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   Table of Contents - Current issue
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January-June 2019
Volume 11 | Issue 1
Page Nos. 1-73

Online since Monday, August 19, 2019

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ORIGINAL ARTICLES  

Analysis of efficacy in postoperative use of closed suction drain in cases of traumatic dorsolumbar spine injury p. 1
Vineet Kumar, Ajai Singh, Shah Waliullah, Deepak Kumar
DOI:10.4103/jotr.jotr_6_18  
Introduction: The use of closed suction drain has been controversial considering its utility in reducing infection and hematoma formation in the postoperative period. This study aims at analyzing the use of closed suction drain in patients of traumatic dorsolumbar spine injury managed by open posterior instrumentation. Materials and Methods: A total of 110 cases of traumatic spine injury with neurological deficit in the age group 18–65 years of either sex were included in this study. All the patients were managed by short-segment fixation without open decompression of the cord and without primary fusion. The use of closed suction drain in the postoperative period was randomized by randomized controlled trial table. Results: On comparing the difference between pre- and post-operative hemoglobin, C-reactive protein, visual analog scale, and duration of hospital stay, there was no statistically significant difference between the two groups. Conclusion: The use of closed suction drain in posterior instrumentation done for the cases of traumatic dorsolumbar spine injury within described parameters did not reduce postoperative wound infection, clinically significant hematoma formation or risk of further neurological injury.
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Functional outcome of subtalar arthrodesis in posttraumatic arthritis p. 6
Nilesh Kumar Jangir, Mahesh Sharma, Mahaveer Meena, Purushottam Jhanwar
DOI:10.4103/jotr.jotr_2_19  
Introduction: Involvement of the subtalar joint in fracture calcaneus malunion may give rise to chronic pain and permanent functional impairment. This study evaluated the functional result of subtalar joint fusion and effectiveness of a technique using double lag screw from the posteromedial calcaneus to the talus. Materials and Methods: In between April 2015 and April 2017, we performed 12 isolated subtalar arthrodeses by double lag screw technique from posteroinferior calcaneus to talus. The average patient age was 39 (range 28–50) years. There were 9 males and 3 females. Results: Eleven out of 12 joints were fused except one who developed infection, resulting in an overall fusion rate of above 91%. The average time for fusion was 4.5 months (ranging from 3 to 6 months). There was no correlation between the type of accident, the weight of the patient, and the recovery period. Conclusion: Using the double lag screws of 6.5 mm across the posterior facet of subtalar joint resulted in fusion of joint in above 91% of patients. The relief from pain was obtained in 100% of cases. This is a simple and reliable technique for achieving fusion of the subtalar joint.
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Functional outcome after management of displaced proximal humerus fractures using angle-stable plates: A prospective study p. 10
Vipin Sharma, Navneet Kohli, Seema Sharma
DOI:10.4103/jotr.jotr_3_19  
Background: Management of three- and four-part fractures proximal humerus is a surgical challenge. Plate and screw fixation of these fractures is a viable treatment option. The aim of the present study is to analyze the clinical results after proximal humerus fracture fixation using angle-stable implants. Materials and Methods: Forty-eight patients (48 fractures) of the proximal humerus (three and four part, Neer classification) were treated at our institute by proximal angle-stable plates. Patients between 27 and 85 years presented to us during the study (Mean = 51.104 years, range = 27–85 years) over a 1-year and were operated by open reduction and internal fixation with angle-stable plates. Patients were followed up at 3, 6, and 9 months and evaluated using the Constant-Murley and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Results: The mean follow-up period was 24 months (8–60 months). Fractures united at an average of 12 weeks (range 8–16 weeks) with a mean follow-up of 1.5 years (10–18 months). The mean Constant-Murley and mean DASH scores at final follow-up visit were 67.438 and 17.154, respectively. Conclusion: Despite some complications, the locking plate system is quite efficient in the management of three- and four-part fractures proximal humerus.
