Hand injuries are a common presentation to an emer- gency department (1). Fractures involving the hand ac- count for up to 28% of all fractures encountered (2). While the most common fractures of the hand are of the distal phalanx (3), metacarpal fractures alone account for about 40% of all hand fractures with 1.5 million injuries occur- ring annually (4, 5). They are the second most common fracture to present to an orthopaedic surgeon (after distal radius fractures) with an incidence of 130.3 per 100,000 pa- tients annually (6). The economic burden is particularly high in these patients as they typically affect young and healthy men (7) leading to missed time from work. Isolated metacarpal injuries can result in up to 3 - 6 weeks of missed time with non-operative management alone (8-10). There- fore, optimizing treatment of these injuries may have sig- nificant benefits in both quality of life and return to work for these patients.
External fixator was applied in the operation theatre under sterile conditions. The pins used for radius were 3.5 mm Schanz type and for that of metacarpal were 2.5 mm schanz type. After painting and draping with or without pneumatic tourniquet a small incision was made on dorsolateral aspect of forearm about 3-5 cm proximal to fracture site. Lateral cutaneous nerve of forearm was identified, 2.7 mm drill bit was used for predrilling. 3.5 mm Schanz pin (half pin) was inserted. Second pin site was selected beyond mid forearm proximally, asgreater the distance from first pin in distal end of radius 3-5 cm proximal to fracture site, more stable is the fixation.
After thorough clinical history and physical examination, standard radiographs are performed in the anteriopos- terior (AP), oblique and true lateral views. Fracture angulation beyond 30° and/or any rotational deformity were the indications for surgical intervention. Patients were counselled about pin site complications and care, and the necessity for removal of the pin after evidence of fracture healing. Only a stable fracture configuration (simple transverse or oblique fractures) or those with minimal communition were fixed using this method. Multi-fragmentary fractures, complex injuries or unreli- able patients were not included for this treatment but were instead referred to a specialist hand surgeon for appropriate management.
Identification and, importantly, prevention of surgical complications were reviewed under the Technical Aspects section. However, complications of metacarpal fractures can also arise from nonsurgical treatment and postoperative decision making. Stiffness can develop after prolonged immobilization or delayed rehabilitation. In most cases, signs of clinical union will be present at 4 weeks after a closed metacarpalfracture. Although the fracture has not yet radiographically united, transitioning the patient to a removable splint and initiation of rehabilitation at this time can minimize stiffness. Patients with crush injuries or open surgical approaches also can form tendon adhesions. Recognition of these risk factors for stiffness should prompt the surgeon to choose the most rigid form of fixation and begin mobilization early. In cases with rigid internal fixation, mobilization should begin at the time of suture removal. Malunion primarily manifests as malrotation or dorsal angulation. At each visit the surgeon should confirm that the patient’s fingertips point toward the scaphoid tuberosity in composite flexion. Five degrees of malrotation can produce 1.5 cm of digital overlap19 and diminish grip strength. Prominent palmar metacarpal heads from an apex dorsal malunion also can produce pain and secondary weakness. A compensatory hyperextension deformity at the MCP often accompanies a dorsal malunion. Corrective osteotomy is the treatment of choice for metacarpal shaft and neck malunions, whereas osteotomy or arthrodesis can be performed at the metacarpal base level. Nonunion is an uncommon complication of metacarpal fractures. Bone grafting and rigid internal fixation are the recommended treatments in the absence of osteomyelitis or soft-tissue defects.
trauma centre paediatric fracture clinic . In a study by Schalamon J et al, the 4-month calculated incidence in children less than 16 years of age was 0.68 per 1,000 for skateboard injuries . They suggested that skateboard injuries accounted for 2.6% of all paediatric traumas within a region. Our annual incidence was 10 patients per year among 5000 new fracture clinic attendances (2 per 1000). Compared to other recreational activities like scooter riding, roller skating and in-line skating, the inci- dence of skateboard related injuries is varied [7,11,12]. The injury characteristics seem to be similar among these activities with forearm injuries being more common . The reported severity of injuries related to skateboards compared to the other activities has been varied in the lit- erature [2,11].
Thirty patients with zygomatic complex fractures with or without other fractures of the facial skeleton who reported to Tamilnadu Government Dental College were included in the study. It was a prospective study. The patients were randomly divided into three groups with each group having ten patients. In Group I patients were treated with subciliary incision, Group II patients were treated with subtarsal incision and in Group III patients were treated with infraorbital incision. The parameters assessed and documented were average time from incision to the fracture exposure, surgical exposure of the operative field attained, aesthetic appearance of the scars, scleral show, chronic lid edema and ectropion. All the patients in the study were reviewed at regular intervals of first, third and sixth month postoperatively and evaluated functional and esthetic outcomes and the findings were evaluated by a single member blinded to the procedure. Ethical approval was obtained for the study from the institutional ethical committee.
