The impact of routine whole spine MRI screening in the evaluation of spinal degenerative diseases.

PURPOSE: Magnetic resonance imaging (MRI) of the spine is a sensitive investigation, which not only provides detailed images of the spinal column but also adjacent spinal regions and para-vertebral organ systems. Such incidental findings (IF) can be asymptomatic but significant. The efficacy of whole spine T2 sagittal screening in providing additional information has been demonstrated in several spinal diseases but its routine use in patients with spinal degenerative diseases has not been studied. METHODOLOGY: A review of 1486 consecutive T2w whole spine screening MRI performed for cervical, thoracic or lumbar spinal imaging for degenerative diseases, was performed to document the incidence and significance of asymptomatic IF in the spinal and extra-spinal regions. RESULTS: 236 (15.88%) patients had IF with a M:F ratio of 102:134 and the mean age being 50.3 years. Of these, spinal IF was observed in 122 (51.7%-Group A) while extra-spinal IF was present in 114 (48.3%-Group B). In Group A, 84 patients had IF in the vertebral column and 38 patients had IF in the spinal cord. IF within the spine included vertebral haemangioma (n = 60, 4.5%), diffuse vertebral marrow changes (n = 18, 1.2%), vertebral metastasis (n = 2), incidental cord myelopathy (n = 21), intradural tumour (n = 7), and others. 33 patients required surgical intervention of the IF (2.2%). In Group B, pelvic IF were most prevalent (n = 79, 5.3%) followed by retro-peritoneal abdominal IF in 22 (1.48%) and intra-cranial IF in 9 (0.60%). 32 (2.1%) of these pathologies required further specialist medical or surgical evaluation. CONCLUSION: Routine T2 whole spine screening MRI identified 15.8% IF of the spinal and extra-spinal regions. 65 patients (4.3%) required either spine surgical intervention or other specialist care. Considering the potential advantages in identifying significant IF and the minimal extra time spent to perform whole spine screening, its application can be considered to be incorporated in routine imaging of spinal degenerative diseases.

Interobserver Agreement and Intraobserver Reproducibility of Barzullah Working Classification of Distal End Radius Fractures among Orthopaedic Residents.

BACKGROUND: The purpose of this study is to test the hypothesis of the new classification system of distal end radius fractures (Barzullah working classification) proposed by one of the author in a prospective cohort study, among the orthopaedic residents. METHODS: The initial post-injury radiographs of 300 patients with distal radius fractures in a tertiary centre were classified by two junior residents (JR1 and JR2) and two senior residents (SR1 and SR2) in the emergency department over a period of two years. The collected data was analysed statistically by using Cohan's kappa for measuring Intraobserver reproducibility and Fleiss kappa for measuring Interobserver agreement. RESULTS: The mean kappa value for Interobserver agreement was 0.53 (moderate agreement) at the end of one year and the mean kappa value at the end of study period was 0.64 (substantial agreement). The mean kappa value for Intraobserver reproducibility of JR1 was 0.45 (moderate agreement), JR2 was 0.39 (fair agreement), SR1 was 0.62 (substantial agreement) and SR2 was 0.67 (substantial agreement). CONCLUSIONS: Barzullah working classification of distal radius fractures presented in this study has good characteristics compared to those of already studied classification systems among orthopaedic residents.

Squat Winnowing: Cause of Meniscus Injuries in Non-Athletic Females.

BACKGROUND: Sports activities were thought to be the major cause of meniscus injury in both men and woman, but our observations of non-athletic females show that the cause of meniscus injury was unrelated to any type of sports activity. OBJECTIVES: This study revealed squat winnowing to be a major cause of meniscus injury in non-athletic females. PATIENTS AND METHODS: This retrospective study was conducted in a tertiary care orthopaedic hospital which caters to a population of 10 million people. We assessed 120 non-athletic females who had received treatment in our hospital over a period of 2 years. The most probable cause of knee injury, per initial patient history, was recorded for all non-athletic females who presented clinical signs and symptoms of meniscus injury. The diagnoses were confirmed by relevant MRI and arthroscopy of patients' knees. All females who engaged in athletic activity and other females with unrelated, non-traumatic knee pathologies were excluded from the study. RESULTS: Through our study, we found that 42% (n = 50) of females suffered an injury during squat winnowing of rice, either at home or at work. Another 29% (n = 35) of females cited a history of slipping and spraining their knee as a cause of knee injury, while 19% (n = 16) of females suffered a knee injury during complex accidents such as a traffic accident. Finally, 13% (n = 16) of the females had no definite history of knee injury. CONCLUSIONS: Our observations add to the knowledge base of the various causes of meniscus tears; this study also revealed that socio-cultural factors influence and contribute to the mechanism of various types of knee injury.

