BOS Journal - January, 1996 - Volume 11, Number 1

The Journal of Bangladesh Orthopaedic Society

January, 1996	Volume 11, Number 1
CONTENTS
EDITORIAL 1. History Taking & Clinical Examination: its Importance Prof. Md. Nurul Absar, FRCS Hon. prof. Orthopaedics, Jahural Islam Medical College Hospital Bhagalpur, Bajitpur.
2. An Overview of Road Traffic Accident Characteristics in Bangladesh – A Study at R.I.H.D. Md. Iqbal Qavi, Jr. Consultant (cc), R. I. H. D., Dhaka. Md. Amjad Hossain, Associate Professor, R. I. H. D., Dhaka.
3. Treatment of Intracapsular Fracture Neck Femur By Cancellous Hip Screw Fication in Adults M. H. A. Choudhury, M. O., RIHD, Dhaka. SK. Nurul Alam, Associate Prof. of Orthopaedic Surgery, RIHD, Dhaka.
4. Congenital Pseudoarthrosis of Tibia: Results of treatment by intramedullary nailing and cancellous bone graft MD. Siraj – Ul – Islam, Assistant professor (C.C), Ortho Surgery, R.I.H.D. Dhaka.
5. Use of Allograft in Treating Bone Defect G. A. S. Md. Shamim. Clinical Assistant, RIHD, Dhaka. A. F. M Ruhal Haque. Director & Head of Dept. of Ortho. Surgery. RIHD. M. A. Hannan. Prof. of Ortho Surgery, RIHD, Dhaka. Azizun Nessa. Principal Scientific Officer, IFRB, AERE, Savar, Dhaka.
6. Conservative Management of Non Specific Low Back Pain – A Study on 51 Cases M. Moyeenuzzaman, Asstt. Prof. of physical Medicine, IPGM & R, Dhaka. K. K. Barua, Asstt. Prof. of Neurosurgery, IPGM & R, Dhaka. Q. D. Mohammad, Assoc. Prof. of Neuromedicine, DMCH, Dhaka. M. A. Samad, Consultant, Orthopedic Surgery, IPGM & R, Dhaka. M. Habibur Rahman, FCPS Part – II Student, Physical Medicine, IPGM & R, Dhaka. M. Q. Islam, Porf. of Physical Medicine, IPGM & R, Dhaka.
7. Evaluation of the Rushnail Fixation in the Treatment of open Tibial shaft fracture in Adult Gouranga Bairagi, Mo, RIHD, Dhaka. Omar Faruque Golam Kibria, Associate Professor of Orthopedic Surgery, RIHD, Dhaka. A. K. M. Ruhal Haque, Professor of Orthopedic Surgery and Project Director RIHD.
8. Krukenberg Amputation – A Review Md. Faruque R. Aolad, Prof. & Head. Deptt. of Ortho. Surgery, Chittagong Medical College Hospital, Chittagong.
9. Routine & Emergency Operation in RIHD in the year 1995 G. M. Reza. Mo, Orthopaedic Surgery, RIHD, Dhaka. M. A. A Hannan. Prof. of Orthopaedic Surgery, RIHD, Dhaka.
10. Comparative Evaluation of Casualty Patients Admitted into General Surgery & Orthopaedic Surgery Unit in M. A. G. Osmani Medical College Hospital, Sylhet S. M. Idris Ali, Consultant (Ortho). MD. Amjad Hossain, Associate Prof. of Ortho Surgery. Aloke Ranjan Das, Indoor Medical Officer (IMO). Rushar Kanti Paul, Internee Surgery ward MAG Osmani Medical College Hospital, Sylhet.
CASE ARTICLES
11. Myxoma of the Jaws – Two Case Report and a Brief Review M. A. Samad, Consultant, Orthopedic dept. IPGMR, Dhaka. M. Habibur Rahman, Consultant, Physical Medical dept. IPGMR, Dhaka. M. A. Kashem, Asstt. Prof. Orthopedic dept. IPGMR, Dhaka. Sohely Rahman, Medical Oficer, Dept. of Physical Medicin IPGMR, Dhaka.
12. Synovial Chondromatosis – Case Report and A Brief Review Brigadier Syed Fazle Rahim, Adviser Orthopaedic Surgery, CMH Dhaka.

HISTORY TAKING & CLINICAL EXAMINATION: ITS IMPORTANCE
Prof. Md. Nurul Absar
FRCS Hon. prof. Orthopaedics, Jahural Islam Medical College
Hospital Bhagalpur, Bajitpur.

