EditorsAnil K Jain MS, MAMS
Professor of Orthopedics University College of Medical Sciences and GTB Hospital,
Delhi, India
Editor, Indian Journal of Orthopaedics
Sudhir Kumar MS, MCh
Professor and Head Orthopedics University College of Medical Sciences and GTB Hospital,
Delhi, India
7Contributors
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
Corporate Office
4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, Phone: +91-11-43574357, Fax: +91-11-43574314
Registered Office
B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021
+91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683
e-mail: jaypee@jaypeebrothers.com, Website: www.jaypeebrothers.com
Offices in India
- Ahmedabad, Phone: Rel: +91-79-32988717, e-mail: ahmedabad@jaypeebrothers.com
- Bengaluru, Phone: Rel: +91-80-32714073, e-mail: bangalore@jaypeebrothers.com
- Chennai, Phone: Rel: +91-44-32972089, e-mail: chennai@jaypeebrothers.com
- Hyderabad, Phone: Rel:+91-40-32940929, e-mail: hyderabad@jaypeebrothers.com
- Kochi, Phone: +91-484-2395740, e-mail: kochi@jaypeebrothers.com
- Kolkata, Phone: +91-33-22276415, e-mail: kolkata@jaypeebrothers.com
- Lucknow, Phone: +91-522-3040554, e-mail: lucknow@jaypeebrothers.com
- Mumbai, Phone: Rel: +91-22-32926896, e-mail: mumbai@jaypeebrothers.com
- Nagpur, Phone: Rel: +91-712-3245220, e-mail: nagpur@jaypeebrothers.com
Overseas Offices
- North America Office, USA, Ph: 001-636-6279734, e-mail: jaypee@jaypeebrothers.com, anjulav@jaypeebrothers.com
- Central America Office, Panama City, Panama, Ph: 001-507-317-0160, e-mail: cservice@jphmedical.com Website: www.jphmedical.com
- Europe Office, UK, Ph: +44 (0) 2031708910, e-mail: info@jpmedpub.com
Neglected Musculoskeletal Injuries
© 2010, Jaypee Brothers Medical Publishers (P) Ltd.
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
First Edition: 2010
9788184488890
Typeset at JPBMP typesetting unit
Printed at
5Dedication
To our respective families, spouses and children whose love and support made this book and all other aspects of our professional career possible.
To our students and residents who, by their thirst for learning, have stimulated us to be better surgeons and teachers.
To our patients who may benefit from the current knowledge and who always inspired us to find better ways to treat their maladies.
To our teachers who have ignited fire of learning and critical analysis with biological concepts.
- Aditya Agarwal
- Associate Professor of Orthopedics
- University College of Medical Sciences and GTB Hospital, Delhi, India
- Aditya Krishna
- Additional Professor
- Postgraduate Institute of Medical Sciences
- Chandigarh, India
- Aditya V Maheshwari
- Department of Orthopedic
- Washington Hospital Center
- Irving St NW, Washington DC 20010, USA
- Ajay Pal singh
- Senior Resident
- Department Orthopedic Surgeon
- GTB Hospital, Delhi, India
- Anand Devnani
- Department of Orthopedics
- School of Medical Sciences
- Universiti Sains Malaysia
- Kubang Kerian, Kelantan, Malaysia
- Anil Arora
- Consultant Orthopedic Surgeon
- Max Hospital
- Ex-Professor of Orthopedics
- University College of Medical Sciences and GTB Hospital, Delhi, India
- Anil Dhal
- Professor and Head Director
- Maulana Azad Medical College, Delhi, India
- Anil Kapoor
- Orthopaedic Hospital and Super Specialty
- Research Centre, Amritsar, India
- Anil K Aggarwal
- Specialist in Orthopedics
- Chacha Nehru Bal Chikitsalya, Delhi, India
- Anil K Jain
- Professor of Orthopedics
- University College of Medical Sciences and GTB Hospital
- Delhi, India
- Editor, Indian Journal of Orthopaedics
- Arun Pal Singh
- Pool Officer
- University College of Medical Sciences, Delhi, India
- Augusto Sarmiento
- University of Miami School of Medicine
- Miami, Florida, 33101, USA
- Banchong Mahaisavariya
- Professor of Orthopedic Surgery
- Faculty of Medicine Siriraj Hospital
- Mahidol University, Bangkok, 10700, Thailand
- David Ring
- Instructor of Orthopedic Surgery
- Harvard Medical School
- Hand and Upper Extremity Service
- Department of Orthopedic Surgery
- Massachusetts General Hospital, USA
- Dilip Sengupta
- Assistant Professor
- Department of Orthopedic Surgery
- Dartmouth-Hitchcock Medical Center
- One Medical Center Drive, Lebanon
- NH 03756-0001, US
- Divesh Gulati
- Senior Resident in Orthopedics
