Interesting Case Reports
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- Interesting Case Reports
Presented here is a case of 35 yr old male patient, who had met with an accident while riding a scooter. He was diagnosed as having multiple fractures in his left leg (segmental fracture tibia with 4 fragments and fracture fibula).
The overlying skin was blistered with swelling of the whole leg. The leg was maintained in a slab plaster for one week to allow the fracture to be immobilized and let the tissues heal with decrease in swelling. At end of one week, we had a relatively less swollen leg and healed blisters. The patient was taken to Operation Theater wherein fracture tibia was fixed with an interlocking nail which spanned the entire length of the bone. It stabilized the distal two fractures adequately. However the most proximal fracture was getting angulated anteriorly due to pull of patellar tendon. So as has been described in various journals. The most proximal fracture was opened and fixed with a unicortical plate to control angulation at fracture site. All the fractures progressed to union with slight delay but without need for any supplementary procedure.
This is a case of a 45 yr old female who had suffered a fracture in both bones left leg due to run over by a vehicle. The patient leg was swollen with bad bruising of skin over the inner aspect of the leg. X rays showed badly comminuted fracture tibia and fracture fibula.
The tibia could not be fixed in the first sitting due to bad overlying skin condition. Hence the plan for interval plating of tibia was done. The patient was taken to operation theatre and fibula was plated first to gin length and alignment of the limb. The plate using in fibula was a strong locking plate to bear the stress of fixation. The tibia was stabilized using an ankle spanning external fixator. After 3 weeks, the swelling markedly decreased. The bruising also decreased. The external fixator was removed and the patient was given a back slab plaster to let the pin tracts heal. After one week, the tibia was plated using per cutaneous minimally invasive technique and no bone grafting was done. The ankle joint was mobilized early. The bone united in good time with no stiffness in the ankle joint. Weight bearing was however delayed and allowed only once satisfactory x rays were there.
72 year old male had slip in bathroom at his home early morning. He had a badly comminuted fracture proximal humerus right side. Under normal circumstances, a plan for locking plate fixation of this fracture would have been made.
However, this patient was evaluated for osteoporosis, which was marked. Further a ct scan of the shoulder confirmed that the head of humerus had split. So keeping in view his age, weak bones, and fracture geometry, a plan for prosthesis replacement of his head was done. The approach used was anterior to the shoulder. Final implant used was cemented shoulder hemiarthroplasty made by zimmer. The cementing was done using manual impaction with concerns of embolization and cement reaction in mind. Care was taken to attach the greater tuberosity and lesser tuberosity fragments to implant using thick strong sutures, so that post mobilization could be done. In post op period, patient had hematoma at local site probably due to not using a drain at surgical site. However, the hematoma didn’t cause many problems in wound healing and patient could be discharged safely.
Young male came to us with history of fall, following which he had pain in his elbow. There was pain on movement with restriction of supination pronation of forearm. X rays were done and fracture radius neck was diagnosed.
The patient was operated using posterolateral approach and the fracture was fixed using AO proximal radius plate. In earlier times, in such fractures the radial head had to be excised due to non-availability of good implants. Hence whatever means of fixation were used, the fracture was inadequately stabilized leading to nonunion at fracture site and eventually requiring radial head excision. Early excision of the radial head carried the risk of destabilizing the elbow and dislocation in some cases. This case is a clear example wherein the use of advanced implants has helped fix the fracture in a stable way. The advantages of preserving the radial head are good range of motion at elbow joint, overall stability of elbow joint, no chances of proximal migration of radius with radio capitellar arthritis, and distal radio ulnar joint pain. This patient had union in good time with excellent elbow mobility and stability.
73 year old male person was hit by a car while he was on morning walk. He was brought to triage with swollen painful right leg with undue mobility in bone. Overlying skin had few abrasions. The knee joint was swollen. After initial resuscitation, x rays were done.
