Blog Elements – Page 52 – Trauma International

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

Digastric Trochantric Flip Osteotomy When and How to do it in Acetabular Fractures-?

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

Vol 3 | Issue 1 | Jan – Apr 2017 | page:24-26 | Harish Makker Author: Harish Makker [1] [1] Consultant Orthopaedic Surgeon, Lucknow, India Address of Correspondence Dr.Harish Makker. 282, Rajendra Nagar,opp.water Tank, Lucknow, India 226004 India. Email: drharishmakkar@gmail.com Abstract There comes a time in acetabular fractures-posterior wall and or posterior column fractures when […]

A Rare Case of Simultaneous Bilateral Elbow Dislocation in a 25 year old Lady following a Simple Fall – An Unusual Mode of Injury

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

Vol 3 | Issue 1 | Jan – Apr 2017 | page:46-48 | Supreeth Nekkanti, C Vijay, Sujana Theja, R Ravi Shankar, Ishani Patel Author: Supreeth Nekkanti [1], C Vijay [1], Sujana Theja [1], R Ravi Shankar [1], Ishani Patel [1] Department of Orthopaedics, JSS Hospital, Mysore, Karnataka, India Address of Correspondence Dr. Supreeth Nekkanti, No. 160, […]

Digastric Trochantric Flip Osteotomy When and How to do it in Acetabular Fractures-?

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

A Rare Case of Simultaneous Bilateral Elbow Dislocation in a 25 year old Lady following a Simple Fall – An Unusual Mode of Injury

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

Full Sized Blog Element (Big Preview Pic)

Digastric Trochantric Flip Osteotomy When and How to do it in Acetabular Fractures-?

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

Vol 3 | Issue 1 | Jan – Apr 2017 | page:24-26 | Harish Makker

Author: Harish Makker [1]

[1] Consultant Orthopaedic Surgeon, Lucknow, India

Address of Correspondence
Dr.Harish Makker.
282, Rajendra Nagar,opp.water Tank, Lucknow, India 226004 India.
Email: drharishmakkar@gmail.com

Abstract

There comes a time in acetabular fractures-posterior wall and or posterior column fractures when simple Kocher-Langenbeck Approach seems handicapped and you need to have some extension, as in cases of cranial extension of posterior wall fractures and /or need to retrieve loose segments from acetabular joint when with all efforts made by traction, space seems wanting.
Kocher-Langenbeck Approach used for posterior and posterior column injuries and also for some T type fractures, gives very little access to intra articular injuries despite a good traction.
Gluteus medius tenotomy and Trochantric osteotomy was done earlier [still being done by some ] but of late Digastric Flip Osteotomy is gaining popularity as it is less traumatic and helps saving blood supply and ,thus reduce chances of AVN.
The femur head is dislocated anteriorly or posteriorly, without much difficulty and internal status of the joint is observed without having to worry about devascularization of acetabular wall leading to further complications.
So to enumerate the need for Digastric Flip Osteotomy in acetabular fractures are-
1.-intra-articular fragments,
2. Impaction of fragments
3. Posterior wall comminution free fragments,
4. Superior acetabular rim or dome fractures,
5. Assessment of the reduction of the anterior Column, and finally
6. Intra-articular assessment of placement of a long screw inserted into the anterior column.
Keywords: Digastric flip osteotomy posterior wall, posterior column, intra articular fragments, head dislocation.

