·
Perkins rules
- Fractures of cancellous (metaphyseal) bone (e.g. those around joints) will take
6 weeks to unite.
- Fractures of cortical (diaphyseal)
bone (e.g. shafts of long bones) will take 12
weeks to unite.
- Fractures of the tibia (because of poor blood supply),
will take 24 weeks to unite.
- Time to union for children equals the age of the
child in years plus one, e.g. tibial
fracture in a 2-year-old child will unite in 3 weeks. Common sense needs
to be applied when applying the rule to fractures of cancellous
bone in older children.
·
As a rule, in children up to 8 years old, as
much as 30° of angulation will heal satisfactorily
without reduction. In older children, percentages are lower. In general,
fractures that are in the metaphysis
or growth plate remodel more completely than midshaft
fractures. Rotational malalignment will not remodel.
·
Treatment of clubfoot
- ■ The Ponseti method of serial casting is successful in
95% of feet, avoiding formal surgical release although percutaneous
tenotomy is usually required
- ■ The standard
sequence is elevation of the first ray, gradual abduction to 60∞
and, finally, dorsiflexion, usually following Achilles
tenotomy
- ■ Tibialis anterior transfer can be used to correct
dynamic supination in toddlers and older
children
- ■ Surgical
release may need to address posterior, medial, plantar and lateral
structures, and may result in a stiffer foot than one treated
conservatively
·
Giant cell
variant tumors
1 - aneurysmal bone cyst
2- osteoclastoma
3- chondroblastoma
4- unicameral
bone cyst
5- chondromyxoid fibroma
6- non osteogenic fibroma
7- fibrous
dysplasia
8- brown
tumor of hyperparathyroidism .
·
The tuberculosis
of hip mainly progresses through three stages .
a- stage of synovitis
( FABER - AL )
b- stage
of arthritis ( FADIR - AS )
c- stage
of erosion ( FADIR - TS )
·
Rupture of the tendon of the
long head of the biceps produced a positive “popeye
sign” where the biceps belly of the muscle becomes prominent in the
mid upper arm. Weakness with supination is prominent,
and forearm flexion is typically preserved.
·
Open reduction of a fracture
involves the restoration of normal bone alignment
under direct observation at surgery. In effect, open reduction converts a simple fracture into a compound (or open) fracture
and thereby increases the risk of infection.
Operative manipulation also increases trauma at the
fracture site and may consequently add to the probability of infection.
Hematomas at the site of fracture may be important for early healing; open
reduction, which usually involves removing the clots in the field, could
contribute to a delay in bone healing and to
nonunion. The major advantage
of open reduction is the shorter period of
immobilization it allows, an advantage that often outweighs all the
disadvantages previously mentioned, as in the open reduction of femoral neck
fractures in the elderly. This allows these patients to get out of bed much
sooner than if they were treated with several weeks of traction.
·
Denis
developed a classification system for a thoracolumbar spine injury based on a three-column concept. In this
system, the spine is divided into three longitudinal regions or columns: anterior, middle, and posterior. Although references to such “columns” is anatomically imprecise, the
term is clinically useful in assessing the stability of the injured spine. In
general, instability results when significant disruption is present in two of
the three columns, regardless of the presence or absence of neurologic deficit.
·
Fracture of the atlas
(Jefferson's fracture) occurs from an axial load, usually to the top
of the head. The resulting forces fracture the ring of C1 and displace the
fragments outward. This results in an increase in the cross-sectional area of
the spinal canal at the level of injury. Neurologic
injury is, therefore, unusual in this fracture. CT is the best roentgenographic study available to evaluate fractures of
the atlas.
·
The best method of treating a supracondylar fracture of the
humerus in a child that is unstable when
the elbow is flexed to 90 degrees is percutaneous pinning. Hyperflexion
of the elbow usually achieves stability but incurs the risk of occluding
arterial inflow and may cause permanent neuromuscular deficit. Open reduction
is not indicated unless the fracture is irreducible or associated with a
vascular injury.
