Mohammed Ramzan Mir

Delayed fixation of displaced femoral neck fractures in younger adults

We report the results of 52 patients aged 20-55 years with displaced femoral neck fractures, in whom delayed closed reduction and internal fixation was performed. Seven patients developed avascular necrosis (AVN) and non-union was seen in five patients. Whereas most patients with non-union were subjected to repeat procedures, none of the patients with AVN required surgery. The follow-up averaged 40 months (range 22-64 months). Three patients were lost to follow-up. Functional outcome was defined by Judets system. Good to excellent functional outcome was achieved in 45 cases. The study demonstrated that delayed closed reduction and internal fixation of displaced fractures in young adults which, we believe, is the prevalent form of treatment of these injuries in the developing world results in high rate of fracture union and good functional outcome. The rate of AVN, however, may be a concern if the patients are followed for a longer period.

The Kashmir Earthquake Experience

On October 8, 2005, a major earthquake measuring 7.6 on the Richter scale struck the Himalayan region of Kashmir. Around 90,000 people died in the mass disaster. The Bone and Joint Hospital in Kashmir found itself in a relatively unique situation of having to deal with the orthopedic morbidity generated by this quake. The hospital received 468 patients over a period of 10 days, out of which 463 were received over the initial 5 days. The admission for a single day peaked at 153 patients on the third day. Due to the unprecedented admission in terms of numbers the hospital utilized outreach methods to streamline admission by sending out specialists to the affected areas. Manpower was judiciously utilized to concentrate specialist advise where required. Besides documenting the pattern of trauma, this paper throws light on some unforeseen problems faced in dealing with a large number of patients far exceeding the normal capacity of the hospital.

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.

Osteosynthesis for a T-shaped fracture of the femoral neck and trochanter: a case report.

Ipsilateral fractures of the femoral neck and trochanter are uncommon. We report a 30-year-old man with a T-shaped fracture separating the trochanter and neck from the head. He underwent osteosynthesis using a dynamic compression plate, screws, and pins. Bone union occurred 4 months postoperatively. At the one-year follow-up, the patient was free of pain and had no evidence of avascular necrosis. It is important to preserve the femoral head in young patients by preventing further compromise of the tenuous blood supply.

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.

Femoral ledge sparing closing wedge osteotomy.

Osteotomies around the hip and knee are important methods in the management of a number of different pathologies.

Acute invaginating docking for infected non- unions of the humerus

Purpose. To assess the efficacy of acute invaginating docking for infected non-unions of the humerus. Methods. Eight men and 3 women aged 17 to 59 years with infected non-unions of the humerus underwent acute invaginating docking with shortening and Ilizarov fixation. Results. The mean shortening was 2.9 cm owing to additional debridement. The mean time to external fixator removal was 14.9 (range, 8–28) weeks. The final bone result was excellent in 1, good in 8, and fair in 2. The functional result was excellent in 7 and good in 4. Conclusion. This modality enables simultaneous treatment of infected non-unions, axial alignment, vascularity, stability, and function.

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.

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°. 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.

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

IntroductionOsteoporosis 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 presentationWe 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.ConclusionUse of such minimally invasive methods can be beneficial in such complicated situations.