The hallmark of anatomical snuffbox tenderness is highly sensitive for scaphoid fractures but lacks specificity. Due to the lack of specificity, those with snuffbox tenderness should undergo radiographic studies of the wrist. Those with initial negative imaging can be managed with either a thumb spica short-armed splint or advanced imaging by MRI or CT to determine if a fracture exists. Given the unique blood flow to the scaphoid, fracture location is important in determining treatment options to prevent avascular necrosis of the bone.

A greenstick fracture is a fracture in a young, soft bone in which the bone bends and breaks. Greenstick fractures occur most often during infancy and childhood when bones are soft.
Some clinical features of a greenstick fracture are similar to those of a standard long bone fracture – greenstick fractures normally cause pain at the injured area. As these fractures are specifically a paediatric problem, an older child will be protective of the fractured part and babies may cry inconsolably. As per a standard fracture, the area may be swollen and either red or bruised. Greenstick fractures are stable fractures as a part of the bone remains intact and unbroken so this type of fracture normally causes a bend to the injured part, rather than a distinct deformity, which is problematic.
Radiographic features
-usually mid-diaphyseal
-occur in tandem with angulation
-incomplete fracture, with cortical breach of only one side of the bone

This is a case of a high-velocity injury and, therefore, requires surgical fixation.

Bony injury resulting in a fracture may occur due to trauma (excessive force applied to bone), stress (repetitive low-velocity injury), or underlying pathology (abnormal bone which fractures during normal use or following minimal trauma).

Diagnosis involves not just evaluating the fracture, such as the site and type of injury, but also other associated injuries and distal neurovascular status. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays, it is important to assess for changes in the length of the bone, the angulation of the distal bone, rotational effects, and the presence of a foreign body such as glass.

The combination of a crush injury, limb swelling, and inability to move digits raises suspicion of compartment syndrome that would require a fasciotomy.

Compartment syndrome is a particular complication that may occur following fractures, especially supracondylar fractures and tibial shaft injuries. It is characterised by raised pressure within a closed anatomical space which may, eventually, compromise tissue perfusion, resulting in necrosis.

The clinical features of compartment syndrome include:
1. Pain, especially on movement
2. Paraesthesia
3. Pallor
4. Paralysis of the muscle group may also occur

Diagnosis is made by measurement of intracompartmental pressure. Pressures >20mmHg are abnormal and >40mmHg are diagnostic.

Compartment syndrome requires prompt and extensive fasciotomy. Myoglobinuria may occur following fasciotomy, resulting in renal failure. Therefore, aggressive IV fluids are required. If muscle groups are frankly necrotic at fasciotomy, they should be debrided, and amputation may have to be considered.

The Gustilo open fracture classification system is the most commonly used classification system for open fractures.
This system uses the amount of energy, the extent of soft-tissue injury and the extent of contamination for determination of fracture severity. Progression from grade 1 to 3C implies a higher degree of energy involved in the injury, higher soft tissue and bone damage and higher potential for complications.
Grade Injury
1 Low energy wound <1cm
2 Greater than 1cm wound with moderate soft tissue damage
3 High energy wound > 1cm with extensive soft tissue damage
3 A (sub group of 3) Adequate soft tissue coverage
3 B (sub group of 3) Inadequate soft tissue coverage
3 C (sub group of 3) Associated arterial injury

It is important to recognize that a Gustilo score of grade 3C implies vascular injury as well as bone and connective-tissue damage. Grade 3C is defined as an open fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury. The lack of peripheral pulses indicate arterial injury.
A less morbid damage control approach (compared with ligation) for patients with extremity vascular injury is vascular shunting, a technique that has been available for over 50 years. A vascular shunt is a synthetic tube that is inserted into the vessel and secured proximally and distally. Shunts were placed in the context of damage control to allow stabilization of Gustilo 3C fractures or limb replantation. Vascular shunts are typically used for larger, more proximal arteries and veins such as the femoral and popliteal arteries. Shunts can remain in place up to six hours, but definitive vascular reconstruction should be performed as soon as the patient is sufficiently stable to undergo the procedure. Once a fracture is identified, it is reduced as much as possible and splinted. If an open fracture is suspected, the patient should be taken to the operating room to debride and stabilize the fracture (usually with external fixation) either after life-threatening injuries have been managed or concurrently while less emergency chest, abdominal, or head injuries are being addressed. Revascularization — Ischemia due to vascular injury is a major risk factor for amputation, and, ideally, the injury will be identified and treated within six hours to minimize ischemic nerve and muscle damage.

