Internal fixation of shaft humerus fractures by dynamic compression plate or interlocking intramedullary nail: a prospective, randomised study.

Compare the results of internal fixation of shaft of humerus fractures using dynamic compression plating (DCP) or antegrade interlocking intramedullary nail (IMN). Fifty patients with diaphyseal fracture of the shaft of the humerus and fulfilling the inclusion criterion were randomly assigned to one of the two groups. Twenty-five patients were managed with closed antegrade interlocking intramedullary nail, and 25 underwent open reduction and internal fixation using dynamic compression plating. The mean age of patients with IMN fixation was 37.28 years (SD 12.26) and 37.72 years (SD 12.70) for those who underwent plating. Road traffic accident was the most common mode of injury in both groups. There was a statistically significant difference between the two groups with respect to duration of hospital stay, operative time and blood loss. There was no significant difference between the two groups in terms of union or complications. The functional assessment at the end of 1 year between the two groups did not show any significant difference in outcome. Antegrade interlocking IMN and DCP fixation are comparable when managing diaphyseal shaft of humerus fractures with respect to union rates and complications. Although shoulder related complications are more in the IMN group, however, it is associated with shorter hospital stay, lesser operative time and less blood loss. This makes interlocking IMN an effective option in managing these fractures.

Isolated osteochondroma of the femoral neck presenting as hip and leg pain. A case study.

Osteochondromas, or exostoses, are overwhelmingly found as isolated lesions although they can be present within the context of multiple hereditary exostosis. Increased exostotic load associated with multiple hereditary exostosis can lead to limb-length discrepancy, increased femoral anteversion, valgus angulation, and acetabular dysplasia. Solitary osteochondromas have been linked with bursal inflammation and pain, compression on neurovascular structures, and malignant degeneration, groin and lower extremity pain. Isolated exostosis involving the femoral neck is a rare entity which is often diagnosed late when the patient is being investigated for other problems. We present a young female with a history of hip pain for 3 years with restriction of movements around the hip joint and radicular pain which turned out to be a solitary osteochondroma of the femoral neck. Surgical excision relieved the symptoms.

Gorham's disease of femur.

Gorham's disease is a rare condition of bones characterized by spontaneous massive and progressive osteolysis. Less than 200 cases have been reported so far. Femur is an uncommon site of Gorham disease. We report a young female, presenting as pathological fracture of the femur, wherein rapid osteolysis of femur occurred. The clinical, pathological, and radiological picture suggested a diagnosis of Gorham's disease. The patient was subjected to radiotherapy (40 Gys) and put on bisphosphonates. At a follow-up of 2 years, the disease process had stopped and partial recalcification of the bone had occurred.

Role of early Ilizarov ring fixator in the definitive management of type II, IIIA and IIIB open tibial shaft fractures.

We evaluated the results of patients with Gustilo types II, IIIA and IIIB open tibial fractures managed early with the Ilizarov external fixator (IEF). Sixty patients (51 males, nine females; age range 20-62 years; mean age 32.8 years) with type II (11 patients), type IIIA (13) and type IIIB (36) tibial diaphyseal fractures underwent emergency debridement and minimal bone fixation (with external fixator), followed by definite fixation with the IEF after three to five days. Average duration of the hospital stay was 8.6 days. All fractures united with an average union time of 21.1 weeks (standard deviation [SD] 3.18) in type II, 21.7 weeks (SD 3.57) in IIIA and 24. 9 weeks (SD 5.14) in IIIB fractures. The difference between union time in type II and IIIA was not significant (p > 0.05), but that between IIIA (and also type II) and IIIB was significant (p < 0.05). The healing index in patients who underwent lengthening was 1.5 months/cm. The wounds in 27 patients were managed by delayed primary closure, in 19 patients with second intent (all IIIB), in 11 patients with skin grafting (mostly type IIIB fractures) and in three patients with musculocutaneous flaps. The most common complications of the procedure were pin tract infection and pain at the fracture site. Most of the patients were able to achieve good knee and ankle range of motion. Early application of the Ilizarov fixator constitutes an excellent management of open tibial fractures, especially types II, IIIA and IIIB, due to good functional and radiological results. Despite the technical difficulties and some complications (which are mostly minor) IEF may be the preferred method in open tibial fractures, especially types II and III.

A case study in bilateral radial head fractures in apparently trivial trauma: a subtle diagnosis.

Radial head and neck fractures are common in young to middle age adults and are seen in nearly 20 % of acute elbow injuries in this age group. These are usually associated with high energy traumas like falls from height, road traffic accidents and sports injuries. Unilateral radial head fractures are relatively common and may be associated with other concomitant injuries. Bilateral radial head fractures are rare and are mostly seen in situations when the patient has a fall on outstretched, supinated hands or a direct fall on the elbow. These injuries can be easily missed by the attending physician if the symptoms are more severe on one side, thus neglecting the other. The treatment of these fractures may be conservative or operative, depending upon the degree of head comminution, the percentage of articular surface involved, presence of loose intra-articular fragments and angulation between the radial neck and proximal shaft. We present a case series of three patients with bilateral type 1 radial head fractures (one case having type 3 on one side) managed with brief immobilization followed by active physiotherapy and full, uneventful recovery. The emphasis in these cases is the need for a high index of suspicion in the diagnosis of multiple injuries, no matter how `trivial` the mechanism of injury and, unless the history of the mode of trauma is highly suggestive, such injuries can be missed easily and cause long term problems for the patient.

Walnut tree falls as a cause of musculoskeletal injury--a study from a tertiary care center in Kashmir.