The patient was found to have comminuted fracture patella, depressed fracture lateral condyle tibia. Comminuted fracture metaphysis tibia extending upto mid 1/3 distal 1/3 junction and fracture fibula. The patient was initially kept in a plaster slab and surgery was planned. Once the swelling decreased and wrinkling of skin was there, surgery was done. Fracture patella was fixed with standard tension band wiring techniques. Fracture lateral condyle tibia was opened and the depression elevated. The bone gap beneath the elevated fragment was filled with cancellous bone harvested from right iliac crest. The fixation has held with long k wires. The long comminuted fracture tibia was not opened. Long locking lateral tibia head plate was passed beyond the most distal fracture line percutaneously. The distal fracture fragments were to be held with 2 lag screws inserted percutaneously. In this surgery, skin incisions were kept long to allow soft handling of the soft tissues and minimal stripping of periosteum was done. The patient had to be kept in back slab plaster for 4 weeks to allow wound healing and also because of the fracture patella. After 4 weeks, the limb was mobilized non weight bearing and monitored closely for fracture union. After 3 months, fracture united with a good range of motion and well healed wounds.one very important element in management of this fracture is use of bone graft. The bone graft was used for joint elevation and buttressing, rather than the common use of graft at fracture site to increase chances of union. Since percutaneous technique was used and soft tissues were preserved, the fracture.
We are presenting a case of 72 yr old moribund patent. The patient had multiple medical problems and was walking with walker only. He had a fall in bathroom following which he sustained comminuted fracture left peritrochanteric region and comminuted fracture left distal end radius.
The patient was counseled for surgery but surgery was possible only after adequate optimization of the patient medically. After 5 days, patient was cleared by anesthesia team only for short duration surgery with minimum blood loss. Patient was taken to operation theatre and under spinal anesthesia; long proximal femur nail was inserted. This kind of fixation allows stabilization of fracture using small incision and with minimal blood loss. The overall morbidity due to surgery is reduced and patient can be mobilized early. This patient was allowed sitting and side turning next day onwards, minimizing risk of deep vein thrombosis and bed sores. The distal radius fracture too was fixed with k wires only. Plaster was given for 6 weeks on wrist. There is some debate on the length of nail used. Shorter proximal femur nails are available where distal locking can be done using zig, thereby decreasing radiation exposure and further shortening surgical time. However, reports also suggest that such nails have shorter lever arm, increasing chances of implant cut out at distal end and postoperative mid anterior thigh pain.
45 year old vegetable vendor fell from his rehri and complained of pain in left hip region. He had a below knee amputation on left side 20 yrs back and was using orthosis for walking. X rays showed a comminuted fracture inter trochanter femur left side.
The patient was planned for dynamic hip screw (DHS) fixation of this fracture. The main surgical issue in this case was giving traction to the amputated limb to reduce the fracture intraop and allow DHS plate to be put. Consent was taken from the patient and an intraop Steinmann pin 4.5mm was put in the distal femur on left side. Traction cords were tied to the pin and traction was given. The fracture was reduced and confirmed under image intensifier. The surgery could be completed successfully.
56 yr old male patient suffered fracture bimalleolar right ankle after falling from motorcycle. The patient was diabetic and alcoholic. The medial malleolus fracture was grade 1 compound. The lateral malleolus had comminuted fracture.
The compounding wound was washed thoroughly and sterile dressing was applied. The ankle was reduced and below knee plaster was given. The patient was prepared and taken to operation theatre. The compounding wound was debrided and necrotic margins removed. Fracture medial malleolus was reduced and fixed with 2 partially threaded cannulated cancellous screws and washers. The fracture lateral malleolus was exposed laterally and all care was taken to preserve the soft tissues. The fracture wad badly comminuted and no contact between two main ends was there to guide fracture reduction. The fracture was bridged using a lateral malleolus locking plate and alignment confirmed under image intensifier. This implant is a relatively new design which allows fixation of comminuted fractures in a difficult zone like lateral malleolus. The flare of plate is also has a thinned profile to reduce implant impingement on skin and allow wound closure safely. The ankle was kept in a plaster post operatively to allow wound healing and swelling to decrease.
