Abstract

Distal radius fractures are commonest injury managed by junior doctors in accident and emergency department. Technique of manipulation is very well described and doctors are prepared from the days of medical school. Though manipulation is done in good position at initial management many patients require re-manipulation and surgical stabilisation due to loss of position on subsequent examination. Many Senior surgeon thinks this is due to inadequate plastering and moulding technique.

Material and methods: We retrospectively, randomly selected 50 patients from 210 manipulations done in one year at District General Hospital. All these patients x-rays were reviewed and data collected for classification of fracture (Frykmann’s classification), radial height, ulnar varience, radial angulation, and Radial inclination measurements. Three Senior Orthopaedic Surgeons reviewed pre and post manipulation x-rays and asked for acceptability of initial reduction, plaster position and moulding signs on x-rays and asked to predict those requiring re-manipulation or loss of position.

Results: 70% of the fractures were frykmann I or II as intra articular fractures Prediction of senior surgeon was right for more than 60 percent of the cases. Average radial angulation was 14 degree on post manipulation films. Radial height and inclination was average 6 mm and 18 degrees respectively.

Discussion: Post manipulation is very important factor for maintaining reduction and poor moulding can lead to loss of position and require unnecessary additional operative procedure for initially well reduced fracture. Teaching of Plastering and moulding technique is very important skill development for junior doctors to improve outcome of these simple injuries

Internal fixation of ankle fractures should be undertaken either before or after the period of critical soft tissue swelling. As part of the clinical governance in our unit, an audit was undertaken to examine the interval between admission and surgery and net inpatient stay of patients with ankle fractures over a 6 month period.

Thirty four patients fulfilled the inclusion criteria of having an acute closed fracture of the ankle requiring open reduction and internal fixation (ORIF). There were 16 unimalleolar, 10 bimalleolar and 8 trimalleolar fractures. 10 Patients underwent surgery on the day of admission, 9 patients had surgery within 24 hours, 15 patients had surgery after 24 hours of admission. The average in patient stay was 9 days (1–61 days).

If surgery was undertaken within 24 hours the average inpatient stay was 9 days (1–14). If surgery was delayed beyond 24 hours the average inpatient stay was 15 days (3–61 days).

Delayed surgery of closed ankle fractures increases the risk of soft tissue complications and prolongs hospital stay with profound cost implications. Long-term disability resulting from ankle fractures can be reduced by optimal early management procedures.

Aim: Retrospective analysis of paediatric supracondylar fractures treated by various closed and open methods of management and study co-relation between type of treatment and outcome.

Method: Retrospective review of children with displaced supracodylar fractures of humerus consecutively treated between January 1999 and December 2003. We included all the patients (63 children) admitted to hospital and had closed or open surgical procedure. Medical records and radiographs were reviewed to identify type of management, pre or postoperative complications, including loss of fracture reduction, infection, loss of motion of elbow and the need for additional surgery. 13 cases were excluded as insufficient records available and patients have either moved from area or treated on injury on holidays.

Results: In this study 70% of children were less than 8 year old. Except for one all the patients had extension type of injury and 58% of total cases had Gartland type III fracture configuration. 38% of patients were treated with closed reduction and immobilisation, 24% had closed reduction and percutaneus k-wires fixation and remaining had open reduction and internal fixation. All the patients underwent procedure with in 12 hrs of admission to hospital. Six patients had pre-operative neuro-vascular compromise and all of these patients recovered completely post-operatively. Loss of position was noted in 20% of children who had only manipulation and required re-manipulation and stabilisation with percutaneus k-wire fixation. All percutaneus fixations were with two lateral entry pin fixation and Open reduction were fixed with cross pin fixation. There was no clinically evident hyperextension or loss of motion but one patient (Gartland type III) who was treated with MUA and immobilisation required corrective osteotomy for cubitus varus. One patient had pin track infection but there was no iatrogenic nerve palsy.

Conclusion: Lateral entry pin fixation is very safe mode of fixation for percutaneus treatment and gives excellent results. Treatment with Manipulation and immobilisation for Gartland type III fractures does not give satisfactory results. We suspect early treatment of these fractures reduces comorbidity and early complications.

Thigh pain and periprosthetic osteolysis associated with the femoral stem, is a common complication of cementless total hip arthroplasty. Treatment of this disabling complication is difficult but usually requires revision of the femoral stem, which is a procedure not without further morbidity. We describe a solution which does not require revision and which brought about resolution of the thigh pain.

The patient was a 79 year old male who had a primary Total hip replacement (year 1998),This was revised (early 2001) to an uncemented cup (ABG type) and uncemented femoral component (Link MP stem) . He continued to experience disabling thigh pain which limited walking to only a few yards.The pain was thought to be related to concomitant paget’s disease in the Right hemipelvis and proximal femur. Rheumatology assessment and treatment with IV Pamidronate (three courses of treatment) did not produce any relief of pain and indicated a mechanical prosthesis related cause of pain. Radiology assessment was also indicating the same with osteolysis at the tip of the prosthesis.

The patient did not want a further revision procedure, but wanted relief of pain.Therfore sufgicsl intervention to treat the osteolysis with allograft ground bone introdued retrogradely via an anterior knee approach with an intercondylar pilot hole and initial supracondylar reaming. Allograft was introduced using a 5 ml syringe and impacted with a 1 cm diameter metal rod. 50 ml of ground bone was introduced and impacted forcibly with rod and hammer impaction.

The knee wound was closed in layers over 2 drains and post-op management was same as for total knee replacement, CPM and active NWB mobilization for six weeks followed by PWB, progressing to full weight bearing mobilization. Walking was free of thigh pain and walking distance was improved.