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  Citation statistics : Table of Contents
   2007| July-September  | Volume 41 | Issue 3  
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Routine chemoprophylaxis for deep venous thrombosis in Indian patients: Is it really justified?
Ashutosh P Mavalankar, Darshan Majmundar, Shubha Rani
July-September 2007, 41(3):188-193
DOI:10.4103/0019-5413.33680  PMID:21139742
Background: Venous thromboembolism (VTE), which consists of deep vein thrombosis (DVT) and pulmonary embolism, is a potentially fatal disease. According to the Western literature, DVT of lower limb veins is one of the most common complications following total hip and knee arthroplasty and surgeries for lower limb fractures. Very few studies have been published from India on the subject and very little is known about the true incidence of the condition. The issue has acquired greater significance in Indian subjects in recent times as there is a manifold increase in the number of joint replacement surgeries and surgeries for lower limb fractures. There are no clear guidelines regarding the prophylaxis for VTE for Indian patients. Materials and Methods: We carried out a prospective study to determine the incidence of DVT. Present study included 125 patients undergoing total knee and hip joint arthroplasty and surgeries for fractures of the lower limb over a three-year period. All the patients underwent duplex ultrasonography between the seventh and 14 th postoperative day. No mechanical or chemical form of DVT prophylaxis was used. Results: Only nine patients (7.2%) showed sonographic evidence of DVT and the majority of them resolved without treatment. There was no case of pulmonary embolism. Conclusion: DVT following total joint arthroplasty and surgery for lower limb fractures in Indian patients is not as common as reported in the Western literature. A high level of suspicion and close clinical monitoring is mandatory, routine chemoprophylaxis is perhaps not justified in every patient undergoing lower limb surgery in our opinion. More trials involving a larger number of patients and at multi centers, in future, would be required to confirm the findings of our study.
  17 4,707 494
Internal fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: A prospective study
S Raghavendra, Haresh P Bhalodiya
July-September 2007, 41(3):214-218
DOI:10.4103/0019-5413.33685  PMID:21139747
Background: The indications for surgical management of fractures of the shaft of the humerus are clear, but selecting the right implant for internal fixation of humeral fractures has been a dilemma. Materials and Methods: Thirty-six patients (mean age 40.53 years) with fractures of the shaft of the humerus were followed for 12 to 24 months in a prospective study. Eighteen patients each underwent open reduction and internal fixation with compression plating and ante grade interlock nailing. Clinical and radiographic outcome measures included fracture healing, shoulder and elbow functions, need for additional procedures and any complication such as infection and recovery of radial nerve palsy. The results were analyzed statistically using the SPSS 11.5 software, with parametric and nonparametric tests. Results: Nine of the fractures treated with compression plating and seven of those treated with interlock nailing achieved union within six months. Though there was no significant difference in union time between the treatment groups, patients operated with interlock nailing underwent more number of secondary bone grafting procedures to obtain union (six against two). There were 12 patients (66.6%) with excellent and good results in the plating group compared to four patients (25%) in the nailing group. Interlock nailing was associated with significant reduction in shoulder function ( P =0.03) and in overall results ( P =0.02). Conclusion: Though there was no significant difference between plating or nailing in terms of time to union, compression plating is the preferred method in the majority of fractures of the shaft of the humerus with better preservation of joint function and lesser need for secondary bone grafting for union.
