A case report of the Hoffa fracture and a review of literature.

The Hoffa fracture is an uncommon fracture. There is a lot of confusion about its diagnosis and management with several conflicting reports in literature. We reported a 25-year-old patient with non-union of Hoffa fracture, and meanwhile tried to develop an algorithm-based treatment for Hoffa fractures. A systematic review of the available literature was performed. Medline, Embase, the Cochrane Library and PubMed were searched for relevant articles. Fifty-five articles were reviewed, and the clinical knowledge base was summarized. The understanding of the mechanism of trauma has become more nuanced. The literature has also evolved to classify the fracture with the purpose of surgical management in mind. This can be used to plan approach and fixation with preservation of blood supply. Classification can also prognosticate the outcomes in Hoffa fracture.

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.

Pattern of rubber bullet injuries in the lower limbs: A report from Kashmir.

PURPOSE: Rubber bullets are considered a non-lethal method of crowd control and are being used over the world. However the literature regarding the pattern and management of these injuries is scarce for the forensic pathologist as well as for the traumatologist. The objective of this report was to add our experience to the existing literature. METHODS: From June 2008 to August 2010 the Government Hospital for Bone and Joint Surgery Barzulla and the Department of Orthopaedics, SKIMS Medical College/Hospital Bemina Srinagar received 28 patients for management of their orthopaedic injuries caused by rubber bullets. We documented all injuries and also recorded the management issues and complications that we encountered. RESULTS: All patients weremales with an age range of 11e32 years and were civilians who had been hit by rubber bullets fired by the police and the paramilitary forces. Among them, 19 patients had injuries of the lower limbs and 9 patients had injuries of the upper limbs. All patients were received within 6 h of being shot. CONCLUSION: Our findings suggest that these weapons are capable of causing significant injuries including fractures and it is important for the surgeon to be well versed with the management of such injuries especially in areas of unrest. The report is also supportive of the opinion that these weapons are lethal and should hence be reclassified.

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.

Open management of neglected inferior dislocation of the shoulder with proximal humeral fracture in an adolescent.

Neglected dislocation of the shoulder is a rare condition with some cases of anterior and posterior dislocation being reported. We report a case with a fracture dislocation of the proximal humerus with the dislocated head lying inferior to the glenoid. We also report on the surgical management of a case with this extremely rare condition which required shortening of the distal fragment to reduce tissue tension.

In the line of duty: a study of ambulance drivers during the 2010 conflict in Kashmir.

PURPOSE: The purpose of this study was to identify the problems faced by ambulance drivers working in a conflict zone. METHODS: This study was conducted on ambulance drivers working for the four major hospitals in Kashmir, India. The drivers were interviewed and asked a series of 30 work-related questions. The individual interviews were conducted over a three-month period in the valley of Kashmir that was affected by continuous violence, strict curfew, and strikes. RESULTS: A total of 35 ambulance drivers were interviewed. Drivers worked an average of 60 h/wk, and they drove an average of 160 km/d. Twenty-nine (83%) of the drivers experienced >1 threat of physical harm; 18 (54%) experienced physical assaults; and 31 (89%) reported evidence of psychological morbidity associated with their jobs. CONCLUSIONS: The atmosphere of conflict on the streets of Kashmir impacted the ambulance drivers adversely, both physically as well as mentally. The stress faced by these professionals in conflict zones during their duty hours should be recognized, and corrective measures must be put in place.

The Gibson and Piggott osteotomy for adult hallux valgus.

BACKGROUND: The Gibson and Piggott procedure for hallux valgus is based on sound surgical principles addressing the basic pathologies of this disorder. However, this procedure has not been studied extensively in the literature in comparison to the Mitchell and Chevron osteotomies. MATERIAL AND METHODS: We report a prospective study conducted on 50 adult feet with hallux valgus. The Gibson and Piggot osteotomy was done on all the feet. RESULTS: We obtained 76% excellent and 18% good results with this procedure. CONCLUSION: The results bear out the fact that this procedure is a useful procedure for the management of this disorder.

Fracture of the humerus caused by a slingshot projectile.

Unconventional and 'non-lethal' weapons are being used in crowd control regularly nowadays. The use of these arms is not risk-free. The paramilitary forces in 2010 used the old fashioned slingshots for crowd control in Kashmir. A young male suffered from a fracture of the distal humerus due to a marble from a slingshot. He was managed by debridement and plaster splintage. Use of apparently innocuous weapons for crowd control is not without risk, as the projectiles fired from them can achieve high velocities and cause significant damage.

Toilet seat injury of the Achilles tendon a series of twelve cases.

Lacerations of the Achilles tendon are caused by a number of mechanisms. The toilet seat as a cause of Achilles tendon injury is rare. We report on this rare mechanism of laceration of the tendo Achilles. The injury can be avoided with the use of western toilets and the additional devascularisation caused by extending the wound should be avoided while repairing the tendon in such situations.

Contracture of the third toe as a delayed presentation of a foreign body in the foot.

Foreign body retention in the foot after a penetrating injury is an unusual occurrence with varied presentation. A degree of suspicion needs to be present in situations where there is an inexplicable swelling, sinus, abscess, or tenderness. The authors present a case with a contracture of the third toe that had been caused by plantar fascial fibrosis secondary to retention of a rubber foreign body in the foot. This case report highlights the fact that an ultrasound to rule out retention of the foreign body might be a judicious investigation if common causes of toe contracture are excluded. It may also have therapeutic implications.

The reciprocal ledge closing wedge osteotomy for post traumatic coxa vara.

To report a proximal femoral osteotomy with retention of bone ledges in a reciprocal position to increase bone contact and stability. The method was applied to 5 patients over a 3-year period. All patients had coxa vara. The average length gained was 1.5 cm, and the average neck shaft angle improvement was 30°. The Harris hip score improved from an average of 63 to 82. The reciprocal ledge osteotomy is technically less demanding and also allows conversion of normal shear forces around the upper femur to stabilizing forces. This method allows easier use of the DHS implant as potential rotation about the axis of the screw is negated by the ledges and the dynamic forces.

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.

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.

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.

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.