NepMed Repository :: Browsing by Author "Shrestha, D"

Browsing by Author "Shrestha, D"

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A Comparative Study on Epidemiology, Spectrum and Outcome Analysis of Physical Trauma cases Presenting to Emergency Department of Dhulikhel Hospital, Kathmandu University Hospital and its Outreach Centers in Rural Area
(Kathmandu University, 2013) Shrestha, R; Shrestha, SK; Kayastha, SR; Parajuli, N; Dhoju, D; Shrestha, D
ABSTRACT Background Physical trauma is one of the major cause of mortality and morbidity among young and active age group and its increasing trend is of main concern. There are only few studies concerning the spectrum of physical trauma in Nepal. Objective This study aims to evaluate the epidemiological spectrum, the extent, severity of the physical trauma and the outcome evaluation of patients with physical trauma over a period of one year in the emergency department of the Kathmandu University Hospital and compare the same parameters with those patients presenting to the various outreach centers of the hospital in the community. Methods Patient treatment files from the emergency department and the reports from various outreach centers were retrieved for a period of one year (May 2011 to April 2012). Epidemiological information, mode, type and anatomic location of injuries were recorded. Outcome evaluation was assessed by number of patients discharged from emergency department of the hospital or the outreach centers after the treatment, patients admitted for inpatient management and referred to other centers for further specialty management. Result In a period of one year, total 2205 (20%) of physical trauma cases presented to the emergency department and 1994 (6.12%) in the outreach centres. Most commonly involved age group in physical trauma both in Hospital set up and in Community set up were the young adults (15 to 49 years). Fall from height was the commonest mode of injury followed by road traffic accidents among the patients coming to the hospital while significant number of trauma patients coming to outreach centers were due to fall from height. In the hospital set up, 1525 (69.2%) of the cases were discharged while 537 (24.4%) needed inpatient management and 85 (3.8%) needed referral to other centers for the specialty management. In case of outreaches, half of the patients were discharged after the primary treatment and almost another half were referred to the hospital, mainly for need of further investigations. Conclusion Fall related injuries and road traffic accidents are the most common mode of trauma in the hospital set up and fall related injuries are the single most important mode of trauma seen in the outreaches. Mostly young adults in their active period of life are involved in physical trauma so appropriate preventive measures through public health approach should be included in comprehensive trauma management for reducing mortality and morbidity rates related to physical trauma. KEY WORDS Emergency department, outreach centers, physical trauma, trauma center
Acetabular Fracture: Retrospective Analysis of Thirty Three Consecutive Cases with Operative Management
(Kathmandu University, 2014) Shrestha, D; Dhoju, D; Shrestha, R; Sharma, V
ABSTRACT Background With the development of better imaging modalities including 3D CT scan and availability of technical expertise, operative management is increasingly performed for acetabular fracture but many patients in developing countries like Nepal, are still being treated with prolonged skeletal traction. Objective To analyses epidemiology, types of acetabular fracture and functional and radiological outcome of patients with acetabular fracture treated with open reduction and internal fixation (ORIF). Method Inpatients hospital records of patients treated with ORIF in between June 2007 to June 2014 were evaluated. Patient’s demographic data, mode of injury, injury hospital interval, injury surgery interval, associated injuries, surgical approach, total hospital stay and peri and post-operative complications were recorded and radiological and functional outcomes were evaluated. Result Thirty three patients (Male: 24 Female: 9) with average age 39 years (range: 21 to 65 years) were operated for acetabular fracture. Twenty one patients (63%) had injury related with motor vehicle accidents and nine (24%) of them had motorbike accidents. Injury hospital interval ranges from 7 to 36 days. Average injury-surgery interval was 21 days and average hospital stay was 22 days. Bicolumnar fractures were found in 15. Nine patients had dislocation of hip and 15 had concomitant other injuries. Biculumanr fixation was performed in 15 patients, posterior column and or wall in nine with Kocher Langenbeck approach and anterior column and or wall in other nine with ilio-inguinal approach. Radiological reduction was anatomical in 18; excellent/good functional outcome was in 26 and radiological outcomes were excellent in 14. Three patients had developed Hypertopic ossification. Follow up period ranged from 6 to 48 months and 15 patients (45%) had follow up >2 years. Conclusion Acetabular fractur can be effectively managed with ORIF and have predictable and comparable functional and radiographic outcomes. Upgrading the existing facilities and training of orthopedic surgeon for acetabular fracture management is important to shorten injury-surgery interval due to lack of such facilities. KEY WORDS Acetabulum, internal fixation, open reduction
