Background: Individuals with cervicogenic headache (CGH) go through problems in activity of daily living, limitedsocial involvement, and emotional distress. CGH patients score the “worse” in the physical function category when compared to migraine patients. Aims: The aim was to study the effect of McKenzie complemented with conventional treatment on cervical rotation and headache in patients with CGH. Settings and Design: This was an experimental study design and systematic sampling method was used to collect data. The study setting was an Smt. Kashibai Navale General Hospital, Physiotherapy Outpatient Department, Pune, India. Methodology: Thirty subjects were selected with CGH which fulfills the criteria given by the CGH International Study Group. They were divided into two groups of 15 each. One group was given conventional treatment and the other was given conventional combined with McKenzie Method. Flexion–rotation test (FRT), Visual Analog Scale, Neck Disability Index (NDI), and Headache Disability Index were used as outcome measures. Statistical Analysis Used: T-test was applied to see the difference in pre and post values for all variables in both the groups. All data were analyzed using the Statistical Package for the Social Sciences 21 with level of significance for all statistical tests set at P ≤ 0.05. Results: The results showed that FRT has a statistically significant difference in both the groups. Headache disability showed a significant improvement in both the groups with statistically significant difference P < 0.05, the improvement being greater in the experimental group than in the conventional group. Conclusion: This study showed that when the McKenzie method is complemented with the conventional treatment, it shows better improvement in function of the cervical dysfunctions that cause CGH and reduce the intensity of headache.

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Acetabular fractures are result of mostly high velocity injury with an incidence of 3/100,000/year. However in elderly patent low energy trauma also result in acetabulum fracture due to osteoporosis. Most of acetabular fracture commonly combined with quadrilateral plate fractures. Till date there is no standard classification system for quadrilateral plate fracture of acetabulum is published which can be utilized for accurately studying the fracture pattern and planning for the surgical approach with management. Initially acetabulum fracture was managed conservatively with traction for at least 6 weeks which results in aggravation of secondary symptoms such as pressure sore, DVT, post traumatic arthritis, loss of muscle strength and endurance. Aim of acetabulum fracture fixation are to allow early mobilization, restoring joint congruity, pain relive and reducing the risk of post traumatic arthritis. An internet search of MEDLINE and PMC using the search term 'acetabular fracture', 'quadrilateral plate fracture' and central hip dislocation in English language was performed on 1^st march 2021. Papers specific with quadrilateral plate fracture were only included in the study and we found variety of technique available for displaced quadrilateral plate fractures, such as cerclage wire-plate composite, pelvic brim long screws, various combinations of spring plates (T-shaped plate, L-shaped plate, infrapectineal plate, H-plate, and multidirectional titanium fixator. In this review article we studied different treatment modalities and techniques used over several decades for management of quadrilateral fracture with their outcome.

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Introduction: Clavicle fracture is one of the most common bony injuries. The most commonly used system of classification of clavicular fractures is that of Allman. It is divided into three groups: Group I – Middle third clavicle fractures (80% of all clavicle fractures), Group II – Lateral third clavicle fractures (15% of all clavicle fractures), and Group III – Medial third clavicle fractures (5% of all clavicle fractures). The prevalence of nonunion or malunion in dislocated midshaft clavicular fractures after conservative treatment is higher than previously presumed, and fixation methods have evolved. Surgery is accepted more and more as primary treatment for dislocated midshaft clavicular fractures, mainly because the results of nonoperative treatment are interpreted as inferior to operative treatment both clinically and functionally. Primary internal fixation of displaced comminuted midshaft clavicular fractures leads to predictable and early return to function. The purpose of this study was to assess the functional outcome of midshaft clavicular fractures treated with precontoured locking compression plate. Methodology: Patients with displaced fractures of clavicle (midshaft) admitted to SRG Hospital, Jhalawar, Rajasthan, from August 2017 to August 2018 were taken up for the study after taking the required consent. Thirty-four patients of displaced fractures of clavicle, satisfying inclusion criteria, were admitted in the study period and were taken up for the study. The results were analyzed by appropriate statistical methods. Results: In our study, 34 cases of displaced middle third clavicular fractures were treated with plate osteosynthesis using anatomically precontoured clavicle plate. Of 34 cases, 16 cases united in 8 weeks, while at the end of 12 weeks, all cases united except one. Of the 34 patients, 24 patients returned day-to-day activities after 2–3 weeks. Of the 34 cases, 30 patients returned to work within 3 months. Of 34 cases, 33 had excellent score and one had fair score. Conclusion: In our study, open reduction and rigid internal fixation of displaced midshaft clavicular fracture has resulted in good fracture union rate and excellent functional outcome.