Vertical Patellar Dislocation: Reduction by the Push Up and Rotate Method, A Case Report and Literature Review.

INTRODUCTION: Patellar dislocation is an emergency. Vertical patellar dislocation is rare, often seen in adolescents and mostly due to sports injuries or high-velocity trauma. Few cases have been reported in the literature. Closed or open reduction under general anesthesia is often needed. We report a case of vertical locked patellar dislocation in a 26-year-old male, which was reduced by a simple closed method under spinal anaesthesia. A literature review regarding the various methods of treatment is also discussed. CASE PRESENTATION: A 26-year-old male experienced a trivial accident while descending stairs, sustaining patellar dislocation. The closed method of reduction was attempted, using a simple technique. Reduction was confirmed and postoperative rehabilitation was started. Follow-up was uneventful. CONCLUSIONS: Vertical patellar dislocations are encountered rarely in the emergency department. Adolescents are not the only victims, and high-velocity trauma is not the essential cause. Unnecessary manipulation should be avoided. The closed reduction method is simple, but the surgeon should be prepared for open reduction.

Concurrent Lateral Condyle Mass Fracture With Olecranon Fracture: A Case Report and Brief Review of Literature.

INTRODUCTION: There is very limited literature describing the association of lateral condyle mass (LCM) fracture of the distal humerus associated concurrently with olecranon fracture. Herein, a case is reported of a displaced LCM fracture with displaced olecranon fracture, due to complex trauma while getting out of a vehicle, which was managed by open reduction and internal fixation. CASE PRESENTATION: A 4.5- year- old boy suffered severe pain and swelling around his right elbow due to trauma which he suffered while trying to get out of a vehicle which was in motion. Plain radiographs of the anteroposterior, lateral, and oblique views showed a displaced lateral mass fracture associated with a displaced olecranon fracture. Open reduction and internal fixation was carried out and near normal function was achieved. CONCLUSIONS: In view of the paucity of literature and rare incidence of this injury, this case report highlights the need to be aware of other injuries which can occur in association with LCM fractures in children.

A Study to Analyses Pattern and Treatment of Upper Cervical Spine Injuries Experience From Developing World.

BACKGROUND: The literature regarding the different patterns of upper cervical spine injuries, their appropriate management, and management development of such injuries is scarce in the world. OBJECTIVES: The current study aimed to present the experience regarding the high velocity trauma of upper cervical spine injuries. PATIENTS AND METHODS: Thirty patients (22 males, 8 females) with upper cervical spine injuries were treated and followed-up for an average of 24 months. The corresponding data were analyzed with respect to various types of injuries and different treatment modalities used to treat such patients keeping the basic healthcare facilities in view. RESULTS: The clinical as well as radiological outcomes of the treatment of such injuries were mostly achievable with minimum facilities in India, with only few complications. CONCLUSIONS: Managing such patients needs a proper transport facility, proper care during transport, appropriate evaluation in the hospital and prompt conservative or operative treatment. Treatment is usually safe and effective by well trained professionals with good clinical and radiological outcomes.

Anterior Tarsal Tunnel Syndrome With Thrombosed Dorsalis Pedis Artery: A Case Report.

INTRODUCTION: The aanterior tarsal tunnel syndrome denotes the entrapment of the deep peroneal nerve under the inferior extensor retinaculum. Although various etiological factors have been reported to cause anterior tarsal syndrome, its occurrence with thrombosed dorsalis pedis artery has not been reported in the English literature. CASE PRESENTATION: A 40 -year-old male patient was presented with the history of persistent pain along the dorsal surface of right foot, which was aggravated with the activities. Conservative management was tried without much relief. Diagnosis of anterior tarsal tunnel syndrome was made and the patient was planned for surgery. Thrombosed dorsalis pedis artery was found along with two adjacent collateral vessels. Retinaculum was released and nerve was mobilized. Tight compartment got released. Postoperative period was uneventful. No recurrence was seen on follow-up. CONCLUSION: The anterior tarsal tunnel syndrome is a known disease. A high index of clinical suspicion is required while dealing with the chronic cases. A detailed history to rule out any traumatic event is necessary too. Timely investigations and surgical release give dramatic relief.

Correlation between magnetic resonance imaging and arthroscopic findings in the knee joint.

