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Dr. Aman Hooda - Orthopaedic Surgeon, Mohali (2025)

$Communited Intertrochanteric femur fracture A 71-year-old female presented to our emergency department with a left-sided...$

18/06/2025

Communited Intertrochanteric femur fracture

A 71-year-old female presented to our emergency department with a left-sided 4-part intertrochanteric femur fracture with severe comminution.

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Intraoperative Tips & Tricks for Reduction
1. Maintaining Length
Initial traction was applied on a fracture table with the limb positioned in abduction and external rotation. This helped disengage the fracture fragments and restore limb length.
2. Assessing Fracture Alignment
After traction, the limb was brought into internal rotation to attempt reduction. However, satisfactory alignment was not achieved at this stage.
3. Fracture Assessment Checklist
Reduction was evaluated under fluoroscopy:
• No varus deformity
• Posteromedial cortex and calcar alignment confirmed
• Lateral view assessment was crucial
4. Posterior Sag Correction
On the lateral view, a significant posterior sag of the proximal fragment was noted. This was effectively corrected using a height-adjustable crutch placed beneath the distal femur. I’ve consistently found this technique reliable and less traumatic than aggressive manipulation.
5. Anterior Displacement of the Neck
Despite posterior alignment, the femoral neck remained anteriorly displaced. An incision was made along the planned helical blade trajectory, and an anterior lever was carefully used to bring the neck into alignment. Once reduction was satisfactory, it was held provisionally with a K-wire.
6. Implant Insertion
The entry point was made just medial to the tip of the greater trochanter. Sequential reaming was done, and a 12 x 200 mm TFNA nail was inserted. The helical blade was placed as planned.
7. Final Reduction and Fixation
After removing the K-wire, compression was achieved using the compression device, and the construct was locked in static mode for added stability.

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Postoperative Plan
• Day 1: Weight-bearing as tolerated was initiated, as the fixation was deemed stable.

12/06/2025

A 30-year-old male was brought to our emergency department after sustaining a fall from a hill. He presented with polytrauma, including blunt trauma to the abdomen and multiple orthopaedic injuries.

Initial Assessment and Management:
• The General Surgery team managed the abdominal injuries with an exploratory laparotomy and did an excellent job in stabilizing the patient.
• Orthopaedic injuries included:
• A closed, extra-articular distal radius fracture on the right side.
• A Gustilo-Anderson type IIIA open distal both bones fracture of the right leg, with a curvilinear medial wound and extrusion of the medial malleolus, which had been exposed for more than 12 hours.

Damage Control Orthopaedics:
• Once the patient was hemodynamically stable, we proceeded with damage control orthopaedics.
• The leg wound was thoroughly irrigated and debrided.
• The medial malleolus was reconstructed, and a spanning external fixator was applied.
• Neurovascular structures remained intact throughout.

Definitive Surgery Planning:

Two weeks later, after successful ICU care and clearance from the General Surgery team, the patient was ready for definitive fixation. A CT scan revealed:
1. A distal tibial plafond fracture with the following fragments:
• Medial fragment (medial malleolus)
• Central intra-articular fragment
• Anterolateral fragment (further split into anterior and posterior parts)
2. A proximal tibial shaft fracture with medial angulation and comminution.
3. A segmental, comminuted fibular fracture.

Operative Strategy:
• Positioning:
The patient was placed in a floppy lateral position without a tourniquet to reduce postoperative edema risk.
• Approach 1 – Anteromedial:
We utilized the previous medial wound to access the fracture. The tibialis anterior was carefully retracted laterally after subperiosteal dissection.
• Severe comminution was noted.
• Anterolateral and anterior fragments were intact and related well with the fibula. However, repeated clamp reductions led to malalignment of the anterolateral fragment and tibial shaft.
• Approach 2 – Posterolateral (First Window):
After provisional anterior fixation with K-wires, we proceeded with a posterolateral approach.
• The fibula was fixed first to restore length and stabilize the anterolateral fragment.
• Anterior access through a window anterior to the peroneal tendons allowed us to assist reduction.
• Return to Anteromedial Approach:
With fibular fixation done, the anterolateral fragment aligned much better.
• The joint was reconstructed and stabilized with an anatomical anterolateral plate.
• The medial malleolus was fixed using a contoured one-third tubular plate.
• Approach 3 – Posterolateral (Second Window):
Through a posterior window (posterior to the peroneal tendons), the posterior malleolar fragment was visualized, reduced, and buttressed with a contoured one-third tubular plate.
• Final Intraoperative Assessment:
The joint surface was well reconstructed and confirmed under fluoroscopy.

