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Introduction: Aneurysmal bone cysts (ABC’s) are expansile, tumour-like vascular lesion. They are more commonly seen in the metaphyseal region of long bones. They are benign lesion although malignant transformation has been reported. Usually presents in the first three decades of life. Common presentation is pain, swelling, or fracture. Proximal femur with ABC’s is a rare entity and with physeal extension is even sparse. Case Report: A 13- year-. old female presented in the orthopaedic emergency with complaints of pain in the right hip region following a trivial fall. Following trauma, the patient was unable to stand or walk. On examination, there was tenderness in Scarpa’s triangle, straight leg raise test was not possible and limb was in external rotation. Plain radiography revealed an inter-trochanteric fracture with cystic lesion in the proximal femur extending till until epiphysis. MRI of the proximal femur showed an air fluid level with septations and soft- tissue oedema suggestive of aneurysmal bone cyst ABC’s. The patient was managed by intra-lesional curettage with fibular strut grafting along with cancellous bone graft and fixation by Uni-planar external fixator. Conclusion: Pathological Fractures fractures of proximal femur management is are a challenge for an orthopaedic surgeon due to its location and biomechanical factors. Treatment of proximal femur ABC’s should be case dependent. In our opinion, aneursymal bone cyst of the proximal femur with physeal extension can be managed by external fixation along with extensive curettage and bone graft. Keywords: Aneurysmal bone cyst, proximal femur, external fixation

Introduction: Proximal humerus fractures account for 4-5% of all fractures and could be managed both conservatively and surgically. As much as 85% minimally or non-displaced fractures can be managed conservatively. In spite of early union and exercise programme by conservative treatment, the problem of shoulder stiffness is common. To overcome stiffness, early mobilisation is mandatory which is not possible in conservative treatment before three weeks. Therefore, surgical intervention is needed for early mobilisation and early return of function. Aim: To compare the functional outcome between the four common methods of managing proximal humerus fractures namely locking plate, Joshi External Stabilisation System (JESS), percutaneous K-wire fixation and conservative method. Materials and Methods: Patients with proximal humerus fracture above 18 years of age between August 2011 to August 2013 were included in the study. The study population was divided into four groups viz., Group A, B, C, D depending on the mode of treatment by locking plate, external fixator, K-wire fixation and conservative method of treatment, respectively. The patients were followed-up at 3 weeks, 6 weeks, 12 weeks, 18 weeks and thereafter every 6 weeks’ interval till 9 months. After union, cases were evaluated radiologically and clinically for functional results by using the Swanson Shoulder Score and Constant Scoring System (Modified). Results: At the end of the study there were 17 patients in the Group ‘A’, 7 patients in the Group ‘B’, 7 patients in the Group ‘C’ and 11 patients in Group ‘D’. At 9 months of follow-up according to modified constant shoulder score the percentage of excellent score in group A was maximum. Group B and Group D had maximum number of good scores. The mean constant shoulder score increased in all groups at 9 months of follow-up as compared to 3 months of follow-up except in group D. Similarly, according to Swanson’s shoulder score, group A had the maximum number of excellent scores. Conclusion: From the above study it can be concluded locking plates are an excellent modality of treatment of proximal humerus fractures with excellent union rate and early mobilisation.

