Clavice Fracture

Clavicle is the bone most commonly fractured during labor and delivery. Although difficult delivery of the shoulder, or extended arms in breech deliveries increase the chances of a clavicle fractures, they can be present even with a history of a normal delivery.

Diagnosis: In addition to delivery history the following features may point towards the diagnosis:
-Decrease/assymetric movement of the limbs. (This may be evident by presence of an assymetric Moro's reflex)
-Palpable crepitus or bony irregularity early on
-A large callus forms quickly and is generally palpable by age 1 week.

Prognosis is excellent. Treatment, if any, is limited to immobilization of the arm and shoulder on the affected side (simply pinning the sleeve to the side of the infant's shirt does the trick). Figure of 8 bandages are no longer used.

Differential diagnosis: Congenital pseudoarthrosis of the clavicle

This condition presents as a palpable lump in the center of the clavicle that does not change or heal with any amount of time. Its cause is unknown. The condition is more common on the right side and generally does not lead to any functional impairment. Surgery is rarely indicated.

Caisson Disease or Decompression Sickness

Caisson disease is also known as decompression sickness or diver's disease. When the body is subjected to high surrounding pressure (e.g. scuba diving), more than usual amount of Nitrogen gets dissolved in the blood. If the pressure is relieved suddenly, the dissolved Nitrogen can become gaseous quicker than the body can get rid of. These bubbles can lead to ischemia by blocking blood vessels. Clinical situations when such sudden depressurization can occur include scuba diving, caisson working, mining, flying in unpressurised aircraft, and extra-vehicular activity from spacecraft.

Depending upon the location of ischemia a variety of symptoms can results. Classically the symptoms are described as the bends, the chokes and the staggers!

The bends: refers to pain in the joints from ischemia of joint capsules
The chokes: refers to dyspnea
The staggers: refers to neurological symptoms.

Prevention:


-Divers should limit their ascent rate to about 10 metres per minute.
-Oxygen pre-breathing

Treatment:

-Administer 100% oxygen by face mask until re-compression with 100% oxygen until hyperbaric oxygen therapy is available.
-Treat dehydration

Osteogenesis Imperfecta

The term Osteogenesis imperfecta was coined by Lobstein. The term is some what self explanatory! It is one of the relatively common bone dysplasias (1 in 20000 live births). OI involves all parts of the body that contain type 1 collagen to some extent giving rise to a variety of clinical presentations. Underlying mechanism in simple words is functional or actual decrease in collagen type 1 secondary to mutations in genes (most are inherited in autosomal dominant manner) coding for the same.

Clinical features include blue sclera, triangular facies, macrocephaly, hearing loss, dentition problems, chest deformity, scoliosis, limb deformities, fractures, joint laxity, constipation, sweating and growth retardation. There are several types, some being more severe than others (classified according to Sillence Classification). Type II has the most severe clinical presentation with most babies dying in newborn period. Type I is the mildest and commonest sub-type.

Diagnosis of OI is usually made clinically and confirmed by genetic testing for mutations. Radiological tests are useful and confirmatory in many cases. Findings include: fractures, excessive callus formation and popcorn bones (multiple radiolucent areas with radiodense rims), wormian bones in the skull, enlargement of frontal and mastoid sinuses, deformities of ribs, narrow pelvis. In mild cases dual x-ray absorptiometry (DEXA) scan can be useful and will show decreased bone mineralization.

Treatment is essentially supportive. Bisphosphonates, especially pamidronic acid, are drugs that inhibit osteoclast-induced bone resorption. These are given in a cyclic manner (every few weeks) and have been shown to decrease the fracture rate (especially in type III and IV OI). Side effects of pamidronic acid include hypocalcemia (usually not severe), leukopenia, increase in bone pain (which is typically transient), and scleritis.

Other drugs with unclear roles in the treatment of OI include: Human growth hormone, teriparatide (which is human parathyroid hormone, brand name is Forteo). Bone marrow transplantation and gene therapy are being investigated. Aggressive physical therapy, occupational therapy and education of parents about injury prevention is essential.

