A Neglected Case of Bilateral Hip Fractures and Other Fractures with Delayed Diagnosis of Hyperparathyroidism as Cause

Vol 4 | Issue 2 | May – Aug 2018 | page: 38-41 | Sanjay Chhawra, Arun Kumar N Kambar, Ravi Gupta

Author: Sanjay Chhawra [1], Arun Kumar N Kambar [1], Ravi Gupta [1].

[1] Department of Orthopaedics, Jaipur Golden Hospital , 2 Institutional Area ,Sec 3 Rohini Delhi 110085.

Address of Correspondence
Dr. Sanjay Chhawra
A-144 Gaytri Vihar Bagh Mughaliya, Bhopal. MP. India.
E-mail: sanjaychhawra@yahoo.com


Introduction: Primary hyperparathyroidism is a disease characterized by hypercalcemia attributable to autonomous overproduction of PTH ParaThyroid Hormone.Primary hyperparathyroidism PHPT is prevalent in approximately 1% of adult population with F;M 3;1. The disease affects multiple systems –Musculosketal, CVS, G.Urinary, Abdomen and Endocrine. Primary hyperparathyroidism present with classic signs and symptoms of hypercalcaemia. Non-specific symptoms may include muscle weakness, thirst, polyuria, anorexia and weight loss along with pathological fractures.The treatment of choice is parathroidectomy after proper investigation.
Case Report: A 40 yrs Male presented with Pain, Swelling and Deformity over Bilateral Hip, Right Shoulder, Right Hand and Right Clavicular Region. Unable to bear weight since 1 year. Along with its General Complaint of Weakness, Joint Pain, Abdominal Pain with clinical syptoms and operated right sided hip after proper investigation patient was diagnosed Hyperparathyridism with B/L Hip fracture {unusual presentation }multiple fractures with implant failure .After Parathyroidectomy and regular follow fracture fixation was done later with calcium supplementation the outcome was satisfactory.
Conclusions: Repeatedly multiple fractures must be investigated with appropriate and precise routine serum biochemical along with PTH Vitamin D Thyroid profile to diagnose endocrine disorder as in this case diagnosed as Hyperparathyroidism.With Clinical examination of neck as specific site with extremities, deformities and systemic examination is essential. USG Neck as routine investigation for this disease. After parathyroidectomy and regular follow up is done. Afterwards fracture fixation is done as secondary procedure with adequate calcium and vitamin D correction give good prognosis better union with best possible outcome. This is rare presentation of PHPT with B/L Hip fracture and other fractures deformities is an excellent example of an endocrine disease that is best managed by a multidisciplinary approach and long term patient follow up.
Keywords: Primary Hyperparathroidism PHPT, Pathological fracture, PTH Parathyroid Hormone.


1. Goode A. W. The parathyroid and adrenal glands. In: Russel R. C.G, Williams N. S and Bulstrode C. J. K (eds). Short textbook of surgery. Arnold, London. 2000; 734-748.
2. Mungadi IA, Amole *AO, Pindiga UH. Primary hyperparathyroidismpresenting with multiple pathological fractures and normocalcaemia.Ann Afr Med 2004;3(1):42e4.
3. Grégoire C, Soussan M, Dumuis ML, Martin A, et al. (2012) Contribution of multimodality imaging for positive and aetiological diagnosis of multiple brown tumours. Ann Endocrinol (Paris) 73: 43-50.
4. Morgan G, Ganapathi M, Afzal S, Grant A.J (2002) Pathological fractures in primary hyperparathyroidism: a case report highlighting diagnostic difficulties. Injury 33: 288-289.
5. Callender GG, Udelsman R. Surgery for pri-mary hyperparathyroidism. Cancer 2014; 120: 3602-3616.
6. John P, Bilezikian MD, Shonni J, Silverberg MD. Asymptomaticprimary hyperparathyroidism. N Engl JMed 2004;350:1746e51.
7. K. A˘gbaht, A. Aytac¸, and S. G¨ull¨u, “Catastrophic bone deformities associated with primary hyperparathyroidism in a middleaged man,” The Journal of Clinical Endocrinology &Metabolism, vol. 98, no. 9, pp. 3529–3531, 2013
8. Henry,J.Mankin.: An instruction course lecture- Metabolic bone disease. The American Academy of orthopaedic surgeons. Journal of Bone & Joint Surgery; 1994;Vol- 76A, No.5; 760-788
9. Albright F, Aub JC, Bauer W (1934) Hyperparathyroidism, a commonand polymorphic condition as illustrated by seventeen proved casesfrom one clinic. JAMA 102:1276-1287.
10. Nussbaum,S.R., & Polt,J.T., Jr.: Immunoassays for parathyroid hormone 1-84 in the diagnosis of hyperparathyroidism. J Bone and Min. Res., 6 (supplement 2); s43- s50, 1991.
11. Lancourt JE, Hochberg F. Delayed fracture healing in primary hyperparathyroidism Clin OrthoP 1977; 124: 214-218
12. A.Khan and J. P. Bilezikian, “Primary hyperparathyroidism: pathophysiology and impact on bone,” Canadian Medical Association Journal, vol. 163, no. 2, pp. 184–187, 2000.
13. Winzelberg G.G ;Parathyroid imaging. Ann.Intern.Med. 1987;vol -107;64-70
14. Lorberboym M, Ezri T, Schachter PP. Preoperative technetium Tc 99m sestamibi SPECT imaging in the management of primary hyperparathyroidism in patients with concomitant multinodular goiter. Arch Surg 2005 Jul;140(7):656e60.
15. Lars Rolighed, MD,1 Lars Rejnmark, PhD, DMSci2 and Peer Christiansen, DMSci Bone Involvement in Primary Hyperparathyroidism and Changes After Parathyroidectomy US Endocrinology 2013;9(2):181–4 3
16. Cristina Stefan1,2, Amalia Arhire1, Luminita Cima1,3 & Carmen Barbu1,3 Long standing primary hyperparathyroidism consequences after parathyroid surgery: fast recovery not only for bone mass Endocrine Abstracts (2017) 49 Ep262 .

How to Cite this article:  Chhawra S, Kambar AN, Gupta R. A Neglected Case of Bilateral Hip Fractures and Other Fractures with Delayed Diagnosis of Hyperparathyroidism as Cause. Trauma International May – Aug 2018;5(2):38-41.

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The Management of the Displaced Fracture Neck Femur by Dynamic Compression Hip Screw with Derotation Screw

Vol 4 | Issue 2 | May – Aug 2018 | page: 29-33 | Wasudeo mahadeo Gadegone, Bhaskaran Shivashankar, Rajendra Chandak, Piyush Gadegone.

Author: Wasudeo mahadeo Gadegone [1], Bhaskaran Shivashankar [2], Rajendra Chandak [3], Piyush Gadegone [4].