The deltoid is the preferred site for intramuscular injection (IMI) because of its easy accessibility for drug and vaccine administration. Government immunization advisories, standard anatomy textbooks, and researchers have proposed various injection techniques and sites, but specific guidelines are lacking for the administration of IMIs in the increasingly used deltoid site. This study analyzes the procedures of administering IMIs in the deltoid related to the neurovascular network underlying the muscle and proposes a preferred site with the least chance of injury. The review protocol was submitted with PROSPERO (ID: 319251). PubMed, Google Scholar, and Websites of National Public Health Agencies were searched from 1950 up to 2022 for articles, advisories, and National Immunization Guidelines using Medical Subject Headings (MeSH) terms, including IMIs, deltoid muscle, safe injection sites, to identify recommendations for safer sites and techniques of administering deltoid IMIs. All the authors strictly adhered to a well-developed registered review protocol throughout the study and followed the risk of bias in systematic reviews (ROBIS) guidance tool. The proposed sites and landmark data were tabulated, and each site was analyzed based on the underlying neurovascular structures. Data were depicted by self-generated images. The initial search identified 174 articles. After applying the inclusion and exclusion criteria, 57 articles were shortlisted. Out of the 39 selected articles, 18 focused on the administration of deltoid IMIs, whereas seven focused on the variations in the underlying neurovascular structures in proximity to the deltoid muscle. The remaining 14 articles were the immunization guides issued by the National Public Health Agencies of the Government of India and abroad, whose data was used for comparison. Twelve deltoid IMI sites and techniques were identified. A site 1-3 fingerbreadths/5 cm below the mid-acromion point (7 studies); mid-deltoid site/densest part of the deltoid (1 study); a site at the middle third of the deltoid muscle (1 study); triangular injection site (1 study). Limitations included the unavailability of free access to complete text in many articles resulting in exclusion. The area around the shoulder joint and up to the lower level of the intertubercular sulcus is highly vascularized by the presence of many anomalous arterial patterns. To avoid injury, a safer site is proposed of 5 fingerbreadths/10 cm below the midpoint of the lateral border of the acromion. The authors received no specific funding for this study except for the journal publication charges.

Introduction The use of a drain after various types of arthroscopic surgeries has long been debated. Whether a drain offers an advantage in terms of pain, swelling, and functional outcome after arthroscopy-assisted reconstruction of the anterior cruciate ligament (ACL) needs to be investigated. This study was designed to assess the validity of the use of an intra-articular drain after routine arthroscopic ACL reconstruction and to assess the various complications associated with its use. Material and methods Forty-four patients (group I included patients for whom an intra-articular drain was used and group II included patients for whom an intra-articular drain was not used) diagnosed with ACL injury were included in the study. The patients in group I had a drain placed inside the joint, while those in group II had a drain placed outside the joint cavity but the drain placement was such that there remained no patient or observer bias. Results Outcome assessment was performed on days one, two, and three followed by weeks one, four, and eight, and six months after surgery by determining a visual analog pain (VAS) score. The assessment was also done for the range of motion (ROM) in terms of loss of flexion and extension with a hand-held goniometer, knee hemarthrosis, and thigh circumference. Although there was a difference in both the groups in terms of the above-mentioned parameters in the early post-operative period, the difference becomes insignificant at the final follow-up at six months. Conclusion From this study, we conclude that putting an intra-articular drain after ACL reconstruction offers no advantage in terms of functional outcome in the long term.

Conflict between patient and health care professionals is increasing over time. Traditionally, the medical profession has been considered the most honourable profession and the professionals are held with great esteem as they are considered next to God. Unfortunately, there seems to have been developed a distinct discord between the patient and the health care professional relationship with disturbing incidents catching the headlines. These conflicts range from simple disagreements to major violence against the very people who are trying to undertake patient’s care. Ultimately, it is in the best interest of both the patient and the health care professional to have a harmonious relationship based on utmost trust which is the very keynote of mutual understanding resulting in the benefit both of them. Authors are now trying with deep sincerity for mitigation of distrust and exploring possible resolution strategies to apply in clinical practice in order to overcome them.

Introduction: Sleeve fracture (SF) represents an unusual type of patellar fracture and has been reported mainly in children or adolescents. Superior pole fracture in adults is a very rare occurrence because the enthesis of the adult patella is more resilient to avulsion injury as compared to an immature pediatric skeleton. Due to the rarity of these fractures in adults and vague radiographic findings, the chances of missing the fracture are very high. Case Report: An 18-year-old boy presented to our outpatient department with a history of fall while trying to jump across a wall 6 months ago. At the time of presentation, the patient mainly complained of loss of active extension of the knee in the sitting position and a palpable gap over the upper part of the patella. After radiographic evaluation, a diagnosis of SF was made. The patient was managed surgically, and thereafter, early rehabilitation was done. After 10 weeks post-surgery, the patient was free from any pain, had a full range of motion, and was able to walk without support. Conclusion: Adults presenting with acute injury to knee with limitation of extension and palpable gap over the superior pole of the patella, a differential diagnosis of SF must be suspected and should be ruled out by clinical examination and relevant investigations. Keywords: Sleeve fracture, patella, superior pole, adult.

