Kneeling Stress Radiography: A Forgotten Yet Dependable Tool for Postero-lateral Knee Instability.

Introduction: Diagnosing postero-lateral knee instability is a challenge from both clinical and radiologic perspective and can lead to significant morbidity if left untreated. Delayed diagnosis leads to a more demanding surgery and prolonged rehabilitation for the patient. Kneeling stress radiograph is a lost art but remains invaluable in the assessment of postero-lateral knee instability. Methods: This prospective observational study is aimed at re-exploring the undeniable utility of this forgotten tool in early diagnosis of posterolateral knee instability and identifying the mean posterior tibial translation distance (PTTD) and also assessing side to side difference (SSD) between the injured and the contralateral normal knee. Results: Total 27 patients were included in the study, with males being 4.4 times more commonly injured as compared to females. The most common mode of injury was motor vehicle accident (MVA). Out of 27 patients, 11 had isolated PCL (posterior cruciate ligament) injury while the rest had PLC (posterolateral corner) involvement. The mean SSD of PTTD was 8.79 mm in patient with isolated PCL. This was increased by 1.65 times (14.52 mm) in patients with co-existing PLC involvement. Conclusion: Stress radiography is an indelible tool and serves as an adjunct to MRI imaging. It is not a substitute for clinical assessment but assists in early diagnosis and management, facilitating surgical planning and furnishing objective evidence of PCL/PLC functionality which is not possible with any other imaging modality.

Immediate Versus Late Flap Coverage for Traumatic Soft Tissue Defects of Lower Extremity: A Comparative Observational Study.

Background The lower extremity trauma in patients often gets operated on late for the wound coverage and is associated with more health costs and other resources. Therefore, this study has been conducted to compare the outcome in terms of flap survival, complication rates, and hospital stay between immediate and late flap coverage of lower extremity traumatic wounds. Methods The comparative analysis of outcome is done in terms of flap survival, complication rates, and hospital stay after immediate and late flap coverage of 25 (n = 25) patients of lower extremity traumatic wounds in each group. The patients were observed, and data obtained were tabulated in a Microsoft Excel spreadsheet. The statistical analysis was done using IBM SPSS (V26.0, IBM Corporation, Armonk, NY, USA) statistical software. The chi-square test was used for descriptive data and the student's unpaired t-test for discrete-continuous data analysis. The p-value of less than 0.05 is considered significant. Results The mean defect size with SD in the immediate flap cover group is 54.5 ± 29.5 cm2, while in the late flap cover group, it is 85 ± 65 cm2 with a significant p-value of 0.0378. The mean flap size with SD in the immediate flap coverage group is 70.5 ± 34.5 cm2, while in the late flap coverage group, it is 117 ± 87.5 cm2, and the difference is statistically significant. The mean hospital stay with SD in the immediate flap coverage group is 7.5 ± 2.5 days. In contrast, in the late flap coverage group, it is 29.5 ± 8.5 days, and the difference is statistically very significant. Conclusion There are equivalent results in patients undergoing immediate and late flap coverage for the traumatic soft tissue defects of the lower extremity. There is a significant decrease in the hospital stay after immediate flap reconstruction, which subsequently reduces both direct and indirect health costs. However, there is a larger size flap requirement in cases of immediate lower extremity wound coverage.

Neglected floating cervical spine fracture with myelopathy and Anderson lesion of D2 D3: report of an unusual case.

INTRODUCTION: The cervical spine is the most commonly affected region in traumatic spine injuries of patients with Ankylosing Spondylitis (AS), accounting for 75% of cases, followed by the thoracic and lumbar spine. The fracture may not be detectable in plain radiographs alone due to pre-existing kyphotic deformity with distorted anatomy and high-riding shoulders. CASE PRESENTATION: We present a case with a floating cervical spine following a trivial trauma injury and with cervical myelopathy symptoms. After posterior fixation of the cervico-thoracic spine, the patient improved with Nurick score and mJOA score improvement. After 6 months follow up the patient was walking without support, and myelopathy symptoms were negligible. DISCUSSION: In this patient, a posterior approach was performed. We obtained a rigid construct so that we were able to mobilize a patient on the very next day and his myelopathy symptoms improved with minimal postoperative complications.

