Patterns of Orthopaedic Injuries among Motorbike Accident Admissions Presenting to a Tertiary Care Hospital in Kathmandu.

BACKGROUND: The anecdotal burden of morbidity secondary to motorbike accidents is thought to enormous by personnel involved in trauma care. The objective of the present study is to ascertain patterns and association of injuries and causes of mortality in a cohort of motorbike accident victims. METHODS: A retrospective chart review of 1337 motorbike accident admissions B and B Hospital in Kathmandu between January 2009 and December 2010 was undertaken. RESULTS: Majority of victims were between 20 to 50 years [1230 (92%) males]. Lower extremity injuries comprised on 816 (61% of total admissions). Tibia fractures were the most common injury in isolation, multiple injury, as well as polytrauma, and a vast majority of these were open fractures. Multiple injuries were seen in 82 (6.1%) patients and 33 (2.5% of Total) patients were polytraumatized. An amputation was necessary in 16 (1.2%) patients and emergent fasciotomy for compartment syndrome was necessary in 23 (1.7%) cases of tibia fractures and 39 (2.2%) of foot and ankle injuries. A floating joint injury was present in 24 (1.8%) patients.. A fat embolism syndrome (FES) was diagnosed in 8 (0.6%) patients. The overall mortality was 0.45% (6 patients). CONCLUSIONS: Motorbike accident is an important cause of morbidity and mortality in Kathmandu, and often involves a very productive age group. There is an imminent need to address this public health problem.

A Snapshot of 1001 Children Presenting with Cerebral Palsy to a Children's Disability Hospital.

BACKGROUND: Cerebral palsy (CP) has largely been an unaddressed problem in low and middle income countries (LMIC's). The purpose of this retrospective study is to provide a facility-based snapshot of CP in Nepal. METHODS: A retrospective chart review of 1001 patients diagnosed as having cerebral palsy, presenting to our institution from December 2008 to December 2011, was carried out. RESULTS: Majority of cases were found to be a result of birth complications and post-natal infections. Most children with CP were born at home, presented after walking age and came from socioeconomically unstable or borderline households. Less than 20% were attending school. Spastic diplegia was the most common presentation. Children with post-natal spasticity secondary to infection seemed to retain greater ambulatory potential. CONCLUSIONS: In contrast to CP in developed countries, the etiology in LMIC's is largely related to birth-related complications and post-natal infections. There is an urgent need to address preventable causes of cerebral palsy in Nepal.

Extra and Intra-articular Synovial Chondromatosis.

Synovial chondromatosis is not so rare intra-articular condition secondary to synovial metaplasia, that affects the knee joint. Extra-articular synovial chondromatosis however is an extremely rare condition that usually involves the synovial sheath or bursa of the foot or hand. We present two cases of synovial chondromatosis, one intra and one extra-articular. The first case was a 25 year old lady who presented with pain, swelling and restricted range of motion of left knee and was found to have an intra-articular synovial chondromatosis which was treated successfully by joint debridement. The second case was that of a 22 year old man who presented with right knee pain and was diagnosed to have an extra-articular synovial chondromatosis of his right medial hamstring tendon sheath, excision of which resulted in complete relief of symptoms.

The Ponseti method in the treatment of children with idiopathic clubfoot presenting between five and ten years of age.

Our goal was to evaluate the use of Ponseti's method, with minor adaptations, in the treatment of idiopathic clubfeet presenting in children between five and ten years of age. A retrospective review was performed in 36 children (55 feet) with a mean age of 7.4 years (5 to 10), supplemented by digital images and video recordings of gait. There were 19 males and 17 females. The mean follow-up was 31.5 months (24 to 40). The mean number of casts was 9.5 (6 to 11), and all children required surgery, including a percutaneous tenotomy or open tendo Achillis lengthening (49%), posterior release (34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue release combined with an osteotomy (2%). The mean dorsiflexion of the ankle was 9° (0° to 15°). Forefoot alignment was neutral in 28 feet (51%) or adducted (< 10°) in 20 feet (36%), > 10° in seven feet (13%). Hindfoot alignment was neutral or mild valgus in 26 feet (47%), mild varus (< 10°) in 19 feet (35%), and varus (> 10°) in ten feet (18%). Heel-toe gait was present in 38 feet (86%), and 12 (28%) exhibited weight-bearing on the lateral border (out of a total of 44 feet with gait videos available for analysis). Overt relapse was identified in nine feet (16%, six children). The parents of 27 children (75%) were completely satisfied. A plantigrade foot was achieved in 46 feet (84%) without an extensive soft-tissue release or bony procedure, although under-correction was common, and longer-term follow-up will be required to assess the outcome.