BACKGROUND: Fall from height is one of the important causes of musculoskeletal injuries. Fall from walnut trees constitutes an important entity that leads to a significant mortality and morbidity amongst those engaged in fruit collection. The present study aimed to determine the prevalence of different musculoskeletal injuries in these victims and to highlight the importance of recognizing this incident as an occupational injury. METHODS: A retrospective study of all patients admitted to the Orthopedic Department of the Sher-i-Kashmir Institute of Medical Sciences (SKIMS) Medical College from January 2003 to December 2007 was conducted. The medical records were studied for the different types of bony injuries, associated injuries and delay in the referral of patients. RESULTS: 94% of falls occurred from August to October. Of the 115 patients, 63 (54.7%) had associated non-orthopedic injuries. Head injury was the most common associated injury, presenting in 34 patients (29.5%). Thoracolumbar (16.5%), calcaneum (10.5%) and distal radius (8.7%) fractures constituted the common fractures encountered in the victims. CONCLUSION: Walnut tree injuries mostly involve young males who form the productive group of the population. Being a seasonal injury, it puts a considerable load on the health resources of the region over a small period of time.

Big toe metastases as first clinical sign of occult bronchogenic carcinoma.

Metastasis to bone is a common manifestation of malignant tumours. However, metastasis to the bones of the foot is exceedingly rare. It usually arise from genitourinary tract and colon, with the tarsal bones accounting for half of all metastases. We report a rare case of pain and destruction of the distal phalanx of great toe, initially suspected as osteomyelitis, which on biopsy proved to be metastases from a clinically silent bronchogenic carcinoma.

Osteoblastoma of body of the talus--Report of a rare case with atypical radiological features.

Osteoblastoma is a benign bone tumour found commonly in the spine and long tubular bones. Involvement of the talus is uncommon, and when present, is found in the neck of the talus. Osteoblastoma of the body of talus is a very rare entity. We report a young male, presenting as chronic ankle pain, with a radiolucent lesion with a thick periosteal shell in the body of the talus. Analysis of clinical, radiological and histological findings confirmed the diagnosis of osteoblastoma. The case is reported for the rarity of the site and atypical radiological features that osteoblastoma can present with.

Ellis-van Creveld syndrome with facial hemiatrophy.

Ellis-van Creveld (EVC) syndrome is a rare autosomal recessive congenital disorder characterized by chondrodysplasia and polydactyly, ectodermal dysplasia and congenital defects of the heart. We present here a case of a 16-year-old short-limbed dwarf with skeletal deformities and bilateral postaxial polydactyly, dysplastic nails and teeth, also having left-sided facial hemiatrophy. The diagnosis of EVC syndrome was made on the basis of clinical and radiological features. To the best of our knowledge, this is the first report of EVC syndrome with facial hemiatrophy in the medical literature from India.

Mitchell's osteotomy in the management of hallux valgus: An Indian perspective.

BACKGROUND: Hallux valgus is a common condition that affects the forefoot. A large number of procedures are described for managing this condition. Mitchell's osteotomy and its modifications are being widely used for treating hallux valgus. However, most of the studies describe the results from the developed world. We present results of the classic Mitchell's osteotomy in hallux valgus in Indian subcontinent. MATERIALS AND METHODS: Forty eight adult patients (including 12 bilateral ones) in the age range of 18-60 years with hallux valgus were managed with the classic Mitchell's osteotomy. Pain over the bunion was the reason for surgery in 53 of 60 feet and cosmesis in the remaining 7 feet. Patients with hallux valgus angle more than 20 degrees and not responding to a trial of conservative treatment were included. Patients having metatarsophalangeal (MTP) joint osteoarthritis (Grade II and higher), hallux rigidus, rheumatoid arthritis, and with subluxation of MTP joint were excluded from the study. Further, patients with first metatarsal more than 3 mm shorter than second metatarsal were also excluded. RESULTS: The average follow-up period is 3 yrs (range 18months - 6yrs). About 55 feet (83%) were painless after surgery. Forty-two (70%) patients were happy with the cosmetic results of the surgery. Metatarsalgia was the reason for dissatisfaction with the procedure in five patients. The average correction of hallux valgus and the intermetatarsal angles achieved was 19.7 degrees and 6.9 degrees , respectively. Using the Broughton and Winson scoring system, 37 (61.7%) feet had excellent results, 18 (30%) had good, and five (8.3%) feet had a poor results. CONCLUSION: The classic Mitchell's procedure is a simple procedure and gives good cosmetic and radiological results.

Familial reactive perforating collagenosis.

BACKGROUND: Reactive perforating collagenosis (RPC) is one of the rare forms of transepidermal elimination in which genetically altered collagen is extruded from the epidermis. This disease usually starts in early childhood as asymptomatic umbilicated papules on extremities, and the lesions become more conspicuous with age. AIMS: The objective of our study was to determine the clinico-pathological features of RPC and the response to various treatment modalities. METHODS: Ten patients of RPC, belonging to five different families, were studied clinically. Various laboratory investigations were carried out and diagnosis was made by histopathology of the lesions. Patients were given various topical and oral treatments. RESULTS: RPC is familial in most cases without any definite inheritance pattern. It begins in childhood and the lesions are usually recurrent and become profuse and large with age. Systemic diseases have no role in the onset of lesions. CONCLUSION: Oral and topical retinoids in combination with emollients is the best treatment option.

Unilateral cleft hand with cleft foot.

Congenital anomalies of the hand form an important class of congenital malformations. They have a huge functional importance because of the part played by the hand in the daily activities of a person. The deformities also have significant cosmetic significance and may also be associated with other anomalies. Amongst the congenital anomalies, central deficiency or cleft hand is relatively rare. The association of cleft foot with cleft hand is an even more rare occurance. We present a case report of a 6 year old child, born of a non-consanginous marriage, having congenital central deficiency of ipsilateral hand and foot.