Rehan Ul Haq

A new classification scheme for open fractures.

Results: Evaluation of 34 factors identified through systematic literature review and ranking in order of importance by our panel resulted in consensus on five essential categories of open fracture severity assessment: skin injury, muscle injury, arterial injury, contamination, and bone loss. These categories were chosen with particular attention paid to avoiding redundancy with existing tools for assessment of fracture configuration. Evaluation of the system through prospective data collection revealed that the five categories were widely applicable to open fractures, but the subcategories of open fracture characteristics required alteration to reflect clinically important parameters for open fracture severity stratification. Skin injury was best assessed by its potential for approximation rather than laceration length. Muscle injury required quantitative and qualitative assessment of potential for function. The effects of arterial injury were most accurately assessed through distal limb ischemia. The depth and nature of contamination were important indicators of overall contamination significance. Bone loss was best assessed quantitatively.

Proximal femoral nails compared with reverse distal femoral locking plates in intertrochanteric fractures with a compromised lateral wall; a randomised controlled trial

PurposeThere is no consensus about the best option of internal fixation for unstable intertrochanteric fractures. The aim of the present study was to compare proximal femoral nail (PFN) with contralateral reverse distal femoral locking compression plate (reverse-DFLCP) in the management of unstable intertrochanteric fractures with compromised lateral wall.MethodIn a randomized controlled study, from November 2011 to October 2012, 40 patients with unstable intertrochanteric fractures with compromised lateral wall (AO 31A 2.2 to 3.3) had osteosynthesis by PFN (n = 20) or reverse-DFLCP (n = 20). Intra-operative variables compared were duration of surgery, blood loss during surgery, fluoroscopy time and surgeons perception of the surgery. Patients were followed up clinically for a minimum of one year. Functional outcome was assessed by Parker Palmer mobility score (PPMS), Harris hip score (HHS), and Short Form-12. Failure was defined as any condition which would necessitate revision surgery with change of implant.ResultsDuration of surgery (p = 0.022), blood loss during surgery (p = 0.008) and fluoroscopy time (p = 0.0001) were significantly less in the PFN group than in the reverse-DFLCP group. No significant difference was found in type of reduction, difficulty in reduction and surgeon’s perception of surgery. The PFN group had better functional outcome than the reverse-DFLCP group. HHS for the PFN group was 81.53 ± 13.21 and for the reverse-DFLCP group it was 68.43 ± 14.36 (p = 0.018). SF-12 physical (p = 0.002) and mental component (p = 0.007) scores in the PFN group was significantly better than in the reverse-DFLCP group. There was one failure in the PFN group as compared to six in the reverse-DFLCP group (p = 0.036).ConclusionDue to favourable intra-operative variables, better functional outcome and lower failure rates, we conclude that PFN is a better implant than reverse-DFLCP for intertrochanteric fractures with compromised lateral wall.

Conjoint bicondylar Hoffa fracture in an adult

Conjoint bicondylar Hoffa fracture is an extremely rare injury. Only one case has been reported previously in the pediatric age group. We describe this injury in a 17-year-old male who presented following a fall with direct impact on his semiflexed right knee. Plain radiographs were inadequate to define the exact pattern of injury. Computed tomographic (CT) scans demonstrated the coronal fracture involving both the femoral condyles which were joined by a bridge of intact bone. The patient was treated with open reduction and internal fixation using swashbuckler (modified anterior) approach. Union occurred within 3 months and at final followup (at 18 months) the patient had a good clinical outcome. The possible mechanism of injury is discussed.

