Erdheim-Chester disease (ECD) was first reported by J. Erdheim and W. Chester, in 1930. There are less than 250 reported cases till date. We report a case of ECD in a 16- year-old Malay male, who initially presented with elusive anemic symptoms with more specific symptoms of bony pain, cardiorespiratory and hepatic involvement evolving as the disease progressed.
We report a method for removing the distal segment of a broken locked intramedullary nail secondary to nonunion of the femur following radiotherapy for fibromatosis. A Kirschner wire with one tip fashioned into a hook was used to remove the distal segment without opening with the nonunion site. Details of the procedure are described.
We present the case of a patient with multiple atraumatic osteoporotic vertebral fractures in an adolescent with suprasellar germinoma and also review of relevant literature. The patient suffered from a rare adolescent brain tumour with common complications which are often overlooked and give rise to significant morbidity. Suprasellar germinoma is an intracranial neoplasm, that in addition to its rarity, has variable clinical presentation. Despite appropriate treatment and good outcome, tumour related morbidity is still of concern for these patients.
Heterotopic ossification (HO) is the growth of bone in soft tissue, and can be broadly classified into neurogenic, genetic and traumatic causes. The pathophysiology of HO remains unknown. This disorder is extremely rare in infants and can mimic or coexist with thrombophlebitis, cellulitis or osteomyelitis. Most importantly, HO has to be differentiated from bone-forming tumours such as osteosarcoma and osteochondroma. We report a case of traumatic HO in a fiveday- old newborn following intravenous cannulation of the right wrist and left ankle, with the latter complicated with osteomyelitis. We highlight the clinical and radiological features of HO and differential diagnoses of soft tissue ossification in early childhood.
Firearm injuries to the spine commonly present with acute neurology caused by direct penetration or indirectly from concussive effects of bullet impact on the vertebral column. We report a case of delayed neurologic presentation of retained intra-spinal bullet in a 42 year-old African who had chronic low back pain and sciatica with a past history of gunshot injury to the spine and radiograph revealed a bullet at the L4-5 disc level. Intra-operative exploration showed a fibrous mass around the bullet compressing on the L4 existing nerve root and L5 traversing nerve root. Removal of the retained bullet resulted in a good clinical outcome with complete resolution of symptoms.
Traumatic hemipelvectomy is an uncommon and life threatening injury. We report a case of a 16-year-old boy involved in a traffic accident who presented with an almost circumferential pelvic wound with wide diastasis of the right sacroiliac joint and symphysis pubis. The injury was associated with complete avulsion of external and internal iliac vessels as well as the femoral and sciatic nerves. He also had ipsilateral open comminuted fractures of the femur and tibia. Emergency debridement and completion of amputation with preservation of the posterior gluteal flap and primary anastomosis of the inferior gluteal vessels to the internal iliac artery stump were performed. A free fillet flap was used to close the massive exposed area.
This prospective randomised study was undertaken to compare surgical parameters as well as clinical and radiological outcomes of subvastus (SV) to midvastus (MV) approaches in staged bilateral total knee arthroplasty (TKA). Twenty-three patients, aged 55-76 years, who underwent staged bilateral TKAs, were followed up for 6 months. The SV approach was used on one knee and MV approach on the other. We found similar lateral retinacular release rates and patellar resurfacing rates between the two approaches .The SV approached knees had a more significant blood loss and increased operative time compared to the MV approached knees but they achieved significantly earlier active straightleg raises (SLR) postoperatively (p<0.05 for all). The average postoperative pain, flexion, and Knee Society scores were comparable for both approaches. TKA via SV vs. MV approaches provides comparable satisfactory short-term clinical and radiological outcomes, even though there was slightly more difficulty, more blood loss and longer operative times with the SV approach.
We report a case of a human bite that was initially inadequately treated and progressed to chronic osteomyelitis, finally resulting in digital amputation. Human bites are seemingly innocuous, but if neglected, may lead to subsequent infection and morbidity. Persistence of symptoms should alert the practitioner to the possibility of infection extending to the soft tissue or bone. Bacteriological studies commonly yield mixed aerobic and anaerobic flora. Early debridement and antibiotic treatment may prevent development of severe soft tissue or bone infection.
