using a LCP for type 12-A (n=26) and type 12-B (n=16) humeral shaft fractures. Eight of the patients were aged ≥ 50 years. Patients were followed up monthly until radiological union in at least 3 of the 4 cortices. Functional assessment was based on the Disabilities of Arm, Shoulder and Hand (DASH) score. RESULTS: The mean follow-up period was 25 (range, 14-35) months. The mean DASH score was 35.1 at month 3 and improved to 8.9 at month 6 and 5.2 at year 1. The mean angulation was 4º in the coronal plane and 7º in the sagittal plane. All fractures united after a mean of 14 weeks. Two patients with transverse fractures had delayed union and received bone marrow injections at 12 or 13 weeks; they achieved union at week 20. One patient developed a radial nerve palsy immediately after surgery and underwent surgical exploration through the anterolateral approach. The plate was re-applied, and the nerve recovered in 48 hours with full power in all the muscle groups. CONCLUSION: MIPO with LCP is a safe and effective technique for fixation of diaphyseal humeral fractures, and results in faster bone union, better cosmesis, and minimal complications.

Normal range of motion of hip and ankle in Indian population.

OBJECTIVE: Most studies that determine the range of motion of joints of the lower limbs study the Western population. The Asian population differs significantly, as daily activities demand different sitting positions. Our study aimed to establish the normal values of hip and ankle range of motion in various age groups in the Indian population and the effect of various functional positions of the hip on range of motion. METHODS: Three hundred and twenty-six Indian subjects, between the ages of 1 month to 75 years, were randomly selected for measurement of the range of motion of the hip and ankle joint. Exclusion criteria included history of injury or disease related to the lower extremities. Changes with age in the arc of joint motion were studied. The influence of various functional positions of the lower limb on the range of motion of the hip and the effect of weight-bearing on the ankle joint range of motion were also analyzed. RESULTS: Hip range of motion differed in various positions. Hip rotations were significantly greater when measured with the knee in flexion in both the sitting and prone positions than in the supine position. The arc of hip rotation was highest in the prone position. A significant increase in the arc of ankle dorsiflexion was found in a weight-bearing (squatting) position. Age related reduction in movement was found mainly in the rotations of the hip and dorsiflexion of the ankle. CONCLUSION: The data compiled in this study on the range of motion in the hip and ankle joint of the Indian population will be useful in the evaluation of patients with disorders of these joints, especially in the Indian and Asian population.

Early adolescent nutritional rickets.

PURPOSE: To evaluate early adolescents with nutritional rickets and their responses to treatment. METHODS: 203 adolescents (aged 10 to 13 years) presenting with clinical features of lower-limb deformity, carpopedal spasm, joint swelling, a significant limp, or non-traumatic joint pain were screened for nutritional rickets. Multi-specialty examinations were performed. Family size, number of earning members, number and gender of children, preference for vegetarian food, composition of the meals, and the amount of milk consumed in a day were recorded. Radiographs of wrists, knees, ankles, and pelvis, as well as serum calcium, phosphate, and alkaline phosphatase levels were evaluated. The diagnosis of nutritional rickets was made based on a combination of clinical, radiological, and biochemical criteria, and confirmed by the responses to treatment. Children with nutritional rickets were treated by a single large intramuscular dose of vitamin D (600,000 IU) along with oral calcium and supplementary vitamin D as well as advice on diet and sunlight exposure. RESULTS: 40 females and 11 males were diagnosed as having nutritional rickets. 65% presented with bilateral knee pain with aggravation at night, 37% presented with lower-limb deformity, 24% had joint swelling especially at the wrist and ankle, 6% had a significant limp and walked with an antalgic gait secondary to pathological fractures. No patient reported carpopedal spasm. All patients had rachitic changes on radiographs in some but not all bones (100% in the ulna, 45% in the radius, 37% in the upper tibia, 37% in the lower fibula and 22% in the lower tibia). Three patients had pathological fractures. 55% had hypocalcaemia, 41% had hypophosphataemia and 100% had raised serum alkaline phosphatase levels. The mean time for biochemical resolution was 12 (range, 3-24) weeks. For radiological resolution it was 5 (range, 2-6) months, with the lower end of ulna being last to resolve. CONCLUSIONS: Radiographs of the lower end of ulna and serum alkaline phosphatase levels can be used as a screening and monitoring tool for nutritional rickets in early adolescents. There may be a high prevalence of subclinical vitamin-D deficiency in our adolescent population.

Rickets: a cause of delayed walking in toddlers.

OBJECTIVE: Children with complaints of not able to walk were investigated for rickets by appropriate history, clinical examination, serum biochemistry and radiology. METHODS: Children more than 1 yr were included. Each child was evaluated keeping in mind the possible causes of delayed walking. Also each child was thoroughly examined and diagnosed by combination of clinical, radiological, biochemical findings and response to treatment. RESULTS: Out of forty-two non-walkers during the study period, 25 patients turned out to be affected by nutritional rickets (60%). On follow-up at 3 weeks of treatment, all 25 patients (100%) showed radiological and biochemical response. Five patients were lost to follow-up after 3 weeks of treatment. Seventeen patients started walking within 3 months of treatment. Two patients did not start walking even after complete biochemical and radiological resolution. Radiological resolution, with limiting factor being the healing of lower end of ulna, averaged 5 months. CONCLUSION: The study reveals that majority of ricketic non-walkers start walking within 2 to 5 months of appropriate treatment.