30 yr old female presented with fall from height. She suffered closed fracture shaft of femur left side at prox 1/3rd amd mid 1/3rd junction. The fracture was badly comminuted, without overlying wound (closed), and without any distal neurovascular deficit. After stabilizing the patient, she was taken to operation theatre.
Traction was given on fracture table, under spinal anesthesia. The fracture was reduced closed. Beaded guide wire was inserted from entry point in piriformis fossa and reaming was done. Zimmer femur nail was inserted in GK mode and 2 proximal – 2 distal screws inserted. GK mode allows us to fix such proximal fractures which cannot be fixed using conventional femur nails. Other option that could have been used was RECON nail but given a choice GK nails are preferred. RECON nails are technically more demanding, more radiation exposure in there, surgical time is increased, and a theoretical risk to blood supply of head of femur is there. Therefore for such fractures, GK nails are best. Adequate alignment was achieved and fracture fixed stably. Fracture union is demonstrated in sequential x rays. Another significant point is importance of fixing comminuted fractures with nail rather than plate fixation. There is no loss of hematoma, no loss of soft tissue attachment of small fragments and minimal blood loss, all contributing to increased chances of union without need of bone grafting.
60 yr old female presented with history of fracture right femur which had been operated twice earlier. Initially plating of femur was done. The plate failed with implant breakage. Revision surgery was done with plate removal, nail insertion and bone grafting.
This patient presented to us 2 yrs after nailing procedure with complaints of shortening of limb, crepitus while walking and slight pain. X rays were done. There was fracture distal femur with non-union and implant breakage. The nail had broken at proximal of distal screw site and also screw breakage at this site. The fracture had collapsed in valgus and the distal fragment was short. The broken piece of nail was stuck in distal part of nail. Other problems in this patient were obesity, short stature, and diabetes. The patient was counseled and consent was taken for shortening in right femur, non-union, and need for non-weight bearing till good radiological union on x rays. The patient was taken to operation theatre and broken nail was removed. The fracture site was opened, bone ends were cut with oscillating saw till bleeding ends, and distal part of nail removed with long forceps. The fracture was fixed with locking distal femur plate and screws. The both parts of bone were prepared for bone grafting with shingling. Cancellous graft was taken from right iliac crest and put circumferentially around fracture site. Wound was closed over drains. The patient was closing followed up with x rays. There was delay in healing callous formation. However, after 9 months satisfactory bridging callous was seen and full weight bearing was allowed.
30 yr old female presented with history of fall in bathroom. She had swollen painful left forearm with pain in elbow region upon foreman rotations. Forearm was splinted and analgesic was administered. X-rays showed fracture ulna proximal 1/3rd –mid 1/3rdregion, comminuted and fracture radial head, comminuted and displaced.
The elbow joint was stable and all fractures were closed type. The patient was counseled about excision of radial head and resulting chances of elbow instability after that. The patient was taken to Operation Theater and ulna plating was done using dorsal approach. The fracture was badly comminuted and bridge plating was done. The radial head was excised using boyds approach. The comminuted radial head was reconstructed on trolley and the resulting cavity examined for any retained bone pieces. Once complete excision was confirmed, the wound was closed. The radial head pieces were debrided of cartilage and cancellous bone was used to graft ulna fracture. The forearm was splinted in above elbow slab for 3 weeks after surgery. Repeat x rays were done to confirm that the elbow joint was reduced.
A 66 yr old female presented with history of fall in bathroom. She had complains of severe pain in left hip region with inability to stand. X rays showed comminuted fracture proximal femur.
