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Capitellar fracture in the paediatric population is extremely rare. There have been only a handful of case reports or case series in the literature. For this reason, it is likely to be missed or misdiagnosed. An untreated capitellar fracture poses a risk of severe compromise of the elbow function and range of movement. We present a rare case of type I capitellar fracture in an 11-year-old girl. She underwent open reduction and percutaneous Kirschner wiring and she subsequently recovered with excellent outcome. A high index of suspicion is needed to diagnose a capitellar fracture. The lateral view of a plain radiograph must be carefully screened and sometimes an oblique view may be helpful in making the diagnosis. Keywords: capitellum; fracture; open reduction

Background Strayer’s gastrocnemius recession is a common technique in treating ankle equinus of gastrocnemius origin. Nevertheless, this technique is associated with a few flaws. We aim to introduce a novel technique of isolated gastrocnemius recession and perform a cadaveric study to evaluate its safety and at the same time compare this novel technique with the existing Strayer procedure biomechanically. Methods Eight fresh cadaveric models of gastrocnemius tightness were established by isolated traction of the gastrocnemius muscles. Gastrocnemius recession was performed on all eight models with Strayer method and the novel method randomized equally. The safety of both the techniques was evaluated by identifying any iatrogenic injury to the surrounding structures. The lengthening and improvement of the ankle dorsiflexion was measured and compared between the two techniques. Results There was no iatrogenic sural nerve or saphenous vein injury in all eight models. There was no significant difference between the two techniques in terms of lengthening (24.25 mm vs 21.00 mm; p = 0.838) and improvement of ankle dorsiflexion (26.5° vs 26°; p = .829). Conclusions Both Strayer technique and the novel technique of gastrocnemius recession lengthened the gastrocnemius and improved the ankle dorsiflexion in this cadaver trial. Both procedures were safe with proper techniques, and there was no significant difference in efficacy between them. Level of Evidence Level II, randomized controlled trial.

Background and objective Femoral neck fractures are relatively rare in young adults, but they result in prolonged loss of function in these patients, thereby placing a huge burden on a country’s healthcare and economy. Femoral neck fractures in young adults are normally treated with head salvage surgery. However, primary head replacement surgeries have been gaining traction recently to expedite the recovery of these patients. In this study, we aimed to investigate the outcomes in young patients with femoral neck fractures and factors associated with their complications. Patients and methods Patients with femoral neck fractures who underwent surgery in three tertiary hospitals [Hospital Tengku Ampuan Afzan (HTAA), Hospital Sultan Haji Ahmad Shah (HOSHAS), and Hospital Kuala Lipis] in Pahang state in Malaysia were reviewed and included in this study. The demographic profile of the patients, injury patterns, intervention details, functional outcomes, and complications were analyzed. The comparison between the sociodemographics, clinical assessment, and complication outcomes was analyzed using statistical software. Results The complications were associated with the mechanism of injury, capsulotomy, and type of fixation. A total of 46 patients were included in the study. Most of the patients were found to have severe displacement based on Garden and Pauwels classification. The majority of the patients underwent femoral head salvage surgeries. Almost half of the patients sustained complications and were unable to achieve weight-bearing status at six months postoperatively. Conclusion Despite a relatively short follow-up period in our study, femoral neck fractures in young adults were found to be associated with a high rate of complications. Primary head replacement surgeries should be considered in high-risk patients with femoral neck fractures.

Introduction After detailed anatomical delineation of the anterolateral ligament (ALL) of the knee, there is a surge in research on this anatomical structure. Owing to the anatomical variation and lack of experience in the identification of this structure, magnetic resonance (MR) evaluation of the ALL produces mixed results. It was aimed to evaluate the ALL using the routinely performed MR imaging of the knee and to determine any associated factors with ALL injuries. Materials and methods Thirty-six MR images of the knee from 31 patients from January 1, 2017, to June 30, 2017, are evaluated. MR sequences performed include TI-weighted, T2-weighted, proton density (PD), and PD fat saturation (FS). All MR images were double-read by two authors and approved by a consultant radiologist with more than 20 years of radiological experience. The ALL was divided into three portions: femoral, meniscal, and tibial, and the ALL was considered fully visualized when all three portions were seen on MR images. Results At least a portion of the ALL was visualized in 27 scans (75%), and it was fully visualized in 20 scans (55.6%). The femoral portion was the most commonly identified (75%), followed by the meniscal portion (69.4%) and the tibial portion (58.3%). ALLs were best visualized on corona! view in PD FS with the lateral inferior genicular artery as a guide to locate the bifurcation of the meniscal and tihial components. Conclusion The ALL can be visualized in routine 1.5-T MR imaging, either full delineation (55.6%) or partially visualized (75%). It is best characterized via a PD-weighted sequence with fat saturation on the coronal plane. The ALL injury was associated with an anterior cruciate ligament (ACL) injury.

