Management of humeral fracture nonunion in severe osteoporosis by a combination of locking plating and intramedullary fibular grafting.

Nonunion of the humerus in a severely osteoporotic bone is a likely event especially if the fracture is transverse. The management of such a combination is a challenge. Most of the conventional fixation methods are unlikely to succeed as the bone failure precedes implant failure in osteoporosis. The challenge is further compounded in severe osteoporosis when the cortical thickness is affected more severely. We used a combination of an intramedullary fibula with a locking plate in 5 cases. The results show that it may be a good combination in such situations as the bone strength is augmented and the plate pullout is less likely.

The Musculoskeletal Manifestations of Type 2 Diabetes Mellitus in a Kashmiri Population.

OBJECTIVES: Diabetes mellitus (DM), is affecting an ever increasing number of people worldwide. Diabetes is associated with several musculoskeletal manifestations. These may involve, the upper as well as the lower limb. We conducted this study to find out the prevalence of musculoskeletal problems in type 2 diabetics in the Kashmiri population. METHODOLOGY: The study was conducted on 403 patients with diabetes and 300 controls. All patients underwent screening for any musculoskeletal abnormalities. The patients with musculoskeletal abnormalities were further assessed to find the exact diagnosis according to predefined criteria. RESULTS: The hand was involved in 80 patients [19.8%] in the diabetic group and 15 (5%) patients of the control group. The elbow was affected in 56 patients [14%] in the diabetic group and 24 patients [5.9%] in the non-diabetic group. The shoulder involvement was diagnosed in 61 patients [15%] on the diabetic cohort and 15 patients in the non-diabetic cohort. All the upper limb figures showed a statistically significant difference i.e. P value <0.05. CONCLUSION: The prevalence of musculoskeletal complications in type 2 diabetics in Kashmir is quite high.

Transmalleolar approach to a tubercular lytic lesion of the talar body: a case report.

Tuberculosis of the talus is a rare condition, and the diagnosis can be difficult to make because of inconclusive laboratory and ancillary testing. In such cases, accurate diagnosis and appropriate treatment may require the use of a transmalleolar osteotomy to gain access to the involved portion of the talar body. In the case described in this article, a transmalleolar approach was used to gain access to a lytic lesion of the talar body so as to obtain microbiological and histopathological specimens for diagnostic purposes, and to thoroughly debride the lesion. After 6 years of postsurgical follow-up, the patient was leading a normal life with a full range of ankle and subtalar motion. The rarity of the diagnosis, and the use of the transmalleolar approach to a lytic and likely infected lesion in the body of the talus, makes this case worthy of public discussion.

Stable relocation of the radial head without annular ligament reconstruction using the Ilizarov technique to treat neglected Monteggia fracture: two case reports.

INTRODUCTION: A Monteggia facture dislocation is not an uncommon injury, and the diagnosis can often be missed. Long-term follow-up of untreated Monteggia fracture dislocations reveals development of premature arthritis, pain, instability, and loss of pronation and supination. Methods involving annular ligament reconstruction require post-operative immobilization and use of transcapitellar pinning for maintenance of reduction, and thus a delay in rehabilitation. The literature reports satisfactory results with methods that involve ulnar osteotomy and open reduction of the radial head without annular ligament reconstruction. We used the Ilizarov method in two cases with neglected Monteggia fracture dislocations to stably reduce the radial head without open reduction and annular ligament reconstruction. CASE PRESENTATION: We report two cases of neglected Monteggia fracture dislocation, in two Kashmiri boys aged four and six years. Using ulnar osteotomy with distraction osteogenesis, we were able to relocate the radial head gradually and maintain the reduction without a requirement for open reduction and annular ligament reconstruction. CONCLUSION: Distraction lengthening and hyperangulation in different planes by use of the Ilizarov technique effectively reduces the radial head without open reduction and annular ligament reconstruction.

Treatment of ipsilateral high energy tibial plateau and calcaneal fractures by a circular wire fixator: a case report.

INTRODUCTION: High energy tibial plateau fractures along with calcaneal fractures individually produce several challenges for the orthopaedic surgeon. The principles of bony reconstruction include anatomic reduction and rigid internal fixation of intra-articular fractures and accurate restoration of the coronal, sagittal and transverse mechanical axes. Due to the tenuous nature of the soft tissue and devitalisation of the comminuted fragments with open reduction, external fixation of type 6 tibial plateau fractures is recommended. We report a case with ipsilateral high energy tibial plateau and calcaneal fractures both of which were managed with an ilizarov ring fixator. CASE PRESENTATION: A 55-year-old Kashmiri female presented to our department with an ipsilateral fracture of the tibial plateau and the calcaneum. Both were closed reduced and stabilized with an ilizarov ring fixator. CONCLUSION: The circular wire fixator provides a viable method to manage such fractures especially if they are co existent. This is especially true in situations where the soft tissue is compromised.

The role of composite technique in managing peri implant re-fractures in a case with supracondylar fracture of the femur: a case report.