[1] GMC Chandrapur, Maharashtra, India.
[2] Iyer Orthopaedic Hospital, Solapur, India
[3] Chandak Nursing Home Nagpur Maharashtra India.
[4] Sion Hospital, Mumbai, India

Address of Correspondence
Dr. W.M. Gadegone,
Vivek Nagar Mul-Road Chandrapur 442402, Maharashtra, India.
Email: gadegone123@yahoo.co.in


Introduction: The aim of the present study was to evaluate the outcomes of displaced intracapsuar fracture neck femur managed by dynamic hip screw (DHS) with derotation screw treated within ten days of injury in patients younger than 60 years.
Materials and methods: This was a prospective study, carried out between December 2010 to December 2016. A total of 42 patients younger than 60 yrs of age with displaced intracapsular fracture neck femur (Garden III and IV, Pauwels III, with the comminution) presenting to the hospital within 2-10 days were included in the study. Data analysis and statistical analysis was done by using SPSS using appropriate tests.
Results: There were 27 males and 15 females, age ranging from 21 to 60 years (mean42.4±10.2 years). There were twenty seven Garden III while fifteen fractures were Garden IV. In forty fractures (95.2 %) average time to union was 3.7 months [3-5 months]. Radiographic evidence of avascular necrosis was seen in four cases(9.5%) and two patients(4.7%) developed non-union of the fracture .There were no cut-outs and breakage of implant .Two patients developed isolated coxa vara ( 120-124°) with backing of screws. Mean shortening of the injured limb was 2 -4 mm in twenty four patients without any functional impairment. Functional results were evaluated by Harris Hip Score. Excellent results were achieved in thirty four (81%), good/fair in six (14.2%) and poor in two (4.8%)patients.
Conclusion: Dynamic Hip Screw (DHS) with derotation screw is a good implant for the fixation of the displaced fracture neck femur with excellent to good radiological and functional outcome.
Keywords: Fracture neck femur, transcervical/ subcapital fracture, cannulated cancellous screw, dynamic hip screw, avascular necrosis, nonunion.


1. Yang JJ, Lin LC, Chao KH, Chuang SY, Wu CC, Yeh TT, Lian YT. Risk factors for nonunion in patients with intracapsular femoral neck fractures treated with three cannulated screws placed in either a triangle or an inverted triangle configuration. J Bone Joint Surg Am. 2013;95:61-69
2. Deneka DA, Simonian PT, Stankewich CJ, et al ;Biomechanical comparison of internal fixation techniques for the treatment of unstable basicervical femoral neck fractures. J Orthop Trauma. 1997;11:337–343.
3. Wei J, Mao YJ, Jia ZZ (Treatment of 212 cases of fresh femoral neck fracture with compressed hollow screws. Chin J Traumatol 2000 16: 142-144 4
4. Makki D, Mohamed AM, Gadiyar R, Patterson M ;Addition of an anti-rotation screw to the dynamic hip screw for femoral neck fractures. Orthopedics. 2013;36:865–868.
5. Bonnaire FA, Weber AT. Analysis of fracture gap changes, dynamic and static stability of different osteosynthetic procedures in the femoral neck. Injury. 2002;33 Suppl 3:C24–C32.
6. W.-C. Chen, S.-W. Yu, I.-C. Tseng, J.-Y. Su, Y.-K. Tu, and W.-J. Chen, “Treatment of undisplaced femoral neck fractures in the elderly,” Journal of Trauma, 2005 vol. 58, no. 5, pp. 1035–1039
7. Gurusamy K, Parker MJ, Rowlands TK. ;The complications of displaced intracapsular fractures of the hip: The effect of screw positioning and angulation on fracture healing. J Bone Joint Surg [Br] ;2005 87-B:632–634
8. Baumgaertner MB, Solberg BD .Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hips. J Bone Joint Surg [Br] 1997;79-B:969–971.
9. Ly, T. V., &Swiontkowski, M. F. Treatment of femoral neck fractures in young adults. Journal of Bone and Joint Surgery. American Volume,2008 90, 2254–2266
10. Haidukewych, G. J., Rothwell, W. S., Jacofsky, D. J., Torchia, M. E., & Berry, D. J. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. The Journal of Bone & Joint Surgery, 2004 86, 1711–1716.
11. Garden RS. Reduction and fixation of subcapital fractures of the femur. Orthop Clin North Am. 1974;5:683-712.
12. Liporace, F., Gaines, R., Collinge, C., &Haidukewych, G. J. Results of internal fixation of pauwels type-3 vertical femoral neck fractures. The Journal of Bone & Joint Surgery, 2008. 90: 1654–1659.
13. Shabnam Samsami,Sadegh Saberi,Sanambar Sadighi,Gholamreza Rouh; Comparison of Three Fixation Methods for Femoral Neck Fracture in Young Adults: Experimental and Numerical Investigations .Journal of Medical and Biological Engineering. 2015 October, Volume 35, Issue5, pp 566–579
14. Bosch U, Schreiber T, Krettek C. Reduction and fixation of displaced intracapsular fractures of the proximal femur. ClinOrthop RelatRes.2002 ;59-71.
15. Karaeminogullari O, Demirors H, Atabek M, Tuncay C, Tandogan R, Ozalay M. Avascular necrosis and nonunion after osteosynthesis of femoral neck fractures: effect of fracture displacement and time to surgery. Adv Ther.2004 ;21:335-342. Andreas Panagiotopoulos
16. AndreaPiccioli,Peter V. Giannoudis;Timing of internal fixation of femoral neck fractures. A systematic review and meta-analysis of the final outcome;Injury 2015 March Volume 46, Issue 3, Pages 459–466
17. Razik F, Alexopoulos AS, El-Osta B, Connolly MJ, Brown A, Hassan S, Ravikumar K. Time to internal fixation of femoral neck fractures in patients under sixty years–does this matter in the development of osteonecrosis of femoral head? International orthopaedics ;2012;36:2127-2132.Slobogean GP
18. 1, Sprague SA2, Scott T3, Bhandari M2; Complications following young femoral neck fractures. Injury.2015. Mar;46(3):484-91.
19. Stiasny J., Dragan S., Kulej M., Martynkiewicz J., Płochowski J., Dragan S.ŁComparison analysis of the operative treatment results of the femoral neck fractures using side-plate and compression screw and cannulated AO screws. OrtopTraumatolRehabil.2008 ;10(4):350–361.
20. Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK;Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint SurgBr. 2004;86:1035–1040.
21. Lee CH, Huang GS, Chao KH, Jean JL, Wu SS.Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. Arch Orthop Trauma Surg.;2003.123:527-33 Lu-Yao GL
22. 1, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports.J Bone Joint Surg Am. 1994. Jan;76(1):15-25.
23. Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg Am. Aug. 2005.87(8):1680-8. Barnes R
24. Brown JT, Garden RS, Nicoll EASubcapital fractures of the femur. A prospective review. J Bone Joint Surg Br.1976 Feb;58(1):2-24.

How to Cite this article:  Gadegone WM, Shivashankar B, Chandak R, Gadegone P. The Management of the Displaced Fracture Neck Femur by Dynamic Compression Hip Screw with Derotation Screw. Trauma International JMay-Aug 2018;4(2):29-33.


