Tibial Tuberosity Avulsion Fracture with Epiphyseal Injury in a Soccer Player: Treatment Options and Challenges.

Introduction: Acute avulsion of the tibial tubercle is an uncommon fracture, with reported incidence rates of 0.4-2.7% of all epiphyseal injuries and <1% of all physeal injuries. Typically, these fractures present with marked displacement of the entire proximal apophysis, with or without intra-articular extension, and variable associated soft-tissue injury. The Ogden classification has historically directed both non-operative and operative treatment of this injury. The overarching objective of several fracture fixation techniques has been outlined as being to restore the joint surface and the extensor mechanism. Case Report: This case report describes the management of a 14-year-old male who sustained a rare avulsion fracture of the left tibial tuberosity with epiphyseal injury during a soccer game. The fracture was classified as Ogden Type III-B, indicating an intra-articular extension. The patient underwent open reduction and internal fixation with three cannulated screws and tension band wiring. Conclusion: The fracture united with no residual deformity and return of full range of motion. Tension band wiring provides stable reduction; hence, prompt diagnosis and appropriate surgical intervention in similar cases is important to optimize outcomes.

Bilateral Distal Humeral Physeal Separation-From Birth Trauma to Family Trauma.

Introduction: Chondro-epiphyseal separation of the distal humerus is a rare injury, which can occur as a consequence of excessive traction on the upper extremity accompanying a dystocic birth or one complicated by cephalopelvic disproportion. Such fracture patterns can also result from a combination of rotatory and shear forces, also typically seen following child abuse. It can be easily mistaken for a posterior elbow dislocation, creating a delay in diagnosis. Since unossified cartilage cannot be seen radiographically, these injuries are better appreciated by ultrasound or magnetic resonance imaging. Case Report: We present a case of an 8-day-old neonate who presented with pseudoparesis of the left arm following birth. Posterior displacement of the elbow joint was identified on the radiograph. On ultrasound, a trans-physical supracondylar distal humerus fracture was identified. This was presumed as trauma secondary to a difficult delivery. At the 11th week of follow-up, the patient presented with a fracture of the right proximal tibia, followed by a fracture shaft left femur at 5 months of follow-up. Chest X-ray at this time revealed uniting rib fractures with callus formation. After ruling out any congenital collagen disorder (osteogenesis imperfecta), the patient was diagnosed with a case of battered baby syndrome. The case was reported to child protection services and parents were questioned and counseled for the same. Conclusion: This case report highlights the importance of a high degree of suspicion of child abuse in any child with a rare fracture pattern, uncommon serial fracture occurrence, and unconventional clinic-radiological presentation.

Chondrosarcoma of Great Toe: A Case Report.

Introduction: Chondrosarcoma (CHS) of the toes is very rare and the involvement of phalanges is extremely rare. The osteolytic destruction of this tumor severely affects limb function and carries the risk of distant metastasis. These tumors are removed surgically to minimize local recurrence and distant metastases, maximize limb function with better prognosis. The main objective of this report is to present the case of a CHS that invaded the phalanx of the left great toe and formed a large phalangeal mass with osteolytic destruction of the distal bone. Case Report: This case report includes a 60-year-old man suffering from swelling of his left great toe for 2 years, with pain and swelling for 6 months. Serial hematological, radiological and tumor investigations were done. Magnetic resonance imaging revealed a well-defined peripherally enhancing multilobulated soft-tissue mass with central necrotic component involving the entire proximal phalanx of left great toe extending to distal phalanx and head of first metatarsal. The patient was planned for operative intervention due to the possibility of invasion into the adjacent bones. The tumor was excised and sent for histopathological examination, which was reported as Grade 2 CHS (PT, Nx, and Mx) and was S100 positive. The patient has been followed-up for 5 months. Results: There were no signs of local recurrence or distant metastasis on radiological investigations or clinical assessment during follow-ups. Conclusion: CHS occurring in toes is extremely rare. In this case, extensive surgical resection of the large low-grade CHS was safe and effective.

Haemophilic arthropathy of the knee: a surgeon's nightmare.