The patient was diabetic, hypertensive and had marked osteoporosis. The patient was prepared for operation theatre. Fracture fixation was done using AO PFNA 2 with angle blade fixation in head of femur. Thus implant allows a very good hold of the blade in the head of femur as minimal bone has to be removed for its insertion. This implant allows a dynamic controlled collapse at fracture site along with the advantages of intramedullary support to overall construct. The surgical time is short and minimal blood loss is there. The blade had a very good hold in the head of femur and the patient could be mobilized early.
39 yr old diabetic female presented to us with comminuted fracture tibia distal 1/3rd region with segmental fracture fibula. The patient was diabetic with poorly controlled blood sugar levels. The patient was also obese.
At time of presentation, there was moderate swelling in leg with overlying skin slightly shiny. There was poor pulse in peripheral vessels of both ankles, implying some underlying compromise on distal blood flow, in both limbs. The fracture was fixed using a distal medial tibia plate with locking screws. This implant was inserted using minimally invasive percutaneous osteosynthesis (MIPO) technique. The advantages of this technique, particularly in this patient were use of short surgical incisions, short operative time, minimal stripping of periosteum from bone ends and very less blood loss. The reduction achieved was anatomical. There was very good and rapid healing of the wounds. The limb was maintained in plaster for 2 weeks and then ankle mobilization was started.
32 yr old male patient presented with history for fall 5 yrs back wherein he sustained compound fracture right femur. However no medical records were available.
This fracture was managed in external fixator and multiple soft tissue coverage surgeries were also done. The patient was walking bearing full weight on this limb, when yesterday he had a sudden clicking sound in right thigh with inability to bear weight on right limb. X rays showed mal-united mid shaft femur with fresh fracture just proximal to the first fracture. The patient was counseled for surgery. The option of corrective osteotomy and nailing was discussed with the patient, but he refused. Decision was taken to fix the fracture and no corrective osteotomy to be done. The patient was taken to operation theatre and fracture was exposed using lateral approach to thigh. Long large fragment 4.5 mm locking plate was used to span and fix the fracture. The fracture progressed onto satisfactory union.
54 yr old male presented with history of being hit by a scooter followed by pain and swelling in proximal part of left leg. There was swelling in knee and a small bone deep wound over the prox-mid 1/3 rd junction left leg. X rays showed type VI proximal tibia bicondylar fracture with a poster medial fragment.
The wound was dressed and antibiotics were started. The limb was elevated on a BB frame. After anesthesia workup, the patient was taken to OR. The proximal tibia was exposed laterally using a lazy curve incision. The fracture was reduced using traction and reduction clamps. The reduction was held using K wires and lateral tibia head plate 3.5mm locking was used to fix the fracture. The posteromedial fragment was exposed medially and buttressed using a 1/3rd tubular plate and screws. Wound was closed in layers and post op limb was supported in slab. The limb was elevated for 3 post op days.
35 yr young male with uncontrolled diabetes and alcoholism, presented with history of swelling left arm for last 10 days. There was severe pain, redness and the swelling was gradually extending upto forearm region.
However, there was no history of trauma or fever. The patient gave history of getting immunized for hepatitis B vaccine in the same arm. X ray of humerus was apparently normal. Blood investigations showed increased total leucocyte count with granulocytosis. The ESR and CRP were markedly elevated. MRI of the arm and forearm confirmed presence of acute osteomyelitis of humerus with abscess formation in medial aspect of arm and cellulitis in forearm. The patient was taken to operation theatre and incision and drainage was done using anterolateral approach. Approximately 250 ml of thick pus was drained and samples were taken for gram stain and culture sensitivity. The wound was thoroughly washed and drill holes were drilled in bone. Pus came from inside bone too. The holes were enlarged to from a cortical window and the bone canal was thoroughly washed.
This is the case of an 8 yr old boy with history of fall from jamun tree. He had severe pain in left forearm with swelling and abnormal mobility.