The patient has Denis B fracture, unstable fracture requiring open reduction and internal fixation (ORIF)
open reduction internal fixation indications:
– any talar displacement
– displaced isolated medial malleolar fracture
– displaced isolated lateral malleolar fracture
– bimalleolar fracture and bimalleolar-equivalent fracture
– posterior malleolar fracture with > 25% or > 2mm step-off
– Bosworth fracture-dislocations
– open fractures
– malleolar non-union

Danis-Weber classification:
type A
below the level of the talar dome
usually transverse
tibiofibular syndesmosis intact
deltoid ligament intact
medial malleolus occasionally fractured
usually stable if medial malleolus intact
type B
the distal extent at the level of the talar dome; may extend some distance proximally
usually spiral
tibiofibular syndesmosis usually intact, but a widening of the distal tibiofibular joint (especially on stressed views) indicates syndesmotic injury
medial malleolus may be fractured
the deltoid ligament may be torn, indicated by a widening of the space between the medial malleolus and talar dome
variable stability, dependent on the status of medial structures (malleolus/deltoid ligament) and syndesmosis; may require ORIF
Weber B fractures could be further subclassified as 9
B1: isolated
B2: associated with a medial lesion (malleolus or ligament)
B3: associated with a medial lesion and fracture of the posterolateral tibia
type C
above the level of the ankle joint
tibiofibular syndesmosis disruption with a widening of the distal tibiofibular articulation
medial malleolus fracture or deltoid ligament injury often present
a fracture may arise as proximally as the level of the fibular neck and not visualized on ankle films, requiring knee or full-length tibia-fibula radiographs (Maisonneuve fracture)
unstable: usually requires ORIF
Weber C fractures can be further subclassified as 6
C1: diaphyseal fracture of the fibula, simple
C2: diaphyseal fracture of the fibula, complex
C3: proximal fracture of the fibula
a fracture above the syndesmosis results from external rotation or abduction forces that also disrupt the joint
usually associated with an injury to the medial side

A Salter–Harris fracture is a fracture that involves the epiphyseal plate or growth plate of a bone, specifically the zone of provisional calcification. It is a common injury found in children, occurring in 15% of childhood long bone fractures.
There are nine types of Salter–Harris fractures; types I to V as described by Robert B Salter and W Robert Harris in 1963, and the rarer types VI to IX which have been added subsequently:
Type I – transverse fracture through the growth plate (also referred to as the physis): 6% incidence
Type II – A fracture through the growth plate and the metaphysis, sparing the epiphysis: 75% incidence, takes approximately 12-90 weeks or more in the spine to heal.
Type III – A fracture through growth plate and epiphysis, sparing the metaphysis: 8% incidence
Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis: 10% incidence
Type V – A compression fracture of the growth plate (resulting in a decrease in the perceived space between the epiphysis and metaphysis on x-ray): 1% incidence
Type VI – Injury to the peripheral portion of the physis and a resultant bony bridge formation which may produce an angular deformity (added in 1969 by Mercer Rang)
Type VII – Isolated injury of the epiphyseal plate (VII–IX added in 1982 by JA Ogden)
Type VIII – Isolated injury of the metaphysis with possible impairment of endochondral ossification
Type IX – Injury of the periosteum which may impair intramembranous ossification

The mnemonic SALTER can be used to help remember the first five types.
N.B.: This mnemonic requires the reader to imagine the bones as long bones, with the epiphyses at the base.

I – S = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)
II – A = Above. The fracture lies above the physis, or Away from the joint.
III – L = Lower. The fracture is below the physis in the epiphysis.
IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
V – R = Rammed (crushed). The physis has been crushed.
Alternatively, SALTER can be used for the first 6 types, as above but adding Type V — ‘E’ for ‘Everything’ or ‘Epiphysis’ and Type VI — ‘R’ for ‘Ring’.

The Monteggia fracture refers to a dislocation of the proximal radio-ulnar joint (PRUJ) in association with a forearm fracture, most commonly a fracture of the ulna. Depending on the type of fracture and severity, they may experience elbow swelling, deformity, crepitus, and paraesthesia or numbness. Some patients may not have severe pain at rest, but elbow flexion and forearm rotation are limited and painful.
The dislocated radial head may be palpable in the anterior, posterior, or anterolateral position. In Bado type I and IV lesions, the radial head can be palpated in the antecubital fossa. The radial head can be palpated posteriorly in type II lesions and laterally in type III lesions.

Colles’ fractures have the following 3 features:
– Transverse fracture of the radius
– 1 inch proximal to the radio-carpal joint
– Dorsal displacement and angulation

Smith’s fracture (reverse Colles’ fracture)
– Volar angulation of distal radius fragment (Garden spade deformity)
– Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed

Bennett’s fracture
– Intra-articular fracture of the first carpometacarpal joint
– Impact on flexed metacarpal, caused by fist fights
– X-ray: triangular fragment at ulnar base of metacarpal

Galeazzi fracture
– Radial shaft fracture with associated dislocation of the distal radioulnar joint

Pott’s fracture
– Bimalleolar ankle fracture
– Forced foot eversion

Barton’s fracture
– Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
– Fall onto extended and pronated wrist
– Involvement of the joint is a defining feature

The College of Emergency Medicine states that the patient should be discharged with no follow-up required if the patient presents with anatomical snuffbox tenderness and plain radiographs show no fracture when done initially and after when wrist splint has been used.