INTRODUCTION: Osteoporosis of the long bones challenges the orthopaedician in several ways. Amongst the difficulties encountered are the reduced bone mass, increased bone brittleness and medullary expansion, which must be factored in when deciding the type of surgical method to be used. One of the commoner complications of fixation of fractures in such bone is the occurrence of peri implant fractures with subsequent management requiring significant surgical acumen and judgment. CASE PRESENTATION: We report a case who sustained a supracondylar fracture of the femur, which was managed initially by a dynamic condylar screw assembly. The patient sustained a peri implant fracture during her rehabilitation, which was managed by the application of a longer side plate. 4 months postoperatively the patient sustained another peri implant fracture. Using a minimally invasive method we removed the screws from the plate and passed an intramedullary implant. The whole assembly was rotationally stabilized using an Ilizarov fixator. The union proceeded uneventfully. CONCLUSION: Use of such minimally invasive methods can be beneficial in such complicated situations.

Delayed fixation of the transcervical fracture of the neck of the femur in the pediatric population: results and complications.

PURPOSE: To determine the impact of a substantial delay in providing surgical treatment on the final outcome in transcervical femoral neck fractures in children. METHODS: Data on all pediatric patients with transcervical fractures of the femoral neck that were fixed by reduction and internal fixation after a delay of ≥7 days in our department between 2000 and 2008 were collected both retrospectively and prospectively. RESULTS: The medical records of 14 patients (15 fractures) were analyzed. The results after an average of 43 months of follow-up showed that the complication and avascular necrosis rates were higher in cases in which treatment had been delayed compared to those in comparable fractures that had been treated promptly after the event in other series. Nine of the 15 fractures had developed avascular necrosis at final follow-up. Overall, there were four excellent, three good, and eight poor results (based on the Ratliff criteria). CONCLUSIONS: Children whose transcervical fractures of the femoral neck were surgically treated after a delay of 1 week or longer had a high avascular necrosis rate and a relatively poor outcome. Reduction and internal fixation as the initial treatment should be implemented shortly after injury in order to enhance treatment outcome.

Delayed manifestations of the "Nail-Slipper injury".

Penetrating injuries of the foot are a common presenting complaint in the emergency department. The residents of the underdeveloped world are especially prone to suffer such injuries as barefoot walking is still common. However, a relatively common injury that occurs in the shod feet is the "Nail-Slipper injury". A metal nail penetrates through the rubber sole of the footwear introducing the rubber piece into the soft tissue of the foot. As the nail is removed the piece remains behind often leading to delayed manifestations. This article describes the various delayed manifestations of this injury. A leading question for the antecedent injury of this kind should be asked from all patients with such presentations, especially in the urban setting.

Draining infected non union of the distal third of the tibia. The use of invaginating docking over short distances in older patients.

BACKGROUND: The distal third of the tibia is unique in the sense that it has a minimal muscle cover and consequently the blood supply is easily compromised after a fracture in this area. Infected non union in this area provides a challenge to the orthopaedic surgeon. These difficulties are especially profound in the geriatric age group. MATERIAL AND METHODS: 12 cases with an infected non union of the distal third of the tibia were managed with acute docking over a distance of up to 2.5 cms. The age of these patients was more than 55 years. RESULTS: The average shortening at final follow up was 1.8 cms. The bone results were assessed according to the protocol laid down by the association for the study and application of the method of Ilizarov. Accordingly we had 3 excellent, 8 good and 1 fair result. The functional result was calculated as per the Ilizarov criteria [1]. On this basis we had 7 excellent, 4 good and 1 fair result. CONCLUSION: The acute docking modality is applicable to the distal tibia in such situations even in the geriatric population with predictable results.

Differentiating mass disasters. The barzullah classification.

BACKGROUND: To assess the pattern of mass casualty incidents managed at our hospital over the last eight years, and evolve a differentiating classification based on this pattern. A combination of retrospective and prospective assessment was made. MATERIAL AND METHODS: All patients receiving injuries in mass casualty incidents and managed at our hospital. Patients with an injury severity score above 9. Management of injuries as per the trauma management protocol. Classification based on the data collected during the study and application of this classification to the subsequent mass casualty incidents to allow comparison between similar incidents in different settings. RESULTS: A classification system that mainly differentiates mass casualty incidents on the hospital basis, the criteria being: the time interval between the first information to first reception, and the percentage of admission above the maximum normal intake. CONCLUSIONS: The Barzullah classification system is the first attempt at developing a hospital based differentiation in mass casualty incidents. It provides a valid and easy method of comparing such incidents between hospitals and perhaps a basis for developing protocol for mass disaster management.

A reciprocating ledge technique in closing wedge osteotomy for genu valgum in adolescents.

