BOS Journal - January, 2000 - Volume 15, Number 1

The Journal of Bangladesh Orthopaedic Society

January, 2000	Volume 15, Number 1
CONTENTS
EDITORIAL
1. IMPACT OF ROAD TRAFFIC ACCIDENT ON OUR SOCIAL SYSTEM Prof. Qazi Shahidul Alam, Professor of Orthopaedic Surgery, R.I.H.D. President, Bangladesh Orthopaedic Society
ORIGINAL REPORT:
2. ANTERIOR CAPSULAR LAXITY AND LABRUM INJURY ARE THE ESSENTIAL LESION FOR RECURRENT ANTERIOR DISLOCATION OF SHOULDER. F.H. Serajee, Asstt. Prof. of. Orthpeadics. Surgery. R.I.H D. Rafiqul Islam, Asstt . Prof. of.Orthpeadics. Surgery. R.I.H D. Qazi Shahidul Alam, Prof. of. Orthpeadics. Surgery. R.I.H D.
3. FEMORAL SHAFT FRACTURES TREATED WITH INTERLOCKING INTRAMEDULLARY NAILING: A REPORT OF TWENTY ONE CASES Md. Faruque Quasem, MS Student (Thesis Part). Ayjaz Ahmed Khan, Associate Professor, Ortho. Surgery, RIHD. Khandokar Shahidul Azim, D. Orth. . A.S.M. Iskander, Asstt. Professor, RIHD. Kamruzzaman, D. Orth. Student. Md. Mushfiqur Rahman, MS Student (Part I).
4. ADDUCTOR TENOTOMY IN POST SEPTIC DISLOCATION OF HIP IN NEGLECTED CASES. Md. Moffazzal Hoque, Asstt. Prof. Of Orthopaedics, RIHD, Dhaka. Faruque R. Awlad, Prof. Of Orthopaedics, RIHD, Dhaka. Amjad Ali, M.S. (Final part) Student, RIHD, Dhaka.
5. HILL SACH’S LESION IS AN IMPORTANT RADIOLOGICAL FINDINGS FOR RECURRENT ANTERIOR DISLOCATION OF SHOULDER F.H. Serajee. Asstt. Prof. of Orthopeadic Surgery RIHD, Dhaka. R. R. Kairy. Associate Prof. of Orthopeadic Surgery RIHD, Dhaka. Shamsuddin Ahmed. Prof. of Orthopeadic Surgery (Rtd.).
6. COMPARATIVE STUDY OF THE TREATMENT RESULTS OF OPEN FRACTURES OF THE LIMB BONES BY ILIZAROV METHOD AND TRADITIONAL METHODS. Golam Kabir, Consultant, Faridpur Sadar Hospital.
7. INTERSCALENE BRACHIAL PLEXUS BLOCK FOR UPPER EXTREMITY OPERATION. Mohammad Alauddin, Junior consultant ( Anaesthesia) R.I.H.D. Dhaka. Md. Mofazzel Hoque, Assistant Professor of orthopaedic surgery, R.I.H.D. Dhaka. Majibur Rahman, Professor ofAnaesthesiology, R.I.H.D. Dhaka. M.C. Paul, Associate Professor of Anaesthesiology, R.I.H.D. Dhaka. A.K.M. Azizul Haque, Junior consultant (Anaesthesia) R.I.H.D. Dhaka.
CASE REPORT
8. DIAGNOSIS OF SACRO COXYGEAL CHONDROMA BY FINE NEEDLE ASPIRATION. A. K. M. S. Khan. MBBS. MPhil(Path). Asst.Prof. Department of Pathology, Chittagong Medical College. A. F. M. S. Islam. MBBS. DMRD. Asst.Prof. Department of Radiology, RIHD, Dhaka. A Awal. MBBS. D. Ortho. Assistant Prof. of Orthopaedic Surgery, RIHD, Dhaka.