Assessment of Knowledge Regarding Oral Hygiene among Parents of Pre-School Children Attending Pediatric Out Patient Department in Dhulikhel Hospital
(Kathmandu University, 2015) Khanal, K; Shrestha, D; Ghimire, N; Younjan, R; Sanjel, S
ABSTRACT Background Level of knowledge regarding oral hygiene among the parents of pre-school children plays an important role on maintaining the good oral hygiene of their children. In Nepal, sufficient research has not been carried out on this area. Objective Objective of this study is to assess the level of knowledge on oral hygiene of pre- school children’s parents attending pediatric outpatient department in Dhulikhel Hospital. Method A descriptive study was conducted from November 2012 to January 2013 among one hundred parents of preschool children visiting pediatrics outpatient department of Dhulikhel Hospital. Paper and pencil based semi structured questionnaire was used for collecting data. Questions related to demographic information and knowledge were asked. Thirty questions were used for assessing knowledge level. Knowledge score was calculated by allocating one point for each correct answer and zero point for each wrong answer. Analyzed data were presented in terms of numbers and percentages. Total knowledge scores were categorized based on percentage. Knowledge score was categorized on four group - exclusive intervals - namely-poor (0-40%), moderate (40-60%), good (60-80%) and excellent (80-100%). Mann-Whitney U test and Kruskal-Wallis test were applied to check significance difference and chi- square test was used to check association among different background characteristic. Result It was found that 81% had moderate knowledge, 15% had poor knowledge and 4% had good knowledge about oral hygiene. Median knowledge score was found to be 15 with range 10 to 21. Following variables were found to be significant difference on knowledge category: Education status (p<0.001), education level (p= 0.041), past experience about oral health problem (p = 0.008), Further significant association was found between knowledge category and educational status (p < 0.001) and between knowledge category and past experience (p < 0.001). Conclusion Knowledge regarding oral hygiene was found satisfactory among the parents of preschool children visiting pediatric OPD of Dhulikhel Hospital. KEY WORDS Knowledge, oral health, parents, pre-school children
Assessment of Post Graduate Medical Students in Nepal: Is it time to introspect?
(Kathmandu University, 2014) Shrestha, D; Shrestha, R
NA
Causes of stillbirths and neonatal deaths in Dhanusha district, Nepal: A verbal autopsy study
(Kathmandu University, 2010) Manandhar, SR; Ojha, A; Manandhar, DS; Shrestha, B; Shrestha, D; Saville, N; Costello, AM; Osrin, D
Abstract Background: Perinatal (stillbirths and first week neonatal deaths) and neonatal (deaths in the first 4 weeks) mortality rates remain high in developing countries like Nepal. As most births and deaths occur in the community, an option to ascertain causes of death is to conduct verbal autopsy. Objective: The objective of this study was to classify and review the causes of stillbirths and neonatal deaths in Dhanusha district, Nepal. Materials and Methods: Births and neonatal deaths were identified prospectively in 60 village development committees of Dhanusha district. Families were interviewed at six weeks after delivery, using a structured questionnaire. Cause of death was assigned independently by two pediatricians according to a predefined algorithm; disagreement was resolved in discussion with a consultant neonatologist. Results: There were 25,982 deliveries in the 2 years from September 2006 to August 2008. Verbal autopsies were available for 601/813 stillbirths and 671/954 neonatal deaths. The perinatal mortality rate was 60 per 1000 births and the neonatal mortality rate 38 per 1000 live births. 84% of stillbirths were fresh and obstetric complications were the leading cause (67%). The three leading causes of neonatal death were birth asphyxia (37%), severe infection (30%) and prematurity or low birth weight (15%). Most infants were delivered at home (65%), 28% by relatives. Half of women received an injection (presumably an oxytocic) during home delivery to augment labour. Description of symptoms commensurate with birth asphyxia was commoner in the group of infants who died (41%) than in the surviving group (14%). Conclusion: The current high rates of stillbirth and neonatal death in Dhanusha suggest that the quality of care provided during pregnancy and delivery remains sub-optimal. The high rates of stillbirth and asphyxial mortality imply that, while efforts to improve hygiene need to continue, intrapartum care is a priority. A second area for consideration is the need to reduce the uncontrolled use of oxytocic for augmentation of labour. Key words: Stillbirth, neonatal death, verbal autopsy, Nepal.
