Prevalence of road traffic injuries in South East and South Asian region - A systematic review.

Background: South and South-East Asian countries report a great liability for the world's road traffic injuries (RTIs) and deaths. A vast number of research studies tested various interventions including specific protective devices to prevent accidents, but no review papers have been conducted to find out the prevalence of RTIs in South-East and South Asian countries. Objective: This review paper was an attempt to find out the prevalence of RTIs and their associated factors in South-East and South Asian countries. Methods: Following the guidelines of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA), we searched the articles in the electronic databases of PubMed/Medline, Scopus, CINAHL, ProQuest, and Web of Science. Articles were selected if they reported the prevalence of RTI, or road traffic accident (RTA) deaths. In addition, a data quality assessment was done. Results: Out of the 10,818 article hits from the literature search, ten articles found the eligibility and inclusion criteria. Most of the studies reported that males are involved in the RTIs more than females. The male mortality rate is more than the female mortality in RTI mortality. Young adult males are the major victims when compared with the different age groups of male victims. Two-wheelers are the major contributors to the accident rate. Religious or national festivals are not free from accident-prone times. Climatic seasons and nighttime have a major influence on the RTIs. RTIs are increasing due to the sudden and huge increase in the number of motor vehicles and the development of cities and towns. Conclusion: Accidents are non-predictable but controllable disasters in society. Overspeeding, bad conditions on road, the vulnerability of the vehicles, and careless driving are the major reported reasons for RTIs. Making and implementing strict laws can help us to control RTAs. The major effect on the reduction of RTI can be assured only with the presence of responsible people. That can be achieved only by creating awareness in society about traffic rules and responsibilities.

Enchondroma in the Diaphysis of Tibia - A Case Report and Review of its Characteristics and Differentials in the Diaphysis.

INTRODUCTION: Enchondroma is a solitary, benign, intramedullary cartilaginous tumor commonly noticed in the phalanges of hands and feet with characteristic radiological features. Its occurrence in aberrant sites with atypical features lead to diagnostic dilemma. Enchondromas which are usually managed non-operatively can mimic other benign and malignant lesions, especially chondrosarcoma. CASE REPORT: We report the case of a 31-year-old farmer who presented with long standing inconspicuous pain in his left leg which turned out to be a diaphyseal enchondroma even though it demonstrated aggressive radiological features mimicking a chondrosarcoma. Incisional biopsy was done from the scalloped areas to obtain the correct histological diagnosis. He underwent thorough curettage of the lesion and remains asymptomatic 2 years after the procedure. We attempt to discuss the differentials which the orthopedic surgeon should keep in mind for diaphyseal lesions mimicking enchondroma. CONCLUSION: Though classically found in metaphysis, Enchondromas are not uncommon in diaphysis of long bones. Enchondromas are generally benign, but can cause diagnostic dilemma when they present with aggressive features at rare locations and surgeons should be wary of the differentials. Despite a size of more than 6 cm and evidence of cortical erosion and intramedullary widening, the lesion could still be benign. Early biopsy will help to differentiate Enchondroma from a malignant transformation or malignant tumor.

Knee Implant Identification by Fine-Tuning Deep Learning Models.

BACKGROUND: Identification of implant model from primary knee arthroplasty in pre-op planning of revision surgery is a challenging task with added delay. The direct impact of this inability to identify the implants in time leads to the increase in complexity in surgery. Deep learning in the medical field for diagnosis has shown promising results in getting better with every iteration. This study aims to find an optimal solution for the problem of identification of make and model of knee arthroplasty prosthesis using automated deep learning models. METHODS: Deep learning algorithms were used to classify knee arthroplasty implant models. The training, validation and test comprised of 1078 radiographs with a total of 6 knee arthroplasty implant models with anterior-posterior (AP) and lateral views. The performance of the model was calculated using accuracy, sensitivity, and area under the receiver-operating characteristic curve (AUC), which were compared against multiple models trained for comparative in-depth analysis with saliency maps for visualization. RESULTS: After training for a total of 30 epochs on all 6 models, the model performing the best obtained an accuracy of 96.38%, the sensitivity of 97.2% and AUC of 0.985 on an external testing dataset consisting of 162 radiographs. The best performing model correctly and uniquely identified the implants which could be visualized using saliency maps. CONCLUSION: Deep learning models can be used to differentiate between 6 knee arthroplasty implant models. Saliency maps give us a better understanding of which regions the model is focusing on while predicting the results.

Operation theatre protocol for COVID-19 cases requiring orthopaedic surgery: A workflow without altering the existing infrastructure.