·
Wrist pain during attempted push-ups or diffuse
swelling on the dorsum of the wrist may be caused by a variety of factors.
Wrist popping on movement may be the result of carpal instability, subluxation of a tendon on extension and flexion of the
wrist, or intra-articular problems such as an articular cartilage flap or a tear of the triangular fibrocartilage. Localized
tenderness at the anatomic snuffbox (scaphoid) is the
most consistent sign of scaphoid fracture.
·
Compression of the median nerve at the elbow by the lacertus
fibrosus causes symptoms at more locations
than just the flexor pollicis longus
and flexor profundus at the index finger, since the entire
median nerve is affected.
Compression of the median nerve at
the axilla
affects both motor and sensory elements diffusely.
The arcade
of Frohse is a fibrous band at the origin
of the supinator
muscle. It can compress the posterior interosseous
portion of the radial nerve but does not involve the median nerve.
The anterior
interosseous portion of the median nerve
can be compressed by an aberrant accessory forearm muscle (Gantzer's
muscle).
·
While patients with carpal
tunnel syndrome often complain of subjective symptoms such as
numbness of the thumb, index, and long fingers, objective decreased sensibility
is not usually present.
Testing with von Frey filaments produces the most sensitive
results.
Decreased light touch is noted
before decreased two-point discrimination.
Dryness of the skin in the median
nerve distribution is evident with severe injury to the nerve but not in the
routine carpal tunnel syndrome.
Although the abductor pollicis brevis and opponens pollicis are supplied by
the motor branch of the median nerve, atrophy of these muscles is not seen
until long-term median nerve compression has occurred. Symptomatic carpal
tunnel syndrome without evidence of thenar atrophy
has a greater frequency than the more severe median nerve compression, with
demonstrable thenar atrophy.
Percussion
over the median nerve at the wrist producing paresthesias distally in the distribution of the median nerve and paresthesias caused by wrist flexion are two
of the most common signs of median nerve compression at the wrist.
Although patients with carpal tunnel
syndrome intermittently complain of weak grip and dropping objects, cramping of
the hand while writing and difficulty writing are not
routine symptoms of this condition.
·
The blood supply
to the femoral head is provided predominantly by the branches of the
medial femoral circumflex
artery, which take a posterior
course and are confluent with the retinacular
vessels. The lateral femoral
circumflex artery runs anteriorly.
·
The amount of
energy absorption and the degree of bony comminution
is the most significant factor in predicting healing of tibial
fractures. Location along the tibia and age are not thought of as
significant factors in healing. The soft tissue damage may contribute to lack
of vascular envelope, but the destruction of soft tissue is based on the amount
of energy absorbed.
·
The blood supply of the talus is somewhat tenuous because there are no muscles or tendons associated with this bone.
·
Level of
amputation: Clinical competence of the extremity with observations
of skin turgor, discoloration, perfusion, sensation,
and integrity is the mainstay of surgical decision making. This can be
complemented by transcutaneous PO2, ankle-arm
systolic pressure ratios, xenon skin clearance, serum albumin levels, and total
lymphocyte count.
·
Hematogenous osteomyelitis
occurs most frequently in children and involves the metaphyseal ends of long bones. The
cause is thought to relate to the pattern of blood flow in the metaphysis wherein arterioles empty into numerous
sinusoidal veins with sluggish blood flow favoring the lodgement
of bacteria.
·
The flexor retinacular system from the metacarpophalangeal
joint to the distal interphalangeal joint maintains
the flexor tendons against the digit during flexion, preventing bow stringing
and allowing the digital tip to flex to the distal palmar
crease. Division of the A 1, A 3, or A 5
pulleys minimally compromises this function; however, division
of the A 2 or A 4 pulleys can significantly limit digital excursion.