Clinical Outcome following Intra-articular Triamcinolone Injection in Osteoarthritic Knee at the Community: A Randomized Double Blind Placebo Controlled Trial
(Kathmandu University, 2018) Shrestha, R; Shrestha, R; Thapa, S; Khadka, SK; Shrestha, D
ABSTRACT Background Knee pain is one of the common complaints patients present with in any community based health camps and Osteoarthritis of knee is a usual diagnosis. Injecting a long acting steroid is a common practice to alleviate the symptoms of osteoarthritic knee. Objective To evaluate the clinical outcome of injecting Triamcinolone acetenoid in osteoarthritis of knee in a community set up over a randomized double-blind placebo control trial. Method A prospective, randomized, double blind, placebo control trial was carried out in community after obtaining the ethical clearance from the IRC. Patients with clinically diagnosed osteoarthritis of knee were injected either Triamcinolone or Placebo after recording the baseline scores of the knee by Knee injury and Osteoarthritis Outcome Score (KOOS) – Physical Function Short form (KOOS-PS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Visual Analogue Scale (VAS). The same tools were used at two, six and at twelve weeks post injection to evaluate the functional outcome and pain. Result One hundred and seventeen patients were available for analysis among which, 55(48.7%) patients received Triamcinolone and 58(51.3%) received placebo. The baseline status of knees of two groups was comparable at the start of study. There was significant pain relief in the group receiving Triamcinolone at two and six week but not in twelve weeks. Group receiving placebo had pain relief only for first two weeks. Functional outcome was significantly improved compared to baseline in both the groups until six weeks however, in the triamcinolone group, it was significant until twelve weeks. No major complications were noted. Conclusion Intra-articular injection of Triamcinolone acetenoid is effective in symptoms control and improving functional outcome in clinically diagnosed osteoarthritis of knees in community set up during health camps. KEY WORDS Community, Health camps, Intra-articular injection, Knee, KOOS-PS, Osteoarthritis, WOMAC
Displaced Intra-Articular Calcaneal Fractures: Evaluation of Clinical and Radiological Outcome Following Open Reduction and Internal Fixation with Locking Branched Calcaneal Plate
(Kathmandu University, 2017) Shrestha, R; Shrestha, D; Kayastha, SR; Winker, H
ABSTRACT Background Calcaneal fractures are common, but are difficult to manage. Immediate concern is soft tissue problems, while long term concern is pain as a sequelae of subtalar arthritis. A consensus has not been reached in the management of calcaneal fractures. Objective This study aims to evaluate clinical and radiological outcomes of the patients managed with open reduction and internal fixation with Calcaneal Locking Plates for the displaced intra-articular calcaneal fractures presenting in Dhulikhel Hospital, Kathmandu University Hospital. Method This was a prospective study, conducted on displaced intra articular calcaneal fractures from January 2014 through December 2016. The patients underwent open reduction and internal fixation with Locking Branched Calcaneal Plates through the extensile lateral approach. Post-operatively, ankle was mobilized after two weeks. Weight bearing was started after 12 weeks. Patients were evaluated clinically with Maryland foot score and radiologically with measurements of Boehler’s and Gissane angle. Result Twenty-two cases of calcaneal fractures managed with open reduction and internal fixation with Locking Branched Calcaneal Plates were available for final evaluation. Seventeen of the enrolled patients were males in their third decade of life. On average, calcaneal fractures were operated on seven days after the injury. Sanders Type II were seen in 68.2% of the cases and Sanders Type III were in 31.8%. Mean follow-up duration was 21.5 months. The average Maryland foot score was 77.27. Seventeen cases (77.13%) had good, four cases (18.2%) had fair, and one case (5.5%) had poor outcome score. There was statistically significant improvement in Boehler’s and Gissane angle across all enrolled patients. Conclusion Displaced intra-articular calcaneal fractures treated operatively with open reduction and internal fixation with Locking Branched Calcaneal Plates through the extended lateral approach, with proper planning of operation and surgical techniques in soft tissue handling, results in good clinical as well as radiological outcomes. KEY WORDS Boehler’s angle, calcaneum, calcaneal locking plates, maryland foot score, ORIF
