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   Table of Contents - Current issue
May-August 2020
Volume 3 | Issue 2
Page Nos. 29-101

Online since Thursday, September 10, 2020

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Editorial p. 29
Ritesh Runu
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Surgical anatomy of distal radius and surgical approaches for distal radius fractures p. 30
Shilp Verma, Alok Chandra Agrawal, Buddhdev Nayak, Bikram Kar, Harshal Sakale, Sandeep K Yadav
Distal radius fractures are increasingly managed by operative means now. Hence the anatomy and surgical approaches are of utmost importance. Distal end of radius articulates with carpal bones forming radiocarpal joint and distal ulna forming distal radio ulnar joint. Presence of multiple tendons and neurovascular structure makes the dissection of this area difficult. Authors have reviewed the anatomy and surgical approaches of this area.
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Classification systems of distal radius fractures p. 36
Vishal Victor Kujur, Alok Chandra Agrawal, J Rakshit, Harshal Sakale, Bikram Kheshri Kar, Sandeep Yadav
The fracture of distal radial was first described by Sir Abraham Colles in 1814. In last two centuries, the clinical features, investigative modalities, treatment modalities and complications have been explored extensively. To standardize the treatment, these fractures have been classified in several ways. Here in this article the author has tried to summarise the classifications of distal radius by various authors. It highlights the indications and implications of each classification modality.
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Distal radial fractures: Conservative treatment p. 41
Sameer Mittal, Alok Chandra Agrawal, Harshal Sakale, Bikram K Kar
Undisplaced distal end radius fracture is traditionally managed with conservative treatment, that is, closed reduction and immobilization. This approach has excellent result in undisplaced distal radial fractures and in displaced fractures where stable reduction can be achieved after closed reduction. Subjective results of conservative treatment are as good as the results of operative treatment in patients aged > 65 years at 1-year follow-up. Closed reduction is done mainly with two methods – direct reduction by manipulation and by ligamentotaxis. Immobilization is done mainly by a cylindrical plaster cast. Immobilization of the wrist in neutral radial-ulnar deviation and neutral or slight extension is recommended. Rehabilitation is a very important part of conservative treatment and is started from the day of the first visit in the form of mobilization of adjacent joints and limb elevation. The goal of rehabilitation is to achieve maximum range of motion and strength in the extremity with good fracture healing.
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Distal radius plating: Role and significance p. 45
Harshal Sakale, Alok C Agrawal, Shilp Verma, Bikram Kar
Distal radius fractures are a very common fracture. They occur mostly due to fall on an outstretched hand. They represent around 17% of all adult fractures. They occur most commonly in young males due to high energy trauma and older females due to osteoporosis. There are various treatment options available for fracture fixation, such as close reduction and manipulation, followed by cast application, close reduction and external fixator application, close reduction with percutaneous K-wire fixation, and open reduction and internal fixation with distal radius plate. Displaced intra-articular fractures are mostly managed with open reduction and distal radius plate fixation. Different fracture patterns require different types of distal radius plates such as T-plate, buttress plate, and variable angle plate. This article outlines the role of plating in distal radius fractures.
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External fixator for distal radius fracture p. 49
Sandeep Kumar Yadav, Alok Chandra Agrawal, Rahul Ranjan, Rudra Narayan Das, Harshal Sakale, Bikram Keshari Kar
Unstable distal radius fractures are challenging condition for orthopedic surgeons. Among an array of options, external fixator is a valuable instrument for the reduction and stabilization of these fractures. It is either joint spanning or joint sparing types. It may be used alone or in combination with other stabilization methods. Limited open reduction, augmentation with K-wires, early range of motion, and care of complex wounds are few of the benefits of external fixation. Moderate distraction at the carpus does not induce postoperative stiffness. Complications of external fixation are usually minor but must be anticipated and treated early.
