Out of 218 fractures of humeral shaft treated in the department, 23 (10.5%) of them developed non-union. 14/23 (60.9%) fracture were located in middle third. Transverse (52.2%), short oblique (17.4%) and comminuted fracture (13.0%) constituted about 82% of all initial fracture pattern. Twelve cases (52.5%) were initially treated with hanging cast. Radial nerve palsy occurred in 4/23 (17.4%) of patient and all of them located at lower third of humerus and only one recovered after eight weeks of injury. Factors such as middle third comminuted opened fractures, soft tissue interposition, improper immobilization and poor patient compliance were found to be directly associated with the non-union. All non-unions healed following plating and bone grafting. Overall 17/23 patient (74%) had good results, 4/23 (17%) fair and 2/23 (9%) with poor functional results.
This is a retrospective study comprising 45 patients who underwent decompressive laminectomy due to secondary malignancy in the spine. There were 31 males and 14 females. Two of them had no weakness, one was treated for radicular pain and the other for severe intractable back pain. Forty-three patients presented with weakness of the limb of which six patients were able to walk unaided, four with an aid, twenty four were unable to walk of which eleven of them were completely paralysed. Nineteen of the patients had urinary incontinence. Out of 10 patients in Frankel's D, 3 of them regained almost normal power post operatively and were able to walk without any aids at the time of discharge. There were 6 patients in Frankel's C and 2 improved. Of 17 patients in Frankel's B, 6 of them improved and were able to walk with walking aids. Only one out of ten patient from Frankel's A had showed an improvement. A total of three patients deteriorated post operatively and all of them presented with multiple level involvement. There was no change in the post operative status of the two patients who did not have weakness. Overall only 27% of the patient showed improvement following decompressive laminectomy.
Forty-one patients with 42 joint infections were admitted to the hospital between June 1989 and June 1994. An overview on the behaviour of septic arthritis in both children and adults, at presentation and after various types of treatment was done. There were 32 knees, 7 hips, 2 elbows and 1 shoulder. Duration of symptoms, type of organism, type of joint drainage, presence of preexisting joint problems and presence of osteomyelitis are among the important factors with prognostic significance. Seventy three percent of patients with less than 7 days duration of symptoms had satisfactory results. Whereas when the duration of symptoms exceeded 7 days, 75% of the patients had unsatisfactory outcome. All cases with poor outcome had positive cultures. Staphylococcus aureus was responsible for 77% of the culture-positive cases. All Staphylococcus aureus in this study were penicillin-resistant but sensitive to cloxacillin. There were 3 instances where Staphylococcus became resistant to cloxacillin following recurrence of septic arthritis. However, they were still sensitive to third generation cephalosporin. Staphylococcus aureus was capable of producing poor results even when the case was treated early. Other organisms were gram-negative bacilli which infect patients with suppressed immune system, that is, intravenous drug abuser, systemic steroid therapy and diabetes mellitus. Open arthrotomy was the method of drainage used in all hip sepsis. This method was also the most reliable method of joint drainage in other joints compared to aspiration method when frank pus was already present. Most immuno-compromised patients recovered badly from septic arthritis. Associated adjacent osteomyelitis, preexisting chronic arthritis and recent intra-articular fractures were also noted to adversely affect the functional outcome.
A study was carried out on 24 patients (36 clubfeet) surgically treated at the Orthopaedic Department National University of Malaysia, Kuala Lumpur, over a period of four and half years. Nine feet underwent posterior release, 24 feet underwent posteromedial release combined with Evan's procedure. The overall operative result was 63.3% good, 9.5% fairly and 27.2% poor. Patients who underwent surgery between 3 to 12 months showed a high percentage of good results (66.7%). Metatarsal adduction was found to be the commonest residual deformity (63.9%), followed by heel varus (11.1%), cavus (11.1%) and equinus (5.6%). Inadequacy of primary surgery and post operative period of immobilization resulted in a significant high failure rate.