PURPOSE: To describe a technique that preserves anterior and posterior alternate ledges in a closing wedge osteotomy. METHODS: Five patients aged 14 to 19 years underwent a closing wedge osteotomy for genu valgum in 8 limbs using a reciprocating ledge technique. A unicortical wedge of bone was removed, with the anterior and posterior cortices spared. The anterior cortex at the proximal level and the posterior cortex at the distal level were cut through. With a wobbling action, the osteotomy site was rotated, and the distal fragment externally rotated. Manual force was applied to close the osteotomy site ensuring overlapping of the reciprocal ledges. The distal fragment was translated laterally to prevent club deformity. The osteotomy site was held with one or 2 staples. Stability was tested by flexion and extension of knee. RESULTS: All 8 limbs attained bone union within 12 weeks, and full range of motion within a mean of 13 (range, 12-15) weeks. The mean correction of the tibiofemoral angle was 13 degrees. At a mean follow-up of 12 months, all patients were pain-free and none developed club deformity. CONCLUSION: Sparing reciprocal ledges in a closing wedge osteotomy for genu valgum may increase stability in the flexion-extension axis, enable early range-of-motion exercises, and facilitate early bone union.

Use of the Ilizarov apparatus to improve alignment in proximal humeral fractures treated initially by a unilateral external fixator.

One of the recommended methods for the management of displaced unstable proximal humeral fractures is the unilateral external fixator. In polytrauma cases this method may be especially useful for the stabilisation of these fractures. However, problems may arise if the fracture is fixed in a malaligned or distracted position. Conversion of the treatment concept to other modalities is difficult because of the problem of pin tract infection. The Ilizarov apparatus provides an useful method in such situations, as it allows distraction, translation and compression without the need for further anaesthesia and additional fixation.

Operative management of a subtrochanteric fracture in severe osteoporosis. a case report.

BACKGROUND: Fractures of the subtrochanteric region of the femur provide several challenges to the operating surgeon due to anatomic and biomechanical peculiarities inherent to this region. These challenges are compounded several times in a severely porotic bone. CASE PRESENTATION: We report a case with severe osteoporosis who sustained a subtrochanteric fracture and was managed with a Dynamic condylar screw DCS. Three years after the surgery the patient is pain free and has a full range of motion. CONCLUSION: This highlights the fact that the DCS provides a viable alternative in the management of fractures of the subtrochanteric region in severe osteoporosis. This advantage is particularly manifest in settings where the image intensifier is not easily available.

Unforeseen difficulties faced by a hospital in dealing with mass disaster victims.

Every major mass disaster challenges the health care services, especially in the third world. These challenges include the expected situations mainly pertaining to the overload of patients and the stretching of hospital facilities. We report our experiences about several unforseen challenges faced by our hospital in the 2005 earthquake that struck the Kashmir region.

Management of lower limb fractures in polytrauma patients with delayed referral in a mass disaster. The role of the Ilizarov method in conversion osteosynthesis.

Polytrauma cases in mass disasters present several challenges to the orthopaedic surgeon. Delayed referral, multisystem involvement and the requirement to manage coexisting injuries by interhospital transfer often make infection an inevitable risk. 28 patients with polytrauma were studied after being referred after being recovered from the debris of their homes in the Kashmir earthquake. All patients were referred more than 24h after sustaining their injuries. The lower limb fractures were fixed by external fixators in all these cases before interhospital transfer for the management of their co existing injuries. Return referral to the orthopaedic facility occurred after an average of 25 days. All cases were converted to Ilizarov fixation. The results bear out the fact that the Ilizarov method may be well suited for conversion osteosynthesis of lower limb fractures in polytrauma cases.

More than two years delay in the union of fracture neck of femur after primary intervention.

INTRODUCTION: More than two years delay in the union of fracture neck of femur is a very rare entity.The treatment of an established non union depends on numerous factors including age of the patient, vascularity of the femoral head and other factors. It is timing of intervention that is not clearly defined in the literature. CASE PRESENTATION: We report 2 cases where fracture neck of femur in 2 Asian males of 37 and 52 years of age took more than 2 years to unite after primary intervention. CONCLUSION: We believe if the implant is holding and patient is able to bear some weight, some of these fractures may unite without any further intervention.

Open reduction and internal fixation in a case with transscaphoid perilunate dislocation 8 months after the injury: a patient with a 5-year follow-up.

The management of perilunate dislocations diagnosed later than three months continue to elicit debate with literature being scarce. We report a 22-year-old male with transscaphoid perilunate dislocation who reported to our hospital 8 months after sustaining the injury. Open reduction was done along with bone grafting. Five years after the surgery the patient is symptom-free with an excellent range of motion.

'Damage control orthopaedics' in patients with delayed referral to a tertiary care center: experience from a place where Composite Trauma Centers do not exist.

BACKGROUND: Management of orthopaedic injuries in polytrauma cases continues to challenge the orthopaedic traumatologist. Mass disasters compound this challenge further due to delayed referral. Recently there has been increasing evidence showing that damage control surgery has advantages that are absent in the early total care modality. We studied the damage control modality in the management of polytrauma cases with orthopaedic injuries who had been referred to our hospital after more than 24 hours of sustaining their injuries in an earthquake. This study was conducted on 51 cases after reviewing their records and complete management one year after the trauma. RESULTS: At one year, out of the 62 fractures, 3 were still under treatment, while the others had united. As per the radiological and functional scoring there were 20 excellent, 29 good, 5 fair and 5 poor results. In spite of the delayed referral there was no mortality. CONCLUSION: In situations of delayed referral in areas where composite trauma centers do not exist the damage control modality provides an acceptable method of treatment in the management of polytrauma cases.