Soumya Ghosh

Management of displaced supracondylar fracture of the humerus in children

Background: There have been controversies regarding the ideal method of treatment of displaced supracondylar fractures of the humerus in children. Aims: The aim was to treat displaced supracondylar fractures of the humerus in children by conservative method and if results are not acceptable then by operative method and evolve a management protocol which will provide minimum complications with available facilities. Materials and Methods: This prospective study was conducted in a tertiary care hospital in a time span of 1-year. Ninety patients with Gartland′s Type II and Type III fractures were initially subjected to closed manipulative reduction, of which acceptable reduction could be achieved only in 27 patients. Sixty-three patients who had unacceptable results were subjected to operative treatment. The final results of the treatment were assessed using the criteria of Flynn et al. Results: Among the Gartland′s Type II fracture patients, acceptable reduction was achieved in 9 patients. Among Type III fracture, acceptable reduction was achieved in 18 patients (25%). The conservative treatment yielded excellent results for 9 patient and good for 9 patients. Of the 63 patients subjected to operative treatment, 15 patients had excellent result (23.81%), 24 good (38. 10%), 15 fair (23.81%), and 9 poor (14.29%). Satisfactory result was achieved in 39 patients (61.90%). Conclusion: Closed reduction in case of supracondylar displaced fracture of the humerus in children still remains an option in a developing country. It may be, followed by closed operating techniques when results are not acceptable as this delay does not affect functional outcome.

Comparative study of treatment of fracture shaft femur by intramedullary interlocking nails through piriform fossa entry and tip of the greater trochanter entry approach

Background: Several techniques and tools are available for achieving fracture reduction during antegrade intramedullary nailing of femur fractures. Aims: To compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the piriformis fossa (PF). Materials and Methods: The present pilot project was conducted in a time span of 1-year. The patients admitted with femoral diaphyseal fractures were alternately selected for antegrade nailing through PF group and greater trochanter entry (GTE group) approach. Total number of patient in each group was 15 (n = 15). Results: Complications of nailing: PE group - 6.7% infection, 20% malunion, 20% delayed union, 20% restriction of hip range of motion (ROM), 6.7% restriction of knee ROM, 13.3% limb length discrepancy, 13.3% hardware prominence. GTE group - 13.3% malunion, 13.3% delayed union, 33.3% Restriction of hip ROM, 6.7% restriction of knee ROM, 20% limb length discrepancy, 26.7% hardware prominence. Radiological union time in PE was 12-15 weeks in 5 patients, 16-19 weeks in 8 patients, 20-23 weeks in 1 and >24 weeks in 1 patient. Radiological union time in GTE was 12-15 weeks in 4 patients, 16-19 weeks in 9 patients, 20-23 weeks in 2 patients. Need for dynamization was 20% in the PE group and 13.3% in GTE group. Thoresen′s scoring system showed no significant difference between the two groups. Conclusion: Femoral nailing through the greater trochanter with specifically designed nails and with attention to specific techniques for such insertion should be considered a rational alternative to femoral nailing through the PF with the benefit of reduced requirement for fluoroscopy and decreased operative time.

Comparative study of fixation of proximal tibial fractures by nonlocking buttress versus locking compression plate

Background: Management of tibial plate fracture represents a challenging problem in developing countries. Aims: To compare the results of treatment of tibial plateau fractures with conventional nonlocking buttress plates (BP group) and locking compression plates (LCPs). Materials and Methods: The study was conducted on 30 patients with intra-articular closed fractures of the proximal tibia who were alternately assigned to two different treatment protocol, conventional nonlocking BP group or locking plates (LP group). Results : Schatzker Type II fracture was found to be the commonest fracture type with 13 patients. Only lateral plating was done in 24 patients, and dual plating was done in 6 patients. In 8 patients, corticocancellous bone graft were used. On follow-up complications like superficial skin necrosis (two cases), infection (two cases), varus collapse (three cases) developed. Sixty percent in LCP group, 66.6% in buttress group fractures clinically united in the time period of 7-9 weeks and 73.3% in LCP group and 80% in buttress group radiological union occurred in a period of 12-15 weeks. The results were graded in accordance with Poul S. Rasmussen′s grading system. During the follow-up, 73.3% in LCP group and 66.6% in buttress group had no pain after clinical union. 66.6% patients in LCP group and 73.3% in buttress group could perform normal walking. About 86.6%in each group had no lack of extension. Nine patients (60%) in LCP group and 10 patients (66.6%) had flexion of up to at least 140°. About 86.6% in LCP group and 80% in buttress group had a stable joint in extension. Conclusion: Considering its high cost, LP group should only be used, where it is more advantageous than conventional plate.

