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Case Study
 
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  1 This 30 year old lady presented at AO Clinic 1 year after a shot gun injury to her right Humerus. She had previously been operated 3 times in various private Hospitals outside Karachi. On presentation she had painless flail mid shaft Humerus. A long Condyler buttress plate was applied with tricortical bone graft .In about 3 months there were radiological signs of union to her Right Humerus and this patient was able to function her upper limb again 30 Years
  2

This 42 year old patient presented to AO Clinic 3 months after she sustained a medium velocity gunshot injury to her left distal 1/3 Humerus. Initially she had an external fixator applied at a private hospital elsewhere in the city. On presentation she had high grade fever and pus discharge from pin tracts of the external fixator. Initially the external fixator was removed and sequestrectomy was performed and a brace was applied.  After her blood picture improved and wounds settled she had an anterior spoon plate applied with bone graft. Fully bony union was achieved after 4 months

42 Years
  3

This 7 year old young boy presented at AO Clinic after an accidental gunshot injury to his right distal Humerus. He presented 2 days after injury with a wrist drop .A distal radial plate was applied together with a Circlage wire and intra fragmentary screw. This young boy achieved fully bony union and recovered from partial tear of his radial nerve after repair.

07 Years
  4

This 56 year old diabetic gentleman presented to AO Clinic with an 11 month old non union to his left radius and ulna. He was initially treated at a local hospital in Karachi with rush nails. As you can see looking at his AP and lateral views he has a segmental fracture not only of his radius but also of his ulna.  He was treated with a compression plating of both his radius and ulna augmented with tricortical bone graft. He achieved full bone union with full range of movement and no restriction of supination and pronation.

56 Years
  5

This 44 year old gentleman presented to us six and half month after an open fracture which was treated in the Kingdom of Saudi Arabia with an Ilizarov frame. On presentation this patient was in agonizing pain and had pus discharge from pin track sites. His Ilizarov frame was removed and fixation was carried out using a dynamic compression screw with extensive bone graft augmented with a cerclage wires. Full bone union was achieved in about six months and at present patient is walking full weight bear without any pain. He has limited flexion to about                100 degrees.

44 Years
  6

This 50 year old gentleman presented to us with a fracture of his intramedullary fibula which was inserted into his humerus for a previous gunshot injury which was treated three years ago at a private hospital in Karachi. A sequestrectomy was performed and a locking plate was applied which was augmented with bone graft. It took about three months for the patient achieved full bone union and patient has resumed his job as a car driver.

50 Years
  7

This 40 year old patient attended AO Clinic with a three month old injury to his distal 3rd of his radius which was treated primarily at a private hospital in Lahore with a one third tubular plate and six screws. Removal of metal was carried out and a mini dynamic compression plate was applied which was augmented with bone graft from his iliac crest. Full bone union was achieved in a few months and the patient is now using his upper limb with no restriction of movements.

40 Years
  8

This 50 year old gentleman presented three months after a comminuted fracture to his distal 3rd of his left humerus which was treated initially in a private hospital with Steinmann pin which was inserted through his humeral head together with a back slab. A posterior approach was performed and a spoon plate was applied which was augmented with bone graft. Patient has achieved full bone union and has full extension, lacks about 10 degrees of full flexion.

50 Years
  9

This 13 year old girl presented to AO Clinic after an incision and drainage was performed in a local private hospital in the city. As you can see in the xrays there is a sequestrum present in the mid shaft of her humerus surrounded by an involucrum. She had multiple sinuses present over her arm and was in immense pain. An extensive sequestrectomy was performed with periosteum left behind and all of the mid shaft of humerus was excised. After about five months fixation was carried out to her right proximal humerus. After three months there was good radiological signs of union and the patient was able to use her right upper arm. She has excellent range of movement, as you can notice she has about 2-3 cm shortening of her right humerus. 

13 Years
  10

This 33 year old patient presented to AO Clinic six months after being operated abroad for distal humeral fracture. He was managed in a private hospital with an intramedullary nail together with three intrafragmentary screws applied at distal 3rd of humerus. He was taken to theatres. His metal work was removed and a spoon plate augmented with bone graft was applied to his distal humerus. Radiological bone union was achieved in about three monthís time and this patient is back to his previous job as a forklift driver. At presentation this patient had a wrist drop and during surgery neurolysis was performed, 3-4 months post op he has made a full neurological recovery and has full wrist extension.

33 Years
  11

This 40 year old patient presented five months after being operative in a private hospital in the city of Karachi. He presented with immense pain around his right proximal tibia, there were multiple sinuses present over the lateral aspect of his proximal tibia as well. Looking at his previous xrays a lateral buttress T plate was applied. Removal of metal was performed with an extensive sequestrectomy of his right proximal tibia. After this patientís wounds healed and his ESR and CRP came back to normal a condylar buttress plate was applied with tricortical iliac crest craft together with cancellous iliac crest craft. At about four months there were radiological signs of union and the patient was commenced on touch toe weight bearing status. The patient was allowed to full weight bear just at five months with full knee flexion and extension. As you can see from his last xrays he has achieved full bone union.