Postoperative Plan:
• A temporary slab was applied for a few days to aid wound healing.
• Early range of motion exercises were initiated once soft tissue conditions allowed

30/05/2025

Elbow Fracture-Dislocation

Patient Profile:
A 50-year-old male presented to the emergency department following a fall onto his right elbow from a height at home. He exhibited significant swelling, crepitus, and complete loss of elbow motion. Fortunately, there were no neurovascular deficits.

Radiological Assessment:
Initial radiographs revealed a comminuted fracture of the proximal ulna with a displaced coronoid process fracture and associated fracture-dislocation of the proximal radius. A CT scan was performed for detailed evaluation of the fracture morphology and fragment configuration. The injury was classified as a trans-olecranon fracture-dislocation – Monteggia variant.

Due to soft tissue swelling, surgery was scheduled for day 7 post-injury.

Surgical Plan:
A single posterior approach utilizing three windows was planned to address all components of the injury.

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Surgical Technique
1. Anesthesia and Positioning:
• The patient was administered general anesthesia with an additional regional block.
• Positioned in the lateral decubitus position with the right arm hanging freely.
2. Tourniquet:
• No tourniquet was used, considering the complexity of the fracture and to avoid postoperative edema. Time was not a constraint—surgical clarity and precision were prioritized.
3. Incision and Exposure:
• A single long posterior midline incision was made, and medial and lateral skin flaps were raised.
• The ulnar nerve was identified, dissected, and looped with a vessel loop for protection.
4. Medial Window:
• Normally planned between the two heads of flexor carpi ulnaris (FCU); however, in this case, the posterior medial structures were already disrupted, providing wide exposure.
5. Fracture Exposure:
• Both proximal and distal ulna were exposed. Fracture patterns were carefully evaluated.
6. Lateral Window (Kocher Approach):
• The lateral window was created through the Kocher interval to minimize injury to posterolateral structures.
• Fracture fragments from the proximal radius were retrieved and assessed for size. Osteotomy was performed to prepare for prosthesis placement.
7. Fracture Reduction and Fixation:
• Returning to the posterior-medial window, the coronoid and proximal ulna fragments were anatomically reduced and temporarily stabilized using pointed reduction clamps and K-wires.
• The coronoid was fixed with a 2.0 mm T-plate system.
• Anatomical olecranon plating was performed to restore the ulna’s posterior column.
8. Radial Head Replacement:
• An appropriately sized radial head prosthesis was selected after trial reductions.
• An uncemented radial head implant was used, achieving satisfactory stability of the posterolateral column.
9. Stability Check:
• Intraoperative stability was confirmed through a full range of flexion-extension and supination-pronation. The elbow was found to be stable.
10. Soft Tissue Repair and Closure:
• The posteromedial structures were meticulously repaired.
• Hemostasis was achieved, and layered closure was performed.

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Postoperative Rehabilitation
• Day 1: Elbow range-of-motion exercises were initiated using a hinged elbow brace to allow early functional recovery.

This surgery is dedicated as a tribute to my teacher and mentor, Dr. Deepak Negi, widely known as “The Elbow Guy of North India.”

