Displaced Distal Radius Fracture in Children, Single vs Double K-Wire Fixation

Introduction: Distal radius fracture in pediatric population is the most common sustained injury1. Treatment often is guided by the amount of displacement, with un-displaced fractures requiring only full cast and displaced fractures requiring fixation following reduction with Kirchner Wire (K-wire). Use of a single or double K-wire fixation technique is mostly dependent on the stability of the fracture as well as surgeon preference. Our study aims to evaluate both the Single vs. double K-wire fixation technique for the fixation of Displaced distal radius fracture in children in terms of time of surgery, fracture re-displacement, functional outcome and rate of complications. Materials & Methods: This was a prospective study conducted at The Children Hospital and Institute of Child Health, Lahore between February 1st, 2020 and July 30th 2021. Following approval from the Institutional Ethical committee, 54 pediatric patients presenting to the Emergency and outpatient department with trauma to affected wrist with Displaced Fracture of Distal Radius were admitted and divided into two equal groups. Closed Surgical Fixation following manipulation under anesthesia (MUA) with single and double cross K-wires was performed in each group and Full Cast below elbow was applied for 4 to 6 weeks. Mean radial shortening, angulation and displacement was measured on radiograph pre-operatively, immediate post operatively and at the time of removal of k-wires. Functional outcome was measured post k-wire removal follow up in terms of normal, mildly reduced, moderately reduced and severely reduced. Results: A total of 54 patients were included in the study with the mean age of 9.61(6-14) years, mean time of surgery was 17.26±3.75 minutes for single k-wire and 23.22±3.48 minutes for double k-wire fixation which was significant (p ≤ 0.05). Mean Follow-up was 6.70±0.76 weeks for single k-wire and 6.19±0.48 weeks for double k-wire fixation. There was a statistically significant increase in mean dorsal angulation immediate post-operatively and at the time of k-wire removal (p ≤ 0.05). There was no statistical difference in mean dorsal angulation between the two groups at the time of k-wire removal (p= 0.55). Seven (29.12%) patients of single k-wire developed complications including 3 (11.11%) pin site infection, 1 (1.85%) loss of reduction and 2 (7.41%) wire migration. In contrast to single k-wire fixation, 13 (48.15%) patients developed complications in double k-wire fixation including 7 (29.12%) pin site infection, 1 (1.85%) loss of reduction, 2 (7.41%) neuropraxia and 2 (7.41%) wire migration. In the single k-wire group, 22 (81.48%) patients had normal, 5 (18.52%) had mildly reduced and none had moderately reduced outcome. In double k-wire group, 21 (77.78%) had normal, 5 (.52%) had mildly reduced and 1 (3.70%) had moderately reduced outcome. Conclusion: We concluded that although functional outcome is similar in both groups, single k wire fixation is superior to double k-wire fixation technique in terms of reduced time of surgery and less post-operative complications specially the pin site infection. Key words: Displaced, Distal radius Fracture, K-wire fixation

Review of Clinical and radiological outcome of 3- and 4-part proximal humerus fracture managed with J nails in elderly osteoporotic individuals.

Introduction: Proximal humeral fracture is 3rd most common fracture in elderly population.Selection of appropriate implant is always challenging to get optimum results in theseosteoporotic bones. Though locking plates are gold standard, major complications range from9% to 36%. Many percutaneous fixation techniques described in the literature are associated with pin site infections, pin backout and loss of reduction.Objective: To study clinical and radiological outcome of J nail technique for Neer’s three orfour part proximal humeral fractures in patients more than 60 years age.Materials and Method: We retrospectively studied 60 patients of 3 or 4 part proximal humeral fractures, >60 years of age treated with J nail technique from the period of 2015 to 2017. J nails were made using 2 mm 12 inches blunt tip L (Lambrinudi) wires. At final follow-up, clinical outcome was assessed using Constant Score and radiological evaluation was done according to the Bahr criteria. Statistical analysis was performed.Results: The mean Constant Score at final follow-up was 90. The postoperative reduction was excellent in 98% of patients and remained excellent in 90%. The mean postoperative neck shaft angle was 135.0° and final neck shaft angle was 131.4°. No deep infection was seen. No avascular necrosis of humeral head was found till follow up upto 2 yrs.Conclusions: Our study suggests that the functional and radiological outcomes obtained with J nailing are excellent and similar to locking plates and percutaneous Kirschner wire fixation with many other advantages of being simple, minimally invasive, avoiding muscle transfixation and no pin site infections. This surgical technique can be considered as one of the effective technique for fixation of proximal humeral fractures in elderly osteoporotics.

