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Nonunion of the humerus in a severely osteoporotic bone is a likely event especially if the fracture is transverse. The management of such a combination is a challenge. Most of the conventional fixation methods are unlikely to succeed as the bone failure precedes implant failure in osteoporosis. The challenge is further compounded in severe osteoporosis when the cortical thickness is affected more severely. We used a combination of an intramedullary fibula with a locking plate in 5 cases. The results show that it may be a good combination in such situations as the bone strength is augmented and the plate pullout is less likely.

Purpose Rubber bullets are considered a non-lethal method of crowd control and are being used over the world. However the literature regarding the pattern and management of these injuries is scarce for the forensic pathologist as well as for the traumatologist. The objective of this report was to add our experience to the existing literature. Methods From June 2008 to August 2010 the Government Hospital for Bone and Joint Surgery Barzulla and the Department of Orthopaedics, SKIMS Medical College/Hospital Bemina Srinagar received 28 patients for management of their orthopaedic injuries caused by rubber bullets. We documented all injuries and also recorded the management issues and complications that we encountered. Results All patients were males with an age range of 11–32 years and were civilians who had been hit by rubber bullets fired by the police and the paramilitary forces. Among them, 19 patients had injuries of the lower limbs and 9 patients had injuries of the upper limbs. All patients were received within 6 h of being shot. Conclusion Our findings suggest that these weapons are capable of causing significant injuries including fractures and it is important for the surgeon to be well versed with the management of such injuries especially in areas of unrest. The report is also supportive of the opinion that these weapons are lethal and should hence be reclassified.

This work aimed to study the pattern and epidemiology of pediatric musculoskeletal trauma and consequent morbidity in Kashmir Valley and compare the results with other studies and to formulate preventive measures and devise management strategies. This was a retrospective study of 1467 pediatric orthopedic trauma patients who presented to our hospital over a 3-year period between September 2005 and August 2008. Information was recorded in a prescribed proforma including the following: age, sex, mode of trauma, type of fracture/injury, radiological study, final diagnosis, intervention performed, and complications. The information was collected from the Medical Records Department of the hospital. The children's ages ranged from 0 to 16 years; there were 996 males and 471 females, with males outnumbering females in every age group (the overall male-to-female ratio was 2.12:1). Most fractures occurred in children aged 7-12 years [n=816 (53.96%)] and decreased in younger and older children beyond this age group. The left side was involved in 762 cases, 612 injuries involved the right side, 24 were bilateral, and 69 patients presented with multiple injuries. In children aged 0-6 years, the most common site of injury was the elbow, whereas in children aged 7-16 years, it was the forearm. In descending order, most injuries were sustained because of fall while playing (34.76%), fall from height (33.74%), road traffic accidents (14.92%), and fall from standing height (7.97%). The majority of injuries were caused by unintentional trauma (94.48 vs. 5.52%). The places where injury occurred were the home [603 (41.10%)], play field and orchards near the home [450 (30.67%)], roads [219 (14.92%)], school [183 (12.47%)], and unknown [12 (0.81%)]. The pattern and epidemiology of pediatric trauma differs from those in adults. The majority of musculoskeletal injuries are because of unintentional trauma in this young age group and hence preventable. Enhanced supervision at home and school is recommended. A safer environment and better playing conditions may decrease the high frequency of trauma in pediatric patients. Dedicated trauma centers with such facilities as orthopedics, neurosurgery, and plastic surgery need to be established for the proper management of pediatric trauma.

Background The Gibson and Piggott procedure for hallux valgus is based on sound surgical principles addressing the basic pathologies of this disorder. However, this procedure has not been studied extensively in the literature in comparison to the Mitchell and Chevron osteotomies. Material and methods We report a prospective study conducted on 50 adult feet with hallux valgus. The Gibson and Piggot osteotomy was done on all the feet. Results We obtained 76% excellent and 18% good results with this procedure. Conclusion The results bear out the fact that this procedure is a useful procedure for the management of this disorder.

Tuberculosis of the talus is a rare condition, and the diagnosis can be difficult to make because of inconclusive laboratory and ancillary testing. In such cases, accurate diagnosis and appropriate treatment may require the use of a transmalleolar osteotomy to gain access to the involved portion of the talar body. In the case described in this article, a transmalleolar approach was used to gain access to a lytic lesion of the talar body so as to obtain microbiological and histopathological specimens for diagnostic purposes, and to thoroughly debride the lesion. After 6 years of postsurgical follow-up, the patient was leading a normal life with a full range of ankle and subtalar motion. The rarity of the diagnosis, and the use of the transmalleolar approach to a lytic and likely infected lesion in the body of the talus, makes this case worthy of public discussion.

