Literature review and case report: Current concepts for concomitant intra and extracapsular fractures of neck of femur in elderly patients.

Though the incidence of concomitant ipsilateral intracapsular and extracapsular fracture neck of femur is still a rare presentation in day to day fracture hip admissions. Cases of simultaneous ipsilateral intra- and extra-capsular neck of femur fractures are forestalled with problems relating to diagnosing this injury as well as debate regarding optimal methods of fixation versus arthroplasty. We did a literature review to assess frequency of such fracture incidence, highlight methods of treatment applied, current practice for management as well as case report presentation.

High-grade infiltrative myxofibrosarcoma in the forearm presenting as acute carpal tunnel syndrome.

Myxofibrosarcoma is one of the most common sarcomas in the extremities of elderly people and is characterized by a high frequency of local recurrence. We report a rare case of high-grade myxofibrosarcoma involving the forearm and presenting as acute carpal tunnel syndrome where absence of a discrete mass lesion and diffuse infiltrative nature precluded early recognition of tumor. To our knowledge, such a presentation with an extreme infiltrative growth pattern in the forearm has not been reported before.

Can carpal malalignment predict early and late instability in nonoperatively managed distal radius fractures?

The purpose of this study was to assess the frequency of carpal instability as a concomitant lesion in distal radius fractures and identify other factors including carpal malalignment in an attempt to predict the final radiological outcome more accurately following conservative treatment of distal radius fractures. An observational study from patient records and standardised radiological follow-up examinations as data sources was used. The alignment of each wrist was checked radiographically immediately post-reduction and subsequently at 1- and 6-week follow-up assessments. Serial measurements of radial length, dorsal tilt, radial inclination, scapho-lunate, radio-lunate, radioscaphoid, scapho-capitate angles and effective radiolunate flexion angle were made. Regression analysis showed high correlation among the severity of axial shortening, pre-reduction dorsal angulation and radio-carpal malalignment pattern with early loss of reduction at 1 week. We found the age, severity of axial radial shortening, dorsal angulation, presence of dorsal comminution and radio-carpal malalignment pattern to be significant predictors of adverse radiological outcome at 6 weeks (late instability). Our study highlights the importance of radio-carpal instability pattern on post-reduction radiographs as a predictor of early and late instability.

Tuberculous pyomyositis of the thigh masquerading as malignancy with concomitant tuberculous flexor tenosynovitis and dactylitis of the hand.

Multifocal involvement of the skeleton is extremely rare, with tuberculous pyomyositis and tenosynovitis of the wrist being uncommon presentations of skeletal tuberculosis (TB). We present an immunocompetent 68-year-old woman with concomitant presentation of these uncommon forms of extrapulmonary TB heralded by tuberculous pyomyositis. Tuberculous pyomyositis can often masquerade as malignancy, leading to misdiagnosis and patients being mistakenly referred to oncologists for management. This delayed the institution of appropriate drug therapy. Similarly, because of its rarity, tuberculous tenosynovitis may be overlooked as a cause of chronic tenosynovitis. In the absence of pathognomonic imaging findings, the diagnosis ultimately rests on histopathological and microbiological confirmation. This case highlights the importance of maintaining a high index of suspicion of the protean manifestations of extrapulmonary TB, not only in high-risk populations, but in immunocompetent individuals as well. It also illustrates the advantage of a clinically-directed multidisciplinary approach in early recognition and treatment of this entity.

Sequential traumatic bilateral extensor pollicis brevis rupture: a case report.

We present an interesting and rare case of a sequential bilateral traumatic rupture of the extensor pollicis brevis tendons distal to the first extensor compartment in a patient with no underlying systemic condition or pathology around the wrist. Satisfactory thumb function was restored by bilateral transfer of the extensor indicis proprius.

Distal radius fracture management in the emergency departments in UK: are we doing enough?

The objective of this study was to ascertain knowledge of the normal anatomy and appreciation of components of an 'adequate' or 'acceptable' reduction by the medical staff responsible for management of distal radius fractures in the emergency departments (A&E) in UK. A nationwide structured questionnaire survey based on literature review was performed on 138 doctors. Of the 100 (72%) respondents, only 40% could cite the correct values for volar tilt, radial inclination and ulnar variance, there being a significant difference between orthopaedic, n = 16 (64%) and A&E staff, n = 24 (32%); p = 0.031; chi(2) = 12.17. Only 18% respondents were aware of the acceptable ranges of adequate reduction; with orthopaedic staff, n = 12 (48%) being more aware than A&E staff, n = 6 (8%); p = 0.002; chi(2) = 6.38. Only 19% formally measure the key parameters before decision making (52% orthopaedic vs. 8% A&E staff; p = 0.018; chi(2) = 7.31). Only 14% of respondents from hospitals equipped with picture archive navigation system stated that they used the angle measurement function.A lack of knowledge of the normal anatomical values and implementation of generally accepted measurement criteria predictive of fractures unlikely to benefit from repeat manipulations is evident. It is important to emphasise the influence of factors reported to affect stability such as age, functional demands of the patient and extent of initial fracture displacement in decision making. The introduction of a set of guidelines and further education of the medical staff could reduce the number of inappropriately treated distal radial fractures in the A&E setting with significant economic implications.

Neurothekeoma of the hand.

Neurothekeomas are rare, benign connective tissue tumours probably of Schwann cell origin. We report an unusual case of a neurothekeoma involving the hand. Histological examination revealed characteristic myxoid nodules with spindle shaped cells. The immunocytochemical reaction for S-100 protein and neuron-specific enolase was positive. Complete excision proved curative as the tumour was well encapsulated.