Giant schwannoma of the first metatarsal: a rare entity.

Schwannomas of osseous origin are rare, and schwannomas of the short tubular bones are even rarer. These benign-looking tumors are difficult to diagnose using imaging alone. However, histopathologic evaluation of a biopsy specimen can establish the diagnosis by identifying Antoni type A and B zones. Curettage and bone grafting will probably be adequate for treatment because malignant changes are unlikely. Large lesions can require en bloc excision and reconstruction. We describe what appears to be only the second case of a schwannoma in the first metatarsal of the foot in a 48-year-old woman. The lesion was poorly contained, with obvious breaks in the cortical shell. The diagnosis was confirmed by pathologic analysis. The lesion was successfully treated with en bloc resection and reconstruction with a nonvascularized fibular graft.

Trans-scaphoid dislocation of the proximal row: a case report.

This report is of a 32 year old man who presented with complains of pain, swelling and deformity of right wrist of four weeks duration. He gave history of road traffic accident four weeks back leading to injury to right wrist; Preoperative radiographs and C.T. scan images were suggestive of trans-scaphoid dislocation of the proximal row of wrist. A volar and dorsal approach were used to reduce this complex dislocation but was not successful. Wrist arthodesis was performed after doing proximal row carpectomy. One year follow-up of the patient showed fair result with grip strength of 85% to contralateral side and modified Mayo wrist score of 65 at one year.

Role of nonoperative treatment in managing degenerative tears of the medial meniscus posterior root.

BACKGROUND: Tears of the medial meniscus posterior root can lead to progressive arthritis, and its management has no consensus. The aim of our study was to evaluate the effect of supervised exercise therapy on patients with medial meniscus posterior root tears. MATERIALS AND METHODS: Between January 2005 and May 2007, 37 patients with this tear verified by magnetic resonance imaging (MRI) and osteoarthritis grade 1-2 by radiographic examination were treated by a short course of analgesics daily for up to 6 weeks and then as required during follow-up, as well as a 12-week supervised exercise program followed by a home exercise program. Final analysis was performed for 33 patients, average age 55.8 (range 50-62) years and average follow-up of 35 (range 26-49) months. Patients were followed up at 3, 6, and 12 months and yearly thereafter using the Lysholm Knee Scoring Scale, Tegner Activity Scale (TAS), and visual analog scale (VAS). The analysis was performed using one-way analysis of variance (ANOVA) and Pearson's correlation coefficient to determine the relationship between Lysholm score and body mass index (BMI). RESULTS: Patients showed an improvement in Lysholm score, TAS, and VAS, which reached maximum in 6 months and later was accompanied by a decline. However, scores at the final follow-up were significantly better than the pretherapy scores. There was also a progression in arthritis as per Kellgren and Lawrence radiographic classification from median 1 preintervention to median 2 at the final follow-up. A correlation between BMI and Lysholm scores was seen (r = 0.47). CONCLUSION: Supervised physical therapy with a short course of analgesics followed by a home-based program results in symptomatic and functional improvement over a short-term follow-up; however, osteoarthritis progression continues and is related to BMI.

Use of ring fixator in the management of degloving injuries of lower limb.

High-velocity trauma causes degloving injuries of extremities. Management depends upon the viability of the degloved flap. The degloved area must be covered either with flaps or with split skin grafts. Various methods have been described to provide skin coverage. However, graft uptake depends upon the surgical expertise, graft quality, graft bed circulation and of course immobilization of the grafted area, especially across joints. We describe here a simple technique, which eventually helps graft bed preparation, eases application of graft tissue, facilitates graft care and allows passive mobilization of joints as well.

Minimizing radiation and incision in minimally invasive percutaneous plate osteosynthesis (MIPPO) of distal tibial fractures.

The traditional approach for plating of distal tibia had many problems. Minimally invasive percutaneous plate osteosynthesis for periarticular fractures are considered ideal these days with the availability of locking compression plate. However, this procedure demands radiation exposure. Indirect reduction, percutaneous plate positioning, and drill guide insertion all may require abundant radiation exposure. Minimizing radiation can still be done at the cost of extended skin incision. But we describe our technique of minimizing radiation and incision in minimally invasive percutaneous plate osteosynthesis in distal tibial fractures.

Study on outcome of fracture shaft of the humerus treated non-operatively with a functional brace.

BACKGROUND: Non-operatively treated fractures of the humeral diaphysis have a high rate of union with good functional results. The objective of this study is to find out the outcome of fractures of the humeral diaphysis treated with a functional brace that permits motion of shoulder and elbow joints and progressive use of the injured extremity. MATERIALS AND METHODS: This was a descriptive analytical study in patients of 16 years and above with closed fracture shaft of humerus treated with a functional brace that permits the motion of shoulder and elbow joints. The fracture arms were initially stabilized with U slab or hanging cast for an average of 11 days before application of brace. Radiographs were made at each follow-up visit until the fracture union occured. Angulation at fracture site, motion at shoulder and elbow joint were measured at the time of removal of brace. RESULTS: One hundred and five out of 108 fractures (97.2 %) were united with mean duration of 12.16 weeks (range, 7.5-19.3 weeks). Radial nerve injury was present in 6 cases (5.5 %). Varus angulation of ≤15° was present in 90.9 % out of 99 patients, while no angulation was present in 6 cases (5.7 %) out of 105 patients. Apex anterior angulation of ≤10° was present in 100 % out of 48 patients, whereas apex posterior angulation of ≤10° was present in 94.1 % out of 51 patients. CONCLUSION: Functional bracing for the treatment of fractures of the humeral diaphysis is associated with a high rate of union with nearly normal elbow motion and some restriction of shoulder motion.