  16 7,859 613
Venous thromboembolism in acute spinal cord injury patients
Shyam K Saraf, Raj JB Rana, Om P Sharma
July-September 2007, 41(3):194-197
DOI:10.4103/0019-5413.33681  PMID:21139743
Background : The western literature on deep vein thrombosis (DVT) and pulmonary embolism (PE) following spinal cord injury (SCI) report an alarmingly high incidence, necessitating thromboprophylaxis. The literature on incidence from the Asian subcontinent is scanty and from India is almost nonexistent. Materials and Methods : Seventy hospitalized acute SCI patients presenting within five days of the injury were included in the present analysis. Forty-two cases were subjected to color Doppler studies and 28 cases had to be subjected to venography due to lack of facility at some point of time. The clinical course of the patients was closely observed during the period of hospitalization. All except 14 were managed nonoperatively. Thromboprophylaxis was not given to any patient at any stage; however, treatment was instituted in those showing the features of DVT on investigations. Results : Twelve patients died during the period of hospitalization. Deep vein thrombosis could be detected in seven patients only, three in the proximal and four in the distal segment of the lower limb and of these three died. Based on the clinical course and positive investigation report in favor of DVT, we presumed that the cause of death in these three patients was pulmonary embolism. In the other nine, in the absence of an autopsy report, the cause of deaths was considered as pulmonary infection, asphyxia, diaphragmatic paralysis, hematemesis, cervicomedullary paralysis etc. Clinical features to diagnose DVT were of little help. Conclusions : There is a much lower incidence (10%) of DVT and PE following spinal cord injury (SCI) in India than what is reported from the western countries. Higher age group and quadriplegia were the only factors which could be correlated. Deep vein thrombosis extending proximal to the knee was significant. In the absence of autopsy and other screening tests like D-dimer test or 125I fibrogen uptake study, the true incidence of venous thromboembolism remains uncertain. Noninvasive screening of all patients for the detection of deep vein thrombosis in SCI patients is strongly recommended.
  13 7,181 340
Salvage versus amputation: Utility of mangled extremity severity score in severely injured lower limbs
M Kiran Kumar, CM Badole, KR Patond
July-September 2007, 41(3):183-187
DOI:10.4103/0019-5413.33679  PMID:21139741
Background: The purpose of the present study was to evaluate the clinical utility of Mangled extremity severity score (MESS) in severely injured lower limbs. Materials and Methods: Retrospectively 25 and prospectively 36 lower limbs in 58 patients with high-energy injuries were evaluated with the use of MESS, to assist in the decision-making process for the care of patients with such injuries. Difference between the mean MESS scores for amputated and salvaged limbs was analyzed. Results: In the retrospective study 4.65 (4.65 1.32) was the mean score for the salvaged limbs and 8.80 (8.8 1.4) for the amputated limbs. In the prospective study 4.53 (4.53 2.44) was the mean score for the salvaged limbs and 8.83 (8.83 2.34) for the amputated limbs. There was a significant difference in the mean scores for salvaged and amputated limbs. Retrospective 21 (84%) and prospective 29 (80.5%) limbs remained in the salvage pathway six months after the injury. Conclusion: MESS could predict amputation of severely injured lower limbs, having score of equal or more than 7 with 91% sensitivity and 98% specificity. There was a significant difference in the mean MESS scores in the prospective study (n=36), 4.53 (4.53 2.44) in thirty salvaged limbs (83.33%) and 8.83 (8.83 2.34) in six amputated limbs (16.66%) with a P -value 0.002 ( P -value < 0.01). Similarly there was a significant difference in the mean MESS score in the retrospective study (n=25), 4.65 (4.65 1.32) in twenty salvaged limbs (80%) and 8.80 (8.8 1.4) in five amputated limbs (20%) with a P -value 0.00005 ( P -value < 0.01). MESS is a simple and relatively easy and readily available scoring system which can help the surgeon to decide the fate of the lower extremity with a high-energy injury.
  12 9,996 642
Orthopedic services and training at a crossroads in developing countries
Anil K Jain
July-September 2007, 41(3):177-179
DOI:10.4103/0019-5413.33677  PMID:21139739
  10 3,635 329
Evaluation of surgical stabilization of metacarpal and phalangeal fractures of hand
Rakesh Gupta, Roop Singh, RC Siwach, SS Sangwan, Narender K Magu, Rahul Diwan
July-September 2007, 41(3):224-229
DOI:10.4103/0019-5413.33687  PMID:21139749
Background: Optimized functional results are difficult to achieve following hand injuries. This prospective study was undertaken to evaluate the functional outcome after surgical stabilization of metacarpal and phalangeal fractures. Materials and Methods: Forty-five fractures of digits of hand in 31 patients were managed by surgical stabilization. Five fractures were fixed with closed reduction and percutaneous Kirschner wire fixation; 10 with external fixator; 26 with open reduction and Kirschner wire fixation; and four with open reduction and plate and screw or screw fixation. Results: Final evaluation of the patients was done at the end of three months. It was based on total active range of motion for digital functional assessment as suggested by the American Society for surgery of hand. Overall results were excellent to good in 87%. Better total active range of motion (excellent grade) was observed in metacarpal fractures (47%) versus phalanx fractures (31%); closed fractures (57%) versus open fractures (27%); and single digit involvement (55%) versus multiple digits (29%). Excellent total active range of motion was observed with all four plate and screw/ screw fixation technique (100%) and closed reduction and percutaneous kirschner wire fixation (60%). Twenty-two complications were observed in 10 patients with finger stiffness being the most common. Conclusion: Surgical stabilization of metacarpal and phalangeal fractures of hand seems to give good functional outcome. Closed fractures and fractures with single digit involvement have shown a better grade of total active range of motion.
