Six-Week Old Neglected Homolateral Lisfranc Injury - A Case Report.

Introduction: Lisfranc injury is relatively rare and is commonly missed at the initial presentation as these injuries are easily misdiagnosed as a foot sprain. We report a case of chronic foot pain following an injury which was later diagnosed to be a neglected 6 weeks old complex Lisfranc fracture dislocation. Case Report: A 53-year-old man presented with chronic foot pain and swelling which was diagnosed to be a neglected 6-week-old homolateral type of Lisfranc injury (type A Hard castle and Meyerson). We treated him with open reduction and internal fixation (ORIF) with plates and screws and achieved excellent functional outcome at 6-month follow-up period. Discussion: Lisfranc injuries are frequently undetected with estimates ranging from 20% to 80%. Anteroposterior, lateral, and medial oblique views of the foot should be included in the radiological workup following a thorough physical examination. Our case will aid the deficient literature and guide the young surgeons in management of such cases. Conclusion: Given the history and nature of the injury, it can be easily missed by a beginner and the clinician must keep a high index of suspicion when treating these injuries in emergency department. To prevent the many complications linked to this kind of injury, it requires a correct diagnosis and timely treatment in the form of closed/open reduction and fixation. Delayed presentation of such cases can be treated with ORIF and good functional outcome can be achieved.

Post-Traumatic Large Segmental Bone Loss - Does Bone Transport Obviate the Need for Successful Soft-Tissue Cover - A Case Report.

Introduction: Management of open tibial fractures with large bone segment and soft-tissue loss can be challenging. To restore the functionality of the limb, the continuity of the soft-tissue envelope and bone needs to be achieved. Case Report: A 29-year-old gentleman sustained right leg crush injury and open Gustilo Anderson Grade IIIB right tibia shaft fracture with 17.2 cm tibial shaft bone segment loss and large soft-tissue defect. An initial free flap failed. In spite of this, the functionality of the limb was restored by bone transport using Ilizarov method. Conclusion: The case report details the surgical technique and obstacles encountered and illustrate that bone transport using Ilizarov technique not only regenerates bone but can facilitate healing of soft tissues.

Correlation Between Traumatic Brain Injuries and Callus Formation in Long bone Fractures.

Introduction: Orthopaedic aphorism teaches that fractures of long bones when associated with head injuries frequently heal with excessive callus and at a faster rate than normal. However, the evidence on this subject is flimsy and the aphorism remains unsubstantiated. Numerous studies have been conducted evaluating the possible humoral and other factors involved leading to excess callus formation in patients with a head injury. This study was designed to evaluate the effects of a traumatic head injury on bone healing in adults with a diaphyseal fracture of the lower limb. Methods: Fiveteen patients with a closed fracture of tibia or femur and associated head injury (cases) and 15 patients with a closed fracture of tibia or femur without an associated head injury (controls) were included in the study. All patients were evaluated in terms of various serum parameters, including IL-6, growth hormone, PTH, LDH, prolactin levels, and ALP. Head injuries were graded as mild, moderate, or severe. Ventilatory support if required was noted. Serum prolactin was repeated at 5 weeks. Patients were followed up with serial radiographs, and the volume of callus formed was calculated and compared. Results: The mean value of growth hormone, interleukin-6 levels, and prolactin levels at 5 weeks were found to be higher in patients with head injuries, and the difference was highly significant (p = 0.001). The severity of head injury also correlated proportionately with the spike in IL-6 levels. There was more pronounced callus formation in patients with head injury group when compared to the controls. This difference was significant at all intervals. Discussion: There was higher volume of callus noted at the end of 6 months in patients with severe head injury (GCS < 7) when compared to patients with moderate head injury (GCS > 7). The patients with severe head injury were naturally under ventilator support for a prolonged period compared to those with moderate head injury. It was thus indiscernible if the excess callus observed is due to the humoral cascade or as an effect of prolonged ventilation. Patients with head injuries show elevated parathyroid hormone levels, growth hormone levels at the time of injury, and elevated prolactin levels 5 weeks after the trauma-all of which might contribute to enhanced osteogenesis. Interleukin-6 levels are also elevated and the levels correlate to severity of head injury. Conclusion: Head injury triggers a humoral cascade invloving interleukin-6, parathyroid hormoe, growth hormone, and prolactin that contributes to enhanced fracture healing.

