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JOURNAL

A Survey Of Elbow Injuries In Badminton Players
Bone Transport In Chronic Infected Non-Union Using AO External Fixator
fractures of the distal forearm bones in children
Internal Fixation Versus Hemiarthroplasty For Intracapsular Fracture Of The Femur
Peripheral nerve granuloma in a patient with tuberculosis


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A Survey Of Elbow Injuries In Badminton Players


Mansour Azarbal, MD 
Assistant Professor , Head 
Department of Orthopaedic Surgery 
Iman Hossein Medical Center 
Shahid Beheshti University of Medical Sciences 
Tehran Iran 
Dariush Adybeik, MD 
Clinical Researcher 
Department of Orthopaedic Surgery 
Iman Hossein Medical Center 
Shahid Beheshti University of Medical Sciences 
Tehran Iran 
Hossein Ettehad, MD 
Senior Resident of Orthopaedic surgery 
Department of Orthopaedic Surgery 
Iman Hossein Medical Center 
Shahid Beheshti University of Medical Sciences 
Tehran Iran 
Mirhadi Arash Kia, MD 
General Director 
Frontierless Researchers Institute 
 
Citation: 
Mansour Azarbal, Dariush Adybeik, Hossein Ettehad, Mirhadi Arash Kia: 
A Survey Of Elbow Injuries In Badminton Players. The Internet Journal 
of Orthopedic Surgery. 2004. Volume 2 Number 1.
 

Abstract 
	We evaluated 124 male badminton players training in Tehran 
Badminton Association's courts. We evaluated the medical and sports
history of all the players. The badminton players mean age was 23.8 
years (10-52 years). 17.7% of the players had the history of medial 
elbow injury and 9.7% of the players had the history of lateral elbow 
injury. The mean of total duration of training badminton was 1688.4 
hours (26-7120 hours). We could not find that the total duration of 
training had a role in the occurrence of medial or lateral elbow 
injuries. Also, we did not find that the hours of training per week had 
a role in the occurrence of medial or lateral elbow injuries. 

Introduction
    	Badminton is an individual, non-contact sport requiring jump, 
lunges, quick changes in direction, rapid arm movements and also 
rapid and repetitive wrist movement. Injuries about the elbow are 
common in racquet sports and are most often related to overuse. 
Lateral and medial elbow pains are two main elbow symptoms. Medial 
elbow pain is related to medial epicondylitis, ulnar nerve injury, medial 
collateral ligament injury, medial elbow intra-articular pathology, or any
combination of these causes. The source of lateral elbow pain is often 
lateral epicondylitis or rarely degenerative changes in radiocapitellar 
joint or radial tunnel syndrome ( 1 ).
	Studies reporting the elbow injuries in badminton players 
are sparse and also very few studies has been carried out regarding
the relation between hours of training badminton and occurrence of 
elbow injuries. The aim of the present study was to determine the 
prevalence of medial and lateral elbow injuries in badminton players 
training in Tehran Badminton Association's courts and also to describe 
the relation between hours of training badminton and the occurrence 
of medial or lateral elbow injury.

Material and Methods
	We evaluated 124 male badminton players who were members
of Tehran Badminton Association. We interviewed and took medical and
sports history of all the players. The standard records included: age, 
total time of training badminton, hours of training badminton per week, 
history of medial elbow injury (medial elbow pain) and history of lateral 
elbow injury (lateral elbow pain), the time of onset of medial elbow pain 
and the time of onset of lateral elbow injury. Our definition for elbow 
injury was the player's expression of history of elbow pain. The 
exclusion criteria was: 1-Playing in addition to badminton other racquet 
sports, boating, gym, golf and polo 2-Players who were typist, carpenter 
or painter 3-Players who were training noticeably irregularly 4- Players 
with history of elbow pain before onset of training badminton.
	A computer using SPSS software analyzed the data. Statistical 
analysis was carried out using Chi-square and t-tests and correlation 
coefficients. Significance was considered if lower than 0.05 in all tests. 
Helsinky was promised in all stages of the study.

Results
The badminton players mean age was 23.8 years (10-52 years). For 
age distribution in badminton players. 22 players (17.7%) had the 
history of medial elbow pain.12 players (9.7%) had the history of 
lateral elbow pain (figure 2). The mean hours of training per week 
was 6.7 hours and the mean hours of training per week for those 
with history of medial elbow pain was 7.1 hours and for those with 
history of lateral elbow pain was 9.4 hours (p>0.05). The mean of 
total duration of training badminton was 1688.4 hours (26-7120 
hours) and in those with history of medial elbow pain the mean of 
total duration of training badminton calculated from onset of training 
badminton to onset of medial elbow pain was 1502.5 hours and in 
those without history of lateral elbow pain was 1490.7 hours and 
also in those with history of lateral elbow pain the mean of total 
duration of training badminton calculated from onset of training 
badminton to onset of lateral elbow pain was 2138.5 hours and in 
those without history of lateral elbow pain was 1423.6 hours 
(p>0.05 for all).We found out that with every 500 hour training time 
increment the incidence of medial elbow injury was significantly 
different (Chi-square=0.000) but without any correlation. Also, with 
every 500 hour training time increment the incidence of lateral elbow
injury was significantly different (Chi-square=0.000) but without any 
correlation. 