Comparative study of operative treatment of mid shaft fracture of humerus by locking plate versus intramedullary interlocking nail

Background: Treatment of humeral shaft fractures with intramedullary nailing compared with dynamic compression plating leads to comparable results. No single treatment option is superior in all circumstances for a particular fracture and each case has to be individualized . Objectives: Comparative assessment of results of plating and Intramedullary Nailing in a rural set up so that proper management techniques can be provided for better functional outcome and minimum complications. Materials and Methods: This prospective study was conducted over a period of three years on sixty patients with closed acute humeral shaft fracture requiring operative interventions. Results: Forty percent of cases were in the age group 31-40 years with males outnumbering females. Motor vehicle accidents (63.3%) were most frequent cause. Right humerus was more frequently (66.6%) involved. Maximum patients (40%) were operated within 4-6 days after injury. Out of 30 patients of plate group complications were: Infection-6.6%; delayed union-13.3%; shoulder movement restriction-13.3%; elbow movement restriction-6.6%. Out of 30 patients of nail group complications were: Splintering of fracture end-6.6%; infection-6.6%; delayed union-26.6%; shoulder movement restriction-13.3%; elbow movement restriction-6.6%; shoulder pain-46.6%. Maximum number of fractures (73.3% in plating group and 60% in nailing group) clinically united in the interval of 11-13 weeks. Maximum number of patients had radiological union in period of 12-16 weeks (73.3% plate group and 66.6% nail group). There was no significant difference between the two groups. On functional assessment, excellent results were obtained in 22 patients (73.3%) in locking plate group and 18 patients (60%) in locking nail group. Conclusion: For patients requiring surgical treatment of mid shaft humeral fractures, locking plating and interlocking intramedullary nailing both provide statistically comparable results but a higher rate of excellent and good results and a tendency for earlier union was seen with locking plating group in the present series.

A study of management of fracture shaft femur in children in a rural population

Background: Femoral shaft fractures account for 1.6% of all bony injuries in children, and the mode of treatment for children between 6 and 16 years of age is still debatable. Objectives: To compare the merits and demerits of operative and conservative managements of fracture shaft femur in children in a rural population in a developing country. Materials and Methods: Forty patients in the age group of 6-14 years with transverse fractures of shaft of the femur and two different treatment protocols were selected. The patients treated in skeletal traction or fixed traction in Thomas′ splint were included in one group and patients who were treated operatively with titanium elastic nails comprised the other group. Data was analyzed using Chi-square test. Results: The commonest cause of injury was motor vehicle accident, accounting for 70% of the cases, with left femur (60%) more commonly injured. All fractures in the operative group united clinically by 8 weeks and radiologically by 10 weeks, and, in the conservative group, by 9 weeks clinically and 12 weeks radiologically. The difference was statistically significant. Shortening and angular mal alignments were found more commonly in the conservative group, and the difference was significant. The follow-up for 1 year of all cases were uneventful. Conclusion: Internal fixation with titanium elastic nails provides better results than conservative treatment in traction.

A study of hand injury and emergency management in a developing country

Background: Injury to the underlying structures of the hand carries the potential for serious handicap. To reduce this risk, even the smallest hand injuries require proper medical care. Aims: To assess wound healing, mobility, and the ability to perform normal essential function post-operatively in open hand injuries associated with fracture. Materials and Methods: Thirty patients with 45 metacarpal and phalangeal fractures of the hand were divided into three groups: Group 1 (n = 13) cases with single fractures of hand, excluding thumb; Group 2 (n = 9) cases with multiple fracture of hand, excluding thumb; Group 3 (n = 8) cases with fractures involving thumb and first metacarpal. Tendon injuries were repaired. For fractures, Kirschner wire fixation was done. In two cases with multiple fractures, Joshis external support system (JESS) fixator was applied. Patients were followed up for 12 weeks. Results: One patient with proximal phalangeal fracture developed extension lag. No stiffness was observed in any of the cases treated by intramedullary Kirschner wire fixation. No non-union or delayed union was observed following cross-wire fixation with two Kirschner wires. Two case of open fracture developed superficial infection. Two patients with multiple fractures developed angulation at fracture site after the Kirschner wires were removed 4 weeks postoperatively, and two cases of multiple fractures developed hypertrophic non-union. Conclusions: Delicate handling of tissues, preservation of gliding planes for tendons, prevention of infection, accurate reduction and fixation, and early and appropriate physiotherapy affect prognosis in case of hand injuries.