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Outcome of comminuted distal-end radius fracture managed with Ulno-Carpal and distal radius stabilization using percutaneous K-wires p. 53
Bikram K Kar, Anand Kumar Singh, Sharath Kaushik, Sandeep K Yadav, Harshal S Sakale, Alok Chandra Agrawal
Background: Distal radial fractures account for up to 20% of all fractures treated in emergency departments, many are not “completely exempt from pain” after treatment. Several treatment modalities have been described with their own merits and demerits. Stabilization of ulno-carpal articulation is an effective method to prevent radial collapse and other complications associated with external fixator during healing, and hence this study has been designed to get a solution with good outcome and minimal complication. Materials and Methods: A prospective study on eighty patients of comminuted intra-articular fracture of the lower end of the radius, between 30 and 65 years of age, irrespective of sex, treated by closed reduction and ulno-carpal stabilization maintaining ligamentotaxis and distal radius percutaneous K-wires fixation and a well-molded above-elbow Plaster of Paris cast for 4 weeks followed by removal of K-wire and below-elbow cast for 2 weeks, has been presented. Patients were evaluated at 6-month follow-up and functionally by Sarmiento's modification of Lindstrom criteria and Gartland and Werley's criteria. Results: Excellent results were seen in 85%, good in 11.25%, and fair in 4.75% of the cases. Complications observed were malunion (n = 2), subluxation of the inferior radio-ulnar joint (n = 2), Sudeck's osteodystrophy (n = 1), and posttraumatic arthritis of the wrist (n = 2). Conclusion: The closed reduction and percutaneous K-wire fixation is a least invasive, safer, and effective method to maintain the reduction, prevent radial collapse during healing, and maintain the stability of the distal radio-ulnar joint even when the fracture is grossly comminuted, intra-articular, or unstable.
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Complications of distal radius fractures p. 58
Mukund Madhav Ojha, Alok Chandra Agrawal, Bikram Kesari Kar, Harshal S Sakale
Distal end radius fractures are the most common fracture encountered by orthopedic surgeons, accounting for 17.5% of all adult fractures. Numerous complications arising during the course of management of these fractures are broadly categorized as immediate (nerve injury, compartment syndrome, and skin injury), early (loss of reduction, tendon rupture, stiffness of joints, and infection), and late complications (maluinon, delayed/nonunion, complex regional pain syndrome, and joint arthropathy). It is imperative for a surgeon to have thorough knowledge of these complications and methods required to prevent and manage them.
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Ipsilateral elbow and distal radial injuries: Experience with management p. 61
Alok Chandra Agrawal, Subeer Kumar Mukharjee, GS Vyas, Pankaj Kumar Lakhtakia, Vinod Tiwari
Simultaneous occurrence of injury to ipsilateral distal humerus/elbow and distal radial and/or radioulnar bone at wrist is extremely uncommon. Most of the textbooks do not mention this combination of injury. This fracture combination was studied in 42 children as a multicentric study where the peak age incidence was 10 years (range: 6–15 years); injury was common in males and on the right side in most of the cases. Open fractures were seen in 12 cases where injury resulted due to fall from height on an outstretched hand. Thirty of these injuries were treated conservatively and 12 by surgery. The study discusses the problems in management and complications observed thereof. A flowchart has been recommended based on experience.
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One bone forearm for massive gap nonunion of distal radius: Our experience and literature review p. 66
Lawrence Kisku, Riddhideb Barman, Amit Ranjan Vidyarthi, Sarkar Pushpal Pijush, Mohammad Nasim Akhtar, Sanjay Keshkar
Background: Large defect or massive gap of nonunion distal radius is a rare entity but not uncommon. It usually presents with manus valgus deformity with a disability and difficult to treat. Due to the extensive gap with surrounding soft tissue scarring, the usual method of gap grafting may not be feasible in these cases. In such cases, the creation of one bone forearm has been found to be a sound and excellent method of treatment. The purpose of this paper is not only to present the results of 5 patients of massive gap nonunion of the distal radius treated by one bone forearm but also to review the relevant literature. Materials and Methods: Five cases of posttraumatic massive gap nonunion of radius were treated by the creation of one bone forearm in the past 8 years. The male-to-female ratio was 4:1 with age ranging from 16 years to 35 years. In all cases, ulnar transposition and fixation in the neutral rotation were done to create one bone forearm. Three cases underwent monoaxial distraction of distal radius to correct distal radio-ulnar joint prior to the definitive procedure of one bone forearm. Results assessed by clinico-radiological evaluation. Finally, literature related to the treatment of such cases were searched by Google search, and systematic review on the subject was done. Results: The follow-up period ranges from 4 to 8 years with an average of 4.5 years. According to clinico-radiological evaluation, one patients came out with excellent result and the remaining 3 had a good result. In toto, all five patients had good functional outcomes. Conclusions: To produce “one bone forearm” for massive gap nonunion of the distal radius is not an outdated but still a dependable, effective, and economical procedure with lesser complication, good outcome, shorter hospital stay, and easier postoperative maintenance.