A scaphoid fracture is a break of the scaphoid bone in the wrist. Symptoms generally includes pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur. Complications may include non-union of the fracture, avascular necrosis, and arthritis.

Scaphoid fractures are most commonly caused by a fall on an outstretched hand. Diagnosis is generally based on examination and medical imaging. Some fractures may not be visible on plain X-rays. In such cases a person may be casted with repeat X-rays in two weeks or an MRI or bone scan may be done.

In this case, there is no delay in treatment and the mechanism by which the fracture occurred fits accidental fracture.

A statement from the parent or guardian and any witnesses regarding how the child sustained the injury will help determine whether the injury is accidental or abusive. A statement from the parent or guardian explaining why he or she delayed in seeking medical treatment is important to the investigation because caretakers often postpone medical treatment or fail to provide treatment for an injured child to hide physical abuse. The abusing parent or caregiver may also put a child in oversized clothing or keep the child inside a residence for extended periods of time in an attempt to conceal the child’s injuries.

Parents who inflict fractures on their children tend to minimize the severity of the accident purported to cause the fracture, whereas many parents of children with accidental fractures will relate a history of high-energy events.

Answer: Fasciotomy

Fasciotomy is a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle. Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. A delay in performing the procedure can lead to neurovascular complications or lead to the need for amputation of a limb. Complications can also involve the formation of scar tissue after the operation. A thickening of the surgical scars can result in the loss of mobility of the joint involved. This can be addressed through occupational or physical therapy.

Answer: Spina bifida occulta

Spina Bifida Occulta is the mildest type of spina bifida. It is sometimes called “hidden” spina bifida. With it, there is a small gap in the spine, but no opening or sac on the back. The spinal cord and the nerves usually are normal. Many times, Spina Bifida Occulta is not discovered until late childhood or adulthood. This type of spina bifida usually does not cause any disabilities.

Eighty percent of those with a spinal cord problem will have skin over the defect with:
a hairy patch
a fatty lump
a haemangioma—a red or purple spot made up of blood vessels
a dark spot or a birthmark—these are red and don’t include blue-black marks, called “Mongolian spots”
a skin tract (tunnel) or sinus—this can look like a deep dimple, especially if it’s too high (higher than the top of the buttocks crease), or if its bottom can’t be seen
a hypopigmented spot—an area with less skin colour.

Myelocele is herniation of spinal cord tissue through a defect in a region of the vertebral column. The protrusion of the tissue is flush with the level of the skin surface. In myelocele, the spinal cord is exposed so that nerve tissue lies exposed on the surface of the back without even a covering of skin or of the meninges, the membranous tissue surrounding the brain and spinal cord.

Perhaps the most important aspect in the treatment of open fractures is the initial surgical intervention with irrigation and meticulous debridement of the injury zone. Irrigation, along with debridement, is absolutely crucial in the management of open fractures.
Early stabilization of open fractures provides many benefits to the injured patient. It protects the soft tissues around the zone of injury by preventing further damage from mobile fracture fragments. It also restores length, alignment, and rotation—all vital principles of fracture fixation. Skeletal traction and external fixation are the quickest fixation constructs to employ. The use of skeletal traction should be reserved only for selected open fracture types (i.e., pelvis fractures and very proximal femur fractures) and if used, it should only be for a short selected time. External fixation is a valuable tool in the surgeon’s arsenal for acute open fracture management. Indications for external fixation are grossly contaminated open fractures with extensive soft-tissue compromise, the Type IIIA-C injuries, and when immediate fixation is needed for physiologically unstable patients.

The administration of antibiotics is best considered therapeutic, rather than prophylactic, because of the high risk of infection in the absence of antibiotics.

Although debate still surrounds some aspects of antibiotic administration for open fractures, the following generalizations can be made:

– All patients with open fractures should receive cefazolin or equivalent gram-positive coverage; this may be sufficient
– Type II or type III injuries likely benefit from the addition of adequate gram-negative coverage, typically with an aminoglycoside
– Injuries at risk for anaerobic infections (e.g., farm injuries, severe tissue necrosis) probably benefit from the addition of penicillin or clindamycin.

Digital photos are helpful for documenting the initial appearance of the extremity and can be a valuable addition to the medical record. Digital imaging allows other members of the treatment team to see the wound preoperatively without repeated manipulations of the wound.
Gauze swabs soaked in normal saline are frequently used as dressing on open wounds.

The Oxford Handbook for Medical school recommends that open fractures should be sealed with saline-soaked gauze and impermeable dressing after removal of gross contaminants.