Prof. Qazi Shahidul Alam
Professor of Orthopaedic Surgery, R.I.H.D.
President, Bangladesh Orthopaedic Society.

Road Traffic Accidents are the leading cause of death of adelosence and young adults World Wide. Nearly three quarters of Road death occurs in developing countries and men comprise a mean 80% of casualties.

Dramatic increases in the proportion and absolute member of traffic fatalities have been recently witnessed in our country. The accident and fatalities increased in number over the last 20 years. But compare to developed world the density of the vehicles are less. R.T.A. has also great impact on the economy of our country. It is roughly estimated that 1-2% of our GNP loss per annum occurs as a result of morbidity, mortality and loss of property following R.T.A.

The causes of R.T.A are multifactorial and involve the people vehicles and road environment. Human error is estimated to account for between 64 and 95%. A high prevalence of old vehicles that carry, many more people or load than they designed to carry. Lack of safety belt and helmet use, poor road design and maintenance and various speed of vehicles on same road are the factors that contribute to the high rate of crash in Bangladesh.

There is no Public Health Policies on road safety. Fortunately the evidence for alcohol related accident is less in Bangladesh. There is a greater incidence of traffic injury during holiday, Eid, Puja etc. It is due to effect of variations in traffic density and unholy competition and few intoxication by the heavy vehicles driver during working period. It would be useful to have available date on traffic flows over the week in order to correct for this potentially important variable.

It is also important to know casualitise by the category of road user. I Pedestrian, fatalities were highest, then comes passengers and after that drivers are the victim. But this picture may not be true in all countries. the motor and non motor cyclist including rickshaw and van, injuries are also high, it reflect the effects of traffic mix on the roads in our country.

The age groups 15 to 45 years comprised bulk, the male to female ration is 5:1, males are still over represented on the road in our society. This can be explained by the greater exposure of men to traffic or their increased risk due to other factors, given similar exposure levels. The finding that adolescence and young adults are at high risk of traffic accident. This has important economic Impact on Bangladesh.

Though traffic rule is present but application in practice is absent partially or completely. Lack of pedestrian facilities in road design, poor knowledge and practice of road safety measures by the general population, uncourageous behaviour of motorists, high speed driving and poor quality of vehicle. The day and night incidence of accident also differs. The case fatality rate to higher for night time crashes than for those occurring during the day. Darkness and decreased visibility have been suggested as contributing factors in night.

Driving and about to sleep is an important present factor in generation of traffic crashes. There is no maximum speed limit on high way of Bangladesh. No effective monitoring system is present. In the last 15 years there have been major changes in design advancement, air bag, side impact protection.

Errors in classifying severity of injury by police, in the absence of clinical information to face the challenge a multidisciplinary team composed of road engineer, Traffic Police, motor vehicle mechanics, Sociologist and Doctors are essential.

So it is evident of a strong negative relationship between economic development and exposure adjusted R.T.A related death rates. The poorest country like Bangladesh, show the highest Road traffic related morbidity rates. This is known as diseases of development. We must improve this situation by taking immediate effective steps.

Studies conducted by WHO & World Bank (1990) have estimated that about 500,000 people lose their lives each year as a result of RTA & over 15 million suffer injuries. The majority of these, about 70% occurs in low or middle income group countries (Jacobs DD, Baguley CJ 1995).

The scenerious of road accidents are slowly improving in the higher income countries whereas most developing countries face a worsening situation. The road safety measures has been improved a lot in developed countries whilst huge expansion of road network with increase in motorised vehicles without proper safety procedures leads to an enormous increase in RTA victims.

Road traffic accident is not a disease. It is a sudden occurrence in one’s life. The price of the casualties of RTA is very high. If the only earning members of a family suffers RTA, whole family becomes disorganised. As there are no health insurance system or the government bears the total expenditure, the cost of trauma management has to be hear by the injured himself or by his family or with the help of society people.

The victim of RTA is not an individual only. It affects the whole family. It does not merely cripples a man or woman physically, it cripples one psychologically, economically & socially. The picture is more tragic for the disabled people. Man is a social element. His disability makes him isolated in the society. If he is not properly rehabilitated, he becomes a burden of the family. Our society does not yet create a welfare programme for the victims of RTA.

Apart from the treatment and rehabilitation, the social status of a disabled man also changed in our country. He is seen as an handicapped people. He is treated either with pity or with negligence. He is often not allowed to participate in social events, sports or programmes. On the contrary, in developed countries the rights & preveledge of the disabled people are constitutionally approved. In every sectors of life, there are rooms & reservations for them. The society does not show them merely sympathy rather they offer them equal rights & opportunity.

We should create such a position in our society to not only to rehabilitate the victims of RTA but also to honour their disability if any.

ANTERIOR CAPSULAR LAXITY AND LABRUM INJURY ARE THE ESSENTIAL LESION FOR RECURRENT ANTERIOR DISLOCATION OF SHOULDER

F.H. Serajee
Associate Professor of Orthopaedic surgery, RIHD, Dhaka
Rafiqul Islam
Associate Professor of Orthopaedic surgery, RIHD, Dhaka
Qazi Shahidul Alam
Professor of Orthopaedic surgery, RIHD, Dhaka

ABSTRACT:

There are many lesion which are termed as Essential lesions and are responsible for recurrent anterior dislocation of shoulder. Hill Sach 's lesion, Bankart lesions, Capsular laxity, Inadequacity of subscapular muscle, ail are termed as essential lesion We have operated 35 shoulder for recurrent antrior dislocation of shoulder. In our series we found most common pathology was anterior capsular laxity which was 57% and than labral injury which was 40%. So in our series we labelled anterior capsular laxity and labral injury are the essential lesion for recurrent anterior dislocation of shoulder.

Md. Faruque Quasem
MS Student (Thesis Part).
Ayjaz Ahmed Khan
Associate Professor, Ortho. Surgery, RIHD.
Khandokar Shahidul Azim
D. Orth.
A. S. M. Iskander
Asstt. Professor, RIHD
Kamruzzaman
D. Orth. Student
Md. Mushfiqur Rahman
MS Student (Part I)

ABSTRACT:

Intramedullary nailing is the most acceptable form of treatment in femoral shaft fractures for many fractures of the femoral shaft. Traditional Kuntscher nail will not control rotation or telescoping of the fragments, i.e. longitudinal, angulatory and rotational instability can not be combated specially in unstable comminuted proximal and distal third fractures. Interlocking nail is designed to control instability and better management of the above mentioned fractures affecting stability. Locked intramedullary nailing combines close nailing with the parcutaeneous insertion of screws that interlock the bone and nail. This method permits static locking that controls rotation and telescoping and subsequently conversion to the dynamic locking when weight bearing is started after approximately twelve weeks. By providing greater stability, this method extends the indication of intramedullary nailing to severely comminuted oblique and spiral fractures as well as fractures complicated by bone loss and fractures in the proximal and distal ends of femur.

This study, a prospective one, have managed twenty one cases of femoral fractures with modified A.O. interlocking nailing. Nineteen of them were close and two were open. Four of them were grossly comminuted and seventeen were transverse or short oblique. Two of them (9.52%) were located in middle third only and 3 (14.28%) in the proximal third. Rest 16(76.19%)were located in the distal third of the femur.

The mean time until full weight bearing was seventy days (range sixty to one fifty days). Radiographic consolidation was seen in all fractures at a median of sixteen days ( range nine to fifty weeks). The patients were followed for 6 months to two years and no infection developed.

The results in seventeen cases were classified as excellent, in two, as good and two as fair with knee stiffness, some pain and oedema.

We have found interlocking nailing to be an excellent method in treating patients with high energy fractures, multiple injuries, open fracture and osteoporosis. As there is a risk of rotational and longitudinal instability with the dynamic method in unstable fractures, we recommend the static method to be used whenever there is a doubt about the stability of the fracture. Moreover, in our series, there is no delay in bone healing in the static method.

