Hallux malleus is a deformity of the great toe. This deformity can be very stiff or flexible. The joint in the great toe becomes contracted in a flexed or downward position. This deformity usually occurs due to an imbalance of the tendons that insert on the top and the bottom of the great toe. When the tendon on the bottom of the toe (the tendon that causes the toe to flex down) over powers the tendon that causes the toe to bend up, this deformity occurs.
Usually patients will develop a callus and even an ulcer on the tip of the great toe. This deformity is often seen in conjunction with hammer toes. High arched feet are typically the most affected by this deformity.
This deformity is treat initially with padding techniques to prevent sores from developing at the tip of the toe. Custom, soft, accommodative orthoses are sometimes prescribed for the patient to provide cushioning and also to prevent worsening of the deformity.
If conservative treatment fails, surgery is indicated. Surgery usually consists of performing a bone fusion of the 2 bones in the great toe. This can be done with screws, staples, or wire fixation.
A 70-year-old female with mild dementia complains of unilateral groin pain. There is some limitation of motion in the right hip. Which of the following is the most appropriate first step in evaluation?
a.CBC and erythrocyte sedimentation rate
b.Rheumatoid factor
c.X-ray of right hip
d.Bone scan
The answer is c.
Hip pain may result from fracture, bursitis, arthritis, tumor, or pain referred from the lumbosacral spine. A film of the right hip is mandatory in this patient. Fracture of the hip must be ruled out, particularly in a woman with mental status abnormalities, who may be prone to falls. Elderly women with osteoporosis are most prone to hip fracture.
Pain from the hip joint is most often felt in the groin radiating down the anterior thigh. It is important to realize that patients will often complain of “hip” pain when they mean pain in the buttocks or low back. Pain in the buttocks is most often referred pain from the spine.
A 43-year-old man with diabetes and cardiomegaly has had an attack of pseudogout. He should be evaluated for which of the following?
a.Renal disease
b.Hemochromatosis
c.Peptic ulcer disease
d.Lyme disease
e.Inflammatory bowel disease
The answer is b.
Calcium Pyrophosphate Crystals
Pseudogout is part of the spectrum of calcium pyrophosphate deposition disease. It is usually an acute monoarthritis or oligoarthritis caused by calcium pyrophosphate crystals in the joint. Pseudogout may be associated with hemochromatosis. Since the patient has a history of diabetes mellitus and cardiomyopathy, hemochromatosis must be considered. Serum iron saturation should be measured. Ferritin may also be a useful measure of iron stores. Pseudogout has also been associated with hyperparathyroidism. A familial form of the disease has been localized to chromosomes 8q and 5p. Inflammatory bowel disease, Lyme disease, and peptic ulcer disease do not predispose to pseudogout.
The anterior approach is an approach to the front of the hip joint as opposed to a lateral (side) approach to the hip or posterior (back) approach. It is a true anterior approach to the hip and should not be confused with the Harding approach which is often referred to as an anterior approach.
Injury to the extensor tendon at the DIP joint is also known as :
A) boutonnière deformity
B) jersey finger
C) mallet finger
D) swan necking
E) “jammed” finger
The answer is (C).
Injury to the extensor tendon at the DIP joint is also known as Mallet Finger or Dropped Finger. The condition is the most common closed tendon injury of the finger.
Mallet finger usually is caused by an object (e.g., a ball ;baseball finger) striking the finger, creating a forced flexion of an extended DIP. The extensor tendon may be strained, partially torn, or completely ruptured or separated by a distal phalanx avulsion fracture. Those affected with mallet finger complain of pain at the dorsal DIP joint; inability to actively extend the joint; and, often, with a characteristic flexion deformity. It is critical to isolate the DIP joint during the evaluation to ensure extension is from the extensor tendon and not the central slip. The absence of full passive extension may indicate bony or soft tissue entrapment requiring surgical intervention.
ANKLE FRACTURE ,Educational animation video describing the anatomy the injury the diagnosis and treatment of ankle fracture ankle fracture are single malleolar bimalleolar trimalleolar syndesmodic injuy is diagnosed and the ankle is fixed to reduce the talus under the dome of the tibia any lateral shift will increase the stress by 40 to 50 percent and accelerate arthritis this ankle fracture video is uploaded by the univresity of toledo orthopedic surgeon
Periosteal reaction: A periosteal reaction is a non-specific reaction and will occur whenever the periosteum is irritated by a malignant tumor, benign tumor, infection or trauma. There are two patterns of periosteal reaction: a benign and an aggressive type. The benign type is seen in benign lesions such as benign tumors and following trauma. An aggressive type is seen in malignant tumors, but also in benign lesions with aggressive behavior, such as infections and eosinophilic granuloma.
