Preoperative estimation of humerus intramedullary nail length using clinical landmarks.

PURPOSE: Intramedullary interlocking nailing is one of the accepted methods of treating humerus diaphyseal fractures. Appropriate nail length and diameter are of paramount importance to achieve a stable fracture fixation. Estimating the nail length can be as challenging in certain cases as it is important. This study aims to provide an easy-to-use formula utilizing clinical measurements from contra lateral arm to accurately estimate humeral nail length. METHODS: This descriptive cross-sectional study was conducted at 3 tertiary care hospitals in Mangalore, India. Patients above the age of 18 years coming to the outpatient department with elbow, shoulder or arm complaints requiring radiological investigation from July 2021 to July 2022 were included. Patients with fractures or dislocations of upper limbs, malunited or non-united fractures of upper limbs, congenital or developmental deformities and patients with open growth plates were excluded. Patients' variables (like age and gender), radiological humerus length and contralateral arm clinical measurements were recorded. An independent samples t-test was used for univariate analysis, and linear regression analysis was done to estimate the desired nail length using the clinical measurement of the humerus (cm) in both genders separately. The significance level was set at p < 0.05. RESULTS: Our study included 204 participants of which 108 were male and 96 were female. The formula for predicting humeral nail length in males is (-2.029) + (0.883 × clinical measurement). The formula for females is 1.862 + (0.741 × clinical measurement). A simplified formula to determine humeral nail length is 0.9 clinical length - 2 cm (in males) and 0.7 × clinical length + 2 cm (in females). CONCLUSION: To improve the stability of fixation with intramedullary nails it is imperative to select the appropriate nail length. There have been studies that devised reliable methods of determining nail lengths in the tibia and femur using preoperative clinical measurements. A similar clinical method of determining humeral nail length is lacking in the literature. Our study was able to correlate radiological lengths of the humerus medullary canal with clinical measurements performed using anatomical landmarks to arrive at a formula. This allows for a reliable and easy nail length determination preoperatively.

Case of bilateral hip joint Charcot arthropathy in a paediatric patient.

An adolescent girl came with swelling of both thighs with difficulty in walking for a few months. Based on clinical, and radiological evaluation and nerve conduction studies, she was diagnosed to be having bilateral hips Charcot's arthropathy due to hereditary sensory autonomic neuropathy type 4. Other common causes of Charcot arthropathy were ruled out. The patient was conservatively managed and parents were educated about preventive measures. Through this case report, we want to highlight the myriad number of manifestations and clinical presentations of a child presenting with hereditary sensory autonomic neuropathy type 4.

Neurogenic heterotopic ossificans of hips in a case of expanded dengue syndrome following critical illness polyneuropathy.

We present a case of 71-year-old man with bilateral hip neurogenic heterotopic ossificans following critical illness polyneuropathy as a complication of expanded dengue syndrome. His left hip was stiff and showed a circumferential ossific mass. After initial medical management, the patient underwent excision of ossific mass using posterior approach. For adequate excision, femoral head and neck were resected and a hybrid total hip arthroplasty was performed. The patient was followed up for 2 years and showed good clinical outcome without recurrence of heterotopic ossification. This case highlights the rare aetiology of neurogenic heterotopic ossification which is critical illness polyneuropathy following expanded dengue syndrome. It highlights that adequate resection and a total hip arthroplasty can be a viable option in selected cases of circumferential heterotopic ossification in old individuals.

"Screw First" Technique to Get Past Nail-Jig Mismatch in Proximal Femoral Nailing.

Proximal femoral nailing is the gold standard of surgical treatment for unstable intertrochanteric hip fractures. One of the intraoperative complications encountered in this procedure is the nail-jig mismatch due to causes such as manufacturing errors and fatigue deformation of sleeves or jig. Nail-jig mismatch leads to eccentric placement of guidewire within the screw slots of PFN and subsequent difficulty in reaming and screw insertion. The potential complications of this include guide wire deformation, breakage, nail damage and screw malposition. We propose a simple and effective technique to tackle this complication, called as "Screw first" technique. The principle of this technique is to utilize screws as guide wire sleeves to effectively centralize the guidewire position within nail slots. On identifying a mismatch by the eccentric position of guidewire, a long screw is first inserted partially till its shaft engages into the screw slot allowing subsequent insertion of a guidewire which assumes a centralized position, thus bypassing the mismatch of jig. Following this, the usual steps of reaming and final screw insertion are undertaken. This method is effective, simple, quick and requires no special instrumentation.

CT based measurement of anatomical dimensions of femur and its relevance in nail designs for proximal femoral fractures.

INTRODUCTION: The purpose of this study was to obtain computed tomography (CT) based measurements of femoral dimensions in adults, to identify its relevance with intramedullary nails used in the management of proximal femur fractures and to suggest a best fitting implant dimensions to our population. To best of our knowledge our study would be first to compile different CT based dimension in single study. METHODS: In our retrospective study of 50 femurs, CT based femoral dimensions measured in standardized cuts and compared with previous studies and commonly available proximal femur intramedullary devices. RESULTS: 68.4 was the mean age in our study, neck shaft angle (NSA) was 127.2±5.20, anteversion 11.2±7.40, endosteal isthmus diameter was 11.9 ± 1.7 mm, anterior radius of curvature (ROC) was 116.8 ± 20 mm, horizontal femoral offset 37.5 ± 4.6 mm, medio-lateral angle 7.8±1.60, with good inter and intra observer correlation. Femoral length and neck width was positively correlated to head diameter, horizontal femoral offset with medio-lateral (ML) angle. One of the 50 femur studied had the parameters in the range of available implant and could match appropriately. CONCLUSION: CT based dimensions in our population is different from other population. Based on this study, a design modification of nails used in present day management of proximal femur fractures has been recommended.

A case of closed isolated medial subtalar dislocation / Un caso de luxación subastragalina medial aislada y cerrada

Introduction: Closed isolated subtalar dislocations are very rare and major cause of subtalar dislocation remains to be road traffic accidents. Objective: Identify isolated medial subtalar closed dislocations and their forms a management. Presentation of case: 22-year-old male sustained road traffic accident following which he had deformed foot with inability to bear weight. On evaluation he was found to have medial subtalar dislocation reduced with manual traction. One year follow up showed, no residual deformity or pain and had very good functional outcome. Conclusions: It is of great importance to identify the difference between medial subluxation or dislocation and medial swivel injury which have different mechanisms as well as different reduction maneuvers(AU)

Introducción: Las luxaciones subastragalinares aisladas cerradas son muy raras y la principal causa de luxación subastragalina resultan los accidentes de tráfico. Objetivo: Identificar las luxaciones cerradas subastragalina medial aisladas y su tratamiento. Presentación del caso: Un paciente hombre de 22 años sufrió un accidente de tránsito tras el cual quedó deformado el pie sin poder soportar peso. En la evaluación se encontró la luxación subastragalina medial que se redujo con tracción manual. El seguimiento al año no mostró deformidad residual ni dolor y tuvo muy buen resultado funcional. Conclusiones: Es de gran importancia identificar la diferencia entre subluxación o luxación medial y lesión por giro medial, las cuales tienen diferentes mecanismos, así como diferentes maniobras de reducción(AU)