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Introduction: This clinical study was conducted to assess the long-term follow-up results of using free fibular graft to augment fracture fixation with cannulated cancellous screw (CCS) or dynamic hip screw (DHS) as a treatment option for femoral neck fractures in young adults who presented after 24 h of injury but within 3 weeks. Methodology: A prospective study was conducted on the patients of femoral neck fractures managed with multiple cancellous screws or DHS with fibular graft. Patients aged between 15 and 50 years and having Garden Type III or IV fracture with duration of injury >3 weeks were included in the study. They were assessed for radiological outcome and functional outcome using modified Harris hip score. Results: Twenty-two cases were operated between day 2 and day 21 after sustaining injury. The mean time of union was 3.4 months. Nineteen fractures united uneventfully. Two fractures went in for nonunion and one developed avascular necrosis (AVN) of the femoral head. According to Harris hip score, 14 patients scored “excellent,” three patients scored “good,” three scored “fair,” and “poor” score was recorded in two patients. Conclusions: Delay in surgery as a contributing factor for the development of complications in fracture neck of femur cannot be ruled out with the present literature available. Using a free fibular graft as an adjunct to implant construct helps in reducing the rates of nonunion and AVN. However, this cannot be a substitute for proper surgical precision that is required in the treatment of fracture neck of femur. Further prospective studies involving large sample size are required.

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Background: Middle third clavicle fractures consist of up to 85% of clavicle fractures. Intramedullary (IM) fixation devices can be accomplished with less soft tissue dissection, more cosmetic incisions, and they may permit callus formation due to the relative stability with a different complication profile from plate fixation. Patients and Methods: Between July 2013 and November 2015, 25 patients presented by fracture midshaft clavicle without comminution were treated at our institution by minimal invasive retrograde IM k-wires. Results: The fractures union ranged from 12 to 16 weeks both clinically and radiologically. The results were excellent in 21 patients (84%) and good in 3 patients (12%). One (4%) had a poor result. All patients returned to their preinjury activities and jobs or sports activities. Conclusions: Surgical treatment of midshaft clavicle fracture without comminution through minimal invasive retrograde IM k-wire fixation improved the results and compared favorably with other techniques.

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Introduction: In this prospective case series, we are reporting a mean 12-month follow up of the utilization of dual plating technique for multi fragmentary articular distal femur fractures. Our technique consists of a lateral distal femoral locked plate and a low profile locked medial plate through a modified anterior (Swashbuckler) approach for the fixation of C2, C3 fractures. Materials and Methods: Fifteen patients (9 males and 6 females) presented with supracondylar femoral fractures type C2/C3, according to Müller long bone classification and its revision, OA/orthopedic trauma association classification. These fractures were treated using dual plating through the swashbuckler approach. They were followed up for clinical and radiological outcomes. Secondary outcomes included postoperative complications. Results: The mean time of radiological union in the studied population was 18 weeks with a range of 14–24 weeks. We did not observe any postoperative varus angulation. 12 out of 14 patients had good to excellent functional outcomes. Fair outcome was reported in only two patients. Conclusion: The technique of Dual plating fixation using modified anterior approach (swashbuckler) for type C2, C3 distal femoral fractures is an efficient method of management. It has several advantages such as precise exposure, easy manipulation, anatomical reduction, and stable fixation. However, surgical indications and principles should be strictly followed. The surgical technique must be perfect, and the biomechanical qualities of the implants must be understood to prevent the development of major complications.

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Introduction: Hip arthroscopy is commonly performed for patients with from femoroacetabular impingement (FAI); however, this procedure is technically difficult due to the anatomy of the hip joint and surrounding tissue. The purpose of this study was to evaluate the complication rates of hip arthroscopy procedures for FAI performed using the MICRORAPTOR Knotless Suture Anchor system. Materials and Methods: Retrospective review of consecutive patients undergoing hip arthroscopy for FAI was conducted. All patients underwent labral repair or reconstruction using the MICRORAPTOR Knotless suture anchor. The primary endpoint was any intraoperative or postoperative complication. Descriptive and inferential statistics were performed to assess the patient characteristics and outcomes. Results: Forty-three hip arthroscopies in 42 patients were reviewed at an average of 9 months (standard deviation 4 months) postoperatively; 36 (85.7%) were reviewed at over 6 months postoperatively. At presentation, 90.7% of patients demonstrated a positive anterior impingement sign, 86.0% demonstrated a positive posterior impingement sign, and the median pain numeric rating scale (NRS) was 7.0 ± 4.0 on a scale of 0–10. Four surgeries (9.3%) were revision hip arthroscopies, whereas the remaining 39 (90.7%) were primary labral repairs or reconstructions. Overall, the complications occurred in two (4.6%) cases. The median postoperative pain NRS was reduced from 7.0 ± 4.0 preoperatively to 2.0 ± 6.0 postoperatively (P = 0.003). Conclusion: The MICRORAPTOR Knotless suture anchor appears to be safe for use in patients undergoing hip arthroscopy for FAI.

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Context: Supracondylar fractures of the humerus (SCFH) are the most common type of pediatric fracture and related to significant morbidity with the complication of nerve injury and loss of reduction. Closed reduction and percutaneous Kirchner wires pinning either by lateral pin fixation or cross pin fixation for the displaced fractures are the mainstay treatment. Aims: This study has purpose to compare the construct stability, functional, and radiological results between the two methods of fracture fixation. Subjects and Methods: A total of 61 children with Gartland III SCFH were placed randomly into two groups, Group A (n = 30) managed by lateral pinning technique and Group B (n = 31) were managed by cross pinning techniques. Both groups were quite comparable with regard to age, gender, duration of injury, and degree of displacement of the fracture. The results were analyzed in terms of clinical and radiological outcome, Flynn functional scoring system, and complications. Fisher's exact test and unpaired t-tests were used. The results were expressed as mean, and the P < 0.05 was considered statistically significant using the SPSS software (version 22). Results: Statistically, there was no significant difference in clinical or radiological results between the two groups at 6 months after operation (P > 0.05). There was no significant loss of reduction found in either of the groups. There was one (6.6%) case of the lateral pinning group that had a minimal loss of reduction and two (6.4%) cases of the iatrogenic ulnar nerve neuropraxia in the cross pinning group. Neuropraxia recovered fully. Superficial pin tract infection was seen in two (6.67%) cases of the lateral pinning group. Conclusions: Although it appears that cross spinning is a more stable construct, the lateral pin fixation provides the same result without risk of iatrogenic nerve injury with comparable results.

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Background: There are multiple modalities to treat clavicle fracture in patients. Both conservative and surgical management are possible and surgen must choose the most appropriate management modality according to biological age, functional demands and type of lesion. Here, we are doing a study of treating clavicle fracture by various modalities and comparing its functional outcome. Aims: The aim of the study is to show the results of management of displaced mid shaft of clavicle by different modalities in terms of: (a) time of union of fracture, (b) functional outcome, and (c) complications. Settings and Design: This was a prospective study with total sample size of 36 consecutively reporting participants in outpatient department as well as in emergency department. Materials and Methods: Study participant was systematically and randomly allocated into three groups of 12 each, Group 1 (TENS), Group 2 (Plating), and Group 3 (Conservative). Patients were randomized into operative (TENS), operative (Plating), and Conservative in a ratio 1:1:1. Statistical Analysis Used: The comparison of normally distributed continuous variables between the groups was performed using Student's t-test. Nominal categorical data between the groups were compared using Chi-square test. For all statistical tests, P < 0.05 was taken to indicate a significant difference. Results: Comparison of normally distributed continuous variables between the groups was performed using Student's t-test. Groups were compared using Chi-square test. For all statistical tests, P < 0.05 was taken to indicate a significant difference. Displaced mid shaft fracture managed by operative manoeuvre either by TENS or Plating shows excellent result in 50% of cases whereas in non operative group excellent result seen only in 25% of cases. Conclusion: Excellent functional outcome is seen in majority of patients treated operatively and those patients are functionally more satisfied when it comes to complications rate.

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Background: In a Guatemalan public hospital, 3710 fractures were diagnosed in 2016, of which 723 corresponded to the tibia. Of these tibial fractures, approximately 15% were exposed. Skin coverage in exposed fractures has always been a challenge for the attending physician. In the case of the lower limb, there is the option of making a sural flap. Objectives: To determine the effectiveness of the sural flaps when utilizing this technique as a treatment for exposed fractures in the lower limb in adult patients. Methods: A prospective observational descriptive study, the evaluated patients and patient files as primary and secondary sources, respectively, and control with observational variables. The sample consisted of 24 patients who got 3 follow-up appointments at 5 days, 2 weeks, and a year. Results: The results manifested effectiveness of 95.8%. The area most affected was the lateral malleolus. Additionally, comorbidities, schooling, and gender showed no influence on the effectiveness of the flap. Conclusion: The effectiveness of the sural flap technique in exposed fractures was 95.8%. Recommendations: Physicians ought to consider using the sural flap as the treatment of choice for skin coverage defects localized in the distal and middle third regardless of the leg and cause of the defect.

