Intraosseous schwannoma of the humerus: a rarity yet warrants consideration

Intraosseous schwannoma is extremely rare that it is not often considered among differential diagnosis for an osteolytic lesion, especially in long bones of the extremities. Amounting to less than 0.2% of all primary bone tumours and less than 200 cases reported so far, with only 3 cases involving the humerus, we hereby report the fourth case. In addition to its rarity, this was the only case of an intraosseous schwannoma involving the humerus bone which presented with a pathological fracture in a 45-year-old woman after sustaining a trivial trauma. Radiological examination revealed a geographic type of osteolytic lesion in distal shaft region of the left humerus. Only a histopathological examination helped in revealing and confirming the diagnosis of an intraosseous schwannoma. Treatment of the tumour with complete excision with bone graft reconstruction and osteosynthesis yields good results with very low risk of recurrence.

Correlation Between the Fracture Line Plane and Perioperative Deep Vein Thrombosis in Patients with Tibial Fracture

Objective To explore the correlation between the fracture line inferior plane and perioperative deep venous thrombosis (DVT) in patients with tibial fractures. Methods Data was collected from the medical records of 536 consecutive patients with tibial fractures at Xi’an Honghui Hospital. The patients were divided into distal, shaft, and proximal segment groups according to the fracture line inferior plane on radiographs. Multivariate logistic regression models were used to identify the role of the inferior plane of the fracture line in perioperative DVT. Results A total of 431 patients were included in the study and 226 patients had perioperative DVT in the lower extremities, including 11 proximal and 215 distal DVTs. Univariate regression analysis showed a significant correlation between the proximal segment and perioperative DVT; however, no correlation was found in the shaft segment group. Additionally, age, coronary heart disease, associated injuries, and time to operation ≥6 days were risk factors for perioperative DVT. However, fixation with intramedullary nails may be a protective factor for perioperative DVT compared with plates. After adjusting for potential confounding factors, the proximal segment group had an increased incidence of perioperative DVT compared to the distal segment group. Conclusions The proximal segment may be correlated with an increased incidence of perioperative DVT by 7.30-fold in patients with tibial fractures compared to that in the distal segment. In clinical practice, surgeons should be vigilant for DVT formation in these patients.

Midterm Results of Minimally Invasive Plating Osteosynthesis Versus Open Reduction and Internal Fixation for the Treatment of Mid-distal Humeral Shaft Fractures: A Case-match Controlled Comparison Study

Background: Surgical treatment of humeral mid-distal shaft fractures is controversial. The purpose of this case-match controlled comparison study was to determine the safety and effectiveness of applying the MIPO technique compared with conventional ORIF for treating humeral mid-distal shaft fractures.Methods: This study was conducted from January 2012 to December 2016, and patients of mid-distal humeral shaft fractures were eligible for this study. The patients were followed up for a minimum period of 1 year. The clinical and radiographic outcomes were evaluated. The inclusion criteria were age between 18 to 60 years and acute displaced mid-distal humeral shaft fracture. The exclusion criteria were intra-articular fractures of the elbow, vascular insufficiency of the upper limb, pathological fracture and multiple or open fractures. The medical records and radiographs of all eligible patients during hospitalization and follow-up after discharge were reviewed. We use a 1:2 (MIPO/ORIF) case-match based on gender and age. All patients had at least 3 years of postoperative follow-up.Results: In total, 216 patients with mid-distal humeral shaft fracture underwent surgery at the departments of orthopedics of the Seventh Medical Center of PLA General Hospital and Beijing Chaoyang Hospital. Of them, 28 underwent MIPO and 56 case-matched controls underwent ORIF; all of them had complete 3-year follow-up data. No significant differences were observed in baseline characteristics between both groups. UCLA scores and MEPS were significantly higher in the MIPO group than in the ORIF group. Furthermore, UCLA score and MEPS grades in the MIPO group were significantly superior to those in the ORIF group. There was no statistically significant difference in major complication rates between both groups; however, the total major complication rate was significantly different between both groups.Conclusion: This study demonstrates that MIPO has a statistically significant clinical benefit over ORIF, including better shoulder and elbow joint function, with few overall major complications after at least 3 years of postoperative follow-up. MIPO is a safe and effective method for treating mid-distal humeral shaft fractures when surgery is indicated.

