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Complications of Surgical Management of Radial Club Hand

Volume 2 | Issue 3 | Sep-Dec 2016 | Page 24-27| Ratna Maheshwari, Rujuta Mehta, Ashok Johari Authors : Ratna Maheshwari [1], Rujuta Mehta [2], Ashok Johari [3] [1] Consultant, Pediatric Orthopedics, Enable International Centre for Pediatric Musculoskeletal Care [2] Head of Dept. Paediatric Orthopedics B J Wadia Hospital For Children. [3] Head, Pediatric Orthopedics, […]

Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 40-42| Soumya Paik, Rujuta Mehta, Alaric Aroojis, Dominic D´Silva Authors : Soumya Paik [1],*, Rujuta Mehta [1], Alaric Aroojis [1], Dominic D´Silva[1] [1] Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, Maharashtra, India. Address of Correspondence Dr Soumya Paik Bai Jerbai Wadia Hospital for Children, […]

Complications of Surgical Management of Radial Club Hand

Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

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Complications of Surgical Management of Radial Club Hand

Volume 2 | Issue 3 | Sep-Dec 2016 | Page 24-27| Ratna Maheshwari, Rujuta Mehta, Ashok Johari

Authors : Ratna Maheshwari [1], Rujuta Mehta [2], Ashok Johari [3]

[1] Consultant, Pediatric Orthopedics, Enable International Centre for Pediatric Musculoskeletal Care
[2] Head of Dept. Paediatric Orthopedics B J Wadia Hospital For Children.
[3] Head, Pediatric Orthopedics, Enable International Centre for Pediatric Musculoskeletal Care.

Address of Correspondence
Dr Ratna Maheshwari
Enable International Centre for Pediatric Musculoskeletal Care
Email: drratnajohari@gmail.com

Abstract

Radial club hand is a congenital deformity of the upper extremity which can present with a spectrum of hand and forearm anomalies ranging from mild radial hypoplasia to complete absence of the radius. The surgical treatment of radial club hand historically has attempted to create a centralized wrist, maintain wrist motion and improve hand function by placing the hand in a more outstretched position.Treatment for these patients has focused on the technique of centralization, in addition to ulnocarpal arthrodesis, ulna and radial lengthening, and microvascular toe transfer. In this paper we review the complications of various surgical interventions described so far for the treatment of this condition.
Keywords: Centralization, recurrence, physeal arrest.

Introduction

There are several treatment options for radial deficiency of the forearm, including nonsurgical management; centralization, radialization, or ulnarization; ulnocarpal arthrodesis; soft tissue procedures including distraction; ulnar lengthening; and vascularized second metatarsophalangeal joint transfer. The most common procedure performed currently is soft tissue distraction followed by a wrist realignment procedure such as a centralization, radialization, or ulnarization. While one-stage procedures subject the patient to a single operation, they are associated with the possible need for carpal resections, ulnar shortening, and sacrifice of the distal ulnar growth plate, stretch injury to the radial neurovascular structures, excessive swelling of the hand, and wound complications [1,2,3,4,5,6]

Centralization/radialization/ulnarization
This technique involves moving the carpus to a central position on the ulna as a means of obtaining correction of radial deviation and wrist subluxation. Unfortunately, this technique has been associated with a high rate of recurrent radial deviation, physeal injury and wrist stiffness [7,8]
Lamb et al [9] reported a recurrence of radial wrist deviation in 7 out of 15 patients.
Damore and colleagues reviewed 19 cases of recurrence after a centralization procedure. The surgery had corrected the radial deviation from a mean of 83 to 25.However at final follow- up (6.5 years), the deviation was back to an average of 63 [10].
Heikel [11] demonstrated in 1959 that the ulna in children with radial club hand may grow between one half to three quarters the length of the unaffected ulna. Centralization procedures, with concomitant ulnar osteotomy and transphyseal pins can all result in potential distal ulnar physeal injury resulting in further shortening of the forearm unit.
In their long-term outcome study, Goldfarb et al [12] noted total ulnar growth to average 12 cm in comparison to 15.4 cm in Vilkki’s series [13] of vasularised metatarsophalangeal joint transfer . While 3 cm may seem clinically insignificant, this must be taken in the context of a longer ulna in addition to a wrist that is in a more balanced position when compared to standard centralization procedures.

