Tibial pilon fracture in a skeletally immature patient: mini open with intrafocal pinning and reduction technique; a case report

INTRODUCTION: Pilon fractures are intra-articular fractures of the distal tibia associated with variable talar injury, articular disruption, and comminution. These fractures were first described by Destot in 1911 and have been reported to represent 7% of all tibial fractures and <1% of all lower extremity fractures in adults. Despite the low incidence of these fractures, the resulting morbidity is considerable. The vast majority of reported cases have involved adults, with sporadic inclusion of children. Pilon fractures are the result of complex forces with axial compression, forced dorsiflexion, often associated with violent rotation resulting in severe, comminuted fractures. Several classification systems have been described; however, the most widely used system in the literature is that proposed by Ruedi and Allgower. They classified pilon fractures into three categories, based on the extent of articular surface fracturing. Type I fractures were nondisplaced, type II fractures were displaced with minimal comminution, and type III injuries were markedly comminuted CASE REPORT We are reporting a case of a 13-year-old boy who fell from rooftop of 2 metres height and landed on his right ankle. Having sustained closed comminuted fracture of distal end right tibia and right lateral malleolus, he was duly planned for surgical intervention. We performed a mini open approach with intrafocal pinning, reduction and further stabilized by conventional plating. Patient was discharged home on day 3 post operation with no complications. DISCUSSION: Preservation of the soft tissue is of particular importance in the care of pilon fractures. Traditional open reduction internal fixation of pilon fractures allows for direct visualization of the fracture(s) but is often criticized for the large exposure and periosteal stripping. External fixation has also been used but has not demonstrated much advantage to internal fixation and requires significant postoperative care. As such, mini open or minimally invasive approach has gained popularity and fast becoming an option in management of pilon fractures. The reduction technique in mini open surgeries are always difficult. In this case, we used an intrafocal pinning and reduction method to reduce the articular fragment. Kapandji described the use of intrafocal K-wires to buttress the dorsal and radial fragments in extra-articular distal radius fractures. We applied the same principles, albeit in this case for the articular fragments of tibial plafond ▲ Pre-operative and intra-operative images CONCLUSION: Mini open approach supplemented with intrafocal pinning and reduction technique offers a reliable option in treatment of pilon fractures, especially in the skeletally immature group

Inventing and validation of questionnaires Muslim doctor questionnaire (MDQ) & Muslim medical student questionnaire (MMSQ)

Background:   International Islamic University Malaysia has pioneered the model of Islamic Input into Medical Program (IIMP). This is part of the main objective to enhance the affective domain in our curriculum. In order to evaluate the effectiveness of IIMP programme, it is important to an assessment tool. Once Kulliyyah is able to prove the effectiveness of IIMP, it is hope IIUM Kulliyyah of Medicine would be a role model in development of Islamic Medical Curriculum. At the moment there is not a single medical Islamic scale available. This we hope will be the pioneer of all.   Objectives:   To invent new questionnaires called MDQ & MMSQ that will be reliable and validated for the Muslim doctors and medical students respectively. To assess the good Muslim values in various academic years. To assess pre- and post- input of Islamic curriculum   Knowledge, Attitude, & Practice aspects on these domains;   Religiosity, Aqidah – (knowledge, practice) Knowledge of Relevant Medical Fiqh (knowledge), Ibadah (Rukhsah) Communication Skill – (attitude, practice) Behavior Professionalism Clinical Competence. Islamic Ethics, Islamic Medical Jurisprudence, Outward Manifestation Sincerity, Akhlak Morality, Confidentiality   Results; A total of 468 participants among students;. Reliability; Cronbach’s alpha of 0.91 and 8 domains were identified by using explanatory factor analysis with Varimax rotation. Validity; From items, 75% had good factor loading (>0.4). Therefore these 2 questionnaires are valid and reliable