Discussion
In our study, we found that 17.7% of badminton players had a history 
of medial elbow pain during training reflecting a history of medial 
elbow injury including medial epicondylitis, ulnar nerve injury, medial 
collateral ligament injury, medial elbow intra-articular pathology, or 
any combination of these causes However we could not define 
exactly the type of the injury. Also, in our study, we found that 9.7% 
of badminton players had a history of lateral elbow pain during 
training reflecting a history of lateral elbow injury including lateral 
epicondylitis, degenerative changes in radiocapitellar joint or radial 
tunnel syndrome. However we could not define exactly the type of 
the injury. In contrast to previous studies, we found that the preva-
lence of elbow injuries is more prevalent than reported and also 
medial elbow injury is more common than lateral elbow injury ( 2 , 3 ,
4 ,5 ,6 ,7 ,8 ). The reason for finding more elbow injuries may result
from the nature of our study that we interviewed all the players in the
sports club not like most of previous studies visiting players with 
injury in sports clinics. We did not find that the total duration of 
training had a role in the occurrence of either medial nor lateral elbow 
injuries. Also, we did not find that the hours of training per week 
played a role in the occurrence of neither medial nor lateral elbow 
injuries. Kluger R, Stiegler H and Engel A in their study in Vienna, 
Austria found that the incidence of acute badminton injuries increased
constantly from the onset of training ( 9 ) but in our study we did not 
find that the incidence of medial or lateral elbow injuries increase 
constantly from the onset of training. It occurred at any time irrelevant 
to the total duration of training. We suggest that more studies, 
especially prospective studies, have to be carried out in order to 
define exactly the type of elbow injuries with considerable attention 
to physical examination of the upper extremities. Also, it has to be 
mentioned that we did not have regularly access to female players 
training badminton.

References
1. Field LD, Altchek DW. Elbow injuries. Clin Sports Med. 1995 Jan; 
    14(1):59-78.
2. Hensley LD, Paup DC.A survey of badminton injuries. Br J Sports 
    Med. 1979 Dec; 13(4): 156-60.
3. Kroner K, Schmidt SA, Nielsen AB, Yde J, Jakobsen BW, Moller-
    Madsen B, Jensen J. Badminton injuries. Br J Sports Med. 1990 
    Sep; 24(3): 169-72.
4. Hoy K, Lindblad BE , Terkelsen CJ, Helleland HE, Terkelsen CJ. 
    Badminton injuries- a prospective epidemiological and socio-
    economic study. Br J Sports Med. 1994 Dec; 28(4): 276-9.
5. Fahlstrom M, Bjornstig U, Lorentzon R. Acute badminton injuries. 
    Scand J Med Sci Sports. 1998 Jun; 8(3): 145-8.
6. Jorgensen U, Winge S. Injuries in badminton. Sports Med. 1990 
    Jul; 10(1): 59-64.
7. Jorgensen U, Winge S. Epidemiology of badminton injuries. Int J 
    Sports Med. 1987 Dec; 8(6):379-82
8. Chard MD, Lachmann SM. Racquet sports--patterns of injury 
    presenting to a sports injury clinic.Br J Sports Med. 1987 Dec;21
    (4):150-3.
9. Kluger R, Stiegler H, Engel A. [Years of training: a new risk factor 
    in acute badminton injuries]Sportverletz Sportschaden. 1999 Dec;
    13(4):96-101.

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Bone Transport In Chronic Infected Non-Union Using AO External Fixator


Gholamhossein Kazemian, M.D. 
Assistant Professor 
Department of Orthopaedic Surgery 
Imam Hossein Medical Center 
Shahid Beheshti University of Medical Sciences 
Tehran Iran 
Saeed Kokly, M.D.  
Chief resident of Orthopaedic Surgery 
Department of Orthopaedic Surgery 
Imam Hossein Medical Center 
Shahid Beheshti University of Medical Sciences 
Tehran Iran 
Dariush Adybeik, M.D.  
Clinical Researcher 
Department of Orthopaedic Surgery 
Imam Hossein Medical Center 
Shahid Beheshti University of Medical Sciences 
Tehran Iran 
 
Citation: 
Gholamhossein Kazemian, Saeed Kokly, Dariush Adybeik:
Bone Transport In Chronic Infected Non-Union Using AO 
External Fixator. The Internet Journal of Orthopedic Surgery.
2004. Volume 2 Number 1.
 
Abstract
We used AO external fixator for bone transport in 4 patients with
chronic osteomyelitis after trauma including 2 cases with femoral 
shaft fracture (type I and III A), one femoral supracondylar fracture 
(type III B) and one case with fracture of the proximal of tibia (plateau) 
type III B. The mean age of the patients was 34.7 years (24-46 years).
All fractures were open because of car accident. Internal fixation had
been initially carried out for the patients with femoral fracture and
calcaneal pin traction for the patient with plateau fracture. The mean
time between fracture and the onset of bone transport external
fixation was 85 days (24-180 days). All the patients were 
culture-positive, identified the gram negative bacteria including
Pseudomona, E-coli and Enterobacter as the causative pathogens.
The mean of bone defects was 10.2 centimeters (7-14 centimeters).
The mean duration of bone transport was 134 days (77-210 days).
The total duration of treatment from placing AO external fixator until 
bringing out the device was 11-25 months (mean, 19.2 months).
According to our experience when bone transport carried out by
AO external fixator and with use of a five-to-seven day latency
period and a rate of distraction of one millimeter per day,
approximately 1.9 month treatment (including time for distraction
and healing) was required per each centimeter bone defect which
is less than the duration of treatment using Ilizarov technique for
bone transport requiring 2 to 3 months treatment per centimeter.
In our experience major intercalary defects in femur and also tibia
have been bridged and new bone has formed in the defect with
concomitant restoration of the osseous integrity and alignment
of the limb. 

Introduction
Infected non-union is one of the most problematic complications
of long bone fractures requiring extensive reconstructive surgery
in many cases. The conventional treatment includes extensive
debridement, external fixation, bone graft and soft tissue coverage.
Radical resection of necrotic bone and bone transport is an
alternative treatment ( 1 , 2 ). In this method, bone defects are
closed from within sliding a bone fragment internally, producing
distraction osteogenesis behind it until the defect is bridged. In
most of previous studies regarding bone transport, the Ilizarov
technique has been used especially in chronic osteomyelitis of tibia
and average bone defects of 6-8 centimeters approximately
( 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ). In previous studies,
using Ilizarov technique for bone transport has been reported to
have good outcomes regarding the management of infection but
with considerable soft tissue injuries in large osseous defects
particularly in femur. Schmidt, Wittek, Faschingbauer, et al reported
high rate of soft tissue injuries using Ilizarov technique bone
transport in femur and recommended to use AO external fixator
with arc of 90 or 120 degree( 14 ). There is a paucity of literature
regarding the use of AO external fixator for bone transport
especially in femoral bony defects due to osteomyelitis. In this
study the authors report 4 patients suffering from chronic
osteomyelitis successfully treated using AO external fixator for
bone transport in Imam Hossein Medical Center.