Deltoid contracture: A study of nineteen cases

Objective: Deltoid contracture is not uncommon in India. Contractures of deltoid often do not have definite etiology. We have critically analyzed the condition as regards the etiopathogenesis and its surgical results. Materials and Methods: Nineteen patients with deltoid contracture operated between June 1990 and September 2001 were enrolled for a unicentric retrospective study. The surgery was indicated in patients with abduction deformity of more than 30° at the shoulder. The etiology of deltoid contracture was idiopathic (n = 13) intramuscular injection in deltoid muscle (n = 5) and blunt trauma (n = 1). All were operated by distal release (incision near the insertion of the deltoid muscle). The average follow-up was of 9.5 years (range 6-17 years). They were evaluated based on parameters like pain, persistence of deformity, range of shoulder movements and strength of deltoid. Results: All patients recovered painless full range of shoulder motion except one. The correction of deformity was achieved in all patients and there was no loss of strength of deltoid compared to the opposite side. Histology of excised tissue showed features of chronic inflammation. The complications observed were hypertrophic scar (n = 1), painful terminal restriction of shoulder movements (n = 1) and prominent vertebral border of scapula (n = 1). Conclusion: Deltoid contracture has features of chronic inflammation, and the intramuscular deltoid injection is the most incriminating factor in its etiopathogenesis. The condition can be effectively managed surgically by distal release of the deltoid muscle combined with excision of the muscular fibrotic contracture band.

Ilizarov ring fixator in treatment of infected nonunion of tibia

Infective nonunion of a long bone is very notorious to be treated and prone to limb shortening when treated by conventional methods. In this case report, we treated a patient having infected nonunion of tibia initially by complete excision of all devitalized tissue from site of nonunion causing bone gap of 7 cm, followed by application of Ilizarov ring fixator using bifocal osteosynthesis by single upper tibial osteotomy. Bone transportation done at a rate of 1 mm/day followed by compression-distraction at the nonunion site following accordion maneuver. Results showed satisfactory bony union by bifocal osteosynthesis with single osteotomy.

Interlocking nail and Ender's nail in management of diaphyseal fracture of tibia in a rural population of a developing country

Introduction: Intramedullary nail fixation has become the standard of treatment for tibial shaft fractures. Aims: The aim was to compare the results of the interlocking nail with Ender′s nail, which are less expensive in our country for diaphyseal fracture of the tibia. Materials and Methods: This prospective pilot project was conducted on 30 patients after taking institutional ethical clearance and consent of the subjects in a time period of 1-year. Fifteen patients were treated with intramedullary nailing (Group I) in the tertiary care hospital while 15 with Ender′s nail (Group II) in a rural hospital (with the lack of modern operative facilities). Results: The skeletal injury was classified according to AO/OTA classification. The majority of the patients were operated in 2 nd week of injury in our study. Average time taken for Ender′s nail was 41.33 min and the average time for interlocking nail was 74 min, and the difference was highly significant (P < 0.01). The mean c-arm shot needed 18.66 and 49.00 for Ender′s nail and interlocking nail, respectively; which was highly significant (P < 0.01). The majority of Ender nail group were allowed partial weight-bearing after 6 th weeks postoperatively while in interlocking nail group it could be allowed as early as 3 weeks. The majority of cases shows sign of clinical union in 8-12 th week in the interlocking group (%) and 13-16 th week in Ender′s nail group. About 60.00% cases in Ender group and 86.66% cases in interlocking nail group had excellent results. Conclusion: Interlocking nails should be the first implant of choice to operate tibial diaphyseal fractures and the use Ender′s nails should be done with caution in selected low-demand patients with suitable fracture patterns having financial constraints as well.

Study of results of total hip replacement with indigenous ceramic components in combination

Background: Total hip replacement (THR) arthroplasty at present it is the most commonly performed adult re-constructive hip procedure. Aims: To assess the clinical and functional outcome of the cementless ceramic THR. Materials and Methods: This pilot study was conducted in a tertiary care hospital of eastern India after taking institutional clearance and informed consent of the subjects. THR components were made from aluminum oxide from Central Glass and Ceramic Research Institute, Kolkata. During each visit, medical history was taken and physical examination was done. The deformity and range of motion (ROM) were measured with a goniometer. The clinical and functional outcomes were evaluated by modified Harris hip score. Results: 16 (80%) THR were on left and 4 (20%) were on left and age ranging from 34 to 66 years with a mean age of 52.2 years at the time of surgery. 14 (70%) were males and 6 (30%) females. At 2 years follow-up, the mean modified Harris hip score was 89.·With regards to the different parameters in the scoring system that is, pain, gait, functional activity, and ROM, there was significant improvement as per history. The results showed a significant improvement, wherein 33.33% had an excellent score and 50% showed good, and 16.7% had fair results. No patient had a poor score. Conclusion: Our study suggests that the current generation implants without cement can provide satisfactory clinical and radiographic outcomes after an intermediate duration of follow-up. Though the study was not free of complications, the overall functional and clinical outcome showed good results.