Forty-one patients with 42 elbow dislocations, of which 13 had acute simple dislocations, 21 had fracture-dislocations and 8 had neglected elbow dislocations, were evaluated with regard to limitation of motion, pain, instability and residual neurovascular deficit. All patients with acute simple dislocation were treated with closed reduction, but the duration of immobilization before commencement of active motion varied. Open-reduction was indicated for failed closed reduction and neglected-dislocations. Internal fixation as a primary procedure was only performed for displaced fracture-dislocation. Excision of radial head or tricepsplasty were performed if the reduction was impossible in neglected elbow dislocation. Despite a good results in acute simple dislocation, 33.07% had flexion contracture of between 5 to 30 degrees. In fracture dislocation, satisfactory results were seen in whom the elbow was immobilized for three weeks or less. Neglected-dislocation is associated with poor functional outcome, 37.5% were good and 62.5% were poor. Prolonged immobilization after injury was strongly associated with an unsatisfactory result. The results indicate that early properly supervised active motion is a key factor in the rehabilitation of elbow dislocation.
The displaced supracondylar fracture of the humerus in children (Gartland type 3) is a most challenging injury to treat. There is controversy regarding the initial treatment either closed manipulation and splint immobilization or open reduction and internal fixation. This is a retrospective study comparing two groups of patients with displaced supracondylar fracture of the humerus (Gattland 3) treated in the Orthopaedic Unit, Universiti Kebangsaan Malaysia. The first group, 13 patients treated with closed reduction and splint immobilization and a second group, 15 patients treated with open reduction and internal fixation as initial definitive treatment. The results showed a high failure rate of closed reduction and splint immobilization. This was due to difficulty in reduction, loss of reduction post operatively or during follow-up. Open reduction and internal fixation was more advantages with reduced hospitalization time, fewer complications, more stable fixation and better anatomical reduction with minimal complications for type 3 supracondylar fracture of humerus. We would recommend that all Gartland 3 supracondylar fracture of the humerus be treated with open reduction and two K-wire fixation.
This is a cross-sectional study on the use of halovest appliance in the Orthopaedic and Traumatology Department, Kuala Lumpur Hospital from June 1993 to September 1996. Fifty-three patients with cervical spine injuries were treated by halovest stabilization. Majority of cases was caused by motor-vehicle accident; others were fall from height at construction sites, fall at home, hit by falling object and assault. The injuries were Jefferson fracture of C1, odontoid fractures, hangman fractures, open spinous process fracture and fracture body of C2, and fracture, and fracture-dislocation of the lower cervical spines. Majority of patients had hospital stay less than 30 days. The use of the halovest ranges from 4 to 16 weeks and the healing rate was 96%. Two patients of lower cervical spine injury had redislocation and one of them was operated. There was one case of non-union of type II odontoid fracture and treated by posterior fusion. Other complications encountered during halovest treatment were minor. They were pin-site infection, pin-loosening, clamp loosening and neck pain or neck stiffness. This method of treatment enables patient to ambulate early and reduces hospital stay. We found that halovest is easy to apply, safe and tolerable to most of the patients.
Thirty-eight tibial plateau fractures were treated with open reduction and internal fixation. The fractures were classified into six groups (Hohl's 1991 Classification) and the clinical results were evaluated using the Rasmussen (1973) criteria. The average follow-up period was 2.07 years. Overall there was one excellent, thirty-four (34) good, three fair and no poor results. In three patients with less than a good score there were other associated ipsilateral injuries and delayed mobilisation of the knee joint. There was no direct association between the type of internal fixation and the end result.
From January 1992 to January 1996, thirty-three patients with persistent clinical and functional knee instability due to anterior cruciate insufficiency underwent ACL reconstruction using central third of the bone-patellar ligament-bone graft. An early experience was presented with average follow-up of 9.8 months (range six to thirty-three months). There thirty-two male and two females. The average age was twenty-four months. Eighty-three percent were involved in football injury. The average time interval from initial injury to operation was twenty-five months. Majority presented with knee pain and giving way. Meniscal tear was the commonest associated injury in more than 70 percent; the lateral meniscus being more frequently injured (42 percent) than the medial meniscus (15 percent). Using modified criteria by Paterson and Trickey (1986), nine patients (27 percent) had good results and twenty-two (67 percent) has satisfactory results. Two patients (6 percent) who had post-operative infection were graded as poor. Functional stability was achieved in twenty-eight (85 percent) and instability persisted in five (15 percent). There were marked clinical improvement in the Lachman and anterior drawer grading post-operatively. The accelerated rehabilitation programme was effective in obtaining early clinical improvement and in reducing post-operative knee stiffness.
