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30 December 2023drpratikdhabalia.comBlog

Introduction

The tibial intra-articular fracture refers to soft tissues envelope and often known as pillion fracture. In such case an anatomic realignment of involved articular fracture in conjunctions with stable fixation is crucial. The major cause of this type of injury involves low energy and rotational forces as well as the position of the foot movement. This type of injury requires careful management of the soft tissues and appropriate system for reduction. The clinical assessment of the injury is essential for managing the issues and proper fixing of the bones. The process of fixing such fracture is involving the various modalities like soft tissue dehiscence, reduction of articular fragmentation with stable fixation through external devices. The use of olive wires enables the multi-directional forces to apply for the reduction of the spiral fracture.

In the treatment of fracture of the distal part of the tibia, care professional need to provide extra care as it involves a small group of fracture which cause difficulty in management and classification. Tibia is the major weight-bearing bone of the leg and open fractures are most common in this area of the body. The treatment of distal tibia fracture often results in several complications including malunion, non-union and ankle surface. The operative treatment of the tibial fracture is caused by high energy trauma and early motion of the tissues. The goal of treatment involves healed, well-aligned, functional range of motion of ankle joint. To offer the treatment the approach of fracture reduction has been successful in treating the complex fracture. The main objective of this technique is to apply stable plate fixation while maintaining the fracture biology and maintaining the soft tissue problem. In the current scenario, the trends towards using the locking plates are beneficial for managing the distal part of the tibia.

The locking plates have the biomechanical properties of internal and external fixation that provide the superior holding power and fixed angular holding. In addition to this, the new techniques of treatment of such fracture involve the Minimally invasive percutaneous plate osteosynthesis which aims to minimal periosteal dissection and disruption of hematoma, stable anatomical fixation and early mobilization. These kinds of treatment techniques are having a significant impact on managing the high-energy fracture of the distal tibia. The research will provide the information related to the outcome of the intra- articular fracture of distal tibia treatment with an external fixator. This kind of injuries is challenging because of its subcutaneous location and precarious blood supply and proximity to the ankle joint. The proper analysis of injury and implementation of the treatment plan helps manage the issues and provide better care services to the patients. The initial radiography is required for determining the particular fracture pattern that could associate with the injury. The IM nailing has reported with higher rates of mal-union because nail cannot provide the tight fit at the distal fracture site and affect the process of offering the treatment.

Aim

The research paper aims to analyze the outcome of communited intraarticular fractures of distal tibia treated with an external fixator.

Materials and Methods

The current study is an observational study that is being conducted in Dr. D.Y. Patil hospital, Navi Mumbai from May 2020 to May 2021. For the study, the researcher has selected 30 people that involve 23 male and 7 female. The mean age of these participants was 53 years (range between 26-72 years). Moreover, the researcher has used Muller-Nazarian classification for analyzing the results and used the clinical approach for identifying the impact of the surgery.

Inclusion criteria

1. Patients of age group 20 to 60 years.
2. Patients with open and closed fractures.

Exclusion criteria

1. Patients with vascular injuries.
2. Patients with pre-existing deformity of tibia.
3. Patients with associated tarsal bone fractures.

Results

For the current study, the researcher has used the observation and opinion method for analyzing the data collected from the different participants. The clinical outcome of the study involves the accuracy of reduction score mean points and external fixator.

Table 1

Quality of reduction

Table 2

Clinical rating

There were no diagnose for deep venous thrombosis and superficial pin tract infection was presented in the identified cases. The infection at 3 pin sites from the distal tibia ring was encountered in two cases and replaced with the wire and screw. The clinical result of study involves the mean score of 81.5 points that range between 58-100. The first requirement of arthrodesis of the ankle and this patient scored 9 points for reduction quality. The development of stiff ankle with equines of the foot from interruption of physiotherapy has helped to maintain the high standards in the treatment. The hospitals are following a myocardial infarction for analyzing the impact and recovery of the patients. However, the 34-year-old man with 43 C3 and the diaphyseal fracture was treated with the wire and plates to manage the issues. Moreover, the second poor result was 55 years old male who was addicted to smoke and it has affected the recovery process. The clinical results have identified that the patient was facing the issues related to A5 valgus deformity that also occurred with diabetes. The consideration of results focusing on the approach of external treatment was found good and applied for the other clinical studies of the patients.

