ACHILLES TENDON CUT due to TOILET BOWL INJURY

The patient slipped in the bathroom and his foot crashed into the toilet bowl. (no he was not squatting on the edge of the toilet seat - see bottom pic)

He sustained a deep laceration over his calf and a clinical examination showed that the achilles tendon was torn.
This was confirmed intra-operatively, where an emergency debridement, exploration and tendon repair was done the same day.

Intra-op findings

Wound blurred out as deemed too gory for public viewing :

Post operatively, a backslab with the ankle in equinus was applied so as to relieve the tension on the operated tendon. This will be replaced later with a special walking boot allowing range of motion exercises to the ankle, with partial weight bearing of the affected limb. Total rehabilitation would take about 4-6 weeks

Apparently a group of doctors reported on this seemingly "rare" case and got it published in the foot and ankle journal.

On another related note, have you been to the toilets in the malls? you would probably come across this sign:

The bottom right symbol is an apt reminder of what not to do if one wishes to avoid getting the injury that our friend above had... perhaps the mall management might want to use the picture above to illustrate the consequences of slipping into a toilet bowl.. hmm...

- the Bomoh Tulang -

reference:

the AAOS Clinical Practice Guideline on the Diagnosis and Treatment of Acute Achilles Tendon Rupture 2009

Elbow fractures in Children - Supracondylar fracture of the humerus

We see a fair number of children's injuries in the hospital, the reason being that the hospital is situated in a residential neighbourhood.

Children frequently fall, and in the process, has the tendency to extend their arms out to protect themselves.
This fact makes injuries involving the upper limbs more frequently seen in the ER (Emergency Room) as compared to the lower limb. The force from the fall, if large enough, can fracture the bone in two common places - the wrist or the elbow.

For the elbow, the forces from the fall travel through the forearm, levers the elbow joint in extension and the bone breaks at the weakest part of the arm - the supracondylar part of the humerus.
This is the so-called supracondylar fracture of the humerus and is the commonest elbow injury seen in children, seen most frequently in the 3 to 8 year old age group. It is also the 2nd most common children's fracture, second only to wrist fractures.

Patients with a suspected supracondylar fracture of the humerus frequently present to the ER with a history of fall, with associated swelling of the elbow and inability to bend the elbow.

*For the parent, if there is a suspicion of an elbow injury or fracture, one should ideally immobilize the limb in a sling prior to bringing to the ER. Besides providing comfort to your child, it limits further movement and displacement (moving out of alignment) of the suspected fracture. Dont know how to do it? look it up here. *

And that was how I met my 7 year old patient in the ER a couple of months ago. He had a nasty fall and was brought to the ER by his parents. His left elbow was deformed and swollen, and painful to the touch.

Swollen left elbow

X rays confirmed my suspicions: a supracondylar fracture of the left humerus.

Now fractures which are minimally displaced, or better yet, undisplaced, can be treated with nothing more than a plaster slab and an armsling. However our patient had what is known as a type III Gartlands fracture, where the fracture ends are totally not in contact with each other. This necessitates an operative reduction (where the surgeon manipulates the fracture ends into place) and fixation with wires.

Fortunately the parents understood the gravity of the situation and agreed for surgery that night. Here are the before and after pics of the X rays:

fracture site (arrowed)

frontal view of the elbow showing the fracture

Fracture reduced (put back) and temporary wires in place. Compare with the first picture

You can see that humpty-dumpty the bone ends has been put back together again.
The wires were removed after a month -   on the x rays below you will note that the fracture is healing well with new bone around the fracture site.

after 2 months

There was still some slight stiffness of the elbow on the last day of treatment which should go away after some physiotherapy. Now our patient is well on his way to playing football again and probably has a nice story to tell his kids later!