Distally Based Sural Faciocutaneous and Fascial (Adipofascial) Flap for Reconstruction of Distal Leg, Ankle and Foot Defects
(Kathmandu University, 2014) Parajuli, NP; Shrestha, D; Panse, N
ABSTRACT Background Any soft tissue defect in distal leg, ankle and hind foot is still a challenging problem. There are various options for coverage of such defects, but the distally based sural neurocutaneous and neurofascial flap based on the sural nerve and superficial sural artery has been an important option. Objective To evaluate the efficacy of distally based sural flap in reconstruction of the distal leg, ankle and hind foot soft tissue defects. Method Seventeen patients with soft tissue defects over distal leg, ankle and hind foot were included in this study. All patients were treated with distally based sural flap. Most of the cases were due to trauma (16 cases) which compromised tendon and bone. One case was of malignant melanoma of sole of hind foot which required wide excision and soft tissue reconstruction with sural flap. Result In all cases defects were successfully covered. Three showed venous congestion and partial necrosis. One developed secondary infection. One flap failed completely. Mean follow up of patients was 20 months (6 – 36 months). Conclusion Sural flap is a good option for reconstruction of distal leg, ankle and foot defects. KEY WORDS Ankle defect, distally based sural flap, heel defect, leg defect, lower limb reconstruction.
Egg Allergy in infancy
(Society of Dermatologists, Venereologists and Leprologists of Nepal (SODVELON), 2010) Shrestha, R; Shrestha, D; Poudyal, R; Mishra, N
Abstract Egg allergies are one of the most common allergies of childhood and the reactions may vary from mild to severe. A family history of egg allergy or atopy is a risk factor for egg allergy. Most food-induced allergic reactions occur on first known oral exposure, especially in the case of eggs and peanuts. We report a case of nine months old infant who developed egg allery (contact dermatitis) after contact with egg white, with a positive family history of atopy and egg allergy. Keywords Egg allergy; contact dermatitis; infancy.
Epidemiological and Outcome Analysis of Orthopedic Implants Removal in Kathmandu University Hospital
(Kathmandu University, 2013) Shrestha, R; Shrestha, D; Dhoju, D; Parajuli, N; Bhandari, B; Kayastha, SR
ABSTRACT Background Orthopedic Implant removal is one of the commonly performed elective orthopedic surgeries. Implants are generally removed after the purpose of keeping implant is solved by healing of the fracture, but there is no consensus whether routine implant removal should be a policy for all fractures that were fixed. Objective This study aims to analyze the epidemiology and outcome of implant removal surgery carried out in the past three years in Kathmandu University Hospital. Methods Patients who underwent implant removal between 2010 January to 2012 December constituted the study cohort. Demographic data, indications, types of hardware and location of fractures were recorded. Similarly, duration of surgery, type of anesthesia and duration of hospital stay were recorded. All the patients who had undergone implant removal in this three years period were called for follow up examination but those who were not able to come were interviewed on telephone. Results There were 275 implant removals constituting 7.8% of total orthopedic operations and 26.3% of fracture fixations. Male to Female ratio