Undiagnosed vertebral fragility fractures in patients with distal radius fragility fractures: an opportunity for prevention of morbimortality in osteoporotic patients in developing countries.

Our study investigates vertebral fractures in individuals with distal radius fractures. Among 512 patients, 41.21% had vertebral fractures, predominantly in the lumbar spine. These findings highlight the importance of screening for vertebral fractures in this population, informing early intervention strategies to mitigate risks associated with osteoporosis. PURPOSE: This study's main goal was to look into the frequency, location, kind, and severity of asymptomatic vertebral fragility fractures (VFF) in people who had fractures of the fragility of the distal radius. Although VFF is frequently misdiagnosed, it is linked to higher mortality, morbidity, and hip fracture risk. The study also attempted to investigate the relationship between VFF and certain demographic and lifestyle factors, as well as FRAX data, in this patient population. METHODS: Between January, 2021, and January, 2022, individuals with low-energy distal radial fractures who presented to the emergency room of tertiary care hospital of Karachi, Pakistan, were the subject of a cross-sectional study and were 45 years of age or older except those who fitted the exclusion criteria (n = 208). The thoracic and/or lumbar spine was imaged using radiology, and information on demographics, way of life, and FRAX (Fracture Risk Assessment Tool) was gathered. Using the Genant semiquantitative approach, an impartial and blinded orthopaedist identified VF in the images and determined their severity. SPSS version 20 was used to analyse the data. RESULTS: Two hundred eleven (41.21%) of them were found to have radiographic VFF and only 12 (2.34%) of the 512 patients who were tested were getting osteoporotic therapy. The thoracic spine (32.7%), followed by the lumbar spine (43.12%), was the area most frequently afflicted. In 24.17% of the patients, multiple fractures of the thoracolumbar spine were found. The wedge form (54.5%), followed by biconcave (30.81%) and crush (14.7%), was the most prevalent VFF type. The majority of detected VFF were rated as having a 25-40% height loss (64.9%) then severe (> 40%) fractures (35.1%), according to the Genant grading method. Notably, there were no variations in smoking, drinking, BMI, or FRAX score between patients with and without VFF that were statistically significant. CONCLUSION: Based on our study's findings, it is clear that osteoporotic vertebral fragility fractures occur in almost half of individuals with distal radius fractures. The lumbar spine is notably the most affected region, predominantly with wedge fractures. Given the high prevalence of asymptomatic vertebral fragility fractures (VFF), proactive measures are necessary to mitigate associated risks. Prioritising comprehensive fall risk assessments for these patients and interventions to enhance bone mineral density and strength are crucial. Early identification of asymptomatic VFF enables timely intervention, optimising patient care and minimising the risk of complications in this vulnerable population.

Introducing the Muzzammil classification for spoke wheel injuries in children to enhance injury assessment and treatment in developing countries.

Motorbike spoke wheel injuries (SWIs) among children are a notable public health concern, especially in low and middle-income regions. The primary objective of this study is to comprehensively examine the patterns of motorbike spoke wheel injuries (SWIs) in children. Additionally, the study introduces a novel classification system for these injuries. The implementation of this classification system aims to streamline the management of SWIs, making it more efficient and facilitating the development of standardized treatment protocols. This prospective observational study was conducted in the Accident and Emergency Department from January 2019 to 2021. Children < 14 years of age of either gender with foot and ankle injury due to motorbike spoke wheels as passengers and presenting within 3 days were included. The motorbike SWI was assessed for its location and classified by a new classification as Class I, Soft tissue injury without skin loss; Class II, Skin loss of more than 1 cm without underlying tissue involvement; Class III, Skin loss with underlying tissue involvement, this class is further divided on basis of underlying soft-tissue involvement; Class IV: mangled foot/toe. Management plan and outcome were noted. In our study158 children suffering from SWI were registered with a mean age of 6.2 ± 5.4 years, 127 (80.37%) males and 31 (19.62%) females. Class I injury was seen in 18 (11.39%) patients, class II in 69 (43.67%), and class III in 68 (43.03%) patients. Class III injuries were further subcategorized as follows: IIIT (Tendon) injuries, which accounted for 32 cases (20.25%); IIIB (Bone) injuries, with 29 cases (18.35%); and IIINV (Neurovascular) injuries, identified in 7 cases (4.43%). Class IV injuries were observed in 3 (1.8%) children. The flap was needed in 33 (20.88%) patients. There were no complications like flap necrosis or graft rejection. In this current study, a new classification system specific for a motorbike SWI has been introduced along with its application on children presenting at tertiary care hospital's emergency department. The application of the proposed classification will enable universal management guidelines for SWIs, especially in the Ino-Pak region where SWIs are common.