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Biological dynamic condylar screw fixation for management of Peritrochanteric hip fractures

Vol 4 | Issue 2 | May – Aug 2018 | page: 25-28 | Ninad Ashok Godghate, Neha Ninad Godghate, Krishnamohan Ananda Saindane, Shriniwas Yemul, Shivraj Suryawanshi.

Author: Ninad Ashok Godghate [1] , Neha Ninad Godghate [1], Krishnamohan Ananda Saindane [2], Shriniwas Yemul [3], Shivraj Suryawanshi [4].

[1] Consultant Grace Ortho Clinic Rajiv Nagar T-Point Wardha Road, Nagpur.
[2] FICS, Consultant, Suyog Hospital, Sakri road, Dhule.
[3] Ashwini Rural Medical College and Research Centre, Kumbhari, Solapur
[4] Consultant Orthopaedic Surgeon, Alexis Hospital Nagpur

Address of Correspondence
Dr. Ninad Godghate,
1, Satpute Layout, Somalwada, Wardha Road, Nagpur-440025
E-mail: drninadgodghate@gmail.com


Introduction: Inspite of routine encounters, hip fractures have the capacity to perplex even experienced orthopaedic surgeons at times. Management of these fractures has evolved with time and soft tissue preserving techniques have gained importance. Through this study we have attempted to analyse the results of traditional dynamic condylar screw plate construct used in a biological manner for treatment of peritrochanteric hip fractures.
Material & Methods: 18 patients in the age group of 22 to 78 years with post traumatic unstable intertrochanteric or subtrochanteric fractures in a pre-operative normal limb were included. All cases were operated within 5 days of trauma and were advised non weight bearing mobilisation for 6 weeks.
Results: Union was achieved in all cases with average duration of 14.6 weeks. 14 patients regained pre-fracture activities.
0.5 cm lengthening was seen in 2 cases.
Conclusion: Biological plating with dynamic condylar screw plate construct is a good modality for treatment of peritrochanteric hip fractures. There is a learning curve like any other surgical technique and results can be improved over time with proper patient selection and planning.
Keywords: Biological, Dynamic condylar screw, unstable, Peritrochanteric fractures


1. Rohilla R, Singh R, Magu NK, Siwach RC, Sangwan SS. Mini-incision dynamic condylar screw fixation for comminuted subtrochanteric hip frcatures. Journal of orthopaedic surgery 2008; 16(2):150-5.
2. Saini P, Kumar R, Shekhawat V, Joshi N, Bansal M, Kumar S. Biological fixation of comminuted subtrochanteric fractures with proximal femur locking compression plate. Injury 2013; 44:226-31.
3. Vaidya SV, Dholakia DB, Chatterjee A. The use of dynamic condylar screw and biological reduction techniques for subtrochanteric femur fracture. Injury 2003; 34:123-8.
4. Boldin C, Seibert FJ, Fankhauser F, Peicha G, Grechenig W, Szyszkowitz R. The proximal femoral nail (PFN) – a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand 2003;74:53-8
5. Garnavos C, Peterman A, Howard PW. The treatment of difficult proximal femoral fractures with the Russell- Taylor reconstruction nail. Injury 1999;30:407-15
6. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P; Hip fracture study group. Integrity of the lateral femoral wall in intertrochanteric hip fratures: an important predictor of a reoperation. JBJS Am 2007 Mar; 89(3):470-5.
7. Krettek C, Schandelmaier P, Miclau T, Tscherne H. Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures. Injury Supplement 1997; 28(1):20-30.
8. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969 Jun;51(4):737-55
9. Siebenrock KA, Muller U, Ganz R, Indirect reduction with condylar blade plate for osteosynthesis of subtrochanteric femoral fractures. Injury 1998; 29(Suppl 3):C7-15
10. Cooper C, Campion G, Melton LJ. Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992; 2:285-9
11. Johnell O, Kanis JA. An estimate of the worldwide prevalence, mortality and disability associated with hip fracture. Osteoporos Int. 2004;15:897-902
12. Kulkarni GS, Limaye R, Kulkarni M, Kulkarni S. Current concept review Intertrochanteric fractures. Indian Journal of orthopaedics 2006; 40(1):16-23.
13. Pilson H, Carol E. Biological basis of minimally invasive osteosynthesis. In Tornetta P, editor. Minimally invasive orthopaedic trauma. Philadelphia: Wolters Kluwer; 2014, p. 1-10.
14. Morshed S, Lin C, Krettek C, Miclau T III. Biological basis of minimally invasive osteosynthesis. In Tornetta P, editor. Minimally invasive orthopaedic trauma. Philadelphia: Wolters Kluwer; 2014, p. 11-23.
15. Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P. The topography of the perforators of the deep femoral artery: a cadaver injection study. Orthopaedic trauma association (OTA), annual meeting Boston 1996; Abstract book 133-134
16. Schemitsch E., Turchin D., Kowalski M., Swiontkowski M. Quantitative assessment of bone injury and repair after reamed and unreamed locked intramedullary nailing. The journal of trauma: Injury, Infection and Critical care. 1998; 45:250-55
17. Leunig M, Hertel R, Siebenrock KA, Ballmer FT, Mast JW, Ganz R. The evolution of indirect reduction techniques for the treatment of fractures. Clin Orthop Relat Res. 2000;375:7-14
18. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: Choosing a new balance between stability and biology. J Bone Joint Surg Br 2002;84:1093-110
19. Steven P, Wade G, Allan SL. Subtrochanteric fractures. In Mohit Bhandari, editor. Evidence based Orthopaedics Vol.II. Wiley Blackwell; 2012: p 502
20. Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade plate. Clin Orthop Relat Res 1989; 238:122-30.
21. Kulkarni SS, Moran CG. Results of dynamic condylar screw for subtrochanteric fractures. Injury 2003; 34:117-22.
22. Nungu KS, Olerud C, Rehenberg L. Treatment of subtrochanteric fractures with the AO dynamic condylar screw. Injury 1993; 24:90-2
23. Arrington, Edward D, Smith, William J, Chambers, Henry G, Bucknell, Allan L, Davino, Nelson A. Complications of iliac crest bone graft harvesting. Clin Orthop Relat Res. 1996; 329:300-09
24. Appelt A, Suhm N, Baier M, Meeder PJ. Complications after intramedullary stabilization of proximal femur fractures: a retrospective analysis of 178 patients. Eur J Trauma and Emerg Surg 2007; 33:262-7.
25. Windolf J, Hollander D, Hakimi M, Linhart W. Pitfalls and complications in the use of the proximal femoral nail. Langenbecks Arch Surg 2005; 390:59-65.
26. Gotfred Y. The lateral trochanteric wall. Clin Orthop. 2004; 425:82-86.
27. Antonini G, Giancola R, Berruti D, Blanchietti E, Pecchia P, Francione V, Greco P, Russo TC, Pietrogrande L. Clinical and functional outcomes of PCCP study:a multicentre prospective study in Italy. Strat Traum Limb Recon. 2013; 8:13-20
28. Pai CH. Dynamic condylar screw for subtrochanteric fractures with greater trochanteric extension. J. Orthop. Trauma, 1996; 10:317-22
29. Sanders R, Regazzoni P. Treatment of subtrochanteric fractures using the dynamic condylar screw. J. Orthop Trauma. 1989; 3:206-13

How to Cite this article:  Godghate NA , Godghate NN, Saindane KA, Yemul S, Suryawanshi S. Biological dynamic condylar screw fixation for management of Peritrochanteric hip fractures. Trauma International May -Aug 2018;4(2):25-28.


