Introduction: Acute knee injuries account for eight percent of all injuries. Ottawa and Pittsburgh knee rules (OKR and PKR) were developed to assess the need for radiographs in acute knee injury. The objective of the study is to analyse the applicability of OKR and PKR to rule out fractures in acute knee injury. Method: This prospective cross-sectional study included 120 patients presenting with acute knee injury. Patients were assessed based on Ottawa and Pittsburgh knee rules (OKR and PKR) and radiographs were evaluated for fractures. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of OKR and PKR were calculated along with possible reduction in radiographs. Association of sex and age with outcome of acute knee injury was also analysed. Result: Among the 120 patients, 74(61.67%) were males and 46(38.33%) were females. Sensitivity, specificity, PPV and NPV of OKR were 95% CI 0.94(0.83-0.99), 95% CI 0.40(0.28-0.52), 95% CI 0.53(0.42-0.63) and 95% CI 0.90(0.74-0.98) respectively with possible reduction in radiographs by 31(25.83%). Sensitivity, specificity, PPV and NPV of PKR were 95% CI 0.88(0.76-0.05), 95% CI 0.57 (0.45-0.69), 95% CI 0.59(0.47-0.71) and 95% CI 0.87(0.75-0.95 ) respectively with possible reduction in radiographs by 46(38.33%). Conclusion: OKR and PKR are highly sensitive in ruling out fractures in patients with acute knee injury and more than one-fourth of radiographs can be avoided if these rules are applied.

The patella is the largest sesamoid bone in the body and an important structure of the extensor apparatus which is under undue stress during flexion and extension of the knee. Bilateral fracture of the patella without trauma is a very rare event and may be multifactorial without a single cause. A repetitive stress reaction in a previously predisposed bone can be an important cause. We report a case of a 45-year-old female with a nontraumatic bilateral transverse patella fracture with loss of extensor mechanism. A stable surgical fixation for such a displaced fracture with a good rehabilitation program can lead to a good functional outcome.

Introduction: Traumatic dislocation of the hip (TDH) is an orthopedic trauma emergency, which is commonly due to high-energy trauma. Morbidity and mortality are very high usually resulting from the associated injuries sustained during the trauma. The condition of the victims worsened when associated with acetabular or femoral head fractures. The prevalence of hip dislocations is increasing worldwide. Materials and methods: From August 2011 to March 2018, a total of 27 cases of traumatic hip dislocation were treated in a public general hospital. The emergency reduction was performed, immobilization with skin tractions was done for 3 weeks by admitting to the hospital. After 3 weeks of hospital stay, discharged and advised for non-weight bearing (NWB) crutch walk for another 3 weeks. Medical records of all patients after 1 year of dislocation were reviewed. Results: There were 21 (77.78%) males, 6 (22.22%) females, and the mean age of the patient was of 37.59 ± 13.69 years (range 8-71), posterior dislocation occurred in 18 (66.66%) cases, anterior dislocation on 6 (22.22%) cases, and central dislocation on 3 (11.11%) cases. The right hip was dislocated in 17 (62.96%) cases and left in 10 (37.04%) cases. A road traffic accident (RTA) was the cause for 16 (59.25%) cases, fall injury in 8 (29.62%) cases, and physical assaults in 3 (11.11%) cases. Associated injuries like abdominal, thoracic, pelvic and acetabular fracture, upper and lower limbs injuries, and sacroiliac joint injury were found in 17 (62.96%) cases. Conclusion: Traumatic dislocation of the hip is a severe injury caused mostly by RTA and young adults are most commonly affected.

Kaplan’s lesion is a rare complex metacarpophalangeal joint dislocation. A 7-year-old female child presented with pain, swelling and inability to move her right index finger. Her mother gave a history of sustaining a fall injury on the same hand around 3 weeks back. Radiographs showed a complex dorsal metacarpophalangeal joint dislocation. As the injury was already 3 weeks old at presentation, a few attempts at closed reduction were tried, under anaesthesia, which was unsuccessful. So, the patient underwent open reduction through a dorsal approach. At a 1-year follow-up, the patient was pain-free and had regained full range of motion of the index finger metacarpophalangeal joint. The differential diagnosis of Kaplan’s lesion should be considered when a child presents with finger dislocation.