Background Interlocking intramedullary nail is used for almost all types of femoral shaft fractures worldwide because of its better mechanical stability. In countries like India with limited healthcare infrastructure, the use of Kuntscher nail (K-nail) in Winquist type I and type II isthmic fractures is still debated. Therefore, we conducted this study to compare the functional outcome, radiation exposure, and cost of the implant between closed reduction and internal fixation of Winquist type I and II fractures in the middle one-third shaft region by K-nail and intramedullary locked nails (IMILN), respectively. Methods This was a hospital-based non-blinded randomized trial which included 56 patients with closed Winquist type I and II femoral shaft fractures of the middle one-third femoral shaft (isthmic and paraisthmic zone). All the patients were either treated by K-nail or IMILN. The patients were followed up every three weeks for the initial six months and quarterly thereafter. Per operative duration of surgery and radiation exposure by C-arm was documented and assuming scattered radiation 20%, radiation exposure to the surgeon was calculated and patients were assessed clinically and radiologically for union. Results The patients were divided into two groups: group I (K-nail, n = 25) and group II (IMILN, n = 31). In groups I and II, the patients achieving radiological union were 88% (n = 22/25) and 84% (n = 27/31) at six months' duration, respectively. The mean duration for the radiological union was 3.65 ± 0.55 months in group I (K-nail) and 3.76 ± 0.59 months in group II (IMILN), respectively. There was no statistically significant difference in the duration of the union (p = 0.4963). The average number of C- arm exposures was 16.36 ± 3.18 in group I as compared to 27.29 ± 4.01 in group II, and the mean scattered radiation was 5.0 ± 1.63 in group I and 6.61 ± 4.06 in group II. This difference was statistically significant. Conclusion Kuntscher intramedullary nailing can provide comparable rates of union as is achieved with interlocking intramedullary nailing with an advantage of less radiation exposure and duration of surgery, provided the patient selection is proper (isthmic and paraisthmic zone).

Introduction:Tibial spine fractures are common injuries and various techniques have been described for the fixation. The purpose of the article is to make familiar with thearthroscopic fixation of the anterior cruciate ligament bony avulsion injuries using non absorbable sutures and simple methods and instruments. Adequate reduction, anterior cruciate ligament integrity and regaining the bio-mechanics of the knee are the ultimate goal to be achieved failing which non union and malunion ensues. This technique has resulted in achieving excellent results and thus avoiding complications like joint laxity, flexion deformity&pain.Methods:Twenty one patients underwent arthroscopic suture fixation of the comminutedtibial spine fractures. Mean age of the patient was 24.28 years (range 16 to 38 years). All of the patients belonged to the Meyer type IV. The mean duration of follow up was 15.5 months with a minimum of one year follow-up.Results:All patients showed negative Lachman test except one having grade 1 positive lachman. No patient showed extension loss. 90.4 % (n=19) patients had an IKDC grade A while two patients belonged to grade B. All patients returned to their previous activity level. Conclusion:The above excellent results show that arthroscopic suture fixation of the comminutedtibial spine is promising and reliable technique to achieve the best biomechanics of the knee.

Osteoarticular tuberculosis comprises 10-15% of the all cases of extrapulmonary tuberculosis. Tubercular involvement of the sternoclavicular joint is very rare. We hereby present a rare case report of the 38 year old female with sternoclavicular joint tuberculosis with cold abscess. The diagnosis was confirmed by FNAC and on ZN staining AFB was isolated. Patient was managed successfully by the anti-tubercular therapy at the end of the treatment. So, a degree of suspicion of the tuberculosis at these rare sites along with investigation followed by anti-tubercular therapy leads to successful treatment of the disease.

The tubercular involvement of the long bones of the extremities is very rare so, tuberculosis as a differential diagnosis is usually missed when a patient present with pain and swelling over long bones. The radiology is usually suggestive of the malignancy. We hereby present a case with pain and swelling over the ulna with a suspicion of malignanacy, but biopsy and per-operative findings were suggestive of tuberculosis.

