Congenital Insensitivity to Pain and Anhidrosis: A painful experience by a painless child

A three-year-old boy with congenital insensitivity to pain and anhidrosis (CIPA) was first presented with transphyseal separation of distal left humerus. Surgical treatment with closed reduction and k-wiring of transphyseal separation of distal humerus resulted in devastating surgical site infection and osteomyelitis. Multiple surgical debridement and application of external fixator to eliminate infection were futile. At the age of four years, he refused to bear weight as a result of left hip dislocation. Closed reduction and spica cast was unsuccessful, resulting in recurrent left hip dislocation. He has since not been able to walk. At the age of five years, the right hip was dislocated followed by ipsilateral subtrochanteric femur fracture. Appropriate treatments such as hip spica and titanium elastic nail were not possible due to extensive bruising and skin ulceration over the right thigh. This child ended up with a functionless left upper limb, bilateral hip dislocation and malunited right femur fracture. Conservative treatment and watchful neglect might be the ideal treatment for patients with CIPA.

Operative versus Non-Operative Management of The Medial Malleolus in Bimalleolar and Trimalleolar Fractures – A Systematic Review

Purpose Ankle fractures are the fifth most common fracture worldwide. Some reviews have shown that non-operative management of isolated medial malleolar fractures has satisfactory outcomes, and more recent studies have suggested the same may apply in bimalleolar and trimalleolar fractures (BTMF). Importantly, non-operative management has the added benefits of avoiding complications including wound infection, and protruding metalwork. This systematic review aims to compare operative and non-operative management of medial malleolar fractures in the context of BTMF. Methods A search syntax of MeSH terms was used to search ScienceDirect, Scopus, Cochrane Library, and PubMed databases. The methodological quality of the included studies was assessed according to the MINORS criteria. Data extracted included patient demographics, operative techniques, functional outcome scores (EQ-5D, OMAS, MOXFQ, VAS, AOFAS return to work/sports) and complication rates Results A total of four studies were included: one randomised-controlled and three prospective study. Two of these directly compared operative and non-operative approaches, while the remaining two reported solely an operative cohort. Of 373 total fractures, 274 were managed operatively and 99 non-operatively. There was no significant difference across all functional scores between operative and non-operative approaches to medial malleolar fractures in the comparative studies. However, there was an association for higher rates of mal/non-union in the non-operative groups (10.5% vs 5.0%). Conclusion Although there is existing belief that operative approach to BTMF would lead to better outcomes, there is currently no evidence that shows operative is superior to non-operative management. Orthopaedic surgeons should consider the morbidity of post-operative complications when deciding the treatment for medial malleolar fractures in BTMF, particularly in the elderly. Further studies need to be performed on this topic before a definitive conclusion can be made.

Minimally Invasive Osteosynthesis of Isolated Coronoid Process Fracture: A Novel Technique

Isolated coronoid process fracture is not a commonly encountered injury of the elbow joint. Coronoid process is an important component in providing elbow stability. We present a case of isolated coronoid process fracture in a young male managed by minimally invasive osteosynthesis technique.

Tibial Diaphysis Fracture in Paediatric Age Group: Outcome with Elastic Nailing Fixation in Tertiary Care Center in Lumbini Province of Nepal

Introduction- Tibial diaphysis fracture in paediatric age group accounts for 10 to 15% of all fractures. Fixation of tibial diaphysis fracture in paediatric age group by elastic nailing system provides relative stability. The purpose of this study is to evaluate the functional outcome of tibial diaphysis fracture in paediatric age group treated elastic nailing system. Methods- A prospective interventional study was conducted at Rapti Academy of Health Sciences, Ghorahi, Dang from November 2018 to November 2020. Ethical clearance was obtained from Institutional review board. All the children who were operated for tibial diaphysis fracture were followed up for six months. Final outcome was analyzed at final follow up. Results- Out of thirty children, there were sixteen male and fourteen female. Mean time of fracture union was 10.03 weeks. Two children develop limb lengthening of 1.5 cm and 1.2 cm respectively. One child had 1 cm shortening and three children develop bursitis on entry site. At final follow up 83.33% of child had an excellent outcome according to Flynn grading. Conclusion- Tibial diaphysis fracture can be treated with elastic nailing system with excellent to good functional outcomes.

Is prophylactic fixation preferable to active surveillance of the unaffected contralateral hip in unilateral slipped capital femoral epiphysis?- A Systematic Review

Slipped capital femoral epiphysis is one of the commonest musculoskeletal disorders amongst children. Whilst its management is reasonable well established, the treatment of the unaffected contralateral hip is controversial. The incidence of subsequent contralateral slip has been reported to be between 19 and 63%. The two treatment modalities are prophylactic fixation at initial presentation or active surveillance and fixation on diagnoses of subsequent slip. Both approaches have their merits but there is no clear consensus. Known risk factors include age, sex, young age at initial presentation, endocrine disorders and obesity. Clinical, epidemiological and radiological predictors have been assessed retrospectively but have limited prospective accuracy. We performed a systematic review of the existing literature as per PRISMA guidelines to determine which treatment modality is more effective. Qualitative analysis of the literature also yielded interesting insights into different aspects of the management of the contralateral hip in unilateral SCFE.