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Background: Total hip arthroplasty (THA) surgery for complex primary hips are challenging not only for its technical difficulties but also for increased risk of complications, thus requiring detailed planning to ensure successful operation. This paper aims to present the pattern of complex primary hips presenting for total hip replacement and the challenges and complications. Materials and Methods: This was a retrospective study in which records of patients who had THA from 2015 to 2019 were analyzed for the demography, pattern of complex primary hip, and the surgical challenges and complications. Outcome of follow-up results was analyzed by clinical (Harris Hip Score) and radiological evaluation at 6 weeks, 3 months, and 2 years. Results: One hundred THAs were done during the study period, out of which 42 THAs in 29 patients (16 unilateral and 13 bilateral THAs) were of complex primary hip. Majority of them were of ankylosing spondylitis (38.1%) followed by posttraumatic avascular necrosis of femoral head (23.8%). The main difficulties were related to soft-tissue contracture, completely fused hip, and removal of hardware in old operated hip fracture. Postoperatively, majority of the patients had anemia (7 patients, 16.6%), followed by postoperative dislocation in 2 patients (4.7%). Outcome of follow-up results was analyzed by clinical (Harris Hip Score) and radiological evaluation at 6 weeks, 3 months, and 2 years, and the overall outcome was satisfactory in 95% of the patients. Conclusion: Complex THA is challenging and needs to assess properly and to be done meticulously. The surgical exposure and subsequent placement of components can be significant challenges in complex THA which can be tackled by using proper instrumentation and modular implants. With proper surgical technique, proper instrumentation, and proper implantation, one can expect good-to-excellent results even in complex THA.

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Background: Shoulder pain is a common musculoskeletal complaint in the general population, mostly in the elderly. Among them, the rotator cuff problems are found to be most common causes. The treatment of rotator cuff pathology has progressed from open repair, first described by Codman in 1911 to arthroscopy assisted “mini open” techniques, to all arthroscopic repair techniques, first reported by Johnson who used metal staples while E.M. Wolf pioneered the first completely arthroscopic repair using suture anchors in 1990. The purpose of this study is to evaluate the functional outcome following all arthroscopic repairs of full-thickness rotator cuff tears with suture anchors. Materials and Methods: A prospective study was done for 24 shoulders in 24 patients treated for full-thickness rotator cuff tear by all-arthroscopic repair between February 2014 and September 2015 and followed until May 2018. The results were evaluated using the University of California at Los Angeles (UCLA) shoulder scoring system. Patients younger than 18 and over 80 and also those with bony lesion were excluded from the study as were those which might have confounded the outcome were excluded. Results: Among the 24 patients, the UCLA clinical scores were excellent in 12 patients, good in 9 patients, fair in 2 patients, and poor in 1 patient. The average UCLA score was 31.84. Conclusion: All-arthroscopic repair is an excellent treatment option for full-thickness rotator cuff tears, although with a steep learning curve.

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Background: Open fractures due to ballistic injuries (bullets and/or splinters due to grenade blasts) have increased in the last decade. Outcome of management of such injuries depends on various factors. Purpose of this study was to frame a management protocol for primary internal fixation of such fractures without significant complications. Materials and Methods: 105 patients (117 fractures) of ballistic injuries evacuated to the trauma care center of this hospital from July 2018 to July 2019 were enrolled. After initial evaluation and optimal resuscitation, patients were considered for primary internal fixation of the fractures followed by multidepartmental rehabilitation involving a physiotherapist, a psychiatrist, and a psychotherapist. Follow-up was done at 3 months, 6 months, and 1 year after the surgery. Results: 74 fractures were due to gunshot-related injuries and 43 due to splinters from grenade blasts. Average interval between time of injury and surgery was 5.68 h. Seventeen patients required repeat debridement after initial surgery, and the subsequent wound healing was uneventful. All fractures united except 15 patients who underwent bone grafting for aseptic nonunion (6–9 months after index surgery). Only six patients were followed telephonically, else there was no loss to follow-up. The study did not encounter any mortality or infection. Conclusions: Open fractures occurring due to ballistic injuries pose a unique challenge in management. Fast-track evaluation and urgent management of the fractures by careful wound debridement and primary internal fixation have shown excellent results, with absolute zero infection rate in 1-year follow-up.

