Human pelvis is a very stable structure. It achieves its stability from the surrounding musculature and ligaments. Hence, pelvic disruption requires high energy trauma specifically in young people. It is usually associated with multisystem injuries due to its close proximity to the vital structures. Mortality in pelvic injuries is mostly due to the uncontrolled hemorrhage and the late mortality due to associated multisystem injuries, multiorgan failure, and sepsis. Acute management focus on the complex pelvic trauma it includes the systemic control of hemorrhage, pelvic stabilization with external pelvic binder or external fixator, use of pelvic angiography, and embolization and preperitoneal packing. Every institute should develop its own protocol depending on facilities available.

Pelvic fractures are one of the common cause of mortality in polytrauma patients, especially following high velocity trauma. The management in emergency requires good clinical judgment and access to radiological modalities. There are various classifications to define the pattern of injury in pelvic fractures. Previously, fracture patterns were described on the basis of anatomical fracture pattern on radiographs. With the introduction of concept of force vector and stability defined by Pennal and Tile, which was further modified by Young and Burgess, the corrective forces required to reduce such fractures were defined. With the introduction of these newer classification systems along with the introduction of external fixators, the mortality and morbidity has significantly reduced in pelvic fractures.

Fractures of the pelvis are difficult injuries to treat surgically. Thorough knowledge of the surgical anatomy is a prerequisite to be able to perform the surgical procedure safely as major neurovascular bundles and viscera are at risk of iatrogenic injury with disastrous consequences which are fortunately rare- but can happen. The approaches ideally need to be learned ideally first on cadavers and then under supervision till thorough familiarity is attained. The learning curve is steep; however it should not dissuade surgeons and once learned can allow for safe internal fixation to be performed in a large number of patients.

The essence of management of pelvic fractures, a high energy injury, is multidisciplinary approach, wherein, the primary goal of treatment is hemodynamic stability. Restoration of a stable pelvic ring which allows optimum weight transmission to the limbs is the ultimate aim of any surgical procedure. Contradicting schools of thought exist between whether to fix the anterior pelvic ring first vis-a-vis the posterior ring. To some extent, the decision is guided by the operating surgeon's preference for percutaneous fixation as opposed to conventional open surgery. Anatomic reduction of the fracture remains an important goal, whether performed open or closed, as residual displacement is associated with poorer outcomes. A comprehensive literature search was conducted using the Ovid interface; 1232 English language citations relating to management of pelvic fractures were screened, out of which 34 articles were perused for surgical treatment of pelvic fractures and 21 of the above, specifically dealing with the principles and techniques and biomechanics of internal fixation of the disrupted pelvic ring, formed the basis of the present narrative.

The pelvic trauma can be a simple isolated one or can involve multiple skeletal structures or viscera also. Women of childbearing age who suffer from pelvic trauma have always a question in their mind regarding the future fertility and type of delivery they are going to have. The final functional outcome of pelvic injury depends on the severity of trauma and the type of surgical management. The aim of this article is to review the female pelvic anatomy, pelvic injuries, management options and future reproductive potential and other impacts of pelvic trauma in women of childbearing age.The pelvic trauma can be a simple isolated one or can involve multiple skeletal structures or viscera also. Women of childbearing age who suffer from pelvic trauma have always a question in their mind regarding the future fertility and type of delivery they are going to have. The final functional outcome of pelvic injury depends on the severity of trauma and the type of surgical management. The aim of this article is to review the female pelvic anatomy, pelvic injuries, management options and future reproductive potential and other impacts of pelvic trauma in women of childbearing age.

Pelvic injuries occur in major crash accidents. Injury to the bladder and membranous urethra are the commonest associated urogenital injuries. More and more urethral injuries are being managed conservatively in the acute phase for fear of hemorrhage and infection, which may result in late sequel of urethral injuries. The definitive surgery can be delayed in favor of simple.