Continuous passive
mobilization (CPM) causes a 16% improvement in range of digital
motion compared to intermittent mobilization. The incidence of poor results is
much lower (3% versus 26%) despite no postoperative ruptures or infections.
Continuous passive mobilization appears to be a more effective yet safe means
of improving postoperative function following flexor tendon injury.
Zone II of
flexor tendon injury that carries the poorest prognosis.
·
A number of PROTEINS
have been demonstrated to directly or indirectly influence bone induction.
Platelet-derived
growth factor from platelets and macrophages has been shown to induce
migration and mitosis of mesenchymal cells in wounds
and to enhance cartilage and bone formation in adult rats.
Fibroblast
growth factors is
a mitogenic and angiogenic
protein that favors new bone formation, particularly if neo-ascularization
is required.
Transforming
growth factor-b is secreted from bone cell cultures. This protein
appears to be naturally released from platelets at the time of a fracture and
stimulates proliferation of osteoblasts and increases
their production of collagen.
Osteogenin has the ability to induce
cartilage and bone formation and to play a major controlling role in the
development of de novo bone in muscle and subcutaneous tissues.
·
Fracture of the
radial head is more common in adults; fracture of the neck is more common in
children.
·
Quadrilateral
Space Syndrome: axillary nerve injury
·
Sprengel's deformity
(congenital elevation of the scapula) results from the failure of normal
scapular descent during fetal life, thereby resulting in an elevated, hypoplastic scapula. The affected side of the neck appears
shorter and broader and may give the appearance of torticollis.
A fibrocartilaginous band or omovertebral
bone may bridge the space between the medial upper scapula and the spinous process of a cervical vertebra. Abduction of the ipsilateral arm is usually limited, but this limitation may
not be clinically significant. Sprengel's deformity
may be associated with congenital scoliosis and renal anomalies.
·
Clubfoot, or talipes equinovarus congenita, is
distinguished pathologically by a combination of forefoot and hindfoot abnormalities (e.g., malrotation
of the talus under the calcaneus and plantar flexion
or equinus of the ankle). As a rule, clubfoot is a rigid
deformity, whereas metatarsus is more flexible. If the ankle can be dorsiflexed to neutral or beyond, metatarsus is a much more
likely diagnosis.
·
Also called "rocker bottom foot," or "Persian
slipper" foot; this abnormality is due to congenital vertical talus.
Lateral radiographs reveal a vertically oriented talus with dislocation of the talonavicular joint. On examination, the forefoot is
markedly dorsiflexed, and the heel is rigid and
points downward, giving the sole the characteristic convex or boat-shaped
appearance. Serial casting and subsequent surgical reversion are the usual
treatments. The syndrome most commonly associated with this deformity is trisomy 18.
·
Tarsal coalition. Fusion of various tarsal bones
via fibrous or bony bridges can result in a stiff foot that inverts with
difficulty. When inversion of the foot is done during an examination,
tenderness occurs on the lateral aspect of the foot, and peroneal
tendons become very prominent. Thus, the condition is also referred to as
"peroneal spastic flat foot." Unless the
condition is very severe and warrants surgery, corrective shoes are usually
adequate treatment. Other possible causes of a rigid flat foot include
rheumatoid arthritis, septic arthritis, posttraumatic arthritis, neuromuscular
conditions, and congenital vertical talus.
·
SCFE involves progressive displacement with
external rotation of the femur on the epiphyseal
growth plate. The patient has intermittent or constant hip, thigh, or knee pain
that has often lasted weeks to months. In 25%, the pain is bilateral. A limp, a
lack of internal rotation, and a hip flexion contracture may be noted. If the
patient's hip is flexed, the thigh tends to fall into external rotation. It is
important to realize that any patient with knee pain may have underlying hip
pathology.