Material and Methods
We used AO external fixator for bone transport in 4 patients with
chronic osteomyelitis after trauma. The primary lab tests including
CBC, ESR, CRP were requested for all the patients and then were
treated by empiric antibiotic therapy. In cases with hemoglobin less
than 10 g/dl blood was transfused in order to reach hemoglobin
to more than 10 g/dl. All were prescribed high protein regimen, and
then after 1 week we carried out sequestrectomy and bone
transport.

Technique of surgery: After adequate blood reservation and with
regard to plain radiography, methylen blue injection the day before
surgery and the appearance of bone during operation, i.e.,
hemorrhage while osteotomy, we defined the extent of bone
resection. We tried to spare the adjacent soft tissue as well as the
periosteum of proximal and distal bone ends. All the granulation
tissue from skin down to the deepest part of the involved area was
considered to be infective and was excised. At this time culture
from the endosteum of sequester was obtained. Curettage and
reaming of proximal and distal bone ends were carried out when
necessary. Finally we irrigated bone ends and medulla of proximal
and distal bone ends with 10 liter of normal saline and culture was
obtained again. The patient was prepared and draped again and the
operation set. Then we installed the AO external fixator-unilateral
biplane (arc: 80-90 degree). Three shanz of 5 to 6 millimeters in
proximal part and three shanz in distal part in one plane were
placed and in the other plane two shanz in proximal part and two
shanz in distal part and two shanz in the portable assumptive part
were placed. In two cases, because of the proximity to the knee,
there was a need for knee span. We closed the wound edges
together and filled out with sterile gauzes and left it open. All the
patients underwent empiric antibiotic therapy after surgery. In
next days considering the wound status we started to close the
wound gradually. After 10 to 14 days osteotomy with preservation
of periosteum and by drill and osteotom was carried out and then
a five-to-seven day latency period before applying distraction was
allowed. The rate of distraction was 1 millimeter per day (0.5
millimeter in day and 0.5 millimeter in night). A few days after
operation toe touch with crutches was commenced. After reaching
the free bone fragment to the end of defect, bone graft for docking
site was carried out if necessary. Then PWB (partial weight bearing)
was started. After bone canalization FWB (full weight bearing) was
started and then the device was brought out. The criteria for bone
canalization was observation of three cortex in two plane X-ray
( 15 ).

Results
We evaluated 3 males and one female including two cases with
femoral shaft fracture (type I and III A), one femoral supracondylar
fracture (type III B) and one case with fracture of the proximal of
tibia (plateau) type III B (See table-1). The mean age of the patients
was 34.7 years (24-46 years). All fractures were open because of
the car accident. Internal fixation had been initially carried out for
the 3 cases of femoral fracture and calcaneal pin traction for the
case with plateau fracture. All the patients were anemic and three
were cachectic. ESR before operation was high and CRP was positive
(2-3+) in all the patients. The mean time between fracture and the
initial fixation was 26.7 days (16-40 days). The mean time between
fracture and the onset of bone transport external fixation was 85
days (24-180 days). All the patients were culture-positive, identified
the gram negative bacteria including Pseudomona, E-coli and
Enterobacter as the causative pathogens. The culture results after
operation were negative in all cases. The direction of bone transport
in two cases was proximal to distal and in the other two cases, distal
to proximal. The mean of bone defects was 10.2 centimeters (7-14
centimeters) and in patients with femoral fracture the mean of bone
defect was 11.3 centimeters. The mean duration of bone transport
was 134 days (77-210 days). The total duration of treatment from
placing AO external fixator until bringing out the device was 11-25
months (mean, 19.2 months). The mean of duration of treatment
(including time for distraction and healing) was 1.9 months per one
centimeter defect. 

Discussion
AO external fixator, if using unilateral biplane, is more stable in
comparison with using unilateral monoplane; and there is no need
to use Ilizarov apparatus which is certainly suitable for mechanical
correction of deformities such as angulation and rotation. Moreover
in bone transport using AO external fixator, unlike Ilizarov technique, 
there is not a high rate of soft tissue injuries ( 14 ). In our study the
extent of bone defect (mean: 10.2 centimeters in four cases and
mean of 11.3 in cases with femoral fracture) was relatively more
extensive in comparison with previous studies. Previous studies
using Ilizarov technique for bone transport were mostly about
chronic osteomyelitis of tibia. Bone transport using AO external
fixator appears to be an efficacious technique in the treatment of
large defects including those in femur. In our experience, major
intercalary defects in femur and also tibia have been bridged and
new bone has formed in the defect with concomitant restoration
of the osseous integrity and alignment of the limb. 
 
According to our experience when bone transport carried out by
AO external fixator and with use of a five-to-seven day latency period
and a rate of distraction of one millimeter per day, approximately
1.9 month treatment (including time for distraction and healing) was
required per each centimeter bone defect which is less than the
duration of treatment using Ilizarov technique for bone transport
requiring 2 to 3 months treatment per centimeter ( 16 ). It seems
that the less time between fracture and using AO external fixator
for bone transport the better treatment outcomes and less 
complication. Interestingly, in cases where internal fixation was not 
used as the initial treatment, the result of treatment was remarkably 
better. Generally, the better general condition before operation, the 
better treatment outcomes. Bone graft in docking site was carried 
out in 2 cases; however, it is suggested to be done prophylactically 
in order to decrease the duration of treatment ( 16 ). In addition, in 
our experience there was neither any re-infection nor a need for 
amputation in any of the cases. Bone transport using AO external 
fixator is an alternative treatment in the salvage of limbs with infected 
non-union that may otherwise have been amputated, and it returns 
disabled patients to normal life and a productive level of activity. 
Considering our experience and previous studies, it is recommended
to diagnose and treat post-trauma infection as soon as possible 
since otherwise if treatment is delayed, as unfortunately is often the
case, the progressive soft tissue and bone destruction will occur 
and aggressive surgical intervention might incur ( 2 ). We also 
suggest that regarding the paucity of existing literature using AO 
external fixator for bone transport and also the small number of our 
studied patients, more studies have to be conducted about this 
method. 

