The patient has a Weber type A fracture, based on the Danis-Weber classification system for lateral malleolar fractures. It is a stable ankle injury and can, therefore, be managed conservatively. Whilst this patient could also be treated in a below-knee plaster, most clinicians, nowadays, treat this injury in an ankle boot. Patients are also advised to mobilise with the ankle boot as pain allows and can wean themselves off as the symptoms improve.

The Danis-Weber classification system is based on the level of the fibula fracture in relation to the syndesmosis (the connection between the distal ends of the tibia and fibula). The more proximal, the greater the risk of syndesmotic injury and, therefore, fracture instability.

1. Weber type A: fracture below the level of the syndesmosis
2. Weber type B: fracture at the level of the syndesmosis/level of the tibial plafond
3. Weber type C: fracture above the level of the syndesmosis. This includes Maisonneuve fracture (proximal fibula fracture) which can be associated with ankle instability.

Ankle fractures are common. They affect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women have a higher rate post-menopausal (fragility-type fractures). Patients present, following a traumatic event, with a painful, swollen ankle, and reluctance/inability to bear weight.

Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious, then plain radiographs are appropriate. Antero-posterior, lateral, and mortise views are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space, and lateral talar shift all indicate a syndesmotic injury.

When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Unimalleolar Weber type A fractures, by definition, are stable and therefore, can be mobilised fully in an ankle boot.

The Frykman classification of distal radial fractures is based on the AP appearance and encompasses the eponymous entities of Colles fracture, Smith fracture, Barton fracture, chauffeur fracture.

Colles fractures are very common extra-articular fractures of the distal radius that occur as the result of a fall onto an outstretched hand. They consist of a fracture of the distal radial metaphyseal region with dorsal angulation and impaction, but without the involvement of the articular surface.
Colles fractures are the most common type of distal radial fracture and are seen in all adult age groups and demographics. They are particularly common in patients with osteoporosis, and as such, they are most frequently seen in elderly women.

Smith fractures, also known as Goyrand fractures in the French literature 3, are fractures of the distal radius with associated volar angulation of the distal fracture fragment(s). Classically, these fractures are extra-articular transverse fractures and can be thought of like a reverse Colles fracture.
The term is sometimes used to describe intra-articular fractures with volar displacement (reverse Barton fracture) or juxta-articular fractures

Barton fractures are fractures of the distal radius. It is also sometimes termed the dorsal type Barton fracture to distinguish it from the volar type or reverse Barton fracture.
Barton fractures extend through the dorsal aspect to the articular surface but not to the volar aspect. Therefore, it is similar to a Colles fracture. There is usually associated with dorsal subluxation/dislocation of the radiocarpal joint.

Chauffeur fractures (also known as Hutchinson fractures or backfire fractures) are intra-articular fractures of the radial styloid process. The radial styloid is within the fracture fragment, although the fragment can vary markedly in size.

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.

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.

This is a case of Brown-Sequard syndrome.

Brown-Sequard syndrome is caused by hemisection of the spinal cord following stab injuries or lateral vertebral fractures. It results in ipsilateral paralysis (pyramidal tract), and also loss of proprioception and fine discrimination(dorsal columns). Pain and temperature sensations are lost on the contralateral side. This is because the fibres of the spinothalamic tract have decussated below the level of the cord transection.

Legg-Calvé-Perthes (LCP) disease is a common cause of hip pain and limp in preadolescent children. Early in its course, this condition, a form of idiopathic osteonecrosis (or osteochondrosis), may be difficult to diagnose both clinically and radiographically. MRI is a useful tool for the evaluation of LCP disease that may assist with prompt diagnosis, staging, and evaluation of associated complications. In addition, a variety of MRI findings may provide valuable prognostic information. The MRI findings of LCP disease are quite variable depending on the different stages of the disease (avascular, revascularization, and healing phases).

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.

Surgical fixation is recommended in this type of fracture. The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane. There is an associated fracture of the medial malleolus or rupture of the deep deltoid ligament. Ankle views may either show a fracture of the medial malleolus or widening of the ankle joint due to disruption of the distal tibiofibular syndesmosis (lateral talar shift) or deltoid ligament complex.
Although management is variable depending on complexity of injuries, this type of fracture pattern is generally managed by operative treatment. Specific aims generally include:
1) internal fixation of the distal tibiofibular syndesmosis
​commonly achieved by trans-syndesmotic screws.
2) reduction and stabilization of medial malleolus fracture and/or ligamentous injuries
​3) reduction and stabilization of fibular fracture- fracture involving distal 2/3 of fibula may compromise ankle mortise, and so may benefit from surgery, fracture involving proximal 1/3 fibula often managed non-operatively

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.

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.

The patient has an injury due to falling on outstretched hands (FOOSH). Putting his clinical picture into consideration, he is most likely to have a fracture of the radial head.
Radial head fractures often occur with FOOSH injuries. Patients will complain of wrist pain, as well as elbow pain, and be hesitant to perform a range of motion. However, pain with supination and pronation at the elbow is imperative for diagnosis. Palpation at the lateral aspect of the elbow will elicit pain; you also may feel crepitus at the radial head with supination pronation. X-rays should be ordered, with a minimum of two views (AP and lateral). Radial head fractures can be difficult to recognize on x-ray. Assess for a sail sign or effusion on the image. A positive fat pad sign aids in diagnosis, as well. If the image is inconclusive, but the exam is consistent, treat until proven otherwise.
Management should include intensive patient education. Compression wrapping for comfort and stability may be used along with a sling. Please note, early light motion is imperative for these patients, as elbow contracture and stiffness are very common after injury, possibly leading to long-term complications. These patients need to be seen by an orthopaedic specialist as soon as possible to begin management. Be aware that if displacement or step-off of the radial head is present, this may require surgical intervention, and motion could worsen alignment if not managed meticulously.
Other INJURIES TO THE UPPER EXTREMITY DUE TO (FOOSH):
Radial Styloid Fracture
Distal Radius Fracture
Scaphoid Fracture
Scapholunate Tear
Distal Radioulnar Joint
Cellulitis
Synovitis

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.