Proximal humeral fractures account for approximately 4 to 5% of all fractures. Their incidence rapidly increases with age, and women are affected over twice as often as men. Similar to other primarily osteoporotic fractures, the incidence of these fractures is increasing. Palvanen et al. found a three fold increase over a 33 year period in the incidence of proximal humeral fractures resulting from low-energy trauma in people aged 60 and above . A large prospective epidemiology study  found that around half of these fractures (51%) are displaced, when assessed according to the criteria of Neer's classification system : one or more parts of the fractured bone are dis- placed by more than one centimetre, or angulated more than 45 degrees. Court-Brown et al  found that the larg- est groups of displaced fractures were 2 part surgical neck fractures (28% of the whole population), followed by 3 part greater tuberosity and surgical neck fractures (9%). Four part fractures without fracture dislocation were around 2% of the total. These figures are consistent with estimates from several members of the trial group. Recent systematic reviews [4,5], one of which was updated in 2007 , have found a lack of evidence from ran- domised controlled trials (RCTs) to inform management decisions for proximal humeral fractures. In particular, there were only three completed RCTs comparing surgery with conservative treatment. All were small studies (num- bers randomised: 30, 32, 40) with flawed methodology. Both reviews [4,5] concluded that it was unclear whether operative intervention, even for specific fracture types, would produce consistently better long-term outcomes.
There is a paucity in the literature of studies compar- ing unicortical and bicortical internal fixation of frac- tures in the hand, with no clinical or in-vivo evidence. In cadaveric studies, Dona et al.  showed that there was no difference in the stiffness, load to failure or failure mechanism between unicortical and bicortical fixation of fractures in 18 freshly frozen human metacarpals. The mean load to failure was 596 N for the unicortical group and 541 N for the bicortical group, using a four-point bending protocol . Afshar et al.  showed that bicor- tical fixation had a load to failure one-fifth greater than unicortical fixation in 20 cadaveric human metacarpals, with a mean load to failure of 370 N for unicortical fix- ation and 450 N for bicortical fixation, using cyclic load- ing. However, Afshar et al.  did not take into account the biomechanical advantage of an intact soft tissue en- velope and conceded that they could not correlate their findings with the loads experienced by the patient during rehabilitation following surgical fixation . Khalid et al .  showed that bicortical fixation resulted in higher pull-out strengths in 40 cadaveric human proximal pha- langes, but recommended unicortical fixation for diaphy- seal fractures, as the pull-out force far exceeds that generated by the flexor tendon in passive and active fin- ger flexion . In an animal fracture model, Ochman et al.  found that the stability of unicortical and bicorti- cal locking and nonlocking plate fixation differed, with
Only one previous study, 13 validating the Finnish hip fracture registry, divide hip fractures into sub-diagnoses. The authors ﬁ nd a PPV of 88.1% for fracture of the neck of femur, 96.0% for trochanteric and 62.5% for subtrochan- teric fractures, slightly lower than our ﬁ ndings on all diagnoses. They argue that the variation in PPV is due to anatomic location, ﬁ nding misclassi ﬁ cations to occur when the fracture is located on the border of the trochan- teric region. However, this study is challenged by different classi ﬁ cation systems in the database and the gold stan- dard, which magni ﬁ es the problem substantially. Despite a uniform classi ﬁ cation system for comparison in our registry, we ﬁ nd 15 – 20% of subtrochanteric fractures to be misclassi ﬁ ed, mainly due to a combined fracture invol- ving both the trochanteric and subtrochanteric region. This is concerning if one needs to distinguish between the two diagnoses, and thus, we recommend to pool them together, if possible, into “ lateral fractures ” .
Dissection of the forelimb revealed that extensor muscles of the digits were originated normally from the lateral surface of the radius, but their tendons were run at the lateral border of the radius to the carpal joint and finally deviated to the caudolateral aspect of the carpal joint to reach to the metacarpal bone. At the metacarpal region according to the outward bending of the forelimb distal to the carpal joint, extensor tendons run slightly to the cranial surface. It had resulted in the change of dorsopalmar axis of metacarpal to the lateromedial one. According to this change, extensor digital tendons in the metacarpal region were observed on the lateral surface of the metacarpal bone but their divisions were normal proximal to the fetlock. Due to these events, normal lateromedial arrangement of the extensor tendons of the metacarpal region had been changed to the caudocranial position (Fig. 1). The cranial tendon, extensor digitrum communis, was divided into the two lateral and medial branches proximal to the fetlock. Medial branch was continued to the medial digit while lateral one divided to two lateral and medial branches which were run to the lateral and medial digits, respectively. The tendon of caudal muscle, extensor digitrum lateralis, was continued to the lateral digit similar to normal arrangement.