Authors response: the lateral femoral wall

Dear Editor, We would like to thank the authors [1] for showing keen interest in our article [2] comparing two different implants for fixation of intertrochanteric fractures with a compromised lateral femoral wall. We have emphasised in our article that in spite of the general consensus about the importance of the lateral femoral wall in the management of intertrochanteric fractures, the literature is not clear about the exact area of the proximal femur which constituents the lateral femoral wall. Gotfried [3] defined it loosely as the proximal extension of the femoral shaft, but did not define its exact proximal or distal extent. Similarly, Palm et al. [4] defined it as the lateral femoral cortex distal to the vastus ridge without qualifying the distal extent. To clarify this confusion, we have defined both the proximal as well as the distal extent of the lateral femoral wall: (1) the proximal extent is the point on the lateral femoral cortex where the line drawn as a tangent to the superior femoral neck meets it (point b in Fig. 4. of the original paper [2]) and (2) the distal extent is the point on the lateral femoral cortex where the line drawn as a tangent to the inferior femoral neckmeets it (point d in Fig. 4. of the original paper [2]). The proximal extent defined by us, as rightly observed by the authors, is slightly above the vastus laterals ridge. This ensures two things: (1) all isolated fractures above it can be safely labelled as avulsion fractures of the greater trochanter and (2) all low intertrochanteric fractures, which exit lateral to the greater trochanter, near the vastus ridge and have a vulnerable lateral femoral wall, can be included. Similarly, taking the distal extent as defined by us ensures that (1) any fracture below it can be safely labelled as subtrochanteric fracture and (2) all reverse oblique (AO 31A 3.1–3.3) intertrochanteric fractures can be included (Fig. 1). If we were to define the lateral femoral wall as drawn by the authors [1], two large groups of intertrochanteric fractures, namely (1) low intertrochanteric fractures, which exit lateral to the greater trochanter near the vastus ridge, with a vulnerable lateral femoral wall, and (2) AO 31A 3.1–3.3 fractures with a preoperatively broken lateral femoral wall, would be excluded. We need to understand that a lateral femoral wall fracture which is seen on immediate postoperative intertrochanteric fracture radiographs fixed with DHS can be due to two reasons: (1) either the lateral femoral wall is broken pre-operatively, as is the case in AO 31A 3.1–3.3 fractures, or (2) the lateral femoral wall is vulnerable pre-operatively and breaks intra-operatively during the large diameter drilling for the sliding hip screw [3–6]. This is usually the case in AO 31A 2.2 and 31A 2.3

Classification of pelvic fractures and its clinical relevance

Pelvic fractures are one of the common cause of mortality in polytrauma patients, especially following high velocity trauma. The management in emergency requires good clinical judgment and access to radiological modalities. There are various classifications to define the pattern of injury in pelvic fractures. Previously, fracture patterns were described on the basis of anatomical fracture pattern on radiographs. With the introduction of concept of force vector and stability defined by Pennal and Tile, which was further modified by Young and Burgess, the corrective forces required to reduce such fractures were defined. With the introduction of these newer classification systems along with the introduction of external fixators, the mortality and morbidity has significantly reduced in pelvic fractures.

Posterior dislocation of hip with ipsilateral intertrochanteric fracture: A report of two cases.

Posterior dislocations of the hip are known to be associated with fractures of the femoral head, neck, shaft, or posterior acetabular wall. However, its association with ipsilateral intertrochanteric fracture has only been anecdotally described in the English literature. We report two such cases managed by open reduction (OR) of the hip and internal fixation (IF) of the intertrochanteric fracture. The first case was a 26-year-old male who was managed by OR of the hip with IF of the intertrochanteric fracture with a dynamic hip screw and had a good functional result at 1-year followup. The second case was a 36-year-old female who was also managed by OR of the hip with IF of the head fragments with Herbert screw and IF of the intertrochanteric fracture with a dynamic condylar screw. The patient had a fair, functional result at 1-year followup. With the increase in high energy trauma, these fracture patterns have become more common, and there is an urgent need to review the existing classifications so that these fractures are better categorized, and treatment guidelines defined.

Posttraumatic progressive cubitus varus deformity managed by lateral column shortening: A novel surgical technique

The outward angulation of elbow with supinated forearm is cubitus varus deformity. This deformity is often seen as sequelae of malunited supracondylar fracture of humerus in paediatric age group of 5–8 years. The deformity is usually non-progressive, but in cases of physeal injury or congenital bony bar formation in the medial condyle of humerus, the deformity is progressive and can be grotesque in appearance. Various types of osteotomies are defined for standard non-progressive cubitus varus deformity, while multiple surgeries are required for progressive deformity until skeletal maturity. In this study we described a novel surgical approach and osteotomy of distal humerus in a 5 years old boy having grotesque progressive cubitus varus deformity, achieving good surgical outcome.