Fragment-specific fracture fixation and double-column plating of unstable distal radial fractures using AO mini-fragment implants and Kirschner wires.

OBJECTIVE: To evaluate the efficacy of AO mini-fragment implants and 1.25-mm Kirschner wires using fragment-specific fracture fixation and double-column plating for displaced or unstable distal radial fractures. DESIGN: prospective and consecutive. SETTING: level II trauma hospital. PARTICIPANTS: 28 people with 30 fractures and an average follow-up of 21.1 (range 12-41) months, treated with fragment-specific fracture fixation. OUTCOME MEASUREMENTS: anatomical assessment using anteroposterior and lateral radiographs, graded according to Sarmiento's modification of Lidstrom's scoring system. CLINICAL OUTCOME ASSESSMENT: DASH and Modified Gartland and Werley scores. RESULTS: There were 24 excellent and 6 good radiological results. Final mean grip strength was 83% of uninjured side, and mean wrist range of motion was 61 degrees dorsiflexion, 54 degrees palmar flexion, 85 degrees supination and 83 degrees pronation. Gartland and Werley's demerit point system revealed 13 (43%) excellent, 12 (40%) good, 5 (17%) fair and no poor results. The mean DASH score was 18, with a standard deviation of +/-18. CONCLUSION: This fixation method is a reliable and low-cost alternative with good clinical and anatomical results, particularly useful in open reduction and internal fixation of comminuted intra-articular distal radial fractures.

Hereditary neuropathy with liablity to pressure palsies.

Hereditary neuropathy with liability to pressure palsies (HNPP) is a disease that presents with recurrent reversible episodes of neurapraxia that occur typically after trivial trauma. It is an autosomal dominant, demyelinating neuropathy. A 20-year-old man presented with left ulnar nerve palsy after a fall. He had reduced two-point discrimination over his left ulnar nerve distribution, with mild clawing of the ring and little fingers, and accompanying weakness of the first dorsal interrosseus and abductor digiti minimi of grade four power. His Froment's sign was also positive. Careful clinical examination and appropriate tests, including electromyography and genetic testing, confirmed the diagnosis of HNPP. This case report is presented to promote awareness and recognition of this disease in the local and regional context.

Condensing osteitis of the medial clavicle--an intermediate-term follow-up.

INTRODUCTION: Condensing osteitis of the clavicle is a benign idiopathic condition affecting the medial end of the clavicle, and is characterised by sclerosis and expansion of the clavicular head. MATERIALS AND METHODS: Nine cases of condensing osteitis were reviewed. Their mean age was 37 years (range, 22 to 65 years). All patients presented with pain and swelling localised to the sternoclavicular region. The mean length of follow-up was 38 months (range, 9 to 77 months). RESULTS: At latest follow-up, all patients had subjective improvement in their pain symptoms, but none had any subjective decrease in the swelling around the medial clavicle. Follow-up computerised tomography (CT) scans were available for analysis in 5 patients. CONCLUSION: The results of this study show that in the intermediate term at least, the severity of the pain appears to improve with time, although the clinical swelling over the medial clavicle does not resolve significantly. Longer follow-up will further define the long-term natural history of this rare condition.

Deep vein thrombosis following hip fracture and prevalence of hyperhomocysteinaemia in the elderly.

INTRODUCTION: The prevalence of deep vein thrombosis (DVT) in the West is reported to be as high as 50% after hip surgery. A study performed 14 years ago showed the incidence in Singapore to be <10%. Lately, some case-control and cross-sectional studies have suggested hyperhomocysteinaemia as an independent risk factor for DVT. This study investigates the local incidence of DVT and plasma hyperhomocysteinaemia in elderly patients presenting with proximal hip fracture. MATERIALS AND METHODS: We recruited 104 consecutive patients from April 2001 to November 2001 who satisfy certain criteria. Firstly, patients of both genders who were >55 years old with radiological diagnosis of neck of femur fracture, intertrochanteric or subtrochanteric fracture. Secondly, these patients must not have any haemorrhagic or thrombogenic disease. Thirdly, patients were not given folate and B complex pre- or postoperation. Duplex ultrasound was then done for these patients on the 5th to 7th postoperative day. RESULTS: The incidence of DVT above the trifurcation was 7.7%, no incidence of pulmonary embolism (PE) was detected. The incidence of hyperhomocysteinaemia was 52.3%. CONCLUSIONS: The incidence of DVT in the local population after proximal hip fracture is much lower than in the West. The use of DVT prophylaxis in Asians should be selective to avoid incurring extra cost and its associated morbidity. Case-control studies and cross-sectional studies clearly indicate that hyperhomocysteinaemia is an independent risk factor for venous thrombosis. Given the high incidence of hyperhomocysteinaemia in our elderly with hip fracture, the prophylactic correction of hyperhomocysteinaemia with folate and vitamin B supplements is justified.

Surgical fixation of intra-articular fractures of the distal humerus in adults.

