Open Reduction of Complex Metacarpo-phalangeal Joint Dislocations

The metacarpophalangeal (MP) joint is resistant to injury due to its strong capsuloligamentous structures, which include the volar plate, deep transverse metacarpal and collateral ligaments. Complex MP joint dislocations are, by definition, irreducible by closed means and require open reduction, as the volar plate becomes entrapped between the metacarpal head and proximal phalanx. Two cases of isolated closed & one case of open complex dislocation of the metacarpophalangeal joint of the three different fingers are presented. Such dislocations require open reduction, and the dorsal approach is simple and effective

A Segmental Fracture of Humerus with Ipsilateral Forearm Fracture

Introduction: Simultaneous segmental humerus fracture with ipsilateral forearm is an uncommon injury and scarcely mentioned in the literature. Case report: We present a case report on such a complex injury in a 9-year old child after falling down from the first floor of his house while playing. The injury pattern consist of ipsilateral supracondylar fracture humerus with distal humerus  and ipsilateral distal forearm fracture. Open reduction and pinning of the both injuries was obtained. Conclusion: Ipsilateral multiple fractures in children often result from high energy trauma and are associated with complications. Immediate reduction and fixation is required. If satisfactory reduction cannot be achieved by closed technique, open reduction should be considered to avert additional soft tissue injury and forthcoming complications

Presentation and Management of Soft-Tissue Foreign Bodies in a Teaching Hospital of Western Nepal

Introduction: Accidental penetrating injuries with foreign bodies are a common presentation in hospital's emergency rooms. If missed, these bodies can remain dormant or result in a wide range of complications. This study evaluated the characteristics of patients, presentation and management who suffered foreign body embedded in soft tissue at a teaching hospital of Western Nepal.   Methods: The study was conducted at Department of Orthopaedics, Lumbini Medical College Teaching Hospital from September 2013 to August 2015. All cases confirmed to have a foreign body in soft tissue were enrolled. Surgical exploration with removal of foreign body was carried in operating room under tourniquet control. The patient demographics, cause of injury, nature of foreign body, occupation of the patient, diagnostic yield of radioimaging, procedures undertaken for retrieval of foreign body, and complications were  recorded. All patients were followed-up up to five months.   Results: Total 28 patients, nine (32.1%) males and 19 females (67.9%) were observed. The mean age was 35.6 yr (SD=11.1). Housewives (n=14, 50%) were the common sufferers. Most of our patients (n=17, 60.7%) presented two weeks after injury. Accidental prick while cutting grass or tree was the common mode (n=13, 46.3%) of injury and among foreign bodies, wooden or vegetative were the commonest (n=19, 67.9%) observed. Among the extremities, hand (n=10, 35.7%) and foot (n=5, 17.9%) were commonly affected. All patients had successful surgical exploration and retrieval of the foreign bodies under anesthesia and tourniquet control in operating room. Image intensifier was employed in seven cases to locate the foreign bodies per-operatively. Wound infection developed in 14.2% (n=4) of patients, all of whom were managed successfully with oral antibiotics. None of the patients required re-hospitalization. All patients were fine at final five months follow up.   Conclusion: Managing foreign body embedded in the soft tissue are challenging. Surgical exploration under tourniquet control suffice a definitive management. At times, image intensifier is required to locate the foreign body

Solitary Osteochondroma Arising from the Dorsal Vertebral Spinous Process

Introduction: Osteochondroma are benign tumors which arise from aberrant cartilage nodules within the periosteum. They can be either pedunculated or sessile and are more common in the extremities and rarely seen in spine. En-bloc excision is the preferred treatment. Case Report: We present a case of 20 year female, who came with a swelling and pain in lower back for two years which was diagnosed to be thoracic vertebra(D11) osteochondroma on x-ray and computed tomography. Excision biopsy was done and confirmed it to be osteochondroma. There has been no recurrence even after 16 months of follow up. Conclusion: Although rare, osteochondroma of the vertebra should be kept in mind as a differential diagnosis when evaluating mass in spine. En bloc excision should be performed

Clinical Results of Surgically Treated Medial Humeral Epicondylar Apophyseal Avulsion Injury in Children and Adolescent.