Shoulder girdle injuries after high energy traumatic impacts to the shoulder have been well documented. Based on the series of 1603 injuries of the shoulder girdle reported by Cave and colleagues, 85% of the dislocations were glenohumeral, 12% acromioclavicular and 3% sternoclavicular (1). Less frequently described are injuries involving both the sternoclavicular and acromioclavicular joints simultaneously in one extremity. The present report discusses a case of traumatic floating clavicle associated with ipsilateral forearm and wrist injury which was treated surgically.
Good knowledge and practice regarding diabetic foot care will reduce the risk of diabetic foot complications and ultimately amputation. This study is conducted to assess patients' knowledge and compliance of diabetic foot care. A cross sectional study performed on patients who were admitted to HSNZ from the 1st September 2013 to 30th April 2014 for diabetic foot infections. They were interviewed with a questionnaire of 15 'yes' or 'no' questions on foot care knowledge and practice. Score of 1 was given for each 'yes' answer. The level of knowledge and practice, whether good or poor, was determined based on the median score of each category. The result was tested using a chi-square test in SPSS version 17. A total of 157 patients were included in this study with a mean age of 56.33 years (31-77). There were 72 male (45.9%) and 85 female (54.1%) patients with the majority of them being Malays (154 patients, 98.1%). Majority of the patients (58%) had poor foot care knowledge while 97 patients (61.8%) had poor diabetic foot care practice as compared to the median score. Based on the chi square test of relatedness, there was no significant association between knowledge and practice with any of the variables. In conclusion, the majority of patients admitted for diabetic foot infections had poor knowledge and practice of diabetic foot care. Education regarding foot care strategies should be emphasized and empowered within the diabetic population.
Study site: Hospital Sultanah Nur Zahirah, Kuala Terengganu,Terengganu, Malaysia
The diaphyseal tibia fracture is best treated with intramedullary nail but in some cases where the nail is not applicable, plate fixation will be the next option of fixation. The extensile anterior approach is normally used for conventional compression plate fixation in tibia shaft fractures. The extensive surgical dissection may devitalizes the bony fragments and interfere with the fracture union as well as soft tissue healing. Minimally Invasive Plate Osteosynthesis (MIPO) provides good preservation of blood supply and fracture hematoma at the fracture site thus promotes biological bone healing. The use of indirect reduction techniques and small skin incisions to introduce the plate is technically demanding and requires fluoroscopy exposures throughout the surgery, being some of its drawbacks. We recommend MIPO for conventional compression plate fixation in tibial shaft fractures in view of the reduced surgical trauma to the surrounding soft tissue and good functional outcome.
A method of transpedicular bone grafting using contrast impregnated bone to improve the visualization of bone graft on the image intensifier is reported. A - 36-year old man who had sustained traumatic burst fracture of T12 vertebra, with Load-Sharing Classification (LSC) score of 8, was treated with posterior short segment fusion from T11 to L1 with transpedicular bone graft of T12 vertebra. We were able to correct the kyphotic end plate angle (EPA) from 19º to 1.4º. Anterior bone graft augmentation was achieved with contrast enhaced transpedicular bone grafts. At six months follow up, CT scan showed good bony integration of the anterior column with EPA of 4.5º and two years later, radiographs showed EPA of 7.6 º.
We are all aware that there has been a dramatic increase in the number of anterior cruciate ligament (ACL) reconstructions that are carried out here in Malaysia as well as around the world. The numbers of ACL injuries have undoubtedly increased over the years with greater participation of young adults in sporting activities. However it is not certain whether the increase in the numbers of reconstructions can be accounted for by the increasing numbers of ACL injuries. Without doubt commercial interests as well the influence of the biomedical companies have a role to play. In the past the rationale for surgical treatment of an ACL tear was that the ACL is vital for knee function and that in the long term ACL deficiency will lead to more injuries of the meniscus and more degeneration of the joint. This belief was prevalent because the natural history of an ACL deficient knee and the ultimate outcome of reconstruction of the ACL were both not known. However in recent years a substantial amount of research has been published, which has elucidated the natural history of ACL deficient knees as well as the long term outcome of reconstruction of the ACL.
