R Maharjan

Giant pseudoaneurysm of subclavian artery after blunt chest trauma

Subclavian artery (SCA) pseudoaneurysm after blunt chest trauma is rare and its delayed presentation months after the SCA injury is even rarer. Herein we discuss a case of SCA pseudoaneurysm in a 74-year-old man who presented to us 5 months after blunt chest trauma. He had been managed conservatively for the fracture of first rib and clavicle until presentation to our hospital. He had uncontrolled hypertension and a rapidly increasing large painful swelling (10 by 8 cm) in left clavicular region along with purplish discoloration of the overlying skin. The diagnosis was confirmed after computed tomography angiography and the patient was successfully treated with surgical evacuation of clots, primary repair of the rent in the SCA, and plating of clavicular fracture.

The effect of alfacalcidol and plain vitamin d on osteoporosis: A randomised controlled trial

Background: Osteoporosis is “a systemic metabolic bone disease characterized by low bone mass and micro architectural deterioration with a consequent increase in bone fragility with susceptibility to fracture. Multiple drug therapy with Alendronate, Calcium & plain vitamin D or alfacalcidol has been established to treat osteoporosis. In any patient with healthy liver and kidneys, plain vitamin D is expected to be as good as more active form of vitamin D. This study was conducted to compare the efficacy, safety and cost effectiveness between alfacalcidol and plain vitamin D in addition to Calcium and Alendronate in the management of osteoporosis. Methods: The Randomized Controlled Trial was conducted in B.P. Koirala Institute of Health Sciences, a tertiary care hospital in Eastern Nepal, over a period of twelve months from January 2013 to December 2014. Patient in group A were given Alfacalcidol, and group B were given plain Vitamin D. Results: Most of the patients were from the age group 60-69 yrs of age; mean age 65.54 ± 7.49. The BMD and T score were recorded at baseline and after treatment. The BMD measured 0.62853±.060241 at baseline and 0.67910 ± 0.059040 after treatment and T score measured -3.204 ±0.5455 at baseline and -2.698 ± 0.5772 after treatment. There is no statistical significance between the parameters (BMD and T score) of the two groups. Conclusion: For the first time in Nepal we have shown that the therapy with alfacalcidol and plain vitamin D when used with alendronate and calcium, have similar efficacy and safety, though the cost of the treatment with alfacalcidol was much higher than that of the plain vitamin D group.

A randomized controlled trial comparing EUSOL versus antibiotic loaded collagen granules as dressing agents in the management of traumatic infected wounds

Background: Traumatic wounds are common cause of morbidity in Orthopaedic patients. There can be associated injury to various vital structures i.e bones, muscles, tendons, nerves and vessels. Despite recent advances in wound care, the challenge of managing chronic wounds remains compounded by a lack of consensus on clearly defined wound care principles. Methods: A randomised controlled trial was used to enrol 130 patients, out of which 65 underwent EUSOL dressing and 65 underwent collagen granules dressing, all the cases were admitted in Orthopaedics ward and were only discharge at the end of treatment or study period whichever was earlier, so there was no loss to follow up. Assessment of wound was done every week for a period of 4 weeks in terms of slough, discharge, granulation tissue, outcome and coverage. Results: Discharge from the wound was found to be lesser in collagen granules group and by the end of 3 and 4 week it was significantly lesser in collagen granules group (P value <0.05). Floor area covered with slough were lesser in collagen granules group, as early as 1 week (P value <0.05). Healthy granulation tissue, final outcome and coverage appeared earlier with collagen granules group. P value<0.05 by the end of 2 and 3 week. Total cost of therapy was less and patient compliance was better with collagen granules group. Conclusion: Antibiotic loaded collagen granules showed better results in terms of discharge, granulation tissue, healing, duration and cost of therapy, patient compliance and acceptability.

Fixation of greater tuberosity fracture in rare unstable bilateral glenohumeral joint dislocations with bilateral fractures of the greater tuberosities: A case report

Introduction: Unstable dislocations of the bilateral glenohumeral joint with fractures of both greater tuberosities are very rare. Case presentation: A 48-year-old gentleman sustained a bilateral anterior dislocation of his glenohumeral joint with fractures of the greater tuberosities on both sides after an episode of seizure. Attitude of both shoulders were abducted and externally rotated. Radiological examination revealed the dislocations of bilateral glenohumeral joint and also the fractures of the bilateral greater tuberosities. Closed reduction and shoulder derotation immobilizer was applied. The Reduction was unstable and needed fixation of both sides greater tuberosity with cannulated cancellous screws. The shoulders were immobilized for 3 weeks and subsequent rehabilitation yielded a good outcome. Results at 6 months follow-up were satisfactory with normal range of motion and no redislocations occurring. To our knowledge, this is the first reported case of bilateral unstable glenohumeral joint dislocation associated with fractures of both greater tuberosities in a middle aged man which was unstable needing fixation of greater tuberosities fractures. Conclusion: Bilateral glenohumeral joint dislocations with bilateral fractures of the greater tuberosities may be unstable needing fixation of greater tuberosity fracture. Health Renaissance 2015;13(2): 173-177

An isolated capitellum fracture of the humerus in adult: A rare case report

Introduction: Isolated capitellum fractures are rare and represent only 1% of all elbow fractures and 6% of distal humeral fractures. Case description: A 45-year-old right hand dominant female presented to us with pain and stiffness in her left elbow following a fall onto the outstretched hand that occurred 6 months prior. She had capitellum fracture with avascular changes and excision of the fractured fragment was done. Physiotherapy was initiated with outcome of nearly normal elbow function. At the time of injury, she was unable to move her elbow actively due to pain and she was misdiagnosed as soft tissue injury earlier in a local hospital. Conclusion: Possibility of rare diagnosis such as capitellum fracture should also be kept in mind while treating elbow injuries.

Transfer of technology regarding correction of congenital talipesequinovarus by ponseti method of treatment to doctors working at peripheral hospitals of eastern region of Nepal covered by BPKIHS, Dharan.

Background: Ponseti method of manipulation and casting has been standard non operative method of treatment for idiopathic clubfoot. We have conducted this study to find out whether Ponseti method of correction can be taught to doctors working at district hospital. Objective: To assess the knowledge, familiarize the Ponseti method of correction and to decrease the need of surgery regarding the congenital talipesequinovarus. Method: We conducted prospective study among doctors working in the district hospitals of eastern Nepal. We assessed knowledge and practice regarding clubfoot management before and after the intervention by questionnaire based method. The data were analyzed using before and after difference for magnitude and paired t test for significance. Result: 13 doctors were included in the study. Among 13 participants, one (7.69%) had formal orthopedic training. Only 30% of the participants had more than 60% correct response regarding questionnaires regarding knowledge of clubfoot. 40% of participants had done referral of cases to orthopedic centre. One (7.69%) of the participants had applied Ponseti cast. 61% percent of the participants responded more than 60% correctly at the final follow up at one year. Conclusion: The study shows that the knowledge and practice regarding Clubfoot correction is inadequate and hence teaching of Ponseti method was useful in the district hospital. Health Renaissance 2015;13(2): 144-152