K-wire stabilisation is not free of complications: wire migration or breakage, skin ulcer, and changes may follow growth. Despite such repeated revision, correction loss is acceptable and the fixation finally stabilizes over growth. If K-wire tension appears excessive, distraction can be slowed down so as to allow the skin and capsule-ligamentous structures to relax progressively [14].

Ulnocarpal arthrodesis
This procedure is generally reserved for recurrence of deformity after centralization. The generally accepted indications for this procedure is radial angulation greater than 450, inability to actively extend the wrist to within 250 of neutral. Pike et al [15] described 12 patients with average age of 12.6 years treated with ulnocarpal arthrodesis for recurrence of deformity after centralization, that was performed at an average age of 2.4 years. The average time to union for 11 of the 12 patients was 4 months. Union was ultimately achieved in the 12th patient after a revision arthrodesis with a plate that was necessary because the initial arthrodesis hardware (K-wires) was removed early owing to concern about infection.

Ulnar lengthening
Farr and colleagues [16] reported on 8 cases in 6 patients and noted that initial postsurgical gains of radial deviation were not maintained. Radial deviation averaged 250 preoperatively and recurred to 230 at an average 4-year follow-up. Two major complications occurred, including an ulna fracture after frame removal and insufficient regenerate during lengthening.
Peterson and colleagues [17] described 9 children who underwent 13 lengthenings after previous centralization procedures. The average gain in length was 4.4 cm. All patients had at least 1 pin site infection that was treated with antibiotics. Furthermore 4 patients had additional procedures, including internal fixation and bone grafting for delayed union in 3 patients and wrist arthrodesis for recurrence in 1 patient.
Yoshida and colleagues [18] investigated the growth of the ulna after repeated lengthenings. After the initial lengthening, the average length improved from 57% to 89% of the normal side, but then regressed to 70%, whereas after the second lengthening the average length was 102% but regressed to 83%. Bone growth was found to be markedly decreased after the second lengthening. Therefore, if multiple lengthenings are performed, the second one should be performed after skeletal maturity.
Although successful in producing multi-planar deformity correction and an approximately 50% increase in ulnar length, the Ilizarov technique brings with it a steep clinician learning curve. Device application, cumbersome hardware, lengthy total treatment time, and relatively high risk of complications may prove problematic and has effectively limited the use of the device to adolescents and older children.

Radial lengthening
Matsuno and colleagues [19] described 4 cases of Bayne and Klug type II and III radial longitudinal deficiency treated with radial lengthening and simultaneous soft tissue distraction. Three of 4 patients required several lengthenings to correct the recurring discrepancy between the radius and ulna. Only 2 of the 4 patients had acceptable function and appearance after the multiple procedures. In 1 patient, lengthening was abandoned owing to severe bone absorption at the distal end of the radius. One patient died of cardiac disease after a lengthening.

Microvascular second toe transfer:
Vilkki [20] used a novel technique for treatment of Bayne type III and IV radial deficiency using the 2nd MTP joint as a vascularized graft to create a radial column within the wrist (see Fig. 1). The metatarsal and proximal phalanx of the 2nd toe are transferred to the forearm to create a Y shaped distal ulna with potential for growth at both limbs of “Y”. He used a monolateral external fixator in conjunction with this. With regard to the design of the external fixator, the author commented, ‘‘the lengthening device can still be improved and it should have the potential to correct angular deformities.’’ The author also acknowledged unpredictable growth of the transferred bone, cosmetic concerns of the transferred skin pedicle, and technical difficulties with microvascular transfer. Residual radial deviation of the wrist averaging 200 was noted at follow-up. One patient developed a traumatic fracture of the transplanted joint. Consequently the treatment protocol was adjusted to using the distraction device for at least nine weeks following MTP transfer.
Vilkki [13] reported the long term results of vascularized second metatarsophalangeal joint on 24 limbs with an average follow-up of 11 years. The average radial deviation at final follow- up was 280, the average active wrist total arc of motion was 830, and the average length of the ulna was 67% of the contralateral side. Complications were present in more than 50% of patients, including 5 cases of failure of the transfer, 2 of which were vascular in origin and 3 of which had necrosis or fracture leading to necrosis of the metatarsal head. Subluxation of the joint was present in 6 cases and several patients underwent subsequent osteotomies or joint transfer procedures. Distractor device complications was present in 2 patients, fracture of the MTP joint in 2 patients, delayed bony union of the metatarsal ulna interface in 2 patients and pseudoarthrosis at the MTP joint in 2 patients. Three children required late joint transport to lengthen MTP constructs that failed to grow adequately. Donor site morbidity was noted in only 4 patients with hallux valgus noted in one patient, prominent scarring in 2 and occasional pain noted in one other.
These findings of ulna length compares favorably with previous reports of Sestero et al. [7] who found that untreated limbs of patients with radial club hand grew to 64% of normal ulnar length, while surgically centralized limbs within their study grew to only 48-58% of normal ulnar length.
The evidence regarding treatment of radial deficiency of the forearm is limited to retrospective case series. The wide variation in types of operative treatment reflects the lack of a clearly superior procedure. All options have high rates of recurrence with the potential for multiple procedures, all of which have considerable complication rates.