Complications of Halo Vest Orthosis: A Narrative Study

Background and Aim: Perry and Nickel introduced the halo vest in 1959. It is the most common immobilization device for the unstable cervical spine. In the literature review, most articles review the beneficial effects of the halo vest, and a few report its complications. This study aims to evaluate the complications associated with halo orthosis. Methods and Materials/Patients: This is a narrative study about halo vest complications. To provide up-to-date information, we reviewed the articles written about halo complications. All relevant articles were retrieved from Google Scholar, Medline, PubMed, etc., using the keywords of “halo vest orthosis”, “unstable cervical spine fracture”, “halo vest complications”, “halo vest immobilization”, “pin-site-related complications”, and “vest-related complications”. Afterward, we reviewed and critically analyzed the articles. Results: At first, the halo vest was used for postoperative paralyzed poliomyelitis patients, and later, it was also used for traumatic injury of the cervical spine or postoperatively in cervical spine reconstructive surgery. Compared to other orthoses, the halo vest provides a more effective external fixation and maintains normal anatomic alignment of the cervical spine without impacting jaw motion and resulting in eating problems. However, it has many temporary complications. To prevent halo vest complications, experienced people should apply it, and the patients should be regularly followed up for early detection and treatment of complications. Conclusion: Our review is the starting point for the evaluation and investigation of halo vest complications. Because of the high incidence of pin loosening and infection, it is better to evaluate the design and application of halo pin. Since the initial design of the halo vest, only its superstructure has been redesigned without any significant change in other parts of it.

Tibial Cortex Transverse Distraction Combined With Debridement and Vacuum Sealing Drainage for Diabetic Foot Ulcers: Validation of Previous Published Study

Objective: Tibial cortex transverse distraction (TCTD) has been recently reported in treating diabetic foot ulcers. However, there is no further studies verifying the effectiveness. We performed TCTD combined with debridement and vacuum sealing drainage (VSD) for diabetic foot ulcers to test the effectiveness.Methods: This study includes 25 patients with diabetic foot ulcers from 3 hospitals. The ulcers of all the cases didn't heal for over 3 months. Then we performed TCTD combined with debridement and VSD for them. After the surgery, the patients were regularly followed-up for more than one year.Results: Among all the patients, one case underwent amputation because of aggravated infections. There were no cases with complication like tibia fractures. Pin-site infections occurred in 2 patients. The infected pin-site healed after changing dressings for 2 weeks. For the rest 22 patients, their ulcers healed at postoperative 8.2 ± 4.5 weeks. The postoperative visual analogue score (VAS) which indicated pain degree, reduced significantly when compared with preoperative VAS.Conclusions: When combined with other measures like debridement and VSD, TCTD can bring advantages for patients diagnosed with diabetic foot ulcers, and the trauma of this operation remains a factor to be considered.Type of study/level of evidence: Therapeutic IV.

Technical points of Ilizarov external mini-fixator for the treatment of phalanx fractures

The Ilizarov external mini-fixator (IEMF) has become an effective tool for the treatment of acute and chronic hand and foot injuries and deformity correction due to its advantages of easy fixation, good holding power, and artful appearance. However, there are relatively few clinical reports on this technique. Materials and methods From June 2019 to March 2021, we preformed IEMF on 113 patients with open phalanx fractures as emergency surgery, and all patients had 3–6 months follow-up. Results All fractures achieved clinical healing. Among them, pin site infection occurred in 8 fractures (7.07 %), arthrolysis occurred after 6 fractures (5.3 %), and 4° rotation malunion occurred in 3 cases (2.65 %).

The Role of Chlorhexidine in the Prevention of Pin Tract Infection as Compared to Povidone-Iodine in Patients Managed by Ilizarov Circular Fixator

Objective: To compare the efficacy of Chlorhexidine in the prevention of pin tract infection as compared to Povidone-iodine antiseptic. Study Design: Prospective, single blinded randomized trial. Study Setting and Duration: Liaquat University of Health Science (LUMHS), Jamshoro between July 2018 to November 2020. Methodology: All patients who underwent Ilizarov external fixation as per indications were eligible for the study. Individuals with a previous history of osteomyelitis were excluded from the study. Pin sites were cleansed with normal saline using clean applicators. In the group chlorhexidine, the antiseptic was applied on the pin skin interphases (1% chlorhexidine). Similarly, 10% povidone iodine was applied to patients in group C. The control group was cleansed with normal saline. Pin sites were either dressed daily or weekly. The primary outcome was the rate of pin site infection days. Results: Chlorhexidine group had significantly lesser pin-site infections as compared to the povidone-iodine group with a frequency of 13 (39.39%) and 19 (63.33%), p=0.04, respectively. The mean pin tract infection rate days ± SD were significantly lower in the chlorhexidine group as compared to the povidone-iodine group (1.35 ± 2.26 vs 3.54 ± 4.30, p=0.041). Similarly, the mean duration to onset of pin site infection was also significantly higher in the chlorhexidine group compared to povidone-iodine and control groups. Conclusion: Patients who used Chlorhexidine as the cleansing agent had significantly fewer pin-site infections as compared to the povidone-iodine group. Keywords: Chlorhexidine, Ilizarov fixator, fracture, Povidone-iodine

Prospective evaluation of pin site infections in 39 patients treated with external ring fixation

Introduction: Pin site infection is a common complication to external ring fixation. While the aetiology is well described, monitoring of onset, location, and the distribution of infection among the pin sites still needs further attention. The present pilot study evaluates the feasibility of a prospective registration procedure for reporting, evaluating, and monitoring of pin site infections in patients treated with external ring fixation. This may promote communication between team members and assist decision-making regarding treatment. Methods: A total of 39 trauma, limb deformity, and bone infection patients (15 female, 24 males; mean age 49 years (range: 12–88)) treated with external ring fixation were followed in the outpatient clinic using the pin site registration tool. Pin site infection (Checketts and Otterburn (CO) grade, onset, location), use of oral or intravenous antibiotics, and any unplanned procedures due to pin sites complications (wire removal and/or replacement, premature frame removal, amputation, etc.) were registered until frame removal. Results: The mean (SD) frame time was 164 (83) d (range: 44–499). We performed 3296 observations of 568 pin sites. Pin infection was registered in 171 of the 568 pin sites (30 %), of which 112 (65 %) were categorized as CO 1, 42 (25 %) as CO 2, 9 (5 %) as CO 3, and 8 (5 %) as CO 5. Neither CO 4 nor CO 6 was observed. A total of 35 patients (90 %) encountered CO 1–3 at least once during the observation time, while 1 patient (2.5 %) developed a major infection at eight pin sites (CO 5). Antibiotics were administered to 22/39 (56 %) of the patients. Conclusion: In an effort to monitor pin site infections in this complex patient group and to ensure the best clinical outcomes, our registration procedure in the outpatient clinic helped to recognize pin site infections early and eased communication between team members providing a concise overview of the treatment course.