Answer: Ankylosing spondylitis

Ankylosing spondylitis (AS), a spondyloarthropathy, is a chronic, multisystem inflammatory disorder involving primarily the sacroiliac (SI) joints and the axial skeleton. Key components of the patient history that suggest AS include the following:
Insidious onset of low back pain – The most common symptom
Onset of symptoms before age 40 years
Presence of symptoms for more than 3 months
Symptoms worse in the morning or with inactivity
Improvement of symptoms with exercise

General symptoms of AS include the following:

Those related to inflammatory back pain – Stiffness of the spine and kyphosis resulting in a stooped posture are characteristic of advanced-stage AS.
Peripheral enthesitis and arthritis
Constitutional and organ-specific extra-articular manifestations
Fatigue is another common complaint, occurring in approximately 65% of patients with AS. Increased levels of fatigue are associated with increased pain and stiffness and decreased functional capacity.
Pharmacologic therapy

Agents used in the treatment of AS include the following:

Nonsteroidal anti-inflammatory drugs (NSAIDs)
Sulfasalazine
Tumour necrosis factor-α (TNF-α) antagonists
Corticosteroids

AS is the prototype of the spondyloarthropathies, a family of related disorders that also includes reactive arthritis (ReA), psoriatic arthritis (PsA), spondyloarthropathy associated with inflammatory bowel disease (IBD), undifferentiated spondyloarthropathy (USpA), and, possibly, Whipple disease and Behçet disease (see the image below). The spondyloarthropathies are linked by common genetics (the human leukocyte antigen [HLA] class-I gene HLA-B27) and a common pathology (enthesitis). The aetiology of AS is not understood completely; however, a strong genetic predisposition exists. A direct relationship between AS and the HLA-B27 gene has been determined. The precise role of HLA-B27 in precipitating AS remains unknown; however, it is believed that HLA-B27 may resemble or act as a receptor for an inciting antigen (e.g., a bacterial antigen).

Acromioclavicular joint (ACJ) dislocation normally occurs secondary to direct injury to the superior aspect of the acromion. Loss of shoulder contour and prominent clavicle are the key features.

An ACJ dislocation, or AC separation, is a very frequent injury among physically active people. It is commonly caused by a fall directly on the shoulder or a direct blow received in a contact sport. Disruption of the ACJ results in pain and instability in the entire shoulder and arm. The pain is most severe when the patient attempts overhead movements or tries to sleep on the affected side.

In general, most AC injuries do not require surgery. There are certain situations, however, in which surgery may be necessary. Most patients recover with full function of the shoulder. The period of disability and discomfort ranges from a few days to 12 weeks depending on the severity of the separation.

Parsonage-Turner Syndrome (PTS), also referred to as idiopathic brachial plexopathy or neuralgic amyotrophy, is a rare disorder consisting of a complex constellation of symptoms with abrupt onset of shoulder pain, usually unilaterally, followed by progressive neurologic deficits of motor weakness, dysesthesias, and numbness. Although the aetiology of the syndrome is unclear, it is reported in various clinical situations, including postoperatively, postinfectious, posttraumatic, and postvaccination.
The most common associated risk factor is a recent viral illness.
The pain is not positional and usually worse at night and may be associated with awakenings from sleep. There are typically no constitutional symptoms associated with the syndrome. The duration of pain is almost always self-limiting, lasting 1 to 2 weeks, but on rare occasion persisting for longer periods.
In the earliest stages of this condition (the first few weeks), pain management with opiates, NSAIDs, and neuroleptics is the mainstay of treatment. Acupuncture and transcutaneous electrical nerve stimulation (TENS) can also be adjuncts to medications. Oral steroids have been recommended by some, but there is poor literature evidence to support its efficacy.
Physical therapy plays an important role in the treatment of this condition. Modalities such as TENS can help in pain management.

Answer: Osteogenesis imperfecta

Osteogenesis imperfecta (OI) is a disorder of bone fragility chiefly caused by mutations in the COL1A1 and COL1A2 genes that encode type I procollagen.

Type II – Perinatal lethal
Some providers who treat large numbers of patients with osteogenesis imperfecta suggest that the diagnosis of Type II OI be made in retrospect for patients who do not survive the perinatal period, and that even patients with very severe forms of OI who nonetheless are long term survivors be classified as Type III. Blue sclera may be present. Patients may have a small nose, micrognathia, or both. All patients have in utero fractures, which may involve the skull, long bones, and/or vertebrae. The ribs are beaded, and the long bones are severely deformed.
Causes of death include extreme fragility of the ribs, pulmonary hypoplasia, and malformations or haemorrhages of the CNS.

Type III – Severe, progressively deforming

Patients may have joint hyperlaxity, muscle weakness, chronic unremitting bone pain, and skull deformities (e.g., posterior flattening) due to bone fragility during infancy.