Managing scaphoid fractures. How we do it?

The scaphoid is the common carpal bone to be fractured. Proper clinical and radiological evaluation is required to establish it's diagnosis. The management of acute fractures includes conservative treatment with cast in minimally displaced to open reduction and internal fixation in case of displaced ones. The established nonunion requires open reduction, bone grafting and internal fixation.

Role of vascular endothelial growth factor as a tumour marker in osteosarcoma: a prospective study.

PURPOSE: A prospective study was undertaken to evaluate the diagnostic and prognostic significance of serum levels of vascular endothelial growth factor (VEGF) in patients with primary localised osteosarcoma. METHODS: Serum VEGF levels were measured by an enzyme-linked immunosorbent assay (ELISA) in blood samples collected prechemotherapy, postchemotherapy, and postsurgery in 40 patients with histologically proven primary osteosarcoma. Comparison was made between serum VEGF level of healthy controls (n = 10) and prechemotherapy patient sera to evaluate its diagnostic potential. Serum VEGF levels of patients with and without metastasis were compared. Immunohistochemical staining was done to establish the correlation between serum and tissue VEGF expression. The Kaplan-Meier curve was used for survival analysis RESULTS: No significant relationship was observed between serum VEGF levels and age, gender, tumour size, local recurrence or histopathological subtypes of osteosarcoma. We observed significantly raised mean serum VEGF in patient sera compared with healthy controls (p = 0.001). Significant fall in mean serum VEGF level was observed following chemotherapy (p = 0.001). Patients who developed metastases had significantly higher serum VEGF levels compared with the nonmetastatic group (P = 0.001). Serum VEGF levels correlated well with VEGF expression in tissues. CONCLUSION: Serum VEGF levels might prove to be of diagnostic, predictive and prognostic value in patients with primary osteosarcoma, although further studies with larger sample size and longer follow-up is needed to support the hypothesis.

Ligamentotaxis for comminuted fracture of capitate: a case report.

We present the technical report for treatment of comminuted fracture of the capitate with ligamentotaxis. The base of third metacarpal was found to be fractured with comminution of the capitate. The decrease in carpal height index and comminution of the third metacarpal base lead to dilemma between conservative treatment and surgical management of this particular injury. The surgical management was chosen to maintain the carpal height index of the wrist to prevent the late degenerative changes.The patient was applied with external fixator in distraction mode expanning the wrist joint for six weeks, and the wrist was mobilised after removal of the fixator. It is shown that the external fixator in distraction mode expanning the wrist joint is a good alternative method for treatment of capitate fracture.

Calcaneal tuberosity avulsion fracture: an unusual variant.

Calcaneal tuberosity fractures involve the posterosuperior aspect of the calcaneus and may involve the insertion of the Achilles tendon. In this report, we describe an unusual presentation of a calcaneal avulsion fracture involving 2 displaced fragments in a male patient who did not seek treatment for 1 month after the original injury. The larger fragment contained the insertion of the Achilles tendon, and tendon lengthening was required in addition to fixation of the fracture fragments with cannulated lag screws and washers. After reduction and healing, the patient recovered fully without clinical weakness of the triceps surae.

The extremes in orthopaedics! Whom to blame?

Traditional medicines especially the herbal paste is routinely prescribed by the herb sellers. The unsupervised combinations and preparations are easily available in our part of world. The demand and supply of such irrational combination is only based on the principle that anything natural is safe. Drugs and preparations made by the people who lack the scientific knowledge of traditional herbal medicines adversely affect the consumer. We put forward few complications that resulted after herbal paste application in those who already had visited the specialist but opted the easily available unsupervised herbal preparations.

Expression of vascular endothelial growth factor in Ewing's sarcoma.

