Shabir A. Dhar

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.

Lateral invaginating peg (LIP) osteotomy for the correction of post-traumatic cubitus varus deformity.

Closing wedge osteotomies are the gold standard for the management of post-traumatic cubitus varus deformity. However, most of these osteotomies are fraught with complications such as lateral condylar prominence, instability, and difficulty in correcting internal rotation. We describe a new technique that provides a means for the management of all these problems simultaneously.

Duloxetine in treatment of refractory chronic tennis elbow: Two case reports

IntroductionTennis elbow is a common musculoskeletal disorder; management options include physiotherapeutic, medical, surgical, and other forms of intervention. Some patients remain symptomatic despite best efforts. We present two patients who did not respond to medical and surgical treatments, and whose symptoms were relieved with duloxetine. This is the first report on the use of duloxetine to treat tennis elbow.Case presentationTwo mentally healthy young Asian women aged 32 and 27 years, each with tennis elbow of about 18 months duration continued to suffer pain despite treatment with analgesics, local steroid injections, physiotherapy, cryotherapy, ultrasound, and surgical release, among other interventions. Both showed substantial improvement within 4 to 6 weeks of receiving monotherapy with duloxetine 60 mg/day. Both were pain-free with continued treatment at a 6-month follow-up.ConclusionDuloxetine may be a useful treatment option in patients with chronic tennis elbow, even those who have failed conventional medical, physiotherapeutic, surgical, and other forms of management.

Pattern and epidemiology of pediatric musculoskeletal injuries in Kashmir valley, a retrospective single-center study of 1467 patients.

This work aimed to study the pattern and epidemiology of pediatric musculoskeletal trauma and consequent morbidity in Kashmir Valley and compare the results with other studies and to formulate preventive measures and devise management strategies. This was a retrospective study of 1467 pediatric orthopedic trauma patients who presented to our hospital over a 3-year period between September 2005 and August 2008. Information was recorded in a prescribed proforma including the following: age, sex, mode of trauma, type of fracture/injury, radiological study, final diagnosis, intervention performed, and complications. The information was collected from the Medical Records Department of the hospital. The children’s ages ranged from 0 to 16 years; there were 996 males and 471 females, with males outnumbering females in every age group (the overall male-to-female ratio was 2.12 : 1). Most fractures occurred in children aged 7–12 years [n=816 (53.96%)] and decreased in younger and older children beyond this age group. The left side was involved in 762 cases, 612 injuries involved the right side, 24 were bilateral, and 69 patients presented with multiple injuries. In children aged 0–6 years, the most common site of injury was the elbow, whereas in children aged 7–16 years, it was the forearm. In descending order, most injuries were sustained because of fall while playing (34.76%), fall from height (33.74%), road traffic accidents (14.92%), and fall from standing height (7.97%). The majority of injuries were caused by unintentional trauma (94.48 vs. 5.52%). The places where injury occurred were the home [603 (41.10%)], play field and orchards near the home [450 (30.67%)], roads [219 (14.92%)], school [183 (12.47%)], and unknown [12 (0.81%)]. The pattern and epidemiology of pediatric trauma differs from those in adults. The majority of musculoskeletal injuries are because of unintentional trauma in this young age group and hence preventable. Enhanced supervision at home and school is recommended. A safer environment and better playing conditions may decrease the high frequency of trauma in pediatric patients. Dedicated trauma centers with such facilities as orthopedics, neurosurgery, and plastic surgery need to be established for the proper management of pediatric trauma.

Outcome of treatment of the mismanaged pediatric elbow trauma: a series of 73 cases.

Purpose. To analyze the outcome of the management of pediatric elbow trauma referred to our hospital after initial intervention by traditional bone setters. Method. Retrospective study of 73 patients, presenting to the hospital with a complication attributable to the initial mismanagement of their injuries. Results. The mode of presentation was directly related to the type of initial intervention on the basis of which we were able to quantify bone setters into two groups. The first group using a rather rough method of trauma treatment involving the application of tight local bandages, massage and manipulation and a second group having a relatively less rough approach, applying splints to the injured extremity without tight bandages and manipulation. The result of treatment of these injuries was determined by the delay in presentation and the type of injury. Conclusion. This study highlights the importance of dealing with the unchecked and unsupervised practice of bone setting in the developing world. We believe that training these people on the pattern of traditional birth attendants can at the very least lower the occurrence, if not entirely eliminate the problem of mismanaged trauma in this part of the world.

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.

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.

Chronic Osteomyelitis of the Carpal Trapezoid

An 18 year-old man presented with a twelve month history of recurrent pain in the left wrist. The patient had had two similar episodes in the past, both of which responded to antibiotics. In this third occasion, the patient had similar wrist pain which had been present for four days and had not responded to Cloxacillin. On examination, there was a swelling on the dorsoradial aspect of the wrist which was tender to palpation. All wrist movements, but especially radial deviation and dorsiflexion, were painful. His ESR and CRP acute phase reactants were elevated. Plain X-ray showed sclerosis in the region of the trapezoid and CT examination showed a sequestrum within the trapezoid (Fig 1). A sequestrectomy was carried out through a dorsal approach. Intraoperatively, cartilage erosion of the adjacent trapezium and second metacarpal was seen. Postoperatively, the patient was treated with antibiotics for six weeks. The pain subsided and recovery was uneventful. At one year, the patient was symptom-free, apart from a 151 restriction of radial deviation of the wrist. While X-ray demonstrated less sclerosis of the trapezoid, ankylosis between the trapezoid, the trapezium and the second metacarpal was present. Osteomyelitis of the carpal bones is extremely uncommon and most cases involve the scaphoid bone (Baek and Chung, 2002; Cosgarea et al., 1993). Our literature review disclosed no previously reported cases of chronic osteomyelitis of the trapezoid. Apart from the dorsal surface and a very small volar surface, this bone is mostly intraarticular. Therefore, ankylosis of the trapezoid, the trapezium and the second metacarpal may be a likely sequel of trapezoid infection, as a result of intraarticular drainage of infection. The blood supply of the trapezoid bone comes mostly from the dorsal side (Panagnis et al., 1983). As sequestrectomy is only possible through a dorsal approach and may reduce the major blood supply, development of ankylosis may be fortunate in sustaining a blood supply to the trapezoid bone.