We present the results of our experience in treating comminuted tibial shaft fractures with reamed interlocking intramedullary nail from September 1993 to December 1995. In this retrospective study, there were fifty patients with an average follow-up of 14.3 months (range six to twenty-eight months). Ninety-eight percent of the fractures were due to motor-vehicle accident with majority of the patients being motorcyclist (96%). Thirty-eight fractures were closed and twelve were open (Gustilo grade I--8; grade II--4); 44% of them had additional fractures or other injuries. According to Winquist-Hansen classification of diaphyseal fracture comminution, there were 24% type I; 18% type II; 26% type III and 32% type IV. The union rate was 98%. There were 6 infections, 2 superficial and 4 deep. All these infections arose from closed fractures, which was possibly due to the long operative time. No patients with open fractures, which underwent delayed nailing, had infection. One of the patient had severe deep infection which required early nail removal before union. Anterior knee pain following nailing occurred in 6% of the patients. The average hospital stay after operation was 3.4 days. Ninety-four percent of the patients had excellent to good functional outcome after nailing. The mean time to regain full range of movement of knee and ankle was 8.4 weeks. Patients were allowed full weight bearing in the average time of 10.7 weeks and the mean time to return to work was 24.7 weeks.
A rare case of an aggressive recurrent giant cell tumour of axis is presented. The problems encountered in diagnosis and management are discussed. High dose dexamethasone was found to be useful managing this inoperable aggressive tumour which was compressing the cord. Early diagnosis would facilitate wide excision of the tumour with good prognosis.
Hemorrhagic lumbar synovial cysts are not commonly reported in English literature. Post-resection recurrence of synovial cyst is unusual and therefore recurrence symptoms required repeat MRI or CT scan. We reported a case of hemorrhagic lumbar synovial cyst presented with neurological deficit that recovered initially after surgery but subsequently developed recurrent of symptoms at a higher level due to fibrous tissue.
We review 81 cases of acute haematogenous osteomyelitis from 1983 to 1990 to establish current pattern of clinical presentation, modes of treatment and success of therapy. Majority of the patient (70%) presented within a week of symptom and significant number of them came with fever and swelling of the affected limb. Sedimentation rate was found to be raised in all of them. Fifty-four (55%) of them were treated surgically. The average antibiotic time was one week by intravenous administration followed by additional oral therapy for period up to four weeks. Average follow-up was 9 months. Six of them (7.5%) end up with various complication which was believed to be due to delay in getting medical treatment.
Thirty-two children with femoral shaft fractures were treated conservatively with initial skin traction followed by an additional period in a spica cast. After 12 to 20 months of follow up, none had any pain and all of them were attending school without problems. Shortening of more than 2 cm occurred in 6 (19%) of the 32 patients. The most important factor associated with shortening was an overlap of more than 2 cm of shortening of the fracture ends at the time of cast fitting. The average compensatory overgrowth at final assessment was 7 mm. Angular deformity did not pose a problem. This is a safe, simple and practical method to treat childhood femoral shaft fractures.
A retrospective review of thirty-eight patients (16 males and 22 females) with spinal infection between 1993 and 1998 revealed that the mean age was 39.9 years and the peak incidence was in the 5th decade of life. Infections in thirty-two patients (84.2%) were tuberculous in origin, 13.2% were pyogenic and 2.6% were fungal. Back pain was a symptom in 94.7% while 55.8% had neurological deficits, of which two-thirds were tuberculous in origin. Twenty-two patients (57.9%) had an impaired immune status secondary to pulmonary either tuberculosis, diabetes mellitus, intravenous drug abuse, prolonged steroid treatment, malnutrition, or advanced age. History of contact with tuberculous patients was elicited in 31.3%, extraskeletal tuberculosis was found in 28.1%, while Mantoux test was only positive in 53.1% of tuberculous patients. Majority of the cases (57.9%) involved lumbar vertebra. The histopathological examination was only positive in 22.2% from material taken via CT guided biopsy but 93.3% were found to be conclusive from open biopsy. 4 out of 5 patients who had a pyogenic infection were treated conservatively and produced a good result. There was no difference in outcome for tuberculosis patients treated with either the 3 drug or 4 drug regimen. Anterior decompression and bone grafting in tuberculous patients was superior in terms of a faster fusion rate, early pain relief and prevention of kvphotic deformity. The initial neurological deficit did not reflect the future prognosis of patients with spinal infection.
