Anteroposterior and lateral views of Oblique Fracture Tibia In a cast

Oblique Fracture Tibia In Cast

The fracture alignment is in acceptable position.

Related posts:

1. Oblique Fracture Distal Tibia In Plaster Cast
2. Oblique Fracture Upper End Tibia – Anteroposterior and Lateral Views
3. Fracture Shaft Of Tibia With Plaster Of Paris Cast

Related posts:

1. Overview of Osteochondrosis or Epiphysitis
2. List of Associated Anomalies in Klippel-Feil Syndrome
3. What Is Iselin Disease or Traction Epiphysitis of Fifth Metatarsal Base

Following are anteroposterior and lateral views of an ankle injury showing fracture of lateral malleolus in an adult along with subluxation of ankle..

Here is the anteroposterior xray showing the fracture and increased joint space on the medial side [marked by arrow] indicating subluxation

Fracture of Lateral Malleolus with Ankle Subluxation

Here is the lateral view

lateral View of Lateral Malleolus fracture With Ankle Subluxation

Such injuries are best managed by open reduction and internal fixation. Restoration of fibular length would automatically reduce the ankle joint as well.

Related posts:

1. Xray of Fracture of Lateral Malleolus
2. Xray of Fracture Fibula With Subluxation of Ankle
3. Xray Showing Isolated Fracture of Posterior Malleolus of Tibia

Iselin disease is the osteochondrosis or epiphyisitis of base of fifth metatarsal. It is also known as traction aophysitis or epiphysitis of fifth metatarsal base.

It was described by Iselin in 1912 as occurring in young adolescents at the time of appearance of the proximal epiphysis [growth plate] of the fifth metatarsal.

The affected epiphysis is a small, shell-shaped fleck of bone is located on the lateral plantar aspect of the tuberosity of fifth metarsal. It is not visible on anteroposterior or lateral radiographs and can be seen in the oblique view.

Peroneus brevis muscle insertion is in vicinity of this epiphysis.

The epiphysis appears in girls at about age 10 years and in boys at about age 12 years and is fused about 2 years later.

Pathophysiology

Iselin disease is thought to be due to overuse injury repetitive pressure during athletic activities and the traction by the inserted muscle is thought to contribute to the pathophysiology.

The disease is very rare. Till 1999 only nine known cases of this conditions were reported.

It is thought that misdiagnosis might have contributed to the rarity.

With the growth of organized sports  especially in younger age groups, overuse injuries are becoming more frequent.

The traction apophyses of fifth metatarsal, a site of active growth  might be injured as a result of either a single  episode of macrotrauma or
from repetitive microtrauma.

This might result in pain, swelling, and occasional bony and cartilaginous overgrowths referred to as apophysitis.

In addition  rapid growth periods in a child or adolescent can cause muscle-tendon tightness and can lead to potential for tiny avulsion fractures at the weak apophyseal growth cartilage. When this occurs at the bases of the fifth metatarsal, Iselin Disease occurs.

Presentation and Diagnosis

Pain at outer aspect of foot that worsen with activity is the usual presentation.There is a visible prominence proximal  part of fifth metatarsal. Weight bearing produces pain over the lateral aspect of the foot.

The affected area over the tuberosity is larger on the involved side, with soft-tissue edema and local erythema.

On palpation the area is tender. Resisted eversion, extreme plantar flexion and dorsiflexion of the foot cause pain.

The diagnosis of Iselin Disease should be considered in adolescents presenting who are active in sports and present with symptoms.

Differential diagnoses are Jones’ fracture [fracture of base of fifth metatarsal, stress fractures of fifth metatarsal]

Imaging

Xrays

Routine foot xrays include AP, lateral and oblique views. In Iselin disease, oblique radiographs show enlargement and often fragmentation of the epiphysis and widening of the cartilaginous-osseous junction.