- the BomohTulang -

references:


Clinical Practice Guidelines
The Treatment Of Pediatric Supracondylar Humerus Fractures
American Academy of Orthopaedic Surgeons 2011

Current Concepts Review Supracondylar Humeral Fractures in Children
J Bone Joint Surg Am. 2008;90:1121-32

Crossed-pin versus lateral-pin fixation in pediatric supracondylar humeral fractures.
Shamsuddin SA, Penafort R, Sharaf I. Med J Malaysia. 2001; 56(Suppl D):38–44.

Wheeless' Textbook of Orthopaedics (online)

Surgery for CARPAL TUNNEL SYNDROME

Continuing from the previous post, lets talk a bit about SURGERY for CARPAL TUNNEL SYNDROME.

Surgery entails cutting or transecting the transverse carpal ligaments that overlies the median nerve and can be done as an outpatient basis or a day care procedure in the OT.

The surgery itself can be accomplished in two ways:

The traditional approach is by open carpal tunnel surgery, whereby a longitudinal skin incision is made in the wrist and the carpal ligament cut to relieve the pressure on the median nerve. Incisions generally have become smaller over the years, and the so-called "mini" 2cm skin incision have become the standard length now.


Surgery takes about 20 minutes and can be done under  local anaesthesia although my preference is to do it under general anaesthesia, unless there are contraindications.

Torniquet applied to prevent bleeding

Local anaesthesia injected

Checking for the landmarks

Incision over the wrist

Incision deepened

The carpal ligament is cut

The underlying median nerve could be seen

Wound washed and closed 

Post operatively, the patient will feel relief from the night pain, as early as the day after surgery. Numbness of the fingers will take a bit more time to disappear, as is wasting of the hand muscles which will be the last to recover.

Sutures are usually taken off at two weeks and patients are advised not to lift heavy objects or to grip tightly for the next 4-6 weeks. There might be some weakness of the hand grip but this will also recover over time.

Another, more minimally invasive method would be through the endoscopic method. A small incision is made at the wrist and a small camera, together with a knife, introduced into the wound to see the carpal tunnel. The ligament is then cut below the skin by the knife. Proponents of this technique claim shorter recovery time and less post operative pain. The downside is the complexity of the procedure as it necessitates more (expensive) equipment and has a steeper learning curve on the part of the surgeon.

- the BOMOH TULANG -

Forearm - Single bone fracture

As I explained in the previous post, we had to operate on the patient with a forearm fracture.

Basically what she had was a fracture of the distal 1/3 of the radius with a concomitant dislocation of the distal radio-ulnar joint (the so-called "Galleazi Fracture" - medical students, take note :) )

Can we treat this non-surgically? I mean people have been treating fractures of the forearm with splints and POP for years right? Well with the advent of modern orthopedic management, that line of treatment has been largely abandoned.
We know that with this fracture, a treatment regimen consisting of closed reduction and cast immobilization has a high rate of unsatisfactory results. Patients will have problems with malunion, pain at the distal radio-ulnar joint, and worse still pronation and supination of the forearm will be severely compromised.
Therefore open reduction of the radial shaft fracture and internal fixation with dynamic compression plate is the treatment of choice in adults. Rigid anatomical fixation of the radial shaft fracture generally reduces the distal radioulnar joint dislocation.

Ladies and Gentlemen, I now present to you the post op x rays:

Tadaa! As you can see, the fractured bone has been aligned in place and the distal radio-ulnar joint is reduced.

Patient went back to work at 6 weeks.. as a GP (!)


- the BomohTulang -

First surgery!

We had our first surgery in our brand new centre the other day, the 3rd day of business.

(well technically I wasn't the first lah, but it was the first Orthopedic case, so that counts right? :P)

Our patient, a 52 year old lady came in to the ER with a broken forearm, after her car skidded somewhere in Kota Kemuning. No other injuries fortunately, so it was a relatively straightforward surgery.

 That's the exterior view of Columbia Asia Hospital Bukit Rimau, btw

 In the OT

Posing for the camera.. ( err yes I do work sometimes) 

.. and presenting to you Dr Paul the anaesthetist in the background..

With the OT staff.. hoping to get busier soon!

 - the BomohTulang -