Prevalence of inadequate vitamin D level and its predictors in children presenting with torus fractures.

BACKGROUND: Review of the published articles does not show any study done to see if children with torus fracture are with Vitamin D deficiency. The aim of this study was to determine association of inadequacy of Vitamin D level with torus fracture and its predictors in children in Karachi Pakistan. METHODS: Patient underage of 13 years came with torus fracture were included in study, and managed non-operatively with below elbow cast. Proforma was made which includes demographic data (age, gender, nutritional status) and exposure to sunlight, dietary habits, kind to apparel and type of accommodation they were living at. All participants underwent measurement of serum vitamin D level. RESULTS: Out of 558 children presented with limb fractures in emergency department, 190 (34.05%) had torus fracture, with mean age of 6.0 ± 4.2 years. 93 (48.94%) in pre-school group, 59 (31.05%) in school and 38 (20%) were breast-fed. On nutritional status, malnourished were 72 (37.89%), out of which 32 (44.44%) had first-degree malnutrition. On vitamin D level status only 52 (27.36%) participants had Vitamin D within normal range while 86 (45.26%) were found Vitamin D deficient. We found that vitamin D level is directly related to nutritional status, duration of sun exposure maternal vitamin d levels and not significantly related to age, gender, type of accommodation and different fabric types. CONCLUSION: In this study torus fracture in children is significantly associated with Vitamin D deficiency, with common predictors including nutritional status, maternal Vitamin D level for lactating mothers and duration of exposure of sunlight. Vitamin D supplementation in children can prevent a significant number of fractures via national programs for food fortification and increase the awareness of general population on the importance of sunlight exposure and intake of food rich in Vitamin D.

Osteoporosis: Prevalence, awareness and pertinent risk factors in a cohort of elderly Asian population presenting with low-energy distal radius fractures.

BACKGROUND: This study aims to evaluate the awareness of osteoporosis and related risk factors in elderly Asian patients who present with distal radius fractures. The distal radius fracture is one of the most frequent fractures in the elderly cohort, owing to osteoporosis, and maybe a harbinger for further fractures, however, data is scarce regarding awareness of this condition among these patients. METHOD: This cross-sectional study was conducted on patients aged 45 and above that presented in the emergency department with low-energy distal radial fractures in Karachi from January-December 2018. Data were collected via a self-designed questionnaire, assessing the demographic information, knowledge about osteoporosis and its risk factors. The data was analysed using SPSS 20 for statistical significance. RESULTS: From a total of 550 patients with a mean age of 70.5 ± 32.82 years, there were 442 (80.36%) females and 108 (19.63%) males. On educational consideration, 243 (44.18%) patients could not read or write and only 110 (20%) of the patients received secondary school education. Only 123 (22.36%) were well informed about osteoporosis, the predominant source of information being their physician. There were 427 (77.63%) patients who were unaware of osteoporosis, 16% of which were smokers, 26% indicated they exercised at least 30 minutes daily, and 2% reported drinking alcohol occasionally. On dietary supplements, 24.27% of patients reported calcium and 17.81% reported vitamin D supplement consumption on regular basis. CONCLUSION: We found a positive correlation between a patient's education status and osteoporosis awareness We believe that the role of the physician could be crucial in preventing further fractures in such patients via physician lead educational campaigns to target modifiable risk factors.

Primary trauma care course: Alternative basic trauma course in developing countries. "The Need Of The Hour".