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Functional outcome of Unstable Inter-trochanteric femur fracture patients treated with Trochanteric fixation nail

Vol 4 | Issue 2 | May – Aug 2018 | page: 22-24 | Yashwant J. Mahale, Vikram V. Kadu.

Author: Yashwant J. Mahale [1], Vikram V. Kadu [1].

[1] ACPM Medical College , Dhule – 424001 , Maharashtra India.
[2] Mahale Accident Hospital , Dhule, Maharashtra India.

Address of Correspondence
Dr. Vikram V Kadu,
C/O Vilas Shamrao Kadu, Plot no. 20, Kadu House, Barde layout, Katol Road, Nagpur – 440013
Email: vikram1065@gmail.com


Introduction: Inter-trochanteric fractures are disabling injuries that most commonly affect the elderly
population. These fractures have a tremendous impact on both the health care system and society in general. These fractures can be managed by conservative methods, but mal-union and complications of prolonged immobilization is the result. Thus, surgery by internal fixation is the ideal choice. DHS was the gold standard treatment for inter trochanteric fractures before intra-medullary devices were developed. These devices have the advantage of shorter lever arm causing less tensile strain on the implant, controlled fracture impaction due to incorporation of sliding hip screw, shorter operative duration and less soft tissue dissection. In view of these considerations, present study is taken up to assess the outcome in terms of adequacy of fixation and results.
Methods: This is a retrospective study including 40 patients of unstable inter-trochanteric fracture treated with trochanteric fixation nail. Mean age group of patient was 61.78 years.
Results: Functional results were assessed in all 40 cases at follow up. Excellent results were noted in 27 cases, good in 10, fair in 3 and none had poor result. Anatomical results were assessed by presence or absence of shortening and range of movements.
Conclusion: The trochanteric fixation nail is a good minimally invasive implant for unstable inter-trochanteric fracture with less blood loss and soft tissue damage.
Keywords: Unstable inter-trochanteric fractures, shortening, trochanteric fixation nail.


1. Robert W Bucholz, James D Heckman, Charles M Court-Brown, Rockwood and Greens volume 2, 6th edition; pages 1827-44
2. GS kulkarni, Rajiv Limaye, Milind Kulkarni, ‘ intertrochanteric fractures- Current concept review’ Ind J Orth, 2006, vol 40, 16-23
3. Boldin, Christia, Seibert, Franz J, Fankhauser, Wolfgang, Szyszkowitz, Rudolf (2003) et al. Acta Orthopaedics, 74:1, 53-58
4. Ganz R, Thomas R.J, Hammerle CP. Clin Orthop 1979; 138:30-40
5. Cleveland, m. Bosworth, D. M and Thompson, F.R. JBJS, 29:1049-67, 1947
6. Mulley G and Espley, A. J. Postgrad Med. J, 55:264-265, 1979
7. Evans EM. JBJS 1949; 31B: 190-203
8. Wolfgang GL. Clinical Orthopaedics and related research 1982; 163: 148-158
9. Sarmeinto, A. Clin.Orthop, 53:47-59, 1967.
10. Wei-Chao Sheng, Jia-Zhen Li, Sheng-Hua Chen and Shi-Zen Zhong. International orthopaedics, vol 33, number 2, 537-42
11. Patil Suresh S, Panghate Atul. J orthopaedics 2008, 5(3) E7.

How to Cite this article:  Mahale YJ, Kadu V. Functional outcome of Unstable Inter-trochanteric femur fracture patients treated with Trochanteric fixation nail.. Trauma International May-Aug 2018;4(2):22-24.

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Role of Antibiotic Cement-coated Nailing in Infected Nonunion of Tibia

Vol 4 | Issue 2 | May – Aug 2018 | page: 18-21 | Clevio Desouza,Vinod Nair, Amit Chaudhary, Harshal Hurkat, Shiju George.

Author: Clevio Desouza [1],Vinod Nair [1], Amit Chaudhary [1], Harshal Hurkat [1], Shiju George [1].

[1] Department of Orthopaedics, Dr D.Y.Patil Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Clevio Desouza,
Department of Orthopaedics, Dr D.Y.Patil Hospital, Pune, Maharashtra, India.
E-mail: ceviod@gmail.com


Introduction: The infection of long bones along with its nonunion is a chronic and debilitating disorder. It becomes difficult to deal with the situation in which the implant which is used for internal fixation itself becomes a potential media for infection because of the formation of biofilms and adhesions. Traditionally, this situation is managed by a two-stage procedure for controlling the infection first and then treating the nonunion. This study has been undertaken to explore antibiotic cement-coated nailing as a single stage treatment modality for achieving stability and treating of the infection at the same time.
Materials and Methods: 20 patients (above 18years of age) with nonunion of tibia associated with infection with bone gap <2 cm were managed using antibiotic cement-coated Kuntscher nail. Antibiotics used were a combination of vancomycin and teicoplanin.
Results: Infection was controlled in 95% of the patients. Bony union was achieved in 12 of 20 (60%) patients with antibiotic cement nailing as the only procedure with average time of union of 32 weeks. Bone grafting or exchange nailing type additional procedures were required in the remaining eight patients, and this was done in six patients, with union of the fracture. Two patients refused to undergo further procedures. The various complications encountered during this study were difficult nail removal in three cases, broken nail in two cases, and bent nail in 1 case. Recurrence of infection was observed in two patients. The average period of follow-up was 12 months.
Conclusion: Antibiotic cement impregnated nailing is a simple, economical, and effective single-stage procedure for the management of infected nonunion of the tibia. It has many advantages over external fixators, as it eliminates the complications and has good patient compliance. The method utilizes existing easily available instrumentation and is technically demanding and therefore can be performed at any hospital.
Keywords: Nonunion, infected, antibiotic, cement, nailing.