was 189: 86. Pediatric age group (34.5%) had the highest incidence of implant removal. Moderate sized implants were the commonest hardwares removed (63.2%). Femur (27.3%) followed by radius (26.9%) were the commonest bone for implant removal. Average operative time was 47.3 minutes with average hospital inpatient stay of 2.6 days. Commonest indication for the implant removal procedure was pain (45%). Conclusion Implant removal procedures are one of the most commonly performed elective orthopedic surgeries. Though, after orthopedic implants removal, pain relief can be expected but it is not so predictive and hence patient should be well counseled before and the indications for implant removal has to be evaluated for better patient satisfaction and safety. KEY WORDS Fracture Management, internal fixation, implant removal, orthopedic hardware, re- surgery
Fetal Ascites Mimicking Maternal Ovarian Tumor: A Rare Cause of Obstructed Labour
(Kathmandu University, 2017) Shrestha, D; Baniya, S; Khatri, RB
ABSTRACT Fetal ascites has been diagnosed more frequently these days because of routine ultrasound scanning in pregnancy. However as a cause of dystocia in labour, it is very rare. Twenty four years second gravida of 28 weeks 6 days of gestation presented to labour room with preterm obstructed labour. Abdominal examination revealed less readily palpable fetal parts and distantly localized fetal heart sounds. An urgent ultrasound showed huge maternal ovarian cyst. She then underwent emergency cesarean section; delivered a male baby with grossly distended abdomen. However, the ovaries were normal looking. Routine antenatal ultrasounds help in identifying maternal and congenital fetal anomalies. They also guide in planning the most appropriate management. Whenever fetal ascites is diagnosed antenatally, possibility of dystocia in labour should be kept in mind. KEY WORDS Cesarean, Fetal ascites, Ovarian tumor
Fluoroscopy Guided Percutaneous Transpedicular Biopsy for Thoracic and Lumbar Vertebral Body Lesion: Technique and Safety in 23 Consecutive Cases
(Kathmandu University, 2015) Shrestha, D; Shrestha, R; Dhoju, D
ABSTRACT Background Though some vertebral lesions have typical imaging findings, histological/ microbiological evidence are required for definitive diagnosis and management, specially for tumor and infective lesions so that wrong diagnosis and wrong treatment can be avoided. Conventionally, open biopsy methods are used. With availability of CT scan, MRI, percutaneous transpedicular vertebral biopsy has now become popular as a minimally invasive technique for biopsy of vertebral lesion. Objective To describes technique and to analyzes safety and feasibility of percutaneous transpedicular vertebral biopsy with fluoroscopy guidance for thoracic and lumbar vertebral body lesions. Method Twenty three patients who underwent percutaneous transpedicular vertebral biopsy under fluoroscopy guidance were retrospectively evaluated for demographic data, indication for biopsy, anatomical locations, histological/microbiological diagnosis, complications and final outcome of treatment. True positive, true negative, false positive and false negative cases were defined. Result There were 17 males and 6 female patients of mean age 47 (range 22-73 years). Biopsies were performed in 17 dorsal and six lumbar vertebral bodies. Adequate sample were obtained in all cases. Seventeen patients (12: tubercular pathology, 1: primary tumor, 3: metastasis, 1: osteoporotic fracture) had definitive histological/ microbiological diagnosis. Four patients had no granuloma and tumor. Two had histological features of chronic non specific inflammation. True positive cases were 17, true negative were four and false negative case were two. Overall accuracy was 92%. One patient developed small hematoma at biopsy site. Conclusion Fluoroscopy guided percutaneous transpedicular biopsy of is a safe procedure with high adequacy and accuracy and low complication rate for thoracic and lumbar vertebral body lesion. KEY WORDS Fluoroscopy, transpedicular biopsy, vertebral body.