  8 6,658 447
Fibular hydatid cyst
Hamidreza Arti, Hossein Yousofi Darani
July-September 2007, 41(3):244-245
DOI:10.4103/0019-5413.33692  PMID:21139754
Hydatid disease is caused by the tapeworm Echinococcus. Genus Echinococcus has different species including Echinococcus vogeli, Echinococcus granulosus and Echinococcus multilucularis . Echinococcus granulosus is the most common cause of hydatid disease in humans. This disease occurs either through direct ingestion of parasite eggs from contact with infected dogs or indirectly from the ingestion of contaminated water or food. Infestation of hydatid disease in humans most commonly occurs in the liver (55-70%), followed by the lungs (18-35%). Bone hydatidosis however is very rare (3%). We present herein a case of hydatid cyst of the fibula, which is an uncommon site for the occurrence of this disease.
  7 4,687 198
Interscalene brachial plexus block for outpatient shoulder arthroplasty: Postoperative analgesia, patient satisfaction and complications
Anand Shah, Karen C Nielsen, Larissa Braga, Ricardo Pietrobon, Stephen M Klein, Susan M Steele
July-September 2007, 41(3):230-236
DOI:10.4103/0019-5413.33688  PMID:21139750
Background: Shoulder arthroplasty procedures are seldom performed on an ambulatory basis. Our objective was to examine postoperative analgesia, nausea and vomiting, patient satisfaction and complications of ambulatory shoulder arthroplasty performed using interscalene brachial plexus block (ISB). Materials and Methods: We prospectively examined 82 consecutive patients undergoing total and hemi-shoulder arthroplasty under ISB. Eighty-nine per cent (n=73) of patients received a continuous ISB; 11% (n=9) received a single-injection ISB. The blocks were performed using a nerve stimulator technique. Thirty to 40 mL of 0.5% ropivacaine with 1:400,000 epinephrine was injected perineurally after appropriate muscle twitches were elicited at a current of less than 0.5% mA. Data were collected in the preoperative holding area, intraoperatively and postoperatively including the postanesthesia care unit (PACU), at 24h and at seven days. Results: Mean postoperative pain scores at rest were 0.8 2.3 in PACU (with movement, 0.9 2.5), 2.5 3.1 at 24h and 2.8 2.1 at seven days. Mean postoperative nausea and vomiting (PONV) scores were 0.2 1.2 in the PACU and 0.4 1.4 at 24h. Satisfaction scores were 4.8 0.6 and 4.8 0.7, respectively, at 24h and seven days. Minimal complications were noted postoperatively at 30 days. Conclusions: Regional anesthesia offers sufficient analgesia during the hospital stay for shoulder arthroplasty procedures while adhering to high patient comfort and satisfaction, with low complications.
  7 8,945 311
Textiloma in the leg
Amol C Patel, Govind S Kulkarni, Sunil G Kulkarni
July-September 2007, 41(3):237-238
DOI:10.4103/0019-5413.33689  PMID:21139751
Textiloma is defined as a tumor formed due to retained gauze. It is rarely reported in the musculoskeletal system. We are presenting a case with a soft tissue swelling over the lateral aspect of the lower third of the leg, come for implant removal of the distal tibia and fibular fracture. We removed the soft tissue mass enbloc thinking it to be a benign tumor. On cutting the mass on the operation table, a gauze piece encased by fibrous tissue was found. Textiloma can present as tumoral forms and can mimic as a pseudo-tumor.