12/04/2025

MIPPO

Patient: 28-year-old female
Presentation: Twisting injury to right ankle
Examination: Swelling, tenderness, and restricted range of motion

Imaging Findings:
• X-ray: Left distal tibia spiral fracture with concurrent fibula Weber Type B fracture
• CT Scan: No intra-articular extension; suggests supination-external rotation injury mechanism

Surgical Plan (after patient and family counseling):
• Fixation of distal tibia via MIPPO (Minimally Invasive Percutaneous Plate Osteosynthesis)
• Fibula fixation using open reduction and anatomical plating

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Intra-operative Details:
1. Position: Supine
2. Anesthesia: Regional
3. Tourniquet: Applied
4. Tibia Reduction:
• Achieved by pronating and internally rotating the distal fragment
• Temporarily held with pointed reduction clamp and K-wire
5. Fibula Fixation:
• Open reduction
• Fixed with anatomical lateral plate
6. Tibia Fixation:
• Medial column plate placed via minimally invasive technique
7. Post-op: Active range of motion started on Day 1

09/04/2025

Orthopaedic surgery isn’t just about putting in plates, nails, or screws — it’s all about how you handle the tissues.

Respect the soft tissues, and the bone will return the favour in the form of healing. That’s the unspoken rule of the game.

During our residency days, we came across all kinds of surgeons. Some were aggressive, chasing speed, stripping away soft tissues like there’s no tomorrow. Others were calm, methodical — clean dissectors who treated every layer with respect. And trust me, the tissues always remembered who handled them gently.

One of the most important things in orthopaedics is learning what not to do. That’s where the real wisdom lies.

Now let’s talk about the big debate — small vs long incisions. These so-called “small incisions” are often just a marketing gimmick. You can’t judge a book by its cover. A long incision handled with care is far better than a short one butchered in haste. After all, it’s not about the size of the cut, but the finesse in your touch.

At the end of the day, surgery isn’t a race — it’s a craft. And in this craft, soft tissue is king.

Here some intra op pictures of our cases

27/03/2025

FRACTURE DISLOCATION PROXIMAL HUMERUS

A 28-year-old female presented to our emergency department following a fall at home, complaining of pain, swelling, and an inability to move her left shoulder.

Investigations
• Radiograph: Left anterior fracture-dislocation of the proximal humerus.
• CT Scan: Neer 3-part proximal humerus fracture with anterior dislocation of the humeral head.
• Neurovascular Status: Intact distally.

Management Decision

After discussing the treatment options with the patient and family, surgical intervention with a PHILOS plate fixation was planned.

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Surgical Steps
1. Anesthesia & Positioning
• General anesthesia with an interscalene block.
• Patient positioned in the beach chair position.
2. Surgical Approach
• Deltopectoral approach utilized.
• Conjoint tendon retracted medially, rotator interval incised, and long head of the biceps tendon identified.
3. Fracture Exposure & Reduction
• Intervening soft tissue cleared.
• Three non-absorbable sutures passed through subscapularis, supraspinatus, teres minor, and infraspinatus.
• Schanz screw inserted into the dislocated humeral head, and a bone hook applied to the medial distal shaft.
• Traction applied, space created, and the head was relocated using the Schanz screw.
4. Fracture Fixation
• Reduction held temporarily using pointed reduction clamps and K-wires.
• PHILOS plate positioned, with rotator cuff sutures passed through the plate after greater tuberosity reduction.
• Reduction confirmed on intraoperative fluoroscopy (AP & lateral views).
5. Postoperative Plan
• Early passive mobilization initiated from postoperative Day 1.

02/02/2025

Metaizeau Technique for Radial Neck Fracture

Case Presentation:

An 8-year-old boy presented to the emergency department after falling from a bicycle onto his outstretched left hand, sustaining an elbow injury.

Clinical Examination:

The patient exhibited swelling and tenderness over the proximal radius. Range of motion, particularly supination and pronation, was painful.

Radiographic Findings:

X-rays confirmed a radial neck fracture.

Treatment Plan:

After discussing the case with the family, a closed reduction was planned using the Metaizeau technique with retrograde elastic nailing.