Figure 1

Case 1: Pre operative x-rays
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Figure 2

CT scan
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Figure 3

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Figure 4

Wound after vac dressing
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Figure 5

Immediate post operative x-ray
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Figure 6

3 month f/u
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Figure 7

Removal of fixator
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Figure 8

Case 2
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Figure 9

3 month f/u
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Figure 10

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Figure 11

Case 3
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Figure 12

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Figure 13

Post operative x-ray
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Figure 14

Post operative 3 months
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Figure 15

Removal of fixator
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Discussion

For managing the intraarticular fractures of the distal tibia is having a significant impact on the body function of the individual. The study has identified issues and approaches of treatments to identify the impact of the external fixator. According to Beytemür et al., (2017), the open reduction and internal fixation (ORIF) has led to variable results for high energy distal tibia. The reduction is stable and having a direct impact on the approaches of treatment offered to the different age people. As per the finding, 74% of cases were good and less than 5% of people found with an infection that influences the healing. However, without complications of deep infection and consideration of articular restoration can be beneficial for gaining a favourable outcome for the patients. The external fixation is allowing the care professionals to manage the fracture in 10-14 days by fixing the soft tissues and periosteum. This kind of approach is helpful for the stable reduction and reported that 55% of patients have achieved good results by applying this technique. However, Aurich, Koenig, and Hofmann, (2018) have stated that internal osteosynthesis of the tibia was performed in 56% cases and founded that greater infection rate. The lack of external support and lack of prevention of the soft tissues is hurting the recovery process of an individual. The quality of reduction and clinical outcome of the fracture group is having a radiography therapy for managing the issues that are helping to improve the situation.

For stable and healing of distal tibia, the patient needs to focus on the weight and physical activities. As per the views of Yoon et al., (2015), the B4 and B3 types of fracture patients are facing serious issues for improving the health. These kinds of fractures are treated with the only external fixator. The proper stabilization with rod and interior angulations that varying from 5 to 25 and can help provide effective care to the patients. Their rotational process for managing the external fixator is helpful for the natural position at the moment of impact. The low energy trauma and the fracture pattern is having a significant impact on the clinical treatment and management of the soft tissues and early fixation. This kind of treatment approach is useful for weight-bearing. However, the external fixator is having skin damage and secondary infection caused by the high energy trauma that influences the result of treatment and tibia shaft fracture. The poor results of internal treatment and lack of satisfaction among the patient is influencing the demand for external fixator treatment. The report has identified that the development of stiff ankle with equines of the foot from interruption of physiotherapy has helped to maintain the high standards in the treatment. The infection at 3 pin sites from the distal tibia ring was encountered in two cases and replaced with the wire and screw. In addition to this, joint surface resulting in forwarding dislocation and healing and setting the right position for increasing the stability.

Conclusion

From the study, it can be considered that external fixator treatment for communited intraarticular fractures of the distal tibia is beneficial and having a positive impact on the process of offering the required support to the patients. The proper analysis of health conditions of individual and treatment helps manage the operations.

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30 December 2023drpratikdhabalia.comBlog

Introduction :-

The Achilles tendon, commonly known as the heel cord or calcaneal tendon, connects the plantaris, gastrocnemius (calf) and soleus muscles to the calcaneus bone at the back of the leg. It is the largest and most powerful tendon in the human body; the fibres of this tendon rotate by 90 degrees internally allowing the tendon to store and release energy through elongation and elastic recoil. The muscles act by means of the tendon resulting in plantar flexion of the foot at the ankle and (apart from soleus) flexion at the knee. A rupture of the Achilles tendon is a partial or complete tear of the tendon connecting the calf muscle and the heel bone. The gastrocnemius and soleus muscles are an essential component of contraction; the weakest point is the blood supply at the union of these two muscles, 2.16 cm above the insertion. The incidence of the Achilles tendon rupture, at this most common site, with a resulting loss of plantar flexion, is about 7 per 100,000 individuals. Tendoachilles tear is more common in middle-aged individuals, especially males, although there have been reports in women involved in sports. Diagnosing an acute tendoachilles rupture is hardly difficult, though the extent of the injury is overlooked by the initial evaluating physician in almost 25% patients. Missing or delaying a diagnosis can be a distressing issue with significant compromise of the clinical outcome. An individual typically narrates a feeling of a sudden snap in the calf or heel or that something struck the calf. Since the acute pain could subside
fairly quickly the patient might defer an evaluation, considering the injury as minor. A careful physical
examination is the foundation of a successful diagnosis of a complete rupture. The three common signs, the Simmonds’ triad, of weakness of ankle plantarflexion, palpable and (often) visible gap in the tendon, and a positive squeeze test are the hallmarks of an Achilles tendon rupture.

Case report :-

This is a case of a 28–year old male patient with a posttraumatic right sided compound grade 3a tear due to an alleged history of fall in the bathroom. In the casualty, the patient presented with an open lacerated wound over the posterior aspect of the right ankle; he did not have history of playing any sports. An ultrasound was performed over the swelling on the right ankle on the same day. There was complete discontinuity of the fibres of the tendoachilles tendon, which were suggestive of complete tear. The posterior tibial artery showed normal colour flow with biphasic spectral waveform pattern, and the posterior tibial vein showed normal colour flow and compressibility. There was no evidence of any free fluid; the underlying bony cortices visualised appeared normal. The clinical diagnosis of tendoachilles tendon rupture was confirmed on the basis of a positive Thompson’s squeeze test and an ultrasound. Radiographs were taken to rule out any bony abnormality (Fig. 2), after which the patient was given a
slab. The patient was then hospitalised on the same day and started on intravenous antibiotics. After 3 days, the patient underwent surgical intervention for the tendoachilles tendon tear. Once taken on the operation table, the patient was placed in the prone position, and a tourniquet was applied. The area to be operated was scrubbed, painted a n d d r a p e d . T h e tourniquet was then inflated to a pressure of
350 mmHg , and an incision was made to expose the tendoachilles tendon. On dissection, contamination of wound was noted, and complete rupture of tendoachilles tendon was seen at both the musculotendinous junction and insertion (Fig. 3). The peroneii muscle and plantaris muscle were found to be cut, blood clots present, margins of the wound were ill-defined, and the edges were ragged. The region was thoroughly washed with normal saline and betadine. A suture anchor of diameter 5 mm was inserted in the calcaneum and confirmed using a c-arm, after which the tendoachilles tendon repair was done. The muscle was then repaired with the suture anchor (Fig. 4). A thorough wash with normal saline and betadine were repeated. Vacuumassisted closure, applied to a pressure of 40 mmHg, was performed using 3-0 Ethlilon. After suturing, the Thompsons test was found to be negative. The patient
tolerated the procedure well and was shifted to recovery Post-operatively a repeat radiograph was repeated to ensure the position of the suture anchor, and was found to be satisfactory (Fig. 5). The patient was given a dorsal slab and strict limb elevation, and was continued on the intravenous antibiotics. The wound dressings were changed on the 2nd and 5th post-operative days and the patient was subsequently discharged.