This study examined how frequent surgical delay longer than one calendar day after admission occurs in hip fracture patients and which are the most common factors influencing the decision to postpone surgery, resulting in such delay. Based on the results it can be assumed that MST is doing well. It is not possible to give a hard judgment instead of making an assumption due to the lack of a standard and the absence of numbers obtained through the same method and/or about the same period in time. The percentage of patients that had hip fracture surgery after one calendar day is only 6% (7/110). Of these seven patients that had delayed surgery between January 1, 2012, and July 9, 2012, six patients had at least one kind of comorbidity at the time of admission in the hospital and five patients used anticoagulants. These factors of delay are of a medical origin and thereby cannot be easily changed or cannot be changed at all.
The mean age of the patient with classification Type C is 61.5 years. Also type C fractures initially have more displacement of fracture fragments which makes reduction difficult intraoperatively and adversely affects the fracture stability. As already stated, initiation of rehabilitation phases depends upon many factors such as fracture pattern, stability of fixation and patients compliance, these factors cumulatively may have reduced the functional outcome of patients with type C fractures .We consider age as a confounding factor in this statistically significant association. The limitation of our study is small sample size and this association have to evaluated in further studies.
We concluded that anterior subtotal corpectomy and posterior open-door laminoplasty are more suitable for multilevel cervical spinal stenosis. The posterior operation offers better decompression and fewer complications and is preferred by patients. The posterior open-door technology was considered simple and offers better decompression, preserving cervical spinal mobility, in an analysis reported by Anthony et al. . In addition, this approach has fewer postoperative complications and lower cost. For patients with complete paralysis, the anterior or anterior in combin- ation with posterior approaches had higher rates of postop- erative infection due to severe surgical trauma . Besides, when Charles et al.  compared the therapeutic outcomes of subtotal corpectomy (n = 49) and laminoplasty (n = 40), they reported better functional improvement with lamino- plasty, with less intraoperative blood loss (360 ml vs. 572 ml with subtotal corpectomy), fewer complications (1/40 vs. 9/49 with subtotal corpectomy), and a lower degener- ation rate (8% vs. 38%). On the other hand, Shibuya et al.  compared therapeutic outcomes of anterior subtotal corpectomy (n = 49) and posterior laminoplasty (n = 40) and found that for multilevel vertebral lesions, the oper- ation time was longer and intraoperative blood loss was greater by subtotal corpectomy, and complications such as disappearance of cervical physiological curvature and ky- phosis were often found. Similarly, Wada et al.  found in a comparative study of corpectomy (n = 45) and posterior open-door laminoplasty (n = 41) that although the cervical functional improvement (JOA score) was not significantly different between the two surgical approaches, a higher rate of degeneration in adjacent vertebra was found with posterior laminoplasty with deteriorated symptoms [2,3]. In addition, shorter operation time and less intraoperative blood loss were found with laminoplasty (182 min and 608 g by laminoplasty vs. 264 min and 986 g by subtotal cor- pectomy). As for postoperative complications, Kazuo et al.  found that the complication rate was 29.3% by anterior subtotal corpectomy and 7.1% by posterior open-door lami- noplasty for the patients with multilevel cervical spinal stenosis. Based on these published reports, we suggest pos- terior open-door laminoplasty as the primary approach for multilevel cervical spinal stenosis, in agreement with Yang et al. . In our study, we found that the operation time was 143.6 ± 31.7 min vs. 116.5 ± 29.8 min, intraoperative blood loss was 107.5 ± 49.6 ml vs. 172.3 ± 68.2 ml, and post- operative complication rates were 21.7% vs. 43.6% for ACDF and ACCF, respectively. Therefore, we propose open-door laminoplasty is more suitable for patients with multilevel cervical spinal stenosis.
