Rajinder Singh Gaheer

Fracture dislocation of the carpometacarpal joints on the ulnar side of the hand is an uncommon injury. These are high-energy injuries seen in motorcyclists and boxers. The mechanism of injury involves violent, forceful dorsiflexion of the wrist combined with longitudinal impact on the closed hand. This article reports a case of fracture of the base of the middle finger with dislocation of the ring and little finger carpometacarpal joints. On first examination, a diagnosis of isolated, minimally-displaced, middle-metacarpal base fracture was made and deemed suitable for nonoperative management. The hand was splinted in a plaster-of-Paris slab. Later, a true lateral radiograph showed the exact nature of the injury. The fracture was successfully treated with closed reduction under general anesthesia and transfixation using Kirschner wires. Functional results were excellent with return to work at 10 weeks and excellent grip strength at 14 weeks. This injury may be missed in an acute setting in a busy accident and emergency unit. Swelling around the wrist with shortening of the knuckle should alert the clinician towards the possibility of such an injury. On routine anteroposterior view, overlap of joint surfaces, loss of parallelism, and asymmetry at the carpometacarpal joints should raise suspicion of the possibility of a subtle carpometacarpal injury. This article highlights the importance of a high index of suspicion, a true lateral radiograph, and careful evaluation of radiographs in diagnosing these injuries. Intensive postoperative physiotherapy is vital to achieving a satisfactory outcome.

Treatment of unstable, displaced, and comminuted fractures of the proximal humerus remains challenging, and optimal treatment continues to be controversial. Fifty-six patients with displaced 3- and 4-part fractures of the proximal humerus had open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate (Synthes, Stratec Medical Ltd, Mezzovico, Switzerland). Data were collected retrospectively, and clinical and radiological outcomes were assessed. Mean follow-up was 40 months (range, 18–62 months). The study shows that the PHILOS plate gives good results in the treatment of displaced 3- and 4-part fractures of the proximal humerus. Good fracture stability can be achieved early, allowing early mobilization without compromising fracture union. Most importantly, it requires minimal soft tissue dissection, does not need contouring, and gives good stability. No differences were observed in the functional outcomes of patients younger and older than 65 years. Few complications were associated with the plate, and the number of ≥2 surgeries was minimal. The complications noted were 1 case each of superficial wound infection, failure of the plate, and persistent stiffness. One patient had screw perforation of the humeral head articular surface, and 1 had subacromial impingement. Of the 32 patients who had been in active employment before the injury, 28 returned to their previous occupation.

Bilateral spontaneous quadriceps rupture is an uncommon injury that is usually seen in association with multiple medical conditions and is frequently misdiagnosed. It is rarely seen in healthy, active individuals. This article presents a case of bilateral simultaneous and spontaneous rupture of the quadriceps tendon in a healthy, athletic, active and highly motivated patient with rapid recovery from injury and return to full sport activity within a relatively short period of time. A 65-year-old healthy man felt both knees give way while walking down stairs at home and collapsed, unable to bear weight. He was fit and well, not on any medications and basic laboratory screening was within normal limits. He was an active sportsman, horse rider, swimmer, and long-distance cyclist, and had completed a half marathon 1 month before his injury. He was diagnosed with bilateral quadriceps tendon ruptures. An ultrasound of both knees confirmed the diagnosis of full-thickness rupture. Surgical repair of both quadriceps tendons was performed 3 days after the injury. Bilateral locking brace in 10° of flexion was used to immobilize both knees and protect the repair for 6 weeks. The patient remained nonweight bearing for 2 weeks, then gradual weight bearing was commenced, with full weight bearing at 6 weeks. Intensive isometric quadriceps exercises were started on the second postoperative day. Immobilization of both knees was maintained for 6 weeks, after which full active range of motion (ROM) was initiated. At 16 weeks after the injury he had bilateral ROM from 0° to 120° flexion, with no extension lag. He was horse riding, playing golf, swimming, and walking distances up to 2 miles at that time.

Orthopedics | Drs Gaheer, Kapoor, and Rysavy are from the Department of Trauma and Orthopedics, Dumfries and Galloway Royal Infirmary, Dumfries United Kingdom.The material presented in any Vindico Medical Education continuing education activity does not necessarily reflect the views and opinions of ORTHOPEDICS or Vindico Medical Education. Neither ORTHOPEDICS nor Vindico Medical Education nor the authors