·
Discitis, which is the
infection and/or inflammation of the intervertebral
disc, most commonly occurs in children between the ages of 4 and 10 years. The
etiology is often unclear, but a bacterial cause (particularly Staphylococcus aureus) is identified by blood cultures in about 50% of
cases. The diagnosis can be difficult because of varied accompanying symptoms,
including generalized back pain with or without localized tenderness, refusal
to stand or walk, back stiffness with loss of lumbar lordosis,
abdominal pain, and unexplained low-grade fever.
As with osteomyelitis,
a most helpful laboratory test is an elevated ESR. WBCs may often be normal,
and early x-rays (<2-4 weeks of symptoms) may not show changes.
Technetium-99 bone scans will demonstrate abnormalities early during the course
of illness. Magnetic resonance imaging studies can help distinguish between discitis and vertebral osteomyelitis.
Treatment consists of 3-6 weeks of antistaphylococcal antibiotics, with variable amounts of
immobilization and bracing, depending on severity of symptoms. Persistent or
atypical cases may require biopsy to identify the etiology.
- If you use the tibiofemoral angle (the angle formed by the tibia and
the femur) as a guide, most children at birth are bowlegged (genu varum) up to 20°, but
this tendency progressively diminishes until about 24 months, when the
trend toward knock knees (genu valgum) begins. Knock knees continue to the age of 3
years (up to 15°) and then begin to diminish. At about the age of 8 years,
most children are-and will remain-knock-kneed at about 7°
- Shin splints. This term
describes the pain and cramping felt in the compartments of the lower leg
after strenuous exercise. It is rare in children but may be seen in teenagers
who exercise (especially running on hard surfaces) after extended periods
of inactivity. The pain results from muscle strain and inflammation of the
musculotendinous units. Swelling and cramping
occur, particularly in the flexor digitorum longus muscle, which flexes the lateral four toes and
plantar-flexes the foot at the ankle joint. The muscle swelling may
contribute to ischemia. Snowshoeing may be the ultimate test of the
anterior tibial muscles.
- Meniscal
tears rarely occur before the age of 12 years. A discoid meniscus is a
congenitally abnormal meniscus and can appear at almost any age. Meniscal tears in youths are typically associated with
significant injuries that arise from a memorable event. They produce pain,
swelling, and limping. There is often an associated injury to the anterior
cruciate ligament.
Spondylolysis
is a condition in which there is a defect in the pars
interarticularis
(vertebral arch) of a vertebra that is most common at L5 in children and
adolescents.
Spondylolisthesis is a condition
(usually resulting from
spondylolysis) that is
characterized by forward slippage of one vertebra on the lower vertebrae.
Pain is the most common presenting symptom for both conditions. The
etiology is unclear, but various theories relate it to hereditary factors,
congenital predisposition, trauma, posture, growth, and biomechanical
factors. Treatment includes watchful waiting, limitation of activity,
exercise therapy, bracing, casting, and surgery, depending on the
patient's age, the magnitude of the slippage, the extent of pain, and the
predicted likelihood of progression of the deformity.
·
Caffey disease, or
infantile cortical hyperostosis, is
characterized by a
clinical triad (fever, soft-tissue
swelling, and hyperirritability) and a clinching radiographic
picture of underlying cortical hyperostosis (thickening or bony expansion).
Caffey's disease (or syndrome), which usually occurs before
6 months of age, is a condition of unknown etiology that consists of tender,
nonsuppurative, cortical swellings of the shafts of bone,
most commonly the mandible and clavicle. It remits spontaneously, but
exacerbations may persist for several years. In severe cases, corticosteroids
may be helpful. Infantile cortical hyperostosis is a rare condition. The
presence of
periosteal reaction, especially if
asymmetric, should raise the suspicion of battered child syndrome.
