Atypical Osteonecrosis of Humeral Head FollowingAnterior Shoulder Dislocation.

INTRODUCTION: Osteonecrosis of the humeral head is not a very common entity. It is usually associated with comminuted proximal humerus fractures. We report a rare case of osteonecrosis of humeral head after anterior shoulder dislocation without any fracture of the proximal humerus. CASE REPORT: We report a case of a 24-year-old male who sustained a left-sided anterior subcoracoid shoulder dislocation following a road traffic accident. The shoulder was closed reduced, and a post-reduction radiograph was taken to confirm concentric reduction. At 6-month and 2-year follow-up, the radiographs showed sclerotic changes and magnetic resonance imaging (MRI) confirmed the occurrence of osteonecrosis. This is the first such report in contemporary literature. CONCLUSION: Osteonecrosis of the humerus head can occur after an anterior shoulder dislocation. It is important to distinguish between the bone bruise and osteonecrosis. This can be done by serially reviewing the patient's radiographs and MRI.

Impalement Injury to Thigh: A Case Report with Review of Literature.

INTRODUCTION: Impalement injuries are one of the rare presentations in the emergency department and present complex surgical challenges in management. Prompt transfer to tertiary centre, pre-operative planning, and multi specialty involvement is crucial in the management of such cases. CASE REPORT: We report a case of 18-year-old male who sustained impalement injury to thigh with an iron rod after falling from height. After quick assessment ofv ital parameters and ruling out major organ injury, wound extent was examined. In collaboration with vascular and plastic surgeons, the rod was successfully removed under direct vision. The patient recuperated without sequelae. CONCLUSION: One should not get distracted by the appearance of the impalement injuries. After initial resuscitation, full trauma evaluation should be carried out before attending to local injury. Minimal manipulation, extraction of impaled object in operation theater under direct vision, wound debridement, and administration of antibiotics to prevent wound infection are pearls of the management of impalement injury.

Functional and radiological outcomes of thoracolumbar traumatic spine fractures managed conservatively according to Thoracolumbar Injury Severity Score.

AIM: To study the functional and radiological outcomes in cases managed conservatively for single-level traumatic thoracolumbar spine fractures without neurological deficit. MATERIALS AND METHODS: In this prospective study design, thirty patients who presented to tertiary care hospital and diagnosed with posttraumatic thoracolumbar vertebral fracture without any neurodeficit were recruited. All the patients were managed conservatively as per the protocol which included bed rest, spinal braces, and physiotherapy. Adequate analgesia was given wherever necessary. The patients were followed at regular intervals up to a maximum of 2 years. Clinically visual analog scale (VAS) score and Roland Morris Disability Questionnaire (RMDQ)-24 were assessed and radiologically local vertebral kyphosis, scoliosis, and loss of body height were noted at each follow-up. RESULTS: The data was statistically analyzed and the results were as follows. Thoracolumbar fractures were more in young adults (<26 years) and more so among the males (80% cases). The most common fracture type in our study was compression fracture. The most common site involved in our study was L1 vertebra (36.7%). There was a significant decrease of VAS score (pain score) in 79% cases with the maximum decrease in type A1 fracture. The mean RMDQ-4 score in our study was 5.53. The overall progression of kyphosis was 1.9°. There was no relation found between the kyphotic deformity and the clinical outcomes (VAS and RMDQ-24 scores). Canal size changes were found to be insignificant at the end of 2 years compared to baseline. CONCLUSION: Study showed favorable outcomes in terms of return to daily activities, making it a good option in managing Type A1 dorsolumbar fractures. Though there was a progression of kyphosis but no neurological deficit was seen.

Osteochondromas at Unusual Sites- Case Series with Review of Literature.