We reviewed 15 adult patients with intra-articular fractures of the distal humerus treated over a period of 2 years. All patients underwent primary open reduction and internal fixation, which included 11 double plating procedures. The fractures were classified according to the AO/ASIF system. Patient outcome was assessed subjectively by scoring the patients' residual symptom of pain and their overall satisfaction of the treatment received. Objective assessment was performed using the Mayo Elbow Performance Index (range of motion, assessment of functional status, pain and stability of the joint). At a mean follow-up of 12.3 months, 7 patients were rated as excellent; 6, as good; one, as fair; and one, as poor. These cases had an average arc of flexion of 109.7 degrees. The sub-group of type C fractures without revision surgery had a mean flexion arc of 110.7 degrees (95-140 degrees ), with 100% Good to Excellent scores. Complications included two post-operative ulnar nerve neuropraxia, one wound infection, and one fracture fibrous non-union. Three patients required revision surgery which included a total elbow arthroplasty for implant failure, whilst four patients (including the patient with the subsequent arthroplasty) required joint mobilisation procedures for residual stiffness.

Fixation of distal radius fractures using AO titanium volar distal radius plate.

This study is to assess the effectiveness and outcome of the AO titanium volar distal radius plate (Synthes) in the treatment of peri-articular volar rim fractures of the distal radius. It was conducted on 22 patients with distal radius fractures who underwent open reduction, internal fixation using the AO titanium volar distal radius plate between July 1998 and December 1999 at the Changi General Hospital. The radiographs of the patients were analysed upon fracture union and assessment of wrist function was done using Gartland and Werley criteria. There were four extra-articular AO Type A2(1) and A3(3): the remaining 18 intra-articular fractures consisted of AO B3(2), AO C1(11), AO C2(2) and AO C3(3). The average follow-up period was 12.6 months (range 7-23). Radiological review showed bone healing in 21 patients (95.5%) and good articular congruity for all intra-articular fractures with less than 2 mm step-off. Three patients defaulted follow-up. Complications were few with one wound infection, one tendon rupture and three neuropraxia of the superficial radial nerve. Wrist function was excellent in three patients, good in 12 and fair in four. The AO titanium plate with its distal buttressing ability is an effective treatment modality in patients with distal radius fractures involving the peri-articular volar rim.

A case of Bizarre Parosteal Osteochondromatous Proliferation of the hand.

We report a case of Bizarre Parosteal Osteochondromatous Proliferation (BPOP) of the hand that was initially misdiagnosed as an osteochondroma. BPOP, although a benign lesion, behaves aggressively with rapid growth and high risk of local recurrence after local resection. The distinguishing features of BPOP as opposed to an osteochondroma are discussed.

Limited magnetic resonance imaging (MRI) and the occult hip fracture.

INTRODUCTION: Diagnosis of hip fracture is normally readily made from clinical evaluation and plain radiographs. Occasionally, clinical suspicion of fracture is not confirmed on plain X-rays. MATERIALS AND METHOD: Between January 2001 and March 2002, 422 patients were admitted to our department for post-traumatic hip pain. The diagnosis of hip fracture was unequivocally made in 365 patients (86%). Fifty-seven (14%) patients had a negative or equivocal radiograph. RESULTS: Limited magnetic resonance imaging (MRI) of the hip in this group of 57 patients confirmed that 8 (14%) sustained a femoral neck fracture, while 5 (9%) had an intertrochanteric fracture. In 19 patients (33%), some other pathology was found, mainly stable fractures of the femoral trochanters and pubic rami. Overall, 32 scans (56%) were positive and 25 (44%) were negative. Limited MRI detected patients with undisplaced hip fractures and identified them as candidates for surgery. CONCLUSION: The use of MRI in this specific and 'limited' way provides orthopaedic surgeons with a rapid, accurate and cost-effective diagnostic tool in this clinical scenario. Definitive diagnosis allows the correct management plan to be implemented early. We recommend that patients, who have significant hip pain following injury but indeterminate plain radiographs, undergo a limited MRI scan as a matter of routine.

Conservative treatment of redisplaced Colles' fractures in elderly patients older than 60 years old - anatomical and functional outcome.

A retrospective study was carried out to compare the functional outcome in two groups of patients who were 60 years old or older. One group had Colles' fractures, which had been reduced and did not redisplace. The other group's fractures redisplaced and were treated conservatively. Of the 11 patients in the first group, 82% had excellent or good functional outcome, which was not significantly different when compared with the second group of 25 patients with 68% having excellent or good functional outcome.

Metastasis of an adenocarcinoma of the stomach to the 4th metacarpal bone.

Metastatic tumours of the hand are uncommon. The majority of these tumours affect the phalanges and the primary tumours are usually bronchogenic in origin, with breast and kidney tumours next in frequency. Metastatic gastrointestinal to the hand is rare and usually from the colon. We report a case of poorly differentiated adenocarcinoma of the stomach antrum presenting with a metastatic lesion to the right 4th metacarpal bone. A review of the literature is included.

Metacarpal and proximal phalangeal fractures--fixation with multiple intramedullary Kirschner wires.