Resumo Objetivo Analisar o resultado radiológico, clínico e funcional das fraturas da clavícula, tratadas pela técnica de osteossíntese com placa minimamente invasiva (MIPO). Métodos De junho de 2018 a julho de 2019, um total de 17 casos de fraturas claviculares foram tratadas com a técnica de osteossíntese com placa minimamente invasiva (MIPO), sob fluoroscopia com o braço em C. Os resultados funcionais foram avaliados por meio do escore de Constant-Murley e pelo escore de incapacidade do braço, ombro e mão (DASH). Foram analisados os resultados clínicos de consolidação, complicações, tempo cirúrgico, permanência hospitalar e infecção. Resultados O tempo médio de acompanhamento neste estudo foi de 10,41 ± 1,75 meses (variação, 8 a 14 meses). Havia 11 pacientes do sexo masculino e seis do feminino, com média de idade de 39,05 ± 10,76 anos (variação de 22 a 57 anos). Todas as fraturas se consolidaram no tempo médio de 15,35 ± 3,08 semanas (variação, 12 a 20 semanas). O tempo cirúrgico médio foi de 98,11 ± 13,83 minutos (variação, 70 a 130), sendo a permanência hospitalar média de 4,7 ± 1,12 dias (variação de 3 a 7). O escore de Constant-Murley médio foi de 74,82 ± 6,36 no 4° mês e 92,35 ± 5,48 no 8° mês do pós-operatório, o que foi estatisticamente significativo. O escore DASH médio foi de 9,94 ± 1,55 no 4° mês e 5,29 ± 1,85 na 8ª semana do pós-operatório, também sendo estatisticamente significativo. Um paciente apresentou infecção cutânea superficial no local da incisão. Conclusões A técnica MIPO é um método alternativo para a fixação de fraturas da clavícula, porém é tecnicamente mais desafiador, já que necessita de instalações cirúrgicas mais bem equipadas.

Resumo Objetivo Analisar o resultado radiológico, clínico e funcional das fraturas da clavícula, tratadas pela técnica de osteossíntese com placa minimamente invasiva (MIPO). Métodos De junho de 2018 a julho de 2019, um total de 17 casos de fraturas claviculares foram tratadas com a técnica de osteossíntese com placa minimamente invasiva (MIPO), sob fluoroscopia com o braço em C. Os resultados funcionais foram avaliados por meio do escore de Constant-Murley e pelo escore de incapacidade do braço, ombro e mão (DASH). Foram analisados os resultados clínicos de consolidação, complicações, tempo cirúrgico, permanência hospitalar e infecção. Resultados O tempo médio de acompanhamento neste estudo foi de 10,41 ± 1,75 meses (variação, 8 a 14 meses). Havia 11 pacientes do sexo masculino e seis do feminino, com média de idade de 39,05 ± 10,76 anos (variação de 22 a 57 anos). Todas as fraturas se consolidaram no tempo médio de 15,35 ± 3,08 semanas (variação, 12 a 20 semanas). O tempo cirúrgico médio foi de 98,11 ± 13,83 minutos (variação, 70 a 130), sendo a permanência hospitalar média de 4,7 ± 1,12 dias (variação de 3 a 7). O escore de Constant-Murley médio foi de 74,82 ± 6,36 no 4° mês e 92,35 ± 5,48 no 8° mês do pós-operatório, o que foi estatisticamente significativo. O escore DASH médio foi de 9,94 ± 1,55 no 4° mês e 5,29 ± 1,85 na 8ª semana do pós-operatório, também sendo estatisticamente significativo. Um paciente apresentou infecção cutânea superficial no local da incisão. Conclusões A técnica MIPO é um método alternativo para a fixação de fraturas da clavícula, porém é tecnicamente mais desafiador, já que necessita de instalações cirúrgicas mais bem equipadas. Abstract Objective To analyze the radiological, clinical, and functional outcomes of clavicle fractures treated with the minimally-invasive plate osteosynthesis (MIPO) technique. Methods From June 2018 to July 2019, 17 cases of clavicular fractures were managed using the MIPO technique under C-arm fluoroscopy. The functional outcomes were assessed using the Constant-Murley score and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The clinical results of union, the complications, the operative time, the hospital stay, as well as infection, were analyzed. Results The mean follow-up time was of 10.41 ± 1.75 months (range: 8 to 14 months). There were 11 male and 6 female patients, with a mean age of 39.05 ± 10.76 years (range: 22 to 57 years). All fractures united on the mean time of 15.35 ± 3.08 weeks (range: 12 to 20 weeks). The mean operative time was of 98.11 ± 13.83 minutes (range: 70 to 130 minutes), and the mean length of the hospital stay was of 4.7 ± 1.12 days (range: 3 to 7 days). The mean Constant-Murley score was of 74.82 ± 6.36 in 4th postoperstive month, and of 92.35 ± 5.48 in the 8th postoperative month, which was statistically significant. The mean DASH score was of 9.94 ± 1.55 in the 4th postoperative month, and of 5.29 ± 1.85 in the 8th postoperative month, which was also statistically significant. One patient had superficial skin infection at the site of the incision. Conclusions The MIPO technique is an alternative method for the fixation of clavicle fractures, but it is technically more demanding, and requires well-equipped operating room facilities.

