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Monteggia fracture dislocations can be classic or equivalents. Equivalents, also known as Monteggia like lesions, are very rare especially type III and IV, which have been added to the literature after Luis Bado presented the original classification system of Monteggia fracture dislocations. Type III equivalent is classically defined as a proximal ulna fracture associated with a fracture of the lateral condyle of the humerus. In the literature only seven such cases have been reported so far. Here we present two such cases where one eight-year-old boy had a complex type of injury with a shear type fracture of the lateral humeral condyle and other a seven-year-old boy who had a plastic deformity of the ulna with an avulsion type fracture of the lateral humeral condyle. We also try to describe a novel mechanism of injury, known as, “Barzulla circle”, for the classical as well as equivalent type III Monteggia fracture dislocations.

Background/Purpose The purpose of this study was to evaluate the results of reconstruction of postosteomyelitic defects in short tubular bones in a paediatric population using a universal mini external fixator (UMEX). Methods This was a prospective case series based on 10 consecutive cases who were followed-up for an average period of 3.5 years. Ten patients (mean age: 10.2 years) with an average shortening of 4 cm of the corresponding digit were operated upon using soft tissue distraction by UMEX followed by interposition bone grafting from the iliac crest. The second metacarpal was involved in five patients, the first metacarpal in three patients, and the proximal phalanx of the right big toe was involved in two patients. Results All of the patients achieved union at the graft host site at an average of 12 weeks and an average of 3.8 cm lengthening of the digit was achieved. All patients had improved digit length, and function and appearance of the hand and toe. Apart from a minor pin tract infection and stiffness, there were no major complications. Final average follow-up at 3.5 years did not show any recurrence of infection or loss of correction. Conclusion We believe that UMEX is a versatile method of managing postosteomyelitic defects in short tubular bones, with fewer complications and a high union rate, even in situations in which bone fragments are small and difficult to handle with other methods.

BACKGROUND Although various operative techniques are available for ankle arthrodesis, it is not rare to see orthopaedic surgeons facing difficult situations with ankles that cannot be reliably treated by any conventional methods other than the Ilizarov technique. This study was conducted to measure the outcome in such patients using the Ilizarov Ring fixator. MATERIAL AND METHODS Sixteen patients (average age 47.5 years) had primary or revision unilateral ankle arthrodesis using the Ilizarov technique. Among the 16 patients the pathology included severe difficult posttraumatic arthritis with diabetes mellitus (n=7), failed arthrodesis with internal fixation (n=4), difficult post-septic arthritis (n=3) and 1 case each of rheumatoid arthritis and post-polio residual palsy with instability. The primary outcome was bony union and ankle alignment. The clinical results were further evaluated according to the American Orthopaedic Foot and Ankle Society scoring (AOFAS) System at 6 months and yearly till final follow-up. RESULTS All ankles achieved arthrodesis at an average of 14 weeks (range 12-18 weeks). The average duration of follow-up was 5.7 years (range 4- 10 years). No major complication was seen except for 5 cases of superficial pin track infections, wound dehiscence in 1 patient and chronic discharging sinus in 1 patient. The average AOFAS score improved from an average of 35.25 (range 20- 44) points pre-operatively to an average of 78.37 (range 72-89) points at final follow-up. CONCLUSION Ankle arthrodesis using Ilizarov technique shows a high fusion rate with no major complications and operative failures even in difficult and complicated situations.

Background: Fractures of the femur are amongst the most common paediatric orthopaedic injuries. The aim of this study was to assess the efficacy of the stainless steel elastic nail in the management of these fractures in the 6-10 year age group.Methods: Fifty patients in the age group of 6-10 years with displaced diaphyseal femoral fractures were stabilized with these nails. Patients were followed up clinically and radiologically for a minimum period of 1 year.Results: There were 64% excellent and 34% satisfactory results. 2% patients had poor result.Conclusions: These nails are a relatively easy to use, minimally invasive, physeal-protective implant system with high rate of satisfactory and excellent outcomes in children aged 6-10 years.