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Role of antibiotic-impregnated cement intramedullary nail in infected nonunion of long bone diaphyseal fractures p. 16
Vikas Chavan, Vimal Kumar Bairwa, Purushottam Jhanwar, Arvind K Bohra
DOI:10.4103/jotr.jotr_4_19  
Introduction: Infected nonunion of long bones is a chronic and debilitating disorder to manage. The problems in treating them are infection, instability, and deformity. This study aims to evaluate the effectiveness of antibiotic-impregnated intramedullary nail as a management for infected nonunion of long bones. Materials and Methods: A total of 12 cases of infected nonunion of long bones (10 – tibia and 2 – femur) without bone loss and age group of more than 18 years are treated using antibiotic cement-coated k-nail. Antibiotics used are vancomycin 4 g and clindamycin 2 g. The average duration of retention of antibiotic nail was 24 weeks. Results: At follow-up, infection was controlled in 90% of cases. Bony union achieved in 8 out of 12 cases (66%). Rest 4 cases required further additional procedures. Recurrence of infection occurred in two cases. Conclusions: This is a very effective and economical with better patient compliance. This method achieves infection control, promotes bone union, and mechanical stability.
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Use of flexible intramedullary nailing in treating diaphyseal fractures of long bone of lower limb in children p. 21
Sanjay Kumar Ghilley, Manoj Kumar Meena, Purushottam Jhanwar, Harish Kumar Jain
DOI:10.4103/jotr.jotr_5_19  
Background: Management of diaphyseal fractures of long bones of the lower limb in the age group of preschool to early teenage has multiple methods of treatment ranging from conservative management to internal fixation using open/closed reduction methods. Objective: The study was performed to know the potential of using principles of intramedullary nailing in treating diaphyseal fractures of long bones of the lower limb in preschool to early teenage population. Materials and Methods: Patients with diaphyseal long bones fractures of tibia and femur in between the age group ranging from 5 to 14 years were treated by closed reduction and internal fixation using titanium elastic nailing system (TENS) nail. The results were evaluated on the basis of radiological signs of union and Flynn's criteria. The average time after which surgery was done is 2 days. Results: Of 14 patients, eight patients had diaphyseal femur fracture and remaining six had diaphyseal tibia fracture treated by TENS nailing.Thirteen patients achieved union in a mean time of 8 weeks with full-weight-bearing in around 10 weeks. The average time duration of hospital stay was 6 days and follow-up period was up to 24 weeks. Conclusion: The use of flexible intramedullary nailing in properly selected patients in the preschool to early teenage population is an effective method of treating diaphyseal fractures of long bones of the lower limb.
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Modified mid palmar flap for middle finger tip injuries: A review of 12 cases p. 27
Ramneesh Garg, Sheerin Shah, Sanjeev Uppal, Rajinder K Mittal, Bhavya Thakur, Soheb Rafique
DOI:10.4103/jotr.jotr_9_19  
Background: Fingertip is the most commonly injured area of the hand. The two most commonly advocated flaps for fingertip reconstructions are cross finger flap and thenar flap. There is another flap, raised from the middle of the palm, midway between thenar and hypothenar eminence, called the mid palmar flap which never became popular because of inherent drawback of causing extensive joint contractures. To overcome the problem of joint contractures we added extra 5 mm to the length of flap and separated it by 14 days. Aims and Objectives: This study was conducted to review the outcome, in terms of joint contracture and scar aesthetics in middle finger tip injuries covered with modified Mid palmar flap. Material and Methods: The present study was done in the Department of Plastic Surgery, at Dayanand Medical College & Hospital, Ludhiana, Punjab. Various variables analysed were age, sex, mode of injury, hand dominance, associated fractures and exposed bone. All cases were done under local anaesthesia. Time to division ranged from 12- 14 days. Results: A total of 12 patients were included in this study. The mean age of patients was 35 years. The most common mode was accidental machine injury. The dominant hand (right) was injured in 5 patients. There was associated distal phalanx fracture in 5 patients. There was exposed bone in 7 patients. There was no reported case of hypertrophic scarring at donor site. Scar tenderness was there in 3 of the 12 patients and it persisted for maximum of 6 weeks. PIP and DIP joint stiffness was there for initial 10 days. Conclusion: For middle finger tip injuries, mid palmar flap, with modifications as described, could be better than thenar flap.