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Orthopedic practices and orthopedic education amidst COVID-19 pandemic – Changing trends and way ahead p. 70
Sandeep Patel, Vishal Kumar, Shahnawaz Khan, Siddhartha Sharma, Sameer Aggarwal
The COVID-19 pandemic has affected people from different walks of life. With limited availability of personal protective equipment and testing facilities, the medical fraternity is at high risk of infection. The orthopedicians were also affected. The management protocols of trauma and nontraumatic cases and the orthopedics teaching have undergone a paradigm shift. The management has changed from aggressive surgery to conservative management. The number of patients suffering from physical trauma has come down significantly. The elective cases are postponed. Newer ways of consultation like teleconsultations have begun. Due to the closure of public transport services, follow-up of patients is also not proper. With the judicious use of resources and proper testing of patients, we can overcome this pandemic.
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Efficacy of gabapentin in the management of failed back surgery syndrome: A scoping review of literature p. 75
Vishal Kumar, Amit Kumar Salaria, Ashish Dagar, Saurabh Aggarwal, Prasoon Kumar, Sarvdeep Singh Dhatt
Failed Back surgery syndrome or persistent low back pain following lumbar surgery is a known complication of lumbosacral spine surgery. The incidence of FBSS ranges from 5% to 10% postlumbosacral surgery. It is characterized by disabling pain resistant to usual analgesic and physiotherapy. Epidural fibrosis is found to be the most common cause of FBSS. Various treatment modalities such as spinal canal stimulation, epidural corticosteroids injection, Non steriodal antiinflammatory drugs, opioids, and repeat surgery have been tried for the management of FBSS, but none of them have shown a promising result. The second surgery in such patients has a poor success rate of only 30%–35%. 15%–20% patients even reported worsening of symptoms after a second surgery. Gabapentin which is an analog of gamma-aminobutyric acid has shown good results in few studies in reducing pain in patients with failed back surgery syndrome FBSS. Few case reports and randomized control trials published in recent past has shown good efficacy of gabapentin in reducing low back pain as well as leg pain associated with failed back surgery syndrome FBSS. To conclude, gabapentin can be tried in a patient with FBSS, but its efficacy needs to be established with a large multicentric study.
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Lumbar facet joint morphometry in the southeast asian population: A cadaveric study p. 79
Vishal Kumar, Rohit Kansal, Ashish Dagar, Parmod Singh, Chiman Kumari, Sarvdeep Singh Dhatt
Objectives: Facet joint morphometry may vary among different ethnic groups. The purpose of this cadaveric study is to delineate the lumbar facet joint morphometry in the Southeast Asian population through direct measurement techniques. Methodology: A prospective study was conducted at PGIMER, Chandīgarh in 2019. In five cadavers, facet joints from L1-L2 to L5-S1 on either side were carefully exposed. With mutual consensus, two senior authors expose and demarcate the facet joint boundaries, and supero-inferior and transverse diameter of the facet joints (total fifty facet joints) were recorded using compass and ruler technique. Results: The mean age was 80.2 ± 7.3 years. The mean transverse and supero-inferior diameter were lowest at L4-L5 (1.08 cm and 1.18 cm, respectively), and maximum at L5-S1 (1.24 and 1.32 cm, respectively). No statistically significant change in both transverse and supero-inferior facet joint diameter was noted from L1 to S1 (P = 0.063 and 0.256, respectively). The supero-inferior diameter of the facet joints on either side was persistently noted to be greater than the transverse diameter at all levels. Further, no significant difference was noted in both diameters on the comparison, on either side from L1 to S1. Conclusion: Cadaveric studies in indexed journals regarding lumbar facet morphometry, particularly in the Southeast Asian population are scarce. The current study has measured the facet joint as a whole from L1 to S1, rather than superior and inferior articular facets separately and these data are more valid, cautionary and clinically useful for spine surgeon while considering trans facet fusion particularly in this subset of the population.