Osteochondroma is one of the most common benign tumors arising from the ends of the long bones which are characterized by irregular bony growth covered by cartilaginous cap. The tumor mass tends to grow eccentrically more, rather than centrifugally. We are reporting a case of 17 year old female who presented to our Outpatient department with large, hard, painful, irregular swelling over anterolateral aspect of right knee. After a series of radiographic screening and its confirmation through CT the tumor was surgically excised and histopathological reports showed benign nature of the tumor mass excised.

Introduction: Humerus shaft fracture is one of the most common injuries to the musculoskeletal system, which are managed both conservatively and surgically. There are pitfalls, advantages and disadvantages in each method. The individual fracture analysis determines the therapeutic options. Aim: To assess the clinical outcome of treatment of diaphyseal fractures of humerus treated by Titanium elastic nail in adult age group by DASH scoring. Materials and Methods: It was a prospective study of 20 cases of diaphyseal fracture of humerus admitted to Era’s Lucknow Medical College and Hospital between October 2014 and September 2015 treated with close reduction and internal fixation with titanium elastic nail. Functional outcome was evaluated using DASH scoring system and radiological outcome was evaluated by serial radiographs. The data was processed with SPSS software version 16.0 (Chicago, inc. USA) and it was summarized in proportion and percentage. Results: In our series of 20 patients, 17 were males and three were females. Most of the patients were between 30-50 years of age (mean 38 years). Most common mode of injury, side of involvement, level of fracture and fracture type were road traffic accidents (60%), right side (53.3%) and mid one third (75%), transverse (60%) respectively. So, in 65% of the patients, there was no disability of arm shoulder and hand as DASH score was within normal range and in 15% of the patients the disability was mild to moderate as scoring was slightly higher than normal and in 20% the disability was severe as the DASH score could not be calculated because of non union. Conclusion: Elastic nail fixation require very minimal soft tissue dissection and being a close reduction, the biology of the fracture is also not disturbed and the chances of nerve injury are much less and as the non union was seen in oblique and spiral fracture type hence it should be used with caution or else other alternative methods of fixation should be used.

Introduction: Many techniques of graft placement in Arthroscopic Anterior Cruciate Ligament (ACL) reconstruction is available nowa-days, like trans-tibial, anatomical accessory medial portal and anatomical all-inside technique. Aim: To compare the improvement in clinical status of patients treated by anatomic accessory medial portal and all-inside arthroscopic ACL reconstruction technique pre-operatively postoperatively using International Knee Documentation Comittee (IKDC) Subjective Knee Scores, Lysholm Knee Score, Knee Society Score, Lachman test, Visual Analog Score (VAS) in both the groups. Materials and Methods: After informed consent from patients and clearance from Ethical Committee, we included patients aged 18 to 50 years with ACL injury and clinical laxity admitted in Department of Orthopaedics, King George Medical University, Lucknow. We included 100 patients in the study, which were divided into two groups, Group1 comprised of patients treated by Anatomic accessory medial portal technique and group 2 comprised of patients treated by All-Inside technique. Then the patients were followed up post-operatively at 6 weeks, 12 weeks and 6 months, clinically for functional status using Lysholm Knee Score, IKDC Subjective Knee Score, Knee Society Score and VAS score. Grading of laxity was evaluated by Lachman test at preoperative stage and 6 months follow-up. After collection of the data, analysis was carried out on SPSS software version 16.0 (Chicago, inc. USA) and the statistical test that was used was 2-Way Analysis of Variance (ANOVA). Results: IKDC Subjective Knee Score, Lysholm Knee Score, Knee Society Score, Lachman Test and VAS Score was better in group 2 treated by All-inside technique as compared to group1 and the difference was significant (p

Tubercular dactylitis is defined as tubercular infection of the metacarpals, metatarsals and phalanges. It is a rare form of extra pulmonary tuberculosis. Bones of the hand are more commonly affected than the bones of the feet. Tubercular dactylitis is common in children and children below 6 year of age accounts for 85% of cases. The diagnosis is usually by a combination of clinical suspicion coupled with radiological investigation and confirmation by biopsy. We hereby present a case report of tubercular dactylitis in a 65 year old female which was treated by antitubercular therapy.