‘Surgical management ofdiaphyseal fracture both bone ...



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

ANNEXURE - II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1. Name of the candidate : and address |DR. M.K.NIZAMODDIN P.G. IN ORTHOPAEDICS ROOM NO. |

| |10, PG & INTERNS HOSTEL FOR MEN, MYSORE MEDICAL COLLEGE, MYSORE-570021 |

|2. Name of the institution : |MYSORE MEDICAL COLLEGE & RESEARCH INSTITUTE MYSORE. |

|3. Course of study and : Subject |POST GRADUATE M.S ORTHOPAEDIC |

|4. Date of admission to course: |30th MAY 2011 |

|5. Title of topic : |“ FRACTURE BOTH BONE FOREARM IN ADULTS USING PLATES & SCREWS” |

|6. Brief resume of the intended work : |

|6.1 Need for the study: |

|Forearm bone fractures are commonly encountered in today’s industrial era. Various treatment modalities were introduced from time to time |

|and each of them had some edge over the previous one .Fractures of the forearm bones may result in severe loss of function unless |

|adequately treated. Severe loss of function may result even though adequate healing of the fractures occurs. Diaphyseal fractures of the |

|radius and ulna present specific problems in addition to the problems common to all fractures of the shafts of long bones. In addition to |

|regaining length, apposition, and axial alignment, achieving normal rotational alignment is necessary if a good range of pronation and |

|supination is to be restored. Malunion and nonunion occur more frequently because of the difficulty in reducing and maintaining the |

|reduction of two parallel bones in the presence of the pronating and supinating muscles that have angulating and rotational influences. |

|Because of these factors, open reduction and internal fixation for displaced diaphyseal fractures in the adult are generally accepted as |

|the best method of treatment, even though closed reduction may be achieved. The muscle mass in the proximal forearm makes maintenance of |

|closed reduction difficult. Fractures of the distal radius tend to angulate toward the ulna by the action of the pronator quadratus and |

|the pull of the long forearm muscles . Although union may be achieved by closed methods, if angular and rotary malalignments are not |

|completely corrected, some loss of function occurs and may make the overall result unsatisfactory .So we decided to study & evaluate the |

|results of internal fixation with plate and screws to confirm its present day relevance. |

|6.2 REVIEW OF LITERATURE: In the 5th century in |

|the Nile Valley G.ELLIOT SMITH and his co-workers found cases of forearm and femur treated with splints. Till the invention of Radiography|

|(Erichsen, 1884) use of two wooden splints to preserve the interosseous space was in practice. |

|I n the year 1852 MATHYSEN introduced plaster of Paris but was not in treatment of fractures of forearm bones. Plaster of Paris was |

|popularized by Bohler (1929). Perhaps the most important remarkable achievement of 20th century in Orthopaedics is development of internal|

|fixation of fractures of long bones. |

|Carrel (1938) studied the causes of poor results and pointed out to the reasons as inadequate immobilization, imperfect reduction and |

|early removal of splints. He claimed that proper traction gave satisfactory results. |

|Cowe (1956) studied 54 cases of fracture forearm bones and concluded that open reduction and plating give excellent results except when |

|severe injury or comminuted fracture or both occurred. In the same year Egger stressed the importance of: |

|1.Control of rotating stress and |

|2.Restoration of bony continuity. He |

|achieved this by medullary fixation in radius and narrow slotted plate in ulna with bone grafts wherever necessary. |

|1.Anderson LD et al, at the Campbell Clinic and City of Memphis Hospital from 1960 to 1970,also analyzed that out of 244 patients (216 |

|with closed and twenty-eight with open fractures) had 330 acute diaphyseal fractures of the radius and ulna which were treated with ASIF |

|compression plates and followed for from four months to nine years. One hundred and twelve patients had fractures of both bones of the |

|forearm. The over-all rate of union for the radius was 97.9 per cent and for the ulna, 96.3 per cent. ASIF compression plates, therefore, |

|provided a successful method for obtaining union and restoring optimum function after acute diaphyseal fractures of the forearm1. |

|2. Hadden WA, Reschauer R, Seggl W. In 1983 in a series of 111 forearm fractures in 108 individuals involving 177 individual bones, and |

|treated by AO plating was reported. There were 18 different surgeons. Open fractures occurred in 24 % of limbs. Reviews at a mean of 3 |

|years after the accident showed 97 % of bones to be solidly united and satisfactory function to be achieved in 80 per cent of limbs. Deep |