In the present day medicine, detailed history taking and methodical clinical examination, a sine qua non for diagnosis and treatment, appears to have lost its importance. Cursory examination by the juniors, rarely by the seniors, if they have time has become the routine. Vital information needing a questioning mind, vigilant eyes and prehensile hands are thereby missed.

Our people are God fearing. For good results the doctor gets the credit and whenever bad, God is blamed. Fortunately they are not legal minded otherwise things might have been different. Three cases are presented as an eye opener:

One Mr. x 45 years old reported to OPD JIMCH (Jahurul Islam Medical College Hospital) with swelling of left knee and occasional locking for one year. He had a history of Assault about 11/2 year back – injury to his knee by a bamboo spike. He was initially treated locally, possibly with antibiotics. Then he went to a premier Medical College Hospital of Bangladesh. He was diagnosed as Traumatic Synovitis and Synovectomy was done.

On Examination by us: Operation scar in front of the knee was present. There was swelling of the knee with effusion and synovial thickening. Occasional creps also noted. While examining he said that sometimes his knee got stuck during movement and sudden jerk relieved it. He felt something moving inside. This arose a suspicion of loose body inside the joint. X – ray showed erosion of the articular surface of the femur. Immediately the joint was opened, fluid gushed forth and a funny looking dark object was visible, It was taken out – a conical piece of bamboo 21/2 long, ľ diameter at it’s base. The wound after thorough toilet was closed. It healed with primary intention and the patient never returned after that.
A 18 year old girl reported to OPD JIMCH complaining of low back pain with radiation to both lower limbs. She was unmarried and had her menses few days ago. She was x – rayed and NSAID prescribed. After a week or two, due to her persisting pain she was referred to the consultant. Her x – ray was reviewed. There was a herring bone pattern of shadow in her lower abdomen. Previously when questioned she claimed to have been wearing a silver waist band (Bicha). It appeared suspicious. She put on the couch and her abdominal examination showed a midline mass arising out of her pelvis. Ultrasound confirmed pregnancy.

Mistakes:
- METAL gives a much denser shadow than bone, was not appreciated.
- The doctor did not examine the abdomen.
- X – ray and NSAID in first trimester of pregnancy should not have been prescribed.
- The patient then confirmed pregnancy and disappeared since.
An interesting example reported in the Journal of Bone and Joint Surgery (GB – 1995) from Military Hospital Cambridge, England. A 44 year old man was found by his wife complaining of severe pain across the chest and shoulders. His suspecting him to be a case of Dissecting Thoracic Aneurysm referred him to cardiac unit. He was examined, Chest X – ray, CT Aortogram was done – declared as normal and treated with analgesics. Two days later he developed petechial rashes across his shoulders. He was referred to the Dermatologist who prescribed him medicines without any diagnosis.

He was next seen by the Neurologist with a diagnosis of Brachio – neuralgia. His cervical spine x – ray was normal. His shoulders x – ray showed evidence of Avascular Necrosis humeral heads. Finally he was referred to the Orthopaedic Surgeon. He noted the peculiar feature – the patient was holding his arms in internal rotation and resisted all movements of rotation. X – ray Axiliary view of shoulders confirmed diagnosis of Posterior dislocation of shoulders and was treated.

Conclusion:
Proper History taking and clinical examination though a teaching of old, still and shall ever hold good as gold. In many instances history only id properly taken leads to a fairly accurate diagnosis.

Costly innovations & advances outstrips patient’s financial resources and we no longer enjoy their confidence. There is view nowadays that many operations done are unnecessary – done either they are therapy for the surgeon rather than for the patient or worse still for personal financial gains. Medicine has ceased to be a profession of cure and compassion but a trade. Consensus members of the profession must rise to the occasion for a remedy before it is too late.

Reference:
Orth. Diag. – Hans. V. Debrunner. 2nd. Ed. JBJS (BB) 77B Suppl – 1.

Md. Iqbal Qavi
Jr. Consultant (cc), R. I. H. D., Dhaka.
Md. Amjad Hossain
Associate Professor, R. I. H. D., Dhaka.

SUMMARY:

The total number of patients that attended the casualty department at Rehabilitation Institute & Hospital for the Disabled, Dhaka, from Jan. ’95 to Jun ’95 was 11, 705 of which 6,593 (56.8%) were victims of road traffic accident. The study was conducted to identify the problems areas, vulnerable involved in the accident. According to our finding, 68% of the casualties took place in the urban areas (Dhaka city and surrounding area). Pedestrians were found to be the most vulnerable group accounting for 50% of all accidents, Heavy vehicles accounted for 88% of highway accidents, while light vehicles and three wheelers accounted for 76% of accidents in the urban area. Loss of control is marked in three – wheeler vehicles e.g. tempo, baby – taxi, and rickshaws. This paper presents a broad overview of the accident characteristics in out country.