INTRODUCTION: Osteochondromas are benign tumours of the skeletal system. Their commonplace of occurrence is around growing ends of long bones like lower end of femur and upper end of tibia, but literature describing their incidence around flat bones of body like pelvis, scapula and small bones of hand, foot is rare. CASE REPORT: We describe two cases of osteochondromas at unusual sites, one on the dorsal aspect of scapula and other at the base of first metatarsal. Patient with scapular osteochondroma had difficulty in sleeping in supine position while that with metatarsal osteochondroma had discomfort while walking. CONCLUSION: Depending on the site of occurrence, osteochondromas can give rise to different local symptoms. Possibility of osteochondroma should be kept in mind during differential diagnosis of bony swelling in flat bones as well as small bones.

Conservative Management of Osteoporotic Vertebral Fractures: A Prospective Study of Thirty Patients.

INTRODUCTION: Osteoporotic vertebral fractures relate to poorer quality of life and higher long-term mortality. In a resource-poor setup, conservative management assumes great importance as primary means of treatment. We assess the clinico-pathological epidemiology of osteoporotic vertebral fractures and prospectively evaluate the effectiveness of conservative management in their treatment. MATERIALS & METHODS   : Thirty consecutive patients, diagnosed with osteoporotic vertebral fracture, underwent the predetermined protocol of conservative treatment (bed rest, titrated analgesia, antiosteoporosis pharmacotherapy, bracing, and supervised physical therapy) after assessment of basic demographic data and clinical examination. They were evaluated every three months for nine months, using visual analog scale (VAS) for backpain, Oswestry Disability Index (ODI), and radiological and hematological parameters. RESULTS : The mean age of the patients was 66.9 +/-7.6 years and the female: male ratio was 14:1. All (100%) women were postmenopausal and the mean time since menopause was 16.75 +/- 8.12 years. The presenting complaints were backpain (100%) and deformity (53.33%). Neurodeficit was noted in one (3.33%) patient. Higher age was correlated to greater vertebral collapse (p=0.001) and higher kyphotic angle (p=0.002). At nine months after treatment, there was a significant decrease in the VAS score (p<0.0001) and the ODI score (p<0.0001), with the final VAS score improving by 49.25% and the ODI score improving by 47.23% from the baseline. There was progressive increase in vertebral collapse (p=0.0474) with no change in kyphotic or scoliotic angles. With treatment there was a consistent increase in serum calcium (p<0.0001), phosphorous (p<0.0001), and vitamin D3 (p<0.0001) levels, and decrease in parathyroid hormone levels (p<0.0001). CONCLUSIONS : A multidisciplinary conservative treatment is effective as the primary treatment for patients with osteoporotic vertebral fractures. It alleviates pain, decreases disability, reduces morbidity, and is effective in preventing further progression of the disease process clinically, radiologically, and hematologically.

Predictors of iatrogenic lateral wall fractures while treating intertrochanteric fracture femur with the dynamic hip screw system in Indian patients.

BACKGROUND: The integrity of the lateral wall has been reported to be an important factor determining fracture stability in an intertrochanteric fracture. Iatrogenic the lateral wall fracture (ILWF) has been reported while reaming for the lag screw and the barrel of the dynamic hip screw (DHS). This study aimed to identify the predictors of iatrogenic lateral wall fractures (ILWF) while using the DHS, which will help to improve the pre-operative planning and avoid their incidence. MATERIALS AND METHODS: A total of 120 adult patients with intertrochanteric fracture femur treated with the DHS were included in this prospective series. Pre-operatively, the parameters noted were the demographic data, quality of bone using Singh's index, fracture classification using AO/OTA and modified Evan's system. The incidence of ILWF was recorded immediately after the fixation with the DHS. The two groups, i.e. one with ILWF and other without ILWF, were compared. RESULTS: The mean age of 46 females and 74 men in the study was 61 years. Among 120 patients, 87 (72.5 %) patients had a posterior sag that had to be corrected while passing the guide wire and while reaming the neck of femur. The incidence of ILWF was 23.33 %. The incidence of osteoporosis in patients with unstable fracture was 66.67 %. 1.7 % patients with a stable AO/OTA A1 fracture had ILWF, as compared to 50 % of patients with type A2.2 and type A2.3 who sustained an ILWF (p < 0.0001). None of the patients with a 2-part fracture on modified Evan's classification had ILWF, while 53.84 % with a 4-part fracture had ILWF (p < 0.01). CONCLUSION: There is a high risk of ILWF using the DHS in unstable intertrochanteric fractures (AO type A2.2 and A2.3 or 4-part fracture patterns). LEVEL OF EVIDENCE: IV (case series).