Fifteen-minute consultation: The toddler’s fracture

The toddler’s fracture is a distinct entity among tibial shaft fractures. It is defined as a minimally displaced or undisplaced spiral fracture, usually affecting the distal shaft of the tibia, with an intact fibula. They are often difficult to diagnose due to the absence of witnessed trauma and because initial radiographs may appear normal. Moreover, the presenting complaint (a non-weight bearing child) has a wide differential diagnosis. A detailed history and examination, together with additional imaging and other investigations, is crucial to diagnose a toddler’s fracture. Analgesia and immobilisation are the mainstays of treatment, with follow-up in fracture clinic recommended. Inflicted injury (Note: this article will use the term inflicted injury which is also called non-accidental injury. In the field of safeguarding, there is a move away from using the term ‘non-accidental injury’ due to misinterpretation of the term as being less serious than ‘abusive injury’ and that in child protection reports the term can be easily misread or mistyped as ‘accidental’ injury) should always be considered when red flags for child abuse are present. In this article, we aim to cover the differential diagnoses for toddler’s fracture including indicators that might suggest an inflicted injury.

THE EFFECT OF TOPICAL GENTAMYCIN APPLICATION AT THE URETHRAL STENT TO THE URETHRAL STENT’S BACTERIAL COLONY-FORMING-UNIT COUNTS IN HYPOSPADIAS PATIENTS PERFORMED URETHROPLASTY: A PRELIMINARY STUDY

Objective: To determine the effect of topical gentamycin application at the urethral stent to the stent’s colony-forming-unit (CFU) in hypospadias patients. Material & methods: This study is a double blind prospective randomized controlled study, conducted from November 2016 - August 2017 in Urology Department Hasan Sadikin Hospital Bandung. We include patients with distal until penoscrotal hypospadias who underwent urethroplasty for the first time. The subjects were divided into 2 groups: Group A were patients performed urethroplasty with nasogastric tube (NGT) urethral stents only. Group B were patients performed urethroplasty with NGT urethral stents that were coated with topical gentamycin. Both group were operated by a single surgeon using either Tubularized Incised Plate (TIP) or Onlay Preputial Flap technique. Both group used supra pubic urinary diversion. Both group were given the same preoperative and postoperative intravenous antibiotics and given same dressing. At post operative day 7, the stents were removed and swabbed for bacterial culture and resistance test and colony-forming-unit (CFU) counts. Demographic data is described and, among others were analyzed statistically. Other adverse events and complications were also documented. Results: There were 25 hypospadias patients who were performed urethroplasty (12 patients in Group A and 13 patients in Group B). The median age in group A was 7 ± 2.995 (years old) and the mean age in group B was 6 ± 3.178 (years old). In group A, 1 patient (8.3%) were distal shaft type, 1 patient (8.3%) were middle shaft type, 8 patients (66.7%) were penoscrotal type, 1 patient (8.3%) were proximal shaft type, and 1 patient (8.3%) were subcoronal type. In group B, 3 patients (23.1.%) were distal shaft type, 3 patients (23.1%) were middle shaft type, 5 patients (38.5%) were penoscrotal type, and 2 patients (15.7%) were proximal shaft type. In group A, 6 patients (50%) using TIP, 6 patients (50%) using onlay preputial flap. In group B, 5 patients (38.5%) using TIP, 8 patients (61.5%) using onlay preputial flap. In Group A, Staphylococus haemoliticus was the most common bacterial found in urethral stent swabbed culture (50%), followed by Pseudomonas aeroginosa (16.7%), Acinetobacter baumannii (8.3%), Enterococcus faecalis (8.3%), Morganella morgagnii (8.3%) and sterile cultures (8.3%). In Group B, 38.5% were sterile urethral stents culture, followed by Staphylococus haemoliticus (30.8%), Enterobacter cloacae (7.7%), Staphylococus warneri (7.7%), Staphylococus epidermidis (7.7%), and Moraxella catarrhalis (7.7%). The most sensitive antibiotics in both group were Amikacin, Gentamycin, Meropenem, Cotrimoxazole, and Cefepime. In group A, 11 patients (91.7%) had >100.000 CFU counts, and 1 patient (8.3%) with no colony found. In Group B, 2 patients (15.4 %) had >100.000 CFU counts, 6 patients (46.2%) had <100.000 CFU counts, and 5 patient (38.5%) with no colony found. In group A, there were 3 patients (25%) with urethra-cutaneous fistula, 4 patients (33.3%) with hematoma, and 5 patients (38.5%) without any complications. In group B, there were 2 patients (15.4%) with urethra-cutaneous fistula, 3 patients (23.1%) with hematoma and 8 patients (61.5%) without any complication. Using Mann-Whitney U-test, we found a significant difference of CFU counts formation between the two groups (p=0.001). Statistically, the lesser CFU counts found, the lesser complication were developed (p=0.001). Conclusion: Topical gentamycin application at the urethral stents in hypospadias patients performed urethroplasty significantly reduced CFU counts found at the urethral stents and thus reduced the urethra-cutaneous fistula and hematoma formation.

