Naseem ul Gani

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.

Humeral biepicondylar fracture dislocation in a child: A case report and review of the literature

IntroductionHumeral biepicondylar fracture dislocation is a very rare injury reported only once in English literature by G R Taylor et al. We report a case of humeral biepicondylar fracture dislocation in a 13-year-old girl with a unique mechanism of injury.Case presentationA 13-year-old girl presented with trauma elbow. Radiographs showed biepicondylar fracture of humerus with dislocation of elbow.ConclusionIn humeral biepicondylar fracture dislocation, reduction is always unstable. So treatment is open reduction and internal fixation.

Midterm Functional Outcome after Operative Management of Midfoot Injuries

Background. Injuries of the midfoot are often missed and therefore underestimated. Early diagnosis and treatment are crucial for the final outcome. The primary aim of this study was to assess the pattern and results of early operative management of mid-foot injuries after a midterm follow up. Material and methods. This study was conducted on 25 patients (19 Males, 6 Females ) with mean age of 34.6 years (range 18-60 years) with mid-foot fracture dislocations who were admitted consecutively at our centre from May 2008 through November 2010. 25 patients fulfilling our inclusion criteria with mid-foot fracture dislocations were included in this study. Mechanism of injury, its pattern and results of operative management of midfoot injuries were assessed after acute management of these fractures on urgent basis. Evaluation of results was done by AOFAS Score. Results. Most common mode of injury was indirect trauma due to fall (n=12) followed by road traffic accident (n=9). Males (n=19) outnumbered females (n=6). The pattern of injuries requiring operative treatment as per our criteria were Lisfranc fracture dislocations (n=22) and navicular fractures (n=3). The mean follow up was 3.2 years and mean AOFAS score at 3.2 years was 78.36, with most patients losing points to pain and decreased recreational function. Conclusion. The Lisfranc fracture dislocations are the most common injuries around midfoot requiring operative treatment, and we believe that operative treatment considerably improves functional outcome in these injuries.

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

IntroductionMore 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 presentationWe 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.ConclusionWe believe if the implant is holding and patient is able to bear some weight, some of these fractures may unite without any further intervention.

Long Term Results in Refractory Tennis Elbow Using Autologous Blood

Tennis elbow (TE) is one of the commonest myotendinosis. Different treatment options are available and autologous blood injection has emerged as the one of the acceptable modalities of treatment. Long term studies over a larger group of patients are however lacking. The purpose of this study was to evaluate these patients on longer durations. One-hundred and twenty patients of TE, who failed to respond to conventional treatment including local steroid injections were taken up for this prospective study over the period from year 2005 to 2011 and were followed up for the minimum of 3 years (range 3-9 years). Two mL of autologous blood was taken from the ipsilateral limb and injected into the lateral epicondyle. The effectiveness of the procedure was assessed by Pain Rating Sscale and Nirschl Staging, which was monitored before the procedure, at first week, monthly for first three months, at 6 months and then 3 monthly for first year, six monthly for next 2 years and then yearly. Statistical analysis was done and a P value of <0.05 was taken as significant. The patients (76 females and 44 males) were evaluated after procedure. The mean age group was 40.67±8.21. The mean follow up was 5.7±1.72 (range 3 to 9 years). The mean pain score and Nirschl stage before the procedure was 3.3±0.9 and 6.2±0.82 respectively. At final follow up the pain score and Nirschl were 1.1±0.9 and 1.5±0.91 respectively. Autologous blood injection was found to be one of the modalities for treatment of TE. Being cheap, available and easy method of treatment, it should be considered as a treatment modality before opting for the surgery. Universal guidelines for the management of tennis elbow should be made as there is lot of controversy regarding the treatment.

Changes in Serum Level of Vitamin D During Healing of Tibial and Femoral Shaft Fractures

Dear Editor, We read with interest the article by Ettehad et al. (1), in which the authors provide a detailed discussion of the variations in serum vitamin D levels during the course of fracture healing. We have a few considerations regarding this study. The authors have not mentioned the treatment modalities used for these fractured limbs. Operatively managed fractures are mobilized early; consequently, the serum vitamin D levels of an ambulatory person may differ from those of a bedridden person. Ambulatory persons are also more likely to be exposed to sunlight, and vitamin D 3 (cholecalciferol) is synthesized by the human skin on exposure to the ultraviolet-B radiation of sunlight (2). Both dietary intake and endogenous synthesis contribute to the body’s vitamin D status. Since different factors modulate the extent of endogenous vitamin D formation, quantification is hardly possible. Regarding the objective of this study, the authors mentioned studying the role of vitamin D supplementation in the process of bone formation. However, they have not mentioned whether vitamin D supplementation was started in these patients. In addition, no mention is made regarding the effects of the low measured vitamin D levels on the final results of fracture healing. Tibia and femoral fractures take a longer time to unite, (3), so the serum vitamin D levels at the time of fracture union (i.e., six months and/or at the time of delayed union/non-union) should have been reported to make the study more effective. The levels of vitamin D showed uniform decreases in all age groups and among both genders in the first week, indicating that the fracture healing takes the same course (direct or indirect healing). All persons with fractured bones may not be targets for vitamin D supplementation, and only patients with previously low levels or patients with refractures might benefit from these supplementations (4). Further studies are required to determine the effect of low initial levels of vitamin D on fracture healing. The authors should expand on the present study by checking the levels of vitamin D at the time of radiological or clinical union of the fractures and then checking the effect of vitamin D supplementation on the fracture healing process. Furthermore, refracture in these patients may be an eye opener for developing countries, where we often see hypovitaminosis in the general populations.

Complications of paediatric elbow trauma treatment by traditional bonesetters.

This is a retrospective review of paediatric elbow trauma, which was initially treated by bonesetters and subsequently reported to the hospital for management. This paper describes the pattern of trauma and the complications of unscientific management. The report also recommends a basic training program for the bonesetters so as to make them aware of the potential complications involved in managing paediatric elbow trauma.

External fixation of “intertrochanteric” fractures

In developing countries, due to limited availability of modern anesthesia and overcrowding of the hospitals with patients who need surgery, high-risk patients with “intertrochanteric” fractures remain unsuita ble for open reduction and internal fixation. The aim of this study was to analyze the results of external fixation of “intertrochanteric” fractures in high-risk geriatric patients in a developing country. The results of 62 ambulatory high-risk geriatric patients with a mean age of 70 years (range 58–90 years) with “intertrochanteric” fractures, in whom external fixation was performed, are reported. Eight patients died during follow-up due to medical causes unrelated to the surgical procedure. So only 54 patients were available for final assessment. Procedure is simple, performed under local anesthesia, requires less time for surgery and is associated with less blood loss. Good fixation and early ambulation was achieved in most of the patients. Average time to union was 14 weeks. Thirty-one patients developed superficial pin tract infection and 28 patients had average shortening of 15 mm due to impaction and varus angulation. Functional outcome was assessed using Judets point system. Good to excellent results were achieved in 44 patients. This study demonstrated that external fixation of “intertrochantric” fractures performed under local anesthesia offers significant advantage in ambulatory high-risk geriatric patients especially in a developing country.