Deformities of upper limbs may compromise function and mobility. The presence of dentinogenesis imperfecta is independent of the severity of the osteogenesis imperfecta. The sclera have variable hues. In utero fractures are common. Limb shortening and progressive deformities can occur. Patients have a triangular face with frontal and temporal bossing. Malocclusion is common. Basilar invagination is an uncommon but potentially fatal occurrence in osteogenesis imperfecta.
Vertigo is common in patients with severe osteogenesis imperfecta. Hypercalciuria may be present in about 36% of patients with osteogenesis imperfecta, and adults may be at higher risk of renal calculi. Respiratory complications secondary to kyphoscoliosis are common in individuals with severe osteogenesis imperfecta.
Constipation and hernias are also common in people with osteogenesis imperfecta.

Obtain a radiographic skeletal survey after birth.

In mild (type I) osteogenesis imperfecta, images may reveal thinning of the long bones with thin cortices. Several wormian bones may be present. No deformity of long bones is observed.

In extremely severe (type II) osteogenesis imperfecta, the survey may reveal beaded ribs, broad bones, and numerous fractures with deformities of the long bones. Platyspondylia may also be revealed.

In moderate and severe (types III and IV) osteogenesis imperfecta, imaging may reveal cystic metaphysis, or a popcorn appearance of the growth cartilage. Normal or broad bones are revealed early, with thin bones revealed later. Fractures may cause deformities of the long bones. Old rib fractures may be present. Vertebral fractures are common.

Ankle fractures most often occur by rotational mechanisms with the external forces transmitted through the foot via the talus to the malleoli. The specific pattern of fracture and ligamentous injury depends on the position of the foot and the direction of the force at the time of injury.

Reduce the ankle fracture as soon as possible once informed consent provided to the patient. Assess the neurovascular status of the limb before and after manipulation. Have splinting materials ready and measured out (use the uninjured, contralateral leg for measuring). Either a short leg splint or cast is applied based on fracture type, patient, surgical urgency, and surgeon preference.

Ensure adequate analgesia for the patient including NSAIDs, IV medications, hematoma block, or procedural sedation. Once reduced and splinted in place, recheck neurovascular status, elevate the leg and obtain a post-reduction X-ray.

Fractures of the distal tibia and fibula may result in loss of stability of the ankle joint. They may present as a fracture only, fracture and ligamentous injury, multiple fractures or a fracture dislocation.

Isolated fibular fractures at the level of the syndesmosis (Weber B) without associated medial injury should be placed in a short leg backslab (ankle at plantargrade) and remain NWB (non-weight bearing).

With medial malleolus fractures care should be taken to rule out any other fracture or injury around the ankle. The entire length of the fibula should be palpated and x-rayed to rule out any Maisonneuve type injuries. Any other fracture, ligament injury or talar shift indicate the fracture is likely to be unstable and should be reviewed by orthopaedics.

If medial malleolar injury is truly isolated then a short leg backslab (below knee plaster cast) should be applied and the patient is to remain NWB until orthopaedic review.

Answer: Ganglion

A ganglion cyst is a fluid-filled swelling that usually develops near a joint or tendon. The cyst can range from the size of a pea to the size of a golf ball. Ganglion cysts look and feel like a smooth lump under the skin.

They’re made up of a thick, jelly-like fluid called synovial fluid, which surrounds joints and tendons to lubricate and cushion them during movement.

Ganglions can occur alongside any joint in the body, but are most common on the wrists (particularly the back of the wrist), hands and fingers.

Ganglions are harmless, but can sometimes be painful. If they do not cause any pain or discomfort, they can be left alone and may disappear without treatment, although this can take a number of years.

It’s not clear why ganglions form. They seem to happen when the synovial fluid that surrounds a joint or tendon leaks out and collects in a sac.
They are most common in younger people between the ages of 15 and 40 years, and women are more likely to be affected than men. These cysts are also common among gymnasts, who repeatedly apply stress to the wrist.

Answer: Osteopetrosis

Osteopetrosis is a clinical syndrome characterized by the failure of osteoclasts to resorb bone. As a consequence, bone modelling and remodelling are impaired. The defect in bone turnover characteristically results in skeletal fragility despite increased bone mass, and it may also cause hematopoietic insufficiency, disturbed tooth eruption, nerve entrapment syndromes, and growth impairment.
Many patients have bone pains. Bony defects are common and include neuropathies due to cranial nerve entrapment (e.g., with deafness, with facial palsy), carpal tunnel syndrome, and osteoarthritis. Bones are fragile and may fracture easily. Approximately 40% of patients have recurrent fractures. Osteomyelitis of the mandible occurs in 10% of patients.

Other manifestations include visual impairment due to retinal degeneration and psychomotor retardation. Bone marrow function is not compromised.

Osteogenesis imperfecta (OI), also known as brittle bone disease, is a group of genetic disorders that mainly affect the bones. It results in bones that break easily. The severity may be mild to severe. Other symptoms may include a blue tinge to the whites of the eye, short height, loose joints, hearing loss, breathing problems and problems with the teeth. Complications may include cervical artery dissection and aortic dissection.