OBJECTIVE: Low- and middle-income countries account for over 90% of all road traffic injury deaths. Despite this, formal training in trauma management is not widely adopted in these countries. No specific training was available in prehospital or emergency department for life support before primary trauma care (PTC) course. This study was conducted to assess the effectiveness of the PTC course in the improvement of knowledge and skills of trauma management among participant in Pakistan. METHOD: Two days of PTC courses were organised and conducted in various regions of Pakistan, participants per course comprising medical students, doctors, house officers, residents, and paramedics. The course comprises lectures of 5 hours and 30 minutes, skills workshops for 3 hours and discussion and multisystem trauma scenarios for 3 hours. Trauma management knowledge and clinical confidence of candidates were assessed using a predetermined multiple-choice questionnaire of 30 MCQs both at pre- and post-course, and using clinical scenarios, confidence matrix was assessed. RESULTS: A total 7852 of participants were trained, an average of 2 courses per month and 302 total courses. Mean score of pre-course MCQs was 60% and mean score of post-course MCQs was 82%. Among the participant postgraduate trainees, average in trauma knowledge and trauma clinical confidence were significantly higher in both pre- and post-course. The mean score of pre-course confidence matrix was 70% and the mean score of post-course confidence matrix was 93%; at the end of course, all participants showed a high level of confidence in managing trauma mock scenarios. A total of 5889 (75%) participants had a ≥78.5% post-workshop knowledge score. However, only 1963 (25%) participants had a trauma skill score with ≤75 marks. CONCLUSION: PTC workshop could be an alternative and cost-effective flexible course for gaining knowledge and clinical skills of initial trauma management and strengthening the capacity of trauma management training in developing countries with minimal resources for saving the life of trauma victims.

Does malnutrition in clubfoot patients affect Ponseti technique and its outcome?

OBJECTIVES: Malnutrition is a crucial health problem predominantly in the developing countries. Malnutrition in children is one of the main risk factors for diseases and mortality. Club foot or congenital talipes equinovarus (CTEV) is the most common form of congenital orthopaedic abnormality. Over the past 20 years, the Ponseti method is considered the gold standard for the treatment of clubfoot. Our objective is to determine the prevalence of malnutrition in clubfoot patients, and its effects on the outcome of Ponseti technique in patients presenting to the Orthopaedic Clinic of tertiary care Hospital in Karachi, Pakistan. METHOD: The cross-sectional study was conducted from January to December 2018. Total 153 clubfoot patients were treated and the World Health Organization (WHO) classification of weight-for-age index was used to assess the nutritional status of patients, and its impact on outcome of Ponseti technique was recorded and analysed with a P value ≤ .05 as significant. RESULTS: Of the 153 patients, 112 (79.7%) were found in good nutritional status and 42 (20.6%) were malnourished. The average number of casts per patient and patients requiring 6+ casts in the undernutrition group was higher compared with good nutrition group (45.5% vs 21.42%, respectively). The number of Achilles tenotomy performed in the undernutrition group was also higher (76.4% vs 51.8%). CONCLUSION: A significant correlation between patients' nutritional status and outcome of the Ponseti technique is found as it influences the number of casts, possible relapse and failure of treatment.

Onsite Triage, Pre-Hospital Management And Effective Hospital Transportation "Where Do We Stand?"

BACKGROUND: To improve morbidity and mortality outcomes in mass casualty victims it is pertinent that a system of prehospital triage be implemented. The objectives of this study are to determine the knowledge, attitude and practices of emergency care transporters and ambulance personnel towards onsite triage, pre-hospital management and transportation to hospital of critically injured and wounded patients in mass casualty incidents and other emergencies in Karachi, Pakistan. METHODS: All ambulance personnel and emergency care transporters who transported patients to the hospital were included in the study. Pre-tested questionnaire was selfadministered after obtaining written consent. RESULTS: Among 250 emergency care transporters (ambulance personnel), mostly belonged to age group 21-25 years 73 (29.2%). Most of emergency transport provider teams were composed of only 1 person who was the driver of ambulance 22 (80%) and only 44 (17.6%) had the facility of paramedics. Regarding lifesaving equipment facilities in ambulance, 188 (75.2%) ambulances did not have these and only 62 (24.8%) were equipped. Predominantly, the ambulance personnel performed the 'scoop and run' practice and the ambulance works as a transport vehicle 188(75.2%), while facilities of basic life support were available in only 45 (18%) and advance life support facility in 17 (6.8%). Among all 203 (81.2%) did not think they are able to decide who is severely injured and 183(73.2%) believe they are unable to do triage in mass causalities. CONCLUSION: Our study showed significant gaps in the knowledge of the emergency care providers regarding triage of patients especially in mass casualty incidents. Though the response time and time to the hospital center is comparable, no prehospital lifesaving interventions are attempted en-route. A coordinated effort by the ambulance services, hospitals and the government are detrimental for a swift functioning of a trauma system.