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Intra-articular fracture distal end radius external fixation versus locking volar radius plate: A comparative study p. 31
S.P.S Gill, Manish Raj, Santosh Singh, Ajay Rajpoot, Ankit Mittal, Nitin Yadav
DOI:10.4103/jotr.jotr_11_19  
Introduction: The purpose of the present study was to compare the results obtained by management of intra-articular fractures of distal end radius with closed reduction and external fixation versus open reduction and internal fixation with locking distal radius volar plate. Material and Method: The present study included 60 patients of distal intra-articular radius fractures. Patients were randomly divided into two groups: group I (close reduction and external fixator) and group II (open reduction and internal fixation with volar plating). Periodic clinical examination and x-ray review was carried out to find out functional outcome,range of motion, radiological outcome and complication. Patients were followed up for 6 month. Mean of all the quantitative variables was compared between two groups by unpaired 'T' test. Functional outcome was measured with Quick DASH score. Result: In present study palmer tilt,radial length and radial inclination was significantly greater in volar plate group.ulnar varience was more(-1.18mm) in volar plate group than external fixator group(-1.28mm). The mean QuickDASH scores and time to return to work were similar in patients treated with a locking plate and external fixator (QuickDASH score 2.4 ± 3.0 and 2.9 ± 5.4; 1.9 ± 0.5 months and 2.1 ± 0.7 months, respectively; P > 0.05).In present study Quick DASH score in ext fix group was 9.71 compaired to volar plating group 6.79 at the final followup. Complication rate were higher in close reduction and external fixation group as compared to open reduction and volar plating group. Conclusion: Open reduction and internal fixation with plate fixation had better functional outcome with less complication rate than close reduction and external fixation in management of intra-articular fractures distal end radius.
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Intra-articular fracture distal end radius external fixation versus locking volar radius plate: A comparative study p. 31
S.P.S Gill, Manish Raj, Santosh Singh, Ajay Rajpoot, Ankit Mittal, Nitin Yadav
DOI:10.4103/jotr.jotr_11_19  
Introduction: The purpose of the present study was to compare the results obtained by management of intra-articular fractures of distal end radius with closed reduction and external fixation versus open reduction and internal fixation with locking distal radius volar plate. Material and Method: The present study included 60 patients of distal intra-articular radius fractures. Patients were randomly divided into two groups: group I (close reduction and external fixator) and group II (open reduction and internal fixation with volar plating). Periodic clinical examination and x-ray review was carried out to find out functional outcome,range of motion, radiological outcome and complication. Patients were followed up for 6 month. Mean of all the quantitative variables was compared between two groups by unpaired 'T' test. Functional outcome was measured with Quick DASH score. Result: In present study palmer tilt,radial length and radial inclination was significantly greater in volar plate group.ulnar varience was more(-1.18mm) in volar plate group than external fixator group(-1.28mm). The mean QuickDASH scores and time to return to work were similar in patients treated with a locking plate and external fixator (QuickDASH score 2.4 ± 3.0 and 2.9 ± 5.4; 1.9 ± 0.5 months and 2.1 ± 0.7 months, respectively; P > 0.05).In present study Quick DASH score in ext fix group was 9.71 compaired to volar plating group 6.79 at the final followup. Complication rate were higher in close reduction and external fixation group as compared to open reduction and volar plating group. Conclusion: Open reduction and internal fixation with plate fixation had better functional outcome with less complication rate than close reduction and external fixation in management of intra-articular fractures distal end radius.
