Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 12 num. 3 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Medical malpractice litigation</b>: <b>Is there an alternative?</b>]]> <![CDATA[<b>Multicentre retrospective study comparing outcome of pinning and locking plates for treating distal radius fractures</b>]]> BACKGROUND: Distal radial fractures are extremely common in the South African private and provincial sector, with intraarticular fractures making up a large portion of this group. Closed reduction is the cheapest method of treatment but the results are poor. Closed reduction and pinning is the next most cost-effective option with slightly better results. Plating of these fractures is another option. Volar locking plate systems have been shown to be the gold standard for fixation of these fractures with good to excellent objective and functional outcomes. The cost of these plating systems is, however, extremely expensive, and the need has arisen to identify patients that can be treated more affordably in the South African provincial healthcare system. AIM: To compare the functional outcomes of patients with intra-articular distal radius fractures treated with volar locking plates, and of those treated with closed reduction and pinning. METHODS: The multicentre retrospective study comprised two groups of patients: one group treated with volar locking plates; and the other treated with closed reduction and pinning. The functional outcome was our main objective, with objective outcomes and complications our secondary objectives. RESULTS: Statistically the results showed that the two groups did the same functionally even though objectively there were more complications in the closed reduction and pinning group. The only statistically significant finding was that the time to functional pain-free independence was 6 weeks earlier in the plate group than in the Kirschner wire (K-wire) group. CONCLUSIONS: Using these results we suggest that patients who have a good support system and/or can afford the time off work be treated with closed reduction and pinning. Those patients who have a poor support system and who cannot afford lengthy times away from work should be treated with volar locking plates. Further studies of this subject are needed. <![CDATA[<b>Restoration of teardrop angle (TDA) in distal radius fractures treated with volar locking plates</b>]]> BACKGROUND: Distal radius fractures are among the most common fractures of the upper extremity. Failure to reduce and stabilise the lunate facet fragment intra-operatively has been shown to result in poor functional and radiographic outcomes. Medoff5 introduced the teardrop angle (TDA), which can herald the presence of articular incongruity of the lunate facet. We assess the reduction of the TDA in intra-articular distal radius fractures treated with volar locking plates. METHODS: This was a retrospective review of the pre- and post-operative TDA in two groups of patients. One group had arthroscopy-assisted reduction prior to volar locking plate fixation, while the other had volar locking plate fixation with fluoroscopy alone to guide reduction. We measured the TDA using the 'central axis' method on the standard lateral wrist X-ray as well as the distal radial tilt angles both pre- and post-operatively. RESULTS: In the arthroscopy group, the average pre- and post-surgery TDA was 27° and 43° respectively, while in the fluoroscopy group, the average TDA pre- and post-operatively was 26° and 42° respectively. There was no significance between the two groups (p=0.98) and none of the fractures had a normal TDA post reduction. CONCLUSION: Whichever technique was used to reduce fractures, the average TDA was not restored to normal. The unawareness of this radiological landmark, its measurement and the significance thereof might be the reason for this. Volar tilt angles were restored close to normal values, a parameter that is well known and actively looked at during reduction under fluoroscopy. <![CDATA[<b>Evaluation of intramedullary nailing in low-velocity gunshot wounds of the radius and ulna</b>]]> BACKGROUND: The objective is to assess whether intramedullary (IM) nailing of the forearm (radius and/ or ulna) after low-energy gunshot wounds, is a safe and effective form of management for these complex fractures. METHODS: A prospective consecutive case series was followed from presentation to fracture union. Cases were enrolled from three tertiary level academic hospitals and one private hospital. Twenty-one patients (between April 2006 and February 2008) who sustained low-energy gunshot wounds to the radius and/ or ulna were enrolled. All fractures were stabilised using a single IM rod. Variation