1. Toh CL, Jupiter JB. The infected nonunion of the tibia. ClinOrthopRelat Res 1995;315:176-191.
2. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: Current management concepts. J Am AcadOrthopSurg 2005;13(6):417-427.
3. Stoodley P, Ehrlich GD, Sedghizadeh PP, Stoodley LH, Baratz ME, Altman DT, et al. Orthopaedic biofilm infections. CurrOrthopPract2011;22(6):558-563.
4. Nelson CL. The current status of material used for depot delivery of drugs. ClinOrthopRelat Res 2004;427:72-78.
5. Cierny G, Mader J. The surgical treatment of adult osteomyelitis. In: CMC Evarts, editor. Surgery of the Musculoskeletal System. New York, USA: Churchill Livingstone; 1983. p. 4814-4834.
6. Court-Brown CM. Fractures of the tibia and fibula. In: Bucholz RW, Heckman JD, Court-Brown CM, editors. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2006. p. 2080-2146.
7. Beals RK, Bryant RE. The treatment of chronic open osteomyelitis of the tibia in adults. ClinOrthopRelat Res 2005;433:212-217.
8. Ueng SW, Chuang DC, Cheng SL, Shih CH. Management of large infected tibial defects with radical debridement and staged double-rib composite free transfer. J Trauma 1996;40(3):345-350.
9. Chen CE, Ko JY, Wang JW, Wang CJ. Infection after intramedullary nailing of the femur. J Trauma 2003;55(2):338-344.
10. Wu CC, Shih CH. Distal tibial nonunion treated by intramedullary reaming with external immobilization. J Orthop Trauma 1996;10(1):45-49.
11. Paley D, Herzenberg JE. Intramedullary infections treated with antibiotic cement rods: Preliminary results in nine cases. J Orthop Trauma 2002;16(10):723-729.
12. Qiang Z, Jun PZ, Jie XJ, Hang L, Bing LJ, Cai LF. Use of antibiotic cement rod to treat intramedullary infection after nailing: Preliminary study in 19 patients. Arch Orthop Trauma Surg 2007;127(10):945-951.
13. Madanagopal SG, Seligson D, Roberts CS. The antibiotic cement nail for infection after tibial nailing. Orthopedics 2004;27(7):709-712.
14. Thonse R, Conway J. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. J Orthop Trauma 2007;21(4):258-268.
15. Sancineto CF, Barla JD. Treatment of long bone osteomyelitis with a mechanically stable intramedullar antibiotic dispenser: Nineteen consecutive cases with a minimum of 12 months follow-up. J Trauma 2008;65(6):1416-1420.
16. Nelson CL, Hickmon SG, Harrison BH. Elution characteristics of gentamicin-PMMA beads after implantation in humans. Orthopedics 1994;17(5):415-416.
17. Nizegorodcew T, Palmieri G, Marzetti E. Antibiotic-coated nails in orthopedic and trauma surgery: State of the art. Int J ImmunopatholPharmacol 2011;24 1 Suppl 2:125-128.
18. Riel RU, Gladden PB. A simple method for fashioning an antibiotic cement-coated interlocking intramedullary nail. Am J Orthop (Belle Mead NJ) 2010;39(1):18-21.
19. Dhanasekhar R, Jacob P, Francis J. Antibiotic cement impregnated nailing in the management of infected nonunion of femur and tibia. Kerala J Orthop2013;26(2):93-97.
20. Kim JW, Cuellar DO, Hao J, Seligson D, Mauffrey C. Custom-made antibiotic cement nails: A comparative study of different fabrication techniques. Injury 2014;45(8):1179-1184.
21. Akinyoola AL, Adegbehingbe OO, Aboderin AO. Therapeutic decision in chronic osteomyelitis: Sinus track culture versus intraoperative bone culture. Arch Orthop Trauma Surg 2009;129(4):449-453.
22. Beals RK, Bryant RE. The treatment of chronic open osteomyelitis of the tibia in adults. ClinOrthopRelat Res 2005;433:212-217.
23. Henry SL, Ostermann PA, Seligson D. The prophylactic use of antibiotic impregnated beads in open fractures. J Trauma 1990;30(10):1231-1238.
24. Chen CE, Ko JY, Wang JW, Wang CJ. Infection after intramedullary nailing of the femur. J Trauma 2003;55(2):338-344.
25. Tunney MM, Ramage G, Patrick S, Nixon JR, Murphy PG, Gorman SP. Antimicrobial susceptibility of bacteria isolated from orthopedic implants following revision hip surgery. Antimicrob Agents Chemother 1998;42(11):3002-3005.
26. Chang Y, Chen WC, Hsieh PH, Chen DW, Lee MS, Shih HN, et al.In vitro activities of daptomycin-vancomycin-and teicoplanin-loaded polymethylmethacrylate against methicillin-susceptible, methicillin-resistant, and vancomycin-intermediate strains of Staphylococcus aureus. Antimicrob Agents Chemother 2011;55(12):5480-5484.
27. Öztemür Z, Sümer Z, Tunç T, Pazarcé Ö, Bulut O. The effect of low dose teicoplanin-loaded acrylic bone cement on biocompatibility of bone cement. ActaMicrobiolImmunol Hung 2013;60(2):117-125.
28. Green SA. Complications of external skeletal fixation. ClinOrthopRelat Res 1983;180:109-116.
29. Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. ClinOrthopRelat Res 1990;250:81-104.
30. Shyam AK, Sancheti PK, Patel SK, Rocha S, Pradhan C, Patil A. Use of antibiotic cement-impregnated intramedullary nail in treatment of infected non-union of long bones. Indian J Orthop 2009;43(4):396-402.
31. Pradhan C, Patil A, Puram C, Attarde D, Sancheti P, Shyam A. Can antibiotic impregnated cement nail achieve both infection control and bony union in infected diaphyseal femoral non-unions? Injury. 2017 Aug;48 Suppl 2:S66-S71
32. Selhi HS, Mahindra P, Yamin M, Jain D, De Long WG Jr, Singh J. Outcome in patients with an infected nonunion of the long bones treated with a reinforced antibiotic bone cement rod. J Orthop Trauma 2012;26(3):184-188.
33. Kendall RW, Duncan CP, Smith JA, Ngui-Yen JH. Persistence of bacteria on antibiotic loaded acrylic depots. A reason for caution. ClinOrthopRelat Res 1996;329:273-280.

How to Cite this article:  Desouza C, Nair V, Chaudhary A, Hurkat H, George S. Role of Antibiotic Cement-coated Nailing in InfectedNonunion of Tibia. Trauma International May-Aug 2018;4(2):18-21.


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Cannulated Schanz Pin: A Novel Concept for Intraosseous Antibiotic Delivery

Vol 4 | Issue 2 | May – Aug 2018 | page: 15-17 | Ninad Ashok Godghate, Neha Ninad Godghate, Ashok Shyam, Krishnamohan Ananda Saindane

Author: Ninad Ashok Godghate [1], Neha Ninad Godghate [1], Ashok Shyam [2], Krishnamohan Ananda Saindane [3].

[1] Consultant Grace Ortho Clinic Rajiv Nagar T-Point Wardha Road, Nagpur.
[2] Sancheti Institute, Pune
[3] FICS, Consultant, Suyog Hospital, Sakri road, Dhule.

