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Background: Pertrochanteric femoral fracture is the most common fractures of the hip especially in the elderly patients with osteoporotic bone, usually due to low-energy trauma like simple falls. Dynamic hip screw (DHS) is still considered the gold standard for treating such factures. Not many studies compare DHS with Proximal Femoral Nail Antirotation (PFNA). We try to compare the efficacy of PFNA with DHS in management of unstable pertrochanteric factors. Aims and Objectives: We aimed to evaluate and compare the clinical and functional outcomes of DHS and PFNA treatment of unstable pertrochanteric femoral fractures in elderly patients. Materials and Methods: This study was a prospective study which included total of 39 patients, 25 patients treated with PFNA and 14 patients with DHS. The study was conducted in Manipal Teaching Hospital from March 1, 2019, to August 1, 2021. All the patients were clinically evaluated and detail history was obtained. After the anesthesia clearance, the patients were operated. Length of skin incision, operating time, intraoperative blood loss, and complications were noted. Postoperatively, the duration of hospital stay, time of partial and full weight-bearing, time for radiological union, and complications were noted. Functional outcome was assessed using Harris hip score at 3 months and 6 months follow-up. Results: The mean age of the patient in this study was 74.68 years for PFNA and 75.57 years for DHS. The average time to complete the surgery was 71 min for PFNA and 92.86 min for DHS. The average blood loss was 162 ml for PFNA and 403 ml for DHS which was found to be statically significant. Partial weight-bearing on axillary crutches was started at the mean time of 3.7 weeks for PFNA and 8.1 weeks for DHS, whereas full weight-bearing was done at the mean of 8.2 weeks for PFNA and 12.1 weeks for DHS. Radiological union was seen at the average of 18.72 weeks for PFNA and 20.14 weeks for DHS which was not statically significant. The mean Harris Hip score at 3 months and 6 months follow-up was 63.84 and 88 for PFNA and 48.50 and 81.43 for DHS, respectively, which showed significantly better result with PFNA. Conclusion: Compared to DHS treatment, PFNA treatment in unstable pertrochanteric femoral fracture is associated with reduced blood loss, shorter operative time, and hospital stay with few intraoperative and post-operative complication. Post-operative rehabilitation with the early mobilization and return to pre-injury status was better with PFNA.

Introduction: The pulled elbow is one of the common conditions in children that bring them to an emergency. Children present with not being able to move their forearms. Methods: We conducted a prospective study of patients presented with a history suggestive of the pulled elbow. Here we study demographic character, clinical presentations, and reduction technique. Results: There were a total of 96 patients with the pulled elbow. The mean age of the patient was 29.62 ± 13.14 months, with boys 27 (28.1%) and girls 69 (71.9%). The left side was commonly involved 67 (69%). History of traction injury is the most common mode of injury. The success rate of reduction by supination-flexion is 87.5%, whereas the success rate of hyper pronation is 95.83%. There was no significant difference between the two methods of reduction (p-value > 0.05). Conclusion: The pulled elbow is common at 2 years, with female children predominant. Click in the region of radial head palpable during reduction confirms the diagnosis and signs of successful treatment. Hyper-pronation was easy, more effective at the first attempt, and the most successful reduction technique.

Introduction: Tibial pilon fractures are difficult fractures mostly secondary to high-energy trauma. There are various options to treat these fractures, but the priority is always an anatomic reduction and articular congruity with good soft tissue handling. The aim of the study was to analyze the functional outcome of tibial pilon fractures managed with a hybrid external fixator as definitive management. Methods: We evaluated 28 patients with tibial pilon fractures with a mean age of 34.8 years. All patients who fulfilled the inclusion criteria were taken to the operating room for debridement and application of a hybrid external fixator. Results: The most common mechanism of injury was road traffic accidents and most of our patients had comminuted fractures. The fibula was fractured in 23 (82.14%) of our patients. The fractures united on an average of 15.28 weeks. Based on the Ovadia & Beals objective scoring system 75% of our patients scored excellent or good on objective scoring and subjective scoring 82.14% of our patients scored excellent or good. We had 12 cases of pin tract infection, 2 cases of delayed union, and 2 cases of malunion but no incidence of non-union, osteomyelitis, or septic arthritis. Eight of our patients had ankle joint stiffness. Conclusion: Hybrid external fixator is an effective method of treatment for tibial pilon fractures with comparable union rate and complications to other modalities.