INTRODUCTION: The surge in the number of trauma cases following relaxation of lockdowns in the backdrop of COVID-19 pandemic, has strained the existing infrastructure to cater to these patients and also prevent the spread of infection. Moreover, with the rise of newer strains, the period ahead has to be tread carefully to prevent resurgence of infections. There have been recommendations regarding the ideal setup to operate orthopaedic cases in this pandemic scenario. However, many of the hospitals in India with financial and logistic constraints are unable to implement these structural changes into their existing setup. We propose a model which can be used in an existing operation theatre which has a single entry and exit corridor, which is the layout in many hospitals. METHODOLOGY: A protocol with the consultation of a panel of health care professionals was designed on the basis of WHO guidelines in a way so as to remain dynamic. Prior to its implementation, online classes were conducted and a dry run of the protocol was done with the whole team involved. The theatre layout is one with a single entry and exit and had predesignated rooms. The personnel were divided into 3 teams, each with a fixed set of people and preset workflow, to be followed during entry and exit. Five COVID positive cases have been operated since then using the protocol and has been used as a pilot study to further amend the protocol. CONCLUSION: This model can be used as a guideline by hospitals having a limited infrastructure, to develop their own protocol to operate on COVID positive cases, in the present situation of increasing trauma cases post the relaxation of lockdown and also in any subsequent waves of infection with newer strains. Simulation and periodic stringent audits with the entire team would prove successful in rectifying errors and avoiding any possible contamination.

Monophasic spindle cell myxoid synovial sarcoma of the hand: promising results with marginal resection.

Synovial sarcomas are deep-seated, genetically distinct, malignant neoplasms seen in young adults, with a male preponderance. They have unusual clinical and pathological presentation and mimic many other sarcomas and carcinomas, making the diagnosis quite challenging. Although four variants are identified, occurrence in the hand is extremely rare and leads to significant morbidity. There is a high incidence of local recurrence and distant metastasis within the first 2 years. We report the case of an elderly woman with monophasic spindle cell synovial sarcoma who presented with painless swelling in her palm and underwent local excision of the neoplasm. At 2-year follow-up, she remains totally asymptomatic with normal function of the hand. We also attempt to give an overview about monophasic spindle cell synovial sarcoma with the differentials, which would help surgeons in prompt diagnosis and appropriate management.

Suprapatellar nailing in proximal third tibial fractures - Clinicoradiological outcome.

AIMS AND OBJECTIVES: To evaluate the clinical and radiological outcome of proximal third tibia fractures managed by suprapatellar nailing with a minimum follow-up of 12 months. METHODOLOGY: In our retrospective cohort study of 43 consecutive proximal third tibia fractures from January 2015 to September 2018 treated with intramedullary nailing through suprapatellar approach in semiextended knee position were included. The patients were followed up regularly at 6 weeks, 3 months, 4.5 months, 6 months, 12 months and every 6 months thereafter. At each visit patients were assessed for union, shortening and rotational alignment. The clinical outcome was analysed using Lower Extremity Functional Scale (LEFS) and anterior knee pain. The radiological outcomes are analysed by evaluating the radiographs for progression of fracture union and tibial alignments. RESULTS: After fulfilling the exclusion and inclusion criteria, 43 out of 60 consecutive proximal third tibia fracture were included in the study with an average age of 38.4 years (20-71 years), follow up of 20.4 months (12-45 months) after the index procedure. The radiological union was achieved in 7.3 months (4-13 months). At the end of 1 year follow up, the average LEFS was 89.4% (60%-95%). 4 patients had Malunion - with 1 valgus and 3 anterior angulations, 8 delayed unions and 1 non-union (with bone loss- which required bone grafting). All the fractures united eventually. No incidence of anterior knee pain. CONCLUSION: We recommend suprapatellar nailing in proximal third tibial fractures when meticulously performed using the current surgical principles and techniques with proper implant selection. It results in excellent clinical and radiological outcomes with minimal complications when compared to other modalities of management. Suprapatellar nailing is a viable option for proximal third tibia fractures due to its inherent advantages of positioning, perfect nail entry and placement. Additionally, noteworthy absence of anterior knee pain is an additional benefit of this technique.

First responder's care package on management of road traffic accident victims of Udupi: Study protocol.