Introduction: Fractures of the medial humeral epicondyle represent approximately 10% of all paediatric elbow fractures. Objective of our study was to assess treatment outcomes of children and adolescent with medial epicondylar fracture of the elbow using standard operative protocols. Methods: 20 surgically treated fractures of the medial humeral epicondyle were analysed & reviewed for their epidemiological, clinical and surgical parameters. A valgus stress test was performed under general anesthesia or sedation. All patients underwent open reduction internal fixation using a similar technique. The medial epicondylar fragment was anatomically reduced and fixed in all cases with screws, Kirshner wires or tension band wiring. At final evaluation, union (radiologically) and elbow function [MAYO elbow performance score (MEPS)] was assessed. Results: An evaluation of all of our patients after a mean follow-up of 8.75 months (SD=4.76) after initial surgery was possible. The mean age of patients at the time of injury was 10.8years (SD=2.3). Fifteen (75%) dominant elbows were injured in our study and 12(60%) elbows had an associated elbow dislocation. On examination in operating room post anaesthesia, all of the elbow injuries revealed some degree of valgus instability. All of our patients(n=20) showed good to excellent results in the MAYO elbow performance score (MEPS). Radiographically, union was achieved in all cases. Three patients developed postoperative ulnar nerve neuropraxia, all recovered at time of final follow up. One patient developed mild lateral heterotrophic ossification but did not require any additional surgical intervention. Conclusion: Our results suggest that open reduction internal fixation of displaced medial epicondyle fractures leads to satisfactory motion and function. A valgus stress test in operating room can reveal the true nature of joint instability that can warrant operative stabilization of medial epicondylar injuries

Fractures of the proximal humerus in children and adolescents

Background: In most children proximal humeral fractures are treated non-operatively with generally good results. The aim of the study was to evaluate the clinical outcome of closed/open reduction in children with severely displaced proximal humeral fractures. Materials and Methods: The charts of 15 patients (8 girls and 7 boys; mean age: 9.4 years) with proximal humeral fractures who were managed at our institution were reviewed from October 2011 to December 2013. Results: There were 7 metaphyseal fractures and 8 physeal injuries which were angulated according to Neer-Horowitz score as grade II (n=2), grade III(n=4) and grade IV(n=9). Associated lesions comprised open fracture with head trauma in a 2 year old female child which was operated on primarily and the 14 others by secondary intention. All patients were treated surgically with either closed (n = 5) or open (n=10) reduction and internal fixation with Kirschner wire or titanium elastic nails (TENs). They were assessed for clinical and radiological healing at a mean follow up of 1.25 years ranging from 0.5 to 2.0 years. Conclusion: Surgical option is indicated for severely displaced and unstable fractures in older children and adolescents. In addition to the periosteum , long head of the biceps, deltoid muscle, and bone fragments in combination can prevent fracture reduction. Key words: Proximal humerus fracture, Children, Open reduction, Operative

Risk Factors Associated with Frozen Shoulder among Nepalese Population: A Hospital-based Comparative Study

Introduction: Frozen shoulder is one of the common musculoskeletal disorders characterized by pain and restriction of motion of the shoulder joint. It is also considered a common self-limiting regional skeletal problem. This study aimed to evaluate related risk factors for frozen shoulders. Methods: This was a hospital-based comparative study involving 60 patients with a diagnosed frozen shoulder in the out-patient department as cases and 60 patients hospitalized during the same period with non-shoulder-related complaints as controls. A face-to-face interview was taken. Univariate and multivariate logistic regression analyses were performed. Results: A total of 120 consecutive subjects (60 patients with frozen shoulders and 60 controls) were taken. The mean age of cases was 54.7±3.21 years and that of controls was 42.08±2.74 years. Among the frozen shoulder patients, 33.3% had diabetes and 15% had a history of thyroid disorder. Multivariate logistic regression analysis showed age, diabetes mellitus, and thyroid dysfunction as independent risk factors for frozen shoulder (p<0.05). The frozen shoulder patients also had a higher prevalence of cardiac diseases and cervical spondylosis than the controls. No significant difference was found in body mass index, cholecystitis, history of surgical intervention, and uric acid level between the frozen shoulder group and the control group. Conclusions: The study findings indicated that diabetes, thyroid disease, and advanced age have been significantly associated with increased frozen shoulders

Functional Outcome of Intramedullary Nailing with Rush Pin for Pediatric Both Bone Fractures of Forearm in Western Hilly Nepal