Xrays showed fracture both bone left forearm with comminution and impaction of radius. A sincere attempt at closed reduction under anesthesia was made. However, the reduction though achieved, was not held satisfactorily in plaster. Since the parents were counseled and preparations were already done, in same anesthesia sitting, the child was operated and plating was done. A distal end radius plate was used to fix radius. The one third tubular plate used to fix ulna had only two screws in distal fragment. The most important thing to keep in mind while operating a pediatric fracture is to respect the physis. The implant must not include-span the physis. Any accidental injury to the physis must be avoided. If the physis must be crossed, then the wires with smallest diameter must be used and all such hardware must be removed as early as possible. However, if the identity of the fracture demands, 1/3rd of the physis can be pierced without significant growth disturbances.
A three and half year old boy sustained injury to left forearm when he was pushed in school by fellow student. After initial splintage, the child was brought to us in triage. The child had deformed left forearm with pain, mild swelling but no gross abnormal mobility, suggesting one bone was intact.
X rays confirmed ulna bone had fractured in mid1/3rd region with displacement, and there was plastic deformation of radius without obvious cortical break. Such injuries are common in children as the bones are soft. The bones tend to bend i.e. tolerate bending forces to a greater extent as compared to adults. However, if force is severe and one of the forearm bones fractures, then the other bone can get deformed in a plastic way. Such deformity can result in ulna remaining displaced and result in overall visible deformity of the forearm. The technique we used was gradual application of force opposite to deformity, the force being gradually increased so as to correct the deformity without fracturing the radius. This procedure was done under general anesthesia. After correction of radius was achieved, confirmed under image intensifier, an above elbow cast was given. As the radius was corrected, the ulna fracture reduced on its own. There have been techniques described where radius is fractured by the surgeon and then cast is given with both fractures aligned anatomically. This technique however had many pitfalls especially since it was difficult to counsel parents for a new facture.
69 year old male patient came to us in opd with complaints of backache and claudication. The claudication distance was decreasing with time. The backache was primarily on exertion. On examination, the patient had decreased forward bending of spine, palpable step in lower back, straight leg raising test negative on both sides.
The neurological examination showed S1 neuro dermatomal involvement. Ankle jerk was absent on both sides. X ray and MRI were done to evaluate the patient further. MRI showed listhesis L5 over S1 with fusion of the two vertebral bodies. There was compression of nerve bundle with marked stenosis at this level. Flexion extension lateral views at this level were taken to confirm any instability at this level. It was confirmed that there was stable fusion between L5 and S1 vertebra. Upon further detailed inquiry from patient, it was found that patient had long standing backache in young age which had decreased over the last decade into a discomfort type of ache, co-relating with fusion of the two vertebras. The long standing backache could have been due to listhesis due to spondylolysis. The patient was taken to operation theatre and posterior decompression with wide laminectomy was done with adequate decompression of neural bundle and the exiting nerve roots at this level. Stability was checked intra-op and not undue movement was noticed. After adequate decompression, the cord was wound pulsating without any dural leak. The wound was closed in multiple layers over gelfoam, without drain. In the immediate postoperative period, neurological status was intact and patient was shifted to recovery.
22 year old male farmer presented with history of fall from tree. He came with complaints of severe pain in back and right foot. There was no neurological deficit and the patient was able to pass urine with control.
There was bruising and tenderness at dorso-lumbar spine junction. Right foot was swollen and deformed. X rays showed compression fracture L1 vertebra with reduction in height of vertebra and focal kyphosis. There were multiple fractures in right foot metatarsals. The patient was stabilized and thereupon, MRI lumbar spine was done. MRI confirmed fracture configuration, the posterior wall was intact and minimal canal compromise was there. The patient was taken to Operation Theater. In prone position on spine frame, injured level was exposed dorsally. One level above and below the injured level were marked in IITV. The entry points of pedicle screws were exposed without injuring the facet capsule. Pedicle screws were inserted in pedicle of D 12 and L2 vertebra. There were connected with rods bent in lordosis. Lordosis was further created with OT table positioning. The rods were connected in screws and distraction was done to achieve height of collapsed vertebra. Wound was washed and closed. Post operatively neurology was found to be intact. The patient was made to sit and mobilized in wheel chair 2 days after surgery wearing Taylor’s brace. Sutures were removed on 12thpost-op day. Taylors brace was continued for 2 months.