Injuries of the pelvis causing fractures in paediatric patients are rare injuries due to the elasticity of the bones and joints and account for 1-2% of all fractures in children. Injuries involving the tri-radiate cartilage are difficult to diagnose and have sequelae of growth arrest which are difficult to treat. Bony avulsion fractures are common in young children while acetabular and pubic or sacroiliac diastases are more common in adolescents. These injuries need radiographs and CT scanning for accurate characterization. Most injuries can be treated conservatively; however treatment needs to be individualized depending on the personality of the injury.

With the advances in the trauma management, the protocol of the treatment of fractures of pelvis has evolved with control of mortality and morbidity, which is associated with these fractures. The goal of management is to achieve anatomical reduction with stable fixation of these fractures with optimum functional outcome. Despite of the better understanding of the pathophysiology of these fractures and advances in the surgical techniques to fix these fractures, the long term outcomes of these fractures are not predictable. Though in majority of patients, we may achieve the pelvic stability and pain free walking, but still we are not able to define a reproducible approach to achieve the optimum functional outcomes in all the patients with fractures of pelvis. The present paper deals with a systematic review of available literature related with controversies related with all aspect of surgical treatment of these fractures including various methods of management, various methods of fixation, techniques of fixation, determination of type and amount of pelvic stablisation and evaluation of long term functional outcome and its correlation with various factors.

Despite numerous advancement in surgical techniques and better understanding on pelvic injuries, it is not uncommon to see neglected pelvic fractures in India. The pelvic injuries are either neglected by the patients themselves by late presentation or poor compliance to treatment or sometimes even neglected by the surgeons by inadequate treatment. The usual manifestations of neglected pelvic fractures are either a nonunion or a malunion. Pelvic nonunion or malunion results in huge disability to the patients. These disabilities manifest in the form of pain, leg length discrepancy, sitting or standing imbalance and even sexual or excretory dysfunction. Treatment of such old injuries is extremely difficult. Correction of malunion may be performed in stage wise procedure with multiple osteotomy. The nonunion may be treated with bone grafting and plate stabilization. This literature review focused on the manifestations, treatment and residual problem of such pelvic malunions and nonunions

Aims: The aim of the following study is to establish the incidence contributing factors and impact of the missed injuries in pediatric trauma patients at adult trauma center on the prognosis and overall outcome of these children. Settings and Design: Longitudinal prospective cohort study involving 603 patients in over 06 months. Materials and Methods: The relevant data (as defined) of all included patients were recorded. These patients were then followed to document the total length of hospital stay and the injury list defined at the discharge or on the 7 ^th day of admission; whichever came first. The injury severity score (ISS) at admission was compared with final ISS (multivariate regression analysis). Results: Total 115 (19.1%) missed injuries (adult + pediatric both) were discovered, out of which 71 (61.7%) were pediatric trauma missed injuries. The pediatric trauma missed injuries were 32.2% of all pediatric trauma patients and 11.8% of all trauma patients. Main contributing factors were incomplete assessment (52.5%) and patients' arrival time. None of the missed injuries led to any mortality, morbidity or increased length of hospitalization. Final ISS did not correlate with missed injury. Conclusions: Missed injuries are a significant problem in trauma patients especially the pediatric trauma patients. Though the majority of children with trauma were treated efficiently in the anaplastic thyroid carcinoma, but there is a need for improvement in patient assessment and monitoring, that is, extended tertiary survey; with special exposure to the attending residents at casualty about pediatric trauma and its pathophysiology.

Introduction: Split hand/foot (SHSF) malformation is characterized by variable suppression of central digital rays. It is a rare congenital hand and foot anomaly usually showing autosomal dominant pattern of inheritance. We report this rare anomaly of hand and foot in a family with 13 cases to discuss its inheritance pattern and clinical features. Observation: One family of 27 members has been identified in which 13 members are affected. The disease has been running dominantly in the family and variably affecting both males and females. Morphologically there is partial or complete absence of central second to fourth digital rays with variable syndactyly and bony changes in adjacent rays. Conclusion: SHSF malformation is type of longitudinal arrest of development of central digital rays. Various theories regarding causation of disease have been proposed. The presentation of disease varies due to varying severity of involvement. Early appropriate surgical intervention is essential in selected cases to achieve a good functional limb.