Md. Moffazzal Hoque
Asstt. Prof. Of Orthopaedics, RIHD, Dhaka.
Faruque R. Awlad
Prof. Of Orthopaedics, RIHD, Dhaka
Amjad Ali
M.S. (Final part) Student, RIHD, Dhaka.

SUMMARY:

A Series of 09 (Nine ) patients with post septic dislocation of hip with adduction contracture were studied with an average of 6 months follow up from November 1998 to October 1999 at Rehabilitation Institute & Hospital for the Disabled (RIHD), Dhaka. All the hips were deformed and the average range of movement adduction=+20° and abduction=-10° with gross shortening of the limb. Two patients had flexion contracture which recovered by Soutters procedure. The hip joint formed a pseudoarthrosis, all other movement were functionally accepted. 7(77.77%) patients were female and 2 ( 22.22 %) were male. At follow-up of an average of 6 months following operation movement increased at hip joint abduction = 35° & adduction =30°. So the biological functions were improved. Average age of these series 20 years( mean 15 to 25).

F. H. Serajee
Asstt. Prof. of Orthopeadic Surgery RIHD, Dhaka.
R. R. Kairy
Associate Prof. of Orthopeadic Surgery RIHD, Dhaka.
Shamsuddin Ahmed
Prof. of Orthopeadic Surgery (Rtd.)

ABSTRACT:

Hill Sach’s lesion is a radiological findings for Recurrent anterior dislocation of shoulder. We have examined 35 Shoulders at RIHD Dhaka where 30% had Hill Sach’s lesion. There are many lesion which are responsible for recurrent anterior dislocation of shoulder such as Bankart’s lesion, capsular laxity Inadequacity of sub scapular muscles, but Hill Sach’s lesion is also an important factor for recurrence.

Key word:
Hill Sach’s Lesion a radiological findings for recurrent anterior dislocation of shoulder.

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COMPARATIVE STUDY OF THE TREATMENT RESULTS OF OPEN FRACTURES OF THE LIMB BONES BY ILIZAROV METHOD AND TRADITIONAL METHODS.

Golam Kabir
Consultant, Faridpur Sadar Hospital

INTRODUCTION:

Open fractures have experienced an unsatisfactory progress healing and various complications. This problems becomes more pressing if we bear in mind that patients suffering from open fractures of bones sustain long period of disability and often become invalid. The most serious complications are deep infections, post traumatic osteomyelities, pseudoarthrosis and contracture of joints.

Reduction of cases can be realised through solving the following most important aspects of the problem a) Characterisation and systematisation of soft tissue damage, b) Problems of infection and the means to control it c) Peculiarities of skin grafting, d) Surgical tactics in treating wounds and bone fragment, means of stabilisation of the bone until they become united.

A scientifically sound tactic for fragment immobilisation appears to be extremely important for a successful treatment of open fractures of bones. In the treatment of open fractures of bones that the advantages of extra focal osteosynthesis become more apparent. The devices provide an immobilisation of the bone fragment for the whole period of fixation which facilitates a more rapid union in condition when no massive parts of the fixation apparatus are present in the wound, thus making its healing smooth and uncoiled by microbial contamination. More over the devices improve the quality of observation over the course of healing and provide for earlier functional mobility, including rated loading of the injured limb.

This approach allows one not only to compact the serious development of wound infection, but also to circumvent in many cases the otherwise unavoidable removal of the metal device used for fixation, in this way the fracture union becomes possible. With the function of the diseased joint being retained, not only for open fractures the method of extra focal compression distraction osteosynthesis is used to treat pseudoarthrosis of the tibia, though, it is recommended for use in other localisations too, in the treatment of patients with orthopaedic diseases and deformities and in the rehabilitation of post traumatic false joint and bone defects.