The real Bigfoot: a pes from Wyoming, USA is the largest sauropod pes ever reported and the northern-most occurrence of brachiosaurids in the Upper Jurassic Morrison Formation

A set of associated left pedal elements of a sauropod dinosaur from the Upper Jurassic Morrison Formation in Weston County, Wyoming, is described here. Several camarasaurids, a nearly complete small brachiosaur, and a small diplodocid have been found at this locality, but none match the exceptionally large size of the pedal elements. Next to the associated pedal elements, an isolated astragalus, phalanx and ungual were found, which match the large metatarsals in size. The elements cannot be ascribed to diplodocids due to the lack of a ventral process of metatarsal I. Moreover, the morphology of metatarsal V has a broad proximal end, with a long and narrow distal shaft, which differs fromCamarasaurus. The size of the material and a medially beveled distal articular surface of metatarsal IV imply an identification as a brachiosaurid. This is the largest pes ever reported from a sauropod dinosaur and represents the first confirmed pedal brachiosaur elements from the Late Jurassic of North America. Furthermore, this brachiosaur material (the pes and the small nearly complete specimen) is the northernmost occurrence of brachiosaurids in the Morrison Formation.

Postoperative complications and outcomes of Mathieu and Snodgrass techniques in a sample of Iraq patients with anterior distal shaft hypospadias

Background: Hypospadias is a common congenital anomaly of the penis in which the urethra opens proximal to its normal position at the tip of the glans. The purpose of this study was to compare the outcomes of Mathieu and Snodgrass techniques in the repair of anterior distal shaft hypospadias.Methods: From October 2009 to November 2010, forty five patients with the ages ranged 1 to 12 years suffering from anterior distal shaft hypospadias, were assessed. Inclusion criteria were anterior distal shaft hypospadias, and exclusion criteria were association with chordee, circumcision, and surgical repair history. Twenty-five patients underwent surgical repair using Snodgrass technique and 20 patients using Mathieu technique. Surgery was performed by one single surgeon, acquainted with both techniques. Patients were examined 1 week, and 1 month after discharge. Data including duration of the surgery, stenting time and any kind of complications such as break down, meatal stenosis, and fistula formation were collected. Also, success rate was calculated for every single patient and accordingly, the two groups were compared.Results: Mean operative time were 74±26minutes for Mathieu group and106.11±23 for minutes in Snodgrass group (P<0.05). Stenting mean duration was 6.8±1.1 days, in Mathieu group and, 6.3±0.8 days in Snodgrass group (P>0.05). The rate of break down, meatal stenosis, and fistula formation were 10%, 0%, and 5% in Mathieu group and 4%, 8%, and 8% in Snodgrass group respectively (P>0.05). Success rate was 88% in Snodgrass group and 85% in Mathieu group (P>0.05).Conclusions: In spite of some reports about preference for Snodgrass technique, we concluded that both techniques are as acceptable and as effective as each other for hypospodias repairing, regardless of cosmetic outcomes; however, we need further studies and larger sample sizes to determine which is the superior technique.

RETROGRADE FEMUR NAIL

Background: Retrograde nailing for fracture of distal shaft of femur is commonprocedure but data about post-operative functional outcome in terms of knee range of motion,union and pain at 6 weeks, 6 months and 1 year follow-up is lacking. Objectives: The mainaim of this study was to determine post-operative functional outcome after performing nailingin a retrograde fashion for distal disphyseal femoral fracture in terms of knee range of motion,pain and union at 6 weeks, 6 months and at least 1 year follow-up. Study Design: Descriptivecase series. Setting: Orthopedics and Spine Centre, Ghurki Trust Hospital Lahore, Pakistan.Period: 1st July 2015 to Dec. 2016. Materials and Methodology: 140 patients of either sex andage with fractures of distal disphyseal femoral fracture and were operated using retrogradenailing were included in the study. All the data were analyzed using SPSS 17.0 version.Results: 140 patients were included with mean age of 31.81± 7.117 ranged from 16 to 75years of age.97 patients (69.3%) were male and remaining 43 patients (30.7%) were female.Pain was significantly decrease in all patients on Visual analogue scale. Mean union were 32.3± 5.3 weeks, Knee range of motion after last follow up were more than 1200 in 126 patients.Conclusion: Retrograde Nailing for distal diaphyseal fractures is an excellent option with goodfunctional outcome. It should always be considered while managing such fractures.