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Introduction: Lumbar disc herniation is one of the common ailments in young adults. The common levels of L4-L5 and L5-S1 have been chosen for ours. The Evaluation was done based on the level of disc herniation and also with different types of disc herniation such as contained, extruded, or sequestrated disc herniations. The outcomes were evaluated using the Japanese Orthopedic Association (JOA) scoring system. Methods: Thirty-three patients with a single-level disc herniation at L4-L5 or L5-S1 who did not show significant improvement of radiculopathy even after a conservative trial were included in the study. All patients were consented and subjected to surgery-unilateral fenestration and fragment discectomy. Patients were evaluated based on their JOA Scoring which was done preoperatively and postoperatively on day 10 and at 1 month, 3 months, 6 months, and 1 year. The functional outcome in percentage was calculated using the “recovery rate” by the Hirabayashi index. Results: Following fenestration discectomy, the functional outcome of the patient was found to be good. O the 33 patients operated, males n = 20 and females n = 13. According to Hirabayashi's recovery rate, 48% (n = 16) patients were found to have an excellent result with recovery rate of >80%. Good results were seen in 43% (n = 14) with recovery rates ranging between 70% and 80%. About 3% (n = 1) had a fair result with recovery rate of 56% and 6% (n = 2) had poor results with recovery rate < 50% following surgery. Applying the paired t-test, P was calculated and was 0.0001 which is statistically significant. Complications included incidental durotomy, pseudomeningocele, recurrent disc herniation, and spondylodiscitis. Conclusion: Patients who underwent fenestration discectomy for single-level lumbar disc herniation at L4/5 or L5/S1 showed significant functional improvement as per JOA scoring and Hirabyashi's recovery rate. The results were comparable with newer techniques such as micro and endoscopic discectomy.

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Aberrations in the deep wrist flexors are frequently documented. These varied muscles might account for anterior interosseous nerve compression syndrome. The present study describes a case with three variations in the deep flexor of wrist comprising two separate small muscle bellies with their tendons and a higher level cleavage of the lateral tendon of flexor digitorum profundus muscle. Such a triple anomaly is a rare occurrence that has to be borne in mind by hand surgeons in case of nerve entrapment syndromes.

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Proximal fibular tumors are treated by en bloc excision and lateral collateral ligament (LCL) repair. Intraoperative injury to the popliteal artery or its trifurcation, common peroneal nerve, and LCL can occur. Three cases of giant cell tumor and one case of exostosis of proximal fibula were analyzed. Apart from routine tests, preoperative computed tomography angiography (CTA) was done in two cases. Vascular injury was seen in two cases where CTA was not done, while in others, it was safe. Foot drop was seen in one case due to peroneal nerve resection. None of the patients developed varus instability even without LCL repair. Authors suggest preoperative CTA in all tumors of proximal fibula for preoperative planning, counseling of patients, vascular consultation, and to prevent complications.

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Tuberculosis (TB) of the musculoskeletal system is not an uncommon clinical condition. Multifocal osseous involvement is often rare and difficult to recognize. Because of the diverse and atypical clinical manifestations, it is easily misdiagnosed in many situations. The present study reports a case of multifocal skeletal TB masquerading as septic arthritis of the interphalangeal joint of the thumb. Because of the high prevalence of TB in developing countries, chronic osteoarticular infective lesions are to be considered as TB unless proved otherwise. The importance of clinical suspicion, systematic investigation, and the role of a biopsy in the diagnosis of skeletal TB is emphasized in this study.

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Tubercular involvement of the proximal fibula is very rare. We present a case of tuberculosis of proximal fibula in an immunocompetent young female. She was diagnosed clinically as a case of cellulitis. Radiological investigations including magnetic resonance imaging revealed a destructive lesion in her right proximal fibula. Finally, by fine-needle aspiration cytology and GeneXpert polymerase chain reaction, a diagnosis of tuberculous osteomyelitis of proximal fibula was established. She was managed nonoperatively with multidrug antitubercular chemotherapy. A high index of suspicion is required to make a diagnosis of musculoskeletal tuberculosis of such rare site in early stages.

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