References
1. Prokuski LJ, Marsh JL. Segmental bone deficiency after acute 
   trauma: The role of bone transport. Orthop Clin North Am. 1994 
   Oct; 25(4): 753-63.
2. Bucholz RW, Heckman JD. Rockwood and Green's Fractures in 
   Adults, Fifth edition, Lippincott Williams & Wilkins; 2002 page: 1988
3. Cattaneo R, Catagni M, Johnson EE. The treatment of infected 
   nonunions and segmental defects of the tibia by the methods of 
   Ilizarov. Clin Orthop. 1992 Jul; (280): 143-52.
4. Carballedo J, Schmauch M, Langa J, Miralles RC. Type III-B open tibial
   fractures in Mozambique. A prospective study of 50 cases. Int 
   Orthop. 1996; 20(5): 300-4.
5. Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov technique 
   for treatment of non-union of the tibia associated with infection.
   J Bone Joint Surg Am. 1995 Jun; 77(6): 835-46.
6. Golyakhovsky V, Frankel VH. Ilizarov bone transport in large bone 
   loss and in severe osteomyelitis. Bull Hosp Jt Dis Orthop Inst. 
   1991 Spring; 51(1): 63-73.
7. Green SA. Osteomyelitis. The Ilizarov perspective. Orthop Clin 
   North Am. 1991 Jul; 22(3): 515-21.
8. Green SA, Jackson JM, Wall DM, Marinow H, Ishkanian J. Management
   of segmental defects by the Ilizarov intercalary bone transport 
   method. Clin Orthop. 1992 Jul; (280): 136-42.
9. Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. 
   Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop. 
   1989 Apr;(241):146-65.
10. Smrke D, Arnez ZM. Treatment of extensive bone and soft tissue
   defects of the lower limb by traction and free-flap transfer. Injury.
   2000 Apr; 31(3): 153-62.
11. Song HR, Cho SH, Koo KH, Jeong ST, Park YJ, Ko JH. Tibial bone 
   defects treated by internal bone transport using the Ilizarov 
   method. Int Orthop. 1998; 22(5): 293-7.
12. Theis JC, Simpson H, Kenwright J. Correction of complex lower 
   limb deformities by the Ilizarov technique: An audit of complications.
   J Orthop Surg (Hong Kong). 2000 Jun; 8(1): 67-71.
13. Prochaska VJ ,Lindgren JU. Treatment of chronic tibial osteomyelitis,
   segmental bone loss, soft tissue damage by bone transport. 
   Nebr Med J. 1994 Oct,79(10): 349-52
14. Schmidt HG, Wittek F, Faschingbauer M, Fink B. [Treatment of 
   chronic osteitis of the femur] Unfallchirurg. 1992 Nov; 95(11): 
   562-5.
15. Morrissy RT, Weinstein SL, Lovell and Winters Pediatric Orthopedics, 
   5th Ed.; William and Wilkins; 2001 p: 1136-45
16. Aronson J, Rock L: Current concepts review-limb lengthening, 
   skeletal reconstruction and bone transport with Ilizarov method,
   J BJ S, 79: 1243-58

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fractures of the distal forearm bones in children



Authors:
Dr. Onwuanyi O.N. MD, FMCS, FRCS, FICS
Consultant (Orthopaedic/ Trauma),
King Khaled Hospital,
Tabuk.
Dr Nwobi D. G. MBBS, FRCS (Ed. & Glasg)
Consultant (Orthopaedic/ Trauma),
King Khaled Hospital,
Tabuk.
Dr. Krishna R.M. M.D.
Consultant (Medical Imaging/Radiology),
King Khaled Hospital,
Tabuk.
 
Grants:
No grant was received or benefits expected from this study.
 
Keywords:
Fracture, distal, forearm, children, pattern, treatment.
 
Reprints Request: Dr. Onwuanyi O N,
Orthopaedic/ trauma unit,
King Khaled Hospital,
P.O.BOX 876
Tabuk, Saudi Arabia.
 
ABSTRACT
Forearm fractures occurring at similar levels on the shaft of the 
distal radius and ulna constitute a unique entity of injury with regard
to reduction and stabilization. We determined the outcome for
113 children treated by three methods, of plaster reduction alone,
reduction-pin fixation and reduction-plate fixation. Group A- plaster
reduction, was made up of children under 4 years in who fracture
reduction was easily achieved beyond 50% of cortical contact.
35% needed re-manipulation from displacement during period of
plaster immobilization. Mal-union was recorded in this group and
the children also required additional X-ray evaluation during follow-up
over twelve weeks. In Group B, 49 children were treated by closed
reduction and percutaneous pin fixation. Fracture reduction with
greater stability was achieved. Complication rate was low and the
range of joint motion was excellent at 12weeks (p>0.05). The
children in Group C, managed by open reduction and plate fixation,
were older with a mean age of 11.1 years. Reduction was difficult
and unstable by closed technique. Operative reduction ensures
anatomic reduction but requires open surgery. Closed reduction-pin
fixation offers an effective method of managing these fractures and
has the advantage of added stability and avoids open surgery.
 
INTRODUCTION
Forearm shaft fractures frequently result from falls on the
outstretched arm. About 90% are closed, usually dorsally displaced
and may be in the proximal, middle or distal third (non-articular/
articular) according to Vince, Miller (1987), and Tredwell et al (1984).
The third type was the most frequent in our series and in 58%, the 
result of pedestrian-vehicular accidents. Direct trauma accounted 
for 18% and falls 24%

Fractures in the distal radius and ulna may also occur at similar levels 
on the shaft. These fractures are usually complete when due to violent 
trauma as in pedestrian-vehicular accidents. They may be difficult to 
reduce anatomically due to the interposition of stripped periosteum, 
muscle, interosseous membrane or tendon. There have been reports 
by Ghazi and Hayes (1990); Voto et al (1990); Fatti and Mosher (1980) 
of lost reduction after closed procedure resulting in the restriction of
full extension of the digits, which necessitated open reduction.