Benign periosteal reaction Detecting a benign periosteal reaction may be very helpful, since malignant lesions never cause a benign periosteal reaction. A benign type of periosteal reaction is a thick, wavy and uniform callus formation resulting from chronic irritation. In the case of benign, slowly growing lesions, the periosteum has time to lay down thick new bone and remodel it into a more normal-appearing cortex. Aggressive periosteal reaction This type of periostitis is multilayered, lamellated or demonstrates bone formation perpendicular to the cortical bone. It may be spiculated and interrupted - sometimes there is a Codman's triangle. A Codman's triangle refers to an elevation of the periosteum away from the cortex, forming an angle where the elevated periosteum and bone come together. In aggressive periostitis the periosteum does not have time to consolidate.
In these X-Rays:
* left: Osteosarcoma with interrupted periosteal rection and Codman's triangle proximally. There is periosteal bone formation perpendicular to the cortical bone and extensive bony matrix formation by the tumor itself. * middle: Ewing sarcoma with lamellated and focally interrupted periosteal reaction. (blue arrows) * right: Infection with a multilayered periosteal reaction. Notice that the periostitis is aggressive, but not as aggressive as in the other two cases.
Note that: Fibrous dysplasia, Enchondroma, NOF and SBC are common bone lesions. They will not present with a periosteal reaction unless there is a fracture. If no fracture is present, these bone tumors can be excluded. So, Periosteal reaction excludes the diagnosis of Fibrous dysplasia, Enchondroma, NOF and SBC unless there is a fracture
Le Fort I fractures (horizontal) may result from a force of injury directed low on the maxillary alveolar rim in a downward direction. The fracture extends from the nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates.
Le Fort II fractures (pyramidal) may result from a blow to the lower or mid maxilla. Such a fracture has a pyramidal shape and extends from the nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates.
Le Fort III fractures (transverse), also termed craniofacial dysjunctions, may follow impact to the nasal bridge or upper maxilla. These fractures start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the sphenoid.
FOOTNOTES: 1. Non-weight bearing: Patient is unable to bear weight through both lower extremities or weight-bearing through both lower extremities is contraindicated. 2. Partial weight bearing: This will include situations where the patient may be allowed: a) Limited weight bearing on one lower extremity and full weight bearing on the other extremity; b) Partial weight bearing through both lower extremities. 3. Safety risks may include: decreased cognition; decreased ability to cooperate/ combativeness; medical stability. 4. Factors that contribute to low safety risk: a) Lack of combativeness; b) Ability to follow commands; c) Medical stability; d) Experience with the assistive device. 5. Factors that contribute to high safety risk: a) Combativeness; b) Lack of ability to follow commands; c) Medical instability; d) Lack of experience with the assistive device, e) neurological deficits.
An 83-year-old man was admitted to the acute medical ward after having fallen down in his home. On admission he was confused and agitated.
Physical examination revealed a swelling with bruising over his right sternoclavicular joint (Panel A) and periorbital bruising. He had a white-cell count of 14×103 per cubic millimeter, a C-reactive protein level of 56 mg per liter, and a urinalysis that was positive for a urinary tract infection. A social history was taken and revealed no suggestion of abuse. Radiography of the chest (Panel B) showed a right sternoclavicular dislocation, which was clinically confirmed to be anterior. Anterior sternoclavicular dislocations often result from an indirect force to the shoulder, rotating the shoulder posteriorly. The physician must always consider the possibility of abuse having caused this type of injury. The patient was treated for his urinary tract infection. His anterior sternoclavicular dislocation was treated conservatively. The confusion resolved, and after a short period of rehabilitation, he regained good function of his right upper limb.
Meniscal injuries can be classified according to their tear patterns. A vertical or longitudinal tear occurs in line with the circumferential fibers of the meniscus . If long enough, this tear is known as a bucket-handle tear. At arthroscopy, the bucket-handle tear may be seen as being attached anteriorly and posteriorly. Alternatively, it may be detached at either end or transected in the middle with unstable anterior and posterior flaps. A bucket-handle tear may displace into the intercondylar notch, where it may cause true locking of the knee joint.
(A) Vertical or longitudinal (Bucket-handle), (B) Flap or Oblique, (C) Radial or Transverse, (D) Horizontal, (E) Complex degenerative.
-Oblique tears are also known as flap or parrot beak tears and are perhaps the most common . These occur generally at the junction of the posterior and middle thirds.
-Radial tears occur in a similar location. They extend from the inner free margin toward the periphery . If such a tear reaches the periphery, it transects the meniscus and renders the hoop stress-distributing capacities of the meniscus useless. Such a tear is the functional equivalent of a total meniscectomy.
-Horizontal cleavage tears usually occur in older individuals. They extend from the inner free margin peripherally to the intrameniscal substance where myxoid degeneration may be present. These tears divide the meniscus into superior and inferior flaps, either of which may be unstable
-Complex degenerative tears occur in older patients. Osteoarthritic changes may be visible on plain radiographs, and chondromalacia of the articular surfaces is commonly encountered. