مجله جراحی استخوان و مفاصل ایران
سال ششم شماره 1 (پیاپی 21، پاییز1386)

Classification and treatment of lateral humeral condyle fracture in children is a matter of controversy. We report the results of treatment in 26 cases along with a comprehensive literature review. Medical records and radiographs of 26 children (8 girls, 18 boys) who had been treated for lateral humeral condyle fracture over 20 year period were reviewed. The cases had a mean age of 4.5 years (1.9-8 years). The patients were evaluated for elbow range of motion, deformity, neurological deficit, and avascular necrosis with an average follow-up of 6 (3-20) years. From the 26 cases, 17 patients had less than 2 millimeters displacement, and had been treated non-operatively; 8 patients with displaced fracture had received internal fixation. One case that presented late and had ulnar nerve symptom with fracture non-union, underwent only anterior transposition of the nerve. The cases had all full range of motion, with no avascular necrosis. The one non-union case had a carrying angle of 26 degrees. Lateral humeral condyle fracture in children requires surgical treatment more than most other pediatric fractures. Initial displacement of over 2 millimeters or any later displacement in the early post fracture period would require surgical intervention.

There are different techniques for brachial plexus block, each with their advantages and disadvantages. The usual side-effects are: Incomplete block, especially ulnar nerve, and pneumothorax. We would like to report a modification of the technique which negates these side-effects. In an applied study, 50 cases (30 males, 20 females) that received a modified technique of interscalen block were studied. The mean age was 35 years. The site for local anesthetic injection was at the junction of the upper two-third and lower one-third of the line joining the midpoint of clavicle and chassaignac tubercle. Average time to production of block, period of sustained anesthesia, and any side-effects and patient's satisfaction were documented. Ulnar nerve block was established in 50 cases. The block was functional within 15 minutes and 44 seconds. The analgesic effect on ulnar nerve was obtained in 96% of the cases, and continued for an average of 3 hours and 32 minutes. Excellent patient's satisfaction was observed in 70% of the cases. No pneumothorax was encountered. Modified interscalenblock is a suitable method of anesthesia for wrist and forearm surgeries with no risk for pneumothorax

Treatment of recurrent shoulder dislocation with open technique has a long successful history in orthopaedic surgery. Arthroscopic repair, however, has a much shorter history especially in Iran. This is a short-term follow-up study of such an operation in Iran. Forty patients (39 males, 1 female) with recurrent anterior shoulder dislocation who had undergone arthroscopic stabilization over a two-year period were evaluated in a retrospective study. The cases had a mean age of 25.3 years, and had 15.5 months (6-30 months) average follow-up. The assessment scores were “The University of California-Los Angeles” (UCLA), “Rowe” and “American Shoulder and Elbow Society Scores” (ASES). Mean Rowe score was 95.5 (77-100); with excellent scores in 32 patients, good in 4, fair in 3 and poor in one. Mean UCLA score was 33.3 (25-35), with good and excellent results in all but 4 cases. ASES was 2-3 in 3 patients, and the rest being painless and without any symptoms. Thirty six patients returned to their previous levels of activity, and achieved good results; the results were fair in 3, and poor in one patient who had recurrent instability. Short-term results of arthroscopic repair of anterior shoulder instability are encouraging.

Spasticity is the most common manifestation of cerebral palsy. In order to decrease the spasticity, oral medications, direct intramascular injections of alcohol, phenol or Botulinum toxin, or surgery are used. This study aimed at comparing the efficacy of 45% ethanol injection with that of Botulinum toxin injection in the spastic calf muscles of diplegic cerebral palsy children. Seventy five children (34 girls, 41 boys) with diplegia were divided into three groups: Group 1 received one injection of 45% alcohol followed by 4 weeks of cast immobilization, and then physiotherapy; group 2 received Botulinum toxin followed by physiotherapy; and group 3 had only physiotherapy with no injection or immobilization. The walking pattern of all three groups were evaluated clinically in one year in terms of independency from walking support, heel-toe gait pattern, neutral position of hind foot at heel strike, and ankle position in stance phase. At one year, support independency was observed in 60% of group 1, 25% of group 2 and 40% of group 3 treated cases. The results in heel-toe gait were 100%, 90% and 50% respectively. Neutral heel placement was observed in 60%, 25% and 12.5%. Neutral ankle position was seen in 100%, 100% and 10% respectively. 45% alcohol injection into calf muscles of spastic diplegic cerebral palsy children gives as good or better result than Botulinum toxin injection. Because of its lower cost and easier accessibility, it is preferred over Botulinum toxin.

MRI is widely used for diagnosis of traumatic intra-articular knee lesions. Its accuracy is variable in different studies and also accuracy of MRI in diagnosis of traumatic intra-articular knee lesions in our country is not clear. This study was performed to evaluate the accuracy of MRI in one of imaging centers in our country in detecting traumatic intra-articular knee lesions by comparing the results of MRI with subsequent arthroscopy as a gold standard. In a case series study, 33 patients with clinical diagnosis of traumatic intra-articular knee lesions underwent prearthroscopic MRI. The sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio and negative likelihood ratio of MRI were calculated relative to the findings during arthroscopy. The Measure of agreement of MRI with arthroscopy was calculated as well. The accuracy of MRI for medial meniscus was 73%, lateral meniscus 82%, ACL 82%, PCL 97% and articular cartilage 85%. The agreement of MRI with arthroscopy in meniscal lesions was moderate and in ACL and articular cartilage was good. In this study, the accuracy of MRI for medial meniscus and ACL, the sensitivity of MRI for medial meniscus, and the specificity of MRI for lateral meniscus and ACL were significantly lower than the most of the studies. The result of MRI for articular cartilage is the similar to other studies. This issue should be considered by physicians that request MRI.

The term “floating knee” is used to describe the flail knee separated from the ipsilateral hip and ankle. Its various forms are expressed in the classification framework. The objective of this research was to review the authenticity of previous floating knee classifications. In a retrospective study, 74 patients (64 males, 10 females) with floating knee, the epidemiology of this trauma and the prevalence of its various kinds of fractures were studied in relation to the five existing classifications. The study was done in two educational trauma centers in Mashhad, in a two year period at one and 3 year period at the other hospital. The mean age of the patients was 25.6 years. In classification of patients, there was some non-conformity with the previous classifications. In previous classifications there are some weaknesses such as not to have location for open fractures, cases with both injured epiphyses and cases that have more than two fractures around the knee. In the new classification ''the floating knee'' has been divided into three types: Conventional floating knee (A,B,C), Complex knee fractures (D,E) and variant floating knee (the hip and ankle ipsilateral fractures). Each subgroup is marked with one of the numerical codes (0,I,II) which determines the open or closed status of the fracture(s). In this research 12% of injuries were complex knee fractures. In the new classification, fractures’ types are classified as relatively comprehensive and simple and are coded.

Ipsilateral fractures of patella and femur are occasionally seen in multiple trauma cases. In such cases duration of surgery, amount of bleeding and treatment modality have effect on rehabilitation of the patient and return of joint motion. In this article we present 2 patients, 18 and 52 years of age that were treated by internal fixation of femur and arthroscopically-assisted percutaneous fixation of patella.

How would you deal with a large bony piece which has vital value for stability and function, has fallen out of wound in an open fracture and is brought to you in a severely contaminated shape? How about a large bony fragment falling out of your hand onto the operating room floor during surgery? Can one take an osteochondral piece as an autologus composite graft out of a badly contaminated amputated limb. If yes, how one may prepare such a graft? There is scanty information in the literature on this subject. The following is an overview of the sporadic reported cases on such issues.