The use of intramedullary wires for fixation of fractures of the metacarpal and proximal phalanx in our hospital was reviewed. Twenty-six patients with 26 metacarpal fractures and four proximal phalangeal fractures were treated using this technique from 1993 to 1998. After a minimal follow-up of nine months, all the patients were assessed clinically and radiologically. All fractures proceeded to bony union at an average of 5.7 weeks (range four to eight weeks). With this simple and minimally invasive technique, most of these patients required very short hospital stay and were able to start mobilisation relatively early. The general outcome was good hand function with few complications.

The use of the external fixator in the treatment of intra-articular fractures of the distal radius.

BACKGROUND: A study to assess the use of the external fixator in the treatment of intra-articular fractures of the distal radius was initiated in late 1994. METHOD: Thirty patients with these fractures have been treated at our hospital between 1991 and 1994 with the use of either the AO or the Pennig external fixator. The patients were assessed at least one year post-operatively (mean 90.2 weeks) after a course of physiotherapy. RESULTS: The majority of patients (65%) had either good or excellent results, based on objective and subjective criteria. The common complications included early finger stiffness, pintract infections and loss of reduction.

Simultaneous open dislocations of the interphalangeal and metacarpo-phalangeal joints in a thumb--a case report.

Simultaneous dislocations of the interphalangeal and metacarpo-phalangeal joints are rare. Most of the previous reports in the literature concerned closed injuries which were not associated with neurovascular involvement and were easily reduced and had favourable outcomes. They were also mainly due to a dorsally directed force on a hyperextended digit. We report a case of this rare injury due to a torsion force in a power drill accident resulting in an open injury with neurovascular damage and gangrene of the thumb distal to the wound despite re-vascularisation attempts.

Massive chylothorax after anterior fusion of the thoracic spine.

We report a case of massive chylothorax occurring postoperatively in a patient with Potts paraplegia who underwent transthoracic anterior debridement and fusion of the T7 and T8 vertebrae. This is an uncommon complication of anterior spinal surgery but has a significant morbidity and mortality. Diagnosis of the condition and the institution of the appropriate therapy will reduce this significantly. The treatment principles are continuous tube drainage, nutritional support and reduction of chyle production. In 50% of cases a surgical procedure will be required. There are a variety of techniques available. We describe a technique that uses a pedicled intercostal muscle flap, which to our knowledge, has not been described previously. Among the other techniques, video-assisted thoracoscopic surgery is the most promising because of its low morbidity.

Necrotising fasciitis: an entity revisited.

Necrotising fasciitis is a disease that still carries a high morbidity and mortality despite our better understanding and advances in treatment since 1924 when Meleney first studied it. In our Department of Orthopaedics, this condition appears to be on the increase, and we therefore felt this entity deserved a restudy. Since 1985, 15 cases were seen, of which 10 were encountered in 1989. There were no recorded case prior to 1985. Our initial results show that the background and outcome parallel that of previous authors. Most were elderly with some form of underlying chronic disease. The duration from symptom onset to presentation was short, with many being in a state of septicaemia at the time of admission with fever, metabolic acidosis and marked leucocytosis. Repeated desloughings were common, and four ended up with some form of limb amputation. As with Meleney's study, the consistent pathogen cultured was B-haemolytic streptococcus. Our recommendation is that we should be more aware of this entity in view of its fulminant course, with early and aggressive surgical intervention being the keystone to management.

Some aspects of breast cancer in Singapore--a review of 306 cases.

A retrospective study of 306 cases of carcinoma breast in Singaporean patients managed at the University Department of Surgery, Singapore General Hospital was made, based on all available case notes, pathology report forms, operation record books, Cancer Registry Notification Forms, and data obtained from the Registry of Births and Deaths. These cases had their initial histological diagnosis made between 1970 to 1978. Basic data like age distribution, sex distribution and racial distribution of our cases are presented. Aspects of breast cancer like stage at time of diagnosis and 5- and 10-year survival figures are also presented. The crude five-year survival for all 306 cases was 56% and the crude 10-year survival for 223 cases was 22%. Survival for small lesions (T1, or less than 2 cm) was 90% at five years and 68% at ten years, a rate comparable with most centres in the world.

Stone composition and metabolic study in urinary calculous disease.

A series of 178 urinary stones is analysed qualitatively during a three year period from 1980 to 1982. The majority (96%) of stones orginate from the upper tract. Calcium oxalate stones are the commonest entity seen in the western countries but less than 20% of such stones occur locally. A large proportion consists of mixed stones and one third are infective as triple phosphate is present. 20% contain urate as a constituent whereas relatively pure urate stones constitute 4%. The true incidence of pure urate stones is higher (about 10%) as we have been dissolving them with alkalinisation of urine without surgery. Idiopathic hypercalciura occurs in 11.8% and none has persistent hypercalcaemia. Hyperuricosuria which is commoner, occurs in 24% of patients. It is important to identify this group as it results in the formation of metabolically active stones, and they can be treated with allopurinol to prevent recurrence of stones.