Introduction: Shoulder dislocations are considered one of the most common joint dislocations. These dislocations are often associated with other injuries. Most of these reductions are done in the emergency department but some may require sedation or general anesthesia. The ideal method should be easy, simple, rapid, painless, effective, atraumatic, and should cause no additional injury to the shoulder joint, nerves, vessels, or musculoskeletal structures. Methods: Fifty-four patients with anterior shoulder dislocation were divided into 2 groups and reduction was done with or without hematoma block. Patients between 18 and 75 and dislocations within 24 hours were enrolled in the study. Spaso method was used to reduce dislocation in all the patients. Demographic data, dislocation side, dominant side, cause of injury, number of dislocations, pre-and post-reduction neurovascular examination findings, reduction time, duration of stay in the emergency department, the presence of a tuberculum majus fracture, and any complications during the pre-and post-reduction period were recorded for all patients Results: Age and gender distributions of patients were similar between both the methods. The majority of the patients were right-handed, and dislocation was in the dominant arm in 74.07 % of patients. The side, number of dislocations, cause of dislocation, presence of tuberculum majus fracture, pre-reduction neurological status, and the success of reduction were similar among both the groups. VAS score was better among the group with the hematoma block though not significant. Conclusion: We suggest that the hematoma block is an effective method to reduce the pain in the treatment of anterior shoulder dislocations as they facilitate pain reduction, muscle relaxation, co-operation from the patient, thus, increasing the success rate and comfort of the patient.

Introduction: Acromioclavicular (AC) joint dislocation is one of the most common shoulder injuries accounting for approximately 9-12% of all shoulder girdle injuries. Rockwood classification of AC joint dislocation is the most widely accepted classification system which classifies the injury into six types. Surgical management with open reduction and fixation with clavicular hook plate without the repair of coracoclavicular ligament has proved to be one of the best treatment options for Type III AC joint dislocations. Methods: Twenty-three patients with Rockwood Type III AC joint dislocation were included in the study. Open reduction was done and the fixation was done with the clavicular hook plate. The functional outcomes were assessed before and two months after the implant was removed using the Constant- Murley Score. Results: A total of 23 patients were included in the study with the mean age of 30.74 years. The plates were removed on an average of 6.43 months and mean follow up was 8.83 months. The functional outcome was assessed using the Constant- Murley Shoulder score. The pain scores were significantly better after the implant removal was done (p= 0.007). The final mean constant score was 74.6 ± 4.11 before removal and 93.91 ± 2.71 after implant removal and all the 23 patient had excellent result (>90 points). Conclusions: The pre-contoured clavicular hook plate has proved to be a good implant option in the fixation of Rockwood Type III AC joint dislocation without the need of any ligamentous repair

Background: Lateral condyle fracture of the distal humerus is the second most common injury around the elbow. Aims and Objective: The purpose of the study was to compare Kirschner wires (K-wire) and Cannulated cancellous (CC) screw for internal fixation of displaced lateral humeral condyle fracture in children. Materials and Methods: Forty-six patients with a displaced lateral condyle fracture of humerus were included in the study. Patients were treated with open reduction and internal fixation either with two 1.8mm K-wires or one 4mm CC screw. Fractures were classified according to Milch classification and clinical outcomes were evaluated according to criteria of Hardacre et al. Results: There were 23 patients in each group with the mean age of 6.57 years (range 2 to 12 years). Milch type II was common (n= 34) than Milch type I (n=12). Fracture union was observed at mean 4.13 weeks in the CC screw and 4.61 weeks in K-wire group.(p value = 0.026). On an average the CC screws were removed at 13.57 weeks and K-wires were at 4.57 weeks. The mean follow-up was 13.83 months in CC screw and 12.52 months K-wire group. Three patients (6.5%) had superficial pin site infection and 2 patient (4.3%) had lateral condyle prominence in the K-wire group and only one lateral condyle prominence (2.2%) was observed in the CC screw group. According to the Hardacre et.al criteria CC screw group were excellent in 20 (87%) and good in 3 (13%) patients whereas 13 (56.5%) excellent and 10 (43.5%) good results were found in the K-wire group. (p value = 0.022). Conclusion: Open reduction and internal fixation with either K-wires or cannulated cancellous screw for displaced lateral condyle fracture of humerus are both effective treatment methods but screw fixation provides absolute stability at the fracture site enhancing the fracture healing, reduces the probability of lateral prominence and allows early range of motion and activity in the affected elbow.

Background: Distal radius fractures are one of the commonest injuries only after clavicle fractures. These fractures poses challenges to the treating surgeons as a result of which these fractures are sometime treated unacceptably and leads to poor outcome. Among various treatment options for these fractures wrist sparing Cobra external fixator is one of the options with an impressive stability and outstanding functional outcomes.Aims and Objectives: To determine whether this system can achieve adequate reduction of a variety of DRF, is able to maintain reduction despite hand and wrist movements, whether it compromises hand and wrist functions and leads to long term problems.Materials and Methods: From July 1, 2016 - June 30, 2017, all skeletally matured patients with acute distal radius fractures (AO-A2, B1, C1, C2) were adequately reduced and fixed with Cobra ex-fix. Immediately post-op patients were encouraged to start range of motion of the wrist as the pain decreased. The patients were followed up in 2,4 and 8 weeks and were analyzed clinically, radiologically, their functional outcomes and any complications.Results: Twenty-two patients were included in our study. Nine were males and 13 were females. Using the AO classification, 15 were classified as A2, 2 were B1, 3 were C1, and 2 were C2. The mean number of weeks the cobra fixator was maintained was 5.3 weeks. The Cobra ex-fix was able to achieve excellent maintenance of radial height and radial inclination and good maintenance of dorsal tilt. Recovery of functional activities according to Gartland and Werley’s functional scoring system was good to excellent in all patients at 8 weeks follow-up.Conclusion: The Cobra external fixation system is an outstanding device for use in fractures of the distal radius. It achieves superior anatomic correction and is dependable in maintaining fracture reduction even with hand and wrist use.Asian Journal of Medical Sciences Vol.9(6) 2018 84-89