Experimental Investigation of Optimal Relay Position for Magneto-Inductive Wireless Sensor Networks.

Magneto-inductive (MI) waveguide technology is often proposed to increase the MI communication distance without adding significant cost and power consumption to the wireless sensor network. The idea is to add intermediate relaying nodes between transmitter (Tx) and receiver (Rx) to relay the information from Tx to Rx. Our study of MI wave-guides has realized that adding a relay node improves the communication distance, however, the performance is greatly dependent on the position of the relaying node in the network. We therefore, in this work have investigated the effect of placement of a relay node and have determined the optimal relay position. We have performed various sets of experiments to thoroughly understand the behavior and identified three main regions: a) for region 1, when the distance between Tx and Rx is equal or less than the diameter of the coils ( d ≤ 2 r ), the optimal relay position is close to Tx , b) for region 2, when the distance between Tx and Rx is greater than diameter of the coils but less than twice the diameter ( 2 r < d < 4 r ), the optimal relay position lies in the center of Tx and Rx , and c) for region 3, when the distance between the Tx and Rx is equal or greater than twice the diameter of the coils ( d ≥ 4 r ), the optimal relay position is close to Rx.

Use of social media while driving from an orthopedic resident's perspective.

PURPOSE: To investigate the orthopedic injuries sustained while driving and using social media on cellular phones from an orthopedic resident's perspective. METHODS: A total of 118 patients who presented with a history of road traffic accident secondary to social media usage and suffered from fractures were included in this cross-sectional study. These patients were reported from October 2018 to April 2019. We collected the data including the type of collision, type of social media usage during driving, location of injury, wearing of safety equipment's such as helmet and seat belt during driving. RESULTS: The mean age of patients was (34.86 ± 12.73) (range 15-71) years. The common types of accident on the basis of collision of vehicles were: car versus motorbike 45 (38.1%), motorbike versus motorbike 28 (23.7%), and motorbike versus pedestrian 22 (18.6%). Most of the accidents (61, 51.7%) occurred due to mistake of motor-bikers. Out of them, 44 (37.3%) occurred on traffic signals, followed by 29 (24.6%) while driving on main roads. The common timing of accident was normal hours with frequency of 44 (37.3%), followed by 39 (33.1%) at late night. According to fracture type, closed injuries were 98 (83.1%) and open fractures were 20 (16.9%). The most common fracture was clavicular fracture (21, 22.5%) followed by soft tissue injury in 19 (16.1%) patients. The most common social media application usage during driving was Facebook 43 (36.4%), followed by Whatsapp 24 (20.3%), Google 19 (16.1%), and Instagram 15 (12.7%). CONCLUSION: This study provides evidence that social media usage while driving put the drivers and other road users' lives at high risk. The most common social media addiction while driving is Facebook and Whatsapp. So there is a need to make strict rules and penalties for using cell phone during driving so as to save the lives of drivers and other people using road.

Complex Tibial Plateau Fractures: Primary Fixation Using the Ilizarov External Fixator. A Two-year Study at Civil Hospital Karachi, Pakistan.

