This is the first time we encountered a peculiar case of osteomyelitis complicating a closed fracture. The patient was a 38 year-old lady who presented just like any other patient with a closed fracture of the right femur. Intraoperatively we were surprised to find pus from the fracture site. This not only changed the surgical management but altered the subsequent outcome as well.
Issues that had been encountered during proximal femoral fracture fixation using proximal femoral nail include (i) the adequacy of the femoral neck width in the local population and (ii) the potential difficulty encountered during fixation in certain prefixed angles as determined by the implant. This was a retrospective, descriptive study evaluating the anterior-posterior pelvic radiographs of 100 consecutive patients, from January to August 2007, managed at University Malaya Medical Centre, Kuala Lumpur. The femoral neck width in the population studied was adequate for placement of femoral neck screw and anti-rotation pin or hip pin using the proximal femoral nail implant. (mean = 34.0 +/- 3.7 mm, min = 24.6 mm). There was no significant difference between the working area using an implant angled at 130 degrees or 135 degrees (P = 0.91). Both femoral neck width and neck shaft angle of the Malaysian population studied were not a factor influencing the placement of femoral neck lag screws and anti-rotation pin.
Primary hyperparathyroidism (PHPT) is an intriguing condition. Routine automated biochemical screening has made the diagnosis commonplace in developed countries and the disease is diagnosed early in its course when it is often asymptomatic. In developing countries or in recent immigrants from these countries, PHPT is often seen in an advanced stage with bone involvement. Associated dietary deficiencies may alter the biochemical profile and cause a diagnostic dilemma. It is important to include it in the differential diagnosis of pathological fractures. We report three cases of PHPT presenting with pathological fractures and discuss their diagnosis and management.
Closed intramedullary nailing is a successful method of treating adult femoral shaft fractures. In comminuted or segmental fractures, this operation is associated with an incidence of rotational malalignment and malunion. After locked nailing, this can only be corrected by further operation. A simple method of judging and obtaining rotational alignment in such cases intra-operatively is described. A comparison of two groups of patients with such fractures, one using this technique and the other using conventional methods of judging alignment, revealed statistically significant improvement in rotational alignment (p = 0.016).
Internal fixation with a plate in the management of non-union for shaft of long bones has been condemned but the review of the literature does not provide such unequivocal evidence. Also there are certain situations where it is either technically not feasible or contraindicated to do closed intramedullary nailing. This study was done to see the outcome of plate-fixation for the treatment of non-union of the shaft of long bones.
Postoperative deep-vein thrombosis (DVT) is believed to be rare in Asians. We studied 88 consecutive patients in Malaysia who had operations for fracture of the proximal femur or for total hip or knee replacement. No patient had prophylaxis against DVT; bilateral ascending venography was performed between six and ten days after operation. A total of 55 patients (62.5%) showed venographic evidence of DVT. The prevalence was greatest after total knee replacement (76.5%), less after total hip replacement (64.3%) and smallest in the fracture group (50%). One patient developed symptomatic pulmonary embolism. In contrast to other reports from Asia, we found an incidence of postoperative DVT which is similar to that reported in Western populations. This suggests that the present practice of withholding routine prophylaxis against thromboembolism in Asian patients undergoing high-risk orthopaedic procedures should be reconsidered.
Management of severe open tibial fracture with neurovascular injury is difficult and controversial. Primary amputation is an acceptable option as salvaging the injured, insensate, and ischaemic limb may result in chronic osteomyelitis and non-functional limb. We report a case of open tibial fracture associated with segmental bone and soft tissue loss, posterior tibial nerve and artery injuries, which was further complicated by chronic osteo-myelitis treated with composite vascularised osteocutaneous fibula and sural nerve graft. Functional outcome of the injured limb at one-year follow-up was satisfactory: the patient was capable of achieving full weightbearing and was able to appreciate crude touch, pain, proprioception, and temperature at the plantar aspect of the foot. There was no pressure sore or ulceration.
Cases of retained surgical guaze are rarely reported because of medico-legal and professional implications. Retained gauze for a period of more than 10 years is even rarer. A case of retained surgical gauze for 11 years, an accidental finding from a plain radiograph of a patient who had sustained proximal femoral fracture, is reported. A review of other reported cases is presented.
Antiresorptive agents have been used as primary or first-line therapy in managing patients with osteoporosis. Bisphosphonates in particular are used widely to reduce bone resorption, increase bone mineral density, improve bone quality and therefore reduce fracture risk. However, prolonged use of bisphosphonates may cause over-suppression of bone resorption, leading on to accumulation of micro-damage in bone. This in turn might lead on to atypical femoral fractures. A patient treated with alendronate sodium for 8 years, and presenting with bilateral atypical femoral diaphyseal fractures is reported. X-rays of both femurs showed typical horizontal fracture line involving the thick lateral cortex with short oblique fracture pattern over the medial cortex. This fracture pattern was further confirmed with intra-operative examination of the fracture ends. Histopathological examination of the endocortical fragment removed from the proximal fracture end showed absence of osteoclasts and osteoblasts. Bone mineral density with dual energy X-ray absorptiometry (DXA) scan showed osteopenia over the femoral neck. Blood investigations did not show significant abnormalities. Bone turnover marker levels were not reliable, as presence of fracture might have altered the marker levels. Both femoral fractures united well. The patient reported here had complete pictures on X-ray examination, intra-operative findings, histopathological examination, DXA, as well as blood test results. Complete data should be collected from patients treated with alendronate sodium presenting with atypical femoral fractures to show any link between the use of alendronate sodium with atypical fracture of femur.