Surgical Procedure:
1. The procedure was performed under general anesthesia with the patient in a supine position.
2. A 2 mm Titanium Elastic Nail (TENS) was selected after assessing the medullary canal of the forearm.
3. One end of the TENS was bent to assist in closed reduction and maintain the anatomical alignment of the radius.
4. The retrograde insertion of the TENS was performed through the distal radius, ensuring the physis was spared.
5. The reduction was achieved in two steps:
• Distraction, which elevated the radial head.
• Rotation, which corrected the angulation at the radial neck.
6. Fluoroscopic imaging confirmed adequate reduction in all views.
7. The distal end of the TENS was bent and trimmed to prevent soft tissue impingement.

Postoperative Rehabilitation:
• Early mobilization was encouraged, with elbow flexion, extension, supination, and pronation initiated on postoperative day 1, as tolerated.
• The patient was advised to wear an arm pouch sling for three weeks.

Follow-Up:

At six months postoperatively, follow-up radiographs confirmed that fracture reduction was maintained. The patient had full range of motion with no pain or movement restrictions at the elbow.

16/01/2025

Case Summary: INFECTED NON UNION DISTAL FEMUR

Patient: 50-year-old male
Presentation: Pain, low-grade fever, inability to walk or bear weight on the left limb.
History: Distal femur plating 9 months ago (performed elsewhere) with no recent trauma.

Examination Findings:
• No sinus over the skin.
• Tenderness and abnormal mobility at the fracture site.

Investigations:
• TLC: 14,000
• ESR: 30 mm/hr
• CRP: 28 mg/L
• Triple-phase bone scan with WBC labeling: Infection localized to the fracture site.

Radiograph: infected and Atrophic non-union of the distal femur with implant failure.

Procedure:
1. Patient positioned supine under regional anesthesia.
2. Implant removal performed (screws were loose with osteolysis, especially at the fracture site).
3. Non-union site revealed friable tissue, fibrosis, and necrotic bone.
4. Complete debridement of infected tissue and resection of 5 cm of bone until healthy bone margins were achieved.
5. Dead space filled with an antibiotic-loaded bone spacer.
6. Rail fixator applied, maintaining length, alignment, and rotation.

Postoperative Plan:
• Weight-bearing as tolerated started on Day 1.
• Knee range-of-motion exercises initiated.
• IV antibiotics for 6 weeks, adjusted based on culture and sensitivity reports.

09/01/2025

Case : Intertrochanteric Femur Fracture in an Elderly Male

Presentation:
An 80-year-old male presented to our emergency department following a fall at home. Radiographs confirmed a comminuted right intertrochanteric femur fracture involving the greater trochanter.

Management:
We performed a closed reduction and internal fixation using a proximal femoral nail (PFN) with a helical blade locked in static mode. Achieving a proper reduction was our primary focus, as anatomic reduction significantly reduces the risk of screw cut-out and implant failure.

Outcome:
The patient was allowed partial weight-bearing postoperatively and progressed to full weight-bearing at six weeks. He is now walking comfortably without assistance.

Discussion:
In elderly patients with osteoporotic intertrochanteric fractures, do you prefer long-stem bipolar hemiarthroplasty over proximal femoral nailing? Or do you first attempt fixation on the fracture table with a PFN? We’d like to hear your approach in managing such cases.

01/01/2025

Case Presentation: POLYTRAUMA

A 50-year-old male presented to the emergency department following a road traffic accident. On arrival, he had a poor Glasgow Coma Scale (GCS) score and bilateral thigh deformities.

Key Findings:
1. Radiographs:
• Right femur: Closed, simple wedge/oblique shaft fracture.
• Left femur: Closed, comminuted shaft fracture.
2. CT head: Revealed a right-sided subdural hematoma, identified as the primary cause of the poor GCS. This was managed conservatively by the neurosurgical team.
3. Laboratory findings: Serum lactate was elevated at 8 mmol/L. There were no clinical signs of fat embolism syndrome (FES).

