Flexible stable intramedullary nailing with titanium elastic nailing system (TENS) is commonly accepted as a preferred treatment in diaphyseal fractures of femur in children aged 6-12 years. However, in cases with significant anaesthetic risk due to medical comorbidities conservative management can be considered. An eight year old boy from a rural area in Kerala with an unrepaired congenital atrial septal defect sustained a displaced, closed mid-shaft fracture of the right femur following a road traffic accident. TENS was recommended for the fracture but surgical intervention was not accepted by the parents because of concerns regarding anaesthesia-related cardiac risk. Hence, the child was managed conservatively with skin traction followed by hip spica cast application. Serial radiographs were then taken which showed evidence of delayed union with progressive callus formation, attaining near-complete union by eight months, with residual angulation and approximately 2 cm limb shortening. Even though these radiological findings were present, child attained an excellent clinical outcome, with painless full weight-bearing, normal hip and knee range of motion, and the ability to squat comfortably. This case shows that conservative management of paediatric femoral shaft fractures may be appropriate in meticulously selected high-risk patients. Functional recovery and patient safety may be considered as a superior factor than radiographic perfection, especially in children with ampleremodelling potential.
Monteggia fractures are unusual injuries in children and adolescents age group wherein the radial head gets dislocated in combination with proximal ulna fractures. Various surgical treatment options are described in the literature to reconstruct these lesions for improvising the limb function. A retrospective study on thirteen patients with missed Monteggia fractures who underwent surgical intervention between 2021 to 2023 at our hospital was done. Patients underwent ulnar distraction angulation osteotomy with or without open reduction of the radial head. Patients were analysed on the visual analogue scale (VAS) for pain; mean VAS 1.9 (range 0 to 5) and functional assessment. There was a significant improvement in rotational movements of the hand after surgery. However, restriction of supination and pronation was observed in 3 patients at the last follow-up. Two patients reported radial head subluxation in last follow-up x-ray out of which one patient has associated elbow stiffness along with the re-dislocation of radial head. Missed Monteggia lesions if identified early can be treated successfully by ulnar angulation osteotomy and reduction of radio-capitellar joint. Good to excellent clinical and radiological outcomes can be expected in those with lesser age and lesser the interval between duration and surgery.
Osteochondroma is a benign osteocartilaginous lesion characterized by a bony projection covered by a cartilage cap. Although it is one of the most common benign bone tumors, its occurrence in the calcaneus is uncommon. A lesion arising from the posterosuperior calcaneus may clinically resemble a Haglund deformity and may remain difficult to distinguish from other causes of posterior heel prominence. We report the case of a patient with insulin-treated diabetes mellitus and diabetic peripheral neuropathy with neuropathic osteoarthropathy who presented with painless, progressive deformities of both feet evolving over six years. The most prominent lesion was located on the posterosuperior aspect of the right calcaneus and caused difficulty wearing shoes because of mechanical conflict. Plain radiography demonstrated marked hypertrophy of the posterosuperior calcaneus without bone lysis or sclerosis. Computed tomography demonstrated an osseous formation measuring approximately 30 mm in anteroposterior diameter. Magnetic resonance imaging showed a lobulated osteocartilaginous-appearing formation measuring approximately 28 × 16 mm arising from the posterosuperior calcaneus and extending anteriorly, with enlargement around the insertion of the Achilles tendon. The imaging characteristics were considered most compatible with an osteochondroma. Calcaneal osteochondroma is a rare cause of posterior heel deformity and may mimic a Haglund deformity or another calcaneal exostosis. Cross-sectional imaging, particularly MRI, is useful for characterizing the lesion and assessing its relationship with adjacent soft tissues. In an asymptomatic patient with diabetes and peripheral neuropathy, conservative management with appropriate footwear and regular skin surveillance may be preferable when there is no ulceration, infection, significant pain, or radiological evidence of aggressive behavior.
Osteochondroma is the most common benign bone tumor; however, involvement of the scapula is uncommon. Scapular osteochondromas may present with swelling, painless, no restricted shoulder movements, snapping scapula, or pseudo-winging, often mimicking neuromuscular causes. We report a case of a 14-year-old male who presented with a gradually progressive swelling over the left scapular region for 5-6 months, associated with pseudo-winging. On examination, a bony hard, non-tender swelling fixed to the scapula was noted, without neurovascular deficit. Radiographs revealed a bony exostotic lesion arising from the left scapular blade. The patient underwent complete surgical excision through a posterior approach. Histopathological examination confirmed osteochondroma, demonstrating a cartilage cap with underlying trabecular bone and marrow elements. At 1-month follow-up, the patient showed satisfactory wound healing, significantly improved shoulder function, and resolution of pseudo-winging, with no evidence of early complications or recurrence. Scapular osteochondroma is a rare cause of pseudo-winging in adolescents and should be considered in the differential diagnosis of scapular asymmetry. Careful clinical and radiological evaluation helps differentiate it from true neuromuscular winging. Complete surgical excision provides excellent symptomatic relief and favorable functional outcomes.
Background: Distal radius fractures are among the most common orthopedic injuries. Joshi’s external stabilization system (JESS) and volar locking plate fixation are widely used surgical options with differing biomechanical principles. Methods: A prospective cohort study of 94 patients with distal radius fractures was conducted. Patients underwent either JESS or volar locking plate fixation. Functional outcomes were assessed using DASH scores at 6 and 12 months and modified Mayo wrist score (MMWS) at 12 months. Results: Volar plating demonstrated superior functional outcomes, with significantly better early recovery and consistently improved scores at final follow-up. Patients treated with volar plating achieved better range of motion and grip strength. The JESS group showed gradual improvement over time but did not match the overall functional outcomes of the plating group. Pin tract infections were more common in the JESS group, whereas hardware-related complications were observed in the plating group. Conclusions: Volar locking plate fixation provides superior functional outcomes in distal radius fractures, both in early recovery and at final follow-up. While JESS remains a viable option in selected cases, volar plating should be preferred where feasible.