Address of Correspondence
Dr. Ninad Ashok Godghate,
Consultant Grace Ortho Clinic Rajiv Nagar T-Point Wardha Road, Nagpur.
Email: drninadgodghate@gmail.com


Infection control and prevention is the first step in any orthopaedic procedure because its treatment can be challenging and complicated. Complex bony architecture, precarious blood supply and presence of biofilm make eradicating infection a difficult task. Local antibiotic delivery in such cases has proved successful as it provides high concentration of antimicrobial agents and prevents systemic toxicity that is associated with systemic antibiotic administration. Of all the options available at present for local delivery, the most commonly used is antibiotic loaded bone cement. However only heat stable antibiotics can be used with cement and studies show that amount of drug eluted from the cement decreases with time. We have attempted to address these drawbacks and make local administration of antibiotics simpler by a novel method which could be used for treatment of established infections as well as prevention of infection in open fractures. This method could allow use of sensitive and specific antibiotic in addition to providing fracture stability.
Keywords: Infection, intraosseous antibiotic delivery, cannulated schanz pin


1. Winkler H. treatment of chronic orthopaedic infection. EFFORT open reviews. 2017; Vol. 2: 110-116
2. James M, Khan W, Nannaparaju M, Bhamra J, Morgan-Jones R. Current evidence for the use of laminar flow in reducing infection rates in total joint arthroplasty. The open prthopaedic journal 2015; 9, Supple. 2: 495-498
3. Electricwala A, Dasgupta R, Rajshekharan S, Mody B, Sancheti K. Laminar air flow and air handling unit. Manual of infection control in orthopaedic surgery: operation theatre protocols and patient optimization. Jaypee. Pg. 40-49
4. Cook G, Markel D, Ren W, Webb L, McKee M, Schemitsch E. infection in orthopaedics. J. Orthop Trauma 2015; 29: S19- S23
5. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. J Am Acad. Orthop Surg. 2005; 13:417–427.
6. Beenken KE, Bradney L, Bellamy W, et al. Use of xylitol to enhance the therapeutic efficacy of polymethylmethacrylate-based antibiotic therapy in treatment of chronic osteomyelitis. Antimicrob Agents Chemother. 2012; 56:5839–5844.
7. Hanssen AD. Local antibiotic delivery vehicles in the treatment of musculoskeletal infection. Clin Orthop Relat Res. 2005; 437:91–96.
8. McKee MD, Wild LM, Schemitsch EH, et al. The use of an antibiotic impregnated, osteoconductive, bioabsorbable bone substitute in the treatment of infected long bone defects: early results of a prospective trial. J Orthop Trauma. 2002; 16:622–627.
9. Ateschrang A, Albrecht D, Schroter S, Hirt B, Weise K, Dolderer J. Septic arthritis of the knee: presentation of a novel irrigation suction system tested in a cadaver study. BMC Musculoskeletal disorders. 2011; 12: 180
10. Schanz A. Ueber die nach Schenkelhalsbruchen Zuruckbleibenden geshtorungen. Munch Med Wochenschr. 1925; 51: 730-732
11. Mehta S., Humphrey JS, Dchenkmann DI, Seaber AV, Vail TP. Gentamycin distribution from collagen carrier. Journal Orthopaedic Research. 1996; 40: 749-754
12. Cierny III G. Infected tibial non-unions. The evolution of change. Clinical Orthopaedics related research, 1999; 360: 97-105
13. Mouton JW, Vinks AA: Pharmacokinetic/ pharmacodynamics modelling of antimicrobial drug effects. J Pharmacokinet Pharmacodyn 2007; 34: 727-751
14. Tsourvakas S. Local antibiotic therapy in the treatment of bone and soft tissue infections. In Stefan Danilla, editor. Selected topics in plastic reconstructive surgery. InTech ; 2012: 17-44
15. McLaren AC, Gutierrez FN, Martin M, McLemore R. Local antimicrobial treatment. In Cierny III G, McLaren AC, Wongworawat MD, editors. Orthopaedic knowledge update: Musculoskeletal infection. AAOS. Vol. 2; 2009: 95-116
16. Wahlig H, Dingeldein E, Bergmann R, Reuss K. The release of gentamycin from polymethyl methacrylate beads: an experimental and pharmacokinetic study. J Bone Joint Surgery Br 1978;60:270-275
17. Nelson CL, Hickmon SG, Skinner RA. Treatment of experimental osteomyelitis by surgical debridement and the implantation of bioerodable, polyanhydridegentamycin beads. J Orthop Res 1997; 15: 249-255
18. McLaren AC. Alternative materials to acrylic bone cement for delivery of depot antibiotics in orthopaedic infections. Clin Orthop Relat Res 2004; 427:101-106.
19. Tam VH, Kabbara S, Vo G, Schilling AN, Coyle EA. Comparative pharmacodynamics of gentamycin against staphylococcus aureus and pseudomonas aeruginosa. Antimicrob Agents Chemother 2006; 50: 2626-2631
20. Pesenti S, Blondel B, Peltier E, Adetchessi T, Dufour H, Fuentes S. Percutaneous cement-augmented screws fixation in the fractures of the aging spine: is it the solution? BioMed research international volume. 2014; 1-5
21. Buck M, Wiggins BS, Sesler JM. Intraosseous drug administration in children and adults during cardiopulmonary resuscitation. The annals of Pharmacotherapy 2007;41: 1679-1686

How to Cite this article:  Godghate N A, Godghate N N, Shyam A, Saindane K A. Cannulated schanz pin: A novel concept for intraosseous antibiotic delivery. Trauma International May- Aug 2018;4(2):15-17.


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Skeletal Stabilization In Open Injuries

Vol 4 | Issue 2 | May – Aug 2018 | page: 12-14 | Dheenadhayalan J, Raja Bhaskara Rajasekaran, Sivakumar S P, Ramesh Perumal, Arun Kamal C.

Author: Dheenadhayalan J [1], Raja Bhaskara Rajasekaran [1], Sivakumar S P [1], Ramesh Perumal [1], Arun Kamal C [1].

[1] Department of Orhtopaedics & Trauma Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India

Address of Correspondence
Dr. Raja Bhaskara Rajasekaran,
Ganga Hospital, Mettupalayam road,Coimbatore, India
Email: rajalibra299@gmail.com


Skeletal Stabilization in open injuries is as important as soft tissue cover in providing a good outcome following open injuries. Unilateral external fixator forms the workhorse of open injuries of the lower limb. In fractured ends with good bone circumference, good reduction and fixation leads to primary union. Primary internal fixation was considered unacceptable even about two decades ago in open injuries. However, nowadays following refinement in techniques of debridement, the pendulum has now swung towards early internal fixation whenever indicated. Definitive internal fixation before soft tissue cover has also shown to give good results.Modern multiplanar and circular fixators are used if there is significant contamination, bone loss and multilevel fractures of the tibia.
Keywords: Skeletal stabilization, external fixator, debridement, primary internal fixation