Proximal femoral locking plate versus dynamic hip screw for unstable intertrochanteric femoral fractures.

PURPOSE: To compare the outcome in patients who underwent surgery for unstable intertrochanteric femoral fractures using the proximal femoral locking plate versus the dynamic hip screw (DHS). METHODS: 15 men and 5 women aged 32 to 78 (mean, 55) years were randomised to the proximal femoral locking plate group, whereas 14 men and 6 women aged 38 to 75 (mean, 59) years were randomised to the conventional 135-degree DHS group. The time to union, medialisation of the shaft, neck-shaft angle, limb shortening, varus collapse, and functional outcome (using the Hospital for Special Surgery Hip Rating System) were assessed. RESULTS: Respectively in the locking plate and DHS groups, the mean times to union were 14.6 and 16.5 weeks (p=0.067) and the mean limb shortenings were 0.3 and 1.4 cm (p<0.001). Medialisation of the shaft occurred in 0 and 15 patients (p<0.0001); varus collapse occurred in 2 and 5 patients (p=0.408); the functional hip score was good-to-excellent in 18 and 11 patients (p=0.031); deep wound infection occurred in 3 and 2 patients; and implant cut-out occurred in one patient each group. CONCLUSION: A non-collapsing locking plate achieved bone union in unstable intertrochanteric fractures with lower risks of limb shortening and medialisation of the shaft.

Fibrodysplasia ossificans progressiva: a case report.

Fibrodysplasia ossificans progressiva or myositis ossificans is a rare disease characterised by bony deposits or the ossification of soft tissues. It transforms skeletal muscles, tendons, ligaments, fascia, and aponeuroses into heterotopic bony deposits through an endochondral process. This leads to progressive immobility; patients are usually wheelchair-bound by the second decade of life and die of thoracic insufficiency by the fourth decade of life. There is no treatment apart from symptomatic treatment with steroids during flare-ups. Excision of heterotopic ossification is not recommended as it can provoke extensive and painful new growths. It is important to detect the disease early from characteristic signs of great toe abnormalities and heterotopic ossifications to improve quality of life through early physiotherapy.

Augmented repair of degenerative tears of tendo achilles using peroneus brevis tendon: early results.

UNLABELLED: Reconstruction of degenerated ruptures of the tendoachilles is a challenge. Ruptured tendons and the remaining tendon ends are abnormal. A number of methods have been described in literature reconstruct the tendoachilles, but with variable results(1). We used peroneus brevis tendon in 20 patients to augment the repair of degenerated tendoachilles tears by creating a dynamic loop as described by Teuffer et al(2). All patients were followed up for atleast 18 months. At the last postoperative visit, 18 out of 20 patients were able to do a toe raise. Eighty-five per cent of patients had excellent or good results and 15% had fair or poor results using modified Rupp scoring. Advantages offered by this procedure are the use of a single incision and mini incision and use of a dispensable tendon such as the peroneus brevis without entirely depending on the damaged tendon for healing. KEY WORDS: Degenerative tear of tendoachilles, augmented repair, peroneus brevis tendon.

Patients with blunt traumatic spine injuries with neurological deficits presenting to an urban tertiary care centre in mumbai: an epidemiological study.