Background: The treatment of proximal and distal diametaphysealtibial fractures remains controversial. This study was performed to evaluate the results of Locking compression plate using MIPO technique in the management of proximal and distal diametaphysealtibial fracture.Aims and Objective: To analyse and observe the result of management of metaphyseal fractures of tibia with respect to operative technique, stability of fixation, union of fracture, post-operative range of motion and complication. Materials and Methods: The study was prospective study. Forty two patients who sustained fractures of proximal and distal dia-metaphyseal tibial fractures with or without articular involvement were included in the study and treated by employing the concept of Minimally invasive plate osteosynthesis during period of August 2015 to December 2017 and followed up at regular interval with minimum six months to thirty months. Intervention: Surgical reduction and fixation of fracture using proximal and distal anatomical locking compression plate followed by rehabilitation. Main outcome measure: Radiological outcome, perioperative and postoperative complication, postoperative alignment, range of motion.Results: All fractures got united with the average duration of 22.7 weeks for proximal metadiaphyseal tibia and 19.9 weeks for distal diametaphysealtibia. There were 3 delayed union cases which got united without any surgical intervention. Deep peroneal nerve palsy was seen in 2 cases with proximal tibia fracture treated with longer plate. 2 cases of superficial infection and one deep infection seen with proximal diametaphyseal fracture and 2 superficial infection with one case of wound dehiscence and implant prominent seen with distal diametaphyseal tibia fracture. No malalignment or angulation of more than 10 degree occurred in any plane for both proximal and distal diametaphyseal fractures.Conclusion: MIPO provides stable fixation with excellent union rate with minimal complication for both proximal and distal diametadiaphysealtibial fracture.Asian Journal of Medical Sciences Vol.9(6) 2018 76-83

Background: Distal tibia fracture is one of the difficult fractures to manage. There are many treatment options from conservative management to operative management. Each treatment methods have its advantages and disadvantages. Minimally invasive percutaneous osteosynthesis (MIPO) in distal tibia fracture has better outcome due to the advantages of minimal soft tissue dissection, preservation of periosteum and fracture hematoma. There is indirect reduction of fracture with correction of axial and rotation malalingement.Aims and Objective: The aim of the current study was to evaluate the functional and clinical outcome of distal tibia fracture treated with distal tibia anatomical contoured plate by MIPO technique.Materials and Methods: This was a prospective study that included 56 patients of which 37 were males. 31 patients had right sided distal tibia fracture. The most common mechanisms of injuries were road traffic accidents and fall injury. There was 6 cases of type I open fracture and 3 cases of type II open fracture. The patients were followed up at2 weeks, 6 weeks, 3 months, 6 month and 12 months’ time.Result: The mean age of the patients was 45.89 years. The mean time for partial and full weight bearing was 7.29 weeks and 14.29 weeks respectively. Radiological union was seen at 17.75 weeks. There was no case of nonunion or delayed union. The most common complication was ankle stiffness (5/56). Conclusion: MIPO is a good treatment option for unstable distal tibia fracture because of minimal soft tissue dissection and preservation of periosteum and fracture hematoma.Asian Journal of Medical Sciences Vol.9(5) 2018 73-76

Background: Distal Radius Fractures (DRF) are common fractures with variety of complications if treated inadequately. Among them, Distal Radio-Ulnar Joint (DRUJ) instability is one of the common residual disabilities leading to chronic and persistent subluxation or dislocation of the DRUJ which causes arthritis, pain and limitation of the hand functions. Aims and Objectives: This study aims to identify the factors either clinical of radiographic, indicative of DRUJ instability patients in acute DRF which may help the orthopedic surgeons to correctly diagnose and allow proper treatment.Materials and Methods: All patients from Aug 1, 2016-July 31, 2017 with acute DRF who were treated at Manipal Teaching Hospital were examined and evaluated for DRUJ instability. The demographic, clinical and radiological parameters of all the patients were analyzed and compared with those with stable DRUJ. Preoperatively all the fractures were classified using AO classification. Based on the classification, the association of fracture comminution, and intra-articular involvement with DRUJ instability, as well as its relation to the osteoporotic age was analyzed. Associated ulna styloid fracture and sigmoid notch involvement if present was noted with its size and displacement.Results: Out of 74 wrists, there were 30 males and 44 females, with a mean age of 44 (range 18-79). Most of the females (72%, n=32/44) sustained low energy trauma, while most of the males (77%, n=23/30) sustained high energy trauma. Irrespective of the sex, it was noted that DRUJ instability was significantly higher in males (p 2mm and 28 (80%) was undisplaced.Conclusion: Factors associated with DRUJ instability in DRF were young male patients, high energy trauma, displaced ulnar styloid base fractures, sigmoid notch involvement, AO type C.Asian Journal of Medical Sciences Vol.9(5) 2018 62-66