  6 4,262 198
Multiple soft tissue aneurysmal cysts: An occurrence after resection of primary aneurysmal bone cyst of fibula
P Karkuzhali, Mahuya Bhattacharyya, P Sumitha
July-September 2007, 41(3):246-249
DOI:10.4103/0019-5413.33693  PMID:21139755
We report a case of multiple extraosseous aneurysmal cysts occurring in the muscle and subcutaneous plane of postero-lateral aspects of the upper right leg. They appeared about 15 months after resection of aneurysmal bone cyst of the upper end of the fibula. They varied in size from 2 cm to 5 cm. Radiologically they were well-defined lesions with central septate areas surrounded by a rim of calcification. Histologically they showed central cystic spaces separated by septa consisting of fibroblasts, osteoclast type of giant cells and reactive woven bone. Thus they showed histological similarity with aneurysmal bone cysts, but did not show any connection with the bone. Only very few examples of aneurysmal cysts of soft tissue had been described in the past one decade and they were reported in various locations including rare sites such as arterial wall and larynx. Recent cytogenetic analyses have shown abnormalities involving 17p11-13 and/or 16q22 in both osseous and extraosseous aneurysmal cysts indicating its probable neoplastic nature. Our case had unique features like multiplicity and occurrence after resection of primary aneurysmal bone cyst of the underlying bone.
  6 5,096 189
Surgical management of intercondylar fractures of the humerus using triceps reflecting anconeus pedicle (TRAP) approach
Amite Pankaj, G Mallinath, Rajesh Malhotra, Surya Bhan
July-September 2007, 41(3):219-223
DOI:10.4103/0019-5413.33686  PMID:21139748
Background: Operative fixation of intra-articular fractures of the distal humerus requires adequate exposure. The transolecranon approach is a commonly used approach. The olecranon osteotomy has potential complications related to prominence/migration of hardware, displacement/nonunion of osteotomy and triceps weakness. Triceps-reflecting anconeus pedicle (TRAP) approach avoids the olecranon osteotomy without compromising the operative exposure. We present outcome of fixation of displaced intra-articular distal humeral fractures with the use of TRAP approach. Materials and Methods: We reviewed the functional and radiological results of 40 consecutive patients with intercondylar fractures of the humerus treated by internal fixation through TRAP approach. There were 28 males and 12 females and the average age was 32 4.5 years. The right elbow was involved in 27 patients and the left elbow in 13 patients. The mechanism of injury was a fall in 20 patients, a motor-vehicle accident in 16 patients and direct trauma in four patients. Results: At a minimum follow-up of 12 months (average 18 4 months) 35 (87.5%) patients had good triceps strength. The average range of motion was 118.4 7 degrees (range 80 o -130 o ). The average time to union was 3.2 1.6 months (range two to six months). No patient had triceps rupture, implant failure, neurovascular deficit or nonunion. Two patients needed removal of the implant because of subcutaneous prominence. Conclusions: The TRAP approach provides good visualization for fixation of intercondylar fractures of the humerus, without any noticeable untoward effect on triceps strength and postoperative rehabilitation; and one can avoid iatrogenic fracture of the olecranon and its associated complications.
  6 11,055 907
Ilizarov methodology for infected non union of the Tibia: Classic circular transfixion wire assembly vs. hybrid assembly
Ranjit Kr Baruah
July-September 2007, 41(3):198-203
DOI:10.4103/0019-5413.33682  PMID:21139744
Introduction: Conventional wire fixation of Ilizarov rings often fails to provide 90-90 configuration because of vital structures, which is essential for optimum stability. Hybrid assembly with half pins is an alternative. The aim of this study is to compare the results of Hybrid assembly with that of conventional classic circular transfixion wire Ilizarov assembly in 50 cases of infected nonunion of tibia between 1994 and 2003. Materials and Methods: This study includes two groups with 25 patients in each group: Group (A) conventional Ilizarov assembly and Group (B) hybrid Ilizarov assembly. Thirty-five cases developed infected nonunion following road traffic accidents while others after fall (6) bullet injury (4), infected osteosynthesis (3) and assault (2). There were 45 males and five females with mean age (18 to 56 years). All active cases (n=28) were treated by debridement including removal of implants in infected osteosynthesis. Twenty out of 22 cases in the quiescent group (non draining for last three consecutive months) were treated without open debridement; only two cases required open debridement for various reasons. All the cases were finally treated as atrophic aseptic nonunion with bone defect and were classified according to ASAMI. Type B1: length of the limb maintained with bone gap (14 cases in both Group A and B) and Type B3: combined shortening with defect (five and seven cases in Group A and B respectively), were treated by bifocal osteosynthesis. Only one case in the B3 group was treated by trifocal osteosynthesis to shorten the time. Type B2: segments in contact with limb shortening (total nine cases; five and four cases in Group A and B respectively) with shortening up to 2 cm (total five cases) were treated with monofocal osteosynthesis while shortening up to 5 cm and beyond (total four cases) were treated with bifocal osteosynthesis. Results: The cases were followed up for two to six years and the results were evaluated by Paley criteria of bony results ( union, infection, deformity and leg-length discrepancy ) and Functional Results (significant limp , equinus rigidity of the ankle, soft-tissue dystrophy, pain and inactivity) . In both the groups, 24 cases out of 25, had excellent to good bony result with Group B having twice more excellent result than Group A. Functional results were found to be similar in both the groups. Although persistence of infection and Grade III pin tract infection (PTI) were slightly higher in Group B, complications like delayed consolidation of regenerate, refracture, deformity and aneurysm of vessel were less in this group. Discussion and Conclusion: Ilizarov methodology produced a satisfactory result in infected nonunion of the tibia. Hybrid assembly was a fruitful advancement in the Ilizarov armamentarium. The results were comparable to Conventional assembly in terms of docking site problems, corticotomy site problems, PTIs and other problems.