Background: This study evaluated the functional result of subtalar joint fusion and effectiveness of a technique using double lag screw from posteroinferior calcaneus to talus in post traumatic subtalar arthritis following the calcaneal intra-articular fracture. Materials and Methods: In between January 2012 and August 2013, we performed 10 isolated subtalar arthrodesis by double lag screw technique from posteroinferior calcaneus to talus, across posterior facet of subtalar joint, after denuding the joint cartilage, combined with application of an autograft taken from iliac crest, by open method. The average patient age was 47 (range 35-60) year. There were 7 male and 3 female. The indication was the pain following the post-traumatic arthritis of subtalar joint in intra-articular fracture of posterior facet of calcaneus. Result: All 10 joints were fused except one who undergone delayed fusion because of infection, resulting in an overall fusion rate of above 90%. The average time to fusion was 12.3+/−3.4 weeks. The fixation screw was removed in 2/10 joint at an average of 8.8+/−0.5 month. Conclusion: Using the double lag screws of 6.5mm across the posterior facet of subtalar joint resulted in fusion of joint in above 90% of patients. The relief from pain was obtained in 100% of cases. This is a simple and reliable technique for achieving fusion of subtalar joint.

Background: The present study was done (a) to assess the role of proximal femoral nailing in the femoral neck fractures. (b) To assess the effect of early weight bearing after stabilization with proximal femoral nail. (c) To assess the incidence of complications in femoral neck fractures treated by proximal femoral nail. Materials and Methods: The present prospective study was conducted in the department of Orthopedics, of this institute from September 2007 to August 2009, which is a tertiary care center. A total of 22 patients of fracture neck of femur were included in the study. Only patients with basal and transcervical type of fractures with viable femoral head were included in the study. Patients with subcapital type of fracture were excluded from the study. All the patients were followed regularly for a period of two years. These fractures were fixed with proximal femoral nail. The final outcome measurement was done according to Harris hip scoring (HHS) method of functional assessment. Results: Sixty three percent of cases of our study presented with non union and 37% showed osseous union of which three were of basal type and five were of transcervical type. Out of the 22 patients assessed according to Harris hip score only 27.24% cases showed good result whereas 63.56% cases showed poor results. Results based on the anatomical type of fracture showed basal type of fractures with good results of union while 73.68% of the transcervical type of fractures showed poor results. Fair results were seen in 10.25% while only 15.26% of the patients showed good results in transcervical type of fractures. Good results obtained in transcervical type of fracture were the ones associated with subtrochanteric fracture femur. The purely transcervical type of fracture showed fair results in only two patients while the rest showed non union. Conclusions: After conduction of this study on results of the treatment of intracapsular fracture neck of femur by proximal femoral nailing we conclude that (A) proximal femoral nail is useful in basal type of fracture and in those types of transcervical fractures which are associated with ipsilateral subtrochanteric fracture. (B) Proximal femoral nail should be avoided in pure transcervical fracture neck of femur. (C) As it is a small study a further study for transcervical fractures is required.

