Is open diaphyseal femur fracture managed by delayed interlocking intramedullary nail: a prudent choice?

To review experience of delayed intramedullary nailing of open femur diaphyseal fractures in resource limited setting and to find out frequency of complications. Patients with open diaphyseal femur fracture were admitted through accident and emergency department. After initial resuscitation of the patients, emergency wound debridements were performed. Fractures were stabilized initially by applying skeletal traction. Subsequent debridements were done when indicated. Unreamed intramedullary nailing were done when there was no evidence of wound infection. After discharge, patients were followed up in out patient department every four weeks and complications noted. All patients were followed for at least 6 months. Forty five open fracture of femur shaft were treated by delayed intramedullary nailing. There were 32 males and 13 females with a mean age of 23 +/- 7.3 years. Road traffic accident was the commonest cause of fracture in 30 patients. Delay between injury and surgery was 8.5 [mean] [SD4.8] days. Average duration of surgery was 60.2 +/- 17.6 minutes. Closed unreamed interlocking nailing was done in 38 patients, while in 7 patients open intramedullary nailing was done. In five patients postoperative infection was noted, delayed union in five and limb shortening in three patients. Knee joint stiffness was noted in 12 and metal failure in three patients. In developing countries where facilities for intramedullary nailing in emergency operation theater, are not uniformly available, delayed internal fixation with unreamed interlocking nailing is a good option for the management of open diaphyseal fracture femur

Prospective randomised study of the management of supracondylar [humerus] fractures in children

From January 1995 to April 2001 this study was concluded, which included only displaced fractures of thirty six children. The fractures were classified according to the Gartland system. There were randomly Type II A, eleven type II B and ten type III. These fractures were randomly picked and managed by different methods. We fixed with open reduction of type II B, and type III fractures by k-wires. Some fractures of IIA and II B were fixed by subcutaneous k-wires under image intensifier. Twenty six patients were managed by senior surgeons and proper guidelines followed with no reoperation and malunion. While in ten children, about four children required further management and six had varus deformity. We have excluded those patients who reported after one week after injury from this study. Surprisingly, there were a great number of late arrivals. Supracondylar fractures of the humerus is one of the most common fractures around the elbow before the age of seven years. The treatment is controversied and often technically difficult. Complications are common cubitus varus deformity, which is the most frequent problem [about 30 percent]. The deformity due to medial tilting of the distal fragment associated with rotation, it does not remodel with growth. Nerve injury occurs in 6-16 percent. Radial pulse is absent in 3 cases. But for vascularity, the best index is capillary refilling time [normally less than two seconds]. So absent radial pulse does not warrant intervention. In rare cases, Volkman's ischaemic contracture develops. Stiffness of the elbow frequently occurs, particularly after repeated manipulsations and posterior approach for open reduction and internal fixation. However, with good physiotherapy cover, there are acceptable results. A variety of methods of treatment for displaced fractures has been recommended, including closed reduction and immobilisation, traction by various methods and closed or open reduction stabilised by k-wires. Although some authors are not in favour of closed reduction and immobilisation, particularly for severe injuries, this treatment remains popular. Others recommend stabilisation by k-wires for all displaced fractures. The aim of treatment is to gain a functional and cosmetically acceptable upper limb with a normal range of movement. Ideally, this should be achieved by on definative procedure. A change in treatment because of loss of reduction may be psychologically with an increased risk of poor outcome. We have followed our patients from 1995 to April 2001. Fixed by different methods, the results were excellent in all type IIA injuries. In type II B and type III fractures there was an acceptable rate of redisplacements. 30 percent [10-32 cases] in total. These ten patients had 21 operations [cubitus varus deformity]. Table I. Classification of Supracondylar fractures of the humerus in children after Gartland and Wilkins Type I Undisplaced fracture IIA Greenstick fracture with posterior angulation IIB Greenstick fracture with malrotation + posterior angulation III Completely displaced fracture The following factors lead to the sub optimal results: 1. Inexperience of the surgeon responsible for the initial management. 2. Not stabilizing fractures by k-wires after reduction. 3 Small diameter [less than 1.6 mm] k-wires used. After good closed reduction achieved, fixation with k-wire is necessary which was achieved through image intensifier with excellent outcome

Prospective study of clinical outcome and complications of postero medial release [soft tissue surgery] in congenital talipes equino varus deformity

This study was carried out at orthopedics department Dow Medical College, and Civil Hospital Karachi, from 1994 to 2000. 60 club feet in 43 patients were operated by [P.M.R.] postero medial relapse. 30 boys and 13 girls, the mean age was 9 months. The surgery consisted of one stage procedure with long postero medial incision, all wounds were closed primary. Immobilization in plaster was used for 14 weeks. Followed by surgical shoes and night splints and also physiotherapy by parents [Mothers]. The feet were classified according to dimeglio et al. All bilateral feet were done in one sitting. Superficial wound infections in 10 feet and wound breakage in 10 feet requiring re-suturing and prolonged dressing all occurred in grade 4 feet. The rate of relapse was 10% in grade 3 feet and 30% in grade 4 feet. P.M.R. for club feet is effective treatment in decreasing relapse rate, but does not give better results in controlling wound infection/breakage. The surgical management of talipes equino various remains a major challenge. There is little agreement on operative treatment and a variety of procedures are described in the literature. The lack of a reproducible classification system remains a fundamental problem when comparing different studies. Work by Bensahel, Catterall and Dimeglio has highlighted the need for a pragmatic classification to enable comparison to be made between cases of similar severity, many report group all cases together which makes analysis difficult and confusing. The assessment of complications and the outcome of surgery are only significant if a reproducible system for classification is used. In this study we have used P.M.R. [Posterio Medial Release]. To address the problem of recurrence and wound healing. It is recognized that with more severe deformities the skin on the medial side of the foot may be under tension which to break down and infection. We employed gradual and serial casts to reduce wound breakage and infection without compromising the relapse rate