1/12. Acute compartment syndrome complicating a distal tibial physeal fracture in a neonate.This case report of a neonate who developed an acute compartment syndrome secondary to a minimally displaced distal tibial physeal injury represents the youngest patient to be reported with such a condition. After undergoing emergency four-compartment decompression fasciotomies, the 4-week-old child had a return of normal neuromuscular function and anatomic remodeling of the fracture. It is difficult to diagnose compartment syndrome in a neonate. The patient can neither give a history, nor follow commands to cooperate with the exam. The physician must rely primarily on the physical examination; however, the quantitative measurement of intracompartmental pressure can corroborate the diagnosis of compartment syndrome. We have found using a monometer to measure intracompartmental pressure to be helpful in conjunction with a physical exam when evaluating a neonate suspected of having a compartment syndrome.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/12. Use of a stockinette in closed reduction of distal extra-articular tibia fractures.Tibia fractures are common orthopaedic injuries. One of the most difficult tibia fractures that physicians encounter is the extra-articular distal third fracture. Operative fixation has certain risks depending on the procedure. Intramedullary nails fail to obtain adequate distal locking, and plate fixation increases the risk of soft tissue complications. Therefore, when indicated, closed reduction should be attempted. We have devised a method of applying in-line traction while performing closed reduction and casting with the use of a stockinette. This method avoids many of the problems encountered with other techniques such as calcaneal traction pins and hair splints. With the use of in-line traction through the stockinette, we are able to apply traction throughout casting without assistance, and the procedure is noninvasive.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/12. Renal hypophosphatemic osteomalacia unmasked by hyperthyroidism.A case of renal hypophosphatemic osteomalacia (RHO) that was unmasked by hyperthyroidism is presented. The patient presented at age 64 with pathologic leg fractures. There was no family history of osteomalacia or rickets. Initial evaluation revealed hyperthyroidism, which was treated with radioactive iodine. Despite control of thyroid function, the patient had recurrent pathologic fractures. Further evaluation revealed histologically proven osteomalacia and the biochemical findings of RHO: elevated serum alkaline phosphatase, decreased serum phosphate and tubular resorption of phosphate, and normal serum calcium, parathyroid hormone, and vitamin d levels. Other causes of osteomalacia were excluded. Treatment with phosphate and calcitriol reversed the osteomalacia. This case demonstrates that hyperthyroidism, and possibly other illnesses that affect vitamin d or bone metabolism, may unmask metabolic bone disease and that physicians should be alert for the subtle clinical and biochemical indicators of unrecognized metabolic bone disease in adults.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/12. Team physician #4. Avulsion fracture of the distal tibial epiphysis in skeletally immature athletes (juvenile Tillaux fracture).adolescent athletic injuries are special in that they differ from those of the skeletally mature athlete in several respects. The physis is weaker than the ligaments, so that the typical mechanism of injury, which might be expected to result in a syndesmosis sprain of the ankle in adults with subsequent tearing of the ligaments, frequently causes an epiphyseal avulsion in children. The potential for leg length discrepancy and growth aberrations exists only if a significant amount of growth remains in the unfused epiphysis. The juvenile Tillaux fracture of the anterolateral distal tibial epiphysis is rare because it requires a specific mechanism of injury of dorsiflexion and external rotation at a time when the tibial epiphysis is fused medially but open laterally. We have also noted in these injuries a tear of the interosseous ligament, which has not previously been stressed in the literature. Intraoperative findings have helped to clarify the pathoanatomy and mechanism of injury. Anatomic reduction is necessary to prevent posttraumatic sequelae.- - - - - - - - - - ranking = 4keywords = physician (Clic here for more details about this article) |
5/12. Surgical stabilization of pathological neoplastic fractures.The most important factor to consider in deciding between treatment options in the management of metastatic bone disease is the level of the patient's dysfunction and pain. Severe dysfunction or pain demands a treatment that predictably leads to a quick resumption of the painless activities of daily living. A treatment that predictably will restore function in months may seem reasonable in patients with a normal remaining life span, but is untenable if those months represent a high percentage of remaining life span, as they do in metastatic disease afflicted patients. The treating physician needs also to understand the basis for the patient's dysfunction. A destroyed joint will not return to painless function even if the metastasis responsible is totally eliminated. A bone that has lost its structural integrity, even though not grossly fractured, will not support weight bearing for months even if the metastasis is eliminated. Control of the metastatic tumor does not always equate with return to function. Treatment options in the management of metastatic bone disease are not mutually exclusive. In many patients treatment options are combined. Surgical stabilization may best return the patient's function while he is being treated postoperatively with radiotherapy or chemotherapy for good neoplasm control. Neoplasm control should not be such an overriding concern that function is not addressed. Function can almost always be returned to the patient, but neoplasm "cure" is rarely achieved in this group of patients. It is a reasonable goal to avoid allowing bone metastasis to progress to pathological fracture. Routine periodic examinations and bone scans should commonly alert the treating physician to the presence of metastatic bone disease well before fracture occurs. Pathological fracture narrows the range of treatment options, mitigates against full functional restoration, demands a rehabilitation hiatus, and acutely frightens the patient who does not have time to participate fully in treatment decisions. An impending pathological fracture can be treated with surgery, radiotherapy, chemotherapy, or hormonal manipulation. The options are basically operative or nonoperative. Lesions that predictably will fracture short term, involve joints, or will cause catastrophic consequences if fracture occurs should be strongly considered for surgical stabilization. Other factors to consider are the location of the metastasis, the primary tumor, and the expected response to nonoperative therapy. The patient becomes a surgical candidate for the above reasons and not because of any estimated life span.(ABSTRACT TRUNCATED AT 400 WORDS)- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
6/12. Occult fractures in the production of gait disturbance in childhood.Trauma to the lower extremities is the principal cause of gait disturbance in early childhood. Three cases are presented to emphasize the relative frequency of children hospitalized for diagnostic evaluation of altered gait who have occult fractures. The cases may refresh the primary physician of the variables that serve as obstacles to accurate diagnosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/12. False aneurysm of the posterior tibial artery complicating fracture of the tibia and fibula.A false aneurysm of the posterior tibial artery associated with a fracture of the tibia and fibula is described. A review of the English language literature of the last 15 years revealed only six other similar cases. The physician should bear in mind that a persisting painful swelling at the fracture site of the leg might be the only clinical sign of a false aneurysm developing in one of the tibial vessels.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/12. diagnosis and management of compartmental syndromes.patients at risk for compartmental syndromes challenge both the diagnostic and the therapeutic abilities of the physician. Suboptimum results may be due to delays in diagnosis and treatment, to incomplete surgical decompression, and to difficulties in the management of the limb after decompression. Although careful clinical assessment permits the diagnosis of a compartmental syndrome in most patients, we have found measurement of tissue pressure and direct nerve stimulation to be helpful for resolving ambiguous or equivocal cases. In our experience, the four-compartment parafibular approach to the leg and the ulnar approach to the volar compartments of the forearm provide efficient and complete decompression of potentially involved compartments. The skeletal stabilization of fractures associated with compartmental syndromes may facilitate management of the limb after surgical decompression.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/12. Torsional fractures and the third dimension of fracture management.Torsional strength is the weakest structural property of bone. Fractures produced by common indirect mechanisms are likely to have significant rotational components that bear on their management. The characteristics of torsional fracture lines in bone specimens are completely predictable and reproducible. The physician who is aware of these biomechanical consistencies can use them for fracture reduction and can anticipate and treat fracture deformities accentuated by torsional loading.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/12. Periarticular fractures after manipulation for knee contractures in children.We report two cases, each of which sustained two separate periarticular fractures from overzealous manipulation for knee contracture. The four fractures reported in this study involve one normal child sustaining asynchronous ipsilateral distal femoral and proximal tibial fractures and a child with the diagnosis of amyoplasia sustaining bilateral proximal tibial fractures. The child with knee contracture must be treated carefully and not exposed to overzealous physiotherapy or manipulation. The child who has developed a joint contracture secondary to lengthy immobilization may be at increased risk for periarticular fracture secondary to disuse osteopenia. The knee joint is at particular risk because of the long lever arm of the leg. These concerns should be conveyed to anyone involved in the patient's care, including the parents, therapists, nurses, and physicians. Passive range of motion in the child should never be painful. Normal children often can obtain maximal range of motion if left alone and not restricted.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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