On xrays, a normal variant which appears as a  small fleck of bone that is oblique to the fifth metatarsal shaft and on the lateral aspect of the tuberosity is found in most children. However, there would not have any clinical symptoms.

For diagnosis of Iselin disease, the radiographic finding must correlate with clinical symptoms

On xrays, in addition to above mentioned differentials, another entity that needs to be diagnosed is Os vesaleanum, an
accessory bone found proximal to the base of the fifth  metatarsal.

Again, there would be absence of symptoms in Os vesaleanum.

Bone Scan

Technetium-99m bone scanning shows increased uptake over the epiphysis.

Treatment

The treatment of Iselin disease  ranges from conservative  to operative.

Rest to part, Ice fomentation help in decreasing inflammation in mild cases.  If tenderness and inflammation do not resolve, oral nonsteroidal anti-inflammatories (NSAIDs) can be added.

If symptoms return on discontinuation of medication, or symptoms ar moderate to severe,  immobi­lization with air cast or plaster cast may be used and the patient is kept non weight bearing. After 2-4 weeks range of motion exercises can be initiated.

If conservative treatment fails, there is a risk of fragment going into non union and surgical intervention like resection of the fragment or fixation at the nonunion site.

Excision is recommended only if  the excised bone does not interfere with the function of the peroneus brevis tendon or stability of gait

Return to sports activity should be gradual and supervised.

Related posts:

1. Overview of Osteochondrosis or Epiphysitis
2. Enchondromatosis or Ollier Disease
3. Dysplasia Epiphysialis Punctata (Conradi Disease)

Osteochondrosis is a self-limiting developmental derangement of normal bone growth that primarily involves the centers of ossification in the epiphysis.

It is a kind of an aseptic ischemic necrosis in a previously normal epiphysis though the role of ischemia is not clearly proved yet.

As the research on osteochondrosis is gathering more data, few of the osteochosndroses are being labeled as phenomenon rather than disease or syndrome.

Classification

Modren classification system was proposed by Siffer.

It divides the osteochondroses into articular, nonarticular, and physeal types.
Articular osteochondroses

•  Primary involvement of the articular and epiphyseal cartilage– Freiberg disease
•  Secondary involvement of the articular and epiphyseal– Perthes disease, Köhler disease [The primary pathology is ischemic necrosis of the bone]

Nonarticular osteochondroses

• Tendinous attachments – Osgood-Schlatter syndrome, Monde-Felix disease
• Ligamentous attachments – Vertebral ring
• Impact sites – Sever disease

Physeal osteochondroses

• Long bones – Tibia vara (Blount disease)
• Scheuermann disease

Pathophysiology

A primary vascular event or trauma have been thought to result in ischemia of the ossification center. Social deprivation, dietary deficiency, and passive exposure to smoke have been implicated as causes.

Most osteochondroses occur shortly after the bony nucleus appears, around the middle of the growth spurt

Clinical Presentation and Diagnosis

Pain that is localized to the affected site is usual presentation in the initial stages. On examination localized swelling, tenderness, limited movement of nearby joint may be noted. Lower limb involvement may show gait problems.

Growth disturbance and secondary deformities may occur in late stages.

Investigations

Labortary findings are mostly normal.

Xray

Xrays in early stage show Early involvement typically results in a epiphysis of reduced size, increased opacity, and irregular architecture.
With advancement, fibrillation and fissures in the cartilage enlarge.

Revascularization phase results in osteoporosis, absorption of necrotic tissue, and deformation. Incomplete restoration of the blood supply and poor protection can lead to misshaped epiphysis.

Joint arthrosis is a late complication in cases of poor restoration.

MRI

MRI can pick up the disease at asymptomatic stage and before xray changes. Early MRIs show focal hyperintensities in the epiphysis or neighboring soft tissues indicating edema. Marrow edema in the parent bone is also seen. Peripheral irregularity can be visualized.

Bone Scintigraphy

Bone scintigraphy is again a very sensitive and specific test which can pick up the problem before symptoms. By showing absence of tracer uptake representing low metabolic activity, and blood flow.

