This is to certify that Dr.E.R.MITHUN, post graduate student (2008-2011) in the Department of Orthopedic Surgery, Government Royapettah Hospital/ Kilpauk Medical College , has done dissertation on ‘‘COMPARISION OF FUNCTIONAL AND COSMETICOUTCOME OF SUPRACONDYLARFRACTURES IN CHILDREN TREATED BY PERCUTANEOUS PINNING AND OPEN REDUCTION AND INTERNAL FIXATION WITH K- WIRES’’ under my guidance and supervision in partial fulfillment of the regulation laid down by the ‘THE TAMILNADU DR MGR MEDICAL UNIVERSITY, CHENNAI -32’ for M.S.(Orthopaedic Surgery) degree examination to be held in April 2011.
Ethical Committee approval was obtained from all the patients enrolled in the study. Regular three weekly follow-ups were done till radiological union followed by long- term follow-up at one and two years respectively. The final results were analysed using the Flynn criteria . This criteria is divided into two components, the functional and the cosmetic component and both are further sub-divided as excellent, good, moderate and poor at an interval of five degrees. The functional component consists of measuring the arc of motion in sagittal plane which includes flexion and extension, whereas the cosmetic further measures the carrying angle which indicates the coronal movements at the elbow joint. Greater loss of movements in both, the sagittal as well as coronal plane indicates unsatisfactory outcome.
distal fragment and avoid post-operative complications, especially iatrogenic nerve injuries and malunion due to loss of reduction with poor cosmetic and functionaloutcome. The most debated subject is the optimal pin configurations to hold the reduced fracture. Various pin configurations have been recommended for the treatment of displaced supracondylar humerus fractures on the basis of choice between the stability versus the risk of iatrogenic ulnar nerve injury. 7-10
early mobalitiy to joint. Preoperative recognition of this type of injury provides proper planning for surgical approaches, selection of suitable implant and their positioning. Purpose of this study was to measure the incidence of coronal plane fracture in association between supracondylar and intercondylar distal femoral fractures and to review literature regarding fixation planning and methods for better outcomes.
Extra articular fractures can be approached through a limited incision using a variety of techniques. An infrapatellar incision 4 to 5 cm long is made either directly over the patellar tendon or at its medial edge. The patellar tendon is correspondingly then either split longitudinally or retracted laterally (as for tibial nailing, hence the ability to fix a floating knee with minimal dissection) .The entry point is 5mm anterior to the attachment of posterior cruciate ligament and it lies slightly medial to the center of the distal femoral condyles. Direct visualization of the entry site in the intercondylar notch can be accomplished by excision of the fat pad. C -arm guidance confirms that the entry site is along the axis of the distal fragment in both the AP and lateral planes. Either of the two intrapatellar incisions can easily be extended to a formal medial para patellar arthrotomy if necessary. A ¼ - inch twist drill or Steinman pain is used to perforate the subchondral cortex. The subsequent path created in the distal fragment by passage of hand-held reamers is the most crucial reduction maneuver of the entire procedure. C-arm must confirm that the reduction is in perfect alignment along the longitudinal axis of the distal fragment, because the varus/valgus and sagittal alignment of the fracture will be determined by this.
fifth metatarsal fractures including Jones fractures, avulsion fractures, spiral and oblique midshaft fractures, and the author-termed "tulip" fracture (impaction fracture of the fifth metatarsal head). These fractures were fixed with the cannulated screw, Kirschner wires, and circlage loop wires combined with Kirschner wires. A one-way analysis of variance (ANOVA) was performed on the data to test for any significant difference in the fixation type used and the overall healing time. The ANOVA was found to be nonsignificant, F(2,10) = 0.379, p < 0.05. Therefore, it can be concluded that all three types of fixation work equally well.
As for hand positioning was concerned, all but 1 patients were able to reach above chest height, which was similar to Kralinger et al  . When this was measured against the various parameters such as age distribution of the patient, sex, time since injury, classification of fracture or the operative duration, none of these factors significantly affected the outcome.