The underlying mechanism is usually a problem with connective tissue due to a lack of type I collagen. This occurs in more than 90% of cases due to mutations in the COL1A1 or COL1A2 genes. These genetic problems are often inherited from a person’s parents in an autosomal dominant manner or occur via a new mutation. There are at least eight main types, with type I being the least severe and type II the most severe.

Osteomalacia it is the disease in which softening of the bones caused by impaired bone metabolism primarily due to inadequate levels of available phosphate, calcium, and vitamin D, or because of resorption of calcium. The impairment of bone metabolism causes inadequate bone mineralization. Osteomalacia in children is known as rickets, and because of this, use of the term Osteomalacia is often restricted to the milder, adult form of the disease. Signs and symptoms can include diffuse body pains, muscle weakness, and fragility of the bones. In addition to low systemic levels of circulating mineral ions necessary for bone and tooth mineralization, accumulation of mineralization-inhibiting proteins and peptides (such as osteopontin and ASARM peptides) occurs in the extracellular matrix of bones and teeth, likely contributing locally to cause matrix hypomineralization (Osteomalacia).

The posterior drawer test is a physical exam technique that is done to assess the integrity of the posterior cruciate ligament (PCL). The PCL is attached to the posterior intercondylar area of the tibia and passes anteriorly, medially, and upward to attach to the lateral side of the medial femoral condyle.
This ligament prevents backward displacement of the tibia or forward sliding of the femur. Injury to the ligament allows displacement of the tibia

The patient has Gustilo-Anderson Grade IIIb.
Options for wound closure in the treatment of open fractures include primary closure of the skin, split-thickness skin grafting, and the use of either free or local muscle flaps. The timing of open wound closure has proponents in the immediate, early, and delayed categories
Gustilo-Anderson classification
Type I – Open fracture with a wound less than 1 cm in length, and clean
Type II – Open fracture with a laceration more than 1 cm in length, without extensive soft-tissue damage, flaps, or avulsions
Type III – Either an open segmental fracture, an open fracture with extensive soft-tissue damage, or a traumatic amputation
The description of type III fractures was subsequently further refined and described by Gustilo et al in 1984, [6] as follows:
Type IIIa – Severe comminution or segmental fractures, but with adequate coverage of bone and a wound that is closable by simple means
Type IIIb – Extensive soft-tissue damage in association with the open fracture, with significant bone exposure and periosteal stripping, typically requiring tissue rotation or free tissue transfer for closure
Type IIIc – Any open fracture with an arterial injury that requires repair

Answer: Stress fracture

A stress fracture is caused by repetitive and submaximal loading of the bone, which eventually becomes fatigued and leads to a true fracture. The typical presentation is a complaint of increasing pain in the lower extremity during exercise or activity. The patient’s history usually reveals a recent increase in either training volume or intensity. Stress fractures result from recurrent and repetitive loading of bone. The stress fracture differs from other types of fractures in that in most cases, no acute traumatic event precedes the symptoms.

Normal bone remodelling occurs secondary to increased compressive or tensile loads or increased load frequency. In the normal physiologic response, minor microdamage of the bone occurs. This is repaired through remodelling. Stress fractures develop when extensive microdamage occurs before the bone can be adequately remodelled.
Common findings on physical examination may include tenderness or pain on palpation or percussion of the bone. Erythema or oedema may be present at the site of the stress fracture. Loading or stress of the affected bone may also produce symptoms.

A stress fracture can be difficult to see on an X-ray, because the bone often appears normal in the X-ray, and the small cracks can’t be seen. X-rays may not help diagnose a stress fracture unless it has started to heal. When the bone starts to heal, it creates a callus, or lump, that can be seen on X-rays. The doctors may recommend a bone scan or magnetic resonance imaging (MRI), which is more sensitive than an X-ray and can spot stress fractures early.

Freiberg disease is a degenerative process involving the epiphyses resulting in osteonecrosis of subchondral cancellous bone. If the process is altered in such a way as to restore normal physiology, this may be followed by regeneration or recalcification. If not, the process continues to subchondral collapse and eventual fragmentation of the joint surface.
Patients who have Freiberg disease typically present with complaints of activity-related forefoot pain. Walking alone is often sufficient to cause pain. Some patients describe an extended (months to years) history of chronic forefoot pain with episodic exacerbation, whereas others present with pain of recent onset that is related to a specific injury or event. A history of trauma may not be noted. Patients may present with stiffness and a limp. The pain is often vague and poorly localized to the forefoot. Some patients describe the sensation of a small, hard object under the foot.

Physical examination typically reveals a limited range of motion (ROM), swelling, and tenderness with direct palpation of the metatarsophalangeal (MTP) joint. In early stages of the disease, MTP tenderness may be the only finding. In later stages, crepitus or deformity may be present. A skin callus may be seen on the plantar surface of the affected metatarsal head.