|infection occurred 6 times, and non-union in 7 bones. Cross-union developed in 6 patients, all of whom had sustained head injuries. Seven |

|patients sustained operative nerve injuries. It is felt that the implant of choice at the moment is the small fragment Dynamic Compression|

|Plate (DCP). |

|3. In 1989 Feb.. Concurrent data were collected by. Chapman, M. W.; Gordon, J. E.; and Zissimos A.G for 104 fractures of the shafts of the|

|radius and ulna in 102 adult patients to determine the relationship of subjective, objective, radiographic and economic outcome parameters|

|to the method of treatment, type of fracture (open or closed), degree of comminution, and the presence of other injuries. Patients treated|

|by open reduction and internal fixation (ORIF) had less pain, lost less forearm rotation, and returned to the same work following injury |

|more frequently than those treated by closed reduction and casting (CR) or pins-in-plaster (PIP). The greatest advantages of ORIF over |

|other treatment methods were improved skeletal alignment and forearm rotation, the factors most often associated with return to the same |

|work following injury2 |

| |

|4.IN 1959 SMITH JE stressed the value of delayed operation in the prevention of non-union in the treatment of fractures of the shafts of|

|the radius and ulna in adults with internal fixation6 |

|5. In 1972 Dodge. s., and cady, G W.: treated fractures of the radius and ulna with compression plates in a retrospective study & |

|analyzed 119 compression plates used in 78 patients with forearm fractures and concluded that the basic objectives of internal fixation |

|namely 1) Anatomical reduction, 2)preservation of vascularity,3)mechanical stable fixation and 4) rapid mobilization of joints in |

|proximity was best achieved by compression plates7. |

|6. In 1980 G.GRACE et al of medical corpse United States Army have published a paper on treatment of both bone forearm fractures by rigid|

|fixation with early motion. They discussed 64 adults patients with 92 acute diaphyseal fractures of the forearm treated with plate and |

|screw fixation, they analyzed the early post operative motion. Patients with open fractures and those with both bone forearm fractures |

|lost significantly more rotation of forearm irrespective of treatment compared with other groups of patients in the series. A programme of|

|early active motion without immobilization increased range of motion of forearm fractures, however this was not in case of single bone( |

|radius or ulna)fractures5 |

| |

|7.1992 Schemitsch EH, Richards RR studied 55 adults who had a fracture of both bones of the forearm managed with plating and were followed|

|for a mean of 6years (range, one year to sixteen years and two months) with functional and radiographic assessment. Malunion was |

|quantified by measurement of the amount and location of the maximum radial bow in relation to the contra lateral, normal forearm. 54 of |

|the radial and the ulna fractures united. 84%of the patients had an excellent, good, or acceptable functional result, according to the |

|criteria of Grace and Eversmann. Bone-grafting did not affect the rate of union. Restoration of the normal radial bow was related to the |

|functional outcome. A good functional result (more than 80 per cent of normal rotation of the forearm) was associated with restoration of |

|the normal amount and location of the radial bow. Similarly, the recovery of grip strength was associated with restoration of the location|

|of the radial bow toward normal8. |

| |

|8.FLEUNG,SP CHOW (2006), studied 45 forearm fractures treated by open reduction and internal fixation with 3.5mm stainless steel LCPs. |

|Radiographic assessment was performed at 3,6,12 and 18 months. Two patients had delayed union but none had nonunion.33% of the fractures |

|were reduced anatomically.56% of the fractures healed with no or minimal callus formation and 44% with moderate callus formation. Mean |

|healing time was 16 months. The LCP is an effective bridging device used for treating comminuted fractures 10 |

|9.SHARMA,H.DANG (2006), conducted a prospective study in 30 adult patients of forearm fractures. Follow up was done at 3,6,and 12 months. |

|Clinical assessment was done for functional outcome. All the fractures united with mean union time of 12.6 weeks. LCP is a stronger |

|construct and by preventing primary and secondary loss of reduction it does not alter the natural course of healing of fracture,which is |

|not possible with the use of DCP and LCDCP11 |

|10.Droll KP, Perna P, Potter J, Harniman E, Schemitsch EH, McKee MD. IN Dec 2007 showed that Internal fixation of diaphyseal forearm |

|fractures has been associated with high union rates and satisfactory forearm motion. The purpose of this study was to investigate |

|patient-based functional outcomes and to objectively measure strength following plate fixation of fractures of both bones of the forearm9.|

|11. Fernando baldy dos Reis (2008), conducted a prospective study in 31 patients presenting with nonunions of forearm diaphysis. Surgical |