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.

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’.

Transient synovitis (TS) is the most common cause of acute hip pain in children aged 3-10 years. The disease causes arthralgia and arthritis secondary to a transient inflammation of the synovium of the hip. Biopsy reveals only nonspecific inflammation and hypertrophy of the synovial membrane. Ultrasonography demonstrates an effusion that causes bulging of the anterior joint capsule. Synovial fluid has increased proteoglycans.
Unilateral hip or groin pain is the most common symptom reported; however, some patients with transient synovitis (TS) may report medial thigh or knee pain. Transient synovitis has the highest incidence rate among causes of nontraumatic hip pain in children. Guidelines for chronic hip pain have been established.

Causes
No definitive cause of transient synovitis is known, although the following have been suggested:
– Patients with transient synovitis often have histories of trauma, which may be a cause or predisposing factor.
– One study found an increase in viral antibody titres in 67 of 80 patients with transient synovitis.
– Postvaccine or drug-mediated reactions and an allergic disposition have been cited as possible causes.

The following studies may be indicated in transient synovitis (TS):
– CBC count: The white blood cell (WBC) count may be slightly elevated.
– Erythrocyte sedimentation rate (ESR) may be slightly elevated. One study found that the combination of an ESR greater than 20 mm/h and/or a temperature greater than 37.5°C identified 97% of individuals with septic hip.

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.

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.

Holstein-Lewis fracture is a fracture of the distal third of the humerus resulting in entrapment of the radial nerve. The radial nerve is one of the major peripheral nerves of the upper limb. It innervates all the muscles in the extensor compartments of the arm.

Conservative treatment for this fracture includes reduction and use of a functional brace. However, vascular injury may require open surgery.

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 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

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: 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: Perthes disease

Perthes’ disease is a condition affecting the hip joint in children. It is rare (1 in 9,000 children are affected) and we do not clearly understand why it occurs.

Part or all of the femoral head (top of the thigh bone: the ball part of the ball-and-socket hip joint) loses its blood supply and may become misshapen. This may lead to arthritis of the hip in later years.

The earliest sign of Legg-Calvé-Perthes disease (LCPD) is an intermittent limp (abductor lurch), especially after exertion, with mild or intermittent pain in the anterior part of the thigh. LCPD is the most common cause of a limp in the 4- to 10-year-old age group, and the classic presentation has been described as a painless limp.
The patient may present with limited range of motion of the affected extremity. The most common symptom is persistent pain.

Hip pain may develop and is a result of necrosis of the involved bone. This pain may be referred to the medial aspect of the ipsilateral knee or to the lateral thigh. The quadriceps muscles and adjacent thigh soft tissues may atrophy, and the hip may develop adduction flexion contracture. The patient may have an antalgic gait with limited hip motion.
Early radiographic changes may reveal only a nonspecific effusion of the joint associated with slight widening of the joint space, metaphyseal demineralization (decreased bone density around the joint), and periarticular swelling (bulging capsule). This is the acute phase, and it may last 1-2 weeks. Decreasing bone density in and around the joint is noted after a few weeks. Eventually, the disease may progress to collapse of the femoral head, increase in the width of the neck, and demineralization of the femoral head. The final shape of this area depends on the extent of necrosis and the degree of collapse.

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.

Answer: Chondromalacia patellae

Chondromalacia patellae, also known as “runner’s knee,” is a condition where the cartilage on the under surface of the patella (kneecap) deteriorates and softens. This condition is common among young, athletic individuals, but may also occur in older adults who have arthritis of the knee. Chondromalacia is understood as patellar pain in the anterior side of the knee which worsens on sitting for prolonged periods, or going down stairs/slopes, with joint clicking and episodes of pseudo-locking and failure.

Chondromalacia is often seen as an overuse injury in sports, and sometimes taking a few days off from training can produce good results. In other cases, improper knee alignment is the cause and simply resting doesn’t provide relief. The symptoms of runner’s knee are knee pain and grinding sensations, but many people who have it never seek medical treatment.
Chondromalacia patella often occurs when the under surface of the kneecap comes in contact with the thigh bone causing swelling and pain. Abnormal knee cap positioning, tightness or weakness of the muscles associated with the knee, too much activity involving the knee, and flat feet may increase the likelihood of chondromalacia patella.

What are the symptoms of chondromalacia patella?
Dull, aching pain that is felt:

Behind the kneecap
Below the kneecap
On the sides of the kneecap
A feeling of grinding when the knee is flexed may occur. This can happen:

Doing knee bends
Going down stairs
Running down hill
Standing up after sitting for awhile

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.

Complications of intravenous drug abuse, such as subcutaneous abscess, joint infections, osteomyelitis, overdose, hepatitis, and infective endocarditis, account for an increasing number of admissions in accident and emergency departments throughout the UK. The organisms that usually cause chronic osteomyelitis in intravenous drug users are Gram‐negative rods such as Pseudomonas aeruginosa and Gram‐positive cocci such as staphylococci. Early treatment is essential to prevent progressive bone destruction. TB tends to affect the thoracic spine and in other causes of osteomyelitis the lumbar spine is affected.

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.