A gastric diverticulum is an outpouching from the gastric mucosa. It is extremely rare. It is normally asymptomatic, but some may present with non-specific abdominal pain. A combination of upper gastrointestinal endoscopy and radiological contrast study such as oral barium study and computed tomography are needed to make a definite diagnosis and to rule out other associated pathology. Although treatment with medical therapy has been reported to be effective, the use of open and laparoscopic resection also yields a good outcome in the management of complicated gastric diverticulum. We present a case of symptomatic gastric diverticulum which has been successfully treated with medical therapy.

Introduction Open discectomy has been the gold standard of care for cases of prolapsed intervertebral disc. Tissue dissection is unavoidable in order to access the pathologic disc material. After skin incision, subcutaneous fat tissue, paraspinal muscles, ligamentum flavum, epidural fat, dura and nerve roots has to be encountered before reaching the disc material. With the in out transforaminal endoscopic technique, only skin and subcutaneous tissue need to be bridged before reaching the disc material. Also known as the targeted surgical technique, this technique minimized the trauma to the soft tissue. Materials and methods We present 3 case series of prolapsed intervertebral disc which was treated with transforaminal endoscopic technique. Case 1 49 year old lady presented with one year history of low back pain and left lower limb sciatica. Straight leg raising sign was positive. MRI showed 2 level disc bulge at L4L5, L5S1 with annular tear at L5S1. At 2 weeks post op pain was improved by 60% and SLR test was negative. case 2 26 year old lady presented with 6 months history of low back pain and left lower limb sciatica. Straight leg raising sign was positive. MRI showed extruded disc at L4L5. At post op day one, her sciatica completely resolved and SLR test was negative. Case 3 28 year old lady presented with 8 months history of low back pain and left lower limb sciatica. Straight leg raising sign was positive. MRI showed extruded disc at L5S1 with annular tear. At post op day one, her sciatica completely resolved and SLR test was negative. Results All three patients underwent transforaminal discectomy. Case 1 and 2 were done under monitored anaesthesia control (MAC) and case 3 was done under epidural anaesthesia. All three patients had satisfactory pain relief. The 1st patient had longer recovery period possibly because of its disease chronicity. Conclusion Early recovery is expected hence early return to work can be accomplished. In the future this might be the gold standard of treating prolapsed intervertebral disc.

Case: A 17-year-old male sustained an open fracture of the right medial malleolus (MM) with significant bone and soft tissue loss following a motor-vehicle accident. Following serial wound debridement, his ankle was effectively reconstructed with MM antiglide plate stabilization, iliac autogenous bone graft, and a free radial forearm soft tissue flap. Conclusions: Open MM fracture with bone and soft tissue loss is rare. It is feasible to treat this injury with a novel surgical reconstruction technique involving autogenous bicortical iliac bone graft and radial forearm free flap.

Since humans evolutionally adapt to a bipedal gait, the foot is important to allow humans to stand up, walk, run, and to jump. Without the soft tissues and bones at the foot and ankle, our lower limbs could not support the weight of the body. Crush injury of the foot and ankle is a consequence of high energy trauma leading to combined bone and soft tissue loss or destruction. The treatment of crush injury of the foot and ankle remains a challenge as it is associated with high morbidity. We report two cases of traumatic injury of foot and ankle to highlight the paramount importance of soft tissue coverage in limb salvaging and reconstructive surgery of foot and ankle.

Introduction: Surgical site infection (SSI) is the most common healthcare-related infection in surgical patients. Patients who have undergone spinal surgeries and have contracted postoperative SSI face increased morbidity and mortality, which invariably leads to additional burden on the healthcare system and higher costs. The risk factors for the increase in SSI in patients who have undergone spinal surgery have been investigated in numerous studies but no studies have been performed in Malaysia. The aim of this pilot study is to determine the incidence and factors associated with deep SSIs in patients that have undergone spinal surgeries. Methods : This retrospective study includes all patients who underwent spinal surgeries at Tengku Ampuan Afzan Hospital, Kuantan, from 1 January 2016 to 31 December 2017. Patients with an active spinal infection, polytrauma, and open fractures were excluded from this study. Patient characteristics and laboratory investigations were extracted to determine the risk factors for deep SSI events. Associations between SSI and risk factors were analyzed with SPSS V21.0 (IBM, Armonk, NY). Results: The univariate analysis indicated that fracture dislocation at the thoraco-lumbar junction (p=0.008) and a history of preoperative blood product transfusion (p=0.003) were associated with deep SSI. Other factors such as age (p=0.162), gender (p=0.262), body mass index (p=0.215), smoking status (0.272), number of vertebrae involved in the surgery (p=0.837), spinal cord involvement (p=0.259), postoperative hemoglobin reduction (p=0.816), and preoperative white blood cell count (p=0.278) were not associated with deep SSI. Conclusions: This pilot study highlights the factors associated with deep SSI in spinal surgeries. A larger study is needed to further confirm these findings.