M. H. A. Choudhury
M. O., RIHD, Dhaka
SK. Nurul Alam
Associate Prof. of Orthopaedic Surgery, RIHD, Dhaka.

SUMMARY:

Fifteen randomly selected patients aged 16 to 55 years with displaced intracapsular fracture neck femur were treated by close reduction and internal fixation by two parallel hip screws in RIHD from January 1994 to June 1996 with follow up for 2 years. Patients were operated after 7 days of injury to 28 days. Short threaded hip screws were preferable to long threaded hip screws. Two parallel screws used to overcome rotational forces at fracture sit and short threaded screws preferable to long threaded screws which facilitates compression at the fracture site thus enhacing healing, patients weight bearing started from 12 weeks after operation.

Three patients lost from the follow up and two excluded from study due to implant failure from second injury due to fall. Out of 10 patients union resulted in 8 patients (80%) and 6 cases (60%) showed no evidence of avascular necrosis radiologically two years after operation.

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CONGENITAL PSEUDOARTHROSIS OF TIBIA
Results of treatment by intramedullary nailing and cancellous bone graft

Md. Siraj – Ul – Islam
Assistant professor (C.C), Ortho Surgery, R.I.H.D. Dhaka.

SUMMARY:

08 cases of pseudoarthrosis of tibia were treated by a simple one-stage method followed by the procedure of Charnley with few modification. They were in both walking & non-walking age group. The results of the treatment varied with the age and type of pseudoarthrosis.

G. A. S. Md. Shamim
Clinical Assistant, RIHD, Dhaka.
A. F. M. Ruhal Haque
Director & Head of Dept. of Ortho. Surgery. RIHD.
M. A. Hannan
Prof. of Ortho Surgery, RIHD, Dhaka.
Azizun Nessa
Principal Scientific Officer, IFRB, AERE, Savar, Dhaka.

SUMMARY:

A prospective study of using irradiated allograft was done in RIHD, Dhaka from Jan ’93 to June 96 in 26 patients. HLA matching was not done between donor and recipient. Age ranges 8 yrs to 60 yrs, average was 34 yrs.

Out of 26 patients 20 (76.92%) were male and 6(23.07%) were female. 14(53.85%) patients out of 26 patients were bening cystic lesions of bone like giant cell tumour, (GCT) simple bone cyst.

Rest 12(46.15%) patients were non – union of shafts of long bones of which 04(33.33%) patients were gap Non – union, 06(50%) pts. were hypertrophic non – union and 02(16.69%) pts. were atrophic type of non – union.

Common post operative complication encountered were stitches infection in 02(7.69%) patient which were treated by ciprofloxacillin according to the report of culture and sensitivity of pus. Recurrence of the lesion was observed in 01(7.14%) pt. with GCT in the lower end of radius. And one (7.14%) patient with gap – non – union showed absorption of the allograft. 24(92.30%) patients out of 26 showed excellent incorporation of allograft.

M. Moyeenuzzaman,
Asstt. Prof. of physical Medicine, IPGM & R, Dhaka.
K. K. Barua,
Asstt. Prof. of Neurosurgery, IPGM & R, Dhaka.
Q. D. Mohammad,
Assoc. Prof. of Neuromedicine, DMCH, Dhaka.
M. A. Samad,
Consultant, Orthopedic Surgery, IPGM & R, Dhaka.
M. Habibur Rahman,
FCPS Part – II Student, Physical Medicine, IPGM & R, Dhaka.
M. Q. Islam,
Porf. of Physical Medicine, IPGM & R, Dhaka.

SUMMARY:

To see the effectiveness of various forms of physical treatments, 51 patients with non – specific low back pain were selected and divided into three groups: shortwave diathermy group (SWD), exercise group and placebo (detuned SWD) group, All the patirnts were treated for 6 weeks, Immediate improvement (after 2 weeks) was reported in short – wave diathermy group (26.66%). After complete course of 6 weeks treatment 73.33% patients in short – wave diathermy group and 64.71% patients in exercise group reported improvement, whereas only 35.71% patients in the placebo group reported improvement.

Gouranga Bairagi,
Mo, RIHD, Dhaka.
Omar Faruque Golam Kibria,
Associate Professor of Orthopedic Surgery, RIHD, Dhaka.
A. K. M. Ruhal Haque,
Professor of Orthopedic Surgery and Project Director RIHD, Dhaka.