A simple technique for removal of the distal fragment of the broken intramedullary interlocking nail is described. It was successfully used in three patients with a broken nail due to nonunion. The technique requires only cerclage wire, which is available in any operating room, avoiding the difficulties obtaining the custom made hook and of excessive exposure to radiation.
Femoral interlocking nailing requires fluoroscopic assistance for insertion of the nail and distal screws. In this study, scattered radiation to the eye and hand of the operating surgeon was measured during the procedure. Thermo-luminescent dosimeter (TLD) was used to quantify the dose received by the surgeon. The mean radiation exposure time during the procedure was 3.89 minutes. The mean scattered radiation doses to the hand and eye were 0.27 mSv and 0.09 mSv per procedure respectively. These very low doses have made a surgeon very unlikely to receive more than the recommended annual dose limit set by the National Council on Radiological Protection.
A prospective study of 25 patients with supracondylar and intercondylar fracture of the femur was carried out from January 1999 to June 2003 at SSG Hospital, Baroda, India. Twenty-eight percent fractures were open and 72% were closed. Twelve pecent of the fractures had intraarticular extension. AO classification was used to classify the fractures. Eighty-four percent of the fractures were due to high velocity trauma. All the cases were operated by percutaneous supracondylar nailing. No postoperative complication related to fracture treatment was seen. Average follow up was 20.1 months (range 6-40 months). Average age of the patients was 31.5 years. Average time of union was 3.1 months (range 2-4 months). Average knee range of motion was 117 degrees. Even in open injuries, 85.7% had more than 110 infinity range of motion. All patients could return to their pre-injury lifestyle. Rating scale developed by Hospital for Special Surgery was used to quantify the results. Eighty-four percent showed excellent, 8% showed good and 8% showed fair results. Percutaneous supracondylar nailing is thus, an excellent method of treating fractures of distal femur.
Trend towards changing the face of management for pediatric femoral fractures tends to advocate operative treatment. This study was undertaken to review our current practice in the wake of recent progress in the management of pediatric femoral fractures. Fifty patients with femoral diaphyseal fracture treated in Sarawak General Hospital were reviewed retrospectively after an average follow-up of 2.6 years. There were 36 boys and 14 girls, with a mean age of 6.2 years (range five months to 14 years). Children under six years of age constituted the majority of the patients. Half of the fractures were caused by road traffic accident. Nine patients had associated injuries. The most common site of fracture was at the middle third (N=31). The treatment regimens were delayed hip spica (DHS) in 16, immediate hip spica (IHS) in 24, plate osteosynthesis (PO) in five, titanium elastic nailing (TEN) in five, and external fixation (EF) in one. The minimum hospital stay was two days, and the maximum 33 days (mean, 9.7 days). Malunion was the commonest complication. Conservative treatment is the preferred option for children under six years of age. It is cost-effective with minimal complication. The other treatment options are reserved for specific indication in older children. Diaphyseal fractures of the femur in children can be adequately managed non-operatively.
Intramedullary nailing is an accepted procedures for femoral fractures gives uniformly good results. Various methods of intramedullary fixation have been practiced in the past. Recently intramedullary fixation without reaming has come into vogue. Preservation of the endosteal blood supply, less blood loss and quicker union have been the alleged benefits of not reaming the medullary canal. This study is a prospective randomised study conducted to compare intramedullary nail fixation of closed femoral fractures with and without a reaming procedure to assess the validity of the above assumptions. One hundred and two consecutive cases of skeletally mature patients with closed fracture of femoral shaft were randomised into two groups, i.e. Reamed (52) and Unreamed (50). The average follow-up was 36 weeks (range 28-86 weeks). Average time taken for various stages of the operation and total operating time were longer in the reamed group (109.9 min vs 78.6 min) and the blood loss was also increased (320 mls vs. 190 mls). Bridging and callus formation were seen to occur earlier in the reamed group compared to the unreamed enabling the patients in the reamed group to return to normal functions earlier. Limb length discrepancy and rotational alignment measured clinically and with CT scan did not however show any significant difference between the two methods. Nails used in this study group were notably of a smaller diameter and of shorter length when compared to those used in the western population highlighting the difference in the femur in the Asian population. Complications were notably more in the unreamed group where these were screw breakage (3/50) delayed unions (9/50) and non-unions (4/50). In the reamed group however there were only delayed union (2/50) and all fractures eventually united without any implant failure. We conclude that closed, reamed, antegrade insertion of an intramedullary nail is the treatment of choice in femoral shaft fractures, especially those involving the distal 1/3. The unreamed procedure should be reserved for certain exceptions, such as in polytrauma, where a shorter operative time and less blood loss is desired.
The removal of broken implanted intramedullary nails secondary to re-fracture or non-union is challenging. In 12 cases a simple and safe method has been used to remove broken implants.