65 year old female with advanced osteoarthritis both knees. She had been carrying on with medications for last 8 years, not convinced enough for surgery. Besides, she had diabetes mellitus, hypertension and had had one event of stroke (fully recovered by now).
So there were apprehensions of a successful outcome. She was operated wherein both knees were operated using minimally invasive technique and medial pivot microport knee implant. The post-operative period was uneventful. These pictures were contributed by the patient herself, from her bedroom, at 3 weeks after surgery. Notice the good range of motion, good bending angle and small surgical scars.
60 yr old male presented to us with advanced tri compartmental arthritis of right knee joint. There was history of trauma and some fracture in right knee.
The injury was managed in plaster and no medical record was available of that injury. The left knee was relatively disease and pain free. The patient was reluctant for surgery as he used to do farming in squatting position, which he believed he shall not be able to do after surgery. He was counseled and total knee replacement was done on right knee. These pictures are 2 months post-surgery. Notice the comfort wth which the patient is able to squat. The patient has now been allowed to return to his profession.
65 yr old farmer from Patiala, Punjab had come to us with advanced osteoarthritis both knees. There was marked varus and gait alteration. His walking speed was markedly reduced.
He was not able to carry on with farming any further for the last one year. The apprehension was whether he will be able to climb up and down his tractor after surgery and whether his knee will be strong enough to drive the tractor. The patient was convinced only for unilateral TKR on right side, on trial basis as per his wishes. These pictures as of the day when sutures were removed, 12 th postop day. Notice that the knee is straight with good range on bending. The patient voluntarily went with replacement of second knee after 1 month. At present, with both knees replaced, he is able to climb up-down and drive his tractor happily.
58 yr old lady presented to us with osteoarthritis of left knee joint. The right knee joint also had early changes of osteoarthritis, but was not very troubling. Plan was made to replace only the left knee, with the hope that it would off load the right knee and increase its life too.
However, the patient was resident of hilly area with tough terrain. She confessed that there was not road access to her home even. The patient was counseled about surgery and it advantage in prolonging preserving her right knee. These pictures are of the day sutures were removed. Notice the good range of motion and absolutely straight limb. After 7 yr follow-up, the patient now has no pain in left knee and very less discomfort in right knee. She is able to climb uneven hilly areas and carry on with her household work. The only medication given to her is glucosamines for her right knee and absolutely no pain killers.
Presented here is a case of 65 yr old woman who had underwent cemented total hip replacement of left hip 5 yrs back. She was apparently well for 5 yrs, walking comfortable full weight bearing. There had been no wound healing problems in postoperative period.
However, after 5 yrs, she started complaining of slight discomfort in left hip region. There was pain particularly localized to anterior thigh on walking. She could appreciate some clicking inside the hip also. X rays were done. The implant was found lose. There was global lysis at cement bone interface in femur stem with stem subsiding into varus. There was lysis at cement bone interface on acetabular side with cup rotation. With this picture, she was advised revision hip replacement at the earliest. In the meantime, patient had a fall wherein she had periprosthetic fracture of femur with bad comminution. She was taken to operation theatre and revision surgery was performed. The same incision as previous surgery was used. The first step was identification and preservation of sciatic nerve. Implant removal was not difficult as it was already loose. Any signs of infection were confirmed to be absent. The remaining cement mantle was removed using long currettes and osteotomes. The acetabulum was deep with very thin medial wall. All debris were removed and acetabulum reamed very carefully. Uncemented cup stryker was used and had a very stable fit. Screws were inserted for additional stability. The femur canal was prepared for a longer stem. The fracture was badly comminuted with loss of bone. All the fragments were brought togather and held using cables. A long stem cemented prosthesis was inserted and hip was stable upon reduction. The patient had uneventful postop period. Anticoagulation was given as mobilization was delayed. This patient was allowed toe touch weight bearing at 6 weeks only. Full weight bearing was allowed at 3 months when all fractures were seemingly uniting and good bone could be seen under acetabular shell. At 3 yr followup, this patient is walking without walker and is able to climb upto her house on first floor.