Intramedullary Nailing for Paediatric Diaphyseal Forearm Bone Fracture
(Kathmandu University, 2011) Parajuli, NP; Shrestha, D; Dhoju, D; Dhakal, GR; Shrestha, R; Sharma, V
ABSTRACT Background Though most of the pediatric diaphyseal forearm bone fracture can be treated with closed reduction and cast application, indications for operative intervention in pediatric both-bone forearm fractures include open fractures, irreducible fractures, and unstable fractures. Controversy exists as to what amount of angulation, displacement, and rotation constitutes an acceptable reduction. Objective To review union time and functional outcome of pediatric diaphyseal forearm bone fracture managed with intramedullary rush pin by closed or open reduction. Methods Fifty patients with both bone fracture of forearm were treated with intramedullary rush pin by closed or open reduction were included in the study and followed up for minimum six months for radilological and functional outcome. Results Out of 50 patients, 31 underwent closed reduction and 19 underwent open reduction. All fractures maintained good alignment post operatively. Forty seven patients had excellent results with normal elbow range of motion and normal forearm rotation and three patients had good results. In all patients good radiological union was seen in three months time. Eight patients had minor complications including skin irritation over prominent hardware, backing out of ulnar pin, superficial skin break down with exposed hardware. Twenty-three (46%) patients had undergone implant removal at an average of 6 months (range 4-8 months) under regional or general anesthesia Conclusion Fixation with intramedullary rush pin for forearm fracture is an effective, simple, cheap, and convenient way for treatment in pediatric age group. KEY WORDS pediatric forearm fracture, rush pin
Ipsilateral Supracondylar Fracture and Forearm Bone Injury in Children: A Retrospective Review of Thirty one Cases
(Kathmandu University, 2011) Dhoju, D; Shrestha, D; Parajuli, N; Dhakal, G; Shrestha, R
ABSTRACT Background Supracondylar fracture and forearm bone fracture in isolation is common musculoskeletal injury in pediatric age group But combined supracondylar fracture with ipsilateral forearm bone fracture, also known as floating elbow is not common injury. The incidence of this association varies between 3% and 13%. Since the injury is rare and only limited literatures are available, choosing best management options for floating elbow is challenging. Method In retrospective review of 759 consecutive supracondylar fracture managed in between July 2005 to June 2011, children with combined supracondylar fracture with forearm bone injuries were identified and their demographic profiles, mode of injury, fracture types, treatment procedures, outcome and complications were analyzed. Result Thirty one patients (mean age 8.91 yrs, range 2-14 yrs; male 26; left side 18) had combined supracondylar fracture and ipsilateral forearm bone injury including four open fractures. There were 20 (64.51%) Gartland type III (13 type IIIA and 7 type III B), seven (22.58 %) type II, three (9.67 %) type I and one (3.22 %) flexion type supracondylar fracture. Nine patients had distal radius fracture, six had distal third both bone fracture, three had distal ulna fracture, two had mid shaft both bone injury and one with segmental ulna with distal radius fracture. There were Monteggia fracture dislocation, proximal ulna fracture, olecranon process fracture, undisplaced radial head fracture of one each and two undisplaced coronoid process fracture. Type I supracondylar fracture with undisplaced forearm were treated with closed reduction and long arm back slab or long arm cast. Displaced forearm fracture required closed reduction and fixation with Kirschner wires or intramedullary nailing. Nineteen patients with Gartland type III fracture underwent operative intervention. Among them nine had closed reduction and K wire fixation for both supracondylar fracture and forearm bone injury. One patient with closed reduction and long arm cast application for both type III supracondylar fracture and distal third radius fracture developed impending compartment syndrome and required splitting of cast, remanipulation and Kirschner wire fixation. There were three radial nerve, one ulnar nerve and one median nerve injury and two postoperative ulnar nerve palsy. Three patients had pin tract related complications. Among type III, 16 (80%) patients had good to excellent, two had fair and one gad poor result in terms of Flynn’s criteria in three months follow up Conclusion Displaced supracondylar fracture with ipsilateral displaced forearm bone injuries need early operative management in the form of closed reduction and percutaneous pinning which provides not only stable fixation but also allows close observation for early sign and symptom of development of any compartment syndrome. KEYWORDS Floating elbow; Forearm bone injury; Ipsilateral fracture; Supracondylar fracture
Learning, education and satisfaction after compulsory rotating internship in Kathmandu University Medical School: A qualitative study of interns’ response
(Kathmandu University, 2008) Shrestha, D; Mishra, B