  5 6,838 648
Reconstruction of iliac crest with rib to prevent donor site complications: A prospective study of 26 cases
BR Dave, HN Modi, A Gupta, A Nanda
July-September 2007, 41(3):180-182
DOI:10.4103/0019-5413.33678  PMID:21139740
Background: The tricortical bone graft from the iliac crest are used to reconstruct the post corpectomy spinal defects. The donor iliac area defect is large and may give rise to pain at donor site, instability of pelvis, fracture of ilium, donor site muscle herniation or abdominal content herniation. Rib removed during thoracotomy was used by us to reconstruct the iliac crest defect. Materials and Methods: Twenty-six patients who underwent thoracotomy for dorsal spine corpectomy or curettage for various spinal pathologies from June 2002 to May 2004 were included in the study. After adequate decompression the spine was reconstructed by tricortical bone graft from iliac crest and reconstruction of the iliac crest was done with the rib removed for exposure during thoracotomy. Results: The mean follow up was 15 months. All patients had good graft incorporation which was evaluated on the basis of local tenderness and radiographs. One patient had graft displacement. Conclusion: The reconstruction of iliac crest by rib is a simple and effective procedure to prevent donor site complications.
  3 4,612 292
Guillain-Barre syndrome: A possibility in a spinal cord injured patient
Yogendrasinh Jagatsinh
July-September 2007, 41(3):239-240
DOI:10.4103/0019-5413.33690  PMID:21139752
A 28-year-old male had paraplegia as a result of fracture dislocation of T12/L1 six years ago. He was functioning independently until four weeks ago, when he started complaining of trunkal paraesthesia which later progressed to include the upper extremities. The initial diagnosis was that of posttraumatic syringomyelia (PTS). While awaiting the MRI scan he developed weakness of upper limbs. The weakness restricted his self-care activities including transfers. The MRI did not show any evidence of syringomyelia. Neurological consultation and assessment yielded provisional diagnosis of Guillain-Barre syndrome (GBS). The patient was treated with immunoglobulins and regained 90% of his previous neurological status. This case is reported to raise awareness among clinicians to include the possibility of the GBS in the differential diagnosis of progressive neurological loss on top of existing neurological deficiency in spinal cord injured patients.
  1 16,134 342
Surface replacement of the hip
NS Laud
July-September 2007, 41(3):252-252
  - 1,962 188
Slipped upper femoral epiphysis with hemophilia A
Deepa Iyer, Richard Brueton
July-September 2007, 41(3):250-251
DOI:10.4103/0019-5413.33694  PMID:21139756
A 13-year-old boy who had hemophilia A was reported with pain in the left thigh and hip on walking. He had no history of trauma. Severe hemophilia A is diagnosed with a Factor VIII level of <1 iu/dl. The presumptive diagnosis was that of a spontaneous bleed into the hip joint. Factor VIII mutational analysis revealed a C to G substitution at nucleotide 6683 which results in a cystine change at codon 2194. However, the symptoms persisted and an X-ray demonstrated the presence of an acute on chronic slip of the upper femoral epiphysis. The patient was transferred to the center treating his hemophilia where the hip was pinned in situ under cover with Factor VIII. This case demonstrates the need to be aware of a possible traumatic diagnosis of hip pain in a hemophiliac child with a longstanding history of spontaneous bleeding into joints.