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Assessment of spinal arthrodesis in dorsolumbar spine trauma using hydroxyapatite, tricalcium phosphate, and 60% hydroxyapatite + 40% tricalcium phosphate: A comparative study p. 44
Sumanta Pal, Kiran Kumar Mukhopadhyay, Anant Kumar Garg, Sanjay Kumar, Pradip Mukherjee
DOI:10.4103/jotr.jotr_13_19  
Study Design: Open level experimental design. Purpose: Ceramics are effective, safe, and good alternatives of iliac crest autograft for spinal fusion. There were not enough study available to compare among ceramics for fusion in spinal surgery. Our aim was comparative assessment of posterolateral spinal arthrodesis radiologically and clinically in dorsolumbar spine trauma using hydroxyapatite (HA), tricalcium phosphate (TCP), and 60% HA + 40% TCP. Overview of Literature: Surgical management of thoracolumbar spine injury has encouraged early rehabilitation and avoided adverse effects of prolonged recumbency. Instrumentation enhanced spinal fusion which was the main technique of spinal stabilization. Although iliac crest autograft is the gold standard for spinal fusion,the procedure is not devoid of major and minor complications. A variety of ceramics are available as good alternatives for spinal arthrodesis. There are not any studies in the literature comparing spinal fusion rate among commonly used ceramics. Materials and Methods: Patients having Thoraco Lumbar Injury Classification and Severity score ≥4 underwent pedicle screw fixation and decompression (if required). We applied chips of HA, TCP, or 60% HA + 40% TCP for fusion. At 12-month follow-up, computed tomography scan of involved spine was done to assess posterolateral fusion by Lenke classification. Clinical follow-up was done evaluating pain status (visual analog scale). Mean follow-up duration was 27.8 months. Radiological and clinical parameters were compared among three groups. Results: A total of 45 patients (16 received HA, 15 received TCP, and 14 received [60%HA + 40%TCP]) were analyzed. About 28.88% of total patients had Lenke Grade A fusion and 51.11% had Grade B, but no statistically significant difference (P = 0.09) among three groups. Although reduction of pain score occurred individually in all three groups,no significant difference (P = 0.3)was noted among three groups. Conclusions: There was no statistically significant difference in fusion rate and change in pain perception with applied ceramics (HA/TCP/[60%HA + 40%TCP]).
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Effect of daily teriparatide for delayed union of fracture neck of the femur p. 49
Jitendra Kumar Mishra, Nirmal Chandra Mohapatra, Bikram Keshari Kar
DOI:10.4103/jotr.jotr_16_19  
Background: Delayed union and nonunion of fracture neck of the femur remains a therapeutic challenge to orthopedic surgeons worldwide which is why this fracture is aptly named as unsolved fracture. Hip joint preservation surgery always remains the primary criteria in fracture neck of the femur in physiologically young patients. However, the outcome is not always satisfactory due to many factors, delayed presentation being one of them. This case series was conducted to determine and establish the role of recombinant teriparatide in fracture healing in delayed union of fracture neck of the femur. Materials and Methods: The study was done on nine cases (six males and three females) of delayed union of fracture neck of the femur with a previous history of some surgical interventions. All cases of delayed union were diagnosed by clinically and radiologically and undergone all routine blood investigations. All were administered 20 μg of teriparatide (recombinant parathormone) subcutaneous injection daily for a period of 3–5 months. Results: Eight patients who were evaluated clinically and radiologically showed satisfactory union and one case showed nonunion. One patient showed mild allergic reaction. Conclusion: This study showed that daily administration of teriparatide accelerates fracture healing in delayed union. It also enhances fracture healing throughout the period of bone remodeling phase. It also emphasizes the safety of teriparatide.