Radiography
Depending on the stage of the disease, radiographs may show only sclerosis and widening of the joint space (early), with complete collapse of the metatarsal head and fragmentation later. Osteochondral loose bodies may be seen late in the disease as well. Oblique views may be especially useful for achieving a full appreciation of subtle changes early in the disease. One study advocated the use of radiographs to assess musculoskeletal foot conditions in women related to poorly fitting shoes.
Occasionally, patients are completely asymptomatic, with changes noted on radiographs taken for other reasons. Whether these patients later develop symptomatic Freiberg disease is not known.

Answer: Rickets

Rickets is a disease of growing bone that is unique to children and adolescents. It is caused by a failure of osteoid to calcify in a growing person.
The signs and symptoms of rickets can include:

pain – the bones affected by rickets can be sore and painful, so the child may be reluctant to walk or may tire easily; the child’s walk may look different (waddling)
skeletal deformities – thickening of the ankles, wrists and knees, bowed legs, soft skull bones and, rarely, bending of the spine
dental problems – including weak tooth enamel, delay in teeth coming through and increased risk of cavities
poor growth and development – if the skeleton doesn’t grow and develop properly, the child will be shorter than average
fragile bones – in severe cases, the bones become weaker and more prone to fractures.

Marfan syndrome (MFS) is a genetic disorder of the connective tissue. The degree to which people are affected varies. People with Marfan tend to be tall and thin, with long arms, legs, fingers and toes. They also typically have flexible joints and scoliosis. The most serious complications involve the heart and aorta, with an increased risk of mitral valve prolapse and aortic aneurysm. Other commonly affected areas include the lungs, eyes, bones and the covering of the spinal cord.

Ehlers-Danlos syndrome is a group of inherited disorders that affect your connective tissues — primarily your skin, joints and blood vessel walls. People who have Ehlers-Danlos syndrome usually have overly flexible joints and stretchy, fragile skin. This can become a problem if you have a wound that requires stitches, because the skin often isn’t strong enough to hold them.
A more severe form of the disorder, called Ehlers-Danlos syndrome, vascular type, can cause the walls of your blood vessels, intestines or uterus to rupture.

Osteoporosis is a disease in which bone weakening increases the risk of a broken bone. It is the most common reason for a broken bone among the elderly. Bones that commonly break include the vertebrae in the spine, the bones of the forearm, and the hip. Until a broken bone occurs there are typically no symptoms. Bones may weaken to such a degree that a break may occur with minor stress or spontaneously. Chronic pain and a decreased ability to carry out normal activities may occur following a broken bone.

Osteoporosis may be due to lower-than-normal maximum bone mass and greater-than-normal bone loss. Bone loss increases after menopause due to lower levels of oestrogen. Osteoporosis may also occur due to a number of diseases or treatments, including alcoholism, anorexia, hyperthyroidism, kidney disease, and surgical removal of the ovaries.

Anterior cruciate ligament (ACL) injuries are most often a result of low-velocity, noncontact, deceleration injuries and contact injuries with a rotational component. Contact sports also may produce injury to the ACL secondary to twisting, valgus stress, or hyperextension all directly related to contact or collision.

Symptoms of an acute ACL injury may include the following:
– Feeling or hearing a “pop” sound in the knee
– Pain and inability to continue the activity
– Swelling and instability of the knee
– Development of a large hemarthrosis

Differential Diagnoses
A- Medial Collateral Knee Ligament Injury
Contact, noncontact, and overuse mechanisms are involved in causing MCL injuries.
Contact injuries involve a direct valgus load to the knee. This is the usual mechanism in a complete tear.
Noncontact, or indirect, injuries are observed with deceleration, cutting, and pivoting motions. These mechanisms tend to cause partial tears.
Overuse injuries of the MCL have been described in swimmers. The whip-kick technique of the breaststroke has been implicated. This technique involves repetitive valgus loads across the knee.

B- Posterior Cruciate Ligament Injury
Knowledge of the mechanism of injury is helpful. The following 4 mechanisms of PCL injury are recognized:
– A posteriorly directed force on a flexed knee, e.g., the anterior aspect of the flexed knee striking a dashboard, may cause PCL injury.
– A fall onto a flexed knee with the foot in plantar flexion and the tibial tubercle striking the ground first, directing a posterior force to the proximal tibia, may result in injury to the PCL.
– Hyperextension alone may lead to an avulsion injury of the PCL from the origin. This kind of injury may be amenable to repair.
– An anterior force to the anterior tibia in a hyperextended knee with the foot planted results in combined injury to the knee ligaments along with knee dislocation.

In chronic PCL tears, discomfort may be experienced with the following positions or activities:
– A semi flexed position, as with ascending or descending stairs or an incline
– Starting a run
– Lifting a load
– Walking longer distances
– Retro patellar pain symptoms may be reported as a result of posterior tibial sagging.
– Swelling and stiffness may be reported in cases of chondral damage.
– Individuals may describe a sensation of instability when walking on uneven ground
– Medial joint line pain may be reported.