40 Years
  12

This 28 year old patient presented five months after a closed fracture of his mid shaft of his left humerus. He was initially treated in a local private hospital with an intramedullary nail which was proximally and distal locked together with a cerclage wire at the fracture site. As you can see in one of slides the yellow avascular piece of bone was excised and a broad dynamic compression plate augmented with bone graft was secured to this patientís humerus. Patient went on to full bone union and has no complaints.

48 Years
  13

This 23 year old patient presented 3-1/2 months after a gun shot injury to his right radius and ulna treated with rush nails in a private hospital in the northern parts of Pakistan. At presentation in our casualty department he was in considerable pain. He was taken to theatres, metal work was removed and AO Plating of his radius and ulna was carried out which was augmented with cancellous bone graft from iliac crest. At around four months there was evidence of radiological union and the patient was pain free.

23 Years
  14

This 50 year old patient presented at AO Clinic after one year of his initial injury, in which he fractured his left proximal femur. He was treated at a local Karachi hospital with an intramedullary nail which was locked proximally. Looking at his AP xray the butterfly fragment seems to be avascular and there was hardly any contact between the proximal and distal fracture ends, showing non union. Removal of metal followed by a DCS using extensive tricortical bone graft augmented with cancellous bone graft was carried out. It took him three months to achieve radiological union and the patient is walking pain free.

50 Years
  15

This 65 year old lady presented two months after a fracture to her proximal ulna which was initially treated elsewhere using a semi tubular plate with three cancellous screws at the proximal end and three screws of the distal end. This injury was compounded with a fracture of her radial head as well. Her radial head was excised together with application of a compression plate with bone graft through a single incision. Post operatively patient had signs of union in about three months and had no restrictions in flexion and extension supination and pronation of her right upper limb.

65 Years
  16

This 23 year old gentleman sustained a medium velocity gun shot injury to his left femur. He had been previously treated with an external fixator in the northern parts of Pakistan and presented to us a year after his injury with multiple sinuses on the lateral aspect of his left femur. An extensive sequestrectomy was performed and once his skin condition healed and blood ESR and CRP decreased. Fixation was carried out with using a dynamic compression plate which spaned the entire femur augmented with extensive tricortical bone graft. It took approximately 3-4 months before the union was present radiologically and patient was commenced weight bearing.

23 Years
  17 This 55 year old gentleman attended AO Clinic after eight months of his initial injury to his right hip joint. He sustained a pipkin type one fracture to his right femoral head and was treated conservatively in a local hospital. This patient was in extreme pain and therefore a total hip replacement was performed. Post operatively patient is walking pain free and, a normal gait. 55 Years
  18

This 70 year old patient attended AO Clinic with a ten month old non united proximal tibial fracture on the left side. There were multiple sinuses present around the fracture site and therefore removal of metal together with a sequestrectomy of his proximal tibia was performed. Once his blood which included ESR, CRP settled down a broad compression plate augmented with bone graft was performed. Radiological union was evident in two and half months and patient was commenced full weight bearing three and half months after his surgery. Patient has no limitations of knee movement and has equal leg lengths.  

70 Years
  19 This 25 year old gentleman presented 2-1/2 years after he was initially treated in a local hospital for a mid shaft radius/ulna fracture with rush nails. Rush nails were removed and compression plate was applied which was augmented with bone grafts. Patient went on to full bony union in a four of monthís time. 25 Years
  20

This 21 year old patient attended AO Clinic six months after he was operated for a closed distal 3rd fracture with an inter locking nail done in a local hospital in Karachi. As you can see from the xrays the entry level of the nail was well below the desired area and distal locking screws were not placed appropriately, the length of the nail was inappropriate therefore it was pinging in his distal tibia causing him great discomfort. His metal work was removed and a broad DCP was applied at his distal tibia  which was augmented with bone graft. Patient went on to full bony union and is walking pain free with no leg length discrepancy.

21 Years
  21

This 48 year old banker presented after five years of his initial injury which was then operated with compression plating of his radius and ulna. On presentation he had a deformed forearm with prominence of the ulnar head and a sinus present. An ulnar screw was protruding out of his skin. Looking at his xrays radial plate had fractured because of non union and there was a shift of the ulna distally due to the disruption of the distal radial ulna joint. A distal radial oblique T-plate was applied on the volar aspect which was augmented with bone graft. The patient went on to full bony union.

48 Years
  22

This 27 year old patient attended AO Clinic five months after she was treated for an open humeral fracture with an external fixator in one of the major northern cities of Pakistan. On presentation there were multiple sinuses present and pus oozing from the pin tracks of the external fixator. She was taken to theatres and a sequestrectomy was carried out. Once her blood came back to normal (CRP + ESR) a broad compression plate was applied which was augmented with bone graft. She presented with a wrist drop and during surgery the radial nerve was found adhered to scar tissue and hence neurolysis was performed. Full union was achieved and full range of movement of her wrist joint was accomplished within six months of her surgery.

