management

Cuboid Fractures

Types

 

1.  Capsular avulsions

 

2.  Body / Nutcracker fracture

 

Nutcracker fracture

 

Epidemiology

- rare

 

Mechanism

- forced eversion / abduction of forefoot

- cuboid crushed between 4th and 5th MT and calaneum

 

Pathology

- displaced cuboid fracture with subluxation of tarsus

Hoffa fracture

Definition

 

Coronal plane fracture of distal femoral condyle

- intra-articular

- often only attachment is posterior capsule

 

Epidemiology

 

Rare

 

Mechanism

 

Usually a severe valgus trauma

 

Xray

 

Usually lateral femoral condyle

 

March Fracture

 

Definition

 

Insufficiency fracture

- secondary to exceeding fatigue threshold

- usually of second or third MT shaft

 

Epidemiology

 

Onset of new and very intense / strenuous physical activity

- i.e. new army recruits / dancers

 

Women with postmenopausal osteoporosis

 

Association

 

Cavus feet

 

History

 

Distal Humeral Physeal Separation

Pathology

 

Children < 6

- entire distal humerus physis is displaced

 

Xray

 

Distal Humerus Physis SeparationDistal Humerus Physeal Separation 2

 

Distal physis not ossified < 1 year

- may be a difficult diagnosis

 

Hypercalcaemia

Definition

 

> 10 mg / dl

- must be corrected for albumin

 

Causes

 

Malignancy

- multiple myeloma / lung cancer / breast cancer

 

Hyperparathyroidism

- elevated PTH

 

Issue

 

High mortality associated with hypercalcaemia of malignancy

 

Physiology

 

40% albumin bound

50% ionised and active

 

Hypocalcaemia

Signs

 

Fall in level promotes tetanus

 

Chvostek sign

- tapping masseter muscle induces spasm

 

Trousseau Sign

-  flexion of thumb & wrist with extension of fingers

 

Carpopedal Spasm

 

ECG

 

Prolonged QT interval on ECG

 

Causes

 

1. Vit D Deficiency

Postero-Medial Corner Injury

Anatomy

 

Layers of the medial knee

 

Layer 1

- sartorius and sartorius fascia

 

Layer 2

- superficial MCL

- posterior oblique ligament

 

Layer 3

- deep MCL (meniscofemoral and meniscotibial ligament)

- posteromedial capsule 

 

MCL

 

Origin

- 3 mm proximal and 5 mm posterior to the epicondyle

 

Management

Non operative 

 

Ponseti casting

 

Aims of treatment

1. Correct the deformity early

2. Correct it fully 

3. Hold the corrected position until foot stops growing

- AFO

- Denis Browne Boots

 

Timing

 

Start 1 - 3 weeks

- let parents settle and get used to diagnosis

- explain method and length of treatment required

 

Postoperative Infection

Incidence

 

Decreasing incidence in recent decades most likely attributable to preoperative antibiotics

 

Ris

 

Conventional discectomy </= 1%

Fusion 2%

Fusion & instrumentation 5-6%

 

Instrumentation doubles infection rate in lumbar fusion

 

Risk factors 

 

Diabetes 

Central Cord Syndrome

Epidemiology

 

Most common pattern cord injury

 

Hyper-extension injury in middle aged man with osteoarthritic spine

 

Usually C3/4 and C4/5

 

Mechanism

 

Most common type / in older patient with pre-existing spondylosis / OPLL

- hyperextension injury

- compression of the cord

- anteriorly by osteophytes

- posteriorly by infolded ligamentum flavum

 

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