However, Blount (1967) opined that such forearm fractures in children,
75% in the distal third almost never require surgery. Lee (1984) held 
the view that repeated attempts at reduction were not necessary if 
the initial reduction achieves an apposition of 50% or more. Premature
 closure of the distal radial epiphysis has been reported following 
repeated forceful attempts at reduction (Nelson, Buchanan and 
Harrison 1984).

Nelson (1986) also observed that satisfactory remodeling of angular 
deformities would occur if displacement were in the plane of joint 
movement. Even complete translocation (bayonet apposition) is 
tolerated in a child because of remodeling potential of the periosteum.
 This will not occur for rotational deformities. The movements of 
pronation and supination will also be adversely affected by 
interosseous space loss, which could occur during external plaster 
immobilization, from early resumption of vigorous activity before 
stable callus is formed

Fatti and Mosher (1980) have reported cross union where scar-like 
tissue binding both bones distally impeded pronation/ supination 
movement in a child managed by external plaster immobilization 
alone in full pronation.

This is probably the direct result of local disruption of interosseous 
membrane at the fracture site.

The peculiarities of both bone fractures of the forearm have attracted
several contributions on its management (Ghazi and Hayes, 1990; 
Voto et al, 1990; Vince and Miller, 1987; Tredwell et al, 1984; Fatti 
and Mosher, 1980; and Blount, 1967). While it is a generally held view 
that operative reduction should be the second option, close reduction 
and plaster immobilization alone may not suffice.

We managed these fractures by closed reduction and percutaneous
pin fixation when the reduction obtained is unstable, as we found in 
a good proportion of the children. The cut-off ages for closed treatment 
were under 4 years (Plaster reduction only), 4-10 years (closed reduction 
and percutaneous pinning) and for 10-12 years (females) and 12-14 
years (males) operative treatment received strong consideration. 
Our study covered 113 children treated by one of the three methods.

PATIENTS AND METHOD
113 children aged between 2-12 years (mean: 6.8) were treated for 
distal fractures of the forearm bones between June 1995 and June 
1999. All fractures were in the distal third, same level and non-articular. 
31 of the patients were treated by closed reduction and casting, 49 
had closed reduction and percutaneous pinning and 33 by open 
reduction and internal fixation.

Inclusion criteria: -Age: under 12 years.Fracture of both bones in the 
distal segment at similar levels, closed, with no neuro-vascular 
complications. Selection of the children for mode of treatment was 
by random sampling.
 
DEFINITIONS: -
Diaphyseal malunion- Fracture union with greater than 15 of angulation
or rotation.
Translocation: Bayonet apposition with overlapping of fragments.
Fracture Reduction: -Fractures were reduced and stabilized by 
percutaneous kirschner wires or 3mm plates. A full arm plaster of 
Paris slab was then applied for six to eight weeks.Statistical analysis 
was by chi square test.
 
RESULTS
113 children with both bone forearm fractures were evaluated in this
prospective work 31 patients (group A) were treated by closed 
reduction and plaster cast, 49 patients (group B) by closed reduction
and percutaneous pin fixation and the last 33 patients (group C) had
open reduction and plate fixation. The respective mean ages were 
3.6, 6.8, 11.1 years. There were more male children 54.8% indicative 
of a greater deal of physical activity.
 
DISCUSSION
Fractures at similar level of both forearm bones may be difficult to 
reduce by closed method. Management by external casting alone 
may be inadequate because of the difficulty in maintaining alignment.
The need for early reduction has long been understood. Charnley 
(1961) described the basic principles underlying the maintenance of 
the reduced fracture position. This requires an appreciation of 
rotational forces of pronation and supination.

Although a reduction of 50% or more (Voto et al, 1990; and Nelson 
et al, 1986) is desirable for adequate remodeling to occur with growth,
some of these fractures may unite with interosseous space loss, 
rotational mal-alignment and cross-union, due to loss of reduction 
during the period of immobilization as trauma oedema resolves. 
Closed reduction and percutaneous pin fixation decreases the 
incidence of these complications (p>O.O5) (Muller et al, 1981; Davis 
and Green, 1976).

Arguments abound for and against Kirschner pin fixation that transgress 
the distal radial epiphysis. The possibility of subsequent growth 
delay, have been highlighted, Muller et al (1981), and Voto, et al 
(1990). We did not record any such complication amongst our patients.
 Probably the use of smooth K-wires obviates this complication. 
Martin Kirschner (1879-1942), surgeon from Heidelberg was the first 
to use thin wires in fracture management in 1909. The K-wire fixation 
is a versatile technique for osseous fixation, though it provides 
stabilization rather than rigidity, it avoids the need for open surgery, 
frequent displacement of external plaster fixation alone and the need 
for plaster reapplication. The removal of the pins is easily done during 
routine outpatient clinic visit.

However, the procedure requires the experienced assistant, as the 
reduced fracture should be held in place during pin fixation. The 
outcome is often a direct function of initial reduction obtained. We 
used double pins in crossed or parallel configurations with low 
complication rate.

A mean age of 3.6 years was recorded in children treated by closed 
reduction and casting alone. In this group, reduction was easier to 
obtain, maintain and the remodeling potential of the bones 
was greatest, as noted in other studies (Lee, Esterhai and Das, 1984;
Tredwell et al, 1984; Blount, 1967) Displacement was significant during
 the duration of casting (p
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Internal Fixation Versus Hemiarthroplasty For Intracapsular Fracture Of The Femur


A. Abosala 
Dr Gray's Hospital 
 
Citation: 
A. Abosala: Internal Fixation Versus Hemiarthroplasty For Intracapsular 
Fracture Of The Femur. The Internet Journal of Orthopedic Surgery. 
2004. Volume 2 Number 1.
 