SUMMARY:

During January 1994 to December 1995, 20 adult patient with Gustilo tupe II diaphyseal fracture of the tibia were treated initially with Rush nail at Rehabilitation Institute and Hospital for the Disabled, Dhaka. Ninety – five percent of the fractures healed uneventfully. The average healing times were 22.6 weeks. Infection occured in 5% cases. Two nonunion healed by secondary procedure. The average duration of hospital stay were 20 days. Follow – up evaluation were average 14.28 months (range 12 to 23 months). The result of the clinical and radiological evaluation were good in 50% cases fair in 30% cases and poor in 20%.

REVIEW ARTICLE

Md. Faruque R. Aolad
Prof. & Head. Deptt. of Ortho. Surgery, Chittagong Medical College Hospital, Chittagong.

SUMMARY:

Krukenberg amputation though ugly looking, is the only treatment of choice in developing countries for hand and forearm amputees in the context of socio – economic aspect and mainly for its unique function and sensation, which a modern costly prosthesis can not give.

ROUTINE & EMERGENCY OPERATION IN RIHD IN THE YEAR 1995
G. M. Reza
Mo, Orthopaedic Surgery, RIHD, Dhaka.
M. A. A. Hannan
Prof. of Orthopaedic Surgery, RIHD, Dhaka.

RIHD being the only orthopaedic and traumatic hospital in the country, is a 500 bedded hospital with all sorts of limitations like other hopitals. The treatments are being gibven routinely and on emergency basis. Initially there were five units like yellow, blue, red, green & plastic but now more two are added like brown & white. Each unit gets only one day for admission that includes routine & emergency. The patients come to OPD & emergency, they come as referred or directly.

The emergency operation are also classified as routine & emergency; again such operations are further classified as major & minor operations. These include all types of open & close injuries and are done on their merit.

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COMPARATIVE EVALUATION OF CASUALTY PATIENTS ADMITTED INTO GENERAL SURGERY & ORTHOPAEDIC SURGERY UNIT IN M.A. G. OSMANI MEDICAL COLLEGE HOSPITAL, SYLHET

S. M. Idris Ali
Consultant (Ortho).
Md. Amjad Hossain
Associate Prof. of Ortho Surgery..
Aloke Ranjan Das
Indoor Medical Officer (IMO).
Rushar Kanti Paul
Internee Surgery ward MAG Osmani Medical College Hospital, Sylhet.

SUMMARY:

Retrospective study has been done to evaluate the number of patients admitted through emergency department into the General Surgery ward and Orthopaedics ward as well as number of operations both routine and emergency done in Orthopaedics O.T. & General Surgery O.T. A. total of 1343 patients were admitted in to General Surgery from January to June 1995. Out of these patients 22% were admitted due to Burn & 45% due to miscellaneous injury including abdominal injury & Head injury. A total of 331 patients were admitted into Orthopaedics Ward during first 6 months of 1995. Out of these patients 65% were admitted due to Road Traffic Accident, 27% due to Assault & remaining 8% due to miscellaneous injury including spinal injury.

MYXOMA OF THE JAWS – TWO CASE REPORT AND A BRIEF REVIEW
M. A. Samad
Consultant, Orthopedic dept. IPGMR, Dhaka.
M. Habibur Rahman
Consultant, Physical Medical dept. IPGMR, Dhaka.
M. A. Kashem
Asstt. Prof. Orthopedic dept. IPGMR, Dhaka.
Sohely Rahman
Medical Oficer, Dept. of Physical Medicin IPGMR, Dhaka.

INTRODUCTION:

Myxomas of paranasal sinuses are slowly growing benign mesenchymal tumor 1,2,3,4,5. They are usually found localized centrally in the maxilla or mandible in the teeth bearing areas. They expand the bone6. They may be related to dental malformations or missing teeth, but may also occur without any such abnormality 1,4. Origin of the tumor is most likely from the follicular remnants of a previously exposed teeth i.e. mesenchymal cells of tooth germ7.

Myxomas are soft gelatious & are composed of stellate & spindle cells embedded in an abundant mucoid stroma in which blood vessels are often scattered throughout the tumor and minimum connective tissue fibers. Its matrix is an acid mucoplysaccharide apparently secreted by the stellate cells 8.

Brigadier Syed Fazle Rahim
Adviser Orthopaedic Surgery, CMH Dhaka.

SUMMARY:
A rare case of synovial chondromatosis is presented here. Complete synovectomy and removal of loose bodies was performed. Recovery was excellent. He did not have any recurrence in eight years follow up. A brief review of literature is presented.

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