Above article also serves as explanation to Quiz 28: 'Femur X-Ray of a 3 year old boy' on the website www.pedsquiz.com

Spinal Canal Stenosis

Usually results from degenerative changes in the lumbar vertebrae. Predisposing factors include older age, history of back injury or surgery, and manual labor.

Clinical features: Leg pain (neurogenic claudication) and paresthesia that comes on while walking or running and gets better on rest.

Diagnosis: Imaging will show degenerative changes and spondylolisthesis (Sliding of one vertebra over another). MRI is diagnostic.

Treatment: Symptomatic with NSAIDs and physical therapy. Steroid injections(epidural) are rarely used if other methods fail. If features of cord compression are present surgery may be needed.

Anterior cruciate ligament anatomy

ACL is attached to a depression on the posteromedial surface of the lateral condyle of femur. On the tibia it inserts into a fossa that is anterior and lateral to the anterior tibial spine. The tibial attachment is known to be stronger than the femoral attachment.

The ACL is intracapsular but is extrasynovial. Its course is anterior, medial, and distal from the femur to the tibia. Close your eyes and imagine this course. It will help you understand the mechanism of injury.

The Anterior Cruciate Ligament has 2 bands - the anteromedial band and the posterolateral band. During flexion when the back of the leg comes closer to the back of the thigh, the anterior band is taught. When the leg is straightened posterolateral band is tight.

Anterior interosseous syndrome

Anatomy: Few inches distal to the cubital fossa, the median nerve gives a branch named anterior interosseous nerve, which travels on the interosseous membrane and supplies the flexor pollicis longus (flexor of the thumb), the flexor digitorum profundus to the radial 2 digits, and the pronator quadratus at its termination. The nerve innervates the pronator teres, flexor capri radialis, the flexor digitorum sublimis, and the 2 radial flexor digitorum profundus tendons.

Symptoms: include pain in the proximal forearm and weakness of the thumb and index finger. Affected persons cannot form a circle by pinching their thumb and index finger (ie, hyperextension of index distal interphalangeal joint and thumb interphalangeal joint).

Treatment: Medical treatment includes rest, NSAIDs (Non Steroidal Anti Inflammatory Drugs), and splints. Surgical treatment includes exploration and release.

Ankylosing Spondylitis (AS)

Characteristic symptoms of AS include back pain that is worst in the morning and improves with exercise. AS is more common in men, and patients usually present at a younger age (18-35 years) relative to patients with mechanical causes of back pain or arthritis.

AS is a clinical diagnosis, HLA B27 testing is positive in a large proportion of patients with AS but one should keep in mind that in the general population, about 8% Caucasian, 4% African, 2-9% Chinese, and 0.1-0.5% Japanese have the HLA-B27 antigen.

Commonest cause of death related to AS is renal failure secondary to amyloidosis in AS.

Scurvy

Hydroxylation of Lysine to Proline is an improtant step in collagen synthesis and  it occurs in Rough Endoplasmic Reticulum and requires Vitamin C. Vitamin C deficiency leads to Scurvy which has bone changes and bleeding gums due to weak collagen formation.

Supracondylar fracture of humerus

Supracondylar fracure of humerus-Positive Fat Pad sign. Damage to Median nerve and brachial artery.

Boutonniere’s deformity

Boutonniere's Deformity is seen in Rheumatoid Arthritis. The components are flexion at the proximal & extention at the distal IP joints

Osgood-Schlatter disease

Typically a 12 year old boy with pain in the knee (tibial tuberosity). Diagnosis is clinical and X-ray. Rx: Physical therapy and NSAIDs.

Monteggia and Galeazzi fractures

Monteggia fracture: Remember that in Monteggia # the Medial bone is fractured (Ulna) with Dislocation of radial head.

Galeazzi fracture: Radial shaft fracture, associated with disruption of distal radio ulnar joint.

Fractured Clavicle

When clavicle injury is suspected and a bruit is present, subclavian arterial injury must be ruled out with an angiogram.