Johnson D. Ogunlusi

Interlocking nailing without imaging: the challenges of locating distal slots and how to overcome them in SIGN intramedullary nailing

Placement of the distal interlocking screw is the most difficult part in all intramedullary nail interlocking screw systems and the Surgical Implant Generation Network (SIGN) interlocking system is not an exception. SIGN nails are interlocking implants designed with a precision instrumentation set for use in treatment of long bone fractures without an image intensifier. Locating the distal slots of SIGN nails could be challenging for young SIGN surgeons when treating very complex comminuted fractures and in obese patients. This study was stimulated by a patient who presented one year after surgery with knee pain due to a migrating nail because of missed distal screws. A total of 48 patients divided into two groups of 24 were studied retrospectively and prospectively. The retrospective studies revealed that failure to locate distal locking slots in ten antegrade nailing procedures was due to wrong entry point and comminution of the fracture. The challenges encountered led us to innovating methods to overcome the difficulties of placement of distal screws in a prospective study. Application of methods A and B made location of the distal slots easier in the prospective study even though there were more complex comminuted fractures. The methods also reduced the antegrade operation time by 1 hour 11 minutes. We concluded that SIGN nailing could be challenging and frustrating at the early learning stage. Application of the two innovative methods will make distal slot location easier. They will also make SIGN interlocking nailing less difficult for young SIGN surgeons as they journey through the learning curves.

Management of complications of age-long tradition presented at Ado-Ekiti, Southwest Nigeria

Context: In the developing countries, traditional bonesetters (TBS) continue to ply their trade, and they treat a large proportion of patients with fractures and dislocations. They are known in the hospital practice because of complications arising from their practice that present in the hospital. Aims: To look at the pattern of complications of TBS limb injuries management that presented at our center; factors influencing the decision to patronize TBS and treatment outcome of the complications. Subjects and Methods: A descriptive study designed to look at the TBSs complications that presented at our hospital between May 2011 and April 2014. Results: Forty-five patients were managed after TBS intervention. Road traffic crash accounted for 64.4% of their injury. Relations (47.8%) and friends (34.8%) influenced largely, decision to patronize TBS. Thirty-three (61.1%) went to TBS believing they have better outcome. Fracture nonunion accounted for the highest complication (53.3%). Most of the patients had operative intervention. Twenty-eight (68.3%) regained full limb functions, whereas 13 (31.7%) had impaired functions. Conclusions: Large percentage of the patients believed TBS have better outcome; and their complications were treated largely by surgery to regain limb functions.

Castries Prone Positioning for Open Reduction and Internal Fixation of Closed Gartland Grade III Humeral Supracondylar Fractures in Children

Pediatric humeral supracondylar fracture Gartland type III is an orthopedic emergency that requires hospitalization and surgical treatment. This is a prospective study to document a simple positioning of the patient for easy reduction. Patients with Gartland type III humeral supracondylar fracture below the age of 12 years were recruited for this study after x-ray and classification. The patients were admitted to the ward from the emergency room after stabilization and subsequently had open reduction and internal fixation with Kirschner wire crossing in prone position. Twenty patients with Gartland type III humeral supracondylar fractures constituted the study group. There were 15 male and 5 female patients with Male:Female ratio of 3:1. The age ranged between 1 and 12 years with average of 6.1±3 years. The left humerus was affected 14 times compared with 6 times for the right humerus. We found out that the prone positioning is simple and does not require an assistant to constantly hold the forearm in position as would be required when the patient is placed in supine position. The prone positioning technique would be useful to fix humeral supracondylar fractures with Kirschner wire fixation where there is no radiologic aid for percutaneous pinning.

Acquired boneless forearm as a complication of traditional bone setting.

An 8-year-old girl sustained closed fracture of the right ulna 10 weeks prior to presentation. She was taken to a traditional bone setter who applied a tight splint. The patient reported pain, but the splint was not removed. A week after application of the splint, a foul odor was detected and removal of the splint showed extensive exposure of the forearm bones. Above elbow amputation was rejected by the patients parents when she was taken to hospital, where she was admitted for 8 weeks by a second traditional bone setter. A trained nurse applied herbal concoctions and dressed the wound daily in anticipation that the skin would cover the exposed bone fragments. She was brought to our hospital for wound dressing so that the skin would cover the exposed bones fragments. Examination revealed a grossly shortened right forearm--by 7 cm compared with her left--extensive exposure of both radius and ulna at the anterior aspect of the forearm, and loss of sensation and movement of the fingers. Radiographs showed sequestrated radius and ulna with involucrum around the olecranon process. Above elbow amputation was offered to the patient but the parents again declined. The forearm bones detached while scrubbing the wound for review and removal of the sequestrated bone. The wound healed within one and a half weeks of dressing, resulting in an acquired boneless forearm.