AIM: To evaluate the effectiveness of 'first responder's care package' on knowledge and skill on the management of road traffic accident (RTA) victims. The outcomes relate to the quality of first responder's care by autorickshaw drivers. METHODS: Autorickshaw drivers (N = 1,040) will be assessed to identify the impediments and knowledge to provide the first responder's care to RTA victims following which, 150 autorickshaw drivers will be selected based on a cut-off knowledge score to train half of them using workshops. Drivers below 55 years and willing to participate will be recruited and drivers with serious health issues, homophobia and who cannot read English or Kannada will be excluded. Randomized controlled trial with repeated measures design will be adopted. Funding for the research is by the Indian Council of Medical Research and it is registered in the Clinical Trial Registry of India. DISCUSSION: Road traffic accidents are responsible for 85% of the total global mortality and 90% of the 'Disability Adjusted Life Years' in the developing countries amounting to an annual loss of $65 billion to $100 billion. India's rate of RTA deaths is high and postcrash care is not addressed efficiently by any agencies in India. Autorickshaw drivers could be ideal candidates for teaching the first responder's care package in India as they are a constant presence on the roads and reach all the main roads and small lanes of the country. IMPACT: The research will add to knowledge on quality of first responder's care provided to accident victims. If the intervention is found to be fruitful for the accident victims of the locality, it can be recommended to be implemented all over the state.

Osteoid osteoma of the calcaneus misdiagnosed as subtalar sprain.

Osteoid osteoma of foot and ankle account for ten percent of benign bone tumors and commonly involve the talus and metatarsals. Its occurrence in calcaneus is extremely rare and can mimic ankle instability, subtalar arthritis, osteochondritis or plantar fasciitis leading to delay in diagnosis. We present the case of a 17 year old boy with periarticular osteoid osteoma in the calcaneum, who presented following an ankle sprain. He was successfully treated with CT guided percutaneous radiofrequency ablation and we feel that it is a safe, precise and effective treatment option for even periarticular osteoid osteoma in the foot and ankle region.

Anterior elbow dislocation without fracture in an adult: a rare injury pattern.

Anterior elbow dislocation without periarticular fracture (simple dislocation) is an extremely rare injury and is usually caused by distraction or torsional forces. It is important to look for associated ligamentous and musculotendinous injuries in this pattern. We report an elderly patient who sustained simple anterior dislocation of the elbow and in whom successful closed reduction could be achieved. Reduction by closed method is possible if we know the exact mechanism of elbow injury. Despite the presence of medial collateral ligament injury, he was managed non-operatively and had full functional recovery. Checking for joint stability and collateral ligaments after reduction and getting additional radiological investigations help in better treatment planning. Early protected active mobilisation should be initiated to achieve better functional results.

Variables affecting functional outcome in floating knee injuries.

BACKGROUND: The surgical outcome of floating knee injuries is difficult to predict. The high-velocity nature of the injury, complex fracture pattern and associated soft tissue/visceral injuries may have some impact on the functional outcome. The present study evaluates the variables affecting the clinical and radiological outcomes of floating knee injuries. MATERIALS AND METHODS: The clinical, radiological and functional outcome (Karlstrom and Olegrud criteria) of 89 patients with 90 floating knee injuries were evaluated at the end of one year who were managed in our level 1 trauma center between January 2013 and December 2016. The details of the injury, fracture pattern, management and complications were collected retrospectively from their records. RESULTS: There were 81 (91.1%) males and 8 (8.9%) females with mean age of 34.34 ±â€¯12.28 years. The mean time for tibia and femur union was 9.52 (±6.6) and 10.5 (±7.37) months. There was significant delay (p < 0.005) in time taken for union in segmental femur fractures (14.3 ±â€¯9.6 months) compared to nonsegmental femur fractures (8.68 ±â€¯5.18 months). Such significant difference in time taken for union was not seen in tibial segmental (10.6 ±â€¯4.62 months) and nonsegmental fractures (9.05 ±â€¯7.27 months). As per the Karlstrom and Olegrud criteria, there were 22 (24.4%) excellent, 26 (28.9%) good, 24 (26.7%) fair and 11 (12.2%) poor outcome. There were 15 patients with malunited tibia, 6 with malunited femur, 10 with limb length discrepancy and 39 with knee stiffness. 28 (33.3%) patients underwent major additional procedures such as bone grafting, re-fixation or bone transport or tendon transfer. It was observed that open tibia fracture, segmental fracture, intra-articular fracture, additional surgical procedures, initial external-fixator (ex-fix) application were significantly associated with development of knee stiffness, limb shortening, malalignment and unsatisfactory (Karlstrom and Olegrud fair to poor) functional outcome. CONCLUSION: Open tibial fractures, segmental fractures, intraarticular involvement, additional surgical procedures and initial external fixator application are the poor prognostic indicators of floating knee injuries.

Longitudinal Midline Sacral Split Fracture - A Rare Entity.