INTRODUCTION: Traumatic spine injuries are on the rise. The literature is sparse regarding epidemiology of patients with traumatic spine injuries from this part of the world. OBJECTIVES: To analyse the following in patients with traumatic spine injuries with neurological deficits: demographic and social profile, common modes of injury, pre-hospitalisation practices, region of spine affected, severity of neurological deficit and the lay individuals' awareness about traumatic spine injuries. METHODS: The study sample comprised 52 adult patients with traumatic spine injuries with neurological deficits. We collected data on demographic and social characteristics, mode of injury, pre-hospitalisation treatment, interval between injury and presentation, spine region affected and severity of neurological deficits and patient's knowledge about such injuries. RESULTS: The average patient age was 31.32y. The male: female ratio was 2.25:1, and the most common modes of injury were fall from height, followed by traffic accident. More than half of the patients suffered cervical spine injuries, followed by dorsolumbar spine injuries. Only 9.61% of patients received pre-hospitalisation treatment. All patients understood there could be complete functional recovery after treatment for traumatic spine injuries. CONCLUSION: There is a growing need to improve railway and roadway safety equipment and to make it accessible and affordable to the susceptible economically weaker population. Attempts should be made to increase awareness regarding traumatic spine injuries. KEY WORDS: Trauma; Spine; Deficit; Poor; safety; awareness.

Pelvic deformity secondary to tensor fascia lata tightness associated with desmoid tumor.

The iliotibial band is a thick, condensed fascia that, when contracted, leads to a hip flexion, abduction, and external rotation contracture in addition to other joint contractures. Iliotibial band tightness occurs secondary to iliotibial band friction syndrome, which commonly occurs at the lateral femoral epicondylar region. However, a proximal cause of iliotibial band/tensor fascia lata friction syndrome leading to a secondary hip contracture is swelling around the hip; this swelling being a desmoid tumor has not been explicitly described in the literature. The authors present a rare case of a hip contracture in a 28-year-old active man who presented with a functionally disabling hip flexion contracture of 20° with further flexion possible up to 130°, a 45° abduction contracture, and a 20° external rotation contracture with further rotation possible up to 40° with a bony hard swelling in the left gluteal region. Ober's test was positive. Opposite hip and spine examinations were normal. The goals of treatment were to establish the causality between the 2 and to diagnose the etiology of the gluteal mass. Radiographs were normal, with only a pelvic obliquity evident. Magnetic resonance imaging revealed an extra-articular mass abutting the iliac blade. Histopathology confirmed the mass to be a desmoid tumor in the left gluteal region. A wide surgical excision of the mass was performed with negative margins; no postoperative radiotherapy was administered. After rigorous physiotherapy, the hip deformity disappeared at 6 months and there was no evidence of recurrence at 2.5-year follow-up, with the patient able to sit cross-legged and squat.

A rare case of open anterior hip dislocation.

Anterior hip dislocation is much less frequent when compared with posterior dislocation of the hip joint, with open dislocation being still rarer. We report a case of an open anterior hip dislocation in a 23-year-old male who presented to us in the emergency department, and also present a review of the literature.

Augmented Repair of Degenerative Tears of Tendo Achilles Using Peroneus Brevis Tendon: Early Results

Reconstruction of degenerated ruptures of the tendoachilles is a challenge. Ruptured tendons and the remaining tendon ends are abnormal. A number of methods have been described in literature reconstruct the tendoachilles, but with variable results1. We used peroneus brevis tendon in 20 patients to augment the repair of degenerated tendoachilles tears by creating a dynamic loop as described by Teuffer et al2. All patients were followed up for atleast 18 months. At the last postoperative visit, 18 out of 20 patients were able to do a toe raise. Eighty-five per cent of patients had excellent or good results and 15% had fair or poor results using modified Rupp scoring. Advantages offered by this procedure are the use of a single incision and mini incision and use of a dispensable tendon such as the peroneus brevis without entirely depending on the damaged tendon for healing.

A safe technique for sternoclavicular stabilization.

Sternoclavicular stabilization using metal implants is associated with an unacceptably high complication rate. A simple and safe technique of sternoclavicular stabilization utilizing sutures and the clinical results thereof are described in this case of an 11-year-old boy with an unstable anterior sternoclavicular dislocation.