Open fractures in spite of best treatment still pose a challenge. Now limb salvage being the order of the day, persistent infections and prolonged time to union are the challenges faced by surgeons today. Chronic osteomyelitis is the long term effect of infection and this is extremely difficult to treat. A condition best prevented to say the least. Treatment of chronic osteomyelitis requires debridement and for Cierny and Mader type 4 osteomyelitis , skeletal stabilization is required. This prolongs time of treatment, requires further admissions and expenditure.
The results demonstrate several benefits of locking plate. More importantly, it is easy to use, it is biological in the sense that the blood circulation to the bone is not compromised, the plate does not need to be reconfigured and the angular screw fixation ensures fixed angle stabilization. Moreover, complications associated with the plate were few and the functionaloutcome was excellent. Thus, many of the common complications of the conventional plating can possibly be avoided. Although the follow up period in our study was relatively short and it was not a randomized controlled study, also the locking plate is comparatively expensive, the number of second or more occasions of surgery is minimal. We therefore recommend the use of locking plate, especially in elderly patients with osteoporotic bone and comminuted fracture. Randomized studies will of course be needed in the future to validate the possible advantages associated with this method. Nevertheless, these new possibilities mean that preoperative planning and an understanding of the different biomechanical principles of osteosynthesis are essential if good clinical outcomes are to be achieved and maximum benefit is to be attained from the options offered by the LCP system.
I, Dr. E.S.ARIVAZHAGAN declare that dissertation titled “FUNCTIONALOUTCOME OF VARIOUS MODALITIES OF MANAGEMENT OF DISTAL TIBIAL FRACTURES” is a bonafide work done by me at Kilpauk Medical College 2004-2007 under the guidance and supervision of my unit’s chief Prof. Dr. A. SIVAKUMAR, M.S.(Ortho)., D.Ortho.,
Various studies have shown that IM nailing can provide acceptable fracture reduction, stabilization for fracture healing, results in minimal cosmetic deformity, and facilitates easy removal of implants after treatment. 21,22 It does not disturb the periosteal blood supply and fracture hematoma. Also, it allows micro motions at the fracture site which are beneficial for callus formation. It works on the principle of three point fixation thus does not allow angulation, translation or rotation post reduction. Some of the reported complications of this technique include superficial nail site infections, skin irritation at nail insertion sites, implant migration or failure (bent or broken pins), loss of reduction, refracture, tendon injury, decreased range of motion, delayed union/non-union. 23-26 Amit et al described the results of treatment of 20 unstable diaphyseal fractures of the forearm in adolescent patients by closed intramedullary nailing. All fractures healed within 4-7 weeks. No cross-union, non-union, pseudarthrosis, or infection occurred. They stated that the advantages of this method are (a) maintenance of accurate reduction, (b) reduction of complication rate, (c) negligible cosmetic defect, and (d) removal of the internal fixation device under local anesthesia. 27 Our results are consistent with this study.
The aim of treatment in fractures of the distal femur prox- imal to total knee arthroplasties is to achieve a painless and stable knee without any residual malalignment. Conservative treatment has been reported with successful results in these fractures . However, this may be asso- ciated with difficulty in maintaining reduction, prolonged period of immobilisation, reduced knee functions, malu- nion and nonunion. Merkell and Johnson recommended conservative treatment, although nine of 26 patients (35%) in their study required revision arthroplasty because of nonunion, malunion, loosening of components and extensor lag . Culp et al.  recommended opera- tive treatment for displaced fractures, as conservative treatment resulted in nonunion in 20% and malunion in 23% of patients. Several authors have recommended open reduction and internal fixation using lateral plates for these fractures [4, 5]. Healy et al.  treated 20 fractures with open reduction and internal fixation using a variety of different implants including blade plate, condylar screw and condylar buttress plates. They performed bone grafting in 15 patients and achieved union in 18 patients. Two patients, who did not undergo bone grafting at the time of index surgery, needed reoperation and bone graft- ing to achieve union. The authors recommended primary bone grafting with internal fixation to increase the chances for union of these difficult fractures . However, internal fixation using plates could be techni- cally demanding in osteopenic bone in elderly patients. Figgie et al.  reported union in only five of 10 cases; the remaining five cases needed further surgical proce- dures. They also noted that eight of 10 cases developed varus alignment despite satisfactory intraoperative align- ment due to metaphyseal comminution . To address the problem of poor fixation in osteopenic bone, locking plates have been developed which can be inserted with a minimally invasive approach. Clinical studies have reported good results using locking plates for the treat- ment of periprosthetic supracondylar femur fractures Fig. 2 Radiographs of the knee showing complete fracture union
The theory was put forward by Meyer (1925) and supported by Lewis (1950) says that course of fracture is determined by three factors position of hand, surface of impact and magnitude of force. The kinetic energy causes the forward movement of body to continue, the wrist becomes hyperextended and patient falls over the hand. This loads the volar ligaments and radius is pressed against carpal articular surface, the force being stopped by scaphoid and lunate bones, it is then transmitted to radius, which fractures at its weakest point in same manner as a beam that is loaded beyond the limits of elasticity, Lewis so considered this fracture as a” bending fracture.”