Acute spine care services during covid-19 pandemic and 'lockdown': case series and our perspective from a level 1 trauma centre.

STUDY DESIGN: Case Series. OBJECTIVE: Sudden 'lockdown' to contain spread of SarsCoV-2 infection had far-reaching consequences on the Spine Unit of our tertiary care hospital, situated in a hilly-region of Northern India. We intend to share our experience of providing care for acute spinal disorders from 23rd March, 2020, when nationwide lockdown and closure of elective services started in our country, to till 12th May, 2020, and to formulate few recommendations at the end. SETTING: Northern India. METHODS: Between 23rd March, 2020 and 12th May, 2020, data of all patients with spinal conditions presenting to Emergency Department for acute care services were collected prospectively. Existing protocols were modified in line with changing national and institute policies for functionality of the spine unit, challenges faced and steps taken were noted. RESULTS: All elective cases were postponed for an indefinite period at the starting of 'Lockdown'. A total of 24 patients were received in ED during study period and 14 (58%) were managed operatively. The majority (79%) were with traumatic spine injury, and fall from height was most common mechanism of injury in traumatic spine patients (84%). There was higher incidence of surgical site infections (14%) among operated patients, compared to our previous average. We had modified routine policies to tackle challenges faced and till date of writing this article, none of the members of spine team or patients treated by us tested positive for SARSCoV-2. CONCLUSION: To continue providing care for acute spinal conditions and maintaining academic activities of spine unit during 'lockdown' needs innovative policies in line with national protocols.

Non-Vascularized Tri-Cortical Iliac Crest Graft-A Reliable Option in the Management of Scaphoid Waist Non-Unions.

Background: Scaphoid non-union often leads to a change in biomechanics of the wrist joint. Various types of bone grafts and different sites of harvest have been described in the literature for scaphoid reconstruction. This study was conducted to assess the clinical and radiological outcome after non-vascularised tri-cortical iliac crest bone graft for non-union of scaphoid waist fractures. Methods: 12 adult patients who underwent reconstruction of scaphoid waist non-union with tricortical iliac crest grafting and internal fixation with headless compression screws (11 cases) and k-wires (1 case) were prospectively analysed. There were 11 males and 1 female (mean age 23.9 years). The mean duration of presentation was 5.7 months following injury. Outcome following surgery were analyzed clinically by range of movements (ROM) and functional scores like DASH and modified Mayo wrist score and radiologically by X-rays and Non contrast CT of the wrist. Radiological assessment included scaphoid length, radio-lunate (RL) angle and scapho-lunate (SL) angle at latest 6 months follow up. Results: Bony union was achieved in 10 cases (union rate 83%). All the cases which achieved union had a significant improvement in radiological and clinical outcome criterias at 6-month follow-up interval. 1 patient had persistent non-union and 1 had k-wire back out with fixation failure. Conclusions: It is important to restore scaphoid length and to correct flexion deformity for a successful outcome. This can reliably be acheived by a carefully planned wedge-shaped iliac crest graft along with secure fixation with a headless compression screw.

An unusual mechanism of hook impalement injury - A case report.

A six-year-old boy was playing at his home, trying to climb up on a metallic gate which was attached with a hooked chain, and suddenly the child slipped down. The hook of the chain, including its 'U' shape segment got embedded into the posteromedial aspect of his thigh, through a small entry wound. An anteromedial aspect of the thigh carries a neuro-vascular bundle of the lower limb. To remove the hooked part from muscles near to femoral vessels without damaging them requires surgical skill and consideration for vascular emergencies. At the same time, the procedure is an important step. After resuscitation, the patient is taken into the emergency operation theatre, and the hook was safely removed under vision. In the postoperative period, the child recovered well, and the wound was healthy at the time of discharge.

A Rare Case of Ipsilateral "Floating Ileum" with Floating Hip and Floating Knee.