Introduction

Pelvi acetabular injuries are almost 6 percent of all trauma. The figure has recently increased in big and small cities due to introduction of high speed vehicles- two and four wheelers, and youngsters more affected [1] because of their experimenting more on these vehicle die to adrenalin rush. Mostly these are high impact injuries [2]
The other sector involved is old and osteoporotic adults, who encounter minor mishaps at home, or fall from height in both the categories. The protocol of treatment changes with age involved and facility /or absence of experienced surgeons in this sub specialty of orthopaedics, availibity of implants and instrumentations and high demand units in the hospital

Surgical Technique—

The technique was described Siebenrock et al.[3]
The initial steps are same as Kocher Langenbeck approach. Skin Incision is followed by, incision of fascia lata in line with skin incision, on deep dissection interval between gluteus maximus and
Medius fibres are seen, this interval is seen in proximal part only. Further dissection is done on
Ilio tibial tract distally. In some cases we may have to detach a small portion of gluteus maximus from lateral part of femur in distal part of dissection. Now the gluteus medius muscle fibre are split with utmost care, next – the trochanteric bursa is dissected and the posterior border of the gluteus medius muscle is exposed at the postero superior border of greater trochanter, along with tendinous insertion of gluteus medius. Fascia of gluteus medius and muscle belly of gluteus maximus are now mobilized preserving blood supply from superior gluteal artery.
Now we need to identify the external rotators of hip and here comes the help from two vascular anastomosis. first is Trochantric anastomosis communicates with ascending branch of medial circumflex artery at the superior border of Quadratus Femoris Muscle ,second vascular marking is branch of superior gluteal artery which is seen on the inferior border of piriforms muscle, this also anastomoses with ascending branch of medial circumflex artery.
By far we are missing an important structure ie Sciatic Nerve, which is now to be identified in its path, posterior to Quadratus Femoris Muscle.

In Arthoplasty cases we usually do not try to see any further but here we need to trace the Sciatic Nerve proximally upto Piriformis Muscle and try to assess its anomalies –if any.[ there are various anomalous positions of Sciatic Nerve which may prove harmful if not identified at this juncture-viz- front of Piriformis, Behind Piriformis ,In between two bellies of Piriformis ,more than one branch of Sciatic Nerve taking different positions in relation to Piriformis Muscle ] and at the risk of being damaged if not traced pre hand. The Nerve is traced where it enters the
Greater Sciatic Notch. In cases where there is single bundle in front of Piriformis Muscle, no
further attempt is made and we come back and no cutting of external rotators, but if there are two bundles of Sciatic Nerve at different positions, we might cut the Piriformis away from GT by at least 1 cm, avoiding damage to nerve in dislocating femoral head.
Next step is, developing Piriformis Muscle, for this Piriformis is retracted inferiorly, while Gluteus Medius is retracted superiorly and Gluteus Minimus is separated along its inferior fascial border. This release is extended upto greater sciatic notch taking care not to damage superior gluteal vessels and nerves. This will clear the area upto mid supra acetabular area.
The Gluteus Minimus can now be seen beneath Gluteus Medius and separation between piriformis and minimus is now carried out, we need to retract piriformis as Minimus carries the circumflex vessels with it and as such needs to be sharply separated from retro acetabular area.
Trochantric anastomosis is now cauterized and osteotomy site is marked by a marker pen or the cautery itself. Now a oscillating saw is used [refr-1] from the tip of greater trochanter to base of
Vastus tubercle.It is better to pre drill the GT so as to ease the fix with screws after job is over.it
is also better to leave a small portion of medius anteriorly with femur ,initially ,till the trochanter is mobilized. This small step provides a prevention from possible injury to retinacular vessels from thick osteotomy. The osteotomy runs lateral to short extensors ,which are left attached to femur and this also helps protect deep branch of medial circumflex artery, which lies deep to obturator externus muscle,[ref-4]
The fascia of vastus lateralis is incised from vastus tubercle, the trochanter is slowly and
cautiously lifted anteriorly and at this stage the remaining fibre attachment of gluteus medius detached from greater trochanter .The piriformis muscle is mostly attached to intact part of GT,
but if its fibres are attached to detached part-they are cut. The hip is now flexed and externally rotated; this causes gluteus minimus mobilization from retro acetabular surface along the capsule to its attachment to femur.
If the gluteus minimus comes in the way of greater trochanter, it can be released from femur to give full displacement to greater trochanter. The trochanteric flip osteotomy, per se ends here but the exposure to operating surface requires visualization of acetabular rim and capsule. The flexion and ext. rotation of hip and mobilization of vastus medialis does the job and entire hemi circumferential rim of capsule is visualized.
A z shaped capsulotomy is performed starting from superior part of capsule and coming down. This aids in intra articular visualization of loose fragments and its restoration.
Here we should see if posterior wall is fractured because if it is fractured, we should modify capsulotomy .carefully incorporating posterior wall. Now this is reflected inferiorly to visualize
the joint. The labrum may be avulsed with posterior wall segment.
The fractured column is now brought close by various instruments and plating is attempted on column. If piriformis or conjoint tendon of obturator internus and gemeli come in the way of plating, they are released two cm posterior from its insertion.
Finally when the plating is over, capsule is stitched loosely, greater trochanter is reattached with
3.5-4 mm screws, Vastus lateralis fascia is stitched and short ext. rotators are reattached. Gluteus
Muscles are reattached over deep drains, ilio tibial tract stitched and then the skin.