27 Years
  23

This 13 year old young girl presented to AO Clinic after complaining of pain in her right proximal femur. She was operated in a local hospital for intracapsular fracture with cannulated screws. She was taken to theatres. Removal of metal was done and an osteotomy at the level of lesser trochanter was performed and a Muller osteotomy plate was applied. This young girl went into full union and walks pain free. 

13 Years
  24

This 13 year old young boy attended AO Clinic six months after being treated elsewhere in a private hospital in the northern parts of Pakistan. On presentation he had a sinus around his proximal 3rd of his left humerus. He was taken to theatres and an extensive sequestrectomy was performed. He was reoperated three months later once his CRP and ESRís levels came to near normal. A clover leaf plate was applied which was augmented with a tricortical bone graft. After three months there were signs of radiological union and after seven months there was full bone union and child had full range of movement of his left shoulder joint.

13 Years
  25 This 28 years old patient attended AO Clinic with chronic Osteomyelitis of his right tibia. Removal of external fixator & sequestrectomy of his right tibia was done on the 14-07-2006. After his skin healed his ESR and CRP came to normal levels, AO Plating right tibia with bone graft was performed. Patient is full weight bearing and back to his full mobility status. 28 Years
  26

This 24 year old patient attended AO Clinic after being treated elsewhere with an intramedullary nail and external fixator for an open fracture.  On admission there was a sinus at the distal 3rd of his femur with pus discharge. Removal of metal together with a sequestrectomy was performed and an interval of two months took place before this patient had his final surgical fixation.  Broad dynamic compression plate was applied augmented with bone graft to his femur. At about three months radiological evidence of union was present and he was full weight bearing by four months. There was no leg length discrepancy.

24 Years
  27 This 30 year old attended our clinic with a non united right tibia, it was initially treated at different hospital with a intramedullary nail. As you can see in one of the xrays there is a considerable gap which prevented this bone to unite.  To complicate matters there was a sinus present at the sight of the fracture gap. A sequestrectomy was performed and the bone ends freshened up and a closure of wound done and a below knee back slab was applied. After couple of months the patient was taken to theatres and a broad dynamic compression plate was applied with bone graft.  At three and half months radiological evidence of union had taken place and he was allowed full weight bearing.  The considerable bone deficit was augmented  with the bone graft therefore there was no leg length discrepancy compared to the opposite side. 30 Years
  28 This 35 year old patient was operated six months ago in a private hospital in the northern parts of Pakistan. He presented at AO Clinic with a discharging sinus and raised WBC and ESR, a sequestrectomy was performed on the 12th of October, 2009. As you can see in the pre operative xray there is a sequestrum present in the proximal part of the fracture area. His definitive fixation was carried out on the 12th of April, 2010. Once ESR and WBC were within normal ranges this tri cortical bone grafting was performed to maintain length of his tibia. As you can see from xrays done on the 10-06-2010 he has achieved full bony union and is walking full weight bearing without any pain and had no leg length discrepancy.

35 Years

View
  29 This 48 year old patient presented 11 month after a DHS which was performed for an I.T. fracture elsewhere. As you can see in the post operative xray there was cut out of the DHS which led to coxavara. Revision surgery was performed here at AO Clinic using a DHS and a sub-trochanteric osteotomy was performed which was augmented with bone grafting. This patient has achieved full bony union and is mobilizing pain free without any support.   48 Years View
  30 This 24 year old young man presented to AO Clinic after having multiple operations for his fracture of his left tibia On admission he had raised ESR and WBC, a sequestrectomy was performed together with intramedullary reaming and wash out with anti biotics and normal saline. His definitive surgery was carried out using a compression plate and tri cortical bone grafting which was secured using a screw. This patient has achieved full bony union and is mobilizing pain free with no leg length discrepancy. 24 Years View
  31 This 25 year old patient presented 4 months after being operated multiple times in a District General Hospital outside the city of Karachi. This patient was warned pre operatively that he will have a fix joint with little or no movement. A spoon plate was performed on the 10th of May, 2007 which was augmented with bone grafting. He has achieved full bony union, was able to eat and wash his face using his right hand. He has limited extension of his right elbow joint as we anticipated. 25 Years View
  32 After injury  this 50 year old patient attended a private hospital  where an external fixator was applied for a 2 centimeter open fracture. When he presented to AO Clinic after a year of his injury he had stiff right knee joint with two sinuses over a mid shaft of right tibia. A Sequestrectomy and definitive fixation was performed on the 21-07-2008 using a femoral condylar buttress plate with extensive bone grafting. He made an excellent post operative recovery and there were radiological signs of union four months post operatively. He has achieved full bony union and is full weight bearing without any leg length discrepancy.   50 Years View
24 Years
  33 This 24 year old presented to AO Clinic eight months after his primary operation which was done elsewhere. He presented with six sinuses over the screw heads of his left tibia. Removal of screws and CAREFUL localised  Sequestrectomy was performed and a plaster cast was applied post operatively. This gentleman achieved full bony union without requiring any major reconstructive surgery. View
  34 This 45 year old patient attended AO Clinic after non united painful right proximal tibial fracture. A condylar buttress plate was applied with bone graft. He went on to full bony union and is walking pain free.

Cont................

45 Years View
 
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