Abstract Background: Internship is an integral part of MBBS training programme and mandatory to all students. Kathmandu University Medical School has adopted a programme of compulsory one year rotating internship including 6 weeks community exposure in out reach clinics for the first batch of students. The purpose of the study is to evaluate interns’ feedback concerning learning, education and satisfaction. Materials and methods: A questionnaire with 47 items was administered to 30 interns who had finished one year rotating internship in Kathmandu University Medical School. Fourty-two responses were graded according in Likert scale and 5 open ended questions were analyzed for common themes. Results: The mean age of the interns was 24.77±0.67 yrs with female: male ratio of 1.5:1. Confidence level of communication of interns with faculties was lesser than with junior doctors and patients. Junior doctors and colleagues contributed more in interns’ learning than faculties. Community exposure for 6 weeks was considered lengthy and lacking of clear objectives. However, 53.3% interns agreed that achievement of objectives of community posting was high or very high. Of the interns, 50% perceived certain degree of physical or mental or sexual harassments during internship. Interns raised the issue of not involving them as a part of team during clinical posting. Clinical competencies for most of the skills were high or very high. Conclusion: Interns have learned clinical skills and patient care in one year internship programme but contribution of junior doctors and colleague are more than teachers. Clear objectives are needed before clinical and community postings. Process of providing regular feedback from interns and vice versa should be implemented to improve interns’ learning, education and satisfaction Key words: Clinical skills; Communication; Community postings; Education; Internship; Harassments
Minimally Invasive Plate Osteosynthesis with Locking Compression Plate for Distal Diametaphyseal Tibia Fracture
(Kathmandu University, 2011) Shrestha, D; Acharya, BM; Shrestha, PM
ABSTRACT Background Distal diametaphyseal tibia fracture though requires operative treatment is difficult to manage. Conventional osteosynthesis is not suitable because distal tibia is subcutaneous bone with poor vascularity. Closed reduction and minimally invasive plate osteosynthesis (MIPO) with locking compression plate (LCP) has emerged as an alternative treatment option because it respects biology of distal tibia and fracture hematoma and also provides biomechanicaly stable construct. Objectives To find out suitability of MIPO with LCP for distal diametaphyseal tibia fracture including union time and complicatios and compare wih other available management options in literature. Methods Twenty patients with closed distal diametaphyseal tibia fracture with or without intra articular extension (AO classification: 12 type 43A1, 4 type 43A2, 2 type 43A3 and 2 type 43B1) treated with MIPO with LCP were prospectively followed for average duration of 18.45 months (range 5-30 months). Results Average duration of injury-hospital and injury-surgery interval was 12.8 hrs (range 2-44 hrs) and 4.45 days (range 1-10 days) respectively. All fractures got united with an average duration of 18.5 weeks (range14-28weeks) except one case of delayed union which was managed with percutaneous bone marrow injection. Two patients had union with valgus angulation < 5 degees but no nonunion was found. There were two superficial and one deep post operative wound infection. All infections healed with extended period of intravenous antibiotics besides repeated debridemet for deep infection. Implants were removed in eight patients among whom six (30%) had malleolar skin irritation and pain due to prominent hardware. Conclusion The present case series shows that MIPO with LCP is an effective treatment method in terms of union time and complications rate for distal diametaphyseal tibia fracture. Malleolar skin irritation is common problem because of prominent hardware. Key Words Distal diametaphyseal tibia fracture; LCP, MIPO
Musculoskeletal ultrasound: Is it underutilised?
(Kathmandu University, 2007) Sharma, UK; Shrestha, D
NA
Operative Fixation of Displaced Middle Third Clavicle (Edinburg Type 2) Fracture with Superior Reconstruction Plate Osteosynthesis
(Kathmandu University, 2011) Dhoju, D; Shrestha, D; Parajuli, NP; Shrestha, R; Sharma, V
ABSTRACT Background Conservative management of middle third clavicle fracture has been recently reported with suboptimal outcomes. Despite higher nonunion rates in initial open reduction and internal fixation, understanding the problem better and taking in accounts of previous shortcomings, such fractures can be optimally treated by open reduction and internal fixation with reconstruction plate. Objective To study the outcome of middle third clavicle fracture treated with superior reconstruction plating in terms of function using Constant shoulder score, union time and rate, complications and patient satisfaction. Methods Twenty patients with displaced middle third clavicle fracture (Edinburg type 2) treated with open reduction and internal fixation with reconstruction plate implanted in superior surface were prospectively followed for at least one year after surgery. Results There were 20 patients, 16 males and 4 females. The mean age of the patients was 31.5 years with SD 11.5 years (range 15-60 years) and 5 patients (25%) had associated injuries. All fractures united in 16 weeks or less in near anatomic position with complication in 2 (5%) patients, one deep infection and one frozen shoulder which on subsequent management recovered well. There was no nonunion or implant failure. The average Constant score was 97.45 in one year follow up and the patients were relatively satisfied with the treatment.The most common indication (25%) for hardware removal was young age of the patient, hardware prominence and occasional discomfort Conclusion This small series shows that displaced midshaft clavicle fracture can be optimally treated with operative fixation implanting the reonstruction plate in superior surface with six cortical purchases on either side and supervised physiotherapy, although subsequent surgery for implant removal might be necessary. KEY WORDS middle third clavicle fracture, reconstruction plate.
Percutaneous Ilio-Sacral Screw Fixation in Supine Position under Fluoroscopy Guidance
(Kathmandu University, 2015) Shrestha, D; Dhoju, D; Shrestha, R; Sharma, V
ABSTRACT Background Pelvic ring disruption when treated conservatively can be associated with prolonged hospital stay and immobilization, mal-union, chronic pain, limb length discrepancy if they are treated conservatively. Open reduction and fixation in an already compromised soft tissue and hemodynamically unstable patient causes more soft tissue injury, heamatoma, infection and neurovascular injury. Percutaneous ilio- sacral joint fixation can be an alternative technique for sacro-iliac joint injury and sacral fracture. Objective To evaluate technique and safety of percutaneous ilio-sacral screw fixation in supine position under single fluoroscopy guidance for sacral fracture and sacro-iliac joint disruption. Method Twenty one patients either with sacral fracture or sacro-iliac joint disruption with percutaneous ilio-sacral screw fixation with cannulated cancellous screw fixation in between 2008 to 2014 were retrospectively evaluated including AP, inlet and outlet views of pelvis X rays and CT scan. Tile’s classification and Dennis classification were used for pelvis and sacral injury. Result Thirty five percutaneous ilio-sacral screws were placed (Male: 6, Female: 15; range: 15 to 54) for sacral fracture involving zone 2 (8 with sacral fracture only and 5 with pelvis injury; Tile’s type B in four and type C in one) and sacro-iliac joint injury (Tile’s type B in three and type C in five). Commonest mode of injury was motor vehicle accidents (10) followed by fall related injury (6). Injury hospital interval and injury surgery interval was five hours to 13 days and 2 to 20 days respectively. Follow period was 3 months to 6 years. One patient developed post-operative deep vein thrombosis and another patient had post-operative haematoma. Two screws were juxtra-foramial. Good to excellent outcome were in 16 patients, fair in four and poor in one patient (Majeed Scoring). Conclusion Percutaneous ilio-sacral screw fixation for sacro-iliac joint injury and sacral fracture with C arm guidance is safe and minimally invasive technique. Clear images and accurate interpretation of X-rays, CT scans and per operative C arm images are important to avoid malpositioning of screws and iatrogenic neurovascular injuries. KEY WORDS Percutaneous screw fixation, sacral fracture, sacro iliac joint injury
Permanent Teeth Emergence Time and Sequence in Children of Kavre District, Nepal
(Kathmandu University, 2016) Upadhyay, S; Shrestha, R; Shrestha, D; Poudyal, S
ABSTRACT Background Population specific standards on the timing and sequence of emergence of permanent teeth are essential in planning dental care for children. There is only a single study on the emergence of permanent teeth in Nepalese children. Objective To determine the standards for permanent teeth emergence time and sequence in children of Kavre district, Nepal. Method A descriptive cross sectional study was conducted in 623 children of age 5 to 14 years from six different schools of Kavre district. The number of permanent tooth erupted except third molar was recorded along with age and gender. Data were analysed using SPSS 20.0. Descriptive statistics was used to determine the number and percentage of permanent teeth emerged at different ages and the mean age of emergence of each tooth. Student ‘t’ test was used to determine the inter jaw differences in the mean age of emergence of each tooth. Result The study population constituted 50.7% boys and 49.3% girls of the total sample. The first tooth to emerge was mandibular first molar, whereas maxillary second molar tended to be the last to emerge in both the genders. Though in general, mandibular teeth tended to precede the corresponding maxillary teeth in emergence but significantly only mandibular central, lateral and second premolar emerged earlier than maxillary.( p ≤ 0.05) Conclusion This study can be used as a reference data for clinical and academic purpose especially for the children of Kavre district, Nepal. KEY WORDS Emergence sequence, emergence time, permanent teeth

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