A severe form of an extremely unusual injury, ipsilateral fracture dislocation of the radial shaft head associated with elbow dislocation, is described. Radial shaft fracture was irreducible even after the radial head and the elbow were reduced. Open reduction and internal fixation are viable options.
Acromio-clavicular joint (ACJ) dislocation usually occurs in young adults following trauma or sports injury. Fourteen patients underwent surgical treatment for symptomatic total ACJ dislocation (Rockwood and Matsen Type III-VI) in our unit between January 1996 and June 1997. Eight patients were operated within three weeks of injury and six in the chronic period (after three weeks). In the acute group, two patients had Botsworth procedure and six had Weaver-Dunn operations. All six in the chronic group had Rockwood procedure. Nine patients achieved excellent outcome with full range of shoulder movement, pain free and return to work within three months of surgery. Two patients had good outcome. Three other patients had satisfactory outcome with tolerable pain and light duty at three months. Two patients developed chronic shoulder pain and one had painful hypertrophic surgical scar. Two patients had screw breakage requiring revision surgery. In conclusion, surgical treatment for ACJ dislocation produces good results. We suggest that surgical treatment be the treatment of choice for young patients requiring early recovery and good shoulder function.
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.
A 2 year-old Malay girl was admitted to our institution with a chesty cough and breathlessness but later found to have a chronic C1/C2 subluxation for one and half year with tetraplegia. Her cervical cord was decompressed and occipito-cervical fusion performed. Her neurological status improved significantly post-operatively and is able to care for her personal hygiene. The authors believe that the ability of the cervical cord to recover in the paediatric age group is remarkable that surgical option should be considered even when all seen lost. We believe that this is the first report in the literature to support this potential.
Traumatic elbow dislocation in a child is rare, and it is usually associated with fractures. Simultaneous proximal radioulnar joint (PRUJ) translocation with ulnar nerve palsy is even rarer. We report an unusual case of a missed PRUJ translocation with ulnar nerve entrapment in a 10-year-old child. The key to diagnosing the translocation is the position of the proximal radius, which lies medial to the ulna. This was treated by open reduction and release of the entrapped nerve. The ulnar nerve palsy recovered fully at the 1-year follow-up. Although PRUJ translocation with ulnar nerve entrapment is a rare injury, a successful outcome is possible with timely open reduction and release of the ulnar nerve.
Subtalar dislocation is a rare injury caused by high-energy trauma. Current treatment strategies include leg casts, internal fixation and external fixation. Among these, external fixators are the most commonly used as this method is believed to provide better stabilization. However, the biomechanical stability provided by these fixators has not been demonstrated. This biomechanical study compares two commonly used external fixators, i.e. Mitkovic and Delta. CT imaging data were used to reconstruct three-dimensional models of the tibia, fibula, talus, calcaneus, navicular, cuboid, three cuneiforms and five metatarsal bones. The 3D models of the bones and cartilages were then converted into four-noded linear tetrahedral elements, whilst the ligaments were modelled with linear spring elements. Bones and cartilage were idealized as homogeneous, isotropic and linear. To simulate loading during walking, axial loading (70 N during the swing and 350 N during the stance phase) was applied at the end of diaphyseal tibia. The results demonstrate that the Mitkovic fixator produced greater displacement (peak 3.0mm and 15.6mm) compared to the Delta fixator (peak 0.8mm and 3.9 mm), in both the swing and stance phase, respectively. This study demonstrates that the Delta external fixator provides superior stability over the Mitkovic fixator. The Delta fixator may be more effective in treating subtalar dislocation.
Chronic neglected subtalar dislocation associated with a non-union talar neck fracture is rare and never documented before. The lack of information from the literature on the optimal management prompted us to describe our experience in the management of this condition. We reported a case of a 57-year-old women presented with this injury. A satisfactory outcome was obtained using a tibio-talo-calcaneal arthrodesis through a plantar approach.
The presence of anatomical anomalies such as absence of C1 posterior arch and presence of C2 high-riding vertebral artery may not allow a conventional C1-C2 fusion, and this patient will require occipitocervical fusion. A 62-year-old lady presented with cervical myelopathy. CT scan demonstrated an os odontoideum with C1-C2 dislocation. The posterior arch of atlas on right C1 vertebra was absent, and there was high-riding vertebral artery on left C2. MRI revealed severe cord compression with cord oedema. The chronic atlantoaxial dislocation was reduced successfully with skeletal traction. Hybrid C1-C2 fusion augmented with autogenous local bone graft with corticocancellous iliac crest bone graft was performed to avoid an unnecessary occipitocervical fusion. She was stable throughout surgery and discharged 6 days later. CT scan 6 months post-operation showed a solid posterior fusion mass. Hybrid C1-C2 fusion can be performed to avoid occipitocervical fusion despite presence of abnormal anatomy at C1 and C2 vertebrae.
Fracture-dislocation of the lumbo-sacral spine was an unusual injury and was divided into anterior, posterior and lateral types depending on the displacement of the cephalad portion of the spine over the caudal portion. According to the authors' knowledge, only 31 cases of traumatic fracture-dislocation of the lumbo-sacral spine were reported in the English literature. Only 3 previous reports referred to this injury with a posterior displacement, which was an even rarer injury. This was the fourth report of this type of injury.