Background: Lower limbs ulcers and wounds, Charcot foot with the presence of peripheral neuropathy or peripheral vascular disease are common complications of the diabetes mellitus (DM). Major extremity amputations (below and above knee) are one of the common surgical procedures performed due to DM complications. Objective: To review the amputations performed due to diabetes mellitus (DM) complications with other associated illness, commonly isolated bacteria, and the demography of the patients in a public general hospital. Materials and Methods: We retrospectively reviewed the cases of above and below the knee amputations due to DM complications from January 2012 to December 2016. The age, gender, duration of DM anyone having, bacteria isolated, vascular condition of the lower limbs, other diseases anyone having, post-surgery wound conditions and status of the ambulation after surgery were analyzed. Results: A total of 53 amputations of the limbs of 51 patients were performed. Below knee amputations were performed on 43 (81.83%) limbs and male gender were 35(68.62%). The mean age of the patient was 57.6±12.01 years (range 31-91 years). The three most common bacteria isolated were Klebsiella pneumoniae, Staphylococcus aureus, Enterobacter cloacae. About 85% of these bacteria were sensitive to commonly used first line of antibiotics like co-amoxiclav and ciprofloxacin. Fifty cases (98.03%) had diabetes for more than five years. End stage renal disease (ESRD) and ischaemic heart disease (IHD) were the other common co-morbidities observed. Conclusion: Major lower limb amputations (below and above the knee) due to uncontrolled blood sugar are common surgical procedures performed on DM. Majority of the bacteria were sensitive to commonly used first line of antibiotics but still 15% were not sensitive and bacteria isolation, sensitivity with the drugs were also important for the treatment of the infection.

Objective  To analyze the results of clinical, radiological, and functional outcomes of tibial plateau fracture (Schatzker Type V, VI) treated with Illizarov ring external fixator with or without minimum opening. Methods  A total of 52 tibial plateau fractures of type V, VI were treated with Ilizarov ring external fixator with or without mininum internal fixation were studied. Functional outcome assessment was done using the American Knee Society (AKS) score with clinical, radiological union, and complications were analyzed. Results  There were 37 (71.15%) male and 15 (28.84%) female patients, with a mean age of 39.07 ± 12.58 years old. Road traffic accidents (RTAs) were the major cause of fracture, accounting for 32 cases (61.53%) followed by fall injury, with 16 cases (30.76%), and direct impact, with 4 cases (7.69%). Twenty-one (40.38%) cases were type V and 31 (59.61%) cases were type VI fractures, and there were 24 (46.15%) cases of open fracture. The mean AKS score of Type V and Type VI fractures were 82.8 and 80.70, respectively, but this was statistically not significant at p <0.05. The mean AKS score of closed and open fractures were also statistically not significant at p <0.05. Conclusions  For Schatzker Types V and VI complex tibial plateau fractures, Ilizarov external fixation is a safe, cost-effective and efficient treatment method that presents a satisfactory outcome.

