A simple and noninvasive technique using Bohlers stirrup facilitating management of posterior soft tissue injuries of heel

Introduction: Many techniques have been devised to solve the problems associated with posterior soft tissue injuries. A noninvasive technique with plaster of Paris cast mold has been described by Ravishankar. Plaster casting techniques have been associated with problems such as tight cast and cast damage. Invasive techniques using external fixators as described by Berkowitz and Kim using tubular fixators like "kick back stand" and by Kamath using ring Illizarov fixators. The external fixators have their own problems like maintaining them for weeks and pin tract infection. Materials and Methods: We have tried to achieve as noninvasive technique using a Bohler stirrup incorporated with slab for patients with only soft tissue in injury and in a fixator for patients with skeletal injury already on tubular fixators. Results: In all the 12 cases where this method was used, the authors achieved the purpose of protecting the split skin graft in four cases and flap in eight cases. We did not encounter any problems related to this method such as skin maceration, sores including loosening of the frame. Conclusion: It is a simple and noninvasive method, which can be easily and reliably performed to maintain adequate limb elevation and soft tissue protection, which can be done is any hospital setup

Role of palmaris longus as a contributing factor in Carpal Tunnel Syndrome-Ultrasonographic evaluation of Median Nerve and Carpal canal diameter

Purpose: To assess the diameter of Carpal tunnel (CT) and the Median Nerve (MN) in individuals with unilateral absence of Palmaris longus (PL) and compare it with the side with presence of Palmaris longus. Materials and Methods: Volunteers (students in the age group of 18-20 years) from a medical college were enrolled over a 2-month period, October to November 2007. Twenty-five subjects with unilateral absence of PL were selected for the study. We used the wrists with PL agenesis as cases and the contra lateral side with PL as controls. Anteroposterior (AP) and transverse diameters of carpal canal and MN were measured at both proximal (pisiform) level and distal (hook of the hamate) level with wrist in neutral position. Results: Significant differences were noted in the dimensions of Carpal canal and MN on the sides with PL as compared to the sides with PL agenesis. The difference in the CT AP diameter was very highly significant at proximal and distal level (P transverse). This study supports the previously done studies on the association between the Carpal Tunnel Syndrome (CTS) and presence of PL tendon

Ultrasound evaluation of carpal tunnel and median nerve in malunited Colles′ fracture

Introduction: Colles′ fractures continue to be one of the most common skeletal injuries of middle aged and elderly population. Compressive neuropathy is one of the most important complications of Colles′ fractures and usually involves the median nerve. The objective of our study was to investigate the impact of malunion of Colles′ fracture on the anatomy and dimensions of the carpal tunnel and the median nerve. Materials and Methods: Fifty cases of Colles′ fracture were included in this study, which was conducted for a period of 2 years. Radiographic and ultrasonographic evaluation was done in all patients. Nerve conduction studies were done in four patients diagnosed with carpal tunnel syndrome (CTS). Results: From our study, it was seen that there was a significant decrease in the dimensions of the carpal tunnel and median nerve in Colles′ fracture based on ultrasonographic evaluation and the loss of radial length and volar shift were the two parameters significant in patients suffering from a CTS, based on radiographic evaluation. There was also an increase in the motor and sensory nerve conduction latency on nerve conduction studies of the median nerve. Conclusion: The loss of radial length and presence of a volar shift of the distal radius are the two deformities when left uncorrected may predispose to a CTS

Optimisation of Surgical Results in de-Quervain’s Disease

Background: De Quervain’s disease poses more problems with respect to management than the diagnosis. Surgery is resorted to when the conservative methods fail. There are known complications of the surgical intervention. Surgeon contemplating the surgery should be aware of these and make every attempt to optimize the results and avoid the above mentioned complication. Methods: Sixty symptomatic wrists in 57 individuals suffering from de Quervain’s disease who needed surgery were studied preoperatively with ultrasound. Number of tendons and the sub septae identified in the ultrasound examination preoperatively were confirmed on the table during the surgery. The release was brought about under local anesthesia, with magnification taking care to avoid injury to the cephalic vein and superficial branch of radial nerve, not to violate the anterior margin of the sheath, thus preventing complications. A negative post release finkelstein test was ensured before the wound closure. Results: All 60 patients who underwent release for de Quervain’s disease were symptom free, satisfied and fully functional. Conclusions: De-Quervain's disease not relieved by conservative methods needs surgical release under local anesthesia with a transverse incision with Preoperative ultrasound examination for the number of tendons and subseptae. Avoiding the violation of the volar aspect of the sheath, loupe magnification, tourniquet and post release Finkelstein’s test before wound closure, will ensure optimal results