Conclusion

Strategies suggested by the authors for preventing complications are as follows:
1. Good volar and radial skin release
2. Accurate reduction of carpus on ulna
3. Good soft tissue repair
4. Tendon balancing
5. Tightening of structures on ulnar side
6. Temporary stabilization of carpus on ulna
7. Distraction of carpus on ulna (when required with a careful watch to prevent physeal distraction)
8. Limited lengthening of ulna restricted to at the most 5 centimeters in one stage. Elbow stability is an important pre-operative consideration, given that sometimes there may be a co-existing shallow olecranon fossa.

References

1. Flatt AE. The Care of Congenital Hand Anomalies, 2d ed. St Louis: Quality Medical Publishing, 1994:366–410.
2. Urban MA, Osterman LA. Management of radial dysplasia. Hand Clin. 1990;6:589–605.
3. Buck-Gramcko D. Radialization as a new treatment for radial club hand. J Hand Surg [Am]. 1985;10:964–968.
4. Lamb DW. Radial club hand. J Bone Joint Surg [Am]. 1977;59:1–13.
5. Watson HK, Beebe RD, Cruz NI. A centralization procedure for radial clubhand. J Hand Surg [Am]. 1984;9: 541–547.
6. Bayne LG, Klug MS. Long-term review of the surgical treatment of radial deficiencies. J Hand Surg [Am]. 1987;12: 169–179
7. Sestero AM, Van Heest A, Agel J. Ulnar growth patterns in radial longitudinal deficiency. J Hand Surg Am. 2006;31(6):960–967. [PubMed]
8. Shariatzadeh H, Jafari D, Taheri H, Mazhar FN. Recurrence rate after radial club hand surgery in long term follow up. J Res Med Sci. 2009;14(3):179–186
9. Lamb DW, Scott H, Lam WL, Gillespie WJ, Hooper G. Operativecorrection of radial club hand: a long-term followupof centralization of the hand on the ulna. J Hand Surg Br.1997;22(4):533-6.
10. Damore E, Kozin SH, Thoder JJ, Porter S. The recurrence of deformity after surgical centralization for radial clubhand. J Hand Surg Am. 2000;25(4):745e751
11. Heikel HV. Aplasia and hypoplasa of the radius: studies on 64 cases and on epiphyseal transplantation in rabbits with the imitated defect. ActaOrthopScand Suppl. 1959;39:1- 155.
12. Goldfarb CA, Klepps SJ, Dailey LA, Manske PR. Functional outcome after centralization for radius dysplasia. J Hand Surg Am. 2002;27(1):118–124.
13. Vilkki SK. Vascularised metatarsophalangeal joint transfer for radial hypoplasia. Semin Plastic Surgery.2008; 22(3): 195- 212
14. C. Romanaa, G. Ciaisa, F. Fitoussi. Treatment of severe radial club hand by distraction using an articulated mini-rail fixator and transfixing pins. Orthopaedics& Traumatology: Surgery & Research Volume 101, Issue 4, June 2015, Pages 495–500
15. Pike JM, Manske PR, Steffen JA, Goldfarb CA. Ulnocarpal epiphyseal arthrodesis for recurrent deformity after centralization for radial longitudinal deficiency. J Hand Surg Am. 2010;35(11): 1755- 1761.
16. Farr S, Petje G, Sadoghi P, Ganger R, Grill F, Girsch W. Radiographic early to midterm results of distraction osteogenesis in radial longitudinal deficiency. J Hand Surg Am. 2012;37(11): 2313-2319.
17. Peterson BM, McCarroll HR Jr, James MA. Distraction lengthening of the ulna in children with radial longitudinal deficiency. J Hand Surg Am. 2007;32 (9):1402-1407.
18. Yoshida K, Kawabata H, Wada M. Growth of the ulna after repeated bone lengthening in radial longitudinal deficiency. J PediatrOrthop. 2011;31(6):674e678.
19. Matsuno T, Ishida O, Sunagawa T, Suzuki O, Ikuta Y, Ochi M. Radius lengthening for the treatment of Bayne and Klug type II and III radial longitudinal deficiency. J Hand Surg Am 2006;31 (5): 822- 829
20. Vilkki SK. Distraction and microvascular epiphysis transfer for radial club hand. J Hand Surg [Br]. 1998;23: 445–452.