Background The proximal tibia with the meta-diaphysis junction is a critical weight-bearing area. An injury around this region may be restricted to the tibia or associated with a significant soft-tissue injury. The objective of the present study is to assess the results of closed reduction and Ilizarov external fixation in the management of complex tibial plateau fractures. Patients and methods The study included 26 patients with high-energy tibial plateau fractures (Schatzker types V and VI). The ages ranged from 23 to 60 years, with an average of 35 years. The trauma was a road traffic accident in 19 cases and a fall from a height in eight cases. The fractures were closed in 18 cases and open in five. The open fractures were Gustilo-Anderson type I in three cases and type II in five cases. Soft-tissue injuries associated with closed fractures were classified according to the Tscherne system. The follow-up period averaged 24 months. The average time of surgery was 85 mins (range: 60-120 min). The mean time to union was 12 weeks. At the final follow-up, the average total range of knee flexion was 120° (range: 0-170°). Results Results were satisfactory in 22 cases and unsatisfactory in four cases according to Rasmussen's knee functional score. Complications included pin-tract infection in 10 cases, an extension lag in three cases and varus deformity of about 17° in one case. Conclusion Hybrid external fixation is a good method for the treatment of comminuted tibial plateau fractures. It allows for early joint movement and reduces the risk of serious complications.

Effectiveness Of Plain Shoulder Radiograph In Detecting Degenerate Rotator Cuff Tears.

BACKGROUND: Studies have demonstrated radiographic findings of sclerosis and cortical irregularity at the greater tuberosity can suggest a rotator cuff tear. Plain radiographs are the most easily attainable first-line investigations in evaluating shoulder injuries. This study determines the effectiveness in predicting degenerate rotator cuff tears by detecting radiographic changes on shoulder x-rays. METHODS: Retrospective cross-sectional study with a consecutive series of patients conducted in Hinchingbrooke Hospital, Huntingdon, United Kingdom from January 2015 to June 2017. Anteroposterior shoulder radiographs of 150 symptomatic patients who underwent shoulder arthroscopy were independently analysed by surgeons who were blinded from the arthroscopic results. Patients aged fewer than 30 and over 70 years were excluded. Patients with advanced osteoarthritis and cuff tear arthropathy evident on x-rays were also excluded. Sixty-five patients included in the study had rotator cuff tears on arthroscopy. Radiographic changes were correlated with arthroscopic findings to determine this test's ability to predict degenerate rotator cuff tears. RESULTS: When both cortical irregularity and sclerosis were present on the plain radiograph, these signs had a sensitivity of 78.8% [95% CI 65.7, 87.8%] and specificity 77.4% [95% CI 67.2, 85.0%] with a positive predictive value of 68.3%, using contingency table analysis. The presence of cortical irregularity was found to be a better predictor of a tear as compared to sclerosis. CONCLUSIONS: This study concludes that plain radiograph are good modality for initial evaluation of rotator cuff tears and detecting when both cortical irregularity and sclerosis. Consideration of these radiographic findings serves as a useful adjunct in diagnostic workup and can guide subsequent investigations and treatment when evaluating rotator cuff tears of the shoulder.

Qing-Qi Rickshaw : A Boon Or Bane For Public Transportation? A Study Of Road Traffic Injury Patterns Involving Qing-Qi Rickshaws In Karachi Pakistan.

BACKGROUND: The three-wheeler Qing-qi and Compressed Natural Gas (CNG) auto-rickshaws were introduced in Karachi to meet the transportation demand of the growing population. These vehicles have directly or indirectly been implicated in a number of road traffic violations as well as road accidents. This study aims to describe the crash characteristics and injury patterns for Qing-qi rickshaw occupants and other road users hit by Qing-qi rickshaw in Karachi, Pakistan. METHODS: An Observational/ Descriptive study was conducted at Accident & Emergency and Orthopaedic Surgery Department, Jinnah Post Graduate Medical Centre, Karachi Pakistan from July 2014 to June 2015.All patients who came with Qing-qi rickshaw accident in Accident & Emergency (A&E) of JPMC were included. Crash characteristics, details of injuries, injury severity parameters and outcome were documented in detailed interviews. RESULTS: Four hundred and eighty-six rickshaw related injuries were noted in road traffic accidents by Qing-gi rickshaw. Age range was 2-85 (43.5±58.68). 350 injured victims were males and 136 were females. By occupation most victims were laborers and daily wage workers (45%) and students (21%). Overloading of vehicle with more than two passengers was found in (28.5%). The most common cause of injury was collision with a moving vehicle (56%), followed by fall from rickshaw. The most common contributing factor was the overloading of rickshaw and roll over on turning (61%). Injury severity on arrival were mild (49%), moderate were (32%), and severe were (19%). Injuries related to head and neck (26%), face (14%), thorax and abdomen (5%), lower extremity and pelvic girdle (31%) and upper extremity (23%) were observed. CONCLUSIONS: Qing-qi rickshaw injuries are common and these vehicles are vulnerable to road traffic accidents. Occupants and road users are both at risk of injuries.