Surgical management of knee synovitis secondary to mild haemophilia, without any significant previous medical history and an adverse family history of haematological disorders, is arduous. Due to its rare occurrence, the diagnosis is often delayed or sometimes missed, leading to the grave and often lethal consequences in intraoperative and postoperative periods. Hardly isolated knee arthropathy due to mild haemophilia has been reported in the available literature. In this report, we present the management of a case of a 16-year-old male with isolated knee synovitis with undiagnosed mild haemophilia, who came to us with the first episode of knee bleeding. We elucidate the signs and symptoms, investigations, surgical management, and difficulties faced, especially during the postoperative period. This case report is presented to enhance awareness of the existence of this disorder and its management to prevent postoperative complications.

A comparative study of Proximal Femoral Nail (PFN) versus Dynamic Condylar Screw (DCS) in management of unstable trochanteric fractures.

Trochanteric hip fractures have become very common with 35-40% of these fractures being unstable. Trochanteric fractures, especially unstable ones are associated with high rates of mortality and morbidity and thus remain an inordinate challenge for surgeon to treat these fractures with proper choice of implant. Aim of the study was to compare the proximal femoral nail and dynamic condylar screw in the management of unstable trochanteric fractures. Our study was a prospective comparative study which included 26 patients with fresh (≤3 weeks old) unstable trochanteric fractures AO 31A2 and AO 31A3, with age ≥18 years of both sexes. Eleven patients in DCS and fifteen patients in PFN were included. Harris hip score was used to compare functional outcomes. Average age of patients in DCS group was 59.82±11.59 years and PFN was 54.2±16.22 years. AO 31A2 fracture pattern (63.64%) was more common than AO 31A3 in DCS group and AO 31A3 fracture pattern (60.00%) was more common than AO 31A2 in PFN group. Mean operative time for DCS was 96.36±15.51 minutes and for PFN it was 79.67±12.02 minutes with P-value of 0.003. Two patients in DCS group and 1 patient in PFN group were lost to follow up. Two patients in DCS group and 1 patient in PFN group died. Seven out of 11 (63.64%) patients in DCS group and 13 out of 15 (86.60%) patients in PFN group were available for final follow up. Union seen in 2 (28.57%) patients with DCS and 12 (92.31%) patients fixed with PFN with P-value of 0.007. Mean HHS of 62.29±24.26 in DCS and 86.92±11.65 in PFN with P-value of 0.037. Patients with combined excellent and good HHS in DCS group and PFN group were 2 (28.57%) and 11 (84.62%) respectively. Non-union was seen in 5 (71.43%) patients fixed with DCS and 1 (7.69%) patient fixed with PFN. Implant failure was seen in 3 (42.86%) patients in DCS group in which barrel plate was broken in 2 (28.57%) patients and lag screw cut out through femoral head in 1 (14.29%) patient and 1 (7.69%) patient in PFN group due to varus collapse and complete backout of screw. Varus collapse was seen in 3 (42.86%) patients in DCS group and 4 (30.76%) patients in PFN group. Proximal femoral nail is better implant as compared to dynamic condylar screw which was statistically significant in terms of lesser operative time, higher union rate and better functional outcome. So PFN is a better implant choice for unstable trochanteric fractures when compared with DCS.

Single-stage versus two-stage reconstruction in chronic multi ligament knee injury.

BACKGROUND: Multi ligament knee injury (MLKI) refers to the disruption of at least 2 of the 4 major knee ligaments. These injuries are managed in single and two-stage surgeries however, treatment guidelines for best practice are unsettled. There is no study in the literature that compares single and two-stage surgery for the management of chronic multiligament knee injury. Therefore, the aim of this study was to compare the functional outcome between single-stage and two-stage surgical fixation in chronic multi-ligament knee injury. METHODS: Twenty seven patients with chronic MLKI with at least 2 years of follow up were included. Fourteen patients underwent reconstruction of torn ligaments in a single-stage operation (Group I) and 13 patients underwent reconstruction of torn ligaments in two stages (Group II). Assessment of clinical outcome was done with IKDC knee score, TEGNER LYSHOLM knee score, range of movement and laxity tests (Anterior drawer test, Lachman, Posterior drawer test, pivot shift test, dial test, varus and valgus stress test). RESULTS: At final follow up, there was no significant difference in post-operative IKDC knee scores in group I and group II (84.7±7.1 and 81.4±8.4 respectively, p=0.3) and Lysholm scores (85.8±8.3 and 80.9±8.3 respectively, p=0.1), range of movement (133.2±5.7 and 131.5±6.6 respectively, p=0.5) and all the patients regained full extension. At the final follow up 12/14 patients (85.7%) in group I and 11/13 patients (84.6%) in group II had a negative/grade 1 anterior drawer test (p=0.6), 14/14 (100%) in group I and 13/13 (100%) patients had negative/grade 1 lachman test (p=0.6), 13/14 patients (92.8%) in group I and 13/13 patients (100%) patients in group II had negative/grade 1 pivot shift test (p=0.4), 9/10 patients (90%) in group I and 12/13 patients (92.3%) in group II had negative/grade 1 posterior drawer (p=0.6), 6/6 patients (100%) in group I and 6/7 patients (85.7%) in group II had negative/grade 1 dial test (p=0.3), 5/6 patients (83.3%) in group I and 5/7 patients (71.4%) in group II had negative/grade 1 varus stress test (p=0.4), 6/7 patients (85.7%) in group I and 7/7 patients (100%) in group II had negative/grade 1 valgus stress test (p=0.1). CONCLUSION: Chronic MLKI managed by single stage and two stage reconstruction provides similar functional outcomes. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Prediction of peroneus longus graft diameter for anterior cruciate ligament reconstruction by inframalleolar harvest and from anthropometric data.

