Data collected throughout history, basic clinical examination, laboratory investigations and outcome measures coded, entered and analyzed using Microsoft Excel software. Data were then imported into Statistical Package for the Social Sciences (SPSS version 20.0) (Statistical Package for the Social Sciences) software for analysis. According to the type of data qualitative represent as number and percentage , quantitative continues group represent by mean ± SD , the following tests were used to test differences for significance;. difference and association of qualitative variable by Chi square test (X2) . Differences between
Background Supracondylar humeralfractures are one of the most common skeletal injuries in children. In cases of displacement and instability, the standard procedure is early closed reduction and percutaneous Kirschner wire fixation. However, between 10 and 20 % of patients pres- ent late. According to the literature, patients with neglected fractures are those patients who presented for treatment after 14 days of injury. The delay is either due to lack of medical facilities or social and financial constraints. The neglected cases are often closed injuries with no vascular compromise. However, the elbow may still be tense and swollen with abrasions or crusts. In neglected cases, especially after early appearance of callus, there is no place for closed reduction and percutaneous pinning. Tradition- ally, distal humeralfractures have been managed with surgical approaches that disrupt the extensor mechanism with less satisfactory functional outcome due to triceps weakness and elbow stiffness. The aim of this study is to evaluate the outcome of delayed openreduction using the triceps-sparing approach and Kirschner wire fixation for treatment of neglected, displaced supracondylar and distal humeralfractures in children.
There was neither early superficial nor deep infection. No vascular or neurological complications were noted. Mean SST score was 9.95. No differences between DCP and LCP fixation was noted (P=.27). Fixing tuberosities was not correlated with the SST (Simple Shoulder Test) score (P=.73). Latest x-ray evaluation showed 4 NHH. No correlation was found between functional outcome and the development of NHH (P=.18). Malunion was found in 6 patients (3 varus, 3 valgus). Perforation of the articular surface from long screws was noted in 3 patients. Intraarticular screw had no effect on functional outcome (P=.3).
14 The Iliacus fascia gives a vertical expansion extending along the pelvic brim from anterior sacroiliac joint to pectineal eminence called Iliopectineal fascia . This forms a distinct band between two compartments below the inguinal ligament – Lacuna musculosum containing iliopsoas , femoral nerve and lateral cutaneous nerve of thigh and Lacuna vasculorum containing femoral vessels and lymphatics. Careful identification of this fascia is essential in ilioinguinal approach.
The fracture is transverse extending from just above the epicondyle and entering the thin area separating the coronoid and olecranon fossa. The fracture line is totally metaphyseal, lying usually at the anterior and posterior capsular origins. In many cases sharp protruding spikes involve the conical process of the respective supracondylar ridges. These sharp medial and lateral spikes of bone can damage the surrounding soft tissues, and may be an impediment to the reduction of fracture segments.
There were 24 intra articular fractures in 22 patients in 1 year which were treated. Mean patient age was 35 years.20 patients were male (90.9%) and 2 were females (9.1%). Right Calcaneum was involved in 12 cases (50%),8 cases (33.33%) had left Calcaneum fracture, 2 cases (16.66%) had bilateral calcaneum fractures. Mechanism of injury was fall from height in all patients. 2 patients (9.09%) had associated vertebra fractures without neurological deficit. Patients were evaluated clinically and radiologically, lateral (Fig.1.), axial (Fig.2.) radiographs of Calcaneum were taken. A routine pre operative Computerized Tomography (Fig.3, ) was taken. Sanders system 3 (Table 1) was
most probably more active .the left more than right, this is for unknown reason, although all cases are right hand dominant, these finding similar to result of Song KS et al and P.S. Marcheix et al (Song, 2010 and Kwang Soon Song, 2008). All patients have similar mechanisms which are fall from height (wall, furniture, etc.) (Robin Smithuis, 2012) except three cases; road traffic accident, fall during sport injury and third case fall on flexed elbow. It's more difficult to decide the specific type of mechanism whether compression or pulling off in our locality because the parent are not well descriptive the sort and the detail of injury history, this Corresponds to a study done by Eksioglu et al (2008), Kirkos et al. (2003) and Pouliart & De Boeck (Pouliart, 2002 and Jakob, 1975). Openreduction and internalfixation is necessary in cases of unsatisfactory reduction, completely displaced, rotated fragments and in long-standing untreated cases hence it is fracture of necessity means that reduction can seldom be achieved by closed means because the fragment is frequently rotated by the pull of the wrist extensor muscles attached to it and cannot be replaced by manipulation, nor can it be held in the reduced position simply by a plaster cast (Johnm, 2010 ; Canale and Beaty, 2008 and Kwang Soon Song, 2008). These are identical to our series where the Jakob et al advocated openreduction and internalfixation for stage II and III (Jakob, 1975 and Launy, 2004). Jakob I (less than 2 mm) can be treated conservatively, also an undisplaced fracture treated by long cast for 4 weeks. Although this method is safe, but needed closed observation every 5 to 7 days. Good quality plain radiographs of the elbow (best taken with the cast off) are obtained to make sure that the reduction has been maintained
The patients were trained to perform a set of exercises consisting of forced active and passive mouth opening. The training was aimed to correct the jaw’s alignment to achieve a satisfactory range of movements. The patients treated for unilateral condylar fracture were instructed to stand in front of a mirror and apply gentle force using their fingers to open the mandible along a straight line, using the upper interincisive line as the reference line; in addition, the gradual recovery of the normal range of jaw movement was encouraged. Use of left and right lat- erality, with particular attention to the movement of the side contralateral to the fractured side, was recom- mended. Furthermore, the rehabilitation of protrusion as well as correction of lateral mandibular deviation of the fractured side was encouraged. The patients treated for bilateral condylar fracture received post-surgery physio- therapy in the same manner described above. We suggest particular attention be paid during protrusive mandibular movement. The patients were instructed to perform the exercises 3 times a day, with 10 minutes spent for each movement. In cases where the Balter’s bionator was used, the device was built by taking the construction bite in maximum protrusive in case of bicondylar fracture and in contralateral laterality in the case of unilateral condylar fracture. The patients were recommended to use it for as long as possible every day.
