Sunday, 20 May 2012

Case 2 - Forearm Deformity

Clinical Picture and movements at presentation

This 15 year old girl was a precious child for her parents, born after many attempts of IVF. 

She had a short and bowed forearm, and in addition had an unsightly prominence in the lateral aspect of the elbow. 

She also complained of pain when she had to do any writing tasks for a long time. 

Xray at presentation

Xrays revealed an exostosis at the distal ulna, which caused a short ulna, which in turn by the check rein effect caused an exaggerated bowing of the radius and dislocation of the head of the radius. Some surgical procedure had been attempted in the past, details of which were unavailable.

The challenge here was to correct the bowing deformity, as well as the prominence of the radial head, without much surgical scars.

We first excised the ulnar exostosis. 6 weeks after that, we applied a pediatric LRS fixator on the ulna.
The trick here was to put in the proximal and distal set of pins without the rail, such that each set of pins was perpendicular to that segment of bone.

C arm pictures of fixator application & osteotomy

Once the clamps were fixed to the rails, the bowing of the ulna was automatically corrected.

Due to the acute correction, instead of the normal 7 days, we began lengthening after 10 days, and continued lengthening, till the distal end of the ulna reached the carpus / distal end of radius.

Sequential Xrays of Ulnar Lengthening
Once the Ulna was at the desired length, she was taken to theatre, and the distal end of the ulna was locked or coupled to the distal end of the radius, by means of 1 screw and 1 K wire, put in percutaneously.

C arm pictures of insertion of Screw and K wire
The ulnar lengthening was then continued, till the radial head prominence disappeared. No attempt was made to reduce the radial head, because even preoperatively, with the gross dislocation of the radial head, she had a good range of movements. We anticipated that she would retain good movement, and IF required, an excision of the radial head could be done later.

The Radial Head moves distally
Function was encouraged while in the fixator, and when the regenerate appeared healed well, the fixator was removed.

Function with the Fixator
Healed regenerate
She had good function equal to her preoperative status even at 1 week post removal
Scars and Prono-Supination
The bone was healed well as confirmed on various views.

At her one year followup, she is obviously a happy patient, free of her deformity, and her complaints.
Notice the the bump of the radial head is hardly (if at all) visible.

She is now back at her village, attending Junior College.

Sunday, 13 May 2012

Case 1 - Continued

Case 1 continued . .


Once we were sure that the infection was settled, (and the circumference of the leg reduced significantly), we went ahead with adding an ilizarov fixator to the limb, and doing a corticotomy in the proximal tibia. 

There were two nonunions we were dealing with, one proximal in the midshaft, and another gap, distally. 

The frame was constructed to allow continued compression across the proximal nonunion site (if you look closely, you will see the arced wires in the xrays and clinical pictures). 

The corticotomy posed a challenge, with the nail already in, and the limb not really a good one to do a Gigli Saw osteotomy on. 

After the a period of 10 days, distraction (transport) was begun. As the osteotomy site opened up, the gap at the lower nonunion closed. 

Improving the Docking site

At one point, the two edges of the gap nonunion came into contact, and would have prevented a good cross section of bone for the healing. Therefore we did a percutaneous osteotomy and osteotomised, in situ the long beak of the proximal fragment such that it could now present a broader surface for the docking.

After docking was achieved, proximal lengthening was continued for a couple of centimetres to equalise his length. 

The Gap nonunion healed without any bone grafting, the regenerate healed without any issues, and the patient has good function. No discharge. 

I am told he will be getting married soon, and we will certainly celebrate with him. 


Case 1 - Infected Nonunion Tibia

Case 1 - Infected Nonunion Tibia

At Presentation
25 year old young man, had a bad accident about 10 months back. The tibia was fractured in two places (segmental fracture) with injury to the blood vessel and nerve. He underwent a number of surgeries namely arterial grafting, muscle flap, skin grafting, Ilizarov fixation before presenting to us with discharging sinuses, inability to walk and lack of confidence.

X-rays at Presentation
The x-rays showed nonunion at both the upper and lower fracture sites. The lower fracture site showed infection and dead bone. The fixator was not holding the bone fragments in good alignment and the wires were all loose and some of them were infected.

PET Scan
The FDG PET Scan showing active infection at the lower fracture site. An arterial DSA (Digital Subtraction Angiogram) was done to determine the course and patency of the arteries.

Sequestrum – Dead Bone
The dead bone was excised. The line of demarcation between the dead and viable bone is shown here in the picture on the left (yellow arrow).

In surgery the dead bone (sequestrum) & all the infective tissue was removed. An intra-medullary V-nail was applied to keep the bone aligned and antibiotic loaded calcium sulphate pellets were instilled in the proximal and distal fracture sites to control infection.

4 Weeks
The calcium sulphate pellets are completely absorbed. The infection is settled and the sinuses healing well. The upper fracture is showing signs of healing.

Bone Transport
The Ilizarov fixator is applied while the intra-medullary nail is still inside. An osteotomy was done in the proximal aspect for the purpose of bone transport.

5 Weeks