Conclusion

This is a very good approach for posterior wall and /or column fractures with superior extension and some T type fractures and saves the morbidity caused by extended approaches. This is now being more often than before.

References

1..Judet R, Judet J, Letournel E (1964) Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg Am 46:1615–1646
2. Liebergall M, MosheiV R, Low J et al (1999) Acetabular fractures: clinical outcome of surgical treatment. Clin Orthop Relat Res 366:205–216.
3. Siebenrock KA, Gautier E, Ziran BH et al (2006) Trochanteric flip osteotomy for cranial extension and muscle protection in acetabular fracture Wxation using a Kocher–Langenbeck approach. J Orthop Trauma 20:S52–S56.
4. Glas PY, Fessy MH, Carret JP et al (2001) Surgical treatment of acetabular fractures: outcome in a series of 60 consecutive cases. Rev Chir Orthop Reparatrice Appar Mot 87:529–538
5. Rommens PM, Gimenez MV, Hessmann M (2001) Posterior wall fractures of the acetabulum: characteristics, management, prognosis. Acta Chir Belg 101:287–293.

How to Cite this article: Makker H. Digastric Trochantric Flip Osteotomy –When and How to do it in Acetabular Fractures-? Trauma International Jan – April 2017;3(1):24-26.

(Abstract) (Full Text HTML) (Download PDF)

A Rare Case of Simultaneous Bilateral Elbow Dislocation in a 25 year old Lady following a Simple Fall – An Unusual Mode of Injury

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

Vol 3 | Issue 1 | Jan – Apr 2017 | page:46-48 | Supreeth Nekkanti, C Vijay, Sujana Theja, R Ravi Shankar, Ishani Patel

Author: Supreeth Nekkanti [1], C Vijay [1], Sujana Theja [1], R Ravi Shankar [1], Ishani Patel [1]

Department of Orthopaedics, JSS Hospital,
Mysore, Karnataka, India

Address of Correspondence
Dr. Supreeth Nekkanti,
No. 160, 11th Cross, 5th Main, 1st Stage, NGEF Layout, Nrupatunganagar, Nagarbhavi,
Bengaluru-560 072, Karnataka, India.
Email: drsupreethn@gmail.

Abstract

Introduction: Bilateral elbow dislocation is a rare injury, with only a small number of case reports in the literature. The majority of these reports describe associated ligamentous injuries only. Simultaneous bilateral radial head fracture in association with bilateral elbow dislocation has only been described on two occasions previously.
Case Report: We report an extremely rare case of simultaneous bilateral elbow dislocation in a 25 years woman following self-fall. Bilateral elbow dislocation with bilateral radial head fractures was confirmed radiographically. Closed reduction under sedation was performed in the emergency room. The patient was immobilized for 5 weeks. The patient was mobilized and had good function of bilateral elbow at 8-month follow-up.
Conclusion: The purpose of this report was to describe a very rare injury pattern, to present the treatment approach chosen for this case, and to emphasize the importance of early mobilization following bilateral elbow dislocation.
Keywords: Bilateral elbow dislocation, female, rare case report, simultaneous.