Wrecked calcaneum: ORIF with primary subtalar fusion; a case report

INTRODUCTION: The calcaneum is the most frequently fractured tarsal bone and comprises 2% of all fractures. Approximately three quarters of these calcaneal fractures are intra-articular and treatment of these fractures is difficult. Treatment modalities range from conservative management to open reduction and internal fixation (ORIF) and subtalar fusion. ORIF of intra-articular calcaneal fractures leads to good and excellent results in 60-80% of the patients. But 2-17% of patients require secondary subtalar fusions because of the development of a painful subtalar arthritis. This has a direct correlation with the degree of subtalar comminution. CASE REPORT We are reporting a case of a 46-year-old man who was involved in an alleged motor vehicle accident. He sustained open comminuted fracture of right calcaneum with subtalar subluxation and underwent urgent wound debridement with cross ankle external fixation. Two weeks later, open reduction, internal fixation with calcaneal locking plate and primary subtalar fusion with cannulated screws were done. Patient was discharged home after an uncomplicated post operative stay in the ward of 5 days DISCUSSION: The treatment of comminuted intra-articular calcaneal fractures is still very much debated. Although several authors have reported good results in these fractures that were managed operatively, prognosis remain poor for some cases especially those with severe comminution. In his case series, Sanders reported secondary fusions in 7 of 30 (23%) Sanders Type III fractures and in 8 of 11 (73%) Type IV fractures. However, the results of secondary subtalar fusion after an intra- articular calcaneal fracture are not always satisfying. Themann et al. found only 10/17 (59%) good and excellent results using the AOFAS Score. The 7 patients (41%) with fair and poor results had an impaired ROM of the ankle joint with a secondary painful arthritis in the adjacent joints. Hence, a primary fusion after open reduction and internal fixation of the calcaneum at the same setting is recommended in selected cases. CONCLUSION: Primary subtalar fusion with ORIF of the calcaneum is certainly an option in treatment of severely comminuted intra-articular calcaneal fractures

Numerical modelling of multiple tuned mass damper equipped with magneto rheological damper for attenuation of building seismic responses

TMD is basically designed to be tuned to the dominant frequency of a structure which the excitation frequency will resonate the structural motion out of phase to reduce unwanted vibration. However, a single unit TMD is only capable of suppressing the fundamental structural mode and for multimode control, more than one TMD is needed. In this study, a 3-storey benchmark reinforced structural building subjected to El Centro seismic ground motion is modelled as uncontrolled Primary Structure (PS) by including properties such as stiffness and damping. For the case of controlled PS which the passive mechanism is included to the system, optimum parameters of both TMD and Multiple TMD (MTMD) are designed to be tuned to the dedicated structural modes where the performance is dependent on parameters such as mass ratio, optimum damping ratio, and optimum frequency ratio. The input and output components of structural system arrangements are then characterized in the transfer function manner and then converted into state space function. For enhancement of the passive system, Magneto-Rheological (MR) damper is added to both single TMD and MTMD passive system. The response analysis is executed using both time history and frequency response analysis. From the analysis, semi-active case is the most effective mechanism with 99% displacement reduction for the third and second floors, and 98% for the first floor, compared to the uncontrolled case. It is concluded that the MR damper significantly contributed to the enhancement of the passive system to mitigate structural seismic vibration

The integration of Islamic values in daily clinical practice among healthcare professionals: a scoping review

Islam is a major world religion that has a universal system encompassing every aspect of daily human activities. In this regard, Islam also provides principles and values related to the practice of medicine. However, it is not known how much of the practices have been practiced in daily clinical settings. Therefore, this paper aims to chart the overview of the studies and publications that have been done related to the integration of Islamic principles and values being incorporated in clinical practice. This paper is a scoping review. Databases like PubMed, PLOS, BMJ, Cochrane, EBSCo, Emerald, ProQuest, ScienceDirect, Scopus, and ACI were used to conduct the literature search. MeSH terms like “Islam," “religion and medicine,” and “attitude of medical staff” are among the keywords used, along with synonyms like “Islam," “Islamic," “Muslim," “medicine," “clinical," “practise," “healthcare," “professionals," “Islamic medical practise," “doctor," “nurse,” and “healthcare professionals.” The Boolean operators “AND” and “OR” were applied during the search. In addition to databases, manual internet searches were conducted to find relevant papers. The review has found that Islamic concepts and ideals have been sporadically incorporated into medical practice worldwide, whether by Muslim or non-Muslim healthcare professionals. The three key themes related to Islamic practice in medicine: are (a) attitude and character of healthcare professionals, (b) clinical decisionmaking, and (c) holistic spiritual care. There is still a big gap and differences in integrating Islamic values into clinical practice. Further work on defining and constructing a framework for a holistic Islamic medical practice is warranted

Using step activity monitoring to assess ambulatory activity before and after total ankle arthroplasty

Introduction: The aim of this study is to compare the walking activity of a cohort of individuals before and after total ankle arthroplasty (TAA). Methods: Nineteen consecutive patients (ten males and nine females) with mean age of 58.72, selected for TAA between January and June 2006, were prospectively reviewed with the use of a dedicated ambulatory activity-monitoring device to assess their natural ambulatory activity. Patients were tested in the community for two weeks duration, one month prior to and at least eighteen months after surgery. The ambulatory parameters were assessed through measurement of the number of steps at different cadence, and the time spent walking at different walking paces. Data were analyzed by using specific statistical methods. Results: This study revealed a significant improvement in the number of steps walked at normal cadence (b = 331.63, p = .00) and significantly reduced at low cadence (b = –402.52, p = .00) and medium cadence (b = –386.29, p = .00), before and after TAA. However, there are no significant different between two phases of assessment in term of time spent walking. Conclusion: These quantitative data allow a clear comparative assessment of walking ability following TAR and demonstrates that this intervention improves patient’s walking pace

Bilateral olecranon fracture in adult. A case report.