·
Hardcastle's Syndome; Diaphyseal
Medullary Stenosis with
Malignant Fibrous Histiocytoma (DMS-MFH)
AD
Radiographs show thickening of the
cortex, with irregularity and loss of distinction of the endosteal
surface. There may be small lucent or lytic areas
within or adjacent to the cortex, which may appear to permeate a region of the
bone. The metaphyseal area has striated densities that
may be seen as confluent fibro-osseous bands on axial imaging. Larger seemingly
lytic areas may be seen, although these may areas of
normal density surrounded by more sclerotic areas. The
diffuse changes seen throughout multiple long bones have the appearance of
"worm-eaten wood". Fractures occur with relatively
minor trauma through affected bone, and healing is slow and incomplete. Visible
fracture lines persist years after surgical stabilization.
Treatment should be based on:
1) Avoidance
of pathological fracture by appropriate activity modifications.
2) Internal fixation, preferably
by intramedullary rodding, is best.
It should be expected that the rods will stay in permanently due to the lack of
complete healing.
3) Ongoing
monitoring for malignant transformation.
·
de Quervain tenosynovitis:
exquisite pain at the thumb with the Finkelstein maneuver (a specific maneuver
in which the thumb is placed in the closed fist and the affected hand is tilted
towards the little finger, into ulnar deviation)
The Finkelstein
sign classically occurs in mothers of infants 6-12 months of
age. Interestingly, the cause is believed to be principally endocrine and
related to fluid retention in breast-feeding mothers, not solely as a result of
repetitive lifting motion. De Quervain tenosynovitis has also, however, been described in fathers.
This suggests that the condition can occur in the absence of postpartum
endocrine changes. Repetitive trauma in manual laborers is also a common cause.
The pain itself may appear either gradually or suddenly
de Quervain tenosynovitis, an
inflammatory process that typically involves the first dorsal extensor
components of the wrist (namely, the abductor pollicis
longus [APL] and the extensor pollicis
brevis [EPB]) within the narrow fibro-osseous tunnel
through which they normally pass
Ultrasonography
of the symptomatic tendon typically shows distention in the tendon sheath, with
surrounding fluid that is hypoechoic or anechoic. An
axial scan of the tendon will exhibit a so-called
"double target" appearance.
·
Bizarre Parosteal Osteochondromatous
Proliferation (Nora's Lesion)
Bizarre parosteal
osteochondromatous proliferation (BPOP) is a rare
lesion that occurs most commonly in the hands
and feet, usually of adults in their 20's and 30's, average age 30
-33 years, range, 2 to 73. Males and females are equally affected. The lesion
is most common in the hands followed by the feet, long bones (commonly of the
upper extremity), skull, jaw, and other sites. It most commonly occurs on the
proximal and middle phalanges, metacarpals, and metatarsals, and it is more rare in long tubular bones. This lesion grows rapidly
and has aggressive features on imaging studies as well as confusion findings on
histopathology, leading to many errors in diagnosis and potentially
inappropriate treatments. The lesion is thought
to be related to myositis ossificans,
reactive periostitis and subungual
exostosis. It was described in 1983 by Dr.
Nora, and is sometimes called Nora's disease or Nora's lesion.
·
Stickler syndrome (or David-Stickler syndrome
or Stickler-Wagner syndrome) is a group of genetic disorders affecting
connective tissue, specifically collagen. Stickler syndrome is a subtype of collagenopathy, types II and XI. Stickler syndrome is
characterized by a distinctive facial appearance, eye abnormalities, hearing
loss, and joint problems.
·
Jaffee-Campanacci syndrome (JCS)
The association of multiple non-ossifying fibromas
with cafe au lait skin patches has been
named Jaffee-Campanacci syndrome (JCS).
This rare syndrome has a wide
range of manifestations, some cases are very mild, consisting only of a few
pigmented skin patches and benign non-ossifying
fibroma (NOF) bone tumors
The author has seen cases with multiple skin patches and multiple or solitary
NOF's where no other abnormality is present.
Reports in the
literature focus on more severe cases which demonstrate cryptorchism,
hypogonadism, ocular abnormalities, alopecia,
cardiovascular abnormalities, renal abnormalities, mental retardation, and
other serious problems