Resumo Objetivo Analisar os resultados clínicos, radiológicos e funcionais da fratura do planalto tibial (Schatzker Tipo V, VI) tratada com fixador externo do anel Illizarov com ou sem abertura mínima. Métodos Um total de 52 fraturas do planalto tibial dos tipos V e VI foram tratadas com fixador externo do anel Ilizarov com ou sem fixação interna mínima. A avaliação do desfecho funcional foi feita utilizando-se o escore da American Knee Society (AKS, na sigla em inglês) com consolidação clínica, radiológica e complicações encontradas. Resultados Foram 37 (71,15%) pacientes do sexo masculino e 15 (28,84%) do sexo feminino, com idade média de 39,07 ± 12,58 anos. Acidentes de trânsito (ATs) foram a principal causa das fraturas, contabilizando 32 casos (61,53%), seguidos por lesão por queda, com 16 casos (30,76%), e impacto direto, com 4 casos (7,69%). Foram 21 (40,38%) casos de fraturas tipo V, 31 (59,61%) casos do tipo VI e 24 (46,15%) casos de fratura exposta. Os escores médios da AKS para as fraturas tipo V e VI foram de 82,8 e 80,70, respectivamente, mas não foi estatisticamente significativo em p <0,05. O escore médio da AKS para fraturas fechadas e abertas também não foi estatisticamente significativo em p <0,05. Conclusões Para a fratura do planalto tibial complexa dos tipos V e VI de Schatzker, a fixação externa de Ilizarov é um método de tratamento seguro, econômico e eficiente que resulta em resultados satisfatórios.

Subluxation or dislocation of the peroneal tendon is uncommon ankle disorder and most of the time misdiagnosed as ankle sprain. Young adults and adolescents who are active on sports activities are more prone to get this problem. The main cause of this disorder is because of the superior peroneal retinaculum avulsion from its insertion with fibular bone. We report a case of peroneal subluxation in a 19-year-old girl after twisting of the ankle one year back. She was initially treated with ankle splintage, rest and analgesics but her problem did not improve. Magnetic resonance imaging (MRI) of the ankle showed subluxation of the peroneal tendon and managed operatively. One year after the operation she is having pain-free ankle without any difficulties for walking.

A 20-year-old male presented to our OPD with stiffness in his right elbow. He gave a history of sustaining a fracture around the same elbow when he was 4 years old. He was treated operatively for the same. In the post-operative period, he did not undergo any physiotherapy. On examination, he had a fixed flexion deformity in his right elbow with a range of motion between 90 and 110 degrees. X-ray did not show any bony abnormalities and MRI revealed susceptibility artifacts in posterior aspect. The elbow was approached anteriorly releasing all the soft tissue contractures. The elbow was immobilised in extension in a plaster cast for 4 weeks. The patient was under regular physiotherapy after plaster removal in the post-operative period. At one year follow up, he has an elbow range of motion between 20 and 120 degrees.

Aneurysmal bone cyst (ABC) of the talus is an extremely rare lesion. Less than 20 cases have been reported in PubMed till 2012 and none from Nepal. We report a rare case of primary ABC of talus in a 17 year old male that was managed by extended intra-lesional curettage and autologous cancellous iliac crest bone grafting. The patient had excellent functional outcome and there was no recurrence at 1 year of follow-up.

