Treatment of inferior patellar pole avulsion fractures with pole resection and patellotibial cerclage wire.

The ideal treatment for avulsion fractures of the inferior pole of the patella has not yet been identified. The options include internal fixation of the pole fragment and resection of the avulsed fragment along with the repair of patellar ligament to the patella. The purpose of the present study was to evaluate the result of pole resection with repair of patellar ligament with augmentation by patellotibial cerclage. We retrospectively studied 13 of patients who had operative treatment of an avulsion fracture of the inferior patellar pole by pole resection with trans-osseous suture fixation of the tendon to the patella and reinforcement of ligament patella with patellotibial cerclage wire. Thirteen patients who had had pole resection were followed for an average of 3 years. The average patellofemoral score (maximum, 100 points) was 88.8 points. Normal patellar height was found in thirteen patients. In patients who have sustained an avulsion fracture of the inferior patellar pole, the normal height of the patella can be maintained by transosseous suture fixation of the tendon to the patella and patellotibial cerclage after pole resection. The present study indicates that patellotibial cerclage can provide better clinical results and avoid prolong postoperative immobilization.

Analytical study of the management of supracondylar fracture of children in our setup.

We performed a clinical-radiological audit of 142 children with consecutive upracondylar fractures of the humerus over a period of 5 years (1996-2001). The fractures were classified according to the Gartland system; 58 types I, 44 type II and 40 type III. And 87.0% were extension and 13.0% flexion types. These cases were managed by closed reduction and posterior cast application (n= 120) and open reduction with internal fixation (n=22). All the stable fractures irrespectable of types were managed by closed method and all the unstable or failed manipulation cases were operated upon. In total 38 required re manipulation in the cast group and twelve (n= 12) had a varus deformity (ten from closed group and two from operation group). Failure to follow the treatment according to the guidelines led to an unsatisfactory result in 12 patients. We have devised a protocol for the management of these difficult injuries in our setup for optimal outcome.

Sedation with ketamine: a safe and effective anaesthetic agent for children in the developing world.

Recently there has been a resurgence in the utilization of ketamine, a unique anaesthetic, for emergency procedures requiring sedation. The purpose of the present study was to examine the safety and efficacy of ketamine for sedation in the treatment of children's fractures in the small clinic setup of rural Nepal. One hundred and fourteen children (average age, 5.3 years; range, twelve months to ten years and ten months) who underwent closed reduction of an isolated fracture or dislocation in the Orthopaedic & Trauma Clinic at Janakpurdham were prospectively evaluated. Ketamine hydrochloride was administered intravenously (at a dose of less than two milligrams per kilogram of body weight) in ninety-nine of the patients and intramuscularly (at a dose of four milligrams per kilogram of body weight) in the other fifteen. Adequate fracture reduction was obtained in 111 of the children. Ninety-nine percent (sixty-eight) of the sixty-nine parents present during the reduction were pleased with the sedation and would allow it to be used again in a similar situation. Minor side effects included nausea (thirteen patients), emesis (eight of the thirteen patients with nausea), clumsiness (evident as ataxic movements in ten patients), and dysphonic reaction (one patient). No long-term sequelae were noted, and no patients had hallucinations or nightmares. Ketamine reliably, safely, and quickly provided adequate sedation to effectively facilitate the reduction of children's fractures at our institution. Therefore, it was ideal for small clinic in our setup.