Purpose.To describe a technique that preserves anterior and posterior alternate ledges in a closing wedge osteotomy.Methods.Five patients aged 14 to 19 years underwent a closing wedge osteotomy for genu valgum in 8 limbs using a reciprocating ledge technique. A unicortical wedge of bone was removed, with the anterior and posterior cortices spared. The anterior cortex at the proximal level and the posterior cortex at the distal level were cut through. With a wobbling action, the osteotomy site was rotated, and the distal fragment externally rotated. Manual force was applied to close the osteotomy site ensuring overlapping of the reciprocal ledges. The distal fragment was translated laterally to prevent club deformity. The osteotomy site was held with one or 2 staples. Stability was tested by flexion and extension of knee.Results.All 8 limbs attained bone union within 12 weeks, and full range of motion within a mean of 13 (range, 12–15) weeks. The mean correction of the tibiofemoral angle was 13°. At a mean follow-up of 12 months, all patients were pain-free and none developed club deformity.Conclusion.Sparing reciprocal ledges in a closing wedge osteotomy for genu valgum may increase stability in the flexion-extension axis, enable early range-of-motion exercises, and facilitate early bone union.

Crowd control has evolved from the baton, bayonet and live ammunition to the use of tear gas, pepper spray and Tasers. In spite of the availability of a wide variety of non-lethal/less-lethal weapons, projectile-based crowd control methods are still used in some parts of the world.[1][1] The recent

PurposeThe purpose of this study was to identify the problems faced by ambulance drivers working in a conflict zone.MethodsThis study was conducted on ambulance drivers working for the four major hospitals in Kashmir, India. The drivers were interviewed and asked a series of 30 work-related questions. The individual interviews were conducted over a three-month period in the valley of Kashmir that was affected by continuous violence, strict curfew, and strikes.ResultsA total of 35 ambulance drivers were interviewed. Drivers worked an average of 60 h/wk, and they drove an average of 160 km/d. Twenty-nine (83%) of the drivers experienced >1 threat of physical harm; 18 (54%) experienced physical assaults; and 31 (89%) reported evidence of psychological morbidity associated with their jobs.ConclusionsThe atmosphere of conflict on the streets of Kashmir impacted the ambulance drivers adversely, both physically as well as mentally. The stress faced by these professionals in conflict zones during their duty hours should be recognized, and corrective measures must be put in place.Dhar SA, Dar TA, Wani SA, Hussain S, Wani ZA, Aazad S, Yaqoob S, Mansoor I, Ali MF, Ahmed M, Mumtaz I, Azhar I. In the line of duty: a study of ambulance drivers during the 2010 conflict in Kashmir. Prehosp Disaster Med. 2012;27(4):1-4.

Foreign body retention in the foot after a penetrating injury is an unusual occurrence with varied presentation. A degree of suspicion needs to be present in situations where there is an inexplicable swelling, sinus, abscess, or tenderness. The authors present a case with a contracture of the third toe that had been caused by plantar fascial fibrosis secondary to retention of a rubber foreign body in the foot. This case report highlights the fact that an ultrasound to rule out retention of the foreign body might be a judicious investigation if common causes of toe contracture are excluded. It may also have therapeutic implications. Level of Evidence: Therapeutic, Level IV

The distal third of the tibia is unique in the sense that it has a minimal muscle cover and consequently the blood supply is easily compromised after a fracture in this area. Infected non union in this area provides a challenge to the orthopaedic surgeon. These difficulties are especially profound in the geriatric age group.12 cases with an infected non union of the distal third of the tibia were managed with acute docking over a distance of up to 2.5 cms. The age of these patients was more than 55 years.The average shortening at final follow up was 1.8 cms. The bone results were assessed according to the protocol laid down by the association for the study and application of the method of Ilizarov. Accordingly we had 3 excellent, 8 good and 1 fair result. The functional result was calculated as per the Ilizarov criteria [1]. On this basis we had 7 excellent, 4 good and 1 fair result.The acute docking modality is applicable to the distal tibia in such situations even in the geriatric population with predictable results.

Penetrating injuries of the foot are a common presenting complaint in the emergency department. The residents of the underdeveloped world are especially prone to suffer such injuries as barefoot walking is still common. However, a relatively common injury that occurs in the shod feet is the “Nail-Slipper injury”. A metal nail penetrates through the rubber sole of the footwear introducing the rubber piece into the soft tissue of the foot. As the nail is removed the piece remains behind often leading to delayed manifestations. This article describes the various delayed manifestations of this injury. A leading question for the antecedent injury of this kind should be asked from all patients with such presentations, especially in the urban setting.