Spine fractures are common in today’s world due to high frequency of motor vehicle accidents and work place injuries. These are major cause of disability in adult population. The mortality rate following spinal injuries is 7%. Thoracolumbar junction is the most mobile segment which makes it more prone to injury. Management of these injuries are still under debate. Internal fixation provides early mobilisation of the patients and protects the neurological structures. Conventional short segment stabilisation is
Fractures of the distal humerus accounts for 2-6% of all fractures and 1/3 of all humeral fractures. In our society the incidence of distal humeral fractures is increasingly having a bimodal distribution .Motor vehicle accidents are the major cause of distal humerus fractures in young population whereas simple accidental falls are the cause in elderly population. In this era of modern orthopaedics, despite various advances ,distal humeral fractures remain one of the most challenging injuries to treat. Composite problems in distal humerus fracture management include frequent articular involvement, metaphyseal communition, bone loss and osteopenia. The fore mentioned issues along with the complex three dimensional geometry pose great difficulties in internal fixation. Poor outcomes like stiffness is secondary to prolonged immobilization.Nonunion, high failure rate are noted with old internal fixation techniques. Attempt to achieve painless stable yet mobile elbow requires a systematic approach.
During 1960s-1970s unstable intertrochanteric fractures were corrected by non-anatomic stable reduction techniques by medial (Dimon&Hughston) valgus osteotomy or lateral (wayne- county) displacement osteotomy. In Gargan, Bundle and Simpson study on 100 patients found more fixation failures hence they advocated that there is no benefit from osteotomy and advised anatomic reduction.
For antero-lateral approach the following land marks are important, the joint line, gerdy’s tubercle, tip of the fibula and lateral femoral condyle. With the knee in 30 ° flexion a slightly curved incision starting from lateral femoral epicondyle and ending between the fibular and gerdy’s tubercle. The wound was extended either proximally or distally as needed. Reduction of Intraarticular fragments was confirmed by image intensifier and a sub-meniscal arthrotomy was done as needed. In type II,V&VI fractures lateral plateau was rotated laterally with it’s soft tissue attachments. This allows for direct inspection of the joint impaction. The depressed articular fragments were elevated and directly reduced. In bicondylar fractures,inaddition to lateral tibial plateau fixation, the medial fragment was fixed with 6.5mm cancellous screws using lag screw principle.
Open reduction & internal fixation of four part fractures with pins, rods, plates and screws can be done but the results usually are not promising. These fractures usually occur in elderly people in whom osteoporosis and poor bone quality preclude any stable internal fixation. Prosthetic replacement offers a distinct advantage in these fractures permitting early motion and return to work. The recent concept of LCP in these patients is gaining momentum.
Intertrochanteric (IT) fractures of femur are common in elderly people with osteoporotic bones and often the result of minor domestic falls. Osteoporosis coupled with a tendency to fall is responsible for high incidence of hip fractures at this age. Life expectancy of Indian population is steadily increasing and this inturn, increases the geriatric population and the hip fractures.
Minimal internal fixation to reconstruct the articular surface of tibia supported with ankle spanning external fixators became the popular modality of treatment in late 1990s. Fibula fractures were secured using one third tubular or reconstruction plate to maintain length and axis alignment. Hybrid fixators later replaced monolateral external fixators because of advantage of stability and early weight bearing.Definitive management of pilon fracture by external fixation has its own complications. They are pin tract infection, secondary loss of reduction and ankle stiffness.