BACKGROUND: The literature is gradually drifting towards a graft of larger diameter for successful ACL reconstruction. There is no published literature regarding the anthropometric predictors for the diameter of the peroneus longus tendon (PLT) graft obtained in ACL reconstruction through the inframalleolar approach. METHODS: Fifty-two patients were finally evaluated for anthropometric parameters to predict quadrupled PLT graft diameter in ACL reconstruction using the inframalleolar technique. Intraoperative quadrupled PLT graft diameter was correlated to the patient's anthropometric data such as age, height, weight, duration of injury, and BMI. We used regression analysis in a stepwise manner to ascertain anthropometric indices associated with the graft diameter. RESULTS: This study included 46 males and six females. Mean age was 28.2 ± 7.4 years, mean height was 172.7 ± 2.8 cm, mean weight was 75.6 ± 3.4 kg, mean BMI was 25.3 ± 0.9 kg/m2, mean duration of injury was 9.2 ± 3.9 months, and mean graft diameter was 9.3 ± 0.4 mm. Positive correlation with graft diameter was found only with height (r = 0.6, P < 0.01) and weight (r = 0.4, P < 0.01). On analysing through linear regression, height and weight had significant association with graft diameter, and we formulated the following prediction equation: PLT graft diameter (mm) = 0.083 × height (cm) + 0.011 × weight (kg) -5.854. CONCLUSION: Patients' characteristics, including height and weight, have a significant correlation with quadrupled PLT graft diameter and the average diameter of graft is > 9 mm through this approach.

Challenges in management of benign bone tumours complicated by pathological fracture in paediatric population.

BACKGROUND: Optimum treatment of pathological fractures following benign bone tumours in paediatric population is controversial. The usual difficulties encountered while dealing such cases is to establish a correct pre-operative diagnosis and to choose between conservative vs operative management. The aim of the work is to highlight the difficult aspects of diagnosis and management of pathological fractures following benign bone tumours in paediatric population. METHODS: All paediatric patients (<18 years) with pathological fractures following benign bone tumours were included. Pathological fractures due to infection, metabolic bone diseases and malignant bone tumours were excluded. Initial pre-operative diagnosis was based on clinico-radiological characteristics of the tumour and FNAC/needle biopsy, while final diagnosis was confirmed with post-operative histology. Primary outcome measure was determination of any disparity between pre-operative diagnosis and final post-operative histological diagnosis and the need of a separate open biopsy procedure for establishing the exact nature of lesion. Secondary outcome measures were determination of complications following surgery, functional grade and any recurrence at latest follow-up at 3 years. RESULTS: Out of 13 patients enrolled for the study, twelve patients met the inclusion criteria. Female to male quotient was 3:1, with average age of 12.17 years. We were able to make correct pre-operative diagnosis in 10 patients (83.3%) with systematic clinico-radiological analysis and carefully performed FNAC/needle biopsy. Disparity between pre-operative and final post-operative diagnosis was seen in two patients. In one of these two patients, initial pre-operative diagnosis was fibrous dysplasia, which turned out to be ossifying fibroma on final post-operative biopsy. While the other patient required an open biopsy to establish the nature of underlying pathology, as the pre-op histological evaluation revealed equivocal nature of bone lesion. Secondary outcome measures showed superficial infection in one, coxa vara in one, limb length discrepancy in 2 and fibular graft donor site morbidity in two. None of the patient had developed recurrence. All patients had complete healing of the fracture and lesion. CONCLUSION: A thorough clinico-radiological analysis and carefully performed FNAC/needle biopsy can establish a correct pre-operative diagnosis in majority of patients with benign bone tumours complicated by pathological fracture. This approach will avoid preventable delay in the definitive treatment of such patients, and also preclude the need of a separate operation prior to definitive management. In sight of the findings of our study along with existing literature we propose for definitive treatment in straight-forward cases and pre-treatment biopsy in cases with inconclusive FNAC/needle biopsy results and lesions with suspicion of malignancy. Proper diagnostic evaluation and differentiation of benign pathological fractures from malignant counterparts followed by extended curettage or excision of lesion and biological reconstruction with or without osteosynthesis represents a feasible approach for managing such fractures.