Introduction: The management of open fractures poses one of the greatest challenges to orthopaedic surgeons because it not only requires management of a contaminated soft tissue injury involving skin, muscles and neurovascular structures but also treatment of underlying fracture which is also contaminated. Primary internal fixation if done can solve many problems. With the use of internal fixation the fracture remain in good position so that soft tissue injuries can be handled easily and effectively. Materials and Methods: Present study was carried out in 12 skeletally mature patients. All open fractures of upper and lower extremities presenting within 12 hours of trauma were included in study. The wound was then cleaned and injured part was then splinted so that movement of fracture fragment causing further damage could be prevented. In operation theatre wound debridement was done before internal fixation under aseptic conditions. Results: Regarding soft tissue healing all the cases of grade I showed either good (66.67%) or fair (33.33%) results. Out of 4 cases of upper limb, 2 cases (50%) of grade I united within 4 months. One case of grade III of upper limb united in 6 months. Out of 8 cases of lower limb, 3 cases (37.5%) united within 5 months and 4 cases (50%) united within 6 months. One case of grade III fracture tibia showed delayed union, bone grafting was done in this case. Conclusion: We conclude from the study that the judicious selection of cases, skillful management of the injured limb and early rehabilitation is the key for compound fractures.

Aim: To evaluate the role of dorsalis pedis artery flap in the coverage of distal lower leg defect. Materials and Methods: a retrospective review of patients who underwent soft tissue coverage over distal lower leg with dorsalis pedis artery flap was performed. A total of 16 patients were identified and included in this study. Soft tissue defects ranged in size from 3 × 7 cm to 6 × 10 cm were located over lower one-third of leg either, anteriorly (n = 8), posteriorly (n = 4), laterally (n = 2), or medially (n = 2). Associated injuries included open fractures of only tibia (n = 5), fibula (n = 2), both tibia and fibula (n = 3), or calcaneum (n = 2). Results: all flaps survived uneventfully except in three cases there was mild venous congestion in the distal part of the flap, two resolved within 4 days without further surgical intervention but one required skin grafting. Three patients developed donor site problems. Wound coverage was achieved in a mean duration of 14 days (range: 11 to 30 days). Conclusion: The dorsalis pedis artery flap is a reliable procedure to cover difficult wound such as distal lower leg.

Background: Salter-Harris type III fracture involves the medial or lateral condyle of femur. The fracture line usually exits through - the inter-condylar notch. These fractures are not common but have a high rate of complications and only very few cases have been reported. Objective: The aim of the surgery is to minimize the complications of epiphyseal injury by early fracture Fixation. Design: A 28 months prospective follow-up study. Setting: Unicentric study, operating on a total of 22 patients during a period of 5 years. Materials and Methods: From July 2005 to July 2010, 22 patients (16 males and 6 females) were recruited from Emergency and outpatient department having closed and open Salter-Harris types III fracture of the medial femoral condyle of the distal femur. All patients were operated under general or spinal anesthesia. The mean follow-up period was 28 months. Results: All children achieved union in a mean time of 10 weeks (range from 6 to 16 weeks) depending on the type of fracture pattern. Full weight bearing was possible in a mean time of 8.8 weeks. Mean duration of hospital stay was 9.8 days. The mean follow-up period was 28 months (17-48 months). Complications were recorded in 3 (13.64%) patients and included 2 Cases of insignificant limb shortening of 1 cm and 1.5 cm and 1 case of significant shortening of 2 cm. The results were excellent in 86.36 and good in 13.64% patients. Conclusion: Early anatomical reduction and fixation with screws provide satisfactory results and minimal complications.

Background: Range of motion and flexion are important outcome measures following total knee arthroplasty. Many of the activities of daily living require knee flexion in the range of 45 to 105°. Several factors affect postoperative range of motion (ROM), including pre-operative and post operative factors, among which pre-operative ROM is the most important factor. Aim: To analyze the patient's pre-operative flexion factor responsible for the outcome of range of motion in post operative Total Knee Replacement (TKR). Materials and Methods: We studied 80 patients having Total Knee Replacement (TKR) by a single surgeon in SRMC, Chennai, between 2005 and 2010 with a minimum follow up of upto 1 year. Results: The mean pre-operative flexion was 85° and post operative mean flexion was 115°. Obesity is associated with poor flexion after TKR. Knees with Rheumatoid arthritis started with a lesser flexion (80°) than those with Osteoarthritis (90°) and the change in flexion score has shown a significant difference of 40 and 20°, respectively. Average post operative range of motion for patient with pre-operative ROM <90° was 110° flexion, whereas in patients with pre-operative ROM >90° flexion, the average post operative ROM was 120° flexion. This shows, the gain in flexion is more in patients with <90° than those with >90° pre-operative flexion. Conclusion: Yes, the pre-operative flexion significantly influenced the post operative flexion and it is a good parameter for predicting the post operative outcome.