Fifteen cases of unstable fracture-dislocation of the thoracolumbar spine have been treated by open reduction, short segment transpedicular fixation and fusion in Universiti Unit, Kuala Lumpur Hospital from January 1994 until December 1997. Twelve male and three female patients were injured; their age ranged from 18 to 45 years. Five fracture-dislocations occurred in the lower thoracic spine (T8 to T11), eight at the thoracolumbar junction (T12 to L2) and two in the lumbar spine (L3 to L5). All the patients had neurological deficit. Seven patients with incomplete or cauda equina lesions regained some neural function, while all eight with complete lesions remained unchanged. Ten of the fifteen cases were grossly unstable and translated beyond 50% of the width of the spinal column. At the time of follow up (more than one year in all patients), no loss of reduction or of fixation was noted in any patient. Solid fusion was achieved in all patients. The advantages of this method of treatment include stable fixation, with maintenance of sagittal and coronal spinal alignments, to allow early rehabilitation.
Between May 1992 through October 1998, twenty-two patients who had adolescent idiopathic scoliosis were treated using Universiti Kebangsaan Malaysia (UKM) spinal instrumentation and fusion. The minimum length of follow-up was 2 years with an average of 2.9 years. Nineteen patients were female and three patients were male. The mean age at the time of the operation was 16.2 years (range, 13 to 24 years). The average blood loss was 1,878 ml and the average operating time was 291 minutes. The mean pre-operative curve was 61.2 degrees, with a range of 40 degrees to 90 degrees. The average post-operative correction of the Cobb's angle was 53.5 per cent, with a range of 33 per cent to 81 per cent. Post-operative immobilization consisted of a maximum of six months in a body cast. There were no neurological injuries, no deep wound infections, and no evidence of pseudoarthroses. Only three complications occurred and these did not disturb the progress of the fusion. This technique safely achieves the objectives of scoliosis correction, and is cost-effective in the treatment of adolescent idiopathic scoliosis.
A case of late reconstruction of the patellar tendon is reported. Besides partial loss of the tendon, the patient also had loss of the distal third of the patella. A rolled strip of fascia lata was used to reconstruct the tendon with tunnels through the patella. At the tenth month of follow-up, the result was deemed successful.
A rare combination of a segmental ulnar fracture with fracture dislocation of the head of the radius and intraarticular fracture of the distal radius concomitant with an ipsilateral scaphoid, lunate and coronoid process fractures is presented. The mechanism of injury could possibly be a tremendous impact on the outstretched hand with a dorsiflexed wrist, fracturing the carpal bones and the distal radius. Transmitted axial forces on the ulna in a pronating forearm resulted in the other fractures. To the best of our knowledge, no such case has been reported. Open reduction with screw fixation of the scaphoid, plating of the proximal ulna and Kirschner wiring of the distal radius and radial head dislocation were done.
Between January 1996 and August 1998, 15 patients with pelvic ring injuries were treated by open reduction and internal fixation. Fractures types included Tile A1 (7%), B1 (33%), C1 (53%) and C3 (7%). The patients were observed for an average of 1 year (range: 5 to 21 months). Thirteen patients (87%) who were operated within 3 weeks after injury had their pelvic disruption healed. One patient with Tile C1 and non-union of the fracture dislocation of sacroiliac joint was operated 11 months after injury and developed implant failure and non-union of the fracture dislocation of sacroiliac joint. Another patient with Tile C1 injury with transforamina sacral fracture was fixed anteriorly only and developed non-union of the sacral fracture and redisplacement of pelvic disruption. Both of them had a poor functional outcome. A 40 points pelvic outcome grading scale (Cole et al 1996) based on physical examination, pain, radiographic analysis and activity/work status was used. Six patients (40%) (1 Tile A1, 5 Tile B1) had an excellent functional outcome. Seven patients (47%) (6 Tile C1, 1 Tile C3) had a good functional outcome.