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Management of supracondylar/intercondylar distal humerus fractures using triceps-reflecting anconeus pedicle approach p. 53
Rakesh Verma, Rahul Choudhari, Arvind Kumar Bohra, Shiv Bhagwan Sharma
DOI:10.4103/jotr.jotr_19_19  
Introduction: Chevron olecranon osteotomies are commonly used for intra-articular distal humerus fractures but are often associated with complications such as prominence of hardware, displacement, and nonunion of osteotomy. We studied the triceps-reflecting anconeus muscle pedicle approach (TRAP) with preservation of the extensor apparatus as a safe alternative, giving a sufficient exposure to the elbow joint. Materials and Methods: We reviewed the functional and radiological results of thirty consecutive patients with intercondylar fractures of the humerus treated by internal fixation through TRAP approach. The average age of the patients was 32 ± 4.5 years. Results: At a minimum follow-up of 12 months (average 18 ± 4 months), 27 (90%) patients had good triceps strength. The average range of motion was 118.4° ± 7° (range, 80°–130°). The average time to union was 3.2 ± 1.6 months. No patient had triceps rupture, implant failure, neurovascular deficit, or nonunion. One patient needed removal of the implant because of subcutaneous prominence. Conclusion: TRAP approach provides good visualization for fixation of intercondylar fractures of the humerus, without any noticeable untoward effect on triceps strength and postoperative rehabilitation; hence, one can avoid iatrogenic fracture of the olecranon and its associated complications.
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Long-term outcome of octogenarians with non-operatively treated distal radius fractures p. 57
Freek A van Brussel, Eva A. K van Delft, Charlotte J. L Molenaar, Karlijn J van Stralen, Niels W. L Schep, Jefrey Vermeulen
DOI:10.4103/jotr.jotr_24_19  
Introduction: Distal radius fractures in patients over 80 years old are traditionally treated non-operatively. The aim of this study is to evaluate patient-reported outcome in octogenarians treated non-operatively for a distal radius fracture. Methods: Retrospective case study of all consecutive patients over 80 years old, treated non-operatively for a distal radius fracture after 1 year. The primary outcome was evaluated by the patient-rated wrist evaluation (PRWE) and quick disability of the arm, shoulder, and hand (qDASH) questionnaire, which were collected prospectively. Secondary outcomes were radiographic characteristics. Results: A total of 124 patients were included, male/female: 4/120, median age of 85 years. Fracture types were mainly Type A and C. The median follow-up was 1.3 years, 18 patients died and 6 patients were lost to follow-up for other reasons. The median PRWE score after follow-up was 3.25. Median qDASH score was 6.82. Only redisplacement after 1 week was associated with poorer outcome. Conclusion: The overall long-term patient-reported outcome of octogenarians with non-operatively treated distal radius fractures with or without deformity is excellent.
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Management of adhesive capsulitis of shoulder joint by single platelet rich plasma injection p. 62
Alok Chandra Agrawal, Buddhadeb Nayak, Harshal Sakale
DOI:10.4103/jotr.jotr_28_19  
Introduction: Adhesive capsulitis of shoulder is a condition characterized by painful and global restriction of active and passive glenohumeral range of motion in at least two directions, most notably shoulder abduction and external rotation. Platelet-rich plasma (PRP) is an emerging treatment option and its efficacy needs to be examined. Aim: The aim of the study is to assess the efficacy of PRP injection in the treatment of adhesive capsulitis of the shoulder joint. Materials and Methods: Patients with adhesive capsulitis received a single injection of PRP (4 ml) (n = 20). All participants were also advised to perform a home-based 10 min exercise therapy after injection. The outcome was measured using Constant and Murley shoulder score. Participants were evaluated at 0, 3rd day, and 1 month. Unpaired t-test tests were used to determine significant differences. Results: PRP treatment showed increase in pain for few participants at the 3rd day, causing decreased active range of motion. However, at 1 month, PRP treatment resulted in statistically significant improvements in constant score. No major adverse effect was seen in PRP injection. Conclusion: This study demonstrates that single injection of PRP improves both in pain and all range of motion of shoulder joint.