How to Cite this Article: Maheshwari R, Mehta R, Johari AN. Complications of Surgical Management of Radial Club Hand. International Journal of Paediatric Orthopaedics Sep-Dec 2016;2(3):24-27.

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Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 40-42| Soumya Paik, Rujuta Mehta, Alaric Aroojis, Dominic D´Silva

Authors : Soumya Paik [1],*, Rujuta Mehta [1], Alaric Aroojis [1], Dominic D´Silva[1]

[1] Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, Maharashtra, India.

Address of Correspondence
Dr Soumya Paik
Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai- 400012, Maharashtra, India.
Email: soumyapaik2006@gmail.com

Abstract

Background: Dysplasia epiphysealis hemimelica is a rare non hereditary epiphyseal disorder characterized by irregular overgrowth of cartilage in the epiphysis. The disease mainly targets distal long bones of the lower extremities e.g. ankle joint and tarsal bones. The guidelines for treatment of dysplasia epiphysealis hemimelica are sparse in literature due to the rarity of the syndrome. We report one such case manifesting in the right knee of a 5-year-old girl, a site which is not commonly reported and therefore prone to missed diagnosis and hence recurrence, along-with its surgical challenges , addressing all the anatomical and biomechanical derangements along with limb length discrepancy and to restore movements.
Keywords: Dysplasia epiphysealis hemimelica , irregular overgrowth , epiphysis, rarity.

Introduction
Dysplasia epiphysealis hemimelica (DEH) is a rare non-hereditary epiphyseal outgrowth of unknown etiology that mimics synovial chondromatosis of the joints [1]. The disease mainly targets long bones of the lower extremities and tarsal bones[1-3] . We report one such case from our institution manifesting in the right knee of a 5 year-old girl. Literature shows approximately 70 cases reported around the knee region since its first description 88 years ago.

Case Report
In February 2013, a 5-year-old girl presented with a 1½ year history of a gradually increasing swelling [Figure 1a] at the right knee and painless limp. There was no other remarkable history: family or past history. Patient had a history of a previous excision on the lateral side of the same knee with recurrence of deformity within six months. However, there was no history of loss of movement at the time of previous surgery. On examination, there was an irregular bony swelling 15 cm by 10 cm by 10 cm on the antero medial aspect of right distal femur and proximal tibia. It was associated with a 1.5 cm shortening of each of the right femur and right tibia. There were no warmth, tenderness or skin changes over the swelling and the knee had 60º fixed flexion deformity [Figure 1b] with further painless motion up to 120º associated with crepitus. The patient also had a genu valgum of 20 degrees which was chiefly femoral. The patella was small and dislocated laterally. There was no distal neurovascular deficit. There were no deformities at the ipsilateral hip and ankle nor at the contralateral hip, knee and ankle. Radiographs [Figure 1c] showed an ossified mass over anteromedial aspect of right knee. 3D CT[ Figure 1d] and MRI [Figure 1e] showed a distinct plane of separation between the lesion and the normal epiphyseal bone.
Arthroscopy revealed that menisci and both the cruciate ligaments were intact and medial proximal tibial articular surface in the weight bearing domain was involved. The mass was too large for piecemeal excision and hence open surgery was performed immediately. Through an anterior mid line approach the right knee extensor mechanism was exposed [Figure 2a] which was found to be dislocated laterally by the mass. A 5cm by 3cm mass was found protruding out of the inter-condylar notch [Figure 2b] which was excised. The excised material [Figure 2c] was a globular bony mass covered by a smooth white glistening cartilage surface. There was involvement of the medial tibial articular surface as well in the form of 1.5cm by 1cm small mass [Figure 2d] which was shaved off. Lateral release and medial plication [Figure 2e] was done to realign the extensor mechanism before closure [Fig 2f]. A back slab was given post operatively for 15 days and then physiotherapy was started. The patient was discharged 22 days after surgery. At the time of discharge there was a 20º flexion contracture with further ROM upto150º and active knee extension from 90º to 60º was achieved. At 2 years follow up the patient was found to be almost completely relieved from the deformity [Figure 3a] and further correction of limb length discrepancy [Figure 3b] is planned.