Answer: Spondylolisthesis

Spondylolisthesis is a condition in which a bone (vertebra) in the spine moves forward out of the proper position onto the bone below it.

Causes
In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. It is often due to a birth defect in that area of the spine or sudden injury (acute trauma).

In adults, the most common cause is abnormal wear on the cartilage and bones, such as arthritis. The condition mostly affects people over 50 years old. It is more common in women than in men.

Bone disease and fractures can also cause spondylolisthesis. Certain sports activities, such as gymnastics, weightlifting, and football, greatly stress the bones in the lower back. They also require that the athlete constantly overstretch (hyperextend) the spine. This can lead to a stress fracture on one or both sides of the vertebra. A stress fracture can cause a spinal bone to become weak and shift out of place.

Symptoms
Symptoms of spondylolisthesis may vary from mild to severe. A person with spondylolisthesis may have no symptoms. Children may not show symptoms until they’re 18 years old.

The condition can lead to increased lordosis (also called swayback). In later stages, it may result in kyphosis (round back) as the upper spine falls off the lower spine.

Symptoms may include any of the following:

Lower back pain
Muscle tightness (tight hamstring muscle)
Pain, numbness, or tingling in the thighs and buttocks
Stiffness
Tenderness in the area of the vertebra that is out of place
Weakness in the legs

Ankylosing spondylitis (AS) is a type of arthritis in which there is a long-term inflammation of the joints of the spine.[2] Typically the joints where the spine joins the pelvis are also affected. Occasionally other joints such as the shoulders or hips are involved. Eye and bowel problems may also occur. Back pain is a characteristic symptom of AS, and it often comes and goes. Stiffness of the affected joints generally worsens over time.

Although the cause of ankylosing spondylitis is unknown, it is believed to involve a combination of genetic and environmental factors. More than 90% of those affected in the UK have a specific human leukocyte antigen known as the HLA-B27 antigen. The underlying mechanism is believed to be autoimmune or autoinflammatory. Diagnosis is typically based on the symptoms with support from medical imaging and blood tests. AS is a type of seronegative spondyloarthropathy, meaning that tests show no presence of rheumatoid factor (RF) antibodies. It is also within a broader category known as axial spondylarthritis.

The signs and symptoms of ankylosing spondylitis often appear gradually, with peak onset being between 20 and 30 years of age. Initial symptoms are usually a chronic dull pain in the lower back or gluteal region combined with stiffness of the lower back. Individuals often experience pain and stiffness that awakens them in the early morning hours.

As the disease progresses, loss of spinal mobility and chest expansion, with a limitation of anterior flexion, lateral flexion, and extension of the lumbar spine, are seen. Systemic features are common, with weight loss, fever, or fatigue often present. Pain is often severe at rest but may improve with physical activity, but inflammation and pain to varying degrees may recur regardless of rest and movement.

A scaphoid fracture is a break of the scaphoid bone in the wrist. Symptoms generally include pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur. Complications may include non-union of the fracture, avascular necrosis, and arthritis.

Scaphoid fractures are most commonly caused by a fall on an outstretched hand. Diagnosis is generally based on examination and medical imaging. Some fractures may not be visible on plain X-rays. In such cases a person may be casted with repeat X-rays in two weeks or an MRI or bone scan may be done.
Scaphoid fractures are often diagnosed by PA and lateral X-rays. However, not all fractures are apparent initially. Therefore, people with tenderness over the scaphoid (those who exhibit pain to pressure in the anatomic snuff box) are often splinted in a thumb spica for 7–10 days at which point a second set of X-rays is taken. If there was a hairline fracture, healing may now be apparent. Even then a fracture may not be apparent. A CT Scan can then be used to evaluate the scaphoid with greater resolution. The use of MRI, if available, is preferred over CT and can give one an immediate diagnosis. Bone scintigraphy is also an effective method for diagnosing a fracture which does not appear on x-ray.

Initially, all tibial shaft fractures should be stabilized with a long posterior splint with the knee in 10-15° of flexion and the ankle flexed at 90°
Closed fractures with minimal displacement or stable reduction may be treated nonoperatively with a long leg cast, but cast application should be delayed for 3-5 days to allow early swelling to diminish. The cast should extend from the midthigh to the metatarsal heads, with the ankle at 90° of flexion and the knee extended. The cast increases tibial stability and can decrease pain and swelling.
Despite proper casting techniques and adequate follow-up, not all nonoperatively treated tibial shaft fractures heal successfully.
Operative fixation is required when fractures are unstable. Surgical options include plating, external fixation, intramedullary nailing, and, in some cases, amputation.
Intramedullary nailing with locking screws (see the image below) has become the treatment of choice for most tibial shaft fractures. The prevalence of non-union and malunion is greatly decreased in comparison with the other methods of fixation. Patients are also able to return to low-impact activities much sooner than they can with the other treatments.