INTRODUCTION: Concomitant ipsilateral floating hip with floating knee is a very rare injury pattern. Its co-occurrence with ipsilateral complete separation of ileum from pelvic girdle, which can be termed as "floating ileum," is even rarer. These are extremely high energy injuries associated with significant systemic insult adding to the dilemma and complexity in management. There is no mention in the literature about this potentially life-threatening injury combination; hence, an attempt has been made to provide a pathway of the management of this rare but complex injury pattern. CASE REPORT: We are presenting a case of 17-year-old male with this menacing amalgamation of injuries along with the challenges associated in the management. The patient had ipsilateral complete disruption of sacroiliac joint along with transverse fracture of acetabulum due to which ileac bone was completely separated from rest of the pelvic bone and was displaced anteriorly, superiorly, and medially. The patient was also having ipsilateral shaft of femur fracture and distal third tibia fracture and acute respiratory distress syndrome as well to further complicate the scenario. CONCLUSION: Early damage control, followed by definitive fixation and aggressive rehabilitation, appears to be the safe and acceptable path to reach good clinical outcome.

Blunt carotid injury with thrombotic occlusion: Is an intervention always required for best outcome?

Blunt cerebrovascular injuries are rare, comprises of 0.08 to 0.33% of all traumatic blunt injuries. Depending on the grade of severity, they may heal with minimal consequences or may lead to debilitating and devastating stroke. Surgically accessible lesions are infrequent and hence endovascular management is preferred modality for high-grade lesions. We hereby present a case of complete thrombosis of the common carotid artery, which couldn't receive either surgical or endovascular treatment due to low resource settings. The patient developed a stroke after 18 h of trauma, which, however, recovered completely and dramatically within 96 h. To the best of our knowledge, such rapid and complete recovery from stroke secondary to blunt carotid injury managed non-operatively hasn't been reported in literature so far. Our report adds to the scarce but growing body of evidence recommending conservative management in BCVI in absence of enlarging pseudoaneurysm and dissection with near-complete stenosis.

Reverse suspension syndrome: First report of a novel mechanism of severe trauma.

About 48,000 workers die at the workplace in India due to occupational accidents of which 38 fatal accidents take place every day in the construction sector. Indigenous innovative methods (Jugaad) devised to accomplish tasks at work are common in our country. We report the case of an abdominal injury sustained while using rope tied around the torso for suspension, termed as 'Reverse suspension syndrome' by authors due to analogy in mode to Suspension syndrome but exactly opposite kinematics of injury. As described in the report, Reverse suspension syndrome is a dangerous mechanism of trauma involving transmission of major energy and severe visceral injuries. Workup to rule out bowel, ureter, great vessels, spine and cord injuries is recommended. The outcome is good if the patient presents in time. To the best of our knowledge, this mechanism of injury hasn't been described in the literature so far.

Bacterial flora on cell phones of health care providers in a teaching institution.

We conducted a cross-sectional study involving culture of cell phones of 288 health care providers (HCP) during a 6-month period. One hundred nine (43.6%) HCP carried infective organisms on their cell phones. It is recommended that cell phones be cleaned regularly.

Lipoblastoma--a rare paediatric foot tumour.

Lipoblastoma, a rare benign tumour arising from embryonic fat, is usually found in areas of abundant adipose tissue. Various reports describe a predilection of lipoblastoma for sites with primitive adipose tissue such as axilla, neck, retroperitoneum and prevertebral soft tissue. The plantar aspect of the foot is an extremely rare site due to scarcity of fatty tissue. Differential diagnosis includes lipomas, fibromyxolipomas and liposarcomas. Age of presentation, chromosomal markers and histopathological examination help in arriving at final diagnosis. Radical surgeries are not advocated; however, complete excision is necessary to avoid recurrence.

Internal fixation in compound type III fractures presenting after golden period.

OBJECTIVE: Patients often reach the hospital late after passage of golden hours (initial 6 hours) after sustaining high-velocity injuries. The decision of internal fixation in Gustilo's Type IIIA and IIIB fractures becomes a formidable challenge in patients reaching late. The purpose of the present study was to find out if internal fixation could be safely undertaken in these patients. MATERIALS AND METHODS: Sixty-three patients, having 70 compound fractures (46 Type IIIA and 24 IIIB), which were internally fixed after 6h but within 24h after injury, were included in the present analysis. Follow-up ranged from 18 to 48 months with mean of 28 months. RESULT: Overall infection rate noted was (n = 11) 15.71% (8.7% in IIIA, and 29.16% in IIIB). The difference in deep infection rate between Type IIIA and Type IIIB was found to be statistically significant (P value < 0.01). Nonunion was seen in five fractures. Functional evaluation using Katenjian's criteria, showed 62.85% (44 fractures of 70) good to excellent results. CONCLUSION: Satisfactory results may be obtained in Gustilo's Type IIIA and IIIB fractures even if fixed after the golden period, provided strict protocol such as aggressive debridement, prophylactic antibiotic coverage, early soft tissue reconstruction and timely bone grafting is followed. The primary coverage of the wound is discouraged.

Ultrasound and colour Doppler sonography in acute osteomyelitis in children.

Early diagnosis of osteomyelitis is of paramount importance to avoid irreversible sequelae. This often requires a multimodal approach. The purpose of the present study was primarily to evaluate how ultrasound might be useful in early diagnosis of osteomyelitis in the paediatric age group. The evolution of ultrasound findings with progression and resolution of disease was also analysed. In this prospective study, 55 children with osteomyelitis of limbs were subjected to sonographic examination including colour Doppler study. The sonographic machine used was a LOGIC-500, using a linear multifrequency transducer (7-9 MHz). Ultrasound guided aspiration was performed in all cases showing sub-periosteal accumulation of fluid, and the aspirate was sent for culture and sensitivity report. Surgical drainage was undertaken in all patients in which a sub-periosteal abscess was demonstrated. Anechoic fluid accumulation contiguous with bone was highly suggestive of osteomyelitis, whereas presence of soft tissue between the bone and the fluid suggested a non-osseous origin of the fluid. Sub-periosteal accumulation of fluid was seen in 42 cases (76.3%). A subperiosteal abscess with periosteal reaction was demonstrated in 35 children (63.63%). Colour Doppler study revealed increased vascular flow within or around the affected periosteum in all cases. Concurrent involvement of a joint was noted in 13 cases. Ultrasound is a rapid, cheap, easily available, non-ionising and reasonably accurate diagnostic modality. It also helps in localising the lesion for diagnostic aspiration. Serial ultrasound and technical innovations such as colour Doppler sonography further help in monitoring the progression and resolution of the disease.

Congenital macrodactyly: a clinical study.

Congenital macrodactyly is a rare congenital malformation characterised by progressive enlargement of all mesenchymal elements of a digit. The present study is an attempt to draw the attention towards the similarities and differences between macrodactyly of the hand and foot. Radiographical, operative findings and histopathological examination of five cases are included in the present study. Emphasis was given to know the possible basic lesion. Radiographic findings, which differentiate this entity from other forms of local gigantism, were also analysed. The most characteristic finding noted was excessive overgrowth of fibro-fatty tissue with unusually large fatty lobules, apparently fixed by a mesh of dense fibrous tissue. Hypertrophy and tortuosity of the digital nerve, a striking feature in macrodactyly of the hand, was notably absent in cases affecting the foot. None of the patients had any other associated congenital anomalies. Neither the patients nor any of their family members had any stigmata of neurofibromatosis. Chromosomal study was normal in all of them. We conclude that in macrodactyly of the foot, excessive proliferation and accumulation of adipose tissue was the basic lesion, whereas involvement of the nerve might be the fundamental lesion in gigantism of the hand. Furthermore, whatever be the basic lesion, the final pathway must be either the local deficiency of a growth inhibiting factor or local expression of a basic intrinsic factor, leading to excessive growth of all elements of the digit.