Malreduction of syndesmosis--are we considering the anatomical variation?

Previous studies have demonstrated the need for accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. A computed tomography (CT) scan allows better visualisation of the transverse relationship between the fibula and incisura fibularis. The difference ('G' a term we coined for ease of description) between the fibula and the anterior and posterior facets of the incisura fibularis was compared between normal and injured ankles following syndesmotic fixation in 19 patients. The mean diastasis (MD) was also calculated, representing the average measurement between the fibula and the anterior and posterior incisura. When compared with the normal side, eight out of 19 (42%) cases were found to have a residual diastasis even after fixation across the syndesmosis. However, if a standard value of G (2mm) was used for the injured leg only, all of the 19 cases would have abnormal values of 'G' following reduction. Our study has clearly demonstrated the need for individualising the assessment method to guide surgeons and radiologists prior to revision surgery. A standard value of 'G' of 2mm as the normal limit cannot be applied universally, as apparent from the data presented in this study.

Sliding hip screw in pelvis: a rare intra-operative complication.

We are presenting an unusual intra-operative complication of penetration of sliding hip screw (SHS) into the pelvis during fixation of an intertrochanteric fracture neck of femur in a 78-year-old man along with the technique of retrieving it.

Outcome of pregnancy in a woman with an increased body mass index.

OBJECTIVE: To show the increased risk of adverse outcomes in labour and fetomaternal morbidity in obese women (BMI > 30). DESIGN: A population-based observational study. SETTING: University Hospital of Wales. The study sample was drawn from the Cardiff Births Survey, a population-based database comprising of a total of 60,167 deliveries in the South Glamorgan area between 1990 and 1999. Population Primigravid women with a singleton uncomplicated pregnancy with cephalic presentation of 37 or more weeks of gestation with accurate information regarding height and weight recorded at the booking visit (measured by the midwives) were included in the study. METHODS: Comparisons were made between women with a body mass index of 20-30 and those with more than 30. SPSS version 10 was used for statistical analysis. Student's t test, chi(2) and Fisher's exact tests were used wherever appropriate. MAIN OUTCOME MEASURES: Labour outcomes assessed were risk of postdates, induction of labour, mode of delivery, failed instrumental delivery, macrosomia and shoulder dystocia. Maternal adverse outcomes assessed were postpartum haemorrhage, blood transfusion, uterine and wound infection, urinary tract infection, evacuation of uterus, thromboembolism and third- or fourth-degree perineal tears. Fetal wellbeing was assessed using Apgar <7 at 5 minutes, trauma and asphyxia, cord pH < 7.2, babies requiring neonatal ward admissions, tube feeding and incubator. RESULTS: We report an increased risk [quoted as odds ratio (OR) and confidence intervals CI)] of postdates, 1.4 (1.2-1.7); induction of labour, 1.6 (1.3-1.9); caesarean section, 1.6 (1.4-2); macrosomia, 2.1 (1.6-2.6); shoulder dystocia, 2.9 (1.4-5.8); failed instrumental delivery, 1.75 (1.1-2.9); increased maternal complications such as blood loss of more than 500 mL, 1.5 (1.2-1.8); urinary tract infections, 1.9 (1.1-3.4); and increased neonatal admissions with complications such as neonatal trauma, feeding difficulties and incubator requirement. CONCLUSION: Obese women appear to be at risk of intrapartum and postpartum complications. Induction of labour appears to be the starting point in the cascade of events. They should be considered as high risk and counselled accordingly.

Treatment of aneurysmal bone cysts with saucerization and bone marrow injection in children.

In four consecutive children, healing of large, active aneurysmal cysts of the long bones was achieved with saucerization, closure of the periosteum, and instillation of autologous bone marrow into the cavity. The saucerization procedure consisted of excision of the subperiosteal new bone with its attached cyst contents and curettage of the remaining cortical bone. A centripetal pattern of bone healing was observed in which an ossification front advanced from the periphery to the center of the cavity. We conclude that autologous bone marrow injections are a simple means of augmenting the healing of aneurysmal cysts of long bones treated with saucerization. The procedure avoids the morbidity and costs associated with alternative methods of bone grafting.

The role of skeletal sonography in limb lengthening procedures.

Eleven patients (8 males, 3 females) undergoing limb-lengthening procedures were subjected to weekly conventional radiography along with fortnightly skeletal sonography of the distraction site, to assess the rate of new bone production and complications. The radiographs were assessed for: (i) distance between the distracted bone ends, (ii) presence of new bone formation at the distraction site, (iii) regeneration of the cortical outline and (iv) overlaying soft tissue abnormality. The sonographs were assessed for: (i) distance between the distracted bone ends, (ii) rate of new bone formation, (iii) density of the new bone produced, (iv) integrity and continuity of the cortical outline and (v) overlaying soft tissue abnormality. Our results indicate the superiority of sonography over conventional radiographs in: (i) detecting early new bone formation, (ii) establishing cortical and medullary canal remodelling, (iii) detecting soft tissue complications at the distraction site and (iv) determining the presence of fluid collection at the distraction site, in patients with delayed consolidation. Conventional radiographs were more accurate in determining the distance between the two distracted bone ends, and thus the degree of distraction achieved. Ideal assessments of events at the distraction site can be achieved by a combined assessment of conventional radiotherapy and skeletal sonography.

Hydatid cyst of the tibia.

A case of hydatid cyst of the tibia, which manifested as a pathologic fracture is being reported. Pain and swelling of left lower limb with inability to bear the weight were the main features. Tender swelling was also noted at the upper and middle third of tibia. Open biopsy revealed the hydatid cyst wall and scolices of Echinococcus granulosus. Albendazole treatment was followed by curettage and bone grafting.

Bizarre parosteal osteochondroma in the foot (a case report).

A rare case of a bizarre parosteal osteochondroma in the foot is presented. The tumour first described in 1983 by Nore et al is rare in any location and has to be differentiated from a juxta-cortical osteosarcoma and a benign osteosarcoma. Its differentiating characteristics are discussed.

Divergent dislocation of the elbow in a child (a case report).

A rare case of simultaneous disruption of superior radio-ulnar joint and posterior dislocation of the same elbow in a 6 year old boy is presented. It was possible to achieve the stable reduction by means of closed manipulation, restoring normal function in 6 weeks time. The possible mode of injury is discussed. There are only 4 cases reported of such a divergent elbow dislocation in modern literature.