BACKGROUND: The knee joint is the largest and the most complex joint of the human body. It is not covered by any thick muscular covering anteriorly. OBJECTIVES: The purpose of this study was to explore the diagnostic capabilities of clinical examination, magnetic resonance imaging (MRI), and arthroscopy in traumatic disorders of the knee joint, to seek correlation between clinical findings, MRI findings and arthroscopic. PATIENTS AND METHODS: A total of 26 patients with a presentation suggestive of traumatic knee pathology were studied prospectively. A detailed history was taken and relevant clinical examination was done, which was followed by MRI of the knee. The patients were scheduled for arthroscopy under general/spinal anesthesia, whenever indicated. RESULTS: Keeping arthroscopic examination as standard, the correlation between clinical and arthroscopy showed a sensitivity of 80%, specificity of 86%, accuracy of 63.16%, negative predictive value of 93.48%; whereas MRI vs. arthroscopy showed a sensitivity of 74.42%, specificity of 93.10%, accuracy of 84.21%, and negative predictive value of 88.04%. CONCLUSIONS: The clinical examination is an important and accurate diagnostic modality for evaluation of traumatic derangement of the knee joint. It is noninvasive, easy, available, and valuable diagnostic modality. The MRI is an accurate diagnostic modality. It can be used whenever there is an uncertain indication for arthroscopy. However, costs have to be kept in mind, especially in patients with low socio-economic status.

Functional outcome of distal radius fractures managed by barzullah working classification.

BACKGROUND: Management of distal radius fractures (DRFs) is still controversial and may be influenced by the initial fracture classification. Even though numerous classification systems have been proposed in this regard, the evaluation and management of this fracture has remained problematic. OBJECTIVES: The purpose of this study was to evaluate the functional outcome of DRF managed on the basis of a new classification. This classification named as Barzullah Working Classification represents a modification of Melone classification, which is based on fracture stability. PATIENTS AND METHODS: A total of 310 DRFs of patients skeletally matured referred to a tertiary care hospital at a period of 18 months were classified as per the new classification system into four types; metaphyseal stable, metaphyseal unstable, radiocarpal stable, and radiocarpal unstable fractures. They were managed and followed over a mean period of 15.10 ± 5.4 months, and the results were recorded at the final follow-up. RESULTS: The mean age of the patients was 51.22 ± 20.58 years. Most of the patients were females (n=189, 64.19%). The minimal follow up was 6 months with a mean of 15.10 ± 5.4 months. Mean mayo wrist scores were 95 ± 4, 80 ± 7.4, 75 ± 7.4, and 70 ± 6.9, for stable metaphyseal fractures, unstable metaphyseal radial, stable radiocarpal fractures and unstable radiocarpal fractures, respectively. The overall mean mayo wrist functional score was 80.58 ± 12.3 (good results) at final follow up. CONCLUSIONS: Various modalities of treatment used differentially in different types of DRFs based on the Barzullah Working Classification give good results in spite of conflicting literature.

Fish hook injury: removal by ''push through and cut off'' technique: a case report and brief literature review.

INTRODUCTION: Fishing is a leisure activity for some people around the world. Accidently the fish hook can get hooked in the hand. If the hook is barbed, removal becomes difficult. We report a case of such a injury in the hand and discuss the technique for its removal with a brief review of the literature. CASE PRESENTATION: A thirty-two year old male accidently suffered a fishhook injury to his hand. He came to the orthopaedic ward two hours after the incident with pain; the fish hook was hanging from the hand. Unsuccessful attempts to remove it were made by his relatives. A push-through and cut-off technique was used for removal of barbed hook. DISCUSSION: Barbed hooks are to be removed atraumatically with controlled incision over properly anaesthetised skin. Proper wound management and prophylactic antibiotics suitable for treatment of Aeromonas species should be initiated to prevent complications.

Long term results in refractory tennis elbow using autologous blood.