Mohammad Alauddin,
Junior consultant ( Anaesthesia) R.I.H.D. Dhaka.
Md. Mofazzel Hoque,
Assistant Professor of orthopaedic surgery, R.I.H.D. Dhaka.
Majibur Rahman,
Professor ofAnaesthesiology, R.I.H.D. Dhaka.
M. C. Paul,
Associate Professor of Anaesthesiology, R.I.H.D. Dhaka.
A. K. M. Azizul Haque,
Junior consultant (Anaesthesia) R.I.H.D. Dhaka.

SUMMARY:

A prospective study of 60 Patients with upper limb traumatic and orthopaedic problems underwent operative treatment in Rehabilitation Institute and Hospital for disabled (R.I.H.D.) Dhaka from August 1998 to December 1999. The age of the patients were from 15 years to 50 years (mean age 32 years) of both sexes Male 40, Female -20) The choice of anaesthetic drugs are Lignocaine 1.5-2% without adrenaline, Bupivacaine 0.5% and mixed drugs both Lignocaine and Bupivacaine. The recommended dosage is upto 25-40 ml of 1.5-2% lignocaine or 0.5% Bupivacaine in a 70 kg adult. The average onset of anaesthesia was 15 minutes ( range 10-30 minutes ) and average duration 150 minutes (range 90-330 minutes).

DIAGNOSIS OF SACRO COXYGEAL CHONDROMA BY FINE NEEDLE ASPIRATION.

A. K. M. S. Khan
MBBS. MPhil(Path). Asst.Prof. Department of Pathology, Chittagong Medical College.
A. F. M. S. Islam
MBBS. DMRD. Asst.Prof. Department of Radiology, RIHD, Dhaka.
A Awal
MBBS. D. Ortho. Assistant Prof. of Orthopaedic Surgery, RIHD, Dhaka.

INTRODUCTION:

Where as the clinical and radiologic presentation of skeletal neoplasms may be specific for a primary osseous pathologic process, biopsy is imperative to confirm the suspected diagnosis and to plan appropriate therapy. Percutaneous fine needle aspiration cytology has slowly become an accepted approach to the diagnosis and management of patients with primary and metastatic skeletal neoplasms.

Chordoma is a malignant tumor that arises from the remnants of the fetal notochord, which is normally situated within the vertebral bodies and intervertebral discs and rarely, in the presacral soft tissues. Most chordomas arise from notochordal remnants in bone rather than from those located inside the discs. They are more frequent in the fifth and sixth decades, but occur at all ages and in both sexes. They grow slowly, the duration of the symptoms before diagnosis usually being over 5 years. Fifty percent arise in the sacrococcygeal area., 35% in the spheno-occipital area, and the remaining along the cervicothoracolumbar spine.

The patient was a 45 yr. old man with a history of cigarette smoking. He had been in good health until 7yrs back when he developed pain in the lower portion of back. He had difficulties in defecation and micturation for the same duration. Radiologic examination of pelvic bones revealed an osteolytic lesion involving the whole of the sacrum. Fine needle aspiration was done from the lesion by posterior approach, using a 10 cc syringe with attached 23- gauge needle. Upon aspiration gelatinous material came out. Aspirated material was spread on slides and fixed immediately by 95% ethanol. Later on slides were stained by Papanicolaou stain.

Microscopic examination of the smear shows highly cellular material consisting of neoplastic cells with oval to irregular nuclei, smooth nuclear membrane. Nucleoli were inconspicuous. The cytoplasm varied from moderate to large in quantity generally rendering the nucleus to cytoplasm ratios small. Most cells contained one to many large clear vacuoles which abutted the nuclei; others had finely vacuolated bubbly cytoplasm. Abundant myxoid ground substance encircling physaliphorous cells are seen in the smear. Tissue sections revealed a neoplasm composed of nests and cords of cells similar to those described above. The clinical, radiological and cytopathological findings are considered diagnostic of chordoma.