in soft tissue management was dependent on surgeon preference and findings. All patients were assessed subjectively; using a DASH score, objectively; by a clinical exam (focusing on range of movement and wound healing) and radiologically; assessing for fracture union. RESULTS: Fourteen patients, all with comminuted fractures, were evaluated at 1 year post-injury. The median DASH score was 7.5 (range 3.3-84), but this was influenced by soft tissue factors. All the wounds healed without complication, and range of movement was adequately restored. Three patients had residual nerve injuries, which affected outcome. The fracture union rate was high (13/14) and complication rate was limited to one non-union and one mal-union. CONCLUSION: The use of IM nailing for low-velocity gunshot fractures of the radius/ulna is safe and effective, with predictable results. <![CDATA[<b>Subungual glomus tumours</b>: <b>Report on 11 cases</b>]]> Subungual glomus tumours are debilitating tumours that arise from the glomus body in the distal aspect of the digit. They normally present with a triad of severe pain in the digit, cold sensitivity, and point tenderness. There is normally a bluish discolouration under the nail, pin-point tenderness and severe pain with exposure to cold. There is typically a long delay from onset of symptoms and diagnosis. We present a series of 11 patients who were typically all misdiagnosed multiple times, surgically treated at the Helen Joseph Hospital, Johannesburg, between 2008 and 2012. We conclude that the diagnosis of glomus tumours should be clinical with meticulous history-taking and a high index of suspicion and careful examination. Special investigations are usually not necessary. <![CDATA[<b>Case report</b>: <b>Giant lipoma of the hand</b>]]> Giant lipomas of hand are rare lipomas that are larger than 5 cm. Comprehensive history and clinical examination is usually sufficient to make the diagnosis of lipoma but with giant lipoma, liposarcoma cannot be excluded. We report a case of giant lipoma in which we excluded liposarcoma by MRI and proceeded to do excisional biopsy. The histology confirmed our pre-operative diagnosis of lipoma, and post-operatively the patient did very well and returned to work with normal function of the left thumb. <![CDATA[<b>The challenges facing the orthopaedic surgeon today in managing femoral neck fractures in HIV-positive patients</b>]]> The use of highly active anti-retroviral therapy (HAART) in treating HIV-positive patients has led to a reversal of complications such as HIV-related mortality and morbidity. The lifespan of HIV-positive patients on HAART especially if started early (CD4 ± 350 cells per microlitre) as is done in developed countries, is as good as is in non-reactive cohorts. However age-related complications such as decreased bone mineral density (BMD) are emerging early, resulting in fragility fractures. We present a case of bilateral neck femur fractures in a 53-year-old female patient on HAART. <![CDATA[<b>Ipsilateral medial and lateral condylar fracture of the humerus in a 4-year-old boy</b>]]> T-Condylar humeral fractures in children are rare. Medial condylar, lateral epicondylar, and T-condylar fractures combined, constitute less than 1% of all fractures in the elbow. Rarer is a T-condylar fracture in a skeletally immature child. We present a case of a T-condylar fracture in a 4-year-old boy following a fall on a flexed elbow. <![CDATA[<b>Leave against medical advice (LAMA) from in-patient orthopaedic treatment</b>]]> Leave Against Medical Advice (LAMA) poses potentially serious consequences on the utilisation of resources and may impact on an institution's finances. This study investigated hospital characteristics, patient factors and physician obligations regarding LAMA in Makurdi, Nigeria. A 12-month prospective study involving orthopaedic in-patients in a tertiary health institution with many catchment areas was conducted. A proforma was designed for the socio-demographic profiles and the contexts surrounding the act of LAMA.Fifty-eight (13.9%) of the patients managed within the stipulated period took LAMA. Injury sustained in motor vehicle collisions was the major indication for admission while disagreement on treatment modality and poor financial status were the main reasons for LAMA. The major destination after taking LAMA was the Traditional Bone Setter's home. 'Disagreement on treatment/duration' and 'patronage of the Traditional Bone Setters' are issues linked mostly to the poor financial status of patients. Educational awareness, implementation of health insurance for all citizens and establishment of a well-equipped orthopaedic division within the hospital are laudable solutions.