72 year old lady presented with a swelling over volar aspect of wrist approx. 2.5 cm by 2.5 cm in size. The swelling had been there for 2 years and was gradually increasing in size.
There was no pain in swelling per se; however wrist movement were mildly painful at terminal flexion. Upon examination, the swelling was soft to firm, non-pulsatile and slightly compressible. X-rays were done and found to be normal. Ultrasound of the swelling reported it as ganglion. The patient was taken to operation theatre and swelling exposed using volar approach to wrist. First radial was identified and protected. There was anatomical aberration due to swelling as the radial artery was prematurely branching and the wrist volar branch as passing right over the swelling. The radial artery and its branches were separate and protected. The swelling was full of gelatinous material. The swelling was excised without rupturing it and making sure all the walls are removed. The wound was thoroughly washed and closed. Biopsy of the swelling confirmed it to be ganglion.
2 yr old male patient, professional weight lifter presented with sudden giving way of right knee while jerking to lift weight. There was excruciating pain and sudden swelling of knee. This knee had been operated by us for ACL reconstruction using semitendinosus and gracilis graft one and half year back.
On examination, the right knee was swollen, bruised, and lack of active extension was there. X-rays showed patella alta and no bony avulsion/ fracture. The limb was splinted in slab and analgesics/ anti-inflammatory medicines were given. On next follow-up at one week, there was reduction in swelling, extensor lag was more evident. MRI was done; findings were patellar tendon rupture from near its insertion and rupture of medial lateral retinaculum. The patient was taken to operation theatre for surgery. The knee joint was exposed anteriorly using midline vertical incision. The patellar tendon was exposed. The frayed end of tendon was debrided and the remaining stump at insertion on tibial tuberosity identified. Holding sutures were passed through medial and lateral retinaculum ends, to felicitate identification and closure at later stage. 2 anchor 4.5mm sutures were inserted into tibial tuberosity area after baring the bone. The suture threads were woven into the main remnant of proximal tendon and tightened with knee in full extension. The distal part of patellar tendon was fanned over this repair. Gracilis tendon was harvested from opposite knee and prepared. This tendon was passed through a tunnel each in tibial tuberosity and patella horizontally forming a figure of 8 construct. When sutured, this tendon acted as support to the overall construct. The retinaculum was repaired at both ends. The wound was closed in layers over drain and the limb was splinted in above knee slab. Important to notice in this case was use of tendon graft from opposite limb, as the same tendon had already been used in this leg. The use of tendon loop also provided good strength the construct.
50 yr old retired army man , alcoholic and smoker, came to us with complaints of gradual infolding of little finger and ring finger of right hand. The deformity was more in little finger, wherein the finger could not be opened up to much extent. Upon attempted extension passively, a fibrous constricting band could be felt right beneath the skin.
X rays were done and any deforming arthritis ruled out. The patient was taken to operation theatre and surgical extension of constricting band was done. It is very important in this surgery to plan the surgical incisions and preserve the palmar skin. As the band is removed, the finger can be extended to full range. However, once extended, there is a big soft tissue defect in palm which can be managed by vy plasty and skin grafting. The fingers are mobilized early and any hematoma under grafted skin is avoided. Once wounds are fully healed, more aggressive grip strengthening can be started.