Clinical outcomes in pediatric tibial lengthening and deformity correction: a comparison of the Taylor Spatial Frame with the Orthex Hexapod System

Purpose Comparison of two hexapod frame systems in paediatric tibial deformity correction; the Taylor Spatial Frame (TSF) and Orthex Hexapod System. Methods Paediatric patients with congenital and acquired tibial deformities treated with either TSF (between 2014 and 2016) or Orthex (between 2017 and 2019) frames were included in a retrospective comparative study. Outcome measures were healing index, pin infection rate, regenerate quality and density, software residual rate, deformity correction accuracy, strut exchanges and quality of life (QoL). Results The TSF group had 17 patients (18 frames) and the Orthex group had 21 patients (25 frames). The most common indications for tibial deformity correction were fibular hemimelia (14) and septic or traumatic growth arrest (8). The median time in frame was 230 days (TSF) versus 203 days (Orthex) (p= 0.06). The mean lengthening achieved was 54 mm (TSF) and 51 mm (Orthex) (p = 0.41). The healing index was 41 days/cm (TSF) versus 43 days/cm (Orthex) (p = 0.70). Pin site infections occurred more in the TSF cohort (40%) than in the Orthex cohort (18%) (p < 0.001). The regenerate in the Orthex group showed higher density at three months (p = 0.029) and was more homogenous (p = 0.023) at six months after frame application. Strut exchanges were less frequent with the Orthex system (p < 0.0001). QoL measures were similar in both cohorts (p = 0.92). Conclusions This is the first study to compare two hexapod designs in paediatric orthopaedics. The Orthex system showed superiority in regenerate quality and a significant reduction in pin site infection rates. Both systems delivered predictable and accurate limb deformity correction. Level of evidence III

Treatment of completely displaced distal radial fractures with a straight plaster or manipulation under anaesthesia

AimsThe management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining.MethodsA total of 34 boys and 22 girls aged 0 to ten with a closed, completely displaced metaphyseal distal radial fracture presented between 1 November 2015 and 1 January 2020. After 2018, children aged ten or under were offered treatment in a straight plaster or manipulation under anaesthesia with Kirschner (K-)wire stabilization. Case notes and radiographs were reviewed to evaluate outcomes. In all, 16 underwent treatment in a straight cast and 40 had manipulation under anaesthesia, including 37 stabilized with K-wires.ResultsOf the children treated in a straight cast, all were discharged with good range of mo (ROM). Five children were discharged at six to 12 weeks with no functional limitations at six-month follow-up. A total of 11 children were discharged between 12 and 50 weeks with a normal ROM and radiological evidence of remodelling. One child had a subsequent diaphyseal fracture proximal to the original injury four years after the initial fracture. Re-displacement with angulation greater than 10° occurred for 17 children who had manipulation under anaesthesia. Four had a visible cosmetic deformity at discharge and nine had restriction of movement, with four requiring physiotherapy. One child developed over- granulation at the pin site and one wire became buried, resulting in a difficult retrieval in clinic. No children had pin site infections.ConclusionNonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. This study suggests that nonoperative management of these injuries is a viable and potentially underused strategy.

Reducing the incidence of pin site infection in hand surgery with the use of a protocol from Ilizarov

Reported pin site infection rates in Kirschner wire fixation in the hand and wrist vary from 2% to 35%. In our unit we follow a strict pin site management protocol adapted from the Russian Ilizarov Scientific Centre. This study aims to identify if our current protocol reduces the incidence of pin site infection in hand and wrist surgery, and improves wire survival rates, to a level where exposed wires can be used safely. A retrospective review of 200 patients, treated with 369 percutaneous wires, in our hand surgery department over a 6-year period was carried out. Nine patients (4.5%) were diagnosed with a pin site infection with a wire survival rate of 99.5%.In our unit using our current protocol, results support the safe use of exposed wires with appropriate pin site care initiated in theatre. Adherence to this protocol allows wires to remain in-situ throughout treatment with minimal complications. Level of evidence: IV