Purpose.To assess the efficacy of acute invaginating docking for infected non-unions of the humerus. Methods. Eight men and 3 women aged 17 to 59 years with infected non-unions of the humerus underwent acute invaginating docking with shortening and Ilizarov fixation.Results.The mean shortening was 2.9 cm owing to additional debridement. The mean time to external fixator removal was 14.9 (range, 8–28) weeks. The final bone result was excellent in 1, good in 8, and fair in 2. The functional result was excellent in 7 and good in 4.Conclusion.This modality enables simultaneous treatment of infected non-unions, axial alignment, vascularity, stability, and function.

Summary Polytrauma cases in mass disasters present several challenges to the orthopaedic surgeon. Delayed referral, multisystem involvement and the requirement to manage coexisting injuries by interhospital transfer often make infection an inevitable risk. 28 patients with polytrauma were studied after being referred after being recovered from the debris of their homes in the Kashmir earthquake. All patients were referred more than 24 h after sustaining their injuries. The lower limb fractures were fixed by external fixators in all these cases before interhospital transfer for the management of their co existing injuries. Return referral to the orthopaedic facility occurred after an average of 25 days. All cases were converted to Ilizarov fixation. The results bear out the fact that the Ilizarov method may be well suited for conversion osteosynthesis of lower limb fractures in polytrauma cases.

The distal third of the tibia is unique in the sense that it has a minimal muscle cover and consequently the blood supply is easily compromised after a fracture in this area. Infected non union in this area provides a challenge to the orthopaedic surgeon. These difficulties are especially profound in the geriatric age group.12 cases with an infected non union of the distal third of the tibia were managed with acute docking over a distance of up to 2.5 cms. The age of these patients was more than 55 years.The average shortening at final follow up was 1.8 cms. The bone results were assessed according to the protocol laid down by the association for the study and application of the method of Ilizarov. Accordingly we had 3 excellent, 8 good and 1 fair result. The functional result was calculated as per the Ilizarov criteria [1]. On this basis we had 7 excellent, 4 good and 1 fair result.The acute docking modality is applicable to the distal tibia in such situations even in the geriatric population with predictable results.

Closing wedge osteotomies are the gold standard for the management of post-traumatic cubitus varus deformity. However, most of these osteotomies are fraught with complications such as lateral condylar prominence, instability, and difficulty in correcting internal rotation. We describe a new technique that provides a means for the management of all these problems simultaneously.

Purpose To determine the impact of a substantial delay in providing surgical treatment on the final outcome in transcervical femoral neck fractures in children. Methods Data on all pediatric patients with transcervical fractures of the femoral neck that were fixed by reduction and internal fixation after a delay of ≥7 days in our department between 2000 and 2008 were collected both retrospectively and prospectively. Results The medical records of 14 patients (15 fractures) were analyzed. The results after an average of 43 months of follow-up showed that the complication and avascular necrosis rates were higher in cases in which treatment had been delayed compared to those in comparable fractures that had been treated promptly after the event in other series. Nine of the 15 fractures had developed avascular necrosis at final follow-up. Overall, there were four excellent, three good, and eight poor results (based on the Ratliff criteria). Conclusions Children whose transcervical fractures of the femoral neck were surgically treated after a delay of 1 week or longer had a high avascular necrosis rate and a relatively poor outcome. Reduction and internal fixation as the initial treatment should be implemented shortly after injury in order to enhance treatment outcome.

Penetrating injuries of the foot are a common presenting complaint in the emergency department. The residents of the underdeveloped world are especially prone to suffer such injuries as barefoot walking is still common. However, a relatively common injury that occurs in the shod feet is the “Nail-Slipper injury”. A metal nail penetrates through the rubber sole of the footwear introducing the rubber piece into the soft tissue of the foot. As the nail is removed the piece remains behind often leading to delayed manifestations. This article describes the various delayed manifestations of this injury. A leading question for the antecedent injury of this kind should be asked from all patients with such presentations, especially in the urban setting.

This is a retrospective review of paediatric elbow trauma, which was initially treated by bonesetters and subsequently reported to the hospital for management. This paper describes the pattern of trauma and the complications of unscientific management. The report also recommends a basic training program for the bonesetters so as to make them aware of the potential complications involved in managing paediatric elbow trauma.