Abstract

The goal of this article is to evaluate our practice. We assessed 
and compared the outcome for 2 groups (internal fixation vs. 
hemiarthroplasty (AM) and total hip replacement THR) with particular
interest in the re-operation rate. We conducted a retrospective 
study with 87 cases in total. 47 had cannulated screws and 40 had 
AM We concluded that there is no significant difference between the 
two groups in regard to mobility, pain status and mortality rate.
We found a higher re-operation rate in screws group, although 
similar to many other studies. 

 Introduction
 3 choices of treatment are available for displaced intracapsular
 fracture , namely internal fixation, hemiarthroplasty (AM) and THR 
 Standard recommendations are: 
   
     - Age more than 70 yrs hemiarthroplasty 
     - Age less than 70 yrs internal fixation 
     - Moderate/sever OA THR 
     - Immobile patient consider no treatment 

Aim of the study
 1. To evaluate our practice. 
 2. Assess and compare the outcome for both groups. Particular 
  interest in the re-operation rate. 

Previous studies
  - A study by k. Ravikumar and G. Marsh shows no difference in 
the mortality rate between the three groups . One year revision 
rate of internal fixation group is 25%. Recommend THR in 
physiologically active patients. 
  - A study by Annti Alho and David Rietti in Norway (1980), the total
 cost of prosthetic replacement was found to be 1.6 times more 
expensive than the internal fixation. 

Type of the Study
  - Retrospective study. 
  - 87 case in total, 47 had cannulated screws and 40 had AM 
     (May 98 - June 2000 ) 
  - Part of the information obtained from original data which have 
     been collected regularly for The Scottish Hip Audit. 
  - 4 months F/U done by questionnaire filled by the mail or on the
     phone. 
  - Only displaced fractures of femoral neck were included. 

  - Both groups compared with regard to: 
         - discharge destination. 
         - Mortality . 
         - Mobility. 
         - Pain status. 
         - Place of residence prior to fracture and at 4 months F/U. 
         - Re-operation rate at 4 months and one year F/U. 

Re-Operation Rate At 4 Months 
- The screws group shows higher figure (12.76%) compared to just 
    (0%) for the AM group. 
- In the screws group 
- 6 patients underwent major surgery ( removal of screws & THR) , 
    one of them dislocated once. 

 
Re-operation rate at 1 year in both groups
Screws group: 
   - further two pts underwent removal of screws and THR. 
   - In addition, two pts underwent removal of screws ( rate risen to 
     21.27%). 
AM group: 
   - two pts underwent removal of prosthesis and THR. 
   - one patient sustained fracture shaft of femur around the prosthesis 
     (ORIF) 

Reasons of re-operation
Screws group: 
1. Early mechanical failure. 4 cases [THR] 
2. Pain 
      - avascular necrosis . One case 
      - screws protrusion 
               - laterally 5 cases 
               - to joint 1 case 
AM group 
1. pain 2 cases 
2. fracture 1 case 

 Conclusion 
 There is no significant difference between the two groups in 
   regard to mobility, pain status and mortality rate. 
 Selecting criteria close to SIGN . 
 Higher re-operation rate in screws group,although similar to 
   many other studies. 
 It is interesting to see the re-operation rate in this group with
   further F/U . 

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Peripheral nerve granuloma in a patient with tuberculosis



R W Orrell1,2, R H M King1, J V Bowler1,2,3 and L Ginsberg1,2 
1 University Department of Clinical Neurosciences, Royal Free and 
      University College Medical School, University College London, 
      London, UK 
2 Department of Neurology, Royal Free Hospital, London, UK 
3 North Middlesex Hospital, London, UK 
Correspondence to: 
Dr R W Orrell, Department of Clinical Neurosciences, Royal Free and 
      University College Medical School, University College London, 
      Rowland Hill Street, London NW3 2PF, UK; 
r.orrell@rfc.ucl.ac.uk 
Received 31 May 2002 
In final revised form 21 August 2002 
Accepted 30 August 2002 

ABSTRACT
The cause of peripheral neuropathy associated with tuberculosis is 
controversial. Possibilities include an immune mediated neuropathy, 
direct invasion of nerves, vasculitic neuropathy, compressive 
neuropathy, a meningitic reaction, and the toxic effects of 
antituberculous chemotherapy. This report describes the unusual 
finding of granulomas in the peripheral nerve of a patient with 
tuberculosis. The pathological findings were of a delayed 
hypersensitivity reaction, but with no more specific indications 
of the mechanism of the neuropathy. 

Keywords: tuberculosis; neuropathy; granuloma 
Neuropathy may occur in patients with tuberculosis for a number of 
different reasons.1,2 It was originally attributed to alcohol and 
malnutrition, and more recently has been related to the neuropathic 
effects of medication,57 and a radiculopathy as a result of 
tuberculous meningitis. In one patient the nerve roots were 
reported to have been invaded by bacilli.8 A vasculitic neuropathy 
has also been proposed, but with no direct evidence of vasculitic 
abnormality in the nerve.9 Tuberculomas have been reported in the 
optic nerve,10 but not in peripheral nerve. We now describe a patient 
with a sensory and motor peripheral neuropathy related to systemic 
tuberculosis. Granulomata were present in a sural nerve biopsy 
specimen. 

CASE REPORT

A 23 year old man, born in Africa, and recently living in England, 
developed a sensation of pins and needles in the soles, spreading 
to the toes. He was finding it increasingly painful to walk. One month
later this progressed to weakness at the ankles, with bilateral foot 
drop, and numbness in the toes. There were no other neurological 
symptoms. Three months earlier he had noticed a prominent lump in 
the neck, and experienced occasional night sweats, weight loss, and 
right sided abdominal pain. 

Examination demonstrated an enlarged right cervical lymph node. 
There was a large, firm, regular mass in the right hypochondrium, 
extending to the right lower quadrant of the abdomen. 