In the early years of the 20th century, Albee popularized bone grafting in spinal surgery. Bauer investigated the preservation and storage of canine allografts in 1910. In the 1930s, Watson Jones described spinal fractures as due to pure flexion violence and treated them with hyperextension casts. In 1930, vitallium, an alloy of chromium, molybdenum, tungsten, and cobalt, was introduced for internal fixation. Ludwig Guttman from Britain, developed the concept of spinal cord rehabilitation in 1940s. He obtained reduction of spine fractures using traction and postural reduction techniques. Rogers described the interspinous wiring technique in 1940s. In 1945, Cloward introduced the technique of posterior lumbar interbody fusion. In 1949, Nicoll reported on 166 thoracolumbar fractures in coal miners and classified these injuries as anterior wedge fractures, lateral wedge fractures, fracture dislocations, and neural arch fractures 11 .
The classic presentation of patellar stress fracture is a young athlete with acute onset of severe anterior knee pain, often associated with a crack or pop, and inability to continue sport.[1-13] The patient has a high intensity, high frequency training program, often involving running or jumping. There is a history of gradual onset of peripa- tellar pain of weeks to years duration prior to the acute injury. There is usually no history of previous injury to the knee. There is localised swelling and tenderness over the inferior half of the patella, occasionally a small effusion or mildly decreased range of movement (ROM), and often a decreased ability to weight bear or straight leg raise. The acute episode corresponds to progression from local- ised microfractures to complete fracture. Early diagnosis therefore minimises the need for surgery. The fracture may occur in either a transverse or vertical direction. Radio- graphs are sensitive initially in only one third of cases, and later in only half. A skyline view is essential. MRI or
Human resources for health planning, management and development have been strewn with crises in sub-Saharan Africa including Nigeria . The find- ing in this study that the obstetric workforce is rela- tively young and disproportionately distributed in favour of government-owned tertiary health facilities in urban communities in the southern part of Nigeria is in line with Nigeria’s human resources for health country profile . According to United Nations recommendations, the surgical resources of primary level facilities include the signal functions of Basic Emergency Obstetric Care (EmOC). Secondary level facilities also include Comprehensive EmOC . A tertiary level facility should provide the highest level of surgery , with 24-h by 7 days safe anaesthesia and safe blood transfusion. In Nigeria, there are no- ticeable inadequacies at all three levels of health fa- cilities such that most of the primary and secondary level and even some of the tertiary level facilities do not have the tools for required EmOC . In addition, most obstetricians in this study work in ter- tiary hospitals located in urban communities, thus starving the primary and secondary facilities in rural communities of skilled staff. Moreover, most of the facilities do not have medical doctors [37, 38]. And contrary to what obtains in some other low income countries [6, 39, 40], associate clinicians are not employed to provide EmOC in Nigeria. Hence, poor illiterate women in rural communities and their unborn babies hardly get the needed attention  in pregnancy and childbirth, thereby increasing the prevalence of uterine rupture.
As the NHFS was purpose-built to predict 30-day mortality, it remains unclear whether the tool reliably predicts a broader range of outcomes of importance to patients, surgical teams and healthcare organisations. Therefore, this study aims to provide independent validation and recalibration of the NHFS with regards to mortality, and compare its predictive ability for functional outcomes, residential status, length of stay and postoperative complications against ASA grade and AMTS. These scores were chosen as they are assessed routinely and could provide simple, more reliable prediction of hip fracture outcomes.
treated only in their nondominant eye, the majority gained several lines of near visual acuity. Some of the eyes showed only slight improvement in near visual acuity, which requires further investigation. Only 54.2% of patients treated achieved at least 20/25 distance visual acuity and were also able to read newsprint (equal to J3). The side effects seen to date are minimal, with a slight disturbance of visual acuity during the early postoperative hours due to the cavitation gas bubbles located in the cornea. The technique lacks the disadvantages of some other corneal refractive surgical techniques, with regard to postoperative pain, inflammation, haze, and bio- mechanical instability, due to the preservation of the corneal epithelium and anterior stromal fibers. Further studies with a larger number of eyes and longer follow-up are necessary to characterize this technology more fully.
Bone fragility may be aggravated by osteoporosis subsequent to immobilization, which derives from an antalgic posture, supine obligatory decubitus and splinting. The vicious circle of fracture, immobilization, osteoporosis and refracture must be interrupted. Use of plaster casts needs to be minimized and the use of traction and mobile splints has to be implemented, since stimulating muscular function and forcing early weight bearing, they produce a stress to the lower limb bones that is essential for bone trophism. Progressive improvement in bone strength during adolescence permits better eventual func- tion for patients in whom good skeletal alignment has been maintained. Patients who have been confined to a wheelchair may start walking. The possibility of autonomy at this stage is inversely correlated to the severity of damage and defor- mities, especially to the spine and lower limbs accumulated in preceding years.