|revision was performed by restoring anatomic forearm length by autologous bone grafting of the resected nonunion from the iliac crest and |

|compression plating. Radiographic showed bone union in 30/31 patients with mean time of 3.5 months12. |

|6.3. OBJECTIVES OF THE STUDY: 1) Preoperative |

|assessment evaluating the age group affected type of fracture, the mechanism of injury and associated neurovascular injuries in both bone |

|fractures of forearm in adults. |

|2) To evaluate the results of treatment of displaced both bone fractures of forearm treated by internal fixation with “plates &screws” |

|3) To note intraoperative and postoperative complication. |

|4) To assess the efficacy and advantage of this treatment. |

|7. MATERIALS AND METHODS : |

|7.1 Source of data : |

|The proposed study is a hospital based prospective study centered in K.R.Hospital attached to the Mysore Medical College, Mysore during |

|the term between Jan2012 to October 2013 |

|7.2 Method of collection of data (including sampling procedures if any) : |

|Inclusion Criteria |

| |

|Age group adults (>18years) |

|Male and female patients. |

|Radiologically diagnosed both bone forearm fractures(Diaphyseal fractures both bone forearm) |

| |

|Consent to participate in the study |

|Exclusion Criteria |

|1. Open fractures |

|2. Both bone fracture with compartment syndrome needing fasciotomy |

| |

|3.Both bone fracture needing vascular repair |

|4. Both bone fracture associated with distal radius/ulna, |

|5. Refusal to provide informed consent |

|Sampling Procedure:- |

|History |

|Clinical examination |

|Radiological examination |

|7.4 Investigations: |

|Blood : Hb, BT, CT, TC, DC, ESR |

|Blood : RBS, BU, & SC |

|ECG : In all leads |

|HIV, HBSAg |

| |

|Plain radiograph AP and lateral view of affected forearm with elbow joint. |

|Patients subjected to surgery will be followed up at regular intervals with clinical and radiological data. Assessment will be done based|

|on a proforma containing all necessary information regarding. |

| |

|Personal details age, sex, address and occupation |

|Type of fracture |

|Surgical procedure carried out |

|Duration of hospital stay |

|Initiation of mobilization |

|Physiotherapy |

|Development of surgical complications |

|Postoperative Evaluation |

|The results will be evaluated with the help of criteria suggested by F.M.Marek et,al 13. considering two factors, cosmetic and functional|

|factor. |

| |

| |

| |

| |

|CRITERIA: |

| |

|RESULTS |

|ANATOMICAL |

|FUNCTIONAL |

| |

|1.EXCELLENT |

|Anatomical alignment of fragments |

|90%of rotation of forearm 90% motion of shoulder, elbow, wrist and fingers of hand. |

| |

|2.GOOD |

|Slight step formation & angulation not > 10deg no rotational deformity |

|70-90% of normal rotation of forearm and similar motion of other joints of upper extremity. |

| |

|3.POOR |

|Narrowing of interosseous space |

|Less than 70% of motion of forearm or other joints of upper extremity. |

| |

| |

| |

|7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please |

|describe briefly. |

|NO |

| |

|7.4 Has Ethical clearance been obtained from your institution? |

|YES , Copy enclosed |

| |

|. |

|8. LIST OF REFERENCES : |

|1. Anderson LD,Sisk D, Tooms RE, Park WI III. “Compression plate fixation in acute diaphyseal fractures of radius and ulna”. J Bone Joint |

|Surg AM 1975; 57:287-97.. |

|2. CHAPMAN MW, Gordon JE , Zissimos AG,. “Compression plate fixation of acute fractures of the diaphyses of the radius and ulna”. J Bone |

|Joint Surg Am 1989:71:159-69. |

|3. Ross ER, Gourevitch D, Hasting GW. Retrospective analysis of plate fixation of diaphyseal fractures of forearm bones". Injury1989 jul |

|20(4):211-4. |

|4. Andrew H.Crenshaw, Jr. and Edward A. Fractures of forearm treated with plates and screws. CAMPBELL’S Operative Orthopaedics. Vol 3. 11 |

|edition pg:3428-31. |

| |

|5.Grace TG, Eversmann WW Jr.Forearm fractures: treatment by rigid fixation with early motion. J Bone Joint Surg Am. 1980 Apr;62(3):433-8. |

| |

|6. SMITH JE. Internal fixation in the treatment of fractures of the shafts of the radius and ulna in adults; the value of delayed |

|operation in the prevention of non-union. J Bone Joint Surg Br.1959 Feb;41-B(1):122–131. |