What to Learn from this Article?

Simultaneous bilateral elbow dislocations are extremely rare injuries in non athletic patients in the absence of generalised ligament laxity. There should be a high index of suspicion for associated injuries by careful examination and evaluation with radiographs. Prompt reduction and early rehabilitation ensures an excellent functional outcome.

Introduction

In adults, elbow dislocations are the second most common dislocation after that of the shoulder, with an estimated incidence of 5.21 dislocations per 100 000 person-years. Simultaneous elbow dislocations are rare,some injuries may be associated with radius head and neck fractures, however, with only a handful of cases described in the literature so far. Our proposition is to report this rare case of bilateral elbow dislocation with bilateral radial head fracture and to present the treatment approach chosen for this case.

Case Report

A 25-year-old female, housewife weighing 95kgs was brought to the emergency department by ambulance with simultaneous bilateral elbow dislocations after landing on both hands with extended elbows. The parents reported no of history consistent with joint hyperlaxity of the patient. There was no positive family history for joint hyperlaxity
Clinical examination showed deformity of both elbows with loss of posterior triangular relationships of the olecranon and epicondyles suggesting bilateral posterolateral elbow dislocation associated with swelling and haematoma formation. There was no neurovascular deficit.Radiographs showed bilateral posterolateral elbow dislocations with a bilateral radial head fracture. (Figure1) Both elbows were reduced under sedation within an hour of the injury. The radial head fracture was undisplaced. She was splinted at 90° of flexion for 3 weeks with an above elbow slab. A check radiograph of both the elbows was taken to confirm the reduction of the elbow joints. (Figure 2) After seven days, the swelling subsided and slab was converted to an above elbow cast. At the end of five weeks both the casts were removed and she underwent physiotherapy. By the end of the 8th week the patient had regained functional range of movement and at twelve weeks she was doing her regular house work. (Figure 3, 4, 5)

Discussion

Elbow dislocation is a common event, being the most frequent joint subject to dislocation after the shoulder, the majority being posterior [2,3,4]. It is common for children to suffer an associated fracture and many are the result of sporting injuries [1]. Bilateral elbow dislocations occurring simultaneously however are extremely rare. Reported cases of bilateral elbow dislocation have been limited to young female gymnasts with proven joint hyperlaxity [3,4,5] and an isolated hang-gliding accident in an adult male, [3] and remain rare.The rarity of bilateral elbow dislocation stems from the fact that it may only occur under special circumstances with both the elbows extended and most of the body weight acting through the elbow joints with elbows in extension and hands outstretched [3,4,5].
Elbow dislocations form 11 to 28% of all injuries to the elbow [3,4]. The most common mechanism of injury is fall on outstretched hand. The body weight generates a downward force with vertical and horizontal component which unlocks the ulna out of trochlea [3]. As the elbow joint continues to hyperextend, the anterior capsule and collateral ligaments fail leading to posterior dislocation of the elbow joint [2,6]. Bilateral posterior elbow dislocations occur in special instances where the patient tries to stop his fall with both hands outstretched at the time of impact [3,4,5].
Cadaveric studies have shown that posterior dislocation is most likely with the elbow between 15 and 30° of flexion [7] and that a rotatory torque applied to the ulna, e.g. in a fall with the forearm pronated, plays a role in the mechanism of dislocation [6]. With the elbow in full extension, the majority of stress is directed on the tip of the coronoid process [7].
Josefsson et al, [8] in 1987, reported outcomes achieved through the analysis of surgical treatment of the elbow dislocation against the non-surgical one, concluding that surgical treatment should not be provided in a simple dislocation, which can be reduced by closed means.
It is agreed that prolonged immobilisation results in poor outcome, [2,3,4] and periods of acceptable immobilisation vary from immediate mobilisation to four weeks immobilisation, although this depends on the post-reduction stability of the elbow [2,4].
In the present study, the patient totally recovered the flexion- extension motion of the left elbow, with good valgus and varus stability. In the eighteen-month follow-up period, the X-ray control was shown to be normal, and the patient returned to all her daily activities
Complications like adhesions, fibrosis, myositis and contractures have been observed by Syed et al [3,9]. Protzman [3,10] had studied the degree of remnant flexion contractures of the elbow after immobilisation to vary from 3 to 21 degrees depending on the duration of immobilisation. In our patient we observed a remnant flexion contracture of around 5 degrees. However our patient did not present with any instability of the elbow or recurrence of the posterior dislocation. She had good functional range both the elbows