The aim of this study was to assess the outcome of surgical treatment in displaced acetabular fractures in our local facilities. Previous studies reveal good outcome via open reduction method with achievement of congruent joint. We note that studies in this respect have not been conducted in our region. We retrospectively analyzed thirty patients with acetabular fractures who underwent open reduction and internal fixation. The data collection was performed over a 4-year period, from 2008 to 2011. The results showed 20 out of 30 patients (66.7%) had excellent/good results (Harris Hip Score equal or more than 80). Post operative complications were deep infection (6.7%), iatrogenic sciatic nerve injury (10.0%), avascular necrosis (16.7%), heterotopic ossificans (3.3%), degenerative changes in hip joint (43.3%) and loss of reduction (3.3%). In conclusion, surgical treatment of displaced acetabular fractures produces good functional outcome despite the complications.
This report details the case of a 12-year-old girl with a painful, progressive swelling of the medial portion of the clavicle with no history of trauma or other constitutional symptoms. All laboratory investigations were normal except for an elevated erythrocyte sedimentation rate (ESR). Initial plain radiographs showed a destructive lesion with magnetic resonance imaging showing features of malignancy. Biopsies revealed osteomyelitis, but with negative bacterial cultures and no evidence of malignancy. Treatment with antibiotics did not result in a favourable response. Over time, the swelling increased in size with episodic exacerbations of pain. Follow-up radiographs showed sclerosis and hyperostosis. After five years, this was recognized as non-bacterial chronic recurrent osteomyelitis of the clavicle.
Synovial sarcoma is primarily a soft tissue malignancy that most often affects adolescents and young adults. It very rarely presents as a primary bone tumour and has only been reported in nine other cases to date. We report a case of primary synovial sarcoma arising from the proximal femur in a 57-year-old man.
Research is an essential activity required for the advancement of science and improvement of human existence. To carry out a research, a proposal is mandatory. However, in spite of the widespread demand for research proposals, experience has shown that a number of them are so poorly written that they rejected by assessors. This article aims at assisting researchers develop acceptable research proposals by reviewing the different components of a research proposal.
A review of relevant literature on research proposal writing sourced from manual library and internet search was used for this review
A research proposal is a formal and detailed statement of intent to carry out a research. It presents and justifies a plan of action and shows how the investigator thinks. A research protocol on the other hand is a plan written to seek approval for research from a supervisor or an organization. It is developed as a guide for a study and helps to keep the researcher focused on the topic and scope of the research. A research proposal has the following components: The Title page; The Abstract/Executive Summary; The Introduction/Statement of the Problem; Literature Review; Information on the applicant's centre; The Objectives/Research Questions/Hypotheses; The Study Design; Methods; Plans for Analysis; Data Analysis; Plans for Data Interpretation; Plans to report. Thus, although proposals and protocols are sometimes used interchangeably, a proposal precedes a protocol.
To reduce the time wastage and frustration faced by intending researchers and their assessors it is essential that good proposals be written at all times.
A series of 11 patients with osteoporotic compression fracture of the spine who underwent posterior instrumentation and transpedicular bone drafting in Siriraj Hospital Bangkok was analysed retrospectively. The indications for surgery were neurological deficit, kyphotic deformity and intractable pain. The mean follow up period was 10.1 months (range, 2.1 - 25.5 months). On follow up, all patients indicated recovery from pain. Most patients (7/11) regained one Frankel grade and one patient who was Frankel grade D preoperatively remained grade D postoperatively. Daily functionality improved in nine patients, but two patients still required aid for walking and standing. There was no pedicle screw loosening, pull-out or implant breakage as of the last date of follow up. Adjacent vertebrae also did not show any fracture or reduction in height. We conclude that this operative method is acceptable for osteoporotic fracture of the spine, although a longer period of follow up is needed to further evaluate its efficacy.