Role of Huntington procedure as a limb salvage surgery for complex gap nonunion of tibia in children.

BACK GROUND: Complex gap nonunion of tibia following open fractures and osteomyelitis with pathological fractures in children is a treatment challenge with unpredictable outcome. Treatment options available are bone transport, bone grafting, induced membrane technique, allograft reconstruction and Huntington procedure (ipsilateral transposition of vascularized fibula). There is no consensus in the literature about which technique is optimal in the given situation. The purpose of the present study is to evaluate the role of Huntington procedure in the management of complex gap nonunion of tibia in paediatric patients. MATERIAL AND METHOD: Eighteen patients (11 males and 7 females) with a mean age of 8.4 years (range 3-12 years) having complex gap nonunion of tibia with an average bone defect of 6.6 cm (range 5-17 cm) were treated with Huntington procedure between June 2008 to December 2016. The mean follow-up was 4.3years (range 3.5-6 years). RESULT: Union was seen in all except one, with an average time to union being 11.5 weeks and13.8 weeks at proximal and distal tibio-fibular synostosis respectively. Revision plating was done in one patient with nonunion. Hypertrophy of fibula was seen in all patients. One patient developed 15° ankle varus and required corrective osteotomy. Ankle was fixed in equinus in three patients with a mean value of 13.3° (range 5°-25°). Lambrinaudi procedure was done to correct 25° fixed ankle equinus in one patient. Fixed flexion deformity of knee was seen in nine patients with a mean value of 9.7° (range 5°-20°). Two patients had iatrogenic foot drop; one recovered completely and one had only partial recovery. Shortening was seen in eight patients with a mean value of 3.5 cm (range 1-5 cm). At final evaluation 9 patients were very satisfied, 8 satisfied and 1 was dissatisfied. CONCLUSION: Huntington procedure is a useful limb salvage surgery for complex gap nonunion of tibia in children. However; further improvements in the surgical technique are needed to increase the patient satisfaction by reducing the risk of complications.

Technical difficulties and mechanical failure of distal femoral locking compression plate (DFLCP) in management of unstable distal femoral fractures.

Objective of the paper is to portray the technical difficulties and mechanical failure of Distal Femoral Locking Compression Plate in the management of unstable distal femoral fractures. The primary outcome measure was defined as revision surgery due to implant failure with subsequent non-union. Secondary outcome measures were mal-union, delayed union, peri-implant fracture and infection. Functional outcome were evaluated using Schatzker & Lambert criteria. Thirty nine patients were available for final follow up. The rate of revision surgery as primary outcome measure was 7.69%. Mal-union was seen in 5.1%, delayed union in 7.69%, superficial infection in 10.25% and deep infection in 5.1% patients. All except three fractures united following index surgery. Functional outcome as per the Schatzker & Lambert Criteria was excellent in 20.5%, good in 48.7%, fair in 18% and failure in 12.8%. In sight of the findings of our study along with existing literature we propose for creating a fixation construct that is conducive for fracture healing by following principles of locking compression plating and augmenting stability by medial column reconstruction.

Inferior glenohumeral joint dislocation with greater tuberosity avulsion.

Inferior glenohumeral dislocation is the least common type of glenohumeral dislocations. It may be associated with fractures of the adjacent bones and neurovascular compromise. It should be treated immediately by close reduction. The associated neuropraxia usually recovers with time. Traction-counter traction method is commonly used for reduction followed by immobilization of the shoulder for three weeks. Here, we report a case of inferior glenohumeral joint dislocation with greater tuberosity fracture with transient neurovascular compromise and present a brief review of the literature.

Locked compression plating for peri- and intra-articular fractures around the knee.