Discussion :-

We have presented a rare case of a tendoachilles tear at two junctions – the musculotendinous junction and insertion. Very few cases of tendoachilles rupture at multiple joints have been documented. Saxena A and Hofer D presented a case report with one-year follow-up data of a 57-year-old male soccer referee with an acute triple Achilles tendon rupture injury at the proximal watershed region, the main body (mid-watershed area), and an avulsion-type rupture of insertional calcific tendinosis. The patient underwent
surgical intervention with primary repair of the tendon, including tenodesis with anchors. He was postoperatively treated with non-weightbearing for 4 weeks and protected weightbearing until 10 weeks, which was followed by formal physical therapy that included an “anti-gravity” treadmill. The patient returned to full activity after a period of 26 weeks, including running and refereeing, without limitations[9]. Garneti N et al presented a case of bilateral Achilles tendon rupture in a 59-year old male who sustained the tendon rupture under normal physiological load. The patient was treated operatively with V-Y plasty on the left side and a fascial turn down to re-enforce the repair on the right side, with post-operative plaster immobilisation for 12 weeks. Most evidence available in literature report patients with an achilles rupture at a single junction. Hagen M and Pandya NK reported a case series of three young female basketball players over a duration of nine months with complete achilles tendon ruptures that underwent surgery. All the patients presented to the clinic with a common complaint of calf pain in the posterior aspect of their lower leg while playing basketball. Intraoperatively, all three had
degenerative tissue and scar formation suggestive of a chronic nature to their pathology. Six months after surgery, all three athletes were able to return to play and played collegiate basketball.

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30 December 2023drpratikdhabalia.comBlog

Introduction :-

Burnout is a syndrome denoting the outcome of chronic work stress which has not been managed successfully. Burnout has only sometimes been at the forefront of studies in healthcare, where patient care and management have received more attention. This study focuses particularly on burnout of residents and healthcare workers during the COVID-19 pandemic that has changed the working environment.

Material and Methods :- 

Questionnaires in the form of surveys have been used to receive feedback regarding work experience within the bubble of isolation and high patient load unique to COVID-19 pandemic. A full and complete analysis of the research is provided after the definition, description, and measurement of burnout are given.

Results :- 

According to a review of the burnout literature, burnout affects medical students, residents, and practicing doctors, with prevalence rates ranging from 28% to 45% for each group. First-year residency during the COVID-19 pandemic, in particular, is plagued with unmanageable burnout symptoms and a depleted support system. Burnout among residents is said to be caused by time demands, a lack of control, poor work organization, naturally challenging employment settings, and interpersonal connections. Workplace solutions might take the form of burnout education, workload adjustments, diversifying job roles, stress management training, mentorship, emotional intelligence seminars, and training in emotional intelligence. In addition, developing interpersonal and professional relationships, meditation, therapy, and exercise are examples of self-directed behavioral, social, and physical activities..

Conclusion :- 

Educators should consider including pertinent instructions and interventions during the process of instructing resident doctors. In addition, they should actively become aware of burnout. Early detection aids in better management of burnout.

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30 December 2023drpratikdhabalia.comBlog

Introduction :-

Osteochondromas (OCEs) are the most common benign tumors arising on the external surface of the bone with aberrant cartilage [1, 2, 3]. OCEs account for 20–50% of benign bone tumors and 9% of all bone tumors [1, 2, 3]. Most of these tumors (85%) are solitary and nonhereditary in nature, while approximately 15% of these tumors are hereditary multiple OCEs [1, 2, 3]. Diagnosis of OCE involves presence of a capped cartilage and cortical and medullary continuity with the parent bone. Many of the patients are asymptomatic, though pain can be a clinical feature due to neural irritation, bursitis, mechanical irritation, fractures, osseous deformities, and malignant changes. There are unique challenges in diagnosis and treatment of OCEs of the proximal humerus. One can be predisposed to tendinitis, tendon ruptures, limitations of shoulder motion, and neurovascular compression depending on their proximity to important structures. Furthermore, additional complications can occur due to surgical excision of symptomatic OCEs, such as brachial artery pseudoaneurysm, constant pain, and improper resections leading to recurrence. To avoid recurrence, wide resection is done, and the whole cartilage cap and bone are removed from the base, after which the whole base is cauterized using electric cauterizatio. Most data concerning surgical treatment of proximal humerus OCE are based on case reports or small case series, particularly in the skeletally immature patient . Here, we present a case of recurrent OCE of the proximal humerus enclosing the brachial artery.