1. Giannoudis PV, Papakostidis C, Roberts C. A review of the management of open fractures of the tibia and femur. J Bone Joint Surg Br. 2006;88:281–289
2. Carroll EA, Koman LA. External fixation and temporary stabilization of femoral and tibial trauma. J SurgOrthp Adv. 2011;20:74–81.
3. Initial Management of Open Fractures. (Book Chapter) S. Rajasekaran et al. Rockwood and Green’s Fractures in Adults. Eigth Edition. Vol1 :353-396.
4. BAPRAS Guidelines: Standards for management of open fractures of the lower limb. 2009.
5. Hyman J, Moore T. Anatomy of the distal knee joint and pyarthrosis following external fixation. J Orthop Trauma. 1999;13:241–246
6. Lethaby A, Temple J, Santy J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Reviews. 2008;(4).
7. Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of fractures. J Am AcadOrthop Surg. 2000;8:285–291.
8. Clifford RP, Beauchamp CG, Kellam JF, et al. Plate fixation of open fractures of the tibia. J Bone Joint Surg Br. 1988;70:644–648.
9. Giannoudis PV, Furlong AJ, MacDonald DA, et al. Reamed against unreamed nailing of the femoral diaphysis: A retrospective study of healing time. Injury. 1997;28:15–18.
10. Kakar S, Tornetta P 3rd. Open fractures of the tibia treated by immediate intramedullary tibial nail insertion without reaming: A prospective study. J Orthop Trauma. 2007;21:153–157.
11. Bhandari M, Guyatt GH, Swiontkowski MF, et al. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br. 2001;83:62–68.

How to Cite this article:  Dheenadhayalan J , Rajasekaran R B, Sivakumar S P, Perumal R, Arun Kamal C. Skeletal Stabilization In Open Injuries. Trauma International May -Aug 2018;4(2):12-14.


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Management of Open Injuries: What has changed?

Vol 4 | Issue 2 | May – Aug 2018 | page: 7-11 | Devendra Agraharam, Arun Kamal C, Raja Bhaskara Rajasekaran, Vel Murugesan P, Ramesh Perumal, Dheenadhayalan J.

Author: Devendra Agraharam [1], Arun Kamal C [1], Raja Bhaskara Rajasekaran [1], Vel Murugesan P [1], Ramesh Perumal [1], Dheenadhayalan J [1].

[1] Department of Orhtopaedics & Trauma Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India

Address of Correspondence
Dr. Raja Bhaskara Rajasekaran,
Ganga Hospital, Mettupalayam road,Coimbatore, India
Email: rajalibra299@gmail.com


Introduction: Open injuries pose a major problem to the treating surgeon as they are prone to higher rates of infection and non-union and are usually associated with life threatening polytrauma. Nowadays, specialized trauma centres and a multimodal team approach have shown to give superior results in the outcome following open injuries. Early wound debridement, early fracture stabilization and early wound closure are important components as nowadays we focus on the ‘Era of functional restoration’. Serum Lactate is a widely used biochemical marker to assess the adequacy of tissue resuscitation and the Ganga Hospital Open Injury score (GHOIS) has a higher specificity towards limb salvage and also gives guidelines regarding timing and type of soft tissue reconstruction. A combined ‘Orthoplastic’ approach in the management of open injuries and adherence to the ‘Revised reconstruction ladder’ with regarding to wound coverage has shown to a favourable outcome.
Keywords: Open fractures, Debridement, Serum lactate, Ganga Hospital Open Injury score


1. Dabezies EJ and D’Ambrosia RD. Treatment of the multiply injured patient: plans for treatment and problems of major trauma. Instructional course lectures 1984; 33: 242-52.
2. Hoff WS, Reilly PM, Rotondo MF, DiGiacomo JC, and Schwab CW. The importance of the command-physician in trauma resuscitation. The Journal of trauma 1997; 43: 772-7.
3. Lu WH, Kolkman K, Seger M, and Sugrue M. An evaluation of trauma team response in a major trauma hospital in 100 patients with predominantly minor injuries. The Australian and New Zealand journal of surgery 2000; 70: 329-32.
4. Simons R, Eliopoulos V, Laflamme D, and Brown DR. Impact on process of trauma care delivery 1 year after the introduction of a trauma program in a provincial trauma center. The Journal of trauma 1999; 46: 811-5
5. Initial Management of Open Fractures .(Book Chapter) S. Rajasekaran et al. Rockwood and Green’s Fractures in Adults. Eigth Edition . Vol 1 :353-396.
6. Pollak AN. Timing of debridement of open fractures. The Journal of the American Academy of Orthopaedic Surgeons 2006; 14: S48-51.
7. Carsenti-Etesse H, Doyon F, Desplaces N, and et al. Epidemiology of bacterial infection during management of open leg fractures. Eur J Clin Microbiol Infect Dis 1999; 18: 315-323.
8. Kreder HJ and Armstrong P. The significance of perioperative cultures in open pediatric lower-extremity fractures. Clinical orthopaedics and related research 1994: 206-12.
9. Lee J. Efficacy of cultures in the management of open fractures. Clinical orthopaedics and related research 1997: 71-5.
10. Patzakis MJ. Orthopedics-epitomes of progress: The use of antibiotics in open fractures. The Western journal of medicine 1979; 130: 62.
11. Edwards CC, Simmons SC, Browner BD, and Weigel MC. Severe open tibial fractures. Results treating 202 injuries with external fixation. Clinical orthopaedics and related research 1988: 98-115.
12. Emami A, Mjoberg B, Ragnarsson B, and Larsson S. Changing epidemiology of tibial shaft fractures. 513 cases compared between 1971-1975 and 1986-1990. Acta Orthop Scand 1996; 67: 557-561
13. Rajasekaran S and Giannoudis PV. Open injuries of the lower extremity: issues and unknown frontiers. Injury 2012; 43: 1783-4
14. Gustilo RB. Management of infected fractures. Instructional course lectures 1982; 31: 18-29.
15. Rajasekaran S, Naresh Babu J, Dheenadhayalan J, Shetty AP, Sundararajan SR, Kumar M, and Rajasabapathy S. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. The Journal of bone and joint surgery. British volume 2006; 88: 1351-60.
16. Rajasekaran S and Sabapathy SR. A philosophy of care of open injuries based on the Ganga hospital score. Injury 2007; 38: 137-46.

How to Cite this article:  Agraharam D, Arun Kamal C, Rajasekaran RB, VelMurugesan P, Perumal R, Dheenadhayalan J. Management of Open Injuries: What has changed. Trauma International May -Aug 2018;4(2):7-11.

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Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) using Locking Compression Plate (LCP) in Distal Tibial Fractures: A Prospective Study of 50 Cases.

Vol 4 | Issue 2 | May – Aug 2018 | page: 34-37 |  Rakesh Sharma,  Rajesh Kapila,  Sarika Kapila,  Dharam Singh, Jagsir Mann

Author: Rakesh Sharma [1], Rajesh Kapila[1], Sarika Kapila [2], Dharam Singh [1], Jagsir Mann [1] .