PURPOSE: Vascular endothelial growth factor (VEGF) is the most potent stimulator of angiogenesis. The aim of this study was to evaluate the role of serum VEGF as a diagnostic, predictive and prognostic marker in Ewing's sarcoma. METHODS: Patients with histopathologically proven diagnosis of Ewing's sarcoma without prior chemotherapy or radiotherapy were invited to take part in the study. Pre-chemotherapy, post-chemotherapy and post-surgery blood samples were collected for analysis of serum VEGF levels. Blood samples from ten sex- and age-matched healthy volunteers were collected for estimation of VEGF levels to act as control. Human VEGF Elisa kit (Bender Medsystem, Austria) was used to assess the serum VEGF levels. RESULTS: A total of nine cases of Ewing's sarcoma were included in the study. Mean age in the group was 12.44 years (range, seven to 18 years). Mean and median serums VEGF level in the study population were 4,547.78 pg/ml and 3,780.00 pg/ml, respectively. Ten age- and sex-matched healthy volunteers were selected as controls. No significant correlation was obtained between serum VEGF, age, sex and tumour size. Mean serum VEGF was significantly raised in the study group as compared to controls (p = 0.001). We observed a significant decline in serum VEGF level following neoadjuvant chemotherapy (p = 0.008). No correlation could be established between serum VEGF level pulmonary metastasis and overall survival. CONCLUSION: Serum VEGF might have a role as a diagnostic and predictive marker in patients with Ewing's sarcoma.

Modified tension band for displaced type 2 lateral end clavicle fractures.

PURPOSE: Displaced type 2 lateral end clavicle fractures have a tendency to delayed union or non-union. Various methods of stabilisation of the displaced lateral end fractures are described. The increasing use of implants to fix such fractures also necessitates extensive dissection for implant retrieval. Adequate reduction and minimal tissue trauma during implant placement and removal would be ideal modalities for fixation of such fractures. METHODS: All displaced type 2 lateral end clavicle fractures fulfilling our inclusion criteria were reduced with a small anterosuperior incision. Anteroposterior drill holes were made in both the fragments and a nonabsorabable polyester suture was passed through. The fracture was reduced and fixed with transacromial smooth Kirshner wires. The suture was tied with the knot superiorly in a figure-eight manner. The arm was supported in an arm pouch for six weeks. The Kirshner wire was routinely removed after six weeks in an out-patient department. Clinico-radiological outcome was studied at six weeks, and monthly intervals thereafter until union. RESULTS: All 16 fractures united. The mean average age of patients was 36.25 years with a SD of 11.35. There was no loss of reduction even after removal of Kirshner wires at six weeks. The mean average time of union was 10.75 weeks with a SD of 3.92. All patients regained near normal range of motion, and the mean average constant score at the end of one year was 98.37 with a SD of 2.87. All patients returned to preinjury level by the one-year follow-up. The range of motion remained the same in those who were followed up in successive years. Skin impingement with bent Kirshner wires were noted in four cases. Kirshner wires backed out in one case before six weeks but there was no loss of reduction. Infection and Kirshner wire breakage were not noted in our series. CONCLUSION: The clinico-radiological outcomes with our modified tension band fixation for displaced type 2 lateral end clavicle fractures were encouraging and comparable with earlier studies.

Birth-related femoral fracture in newborns: risk factors and management.

PURPOSE: Femoral shaft fracture following birth in newborns is a very rare injury. However, the risk factors for, mechanism of and management of these injuries remain a matter of debate. We describe our observations in a tertiary centre. METHODS: Ten cases of femoral shaft fracture encountered during a study period from January 2005 to December 2009 were evaluated. The demographic details, risk factors during birth, systemic illness, mode of delivery, type of fracture and management used were documented, and an analysis was performed. RESULTS: Mean gestational age was 37.2 weeks. Mean time to diagnose was 4 days. Two patients had subtrochanteric fracture, and eight patients had mid-shaft fracture. Most patients had breech presentation and had been born by Caesarean section. All patients showed complete union at the end of 4 weeks. No residual angulation or limb length discrepancy was noted after mean follow-up of 5 years. CONCLUSIONS: Thorough clinical examination and proper orthopaedic consult in the event of doubtful presentation help in early diagnosis and management. These fractures have good prognosis at long-term follow-up.

Simultaneous bilateral femoral neck stress fractures in a young military cadet: a rare case report.

Simultaneous bilateral femoral neck stress fracture in healthy young adult is one of the very rare clinical entities that an orthopedic surgeon may encounter once in lifetime. Bilateral femoral neck stress fractures have been very well documented in elderly and osteomalacia patients; however, its simultaneous occurrence in a healthy adult is challenging to diagnose and manage. This article describes a 34-year-old man a military personnel who sustained bilateral stress femoral neck fractures, during a routine training activity. The patient was come to our institution, and a full endocrine evaluation was performed and proved unremarkable. He underwent closed reduction and internal fixation of the fractures using cannulated screws on both the sides. At 1-year follow-up, the fractures went on to complete union. Despite strict non-weight-bearing instructions for initial 3-month period, patient bore weight on the limbs resulting in varus union on the left side. Our case emphasizes the significance of obtaining a complete and thorough medical history on physical examination and appropriately counseling patients regarding activity level even after successful fixation.

It is a glomus tumor! Not at all a paronychia.

We report an interesting case of chronic obscure pain over the toe tip. This earlier was misdiagnosed as chronic paronychia and operated twice. Obvious clinical appearance and high index of suspicion rendered it a glomus tumor on histopathology. We cite here a simple technique of advancement of flap for covering scarred defects created due to nail bed excision.