Introduction: The COVID-19 pandemic has paralyzed the world, including elective health care services. To prevent the spread of infection, most countries have gone into lockdown and adjustments have been made to provide urgent medical care, including Orthopaedic services. In accordance with the guidelines from worst affected countries and neighboring India, Patan Hospital followed instructions from Ministry of Health and Population to provide only urgent and semi-urgent Orthopaedic services. This study aims to audit the patient profile during lockdown so as to have a clearer picture, which will enable us to be prepared for similar epidemic in the future. Method: All patients admitted to the Orthopaedic ward of Patan hospital from 24 March to 27 April 2020, during the lockdown, were included. Clinical profile, including cause of admission, management, hospital stay were descriptively analyzed. Ethical approval was obtained. Result: Out of 44 admissions, there were male 27 and female 17. Trauma cases were 38, and 18 were in age group 20-26 years. Admission due to infections were four. Conservative management were done in seven while 33 were treated surgically, out of which 30 accounted for trauma. Average 6.14 days hospital stay, range 1-22 days. Conclusion: Trauma comprised of major bulk of patients seeking urgent Orthopaedic care. Hospital needs to be prepared with necessary measures to ensure safety of health care workers and yet provide urgent Orthopaedic services.

ResumoA fratura intertrocantérica do fêmur em um quadril anquilosado é extremamente rara. O objetivo do manejo operatório em idosos com fraturas intertrocantéricas é prevenir complicações gerais, manter a mobilidade, e aliviar a dor. O manejo ideal para atingir tal objetivo não é claro. Os autores apresentam o caso de um paciente do sexo masculino de 74 anos com fratura intertrocantérica do fêmur em um quadril anquilosado. A fratura foi tratada cirurgicamente com parafuso de quadril dinâmico e parafuso canulado. Dois anos após a cirurgia, observou-se boa união na fratura, e o paciente deambula de forma independente.

Resumo Objetivos A maioria das fraturas dos ossos do antebraço em crianças é tratada com sucesso de forma conservadora com redução fechada e imobilização gessada. No entanto, alguns pacientes podem necessitar de manipulação adicional da fratura ou intervenção cirúrgica devido a angulações residuais. O presente estudo avalia o resultado clinico e radiológico do tratamento de fraturas com desvio do antebraço em crianças fixadas com haste elástica intramedular de titânio. Métodos Um total de 31 pacientes com idades entre 7 e 15 anos com fraturas com desvio do antebraço foram submetidos a haste elástica de titânio flexível. Os pacientes foram acompanhados por um período médio de 8,51 meses (variação: 6–12 meses) e avaliados quanto aos resultados funcionais pelos critérios de Price e radiológicos. Resultados Dos 31 pacientes, 21 foram submetidos a redução fechada e 10 necessitaram de abertura mínima do local da fratura durante a redução. Um total de 29 pacientes tiveram excelentes resultados com arco de movimento normal, e 2 pacientes apresentaram bons resultados. Em todos os pacientes, a consolidação ocorreu em um tempo médio de 7,9 semanas. Cinco pacientes tiveram complicações menores, como irritação da pele sobre a haste proeminente (n = 2), infecção superficial do local de inserção no rádio (n = 2) e recuo da haste ulnar (n = 1), que exigiu remoção precoce. Conclusão A haste flexível é um método eficiente para tratamento da fratura do antebraço em crianças, permitindo mobilização precoce e retorno às atividades normais dos pacientes, com baixas e tratáveis complicações.

Abstract Intertrochanteric fracture of femur in an ankylosed hip is extremely rare. The aims of operative management for elderly patients with intertrochanteric fractures are to prevent general complications, maintain regarding mobility, and to relieve pain. The optimal management to achieve these goals is not clear. The authors present a case 74-year-old man with intertrochanteric fracture of femur in an ankylosed hip. The fracture was managed surgically with dynamic hip screws and cannulated screws. Two years after the surgery, good union was observed at the fracture and the patient was also ambulating independently.