Cranial nerve examination was normal. He walked with bilateral foot 
drop. There was normal muscle bulk in the limbs, with no fasciculations.
 Tone and power were normal in the upper limbs, with diminished 
biceps reflexes. In the lower limbs, tone was normal. There was 
moderate weakness (MRC grade 4) of hip flexion bilaterally, absent 
(MRC grade 0) dorsiflexion of the foot and extension of the big toe 
bilaterally, and moderate weakness (MRC grade 4) of foot inversion 
and eversion bilaterally. Lower limb power was otherwise normal 
(MRC grade 5). Tendon reflexes were brisk at the knees and normal 
at the ankles, with absent movement of the big toe on plantar 
stimulation, but some upward fanning of the other toes. Light touch
and pinprick sensation were normal. Vibration sensation was 
diminished at the toes and ankles. Proprioception was preserved. 

Sensory nerve conduction studies were normal in the upper limbs 
(median nerve sensory amplitude 14 V on the right and 15 V on 
the left, and ulnar nerve 11 V on the right and 14 V on the left), but 
sensory action potential amplitudes were reduced in the sural nerves
 (right 1.5 V, left 3.5 V, normal >8 V). There was no response to 
stimulation of the common peroneal nerves when recording at 
extensor digitorum brevis, but normal velocity (45 m/s on the right, 
53 m/s on the left) when recording at tibialis anterior. There were no 
motor responses from abductor hallucis on stimulation of the right 
and left tibial nerves. Electromyography of tibialis anterior and 
gastrocnemius demonstrated frequent fibrillation potentials and 
positive sharp waves, with a mild excess of polyphasic motor unit 
action potentials of normal and increased duration, and of normal 
amplitude. Right quadriceps femoris demonstrated no spontaneous 
activity, with a mild excess of polyphasic units of normal duration and
 amplitude, and full interference pattern. Left mid-lumbar and lower 
lumbar paraspinal EMG demonstrated increased insertional activity, 
but otherwise normal appearances. The findings suggested a distal 
sensory and motor axonal polyneuropathy in the lower limbs. 
Biopsy of the cervical lymph node revealed multiple large granulomas 
with extensive central caseous necrosis. Scanty acid fast bacilli were
identified on Ziehl-Neelsen staining. Culture demonstrated 
Mycobacterium tuberculosis, resistant to isoniazid. Tuberculin
test was not performed. Computed tomography (CT) of the chest 
demonstrated anterior mediastinal lymphadenopathy, with a 3 cm 
soft tissue density at the left hilum. CT of the abdomen demonstrated 
a 10x5x5 cm low density lesion arising from the liver, largely fluid 
filled, with a thickened wall extending anteriorly over the liver. 
Magnetic resonance imaging of the brain and spinal cord, with 
gadolinium, demonstrated no abnormality. Examination of the 
cerebrospinal fluid was normal, with no cells, no organisms, protein 
0.3 g/l, glucose 3.0 mmol/l, blood glucose 5.2 mmol/l. Opening 
pressure 18 cm of cerebrospinal fluid. There was no growth on 
culture. Full blood count, urea and electrolytes, and calcium were 
normal. Liver function tests were normal apart from a raised -
glutamyltransferase of 117 U/l (normal 954 U/l). Erythrocyte 
sedimentation rate was raised at 69 mm 1st h (normal <20 mm 1st h),
 and C reactive protein raised at 61 mg/l (normal <7 mg/l). HIV and 
treponemal serology were negative. Antinuclear antibody titre was 
<1/1000, and anti-double stranded deoxyribonucleic acid negative. 
Plasma protein electrophoresis revealed a polyclonal increase in 
immunoglobulins, with no paraprotein. Thyroxine was normal, but 
thyroid stimulating hormone rasied at 7.3 mU/l (normal 0.34.2 mU/l). 
Treatment was started before culture and sensitivity results were 
available, with rifampicin, isoniazid, pyrazinamide, and ethambutol. 
Within three days of starting treatment there was improvement in 
the paraesthesias, but gait and weakness remained unchanged. 
Isoniazid was withdrawn after three weeks when sensitivity results 
were available. Right sural nerve biopsy was performed to assess the
 possibility of an inflammatory or vasculitic component to the 
neuropathy. Light microscopy  demonstrated a normal myelinated 
fibre density within the fascicles, but many myelinated fibres were 
undergoing acute axonal degeneration, and there were numerous 
debris containing macrophages  Mild subperineurial oedema was 
present. Some of the epineurial blood vessels were associated with 
groups of inflammatory cells, but there was no clear evidence of
vasculitis. Several noncaseating granulomata were present in the 
epineurium . There were no giant cells. Immunocytochemical staining 
was negative for B lymphocytes in the endoneurium and epineurium.
There was marked staining for CD4 lymphocytes in the epineurium, 
especially in relation to the granulomata ( and also blood vessels, 
and in patches in the endoneurium. There was significant but less dense 
staining for CD8 lymphocytes in a similar distribution 
An early macrophage marker (CD68) was dense in relation to the 
granulomata. A late macrophage marker (mac387) was positive in the 
epineurium, especially in relation to the blood vessels and granulomata, 
and occasionally in the endoneurium. Bacilli were not demonstrated 
on Ziehl-Neelsen stain for light microscopy, or by electron microscopy.

After three months of antituberculous medication, there was 
improvement in power, with weakness of ankle dorsiflexion (MRC 
grade 4 bilaterally), ankle inversion (MRC grade 4 bilaterally), and 
eversion (MRC grade 4 on the right and 4- on the left). Ankle plantar 
flexion was normal. There was still marked weakness of extensor 
hallucis longus (MRC grade 2 bilaterally). He was given prednisolone 
40 mg daily, because of continuing concern about an additional 
inflammatory component to the neuropathy, and the rifampicin, 
pyrazinamide, and ethambutol were continued. By 12 months, the 
prednisolone had been reduced and withdrawn. There was full power 
(MRC grade 5) on plantar flexion, inversion and eversion, with mild 
weakness of dorsiflexion (MRC grade 4+, stronger on the right than 
left), at the ankles. Extensor hallucis longus had full power (MRC 
grade 5) on the right, and moderate residual weakness (MRC grade 4) 
on the left. 