A 62 year old diabetic male presented to us with sudden onset severe pain in left knee while getting up from floor. He was already under treatment for early osteoarthritis knee. Now, there was sudden swelling around knee region with ecchymosis, inability to actively extend left knee and palpable gap just above the patella.
X ray and mri confirmed there was complete tear of quadriceps tendon near its insertion on patella. Patient was kept in knee brace for 5 days to allow the swelling to decrease. Plan for repair was made. Anterior midline incision was used and torn tendon exposed. The tendon end s showed degeneration with no significant remnant attached to patella. The ruptured end was debrided and woven with a strong non absorbable suture. Tunnels were drilled trough patella longitudinally. A high speed burr was used to make a trough in proximal part of patella to allow the seating of quadriceps tendon. The tendon end was then tightened to the patella. The knee was moved through its entire range and strength of repair checked. Wound was closed in layers and knee brace was given. Weight bearing was allowed next post op day in knee brace. Knee bending passively was started after 2 weeks and actively after 6 weeks.
Here is presented a case of an old man who had sudden onset pain and abnormal mobility in his left arm while getting up from chair with support from his left hand. The patient had history of fracture in this arm one year back which was operated outside.
The patient was operated using posterolateral approach and the fracture was fixed using AO proximal radius plate. In earlier times, in such fractures the radial head had to be excised due to non-avaThe left had a healed scar spanning almost the entire distal 2/3rd of the arm dorsally. X rays showed nonunion distal metaphyseal humerus with 2 plates in situ. A fresh fracture had taken place at the end of the two plate’s most likely due to stress on bone due to the implant. Some of the screws were also broken suggestive of stress on implant also. The patient was taken to operation theatres. All metal ware was removed. Broken screws were retrieved with hollow mill. The nonunion site was freshened, exposed and reduced. However varus at nonunion site could not be corrected fully due to very tight soft tissues and loss of bone on medial side of humerus. The fracture and nonunion were fixed with 2 locking plates. Both the sites were grafted using cancellous bone from iliac crest. We had a tight closure over drain. Post operatively the limb was elevated and ice compression was done. After three days, by the time of first dressing, swelling had markedly decreased.
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23 yr old male farmer presented with history of road traffic accident one year back. He suffered compound fracture distal femur inter-condylar super-condylar femur. The fracture was managed outside with articular reduction maintained with screws, supported by a trans-articular spanning external fixator.
The fixator was removed at 6 months and the patient was allowed partial weight bearing. He progressed on to bear full weight on right leg, but he had minimal movement in knee and the leg gradually deformed into valgus. Upon presentation, the range of motion in knee was 0 to 5 degrees. There was well healed scar over anterolateral aspect of knee approx. 12 cm in length. The limb was in approx. 7 degrees valgus. X rays were done. Intra-articular reduction was acceptable with screws and k wire in situ. There was metaphyseal non-union and overall valgus at fracture site. The patient was taken to operation theatre and distal femur was exposed laterally. Three screws and k wire were removed. Most medial screw was left as it was not coming in field of surgery and fixation. Medial incison was given to release the patellar retinaculum medially. The patella was found adherent to distal femur and was released with osteotome, carefully preserving as much bone as possible. The nonunion site was exposed and the distal condylar area freed of adherent soft tissue. The bone ends were freshened and acceptable alignment achieved. The construct was fixed with distal femur locking plate and screws. The range of motion achieved after this step was upto 15 degrees. All intra-articular adhesions were removed with shard dissection using blade. After this maneuver, the knee was bend upto 60 degrees. Quadricepsplasty was done wherein vastus intermedius was separated; L plasty of vastus intermedius was done; and pie crusting of rectus femoris was done. The iliotibial band was sectioned at two places. The vastus medialis and vastus lateralis were separated from quadriceps tendon. The range of motion was now upto 100 degrees. The wound was washed. Non-union was bone grafted. Wound closed in layers over drain and knee brace was given.