Associated fractures of the coronoid process and olec- ranon were fixed concomitantly. After fixation, the sta- bility of the fixation and the range of movement of forearm rotation were checked. The radial head and proximal radioulnar joint were examined by fluoroscopy to ensure extra-articular screw placement. The capsule and annular ligament were closed with absorbable su- tures. Avulsion of the lateral collateral ligament occurred in 13 patients; reattachment to the lateralcondyle was performed with a transosseous suture in 4 patients and with bone anchors (Johnson & Johnson Co., America) in 9 patients [16, 17]. Finally, stability of the elbow was tested by the hanging arm test in patients with terrible triad injuries . If unacceptable instability persisted, then the medial collateral ligament was exposed and repaired (in two patients).
During functional activity there are tensile strains at the antero - lateral border, compressive strain along the posterior-medial border and permanent latero medial bending of the condyle 4 . These principles mandate that, in order to provide the best possible bio functionality, the plates must be placed along the ideal lines of osteosynthesis. The plate is trapezoidal in shape, so that the anterior arm of the plate can be superimposed over the tension lines under the sigmoid notch. Because of their grids form, the TCP plates belong to 3D plates which were developed by Farmard 46 in nineties. The 3D plates were developed to offer
Surgical treatments for PHFs include openreduction and internalfixation (ORIF), closed reduction and internalfixation (CRIF), hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA) (Fig. 1) . Since the development of the biomechanically more advanta- geous locking plates and locking intramedullary nails, the surgical indications for ORIF have been extended to elderly patients with osteoporosis [9, 10]. However, for both devices, high implant-related complication rates and reoperation rates have been reported [11 – 13]. Although HA may be an attractive treatment method for comminuted fractures in elderly patients, it is known to have poor outcomes when nonunion or malunion of the tuberosity occurs [14, 15]. RSA has recently been used to treat PHFs in elderly patients and reported to
There is an increasing trend of shaft of humerus fractures being treated operatively . Denies  in his study compared conventional plating with intramedullary interlocking nail in 91 patients. He reported high complica- tion rate with intramedullary nail and suggested plating as primary treatment for humeral shaft fractures. In most instances dynamic compression plating is preferred   . The most commonly used approach are the post- erior and anterolateral approaches  . Oh  in his study compared openreduction with internalfixation and minimally invasive plate osteosynthesis in humeral shaft fractures he reported no difference in fracture un- ion however radiation hazard was high with mippo technique. Boschi  in his study concluded subbrachial ap- proach as practical and effective and the loss of muscle strength was significantly less with subbrachial approach. In our study medial plating was done through anterolateral approach without splitting the brachialis, the brachia- lis was elevated and retracted laterally
fixation (ORIF), the humerus has traditionally been approached posteriorly. The posterior approach offers bio- mechanical advantages due to the ability to apply the plate on the tension side of the humerus (Fig. 1a-c) . Never- theless, there are different surgical approaches for treating humeralfractures [10, 11]. The anterolateral approach  and its modifications are widely employed for expos- ure of the humerus in various pathological conditions [13–16]. The anterolateral approach allows supine posi- tioning, which is the most notable advantage for patients with multiple injuries . According to Orthopaedic Trauma Association (OTA) techniques, the anterolateral approach is frequently used for lateral plating, which in- cludes the risk of secondary nerve injury [17, 18]. Anterior plating was delineated years later (Fig. 2a-d) . How- ever, there are limited reports on the use of an anterolat- eral approach for the surgical treatment of midshaft fractures with anterior plating. Therefore, we conducted this study to assess the results of the treatment of a series of our patients with humeral midshaft fractures with an- terior plate fixation and compare these results to those achieved in patients treated with posterior plating regard- ing the healing rate and occurrence of procedure-related complications. We hypothesized that compared to poster- ior plating, the anterolateral approach with anterior plat- ing results in an equal union rate, a reduced rate of
In fact, we used plain anteroposterior (AP) and true lat- eral (Lat) radiographs to measure the displacement of LC or assess the fracture union. Therefore, we did not order a CT scan to evaluate the pattern or the union of the fracture. Our inclusion criteria consisted of more than 21 days elapsed from untreated injury, displacement more than 2 millimeters, and having at least 6 months follow up pe- riod prior to report the results. We excluded the patients who received any surgical treatment before their admis- sion including closed reduction and percutaneous fixation as well as those who expressed a history of previous trauma to the same elbow. We also excluded the patients who had a follow up duration of less than 6 months at the last visit prior to reporting the results.