[1] Department of Orthopaedics, Govt. Medical College, Amritsar – 143001 (Punjab). India

[2] Dept. Of Oral and Maxillofacial Surgery, SGRD institute of dental sciences. Amritsar

Address of Correspondence
Dr. Rajesh Kapila

2-B , circular road, Amritsar-143001
Email: kapila.rajesh@ yahoo.com


Background: The limited soft tissue, subcutaneous location of large portion of tibia and precarious blood supply renders the treatment of distal tibial fracture very challenging. The main treatment of this type of fracture is reinstatement of the normal alignment and articular congruity. Conventional osteosynthesis is not suitable because distal tibia is subcutaneous bone with poor vascularity. Closed Reduction and MIPPO with locking compression plate (LCP) has emerged as an alternative treatment option because it respects biology of distal tibia, maintains fracture haematoma and provides biomechanically stable construct, early mobilization, less complications and relatively higher rates of union. The aim of this study was to evaluate the functional and clinical outcomes of distal tibia fracture of patients, treated by internal fixation by minimally invasive plating osteosynthesis (MIPPO) technique with locking compression plate (LCP).
Methods: 50 patients with distal tibia fracture with or without intra articular extension were treated in our department, with MIPO with LCP and were prospectively followed for average duration of 6 months. The outcome was evaluated using American Orthopedic Foot and Ankle Society (AOFAS) score ( Ankle – Hindfoot Scale )
Results: There were 50 patients (36 males and 14 female) with mean age of 38.4 years. The mean follow up period of our patients was 6 months. All fractures united at an average of 19.13 weeks (range- 16-24 to weeks) except two cases of non- union. There were 8 superficial wound infections which were treated with oral antibiotics and progressed to union and there were no failures of implants. According to AOFAS score at 6 months, 6 cases had score of 31 to 70 and 44 cases had score of 71 to 100.
Conclusions: Minimally invasive plating osteosynthesis (MIPPO) is an effective method of treatment for distal tibial fractures. The use of indirect reduction techniques and small incision is technically demanding and it is effective, minimally invasive, optimises the operation time, promotes early healing and reduces the incidence of infections and complications associated with conventional method of open reduction and internal fixation.
Keywords: Distal tibia, LCP, MIPPO, Osteosynthesis, Plating.


1. Ruedi T, Algower M. Fractures of the lower end of tibia into the ankle joint. Injury 1969; 1:92-9.
2. Orthopaedic Trauma Associated Committee for Coding and Classification. Fracture and Dislocation compendium. J Orthop Trauma 1996;10(1):1.
3. Smith WR, Ziran BH, Anglen JO, Stahel PF. Locking plates: tips and tricks. J Bone Joint Surg Am. 2007 Oct 1;89(10):2298-307.
4. Gustilo open fracture classification. OrthopaedicsOne Articles. In: OrthopaedicsOne – The Orthopaedic Knowledge Network. Created Mar 01, 2009 16:47. Last modified May 09, 2012 08:33 ver.246. Retrieved 2017-03-15, from http://www.orthopaedicsone.com/x/r4EqAQ.
5. American Orthopaedic Foot and Ankle Society
6. Hazarika S, Chakravarthy J, Cooper J. Minimaly invasive locking plate osteosynthesis for fractures of distal tibia-results in 20 patients. Injury 2006; 37(9): 877-87.
7. Mushtaq A, Shahid R, Asif M. distaltibial fracture fixation with locking compression plate (LCP) using minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. Eur J Trauma Emerg Surg 2009; 35: 159-64.
8. Gupta RK, Rohilla RK, Sangwan K, Singh V, Walia S. Locking plate fixation in distal metaphyseal tibial fractures: series of 79 patients. Int Orthop 2009; 33: 120-3.
9. Leung FK, Law TW. Application of minimally invasive locking compression plate in treatment of distal tibial fractures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009; 23: 1323-5.
10. Ronga M, Longo UG, Maffulli N. Minimally invasive locked plating of distal tibia fractures is safe and effective. Clin Orthop Relat Res 2009; 468: 110-4.
11. Bahari S, Lenehan B, Khan H, McElwain JP. Minimally invasive percutaneous plate fixationof distal tibia fractures. Acta Orthop Belg 2007; 73: 635-40.
12. Zha G, Chen Z, Qi X. Minimally invasive percutaneous locking compression plate internal fixation in the treatment of tibial fractures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2008; 22: 1448-50.
13. Protzman R, Collinge C. Outcomes of Minimally Invasive Plate Osteosynthesis for Metaphyseal Distal Tibia Fractures. J Orthop Trauma 2010; 24: 24-9.
14. Collinge C, Kuper M, Protzman R. Minimally invasive plating of high-energy metaphyseal distal tibia fractures. J Orthop Trauma 2007; 21(6): 355-61.

How to Cite this article:  Sharma R, Kapila R, Kapila S, Singh D, Mann J.Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) using Locking Compression Plate (LCP) in Distal Tibial Fractures. A Prospective Study of 50 Cases. Trauma International May-Aug 2018;4(2):34-37.


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Primary Management and Antibiotic Prophylaxis in Open Injuries of the Lower Limb: Current guidelines

Vol 4 | Issue 2 | May – Aug 2018 | page:4-6 | Dheenadhayalan Jayaramaraju, Raja Bhaskara Rajasekaran, Devendra Agraharam, Ramesh Perumal.

Author: Dheenadhayalan Jayaramaraju [1], Raja Bhaskara Rajasekaran [1], Devendra Agraharam [1], Ramesh Perumal [1].

[1] Department of Orhtopaedics & Trauma Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India

Address of Correspondence
Dr. Raja Bhaskara Rajasekaran,
Ganga Hospital, Mettupalayam road,Coimbatore, India
Email: rajalibra299@gmail.com


Primary management of open injuries is of utmost importance as it has direct implication on the functional outcome. Strict adherence to the ATLS protocol followed by appropriate splintage of the limb must be done. While antibiotics need to be given within 3 hours since injury, wound lavage and wound cultures have no role. Documentation and adequate counselling regarding the complications also needs to be done while managing every case of open injury.
Keywords: Open injury, antibiotic prophylaxis, wound lavage, limb splintage


1. Dabezies EJ and D’Ambrosia RD. Treatment of the multiply injured patient: plans for treatment and problems of major trauma. Instructional course lectures 1984; 33: 242-52.
2. Hoff WS, Reilly PM, Rotondo MF, DiGiacomo JC, and Schwab CW. The importance of the command-physician in trauma resuscitation. The Journal of trauma 1997; 43: 772-7.
3. Initial Management of Open Fractures. (Book Chapter) S. Rajasekaran et al. Rockwood and Green’s Fractures in Adults. Eigth Edition. Vol 1 :353-396.
4. Kreder HJ and Armstrong P. The significance of perioperative cultures in open pediatric lower-extremity fractures. Clinical orthopaedics and related research 1994: 206-12.
5. Lee J. Efficacy of cultures in the management of open fractures. Clinical orthopaedics and related research 1997: 71-5.
6. Gosselin RA, Roberts I, Gillespie WJ. 2004: Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev; Issue 1: Cd003764.
7. BAPRAS Guidelines: Standards for management of open fractures of the lower limb. 2009

How to Cite this article:  Dheenadhayalan J, Rajasekaran R B, Agraharam D, Ramesh Perumal R. Primary Management and Antibiotic Prophylaxis in Open Injuries of the Lower Limb: Current guidelines. Trauma International May -Aug 2018;4(2):4-6.

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