Magnetic Resonance Imaging Evaluation of Musculoskeletal Diseases of Ankle and Foot.

Background Ankle and foot pain is a common clinical problem, that may be due to a variety of soft tissue and osseus abnormalities. Magnetic resonance imaging plays vital role for diagnosing internal derangement of the ankle joint, assessing soft tissue structures around the ankle such as tendons, ligaments, nerves and osseus structures. Method Retrospective magnetic resonance imaging evaluation of the ankle and foot was done in 100 patients using 0.3T and 1.5T magnetic resonance imaging. Clinical history included pain, swelling of the ankle and foot, trauma, twisting injury, palpable mass and difficulty in walking. Result Fifty two patients were male and 48 patients female aged 6 months to 70 years. Ligaments tear were the commonest and seen in 22% patients. Tenosynovitis found in 17%, Pigmented villonodular synovitis (PVNS) in 3%, Achilles tendon abnormality in 8%, stress fracture-9%, osteomyelitis-8%, soft tissue vascular malformation in 5%, soft tissue and bone tumor-4%, marrow edema-20%, osteoarthritis-10%, Osteochondral lesion of talus-8%, sinus tarsi syndrome-3%, posterior impingement-5%, plantar fasciitis-2%, Sever disease-2%, peroneus tendon split-2%. The commonest clinical presentation was pain and swelling of the ankle in 42 patients, twisting/inversion injury of the ankle in 23 patients followed by traumatic injury with difficulty in walking in 20 patients and palpable mass in 8 patients. Ligaments injury were mostly associated with inversion/twisting injury. Conclusion Magnetic resonance imaging is advantageous for assessing soft tissue structures around the ankle and foot, such as tendons, ligaments, nerves, masses and occult osseus lesions. It provides a quick, non-invasive tool for the diagnosis of related injuries and guide for the further treatment planning.

Distally based sural faciocutaneous and fascial (adipofascial) flap for reconstruction of distal leg, ankle and foot defects.

BACKGROUND: Any soft tissue defect in distal leg, ankle and hind foot is still a challenging problem. There are various options for coverage of such defects, but the distally based sural neurocutaneous and neurofascial flap based on the sural nerve and superficial sural artery has been an important option. OBJECTIVE: To evaluate the efficacy of distally based sural flap in reconstruction of the distal leg, ankle and hind foot soft tissue defects. METHOD: Seventeen patients with soft tissue defects over distal leg, ankle and hind foot were included in this study. All patients were treated with distally based sural flap. Most of the cases were due to trauma (16 cases) which compromised tendon and bone. One case was of malignant melanoma of sole of hind foot which required wide excision and soft tissue reconstruction with sural flap. RESULT: In all cases defects were successfully covered. Three showed venous congestion and partial necrosis. One developed secondary infection. One flap failed completely. Mean follow up of patients was 20 months (6-36 months). CONCLUSION: Sural flap is a good option for reconstruction of distal leg, ankle and foot defects.

Scaphoid fracture: functional outcome following fixation with Herbert Screw.

BACKGROUND: Most scaphoid fractures though heal uneventfully with cast treatment, immobilization with cast is associated with complication like wrist stiffness. Open reduction and fixation with Herbert Screw though technically demanding procedure can yield excellent results and prevents complication like nonunions and loss of wrist function. OBJECTIVES: To assess clinical outcome and radiological union of scaphoid fracture after operative management following Herbert screw fixation in patient attending Dhulikhel Hospital. METHODS: All scaphoid fracture, treated from Feb 2007 till Feb 2011, were retrospectively studied in Dhulikhel Hospital, Kathmandu University Hospital. Fifteen patients with scaphoid fractures were treated with Herbert screw. Fourteen were males and one was female. Serial radiographs were taken to assess radiographic union and functional outcome was assessed using Modified Mayo wrist score. RESULTS: Out of 15 patients, 13 scaphoid had waist fractures and two had proximal pole fractures. All scaphoid were treated with open reduction and Herbert screw fixation either by volar approach or by dorsal approach. All fractures maintained good alignment post operatively. Nine (60%) patients had excellent results with normal wrist range of motion, five (33.3%) patients had good results and one (6.7%) patient had poor outcome. In 14 (93.3%) patients good radiological union was seen at final follow up at six months time. CONCLUSION: Fixation with Herbert screw for scaphoid fracture is an effective and convenient way of treatment with satisfactory functional outcome and less complication.

Operative fixation of displaced middle third clavicle (Edinburg Type 2) fracture with superior reconstruction plate osteosynthesis.

BACKGROUND: Conservative management of middle third clavicle fracture has been recently reported with suboptimal outcomes. Despite higher nonunion rates in initial open reduction and internal fixation, understanding the problem better and taking in accounts of previous shortcomings, such fractures can be optimally treated by open reduction and internal fixation with reconstruction plate. OBJECTIVE: To study the outcome of middle third clavicle fracture treated with superior reconstruction plating in terms of function using Constant shoulder score, union time and rate, complications and patient satisfaction. METHODS: Twenty patients with displaced middle third clavicle fracture (Edinburg type 2) treated with open reduction and internal fixation with reconstruction plate implanted in superior surface were prospectively followed for at least one year after surgery. RESULTS: There were 20 patients, 16 males and 4 females. The mean age of the patients was 31.5 years with SD 11.5 years (range 15-60 years) and 5 patients (25%) had associated injuries. All fractures united in 16 weeks or less in near anatomic position with complication in 2 (5%) patients, one deep infection and one frozen shoulder which on subsequent management recovered well. There was no nonunion or implant failure. The average Constant score was 97.45 in one year follow up and the patients were relatively satisfied with the treatment.The most common indication (25%) for hardware removal was young age of the patient, hardware prominence and occasional discomfort. CONCLUSION: This small series shows that displaced midshaft clavicle fracture can be optimally treated with operative fixation implanting the reonstruction plate in superior surface with six cortical purchases on either side and supervised physiotherapy, although subsequent surgery for implant removal might be necessary.

Intramedullary nailing for paediatric diaphyseal forearm bone fracture.

BACKGROUND: Though most of the pediatric diaphyseal forearm bone fracture can be treated with closed reduction and cast application, indications for operative intervention in pediatric both-bone forearm fractures include open fractures, irreducible fractures, and unstable fractures. Controversy exists as to what amount of angulation, displacement, and rotation constitutes an acceptable reduction. OBJECTIVE: To review union time and functional outcome of pediatric diaphyseal forearm bone fracture managed with intramedullary rush pin by closed or open reduction. METHODS: Fifty patients with both bone fracture of forearm were treated with intramedullary rush pin by closed or open reduction were included in the study and followed up for minimum six months for radiological and functional outcome. RESULTS: Out of 50 patients, 31 underwent closed reduction and 19 underwent open reduction. All fractures maintained good alignment post operatively. Forty seven patients had excellent results with normal elbow range of motion and normal forearm rotation and three patients had good results. In all patients good radiological union was seen in three months time. Eight patients had minor complications including skin irritation over prominent hardware, backing out of ulnar pin, superficial skin break down with exposed hardware. Twenty-three (46%) patients had undergone implant removal at an average of 6 months (range 4-8 months) under regional or general anesthesia. CONCLUSION: Fixation with intramedullary rush pin for forearm fracture is an effective, simple, cheap, and convenient way for treatment in pediatric age group.