Assessment Of Safety Levels In Operation Rooms At Two Major Tertiary Care Public Hospitals Of Karachi. "Safe Surgery Saves Life".

BACKGROUND: The objectives of this study are to determine the knowledge and attitude towards surgical safety among the health care professionals including surgeons, anaesthetist, hospital administrators, and operation room personnel and raise awareness towards the importance of safe surgery. METHODS: A pilot cross- sectional study of 543 healthcare providers working in the operating rooms and the surgical intensive care units was conducted in two tertiary care hospitals, within a study period of one month. A structured questionnaire was constructed and an informed verbal consent was taken. The questionnaire was then distributed; data collected and analysed on SPSS 20.0.. RESULTS: A total of 543 respondents participated in the study out of which there were 375 (69%) men and 168 (31%) women. The ages ranged between 23-58 years, mean 40.5±24.74. There were110 (20.25%) surgeons, 58 (10.68%) anaesthetist, 132 (24.30%) trainees, 125 (23.02%) technicians, and were 118 (21.73%) nurses. The question regarding briefing operation room personnel is important for patient safety was agreed by 532 (98%) respondents. Amongst the respondents, 239 (44%) did not feel safe to be operated in their own setup. Team communication improvement through the check list implementation was agreed by 483 (89%) respondents. 514 (94.7%) opted for the checklist to be used while they are being operated. That operation room personnel frequently disregard established protocols was agreed by 374 (69%) respondents. 193 (35.54%) of the respondents stated that it is difficult for them to speak up in the OR if they perceive a problem with patient care. CONCLUSIONS: Operation room personnel were not aware of several important areas related to briefing, communication, safety attitude, following standard protocols and use of WHO Surgical Safety check list. A pre-post intervention study should be conducted after formal introduction of the Checklist. Successful implementation will require taking all stake holders on board and rigorous training workshops, reinforcing and revisiting.

Giant cell tumour of foot bones - 25 years experience in a tertiary care hospital.

OBJECTIVE: To determine the incidence of giant cell tumour in foot, its clinical features, stage of tumour, treatment and outcome of surgery. METHODS: This retrospective case series study was conducted at Jinnah Postgraduate Medical Centre, Karachi, and comprised cases of giant cell tumour of foot bones diagnosed between January 1990 and March 2015. Tumour Incidence, type of procedure and results were recorded on a proforma and analysed for function outcome and recurrence. Clinical and radiological follow-up was done for a maximum 6 years. RESULTS: There were 240 cases of giant cell tumour but only 13(5.4%) related to foot bones. Of them, 8 (3.3%) were females and 5(2.0%) males. The mean age was 25 years (SD 10.59) (range: 17-38 years). In 7 (2.9%) cases lesion was in metatarsals, 2(0.8%) cases in phalanges, 3(1.2%) cases in calcaneus and 1(0.4%) case in talus. Duration of symptoms ranged from 4 to 12 months. All presented with radiologically stage 2 or 3 lesions. Resection of tumour and reconstruction with fibular graft was performed in 5(2.0%) cases, excision/curettage and filling cavity with cancellous bone graft in 5(2.0%) cases, resection in 2(0.8%) cases and toe amputation in 1(0.4%) case. There was recurrence in 2(0.4%) cases. No other complication was noted on last follow-up. CONCLUSIONS: Giant cell tumour in foot bones is a rare tumour and shows specific clinical and radiographic features with early involvement of entire bones, more aggressive behaviour with recurrence potential. The preferred treatment options are resection with reconstruction, curettage and filling cavity with bone graft/cement and amputation.