|7. Dodge HS, Cady GW. Treatment of fractures of the radius and ulna with compression plates. J Bone Joint Surg Am. 1972 Sep;54(6):1167-76.|

| |

|8. Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm|

|in adults. J Bone Joint Surg Am. 1992 Aug;74(7):1068–1078.  |

|9. Droll KP, Perna P, Potter J, Harniman E, Schemitsch EH, McKee MD. J Bone Joint Surg Am. 2007 Dec;89(12):2619-24 |

|10. Leung F, Chow SP:" Locking compression plate in the treatment of forearm fractures’ a prospective study. J Orthop Surg(Hong Kong). |

|2006 Dec;14(3):291-4. |

|11. S. Sharma, H. Dang, V. Sharma & S. Sharma: Treatment of diaphyseal forearm bone fractures by Locking compression Plate (LCP)." The |

|internet journal of orthopaedic surgery.2009 volume 11 no:1. |

|12.Fernando Baldy dos Reis, Flavio Faloppa."Outcome of diaphyseal forearm fracture- nonunion treated by autologous bone grafting and |

|compression plating”Annals of surgical innovation and research 2009,3:5. |

|13.Marek F.M: Axial fixation of forearm fractures.JBJS, 43-A, 1099, 1961. |

| | |

|9. Signature of the candidate : |Dr. M.K. NIZAMODDIN |

|10. Remarks of the guide : | |

| | |

| | |

|11.Name and designation of (in |Dr.KALADAGI.P.S |

|block letter) |Professor & HOD, Department of Orthopedics |

|11.1 Guide |K.R. Hospital, Mysore Medical College & Research Institute, Mysore. |

|11.2 Signature of guide: | |

|11.3 Co-Guide (if any) |DR.SHOBHA |

| |Assistant Professor of Orthopaedics, Department|

| |of Orthopaedics, K.R. Hospital, Mysore Medical College & Research |

| |Institute, Mysore. |

|11.4 Signature of co-guide: | |

|11.5 Head of Department |Dr.KALADAGI.P.S |

| |Professor & HOD, Department of Orthopedics |

| |K.R. Hospital Mysore Medical College, Mysore. |

|11.6 Signature of HOD |

|12. Remarks : |

|12.1 Remarks of Dean & Director: |

|12.2 Signature : |

ETHICAL COMMITTEE CLEARANCE

1.Title of dissertation : FRACTURE BOTH BONE

FOREARM IN ADULTS USING PLATES & SCREWS

2. Subject : M.S. ORTHOPAEDICS

3. Name of the Candidate : DR. M.K.NIZAMODDIN

4. Name of the Guide : DR. P.S.KALADAGI

M.S(ORTHO)

Professor and HOD

Department of Orthopaedics

Mysore Medical College &

Research Institute, Mysore.

5. Approved / not approved

(If not approved, suggestions) :

MEMBERS OF THE ETHICAL CLEARANCE COMMITTEE

PROFESSOR & HOD PROFESSOR & HOD

DEPARTMENT OF SURGERY DEPARTMENT OF MEDICINE,

MYSORE MEDICAL COLLEGE & MYSORE MEDICAL COLLEGE &

RESEARCH INSTITUTE, RESEARCH INSTITUTE,

MYSORE MYSORE

MEDICAL SUPERINTENDENT MEDICAL SUPERINTENDENT

K. R. HOSPITAL CHELUVAMBA HOSPITAL

MYSORE MYSORE

MEDICAL SUPERINTENDENT LAW EXPERT

PKTB HOSPITAL

MYSORE

DEAN AND DIRECTOR ,

MYSORE MEDICAL COLLEGE & RESEARCH INSTITUTE MYSORE.

From, Dr. M.K.NIZAMODDIN

Post-graduate in Orthopaedics

Department of Orthopaedics

Mysore Medical College & Research Institute

Mysore.

To,

Registrar (Evaluation)

Rajiv Gandhi University of Health Sciences

Bangalore.

Through proper channel.

Respected Sir,

Subject: Submission of Synopsis titled “ FRACTURE BOTH BONE FOREARM IN ADULTS USING PLATES & SCREWS”

I am here by submitting the above titled synopsis (4 copies) as mentioned above, so kindly accept my application and do the needful.

Thanking you,

Yours faithfully,

(DR. M.K.NIZAMODDIN)

Forwarded to Dean and Director, MMC & RI, Mysore for further needful action

Professor and Head,

Date: Department of Orthopaedics place: MMCRI,Mysore.

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