Adequate pain relief is a requisite for a successful closed manipulative reduction (CMR) of fractures and dislocations. This prospective study was undertaken to assess the mode and adequacy of pain relief given to patients undergoing such procedures at Seremban Hospital from the 1st April to the 31st May 2001. All patients with fractures and dislocations scheduled to undergo CMR were included in this study. The type of sedative agents and analgesia administered were recorded. Demographic data and the type of fracture or dislocation of the selected patients were documented. A visual analogue scale (VAS) for pain perception was given to both to the patients and the medical personnel who performed the procedure. All data were collected manually before entered into computerized database for analysis. Of 72 patients included in this study, 47% were Malay, 26% Indian, 21% Chinese and 6% others. There was male predominance and the patients' age ranged between 9 to 79 years (average 27.4 years). Upper limb injuries (79%) were mainly fractures of the radius and ulna (29%) and isolated fracture radius (21%). For the lower limb injuries (21%), combined tibia and fibula fractures constituted 10% of the total cases followed by isolated tibia fractures (10%) and hip dislocation (1%). The most common pain relieving agents given during the CMR were intravenous pethidine alone (43%) followed by combination of intravenous pethidine and valium (36%), intramuscular pethidine (17%) and intramuscular tramal (4%). The Visual Analogue Score (VAS) for pain perception revealed that 61% of the patients had moderate pain while 21% had severe pain during the course of the procedures. Suboptimal pain relief administered during CMR should prompt positive actions to ensure that the patient is not subjected to undue pain just for the sake of an acceptable fracture reduction.
This is a case report of an extremely rare condition of atlanto-axial subluxation secondary to gouty arthritis, which mimicked rheumatoid arthritis at presentation. Gouty arthritis involving the spine is a rare condition. We highlight a case of gouty arthritis involving the atlanto-axial joint resulting in joint instability, subluxation, and neurological deficit. A 66-year-old obese woman who had a polyarticular disease for the previous 3 years presented with neck pain and progressive neurology. A 2-stage procedure was performed: posterior decompression and occipitocervical fusion followed by further anterior trans-oral decompression. However, after an initial neurological improvement, she succumbed to aspirational pneumonia and septicaemia. Atlanto-axial subluxation caused by gouty arthritis can present in the same way as rheumatoid arthritis. Therefore, the possibility of this as a differential diagnosis should be kept in mind.
To conduct a prospective randomised controlled study to compare the stability and risk of nerve injury between fractures treated by medial-lateral pin fixation and those treated by 2-lateral pin fixation.
To study the long term result of open reduction of longstanding dislocated elbows with regard to stability, avascular necrosis of the distal humerus and degenerative changes of the joint.
A retrospective study of nerve injuries with displaced supracondylar fractures of the humerus in children younger than 12 years of age, treated in Hospital Universiti Kebangsaan Malaysia. Our objectives were to determine the incidence of primary and iatrogenic nerve injuries in supracondylar humerus fractures Gartland types II and III and to determine the outcome of nerve recovery. A total of 272 patients with displaced supracondylar humerus fractures who required admission to Hospital Universiti Kebangsaan Malaysia from January 2000 to December 2007 were reviewed. There were 182 boys (67%) and 90 girls (33%). The mean age was 6.0 years, ranging from 1 to 12 years. Of 272 supracondylar fractures, 79 were type II and 193 were type III. Fifty-one (19%) patients had closed reduction, 160 (59%) had closed reduction and percutaneous crossed Kirschner (K) wires, and 61 (22%) had open reduction and crossed K-wires. Associated nerve injuries involving the median, radial, and ulnar nerves were observed in 48 (18%) patients. Nerve injuries were observed in nine (3%) patients upon admission. Thirty-nine (14%) patients developed nerve injuries following treatment. Of these 39 patients, 34 had ulnar, three had radial, and two had median nerve injuries. Nerve exploration was performed in five patients (in four patients following debridement of open fracture and in one because of unacceptable postoperative radiographs, and they subsequently underwent open reduction and exploration). Except for these five patients, the K-wires were not removed earlier nor were the nerves surgically explored in others. The nerve injuries resolved clinically on an average time of 3.5 months (range from 3 weeks to 8 months). Our study found complete resolution of all patients with nerve injuries confirmed by clinical assessment. On the basis of our study, we believe that there is no indication to remove the K-wires immediately or to explore the nerve surgically following a mini-open technique, which reduces the risk of penetrating a nerve during pinning.
Acromioclavicular joint (ACJ) injury is a common shoulder injury. There are various techniques of ACJ reconstruction. Superficial infection after ACJ reconstruction is not an uncommon complication. However, osteomyelitis post ACJ reconstruction has never been highlighted as a possible complication. Our patient is a 31-year-old male who sustained a Rockwood 5 ACJ dislocation and had anatomical ACJ reconstruction with autogenous gracilis and semitendinosus graft. Our technique involved the anatomical reconstruction of the ACJ and the coracoclavicular ligament with the usage of two bioscrews and the temporary stabilisation of the ACJ with two k-wires. As in any orthopaedic surgery, infection is often disastrous especially when the surgery involves implants. It can be disastrous with high morbidity to the patient as well as a costly complication to treat. Therefore, we wish to highlight this case as despite its rarity, osteomyelitis can be devastating to the patient and should be prevented if possible.