Tennis elbow (TE) is one of the commonest myotendinosis. Different treatment options are available and autologous blood injection has emerged as the one of the acceptable modalities of treatment. Long term studies over a larger group of patients are however lacking. The purpose of this study was to evaluate these patients on longer durations. One-hundred and twenty patients of TE, who failed to respond to conventional treatment including local steroid injections were taken up for this prospective study over the period from year 2005 to 2011 and were followed up for the minimum of 3 years (range 3-9 years). Two mL of autologous blood was taken from the ipsilateral limb and injected into the lateral epicondyle. The effectiveness of the procedure was assessed by Pain Rating Sscale and Nirschl Staging, which was monitored before the procedure, at first week, monthly for first three months, at 6 months and then 3 monthly for first year, six monthly for next 2 years and then yearly. Statistical analysis was done and a P value of <0.05 was taken as significant. The patients (76 females and 44 males) were evaluated after procedure. The mean age group was 40.67±8.21. The mean follow up was 5.7±1.72 (range 3 to 9 years). The mean pain score and Nirschl stage before the procedure was 3.3±0.9 and 6.2±0.82 respectively. At final follow up the pain score and Nirschl were 1.1±0.9 and 1.5±0.91 respectively. Autologous blood injection was found to be one of the modalities for treatment of TE. Being cheap, available and easy method of treatment, it should be considered as a treatment modality before opting for the surgery. Universal guidelines for the management of tennis elbow should be made as there is lot of controversy regarding the treatment.

Midterm functional outcome after operative management of midfoot injuries.

Background. Injuries of the midfoot are often missed and therefore underestimated. Early diagnosis and treatment are crucial for the final outcome. The primary aim of this study was to assess the pattern and results of early operative management of mid-foot injuries after a midterm follow up. Material and methods. This study was conducted on 25 patients (19 Males, 6 Females ) with mean age of 34.6 years (range 18-60 years) with mid-foot fracture dislocations who were admitted consecutively at our centre from May 2008 through November 2010. 25 patients fulfilling our inclusion criteria with mid-foot fracture dislocations were included in this study. Mechanism of injury, its pattern and results of operative management of midfoot injuries were assessed after acute management of these fractures on urgent basis. Evaluation of results was done by AOFAS Score. Results. Most common mode of injury was indirect trauma due to fall (n=12) followed by road traffic accident (n=9). Males (n=19) outnumbered females (n=6). The pattern of injuries requiring operative treatment as per our criteria were Lisfranc fracture dislocations (n=22) and navicular fractures (n=3). The mean follow up was 3.2 years and mean AOFAS score at 3.2 years was 78.36, with most patients losing points to pain and decreased recreational function. Conclusion. The Lisfranc fracture dislocations are the most common injuries around midfoot requiring operative treatment, and we believe that operative treatment considerably improves functional outcome in these injuries.

Atlas and axis injuries role of Halovest.

BACKGROUND: The literature regarding the different patterns of atlas and axis injuries and their appropriate management and the progressive development in the management of these injuries is scarce from our world, so we presenting here our experience of management of these injuries by applying Halovest. MATERIALS AND METHODS: Thirty patients (22 males, 8 females) with atlas and axis injuries were treated and then followed-up for an average of 24 months. The data was analysed with respect to type of injury and use of Halovest in the treatment of these injuries. The patients with neuro defecit were scored as per ASIA grading scale (from Grade A to Grade E). RESULTS: The halo-vest immobilization was used for a mean period of 12 ± 3weeks (range 9 to 15 weeks) for atlas and axis injuries. Four patients had neurodeficit. Two patients recovered from ASIA Grade C to ASIA Grade D. One patient improved from ASIA grade D to ASIA grade E while as one patient with neurodeficit was lost to follow up. No death or worsening of the neurodeficit was observed during the follow up period. CONCLUSION: The clinical as well as radiological outcome of these injuries is mostly satisfactory with the conservative management using Halovest. More studies should be conducted to form the guidelines regarding patient selection for conservative management using halovest.

Congenital Insensitivity to Pain with Anhidrosis (HSAN Type IV), Extremely Rare Syndrome that Can Be Easily Missed by Bone and Joint Surgeons: A Case Report.

BACKGROUND: Congenital insensitivity to pain with anhidrosis is an extremely rare disorder in which injuries can often be missed by patient, parents and even by orthopedic surgeon. Pain and tenderness, on which a trauma team so much depends to make a clinical diagnosis and to decide whether to go for radiological evaluation can be misleading in this rare syndrome. So complete clinical examination still forms the corner stone to avoid misdiagnosis and pick up the rare disorders. CASE PRESENTATION: We present a 5 year old girl child, who was brought to us as a case of one and a half month old neglected trauma left leg and was diagnosed to be suffering from congenital insensitivity to pain with anhidrosis (HSAN Type IV). CONCLUSION: Congenital insensitivity to pain with anhidrosis is extremely rare entity, in which patients are subjected to repeated injuries which are often neglected. There is no specific treatment but patient training and parent education are key to avoid further neglect and damage.