Conclusion

He purpose of this report was to describe a very rare injury pattern, to present the treatment approach chosen for this case, and to emphasise the importance of early mobilisation following bilateral elbow dislocation.

References

1. J.A. Mehta, G.I. Bain Elbow dislocations in adults and children. Clin Sports Med, 23 (4)(2004), pp. 609–627
2. A.A. Syed, J. O’Flanagan. Simultaneous bilateral elbow dislocation in an international gymnast. Br J Sports Med, 33 (2) (1999), pp. 132–133
3. A. Wilson. Bilateral elbow dislocation.Aust N Z J Surg, 60 (1990), pp. 553–554
4. A.A. Tayob, R.A. Shively. Bilateral elbow dislocations with intra-articular displacement of the medial epicondyles. J Trauma, 20 (4) (1980), pp. 332–335
5. J.O. Søjbjerg, P.Helmig, P. Kjærsgaard-Andersen. Dislocation of the elbow: an experimental study of the ligamentous injuries.Orthopedics, 12 (3) (1989), pp. 461–463
6. H. Wake, H. Hashizume, K. Nishida, et al. Biomechanical analysis of the mechanism of elbow fracture-dislocations by compression force.JOrthopSci, 9 (2004), pp. 44-50
7.Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. J Bone Joint Surg Am. 1987; 69: 605-8.
8.MelhoV TL, Noble PC, Benett JB, et al. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg [Am] 1988;70:244–9.
9.Protzman RR. Dislocation of the elbow joint. J Bone JointSurg [Am] 1878;60:339–41.

How to Cite this article: Nekkanti S, Vijay C, Theja S, Shankar RR, Patel I. A Case of Simultaneous Bilateral Elbow Dislocation in a 25-year-old Female following a Simple Fall: An Unusual Mode of Injury. Trauma International Jan-Apr 2017;3(1):46-48.

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

Digastric Trochantric Flip Osteotomy When and How to do it in Acetabular Fractures-?

A Rare Case of Simultaneous Bilateral Elbow Dislocation in a 25 year old Lady following a Simple Fall – An Unusual Mode of Injury

Digastric Trochantric Flip Osteotomy When and How to do it in Acetabular Fractures-?

A Rare Case of Simultaneous Bilateral Elbow Dislocation in a 25 year old Lady following a Simple Fall – An Unusual Mode of Injury

Full Sized Blog Element (Big Preview Pic)

Digastric Trochantric Flip Osteotomy When and How to do it in Acetabular Fractures-?

Author: Harish Makker [1]

Abstract

Introduction

References

(Abstract) (Full Text HTML) (Download PDF)

A Rare Case of Simultaneous Bilateral Elbow Dislocation in a 25 year old Lady following a Simple Fall – An Unusual Mode of Injury

Author: Supreeth Nekkanti [1], C Vijay [1], Sujana Theja [1], R Ravi Shankar [1], Ishani Patel [1]

Abstract

What to Learn from this Article?

Introduction

Case Report

Discussion

Conclusion

References

(Abstract) (Full Text HTML) (Download PDF)

Contact

Important Links

LICENSE