Clinical, MRI and arthroscopic correlation in internal derangement of knee.

BACKGROUND: The traumatic or degenerative internal derangement of the knee requires certain investigations for the establishment of diagnosis, in addition to clinical history and a thorough physical examination. The use of arthrography and arthroscopy improves the accuracy of the diagnosis. MRI scanning of the knee joint has often been regarded as the noninvasive alternative to diagnostic arthroscopy. OBJECTIVE: The purpose of the study was to correlate clinical and low field MRI findings with arthroscopy in internal derangement of the knee. METHODS: Forty one patients with suspected internal derangement of the knee were subjected to MR examination followed by arthroscopy. Clinical criteria used were history, mode of injury, Mc Murray, Apley grinding, Thessaly test for meniscal injury. Drawer test was considered to be essential for clinical diagnosis of cruciate ligament injury. MRI of the knee was performed in low field open magnet (0.35T, Magnetom C, Seimens). Arthroscopy was done within two months of MR examination and was considered gold standard for the internal derangement of the knee. RESULTS: The sensitivity, specificity, diagnostic accuracy of clinical examination were 96.1%, 33.3% and 73.1% respectively for medial meniscal tear; 38.4%, 96.4% and 78.1% respectively for lateral meniscal tear. The sensitivity, specificity, diagnostic accuracy of MRI were 92.3%,100% and 95.1% for medial meniscal tear; 84.6%96.4% and 92.6% respectively for lateral meniscal tear. CONCLUSION: Clinical examination showed higher sensitivity for medial meniscal tear compared to MRI, however with low specificity and diagnostic accuracy. Low field MRI showed high sensitivity, specificity, diagnostic accuracy for meniscal and cruciate ligament injury, in addition to associated derangement like articular cartilage damage, synovial thickening.

Managing the injury burden in Nepal.

Nepal loses about 530,000 disability adjusted life years (DALYs) per year to injury, predominantly due to falls. It takes 30,000 Nepali rupees (NR), or approximately US$430 at 70 rupees per $US saved per DALY to achieve primary prevention and 6000 NR per DALY if we invest in hospitals, versus 1000 NR invested in prehospital care, because simpler less expensive actions performed early have a greater impact on outcome than more complex measures later. A system for prehospital services was planned for medical emergencies at a national level meeting at the Medical University of Nepal to promote healthcare to victims in inaccessible regions by empowered or enlightened citizens. Feasible actions for common emergencies were defined and a tutorial required to help the majority of such victims was created and packaged. The knowledge and attitude component of the tutorial will be delivered through a web site to citizens motivated to learn and help with emergencies. The knowledge will be tested through a net-based Multiple Choice Questions (MCQ) test. Practical training in medical triage skills will be provided to those who qualify for the test at the University or its designated affiliates. A mobile phone-based information system will be created and used to make these enlightened citizens available to the victim at the site/time of the emergency.

Anterior dislocation of the shoulder with ipsilateral humerus shaft fracture.

Anterior dislocation of the shoulder joint with ipsilateral humerus shaft fracture is a very rare injury. Until July 2006 only 18 cases have been reported in the literature. Here we report a case of Anterior Shoulder dislocation with greater tuberosity and shaft of humerus fracture. The patient was treated by Open reduction and internal fixation of the shaft fracture followed by closed reduction of the dislocation. A post-operative rehabilitation program was instituted for complete rehabilitation of the shoulder function.

Two faces of major lower limb amputations.

OBJECTIVES: To review the indications for major lower limb amputations in adults and children in our patient population and to compare our experience in prosthetic rehabilitation with that of other published information. MATERIAL AND METHODS: We retrospectively reviewed charts of patients who underwent amputation between 1997 to 2004 at the Orthopaedic Department of B& B Hospital (BBH), Gwarko and Hospital and Rehabilitation center for Disabled Children ( HRDC), Banepa. There were 113 patients at BBH & 89 patients at HRDC. Major amputation was defined as any amputation at or proximal to wrist and ankle. RESULTS: Major lower limb amputations constituted 73.58%(39/53) of all major amputations at BBH and 97.77% (44/45) at HRDC. Road traffic accident was found to be number one cause for major lower limb amputations (74.29%) in adult population. In children postburn contracture was the leading cause for amputation (29.54%) followed by Congenital limb conditions (22.72%), Spina bifida with trophic ulcers ( 20.45%), Tumor (13.63%), Chronic Osteomyelitis (6.81%), Trauma (4.54%) and Arthrogryposis (2.27%). Prosthetic fitting and rehabilitation is as yet far from satisfactory in the adult population but all the children who had amputation at HRDC were fitted with prosthesis. CONCLUSION: Main causes of major lower limb amputation in both population is largely preventable by instituting safety measures and conducting awareness program. There is a need for an effective prosthetic fitting center for adults.