Case Report :-

We report a unique case of a 13-year-old female who had presented with a history of pain and recurrent swelling for 5 years. On physical examination, the swelling was of size 4.4 cm × 3.7 cm × 4 cm, non-tender, non-mobile, two in number, non-cystic without any redness or sinus discharge, no visible pulsations, and no dilated veins. A 10 cm previous scar mark was present and the brachial artery pulsations were felt just over the swelling with a previous history of swelling at the same place, for which she was operated in 2018 (Fig. 1). The patient provided with discharge card and radiological investigation of previous surgery of a tertiary hospital from which OCE was diagnosed. CT reports were suggestive of a large well defined broad-based exophytic diaphyseal lesion in the medial side of the proximal humerus extending posteriorly (Fig. 2, 3). It measured approximately 4.4 cm × 3.7 cm × 4 cm in size. Another similar morphological lesion measuring approximately 9 mm × 7 mm was noted involving the posterior humeral shaft (Fig. 4). The minimal distance between the lesion and the brachial artery was 2 mm just anterior to the posteriomedial growth.

A cardiovascular thoracic team was involved for the dissection and a 6 cm incision was taken on the previous scar. The tumor was first dissected posteriorly (Fig. 5). A first interval was made between biceps brachii muscle and triceps brachii muscle. Then, the neurovascular bundle was identified and retracted followed by a second interval made by splitting the biceps brachii muscle. The anterior tumor was identified, after which the brachial artery was isolated and posteromedial exostosis was removed with the help of an osteotome of size 6 cm × 4 cm × 3.7 cm. This was followed by anterior exostosis of size 1 cm × 1.2 cm and of the whole cartilage cap was excised and electrical cauterization of the base was done to prevent further reoccurrence and a requirement of second surgery. Postoperatively, the patient was started on broad spectrum antibiotics and shoulder and elbow range of motion exercises were started post-operative day 1. The patient was discharged on post-operative day 5 and suture removal was done on post-operative day 14. Immediate post-operative X-Ray and post-operative 6 months X-Ray were done (Fig. 6, 7).

Discussion :-

OCE is a cartilage-capped bony exostosis on the external surface of a bone containing a marrow cavity continuous with that of the underlying bone. Most cases are identified in children and adolescents which could be asymptomatic or complicated due to fractures and other lesions. OCEs may become malignant in approximately 1% of solitary forms and around 3–25% of multiple forms . OCE can also recur post-excision if it has been removed imperfectly and is in close proximity to neurovascular structures. Although, this might not always be true. In a study reported by Vallance et al., they present cases of vascular complications of OCE. In one of the cases, they report an OCE of 6 cm in diameter arising from the upper medial fibula in a 19-year-old football player. Arteriography revealed complete occlusion of the proximal 2–3 cm of the anterior tibial artery. The posterior tibial artery was displaced backward and reduced above the origin of the peroneal artery .
In another case, a 24-year-old man presented with swelling in the upper part of his right arm with pain. The authors reported a very large calcified OCE arising from the upper humerus and clinical examination revealed reduced but palpable brachial and radial pulses. It was observed that there was marked forward displacement of the brachial artery which was lengthened and narrowed by extrinsic compression. Successful resection was done with placement of a vascularized graft . Both these cases demonstrate that when presented with a case of recurrent OCE, proper removal of tumor is important keeping in view any blood vessels or nerves surrounding the tumor.

Conclusion :-

Proper curettage and excision of the tumor were done after dissecting and removing the soft tissue, blood vessels, and nerves so that there were very less chances of relapse. Post-operative X-ray was done and post 6 months of follow-up, there were no changes, and no relapse was observed. To conclude, OCE of the proximal humerus near the base of the axilla should always be excised properly so that the chances of reoccurrence should be very less as the neurovascular bundle is very near to the shaft.

Clinical Message :-

When presented with a case of recurrent OCE of the proximal humerus, OCE could also be in proximity to important vasculature as in this case enclosing the brachial artery. Thus, proper curettage and excision should be done in such cases to avoid recurrence.

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