Introduction: Both bone diaphysis fracture of forearm is common in children of hilly area in Nepal because the children climbs tree and cliff for playing and cutting grass. Close reduction and casting is the preferred method of treatment these fractures but the chances of re-displacement is very high. Intramedullary nailing with titanium elastic nails or rush pins is widely accepted these days with good outcome. Titanium nails are popular in western world but is costly whereas rush pins are cheap and are preferred in developing world. The aim of this study was to evaluate the functional outcome of intramedullary rush pin for pediatric both bone fracture of forearm. Methods: In this retrospective, observational study done from 1st of February 2017 to 31st of March 2017, a total of sixty patients with both bone fractures of forearm were treated with intramedullary rush pin and followed up for six months for evaluation of functional outcome. T-test and Chi-square tests were done. Results: Closed reduction and internal fixation was done in 48 (80%) patients. Mean age of the patients was 9.23 year (SD=2.77). Fifty-six (93.3%) patients were male with a significant difference (p<0.001). With price et al. grading system, 49 (81.7%) patients had excellent results, nine (15%) had good and two (3.3%) patients had fair results. There was no major complication. Mean time to implant removal was 24.16 weeks (SD=1.62) from the time of surgery with range of 20 to 28 weeks. Among transverse and oblique fractures, patients with transverse fracture were likely to have better outcome (p=0.04). Conclusion: Intramedullary nailing with rush pin gives excellent to good functional outcome in majority of the cases without major complications at low cost for management of both bone fractures of forearm in children

Outcome of Inferior Patellar Pole Avulsion Fractures

Introduction: The optimal treatment for inferior pole patella avulsion fractures has still been a topic of debate. The options include (a) internal fixation of the pole fragment and (b) resection of the avulsed fragment and repair of the patellar ligament to the patella. We present the comparative outcomes for patients with displaced inferior pole patella treated by resection and transosseous Ethibond® Krackow suture repair of patellar ligament with open reduction and internal fixation with modified tension band wiring and circumferential wiring. Methods: During a three year period between August 2013 and September 2016, twenty consecutive patients with distal pole fractures of the patella were prospectively enrolled in this study. These patients were divided into two groups. Group-T patients were treated with open reduction and internal fixation with modified tension band wire and  group-R patients by resection of the avulsed fragment and reattachment of the patellar ligament to the patella with #5 Ethibond®. Data entry and analysis was done by using SPSS version 20. Anatomical and functional outcome were compared. Results: Consecutive 20 patients were treated either with resection lower patellar pole (n=10) or with open reduction internal fixation with tension band wiring (n=10). Demographics were matched in two groups. Group-T required a longer hospital stay (U=13.5, p=0.005). Complications were seen more often in Goup-T compared to Group-R (p=0.005). Group-R had better scores (Bostman score U=6, p=0.001; SFMA U=7.5, p=0.001) and range of movement (p<0.05). Conclusion: Resection of the avulsed fragment and reattachment of the patellar ligament to the patella had better outcome according to the Bostman and SFMA dysfunction score, shorter hospital stay, and less complications as compared to open reduction and internal fixation with tension band wire and circumferential wiring

Simultaneous Ipsilateral Pediatric Fractures of the Elbow and Forearm Attending a Tertiary Care Hospital

Introduction: Ipsilateral supracondylar humerus and forearm fractures in the pediatric population are an uncommon injury associated with high-energy trauma. The incidence varies between 3% and 13%. Our aim was to conduct a descriptive analysis on seventeen cases of children with floating elbow injuries who attended our institution and to review the literature relating to this topic. Methods: Between April 2013 to March 2016, data were obtained through the medical records. Children who had completely displaced supracondylar fractures of the humerus associated with ipsilateral forearm fracture were reviewed. All patients underwent operative reduction and percutaneous K-wire stabilization. At mean follow up of 12.9 months, all patients were assessed clinically and radiologically. The following variables were used: age, gender, side, mechanism, type of fracture, classification, treatment and complications. Results: Seventeen pediatric 'floating elbow' cases that had operative management were identified. Twelve (70.5%%) were male and five (29.4%) female. The mean age was 9.5 (SD = 2.1) years, ranging from six to 14 years. The left side was predominantly affected (70.5%). The commonest injury mechanism was fall from a height (76.47%). All the supracondylar fractures were Gartland type III. Majority of forearm fractures (76.4%) were at distal meta diaphyseal region. Distal radius physeal fractures were diagnosed in three patients. Open fractures occurred in three cases (17.6%). All supracondylar fractures were reduced and fixed using K-wires. There was one radial nerve, and three median nerve injury. Five patients had pin tract related complications. Fifteen (88.2%) patients had good to excellent, two had fair in terms of modified Flynn criteria in last month follow up. All patients went on to radiographic union without secondary procedures. Conclusion: This, uncommon injury in most cases, results from high-energy trauma. Early surgical treatment for both fractures is required in the form simultaneous closed reduction of the displaced forearm fracture followed by supracondylar fixation with K-wires. This provides not only stable fixation but also allows close observation for early sign and symptom of development of compartment syndrome