No abstract

Isolated fracture of the pisiform is an extremely rare injury. Generally fractures of the pisiform are associated with fractures of other carpal bones or the distal radius. Fractures of the carpals and metacarpals account for roughly 6% of all fractures. The average incidence of pisiform fractures is 0.2% of all carpal fractures and approximately half of them are isolated fractures. Fracture of the pisiform may be missed on standard radiographs due to orientation of the fracture, improper wrist positioning, superimposition of adjacent bones, an inadequate number of projections or more obvious fractures of other carpal bones. Special radiographic projections such as carpal tunnel, scaphoid or supinated oblique view are indicated if routine AP and lateral views fail to demonstrate a fracture. MRI is the second-step imaging method in patients whose radiographs are negative or indistinct. MRI not only shows the fracture line but also shows marrow edema within the pisiform bone indicating fracture. Late sequels include pisotriquetral chondromalacia, subluxation and osteoarthritis consequent to poor alignment of the articular surfaces.

High-velocity trauma is increasing the frequency of proximal humeral fractures in the younger population. Proximal humeral fractures are the second most common upper-extremity fracture and the third most common fracture after hip fractures and distal radial fractures, in patients who are older than 65 years of age. Overall, this injury tends to follow a bimodal age distribution except 2-part fractures, which follow a unimodal distribution in the elderly. Osteoporotic, comminuted, and displaced fractures of upper-end humerus with or without compromised soft tissue were considered as complex fractures. Displaced proximal-end humeral fractures are often unstable and could be associated with injury of the rotator cuff and avascular necrosis of the head of the humerus. Avascular necrosis of the head is found in 12% to 34% cases of 3-part fracture and 41% to 59% cases of 4-part fracture. The reason attributed to this is an increased risk of loss of blood supply to the head of the humerus in 3-part or 4-part fractures. Many modalities of management, including nonoperative management, percutaneous multiple K-wire fixation, fixators, and open reduction and internal fixation by plate/screws have been described for the treatment of these complex proximal humeral fractures. Despite early exercise programs, the problem of shoulder stiffness is associated with a conservative protocol. To overcome this problem, early mobilization of the joint is mandatory, which is not possible with conservative treatment/K-wire fixator before 3 weeks. Open reduction and internal fixation requires soft tissue stripping, which may lead to higher chances of avascular necrosis of the head of the humerus and stiffness of the shoulder. Thus, the above-described complex fracture patterns present extra challenge to practicing orthopedic surgeons. In this report, we aimed to present a multiplanar external fixator assembly with the technique of indirect closed reduction of complex proximal humeral fractures. FIGURE 1. Preoperative radiographs (AP) showing comminuted fracture of proximal humerus. AP indicates anteroposterior.

An isolated dislocation of pisiform bone in a sixteen years male child has been reported here with its clinical presentation, treatment and a brief review of literature. The aim of presenting this case is its rarity due to trauma.

Introduction: This study compares the outcome of two treatment modalities of fixing neglected lateral condyle fracture of humerus in children in terms of clinical and radiological outcomes. Materials and Methods: All patients presenting to our institution were screened for eligibility by clinico-radiological evaluation. Patients were randomized into two groups i.e. Cancellous screw (CS) fixation (group I) and K wire fixation (group II). Patients were treated by open reduction and internal fixation using CS or K wires of appropriate size accordingly. (21 patients in group I and 19 patients in group II). Bone graft was used in all patients to promote osteosynthesis. Average follow up of patients was 18 months (range 11-22 months). Final outcome was measured in terms of clinicoradiological union, immobilization time, loss of reduction, gain in range of motion and functional outcome measured by Liverpool elbow score. Result: 21 patients were in group I (CS) and 19 patients were in group II (K wire). Mean age for group I and II was 7.9 and 7.5 years. Mean delay in presentation for group I and II was 14.9 and 13.2 weeks. Mean gain in range of motion (at final follow up as compared preoperatively) for group I and II was 23.5 and 17.8. Mean duration of immobilization for group I and II was 11.3 and 9.6 weeks. Mean LES score was 8.7 and 8.3 in group I and II. Union was seen in 37 cases. Three patients had pre mature physeal closure. Pin tract infection was seen in 4 patients in group II which healed by dressing and antibiotics. No patient had ulnar nerve palsy. Conclusion: Both techniques provide stable fixation, union and good functional outcome and there was no difference in the LES, however less immobilization and improvement in range of motion was seen in Group I (CS)