- GTB Hospital, Delhi, India
- GS Kulkarni
- Fracture and Orthopaedic Hospital
- Postgraduate Institute and Swasthiyog
- Pratishthan, Miraj, India
- Hardas Singh Sandhu
- Orthopedic Hospital and Super Specialty
- Research Centre, Amritsar, India
- HS Chabra
- Chief of Spine Service and Medical Director
- Indian Spinal Injuries Centre, New Delhi, India
- Ish K Dhammi
- Senior Specialist in Orthopedics
- University College of Medical Sciences and GTB Hospital, Delhi, India
- Jesse Jupiter
- Director, Orthopedic Hand Service
- Massachusetts General Hospital
- HansjÃrg Wyss/AO Professor
- Harvard Medical School
- Yawkey Center, Suite 2100
- 55 Fruit Street, Boston, MA 02114, USA
- John Mukhopadhyay
- Consultant Orthopedic Surgeon
- Mukhopadhyay Orthopaedic Clinic, Patna, India
- Kamath Vijay HD
- Research Fellow
- Department of Orthopedic and Spine Surgery, Ganga Hospital
- Mettupalayam Road, Coimbatore, India
- Mandeep S Dhillon
- Professor and Head
- Postgraduate Institute of Medical Sciences
- Chandigarh, India
- Manoj Goyal
- Senior Resident of Department
- Orthopedic Surgeon, GTB Hospital, Delhi, India
- NK Magu
- Professor of Orthopedics
- Pt BD Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
- Neal C Chen
- Clinical Lecturer
- Medsport University of Michigan, 24 Frank Lloyd Wright, Ann Arbor, MI 48103, USA
- Parvinder Singh Sandhu
- Orthopaedic Hospital and Super Specialty
- Research Centre, Amritsar, India
- Prakash P Kotwal
- Professor and Head of Orthopedics
- All India Institute of Medical Sciences
- New Delhi, India
- Puneet Mishra
- Associate Professor of Orthopedics
- University College of Medical Sciences and GTB Hospital, Delhi, India
- R Limaye
- Fracture and Orthopaedic Hospital
- Postgraduate Institute and Swasthiyog
- Pratishthan, Miraj, India
- Rajesh Malhotra
- Professor of Orthopedics
- All India Institute of Medical Sciences
- New Delhi, India
- Ramesh K Sen
- Additional Professor of Orthopedics
- Postgraduate Institute of Medical Sciences
- Chandigarh, India
- RP Singh
- Senior Resident of Department
- GTB Hospital, Delhi, India
- S Rajasekaran
- Director and Head
- Department of Orthopedic and Spine Surgery, Ganga Hospital
- Mettupalayam Road, Coimbatore, India
- Saumyajit Basu
- Consultant Spine Surgeon
- Park Clinic and Kothari Medical Center, Kolkata, India
- Saurabh Jain
- Senior Resident in Orthopedics
- GTB Hospital, Delhi, India
- SC Gaur
- Consultant Orthopedic Surgeon
- Ex. Professor of Orthopedic
- MLB Medical College, Allahabad, India
- Shah Alam Khan
- Additional Professor of Orthopedics
- All India Institute of Medical Sciences
- New Delhi, India
- Sharad Prabhakar
- Senior Resident
- Postgraduate Institute of Medical Sciences,
- Chandigarh, India
- SK Mukherjee
- Dean and Professor of Orthopedics
- Pt Ravi Shankar Medical College
- Raipur, India
- Skand Sinha
- Specialist in Orthopedics
- Ram Manohar Lohia Hospital
- New Delhi, India
- Sudhir Babhulkar
- Director
- Sushrut Hospital and Research Centre
- Nagpur, India
- Sudhir Kumar
- Professor and Head of Orthopedics
- University College of Medical Sciences and GTB Hospital, Delhi, India
- Surendra Mohan Tuli
- Consultant Orthopedic Surgeon
- Vidyasagar Institute of Health and Neurosciences (VIMHANS), New Delhi, India
- Surya Bhan
- Consultant Orthopedic Surgeon
- Primus Hospital, Chanakya Puri
- New Delhi, India
- Ex Professor and Head
- All India Institute of Medical Sciences
- New Delhi, India
- Vikas Gupta
- Consultant and Head Surgeon
- Medicity, Gurgaon, Haryana, India
- Vrisha Madhuri
- Professor and Head
- Department of Orthopedics
- Christian Medical College, Vellore, India
It is a pleasure to write the Foreword to this book on Neglected Musculoskeletal Injuries. In any teaching hospital run by the government (public hospitals), there is a large number of patients who are seeking advice and treatment for neglected orthopedic trauma. The best strategy to eliminate neglected trauma would be to provide effective facilities for safer pre-hospital care and competent treatment of all injured persons at the first-contact hospital, and safe transfer of complicated cases (after first aid) to advanced centers. Unfortunately, there is no hope of sudden improvement in such infrastructure facilities.