Procedure: All cases were initially assessed and admitted in the Accident and Emergency department for Bone and Joint hospital GMC Srinagar. They were provided first aid in the form analgesia, splintage and other resuscitation measures. In case of compound fractures wound wash and wound debridement was done besides starting I/V antibiotics and checking the tetanus immunization status. Compound fractures were classified according to Gustilo and Anderson classification. The patients were subjected to history taking, thorough clinical examination with analysis of preoperative radiographs. The radiographic analysis includes evaluation of standard antero-posterior and lateral views of X- rays of the wrist joint of bilateral upper limbs.
because of the small Size of fragments and poor resistance of porous bone. These mechanical obstacles are increased by the risk of avascular necrosis. [10, 22, 12, 23] That is why some surgeons [5, 24, 25, 27] recommend the use of the humeral prosthesis. Others [8, 28, 29, 30, 31, 26, 32, 33] were disappointed by the modest functional results of prosthetic replacement and the tendency. [34, 35, 36, 9, 10, 11, 37] The discussion of the best treatment is obscured by the fact that Conventional osteosynthesis methods do not allow an anatomical reduction of the complex fractures of the elderly, nor a stable fixation of the fragments to allow an early mobilization. In this study, we have developed an implant called "Bilboquet" that allows for an early reduction of all fractures and stabilizes them. [38,
Anatomic reduction, meticulous soft tissue handling , proper plate positioning, accurate screw trajectory and supervised operative rehabilitation in our study enabled mean recovery of ~ 82% in wrist range of motion & ~85% in grip ctional impairment at the final follow up when compared to the contra-lateral side. With the use of Gartland and Werely evaluation scale (Gartland and Werley, , we had 84% excellent, 14% good and 2% fair results. articular congruency is an important cause of post traumatic arthritis, which may not always correlate with the outcome scoring systems. Volar locked compression plate are very useful in achieving anatomical reduction, particularly in displaced unstable intra-articular Fitoussi and Chow, 1997; Adani et al.,
So improved understanding of the complex patho-anatomy of unstable distal humerus fractures in adults has prompted a global interest in more precise treatment for this diverse group of injuries. Surgeons who treat fracture of the distal humerus frequently have realized the challenges that arise related to poor bony quality, distal separation of the articular fragment from the columns of the distal humerus and fragmentation of the articular surface in one or more planes. Varying patterns of distal humeralfractures are common in adults. Malunion and nonunion are also common. Even minor irregularities of the joint surface of the elbow usually cause some loss of function.
rated by two independent observers on the basis of antero- posterior and transscapular Y-view radiographs, two- and three-dimensional computed tomography, if applicable, and intraoperative fracture visualization obtained from operation notes. There were 19 two-part fractures, 11 three- part and 3 four-part fractures (12). Injury mechanisms in- cluded high-energy trauma in 13 patients and a fall from a standing height in 20 patients. The American Society of Anesthesiologists (ASA) classification was ASA-1 in 14 pa- tients, ASA-2 in 13 patients, ASA-3 in 5 patients. Among these 33 patients 2 were treated with percutaneous K-wires, 5 with screws, 3 with intramedullary nails, and 23 with a lock- ing plate and screws (Table 1).
One of the reasons for the poor result of previous studies has postulated to a residual displacement of 10mm and more was critical for a significant increase of residual pain . Semba et al also reported a correlation of primary anterior and posterior displace- ment exceeding 10mm being correlated with a markedly higher incidence of severe low back pain . Holdsworth in 1948 reported that 50% of the patients they studied re- turned to their original job . Our study showed that 7 patients returned to their original jobs. In the largest series of patients treated with openreduction and internalfixation of unstable posterior pelvic injuries, 67% returned to their former jobs without restrictions . In other study where all fractures were reduced operatively to less than 10mm of residual displacement; 35% of patients had neurologic injuries, and another 23% had associated injuries inhibiting nor- mal gait. Females with pelvic fractures tended to have increased urinary complaints and dyspareunia, which were shown to cor- relate with residual displacement of >5mm .Our study has shown that anatomical restoration of the pelvic ring correlated with higher probability of a good functional and clinical outcomes.