Discussion
The incidence of this entity was reported as 1 in1000,000[4] . It was first described as tarsomegalie in 1926 by Mouchet and Belot[5] . Trevor used the term tarso-epiphyseal aclasis in 1950[6] . Since then this abnormality is commonly referred to as Trevor’s disease. The term dysplasia epiphysealis hemimelica (DEH) was coined by Fairbank [1] in 1956. The word hemimelica is derived from 2 Greek words, hemi (half) and melos(limb). According to Fairbank , DEH is confined to the medial or lateral half of an epiphysis of a single limb it has a male-to-female ratio of 3:1 [4].
The etiology of DEH is unknown. There is no strong evidence to suggest a hereditary component . It has been hypothesized that this condition represents a fundamental defect in the regulation of cartilage proliferation in the affected epiphyses. Azouz et al [8] introduced a 3-group classification: group 1, localized, in which only one epiphysis is affected; group 2 (most common), classic, in which more than one epiphysis in the same limb is affected; and group 3, generalized, in which the whole lower limb is affected. Our patient in discussion fits into group 2.
Epiphyseal cartilage capped benign over growth is the unique feature of DEH. Struijs et al [9] showed the rarity of this disease in this location in a systematic review. They found a total of 48 studies having 138 patients with 255 lesions. Most lesions were located in the ankle or foot (139 of 255), and the talus was the most frequently affected bone. Rosero et al [10] showed only 21% distal femur and 11% proximal tibia were involved in their study of 57 patients.
The most common presenting symptom is a painless mass around the affected joint. The diagnosis can be guided by imaging studies. Initially radiography shows stippled calcification at epiphysis region. Eventually it looks like exostosis. It is possible that the earlier surgeon in this case confused it as a simple exostosis and excised it through a lateral approach. 3D CT scan should be done to assess the continuity of the lobulated mass with the underlying epiphysis. MRI is mandatory for identifying the extent of epiphyseal involvement, joint deformity and any effects on surrounding soft tissues. Teixeira et al. (2001) [11] reported the role of bone scintigraphy as increased uptake in the pathological epiphyseal area. It is useful check for other sites of involvement.
DEH is benign and its prognosis is favourable; no malignant transformation has been reported [6, 12].
Histopathologically, it was not possible to distinguish DEH from osteochondroma [3] . But genetic expressions (EXT1, EXT2) can be helpful [13].
The literature shows evidence that recurrences are more likely in patients with open physes at the time of surgery or after incomplete resection[1, 4] . There is no literature support to guide the management of limb-length discrepancy in this disease either by same limb lengthening or contralateral limb epiphysiodesis. It is also not described how to manage residual deformity. So the patient was counselled regarding the need for a long follow up with the possibility of further intervention.

Conclusion
Dysplasia epiphysealis hemimelica is a relatively rare disease, but the numbers of reported cases are gradually increasing. Hence, during the examination of a paediatric patient with a swelling of either the medial or lateral half of a joint, or a swelling that appears bony, painless and intra articular it is necessary to include DEH in the differential diagnosis. Provisional diagnosis can be made by clinical examination, surgical treatment is mandatory when symptoms like pain, joint impingement or deformation are present. Surgical prognosis is favourable when the mass is juxtaarticular or extraarticular. When the mass is intraarticular, early surgery may cause secondary osteoarthritis.