Clinical Course:
• The patient was stabilized over 5 days, with priority given to addressing life-threatening conditions. Once serum lactate levels normalized and the neurosurgical team cleared him for surgery, definitive fixation of the bilateral femur fractures was planned.

Surgical Plan and Procedure:
• Positioning: The patient was placed in a sc******ng position on a fracture table, with the right leg positioned lower and the left leg higher.
• Procedure:
1. Left femur: Closed intramedullary nailing was performed using the principles of relative stability to facilitate secondary bone healing.
2. Right femur: Closed intramedullary nailing, which was technically less complex, followed.
• Duration: Total operative time was 70 minutes.
• Postoperative care: Mobilization was initiated the following day.

19/12/2024

A 68-year-old male presented to the emergency department following a road traffic accident, complaining of pain in the right ribs and right proximal tibia region.

Initial Examination:
• Oxygen saturation: 90% with irregular breathing.
• Right proximal tibia: Swelling, crepitus, and inability to move.

Following ATLS protocol, the patient was stabilized. An above-knee slab was applied to immobilize the right leg.

Imaging Findings:
• Chest X-ray: Fractures of the 2nd to 5th ribs with mild hemothorax.
• Radiograph of the right tibia: Comminuted proximal tibia fracture with intra-articular extension, an anterolateral exit, and apex directed medially.
• CT scan: Confirmed the comminuted fracture pattern, highlighting a large fracture zone with intra-articular involvement.

Preoperative Management:

The patient was stabilized, and surgery was deferred until the swelling subsided to minimize the risk of wound dehiscence and compartment syndrome.

Surgical Management

Steps of Surgery:
1. Positioning and Anesthesia:
• Supine position with a right thigh tourniquet.
• Regional anesthesia.
2. Approach:
• Anteromedial Approach (Minimally Invasive):
• The pes anserinus was identified and lifted.
• A plate was slid in after restoring medial varus alignment, length, and rotation.
• Reduction steps:
• Middle window: The fracture apex was identified and reduced using a pointed reduction clamp.
• Distal window: A 30 cm, 3.5 mm plate was centralized, and the distal-most drill bit was placed.
• Reduction and plate position were confirmed under fluoroscopy, followed by sequential screw insertion.
• Anterolateral Approach (Minimally Invasive):
• Proximal window: Soft tissue dissection exposed the fracture site. The fracture was reduced and fixed using a 4.5 mm anterolateral hockey plate, slid in minimally invasively.
• Distal screws were inserted through the middle and distal windows on the lateral side.
3. Closure:
• The surgical site was irrigated and closed in layers.
4. Postoperative Rehabilitation:
• Knee range of motion exercises were initiated on postoperative day one.

Principle Used:

Bridge plating was employed for relative fixation to promote secondary healing.

Questions:
1. How long do you wait in proximal tibial fractures with swelling before surgery?

$A 13-year-old boy sustained a grade 1 open fracture of the left distal forearm (both radius and ulna) after a fall from ...$

06/11/2024

A 13-year-old boy sustained a grade 1 open fracture of the left distal forearm (both radius and ulna) after a fall from a bicycle. The injury included a puncture wound with an inside-out trajectory and no neurovascular deficits.

Management involved open reduction and internal fixation of the radius using a 3.5 mm limited contact dynamic compression plate (LC-DCP), followed by fixation of the ulna with a one-third tubular plate, taking care to avoid the physeal areas in both bones.

Rationale: Given the patient’s weight (54 kg) and muscular build, the rotational forces in this case are expected to be high, warranting a more stable fixation.

In similar cases, what is your approach for fixation?
• Do you prefer closed or open reduction?
• Would you consider elastic nails?
• Do you use external fixators or K-wires?

Dr. Aman Hooda - Orthopaedic Surgeon

18/06/2025

12/06/2025

30/05/2025

12/04/2025

09/04/2025

27/03/2025

02/02/2025

16/01/2025

09/01/2025

01/01/2025

19/12/2024

06/11/2024

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