CASE PRESENTATION: This is a case of a 37-year-old, right-hand dominant, Malay man who fell approximately 6 meters from a rambutan tree and his left arm hit the tree trunk on his way down. He was an active tobacco smoker with a 20 pack year smoking history. On clinical examination, Doppler signals over his radial and ulnar arteries were poor. He proceeded with emergency computed tomography angiogram of his left upper limb which showed non-opacification of contrast at the distal left brachial artery just before the bifurcation of the left brachial artery at his left elbow joint. Radiographs and computed tomography scan also showed undisplaced fracture of left lateral epicondyle and radial head with no evidence of elbow dislocation. He subsequently underwent left brachial to brachial artery bypass which was done using reversed saphenous vein graft and recovered well. His fractures were treated using 90 degree long posterior splint for 2 weeks and he was then allowed early range of motion of the left elbow. This patient developed left elbow dislocation 6 weeks postoperatively. Closed manipulative reduction of his left elbow resulted in incomplete reduction. The functional outcome of his left elbow was limited with a range of motion of left elbow of 0-45 degrees. However, he was not keen for surgery to stabilize his elbow joint during his last follow-up 6 months post injury.
CONCLUSIONS: This is an uncommon case of brachial artery injury in a civilian caused by blunt trauma associated with occult elbow instability/dislocation and minor fractures around the elbow joint. The treatment of brachial artery injury with clinical evidence of distal ischemia is surgical revascularization. The possibility of elbow instability and dislocation need to be considered in all cases of brachial artery injury because early radiographs and computed tomography scans may be normal. Short-term posterior splint immobilization is not sufficient to prevent recurrent dislocations.
METHODS: Patients treated for Blount disease using external fixator from 2002 to 2016 were recruited for the study. We used Ilizarov and Taylor Spatial Frame (TSF) external fixator to perform simultaneous correction of all the metaphyseal deformities without elevating the tibia plateau. Surgical outcome was evaluated using mechanical axis deviation (MAD), tibial femoral angle (TFA), and femoral condyle tibial shaft angle (FCTSA).
RESULTS: A total of 22 patients with 32 tibias have been recruited for the study. The mean MAD improved from 95 ± 51.4 mm to 9.0 ± 37.7 mm (medial to midpoint of the knee), mean TFA improved from 31 ± 15° varus to 2 ± 14° valgus, and mean FCTSA improved from 53 ± 14° to 86 ± 14°. Mean duration of frame application is 9.4 months. Two patients developed pathological fractures over the distracted bones, one developed delayed consolidation and other developed overcorrection.
CONCLUSIONS: Correction of Blount disease can be achieved by gradual correction using Ilizarov or TSF external fixator with low risk of soft tissue complication. Longer duration of frame application should be considered to reduce the risk of pathological fracture or subsequent deformation of the corrected bone.
CASE PRESENTATION: A 25 years old female had neglected an extremely large midline sacral mass for 2 years. On presentation to hospital, she had been bed bound for the past 2 years. The sacral mass was so large that it prevented her from lying down supine and sitting on the wheelchair comfortably. Clinical examination showed a 40 cm × 30 cm × 20 cm hard mass over the sacrum that involved both buttocks and the gluteal fold. Neurological exam of bilateral lower limb was normal. Computed Tomography Scan of the Pelvis showed a large destructive sacrococcygeal mass measuring 43 cm × 38 cm × 27 cm with extension into the presacral space resulting in anterior displacement of the rectum, urinary bladder and uterus; and posterior extension into the dorsal soft tissue with involvement of the gluteus, piriformis, and left erector spinae muscles. Biopsy taken confirmed Chordoma. This patient was managed by a multidisciplinary team in an Oncology referral centre. The patient had undergone Wide En Bloc Resection and Sacrectomy, a complex surgery that was associated with complications namely bleeding, surgical site infection and neurogenic bowel and bladder. Six months post operatively the patient was able to lie supine and sit on wheelchair comfortably. She required extensive rehabilitation to help her ambulate in future.
CONCLUSION: This is a rare case of neglected sacral chordoma in a young female treated with Wide En Bloc Resection and Sacrectomy associated with complications of this complex surgery. Nevertheless, surgery is still worthwhile to improve the quality of life and to prevent complications secondary to prolonged immobilization. A multidisciplinary approach is ideal and team members need to be prepared to address the complications once they arise.
METHODS: We retrospectively reviewed the radiographic parameters of 22 patients (32 lower limbs) with Blount's disease who underwent gradual correction of deformity surgery using ring external fixator without surgical elevation of the depressed medial tibial plateau at a mean age of 15 (10-37) years. Preoperative and postoperative angles of depressed medial tibia plateau (ADMTP) of the same patient were compared for any significant change. Normally distributed data were analysed using Student's t-test when comparing two groups or one-way ANOVA when comparing more than two groups. Skewed data were analysed using Mann-Whitney test.
RESULTS: After extra-articular mechanical alignment surgery, statistically significant improvements in medial tibial plateau depression were seen in the Infantile (p = 0.03) and Juvenile (p = 0.04) Blount's subgroups. Change of ADMTP was greater in patients who were operated on at age < 17 years, before skeletal maturity (p = 0.001). The improvement was likely due to ossification of unossified cartilage at the posteromedial proximal tibia and remodelling potential of proximal tibia physis after mechanical realignment.
CONCLUSION: Improvement of medial tibia plateau depression is possible after mechanical realignment without surgical hemiplateau elevation in cases of Infantile and Juvenile Blount's disease that present late for treatment, especially when the operation is performed before age 17 years old.