Neglected Acromion Fracture Causing Chronic Post-traumatic Shoulder Pain - A Case Report.

Introduction: Patient presented with persistent shoulder pain 8 months following an injury which was diagnosed to be an old non-united missed acromion fracture. The difficulties in diagnosing such fracture, the functional and radiological outcome of surgical fixation of this type of missed acromion fracture with 6-month follow-up has been discussed in this case report. Case Report: We report a case of 48-year-old male who presented to us with chronic shoulder pain following an injury which was later diagnosed to be a missed non-united acromion fracture. Conclusion: Acromion fractures are commonly missed. Non-united acromion fractures can cause significant chronic post-traumatic shoulder pain. Reduction and internal fixation can alleviate the pain with a good functional result.

Management of Grade 3C Compound Injury of Lower Limb with Floating Knee - Salvage versus Amputation (Case Series).

INTRODUCTION: Severe open injuries of limbs, especially of the femur and tibia when associated with vascular injuries, present major challenges in management. The decision to amputate or salvage can often be a difficult one even for experienced surgeons. Mangled lower extremity results due to high-energy trauma, especially due to motor vehicle accidents, and is defined as injury to three of the four systems in the extremity that is soft tissues, bone, vascular, and nerve. Open fractures are classified by Gustilo and Anderson's classification in which type 3B is an injury where soft-tissue loss and primary closure of the wound are not possible and type 3C is any open fracture with vascular compromise. CASE REPORT: We report a series of six ipsilateral fractures of the femur and the tibia treated at the Department of Orthopaedics, Sri Ramachandra Medical College and Hospital, Chennai, Tamil Nadu, over a 3-year period (2014-2017). The mean age of our patients was 30 years old, and there were five men and one woman. The right side lower limb was frequently involved (five cases), and the main etiology was road traffic accidents (six cases). Articular involvement was found in six cases. Skin wounds were noticed in all cases (type III C of the Gustilo classification). Urgent wound care, fluid replacement, and antibiotic therapy were undertaken for open fractures. According to modified Fraser classification, all six cases was classified under type II-C. Mangled extremity severity score for five cases was 7 and for one case it was 8. Ganga Hospital Open Injury Severity Score was also used which was found to be in borderline range of 16 score for three cases, 15 score for two cases, and 14 score for one case. All six cases were managed with serial wound debridement + Ilizarov fixator + soft-tissue repair with involvement of orthopedic, vascular, and plastic surgery team. Limb salvage was done for all six cases after considering all the factors. Postoperatively, rehabilitative care and physiotherapy in the form of non-weight-bearing mobilization with walker support was given to all patients. The patients were followed up for the period of 2 years and doing symptomatically better. Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision-making in these situations. CONCLUSION: With great effort and good team work (like vascular and orthopedic surgeons), badly comminuted compound injuries (Type III C injury) can be managed well with Ilizarov fixation. Even though the decision of amputation versus salvage was based on more scientific/scoring system, patient's option should be taken, especially in borderline cases considering the present medicolegal scenario.

A Rare Case of Ribbing Disease- Diagnosis and Management.

INTRODUCTION: Ribbing diseases is rare and have only been occasionally reported. We here in report a case of Ribbing disease affecting bilateral tibia which was diagnosed based on computed tomography (CT), magnetic resonance imaging (MRI), and histopathological features and managed by intramedullary reaming . CASE REPORT: A 45 - year - old female presented with complaints of pain in the right leg for the past four 4 months duration and the patient had similar complaints of pain in the left leg 3 years back for which she had had taken treatment at an outside hospital where she underwent saucerization of the left tibia as a case of low- grade osteomyelitis . To evaluate the cause of pain X-ray, CT and, MRI were done which were suggestive of Ribbings disease and biopsy was performed which favoured the diagnosis of Ribbings disease. The patient was tried on a course of analgesics , with no symptomatic betterment , after going through the literature, the patient was taken up for the right tibia intramedullary reaming. Post operatively, the patient symptomatically improved and is pain free for the past 4 years. CONCLUSION: Ribbing disease is an uncommon cause of a common symptom. It is a rare diaphyseal sclerosing dysplasia. With lack of clinical signs of infection and biochemical evidence of metabolic bone disease and positive clinical, radiological and histological features in favour of ribbing disease helped us in arriving at the diagnosis. Intramedullary reaming of the affected bone has been useful in providing symptomatic betterment .