To assess the pattern of mass casualty incidents managed at our hospital over the last eight years, and evolve a differentiating classification based on this pattern. A combination of retrospective and prospective assessment was made.All patients receiving injuries in mass casualty incidents and managed at our hospital. Patients with an injury severity score above 9. Management of injuries as per the trauma management protocol. Classification based on the data collected during the study and application of this classification to the subsequent mass casualty incidents to allow comparison between similar incidents in different settings.A classification system that mainly differentiates mass casualty incidents on the hospital basis, the criteria being: the time interval between the first information to first reception, and the percentage of admission above the maximum normal intake.The Barzullah classification system is the first attempt at developing a hospital based differentiation in mass casualty incidents. It provides a valid and easy method of comparing such incidents between hospitals and perhaps a basis for developing protocol for mass disaster management.

To analyze the outcome of the management of pediatric elbow trauma referred to our hospital after initial intervention by traditional bone setters.Retrospective study of 73 patients, presenting to the hospital with a complication attributable to the initial mismanagement of their injuries.The mode of presentation was directly related to the type of initial intervention on the basis of which we were able to quantify bone setters into two groups. The first group using a rather rough method of trauma treatment involving the application of tight local bandages, massage and manipulation and a second group having a relatively less rough approach, applying splints to the injured extremity without tight bandages and manipulation. The result of treatment of these injuries was determined by the delay in presentation and the type of injury.This study highlights the importance of dealing with the unchecked and unsupervised practice of bone setting in the developing world. We believe that training these people on the pattern of traditional birth attendants can at the very least lower the occurrence, if not entirely eliminate the problem of mismanaged trauma in this part of the world.

Osteotomies around the hip and knee are important methods in the management of a number of different pathologies.

Polytrauma cases in mass disasters present several challenges to the orthopaedic surgeon. Delayed referral, multisystem involvement and the requirement to manage coexisting injuries by interhospital transfer often make infection an inevitable risk. 28 patients with polytrauma were studied after being referred after being recovered from the debris of their homes in the Kashmir earthquake. All patients were referred more than 24h after sustaining their injuries. The lower limb fractures were fixed by external fixators in all these cases before interhospital transfer for the management of their co existing injuries. Return referral to the orthopaedic facility occurred after an average of 25 days. All cases were converted to Ilizarov fixation. The results bear out the fact that the Ilizarov method may be well suited for conversion osteosynthesis of lower limb fractures in polytrauma cases.

Introduction A Monteggia facture dislocation is not an uncommon injury, and the diagnosis can often be missed. Long-term follow-up of untreated Monteggia fracture dislocations reveals development of premature arthritis, pain, instability, and loss of pronation and supination. Methods involving annular ligament reconstruction require post-operative immobilization and use of transcapitellar pinning for maintenance of reduction, and thus a delay in rehabilitation. The literature reports satisfactory results with methods that involve ulnar osteotomy and open reduction of the radial head without annular ligament reconstruction. We used the Ilizarov method in two cases with neglected Monteggia fracture dislocations to stably reduce the radial head without open reduction and annular ligament reconstruction. Case presentation We report two cases of neglected Monteggia fracture dislocation, in two Kashmiri boys aged four and six years. Using ulnar osteotomy with distraction osteogenesis, we were able to relocate the radial head gradually and maintain the reduction without a requirement for open reduction and annular ligament reconstruction. Conclusion Distraction lengthening and hyperangulation in different planes by use of the Ilizarov technique effectively reduces the radial head without open reduction and annular ligament reconstruction.

IntroductionHigh energy tibial plateau fractures along with calcaneal fractures individually produce several challenges for the orthopaedic surgeon. The principles of bony reconstruction include anatomic reduction and rigid internal fixation of intra-articular fractures and accurate restoration of the coronal, sagittal and transverse mechanical axes. Due to the tenuous nature of the soft tissue and devitalisation of the comminuted fragments with open reduction, external fixation of type 6 tibial plateau fractures is recommended. We report a case with ipsilateral high energy tibial plateau and calcaneal fractures both of which were managed with an ilizarov ring fixator.Case presentationA 55-year-old Kashmiri female presented to our department with an ipsilateral fracture of the tibial plateau and the calcaneum. Both were closed reduced and stabilized with an ilizarov ring fixator.ConclusionThe circular wire fixator provides a viable method to manage such fractures especially if they are co existent. This is especially true in situations where the soft tissue is compromised.