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Management of adhesive capsulitis of shoulder joint by single platelet rich plasma injection p. 62
Alok Chandra Agrawal, Buddhadeb Nayak, Harshal Sakale
DOI:10.4103/jotr.jotr_28_19  
Introduction: Adhesive capsulitis of shoulder is a condition characterized by painful and global restriction of active and passive glenohumeral range of motion in at least two directions, most notably shoulder abduction and external rotation. Platelet-rich plasma (PRP) is an emerging treatment option and its efficacy needs to be examined. Aim: The aim of the study is to assess the efficacy of PRP injection in the treatment of adhesive capsulitis of the shoulder joint. Materials and Methods: Patients with adhesive capsulitis received a single injection of PRP (4 ml) (n = 20). All participants were also advised to perform a home-based 10 min exercise therapy after injection. The outcome was measured using Constant and Murley shoulder score. Participants were evaluated at 0, 3rd day, and 1 month. Unpaired t-test tests were used to determine significant differences. Results: PRP treatment showed increase in pain for few participants at the 3rd day, causing decreased active range of motion. However, at 1 month, PRP treatment resulted in statistically significant improvements in constant score. No major adverse effect was seen in PRP injection. Conclusion: This study demonstrates that single injection of PRP improves both in pain and all range of motion of shoulder joint.
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Early results of clubfoot management by Joshi's external stabilizing system p. 66
Alok C Agrawal, Sharath Kowshik, Bikram Keshari Kar
DOI:10.4103/jotr.jotr_29_19  
Introduction: With the use of Ponseti's technique, majority of children with clubfoot do not need operative treatment; however, some severe clubfoot including neglected, recurrent, and resistant forms cannot be managed by conservative methods and needs surgical intervention. The foot becomes rigid with soft tissue surgery, and bony operations can make the foot even more smaller. To avoid it, a simple alternative is to use joshi's external stabilising system (JESS) and distractor components which are used on the principle of controlled differential fractional distraction histogenesis. JESS distractors allow gradual distraction of contracted soft tissues and align all the joints of the foot so as to bring corrections of all aspects of deformity of the foot simultaneously. Purpose: To analyze the role of JESS fixator in correcting case of clubfoot in terms of cosmetic, functional, and anatomical outcome which were assessed by International Clubfoot Study Group (ICFSG) scores. Materials and Methods: Total of 6 Clubfoot underwent differential fractional distraction in AIIMS, Raipur. Patients were assessed preoperatively for morphology and functionality and radiologically by ICFSG score. Period of correction varied from 5 to 8 weeks. Once correction is obtained, then apparatus is locked in that position for the same period and later converted to cast in plantigrade for maintenance and followed up regularly. The results were analyzed with ICFSG score. Results: Excellent to good results were obtained in all the cases which were assessed by ICFSG score. There were only minor complications in patients. Conclusion: JESS frame is simple, versatile, and best suited for correcting clubfoot deformities which were neglected, resistant, and recurrent.
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CASE REPORT Top

Peritalar fracture dislocation: A case report with review on its biomechanics p. 70
Raju Karuppal, Jipin Gopi, Jacob Mathew, Sandhya Somasundaran
DOI:10.4103/jotr.jotr_64_17  
Peritalar dislocations are very rare injuries involving a simultaneous dislocation to both the subtalar and talonavicular joints. Mostly, they result from high-energy trauma such as road traffic accident and may also result from sports injuries. The most common type is medial dislocation. An inversion force in medial dislocation and an eversion force in lateral dislocation are applied to a plantar flexed foot. The treatment modalities for most peritalar dislocations include closed reduction and below-knee cast, although surgical intervention may be required in failed close reduction. We report a case of medial peritalar dislocation and comminuted fracture involving the posterior aspect of the talus with literature review on its biomechanics. A thorough knowledge of the biomechanics is essential for its better understanding and successful reduction maneuver.
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LETTER TO EDITOR Top

Chemoprophylaxis for deep vein thrombosis after hip surgery: Clinical guidelines and treatment options p. 73
Tan Yeow Leng, Lee Jun Yin
DOI:10.4103/jotr.jotr_20_19  
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