DISCUSSION

The patient had tuberculosis, affecting the cervical lymph node, and 
presumably also involving the liver. He had a peripheral neuropathy 
that preceded chemotherapy for tuberculosis. The peripheral nerve 
abnormality we describe is consistent with the delayed or type IV 
hypersensitivity reaction seen with persistent or non-degradable 
antigens such as tubercle bacilli.11 Accumulations of macrophages
 transform into epithelioid cells. An aggregation of epithelioid cells, 
surrounded by a collar of lymphocytes, is termed a granuloma. The 
cytokines most directly implicated are interleukin 12, which is produced 
by macrophages, and interferon gamma, an activator of macrophages. 

In the patient we describe, it is not clear how the granulomata relate
to the neuropathic symptoms and signs. Possibilities include a 

compressive or vascular effect, and also cytokine mediated damage. 
In experimental studies, using intravenous injection of a variety of 
strains of mycobacteria in mice, granulomata developed in the 
peripheral nerves.12 Nodules within the peripheral nerves consisted
principally of macrophages, with no epithelioid cells or necrosis. 
In these experimental studies, it was suggested that the neuropathy
was caused by compressive effects of the nodules.12 More typical 
tuberculous granulomata with destructive features were present in 
other organs. The origin of the neural granulomata, probably from 
macrophages or Schwann cells, was difficult to define. The nodules 
appeared later in peripheral nerves (15 days) than in lungs (two days), 
and were present in peripheral nerves only when using virulent 
strains. 

Infection with the related bacillus, Mycobacterium leprae, is one of the 
most common causes of neuropathy in the world.13 This may present
as lepromatous leprosy (with infiltration of the nerve by bacteria and 
inflammatory cells, and fibroblast proliferation, causing fusiform 
enlargement of nerves); tuberculoid leprosy (where nerve enlargement 
occurs as a result of the inflammatory response rather than bacterial 
infiltration); and an acute neuritis. There is also a broad range of 
borderline or intermediate forms, which combine features of the 
lepromatous and tuberculoid forms.14 The pathological features we 
describe most closely resemble tuberculoid leprosy, with granuloma 
formation. In leprosy, the entire endoneurium may be replaced by a 
single granuloma, and caseation may occur. Organisms may not be 
detectable. The primary process is axonal damage, often multifocal, 
and probably secondary to the inflammatory response.14 Intrafascicular 
ischaemia attributable to increased endoneurial pressure may be 
important.15 In lepromatous leprosy, there is evidence to suggest 
hematogenous spread of the bacilli, with entry into the nerve through 
the endoneurial capillaries. The organism is relatively inaccessible to 
the immune system within the nerve. The Schwann cell is probably 
primarily infected, and the organism spreads within the nerve. 
Macrophages may also carry the organism, by travelling in the 
subperineurial space.14 

In tuberculoid leprosy, where no organisms are detectable, other 
granulomatous conditions, including sarcoidosis may be considered. 
Peripheral neuropathy is a rare manifestation of sarcoidosis. Epineurial 
non-caseating granulomas may be found.16 Sarcoidosis and 
tuberculosis may occasionally coexist, for example tuberculosis may 
develop after corticosteroid treatment for sarcoidosis, or tuberculosis 
may masquerade as sarcoidosis.17 The temporal relation and 
response to treatment make additional sarcoidosis unlikely in this 
patient. Mycobacterium avium-intracellulare has been implicated in 
neuropathy in patients with HIV.18,19 

In patients with tuberculosis, neuropathy attributable to direct 
peripheral nerve infiltration has not been previously recognised.
2,14 In a patient with tuberculosis, neuropathy occurs as a 
complication of meningitis, causing spinal nerve root and cranial 
neuropathies (especially cranial nerves II, III, VI, VII, and VIII).2,20 
Cranial nerve involvement may result from longstanding increased 
intracranial pressure, and direct effects of the tuberculous exudates 
on the nerve.21 Arteritis of the nerve root, within exudates, has
been described.21 Isolated tuberculomas in the optic nerve have 
been reported.10,22 Local pressure in the nasopharynx (cranial 
nerves IX, X, and XI palsies), in the middle ear and mastoid (cranial 
nerve VII palsy and hemifacial spasm), and chest (recurrent laryngeal 
nerve palsy), have all been observed.14 Carpal tunnel syndrome may
result from tuberculous tenosynovitis in the hand.23 The association
of tuberculosis with Guillain-Barr syndrome is uncertain, although
patients have been reported with both conditions coexisting.7 This 
may be a chance association. 

The most important consideration in a patient with tuberculosis is probably 
the potential neurotoxic effects of antituberculous medication. Isoniazid 
combines with pyridoxine, causing a pyridoxine (vitamin B6) deficiency 
neuropathy.24 The peripheral neuropathy is initially sensory, and later 
motor, with features of axonal degeneration. This should be prevented 
by coadministration of pyridoxine. Excess pyridoxine itself may cause a 
reversible sensory neuropathy.24 Neuropathies are also observed with 
ethambutol and streptomycin. Ethambutol more commonly produces a 
retrobulbar toxic neuropathy, but may also occasionally cause a reversible 
distal sensory peripheral neuropathy, with late motor involvement, and 
axonal features.24 Streptomycin is vestibulotoxic, but does not 
cause peripheral neuropathy. 

In the patient we describe, there was definite evidence that the 
neuropathy preceded treatment. We suggest that the granulomata 
disrupted the endoneurial blood supply, producing the acute 
Wallerian-type degeneration observed. It should not be assumed 
that neuropathy in patients with tuberculosis is iatrogenic, and the 
possibility of a primary effect on the nerves should be considered. 

FOOTNOTES
Competing interests: none declared. 

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