Fractures involving the central canal of the sacrum are rare injuries and can be transverse or longitudinal. Transverse fractures are by far common and associated with high incidence of neurological injuries. On the contrary, longitudinal midline split fracture is an extremely rare injury with minimal or no neurological injury. They are always associated with anterior pelvic ring fracture and are vertically stable needing only fixation of the anterior pelvic injury. Plating of the anterior pelvic ring in two planes would be beneficial than single plate to prevent gradual loss of reduction.

A rare tumour of hand: angioleiomyoma.

Angioleiomyoma is a benign tumour composed of smooth muscle and vascular tissue. Because of the paucity of smooth muscles in the hand other than tunica media of the blood vessels, its occurrence is quite rare in the hand and only few cases are reported in the English literature. We present the case of a 49-year-old man with benign painless swelling on the dorsum of hand. Differential diagnosis of ganglion cyst and tendon sheath tumour were considered. However, excision biopsy revealed angioleiomyoma. At 2-year follow-up, the patient remained asymptomatic with no evidence of recurrence.

Fracture neck of femur in Factor XIII deficiency: Was better outcome possible?

The fracture in a Factor XIII deficiency patient is being reported for the first time in the literature. We report a displaced fracture neck of femur in a 17-year-old boy with Factor XIII deficiency. Open reduction and internal fixation was done 8 days after the following the initial injury. Two units each of fresh frozen plasma and cryoprecipitate were given perioperatively to prevent excessive bleeding. No perioperative bleeding complications were encountered. At 18-months follow-up, the fracture had united with evidence of avascular necrosis. The fracture neck of femur in a child or young adult needs to be reduced and stabilized at the earliest to prevent devastating complications. Its occurrence in a patient with Factor XIII deficiency is to be managed like in a normal patient, but with extra perioperative care. Undue delay in fixation as happened in this case should be avoided for a better outcome.

Simultaneous, Isolated Traumatic Bilateral Patella Fractures.

INTRODUCTION: Isolated traumatic fractures of both Patellae, occurring at the same time, in an otherwise healthy person, are very rare. The Patella, as a subcutaneous and a cancellous bone, is vulnerable to injury. However, simultaneous injury to both Patellae without the involvement of any other bony injuries occurs infrequently, and only a few cases have been reported in the literature. CASE PRESENTATION: We report a rare case of isolated, traumatic bilateral Patella fracture with unusual fracture patterns and briefly review the literature. CONCLUSIONS: In simultaneous bilateral Patella fractures, good functional outcome can be expected following a stable surgical fixation and a structured rehabilitation regime. However, personality of the fracture determines salvage versus sacrifice of the Patella.

Extensive subcutaneous emphysema complicating a percutaneous Mumford procedure.

Subcutaneous emphysema may be a part of a life-threatening pneumomediastinum or pneumothorax and usually does not occur alone. A case of a 75-year-old lady who underwent a percutaneous Mumford procedure for acromioclavicular osteoarthrosis has been reported. She developed extensive subcutaneous emphysema of the neck, chest, bilateral shoulders, and upper arms, in the absence of pneumomediastinum or pneumothorax, during the procedure. Isolated subcutaneous emphysema as a complication of a percutaneous Mumford procedure has not been reported so far in the English literature. The possible mechanism of this complication is discussed. Understanding the mechanism is essential in avoiding this preventable complication.

An isolated case of first metatarsal tuberculosis.

An apparently healthy adolescent presented to us with multiple discharging sinuses from his right foot for the past 1 year. All serological parameters were within normal limits. X-ray picture revealed an expansile osteolytic lesion of first metatarsal. Tissue biopsy and PCR confirmed it be of tubercular etiology. The incidence of isolated occurrence of metatarsal tuberculosis is very rare and the diagnostic dilemma it brings about is briefly discussed in the following report.

Chondroblastoma of the scaphoid: A case report.

Benign Chondroblastoma generally occur in the epiphysis of long bones and rarely arise in carpal bones. We report a young male with chondroblastoma of scaphoid treated with curettage, bone grafting and K-wire fixation. At the last follow-up, 4 years after surgery, the patient was asymptomatic without recurrence.

Three floating metatarsals and a half-floating cuneiform.

Floating metatarsals are rare and complex injury patterns in the world of foot trauma. The injury is typically characterised by concomitant dislocations of the metatarsals from both articular ends ('bipolar dislocations'). Fascination arises from the fact that there have been only 15 cases reported in the English literature from 1964 to date. The first metatarsal has been more frequently reported than the lesser metatarsals. More than one floating metatarsal is also extremely uncommon. Inter-cuneiform diastasis is another rare entity seen in low velocity injuries and sports injuries; this condition is very difficult to diagnose clinically and radiologically. The occurrence of these two injury patterns in isolation is itself rare, making their combination even more unique.