OBJECTIVE: To evaluate the role of locked compression plates (LCPs) in management of peri- and intra-articular fractures around the knee. METHODS: Twenty distal femoral and 20 proximal tibial fractures were fixed with LCPs. The types of femoral fractures were A1 (four), A2 (three), A3 (two), C1 (one), C2 (seven) and C3 (three). The types of tibial fractures were A2 (one), A3 (two), B2 (two), C1 (four), C2 (five) and C3 (six). All patients were followed up for up to 18 months (mean, 12 months). Fourteen patients with distal femoral fractures and 19 with proximal tibial fractures underwent surgery using a minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. The others were treated by open reduction. The average time of fixation was 8 days after injury (0-31 days). Knee Society scores were used for clinical and functional assessment. RESULTS: All fractures, except one of the distal femur and one of the proximal tibia, united. The mean union times for distal femoral and proximal tibial fractures were 15.2 and 14.9 weeks, respectively. One patient with a distal femoral fracture had implant failure. One patient was quadriplegic and did not recover the ability to walk. The average Knee Society scores of the remaining 18 patients were 82.66 (excellent) and 77.77 (functional score, good). There was one case of implant failure and one of screw breakage in distal femoral fractures. One case of nonunion occurred in a proximal tibial fracture. CONCLUSION: Provided it is applied with proper understanding of biomechanics, LCP is one of the best available options for management of challenging peri- and intra-articular fractures.

Pathological Fractures in Primary Non-Hodgkin's Lymphoma of the Bone: A Case Series with Review of the Literature.

Primary non-Hodgkin's lymphoma of bone (PLB) is a rare entity. Patients generally present with localized bone pain and, less frequently, soft-tissue swelling or a palpable mass. Pathological fracture of the proximal femur and proximal humerus secondary to soft-tissue tumours is well documented in the literature; however, lymphomas presenting primarily at these sites with pathological fracture is unusual. A review of the world literature shows that the incidence of skeletal manifestation from NHL is less than 5%, and in all these cases, bony involvement was reported many years after presentation of the primary cancer. Histopathologically, PLB usually represents diffuse large B-cell lymphoma. We report our experience with two cases of Primary non-Hodgkin's lymphoma of proximal femur and proximal humerus with pathological fracture and their management.

Giant cell tumor of the first metatarsal.

Giant cell tumor (GCT) is a benign locally aggressive tumor with a tendency for local recurrence. GCT of metatarsal is of rare occurrence with very few cases reported so far. GCT in this location is rare and should be considered in the differential diagnosis of a destructive bony lesion in both skeletally immature and mature patients. We report the case of GCT of 1 st metatarsal in a 28-year-old female and discuss the difficult aspects of diagnosis.

Metachronous multicentric giant cell tumour of the upper extremity in a skeletally immature girl : A rare presentation.

Giant Cell tumour (GCT) or Osteoclastoma is a benign locally aggressive tumour with a tendency for local recurrence. Long tubular bones (75-90%) are frequent sites of involvement. GCT constitutes 5% of all primary bone tumours. Metachronous multicentric giant cell tumour of bone is a rare entity. Multicentric GCT, in contrast to unifocal GCT, has a tendency to involve the small bones of hands and feet, involving the metaphysis/diaphysis of long bones and tends to occur in a slightly younger population. We report a young girl presenting with metachronous multicentric recurrent benign GCT, with the lesions involving the ipsilateral right hand and distal humerus. She was successfully treated with an aggressive surgical approach (en-bloc resection).

Metastasis from scapular Ewing's sarcoma presenting as sutural diastasis: An unusual presentation.

Ewing's sarcoma is a malignant non-osteogenic primary tumor of the bone. It is one of the most common primary malignant tumors of bone. Peak incidence is noticed in second decade of life with male preponderance of 1.6:1. It occurs most frequently in long bones and flat bones of pelvic girdles. In 30% cases, Ewing's sarcoma is multicentric in origin. In 14-50%, multiple metastases are present at the time of diagnosis. CNS spread is rare and isolated CNS involvement is not seen. Skull metastasis of Ewing's sarcoma is not rare compared to primary Ewing's sarcoma of the skull, but the actual frequency is unknown. We wish to report a case of "Primary Ewing's sarcoma of scapula with metastasis to Skull Vault in a Child resulting in sutural diastasis" diagnosed by clinicoradiological examination and confirmed by histopathology.