  - 3,686 159
Hydatid disease of scapula and upper third of humerus treated by en bloc excision and fibular bone grafting
P Ranga Chari
July-September 2007, 41(3):241-243
DOI:10.4103/0019-5413.33691  PMID:21139753
35-year-old male patient presented with gradually increasing painful swelling of the right shoulder, which was incised and drained and wound persisted as a discharging sinus on the anterolateral aspect of the deltoid region with seropurulent discharge. A clinical diagnosis of tuberculosis of the shoulder was made. Plain skiagram of the right shoulder revealed multicystic lesion involving the entire scapula and upper third of the humerus with loss of joint space and pathological fracture at the junction of upper one-third and lower two-thirds of the humerus. A clinico-radiological diagnosis of hydatid disease was made. In view of the extensive involvement of the scapula with stiff shoulder and an active sinus, a two-stage surgical procedure was performed. Stage 1 consisted of en bloc excision of the scapula, upper half of the humerus and lateral end of the clavicle. Stage II surgery, consisting of fibular bone grafting. Tablet albendazole (400 mg, thrice daily) was given as systemic scolicidal agent. This case is reported in view of it's rarity and to highlight the management.
  - 3,412 162
Internal fixation in compound type III fractures presenting after golden period
Quamar Azam, MKA Sherwani, Mazhar Abbas, Rahul Gupta, Naiyer Asif, AB Sabir
July-September 2007, 41(3):204-208
DOI:10.4103/0019-5413.33683  PMID:21139745
Objective: Patients often reach the hospital late after passage of golden hours (initial 6 hours) after sustaining high-velocity injuries. The decision of internal fixation in Gustilo's Type IIIA and IIIB fractures becomes a formidable challenge in patients reaching late. The purpose of the present study was to find out if internal fixation could be safely undertaken in these patients. Materials and Methods: Sixty-three patients, having 70 compound fractures (46 Type IIIA and 24 IIIB), which were internally fixed after 6h but within 24h after injury, were included in the present analysis. Follow-up ranged from 18 to 48 months with mean of 28 months. Result: Overall infection rate noted was (n = 11) 15.71% (8.7% in IIIA, and 29.16% in IIIB). The difference in deep infection rate between Type IIIA and Type IIIB was found to be statistically significant ( P value < 0.01). Nonunion was seen in five fractures. Functional evaluation using Katenjian's criteria, showed 62.85% (44 fractures of 70) good to excellent results. Conclusion: Satisfactory results may be obtained in Gustilo's Type IIIA and IIIB fractures even if fixed after the golden period, provided strict protocol such as aggressive debridement, prophylactic antibiotic coverage, early soft tissue reconstruction and timely bone grafting is followed. The primary coverage of the wound is discouraged.
  - 5,759 434
Functional outcome after open reduction and internal fixation for symptomatic delayed union and nonunion after fracture clavicle: A series of 31 cases
John Mukhopadhaya, Swastik Shivapuri
July-September 2007, 41(3):209-213
DOI:10.4103/0019-5413.33684  PMID:21139746
Background: Non-union after clavicular fractures can cause significant disability due to pain, impaired function of the shoulder joint and limitations of certain activities, especially in high-demand patients. Materials and Methods: 31 patients (21 males and 10 females) of symptomatic delayed union or nonunion were treated operatively using plate osteosynthesis with bone grafting where required between January 1994 to September 2005. Out of the 31 patients, 14 cases were of delayed union (no evidence of union > six wks) and 17 cases were of nonunion (no union > three months). Fracture of the lateral one-third and open fractures of the clavicle were not included in the study. Bone grafting was done in 23 patients. The outcome was assessed with the American Academy of Orthopedic Surgeons (AAOS) disabilities of the arm, shoulder and hand (DASH) questionnaire. Results: The patients were followed-up for an average of 13 months (range six months to four years). All fractures united with in three months Most of the patients had their DASH scores in the range of 10 to 20, the average being 14.7 in our series. Functionally, this was very much acceptable. Conclusion: Open reduction and internal fixation with a plate in conjunction with an autogenous bone graft where required is a successful procedure with good outcome and most of the patients can return to a near normal level of function.
  - 9,037 401
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