We report a case of a 14 - year - old Malay male who fell at school and sustained bilateral olecranon fractures. He had undergone an open redu ction and tension band wiring to stabilize the fracture. Three months after the surgery, the movement of both his elbows was satisfactor

Long-term effect on foot and ankle donor site following vascularized fibular graft resection in children

This study was carried out to evaluate the long-term effect on the donor side of the foot and ankle following vascularized fibular graft resection in children. Eight patients underwent resection of the fibula for the purpose of a vascularized fibular graft by a surgical team who practiced leaving at least 6 cm residual distal fibula. The age of these children at the time of surgery was between 3 and 12 years. They were reviewed between 3 and 12 years after surgery. Two patients who underwent resection of the middle shaft of the fibula at 3 and 5 years of age developed abnormal growth of the distal tibia, leading to ankle valgus. They were treated with growth modulation of the distal tibial physis and supramalleolar osteotomy with tibiofibular synostosis. Another patient who underwent the entire proximal fibula resection at the age of 6 years had developed hindfoot valgus because of weakness of the tibialis posterior muscle. He required talonavicular fusion and flexor hallucis to tibialis posterior muscle transfer. Patients operated at the age of older than 8 years neither had ankle nor hindfoo

Quality of life of diabetes amputees following major and minor lower limb amputations

Introduction: Minor amputation was performed as a salvage procedure because most of the patients were not able to ambulate and become dependent following major amputation. Minor amputation is defined as amputation at the level of ankle joint and below while major amputation is defines by amputation above the ankle joint. The aim of this study was to compare the quality of life among diabetes patients following major and minor amputations. Methods: A total of 94 diabetes patients were reviewed six months following amputation. Their walking ability, dependency status and quality of life were evaluated, using the Malay translated version of the Short Form Health Survey 36 (SF-36) questionnaire. Results: During the follow up only three patients (8.3%) following major amputation were dependant compared to 30 patients (51.7%) following minor amputation. Forty-nine (84.5%) of minor amputation and only 15 (41.7%) of major amputation patients were ambulating independently. Patients with minor amputation have significantly better Physical functioning, Role - physical, General health, Role – emotional, and Mental health score (p<0.001). However, they have worse BP and SF score than those following major amputation (p<0.001). The VT score of both groups were not significantly different. Conclusion: Patients with minor amputation are more independent, ambulatory and had better quality of life than those with major amputation. Despite the risk of persistent infection and amputation stump complication, minor amputation should be attempted in diabetes patients

Pedobarography study among Malay population in Kuantan, Malaysia: A pilot study

Pedobarography has been widely used in developed countries for few decades. However, in Malaysia it is still in its infancy. Studies showed that the normal values of pedobarography vary between races. To the best our knowledge there is no standard value available for Malaysian or Southeast Asia. This study is designed to measure the pressure values in the normal foot of Malays in Pahang, Malaysia and its difference between different gender and body mass index (BMI). A total of 400 feet of adult Malay subjects with no existing diabetes mellitus, lower limb and spine pain or problem are measured using Emed-q100 pedobarography device. 226 (56.5%) were females. 44.5% were with normal BMI followed by overweight (31.5%), and obese (24%). The mean-maximum-peak pressure (MPP) is 509kPa (SD 167) with no significant difference among gender and BMI. Most (38.5%, n=154) of the peak pressure area (PPA) are observed in 1st metatarsal head and big toe region (1MH&T), followed by 2nd metatarsal head (2MH) (34.3%, n=137). In the normal BMI group, 48.3% were in 1MH&T region while in the overweight and obese groups, 42.1% and 43.8%, respectively were in 2MH. This difference is significant (x2(df=8)=36.963, p<0.001). There was no significant difference between PPA and gender. The MPP among Malays in this study was 509kPa(SD 167) and it is not affected by different genders or BMI. The PPA are most commonly fall on 1MH&T. There is a significant shift in the overweight and obese groups to the 2MHT. This finding can be used as initial reference for further studies, in Malaysia particularly