Fibrodysplasia ossificans progressiva (FOP) is an inherited disease in which progressive ossification of striated muscles leads to severe disability and there are associated characteristic congenital skeletal malformations. FOP used to be referred to as Stoneman's Syndrome. There are no ethnic, racial, or religious patterns. Also, there are no other known examples in medicine of one normal organ system turning into another. The case we report herein is a 23-year-old male patient with the clinical and radiologic characteristics of FOP. The importance of this case was that in spite of beginning early with the typical presentation of FOP for a long time and the fact that the patient consulted with tertiary care specialists, the diagnosis had been missed. This indicates that the general physicians, radiologists and other specialists' awareness and knowledge of FOP are low.

Orthopedic injuries can be misdiagnosed if physical examination is not feasible. The literature is abundant with different pattern of hand injuries. Carpometacarpal fracture dislocations constitute one of the rarest patterns of injuries of the hand. These injuries can often be missed because of the gross swelling and edema of the hand. The diagnosis of this unusual form of injury requires a high index of suspicion, vigilant examination and high-quality radiography. Apart from the routine antero-posterior and oblique radiographs, a lateral radiograph of the hand is essential for making an accurate diagnosis in suspected cases of carpometacarpal dislocations. Although many such case reports are described in the literature, we are reporting a rare case of dislocation involving all the five carpometacarpal joints which has never been reported in the literature till date.

Osteochondral fractures of patella are commonly associated with acute patellar dislocations and are frequently missed or misinterpreted in initial radiograph. Usually such fractures need surgical treatment. This article presents a case of a 13-year-old girl who sustained a twisting knee injury while doing exercise (yoga) and sustained a small osteochondral fracture of the central part of the patella, displaced inferolaterally, lying close to lateral femoral condyle. The initial radiograph was misinterpreted as chip fracture of lateral femoral condyle. Diagnosis of osteochondral fracture of patella was confirmed only during the surgery. This case needs to be reported as the osteochondral fracture of patella was not only missed but also misinterpreted.

In this case report, we describe a 1 and ½-year-old girl who presented with the full clinical and radiographic features of congenital dislocation of knee (CDK). The knee deformity in our patient was compatible with a complete grade 3 anterior dislocation of the tibia on the femur. The classic surgical approach to true CDK has been a V-Y quadricepsplasty combined with medial and lateral arthrotomies of the knee, which allow mobilization of the ligamentous structures that are anteriorly displaced is performed. CDK is a rare congenital disorder. The results of treatment are favorable if started before age 3 months, or sometimes before age 1 year, but there is no effective treatment for older, neglected cases; therefore, we believe this case report demonstrates a novel surgical approach.

Costal exostosis occurs either sporadically or as a manifestation of hereditary multiple osteochondromas (HMOs), a disorder that is inherited in an autosomal dominant manner. Costal exostosis may cause chest pain and, on rare occasions, result in intra-thoracic complications. We report a case of a 15-year-old boy with exostosis in the right anterior fifth rib, who presented with protruded painful skin lesions that had ulcerated over the last one month. He previously received a diagnosis of multiple exostoses. There was no evidence of a malignant change on histopathological analysis. Enbloc excision was done and there has been no recurrence to date. To the best of our knowledge, the present case is the only report of costal exostosis presenting as an extrathoracic chest wall ulcerating mass. The present report illustrates this rare clinical scenario and reviews the relevant literature.