Public hospitals largely cater to the needs of the lower-half of the population pyramid. A broader outlook of clinical problems in such facilities shows that nearly half of the hospital time of senior orthopedic faculty is spent on planning, innovating and improvising the treatment of neglected orthopedic trauma with scant resources. As the affluent countries do not often face such problems, the standard textbooks and scientific publications have very little to offer in the management of “neglected musculoskeletal injuries”. It is heartening to see the fraction of the team work of Prof Anil K Jain and Prof Sudhir Kumar who collected and organized the thoughts and philosophy of experienced orthopedic surgeons, who, for many years, have managed such difficult problems. I am confident that the first edition of this book is just the beginning of a much bigger project to include many more conditions.
There is no cook-book solution for most of such conditions and there are many grey areas. The dexterity and ingenuity of the treating orthopedic surgeons is constantly under challenging responsibilities. The cost of treatment in terms of financial burden, period away from work, and time taken for sound healing is nearly four times the figures of the correct and timely primary treatment. The book provides wisdom and guidelines based upon hind-sight for management of malunions, nonunions, neglected dislocations, neglected injuries of the vertebral column and its contents, and neglected injuries of vessels, nerves, tendons and soft tissues. The greatest gift of the work would be to pass on the wisdom to the next generation.
SM Tuli
ms, phd, fams
Formerly: Director
Institute of Medical Sciences
Banaras Hindu University, Varanasi, India
Presently: Senior Consultant in Orthopedics
VIMHANS Hospital, Nehru Nagar, New Delhi, India
13Preface
There is rapidly growing burden of trauma worldwide, in a wide spectrum of socioeconomic societies and a complex heterogeneous health delivery infrastructures. There is a mixture of great contrast with most advanced corporate hospital of international repute and the poorest of the health unit with no medical facility. The injuries may remain neglected as a large section of population may not have an access to modern health care either due to lack of education or because of high cost of treatment or the non-availability of transportation to reach the required place in right time. The suboptimal conditions in the management of musculoskeletal injuries either due to lack of proper training or infrastructure add to the rate of avoidable morbidity and disability.
The textbooks of fractures and dislocations mainly focus on the management of fresh trauma. The tertiary care hospitals are over-burdened in treating complicated and complex injuries which require higher expertise and are a great challenge. Those test the ingenuity of treating surgeon. It requires developing new and innovative strategies to treat neglected injuries. The treatment recommendations in this book are grounded with peer reviewed evidence and clinical experience and concise clinically relevant bibliographies. The present book has its origin in a symposium on Management of Neglected Trauma in Clinical Orthopedics and Related Research 431; Feb 2005. The overwhelming response to the symposium has stimulated us for this book.
It is our pleasure to record our indebtedness to the contributors of this book. We admire their efforts and patience to have responded to our invitation to record their experience in managing the neglected trauma.
Our purpose in writing this book has been to provide a practical and useful guidelines in the treatment of trauma that has remained untreated/neglected due to one or the other reason. This compilation may act as a nucleus for further research work and developing treatment algorithm on such clinical problems to reduce morbidity and disability.
Anil K Jain
Sudhir Kumar