Results of simultaneous open reduction and Salter innominate osteotomy for developmental dysplasia of the hip.

OBJECTIVES: To assess the results of simultaneous open reduction and Salter Innominate Osteotomy for developmental dysplasia of the hip in our context where there is a tendency for these cases to present late without having undergone any treatment previously. MATERIAL AND METHOD: We retrospectively reviewed the record files and radiographs of 22 dislocated hips of 20 patients managed with simultaneous open reduction and Salter osteotomy at Hospital and Rehabilitation Centre for Disabled Children from 1999 to 2001. Only eight patients with 9 hips with purely developmental dysplasia of hip aged one to seven years were included. The acetabular index on the initial and final radiographs was measured. The neck shaft angle was also measured. All radiographs were evaluated to determine the presence of avascular necrosis of the femoral head and position of the head after the operation. Clinical results were determined using modification of the McKay criteria (Pain, ROM, LLD, Containtment and Gait) . Follow-up ranged from a minimum of 1 year to a maximum of 5 years (average 3 years and 1 month). RESULTS: The results were excellent in 7 hips (77.77%) good in 1 hip (11.11%) and poor in 1 hip (11.11%) according to modified McKay criteria.. No complications related to infection, graft fracture, vascular or neural injury were encountered. CONCLUSION: When case selection for surgical treatment is appropriate, a reasonable excellent to good result can be expected even in cases such as ours which present late.

Radial club hand deformity--the continuing challenges and controversies.

The records of 27 patients with Radial club hand deformity attending the Hospital and Rehabilitation Centre for Disabled Children (HRDC) were reviewed. This longitudinal intercalary deficiency of forearm growth has a varied clinical presentation and the goals of management are both improved function and cosmesis. We present the results of our treatment and review the current world literature on this challenging orthopaedic deformity.

Surgical interventions in chronic osteomyelitis.

Chronic osteomyelitis is a leading cause of morbidity in orthopaedic practice in Nepal. Various factors like health service inaccessibility, inadequate treatment, malnutrition, poverty, and to some extent antibiotic resistance contribute to disease progression from acute osteomyelitis to chronic osteomyelitis in this region of the world. This paper presents our experience of managing ninety patients with chronic osteomyelitis over a period of four years, from February 1998 to November 2001.

Tibial plateau fractures: four years review at B & B Hospital.

BACKGROUND: Tibial plateau fractures involve the articular surface of the tibia resulting from a combination of axial loading with varus or valgus stress. Inadequate and inappropriate treatment may result in significant functional loss. OBJECTIVE: The purpose of this study was to determine the outcome of our treatment modalities and to compare with the results of comparable studies. METHODS: The results of treatment of 81 knees were reviewed over the period of five years (1997 to 2002). There were 62 men and 18 women, with an average age of 37 years (15 years to 75 years) at the time of initial evaluation. One patient had bilateral involvement. Fractures were classified according to Schatzker. Seven patients were treated conservatively. Sixteen patients (17 knees, one had bilateral involvement) were operated with closed reduction and percutaneous cannulated screws fixation. Thirty one patients' required open reduction and internal fixation with cannulated screws. Fifteen fractures were plated, and in eleven cases, external fixators were used. Follow up period ranged from six months to three years. RESULTS: Results were graded as excellent, good, fair and poor on the basis of functional outcome. Forty three (54%) patients (44 knees) had excellent, twenty two (26%) had good, five (6%) had fair and ten (14%) had poor results. Poor results were associated with high energy fractures, late presentation, and inadequate physiotherapy follow up. Eight patients (10%) had complications. One had common peroneal nerve palsy, six had wound infection and one patient demonstrated early arthritic changes. CONCLUSION: Tibial plateau fracture is a challenging fracture to manage. Restoration of articular congruity and early range of motion should be the primary goal. Proper and adequate preoperative planning is mandatory. Well maintained articular congruity with stable fixation helps early mobilization and better functional outcome.