References

1. Fairbank TJ. Dysplasia epiphysialis hemimelica (tarso-ephiphysial aclasis). J Bone Joint Surg Br. 1956;38-B(1):237-57. Epub 1956/02/01. PubMed PMID: 13295331.
2. Timm C, Immenkamp M, Roessner A. [Disease picture of dysplasia epiphysealis hemimelica]. Z Orthop Ihre Grenzgeb. 1986;124(2):148-56. Epub 1986/03/01. doi: 10.1055/s-2008-1044540. PubMed PMID: 3087078.
3. Glick R, Khaldi L, Ptaszynski K, Steiner GC. Dysplasia epiphysealis hemimelica (Trevor disease): a rare developmental disorder of bone mimicking osteochondroma of long bones. Hum Pathol. 2007;38(8):1265-72. Epub 2007/05/11. doi: S0046-8177(07)00063-9 [pii] 10.1016/j.humpath.2007.01.017. PubMed PMID: 17490719.
4. Wynne-Davies R, Hall CM, Apley AG. Atlas of skeletal dysplasias: Churchill Livingstone Edinburgh; 1985.
5. Mouchet A, Belot J. La tarsomegalie. J Radiol Electrol. 1926;10:289-93.
6. Trevor D. TARSO-EPIPHYSIAL ACLASIS. Journal of Bone & Joint Surgery, British Volume. 1950;32-B(2):204-13.
7. Connor JM, Horan FT, Beighton P. Dysplasia epiphysialis hemimelica. A clinical and genetic study. J Bone Joint Surg Br. 1983;65(3):350-4. Epub 1983/05/01. PubMed PMID: 6841410.
8. Azouz EM, Slomic AM, Marton D, Rigault P, Finidori G. The variable manifestations of dysplasia epiphysealis hemimelica. Pediatr Radiol. 1985;15(1):44-9. Epub 1985/01/01. PubMed PMID: 3969295.
9. Struijs PA, Kerkhoffs GM, Besselaar PP. Treatment of dysplasia epiphysealis hemimelica: a systematic review of published reports and a report of seven patients. J Foot Ankle Surg. 2012;51(5):620-6. Epub 2012/07/24. doi: S1067-2516(12)00199-8 [pii] 10.1053/j.jfas.2012.05.008. PubMed PMID: 22819617.
10. Rosero VM, Kiss S, Terebessy T, Kollo K, Szoke G. Dysplasia epiphysealis hemimelica (Trevor’s disease): 7 of our own cases and a review of the literature. Acta Orthop. 2007;78(6):856-61. Epub 2008/02/01. doi: 790014159 [pii] 10.1080/17453670710014662. PubMed PMID: 18236195.
11. Teixeira AB, Sa de Camargo Etchebehere EC, Santos AO, Lima MC, Ramos CD, Camargo EE. Scintigraphic findings of dysplasia epiphysealis hemimelica: a case report. Clin Nucl Med. 2001;26(2):162. Epub 2001/02/24. PubMed PMID: 11201484.
12. Kuo R, Bellemore M, Monsell F, Frawley K, Kozlowski K. Dysplasia epiphysealis hemimelica: clinical features and management. Journal of Pediatric Orthopaedics. 1998;18(4):543-8.
13. Fletcher CD, Unni KK, Mertens F. Pathology & genetics: tumours of soft tissue and bone: World Health Organization; 2002. 229-30 p.

How to Cite this Article: Paik S, Mehta R, Aroojis A, D´Silva D. Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report. International Journal of Paediatric Orthopaedics Jan-April 2016;2(1):40-42.

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Complications of Surgical Management of Radial Club Hand

Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

Complications of Surgical Management of Radial Club Hand

Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

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Complications of Surgical Management of Radial Club Hand

Authors : Ratna Maheshwari [1], Rujuta Mehta [2], Ashok Johari [3]

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References

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Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

Authors : Soumya Paik [1],*, Rujuta Mehta [1], Alaric Aroojis [1], Dominic D´Silva[1]

Abstract

References

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