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Unreamed solid interlocking nail for the management of compound tibial diaphyseal fracture? A prospective study p. 83
Ashiwani Kumar Pankaj, VK Goyal
Background: Compound tibial fractures have always been a challenge to the orthopedic fraternity. Goals of treating these fractures are preventing infection, restoring soft-tissue vitality, achieving union, and instituting early joint motion and rehabilitation. Aim: The aim was to evaluate the rate of union, infection rate, post-union deformity, and the functional outcome following unreamed solid interlocking nailing in compound tibial diphyseal fracture of Gustilo–Anderson Grade I to IIIB. Materials and Methods: Twenty patients presenting to the emergency orthopedic department with compound tibial fractures, between 2014 and 2016, were included in the study. This was a hospital-based, prospective study. The fractures were classified according to Gustilo–Anderson classification, and the final outcome was measured by Johner and Wruh's criteria with modification. Results: We had more cases of male patients than females (75% vs. 25%) in the age group of 20–60 years (average 37.10). Road traffic accident was the most common cause in our study (75%) followed by fall from height (25%). Gustilo and Anderson classification was used, and 10% were Grade I, 20% were Grade II, 65% were Grade IIIA, and 5% were Grade IIIB. The average time to union was 22.53 weeks and the average time to start full weight bearing was 11 weeks with a standard deviation of 1.38 weeks. Complications such as delayed union (10%), nonunion (5%), shortening (5%), superficial infection (10%), gait disturbance (5%), and angulation (10%) were found; 5% had more than 25° of restriction of ankle rom and 5% had more than 10° of restriction of knee rom. Final outcome was excellent results in 65%, good in 20%, fair in 10%, and poor in 5% of cases. Conclusion: The present study demonstrates that unreamed solid interlocking nailing is considered a good option for the management of compound tibial fractures (Grade I–IIIB) as it allows early weight bearing, early rehabilitation with high union rate, and low complication rate.
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Indigenous method to prevent aerosol dissemination while bone drilling using powered drill during COVID-19 p. 90
Sudeep Kumar, KV Charan Teja, Anup Kumar, Kranti Bhavana
Introduction: World is now faced with a pandemic caused by Covid-19 causing unprecedented burden on the healthcare systems of the countries. As everyone is at the risk of exposure and contracting the infection, recent evidences started stating possible modes of transmission including aerosol. Aerosol generation is very common in surgical procedures, especially in orthopaedic trauma where the usage of electrocautery and powered drill are abundantly used. The purpose of this article is to describe how we used the barrel of syringe to decrease aerosol dissemination while drilling bone. Material and Methods: 50 and 20ml syringes were used during drilling in orthopaedic surgeries in consecutive patients. Observations and results: The spread of aerosol generation was found to reduce. Conclusion: It is a cheap and viable method to reduce the dissemination of aerosol during Covid pandemic.
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Dog bite causing open radial neck fracture with posterior interosseous nerve palsy in a child p. 92
Sandeep Patel, Saurabh Vashisht, Rakesh John, Tungish Bansal, Vishal Kumar
Fractures secondary to dog bites are extremely rare with an incidence of around 1.4%. These are usually reported above the clavicle in children and in the extremities in adolescents and adults. Upper extremity fractures, other than hand fractures, have been reported very infrequently. We report a rare case of a Gustillo-Anderson grade 3b open fracture of the radial neck with associated posterior interosseous nerve palsy following a dog bite in a 12-year-old boy. The fracture was picked up promptly due to thorough history-taking, careful clinical examination and screening with plain radiographs. The wound was debrided aggressively under antibiotic coverage with standard tetanus and rabies prophylaxis and was allowed to heal by secondary intention after immobilizing the fracture in an above-elbow plaster splint. The fracture united uneventfully and neurologic function recovered completely within 12 weeks with excellent functional outcome at the one-year-follow-up visit.
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Diaphyseal depression fracture of the tibia by a cricket ball in a child: A probable first report of rare injury p. 95
Pankaj Mourya, Ganesh Singh Dharmshaktu
Undescribed fracture patterns are rare presentations in fracture clinics and are mostly limited to a few reports in the literature if any. The pediatric diaphyseal fractures of the tibia usually follow common described patterns, such as transverse, spiral, oblique, or comminuted configuration. Depression fractures, though well described at the articular region such as tibial plateau, are not found at diaphyseal sites. The localized saucer-shaped depression fracture in the diaphysis thus is an undescribed injury. We present a rare report of an isolated, unicortical, and localized depression fracture of the tibial diaphysis in a 10-year-old child following hit by a cricket ball during the match. He was managed conservatively with good functional outcome. Knowledge of this rare pattern of injury is helpful to acknowledge its occurrence and its listing in scientific literature.
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Anterior dislocation of the elbow with lateral condyle fracture in a child: A rare concomitant injury p. 98
Ganesh Singh Dharmshaktu
Elbow dislocation in children is a rare injury and the anterior dislocation is a rarer variant. These may at times be associated with fractures of condyles or epicondyles of the distal humerus among others. An anterior elbow dislocation along with concomitant fracture of the displaced lateral condyle is a very rare injury, which was successfully managed and is described here with relevant details. Anterior elbow dislocation in a 7-year-old child was reduced, and the lateral condyle fracture was managed by open reduction and K-wire fixation. Good functional outcome was noted despite radiological irregularity over the capitellum with child performing all activities of daily living.
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Prof. Dr. H.N. Sinha p. 100
Rajeev Anand, Dilip Sinha
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