The effect of low-intensity pulsed ultrasound therapy on fracture healing

Purpose: Multiple methods of accelerating fracture healing have been proposed and some are approved for use in the clinical settings. A low intensity (30 nW/cm 2 ) pulsed ultrasound (LIPUS) signal will promote fracture healing. This study is conducted to determine the effect of LIPUS on fresh fracture healing. Materials and Methods: Out of the 60 patients with diaphyseal fractures of the tibia and femur fixed with an interlocking nail, 33 received LIPUS and 27 were kept as control. Ultrasound treatment was started three days after surgery, 20 minute sessions each day, for 30 days. The rate of fracture healing in the LIPUS group was compared with that of the control group. Six orthopedic surgeons and two radiologists analyzed the follow-up x-rays. Results: Five out of the six surgeons interpreted that there was significantly more callus formation and union in the LIPUS group compared to the control group, especially in the initial stage of healing. The need for dynamization decreased by 50% in the LIPUS group. Both radiologists interpreted that there was significantly more callus in the case where ultrasound was administered, when they evaluated the same with an diagnostic ultrasound scan at the fracture site. Conclusion: The present study establishes the relation between low intensity pulsed ultrasound therapy and fresh fracture healing, especially in the early stages. We strongly recommend the use of LIPUS as an adjunct therapy where the surgeon anticipates delayed union of the fracture

Carpal tunnel syndrome: Ultrasonographic evaluation of median nerve diameter

Background: Carpal tunnel syndrome is the most frequently encountered peripheral compression neuropathy. Diagnosis of carpal tunnel syndrome involves physical examination, nerve conduction studies and electromyography. Ultrasonography (USG) examination of median nerve in carpal tunnel has been proposed as a useful alternative in diagnosing carpal tunnel syndrome. Materials and Methods: Patients were selected from those undergoing diagnostic workup for carpal tunnel syndrome in pre-treatment period. USG was performed using 11 MHz linear array transducer. Cross-sectional area at each level, major and minor axes were measured. Results: In our study, the mean median nerve cross sectional area at proximal part of carpal tunnel by direct method was 12.33 mm 2 in patients and 7.33 mm 2 in controls. By indirect method it was 12.01 mm 2 and 6.633 mm 2 in cases and controls respectively. In this study we found significant difference in flattening ratio between cases and controls. The mean flattening ratio in distal part of tunnel (at the level of hook of hamate) was 2.97 and 2.38 in cases and controls respectively. The sensitivity and specificity for cut-off value ≥2.5 was 76% and 63% respectively. Conclusion: We found that best discriminatory criterion for diagnosis of carpal tunnel syndrome are median nerve cross sectional area in the proximal part of carpal tunnel ≥9 mm 2 (Direct method) and ≥8.5 mm 2 (Indirect method). With our experience, we found it easier to evaluate the median nerve in the carpal tunnel in the disto proximal sequence by identifying the flexor pollicislongus (FPL) first with dynamic evaluation. As the percentage of space occupying lesions causing symptoms in unilateral (atypical) carpal tunnel syndrome is 35%, we highly recommend this pre-operative investigation in all carpal tunnel syndrome patients

Timed wake-up anaesthesia in hand: A modification to wide awake surgery of hand

Introduction: Wide awake surgery of the hand (WASH) is a well-accepted technique in hand surgery which allows the surgeon to identify and rectify on the table of some of the inadvertent shortcomings in the surgical procedures to optimise the final outcome. The advantage, however, precludes the use of tourniquet. We describe a modified method which preserves all the advantages of WASH and allows the surgeon to use tourniquet. Patients and Methods: Thirty-one cases of hand surgeries were carried out using the modified technique where a wrist block was supplemented with the ultra-short acting intravenous propofol which allowed the surgeon to use the upper arm tourniquet. The propofol infusion was stopped, and the tourniquet was released after the important surgical step. Within an average of 10 min of stoppage of the infusion, all the patients were awake for active intraoperative painless movements to aid the surgeon to identify, rectify and fine tune the procedure to optimise the results. Results: Five of the 31 patients needed correction based on the intraoperative movements. All the 31 patients were pain free at the surgical site during surgery. All the 31 patients were cooperative enough to perform full range of pain-free intraoperative movements. No patient experienced significant tourniquet pain during the procedure. Patient’s and surgeon’s satisfaction at the end of the procedure has been quite satisfactory. Conclusion: Timed wake-up anaesthesia, an improvement over the original WASH, has been suggested where the surgeon can add without subtracting the benefits of the procedure in the form of usage of the tourniquet providing the clear tissue plane and haemostasis during the surgery. However, an additional cost is incurred for the use of anaesthesia and equipment should be kept in mind