In restoration stage, the scan shows increased flow or activity at the margin of the hypoactive, necrotic and neighboring physis and metaphysic.

A normal distribution marks the complete healing.

Bone scan is able to indicate the phase of disease as well and thus can be used as prognostic marker.

Treatment

Most of the cases of osteochondrosis have a self limiting course. Medical and supportive therapy constitute the mainstay of treatment.

The goal is to obtain a congruous, mobile, and painless joint.

Surgery is indicated only in cases where conservative therapy has failed when it would help to reduce late disability.

Medical Treatment

• Rest to joint, ice application and analgesics to prevent further trauma
• Traction, immobilization by plaster or brace, assisted weight bearing and physiotherapy to prevent secondary deformity and to reduce mechanical stress across the joint.

Surgical Treatment

Surgical treatment is usually undertaken when conservative methods are not effective. Surgery is also used when it may help restore the reparative process or way as to improve outcome over conservative means.

Arthroscopic procedures may be done to facilitate regeneration by microfracture technique or to pin or fix a salvageable fragment. Oseotomy is done to correct the deformity.

Salvage surgeries and reconstructive procedures are done in to improve situations in cases with poor outcomes. These may include arthrodesis, arthroplasty or bone lengthering procedures where required.

The surgery needs to be individualized.

Prognosis

Because osteochondrosis is a self-limiting disorder, the outcome is usually good.

However, when osteochondrosis does not remit with conservative treatment or surgery,

Related posts:

1. A List of Eponyms of Osteochondrosis
2. What Is Iselin Disease or Traction Epiphysitis of Fifth Metatarsal Base
3. Klippel-Feil Syndrome-Overview and Clinical Presentation

Yep! You are looking at the site with a new theme. While I liked the old look too, I am quite excited about the new theme I have adopted for the website.

It is Eleven-40 theme child theme for Genesis platform [on which the site is run]. The name comes from its maximum width 140 pixels.

This is one of the minor reasons I chose the new theme.

The major one is that the new theme is mobile responsive theme. It can detect the mobile devices and adjust the breadth accordingly.

So here is the good news. Accessing the website from a mobile device just becomes easier and better.

Would you please test on your devices and leave a comment on your user experience.

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1. Bone And Spine Professional
2. Presenting Bone And Spine Professional
3. Bone And Spine Communities Page Suspended

Lateral View of wrist showing distal radius fracture.

Fracture of Distal Radius

It might be difficult to appreciate on this view but the fracture has intra-articular extension as well.

No related posts.

Postoperative xrays images of fracture patella shown here

Fracture of Patella Treated With Screws and TBW

The screws were used along with TBW because of comminution.

Related posts:

1. Hoffa’s Fracture Fixed With Cannulated Cancellous Screws and Herbert Screws
2. Fracture Lateral Condyle Humerus Fixed With Cannulated Cancellous Screws
3. AP and Lateral Xrays of Fracture Capitellum and Medial Epicondyle Humerus Fixed With Screws

Following xrays are of a foreign body in hand. The foreign body in this case is a needle which was stuck in index finger and on attempted removal got broken.

Here is the anteroposterior view of the broken needle showing needle part at level of proximal phalanx of index finger.

A Broken Needle In Proximal Phalanx Of Index Finger - AP Xray

Here is the oblique view

Oblique View Of Broken Needle in Proximal Phlanx Of Index Finger

The broken piece of needle was removed using Carm image intensifier.

No related posts.

Twenty six years old male fell from motorbike and injured his knee. The xray revealed comminuted fracture of patella

Comminuted Fracture Of Patella

The fracture was treated with tension band wiring using screws and kwires.

Related posts:

1. Xray of Comminuted Fracture of Patella
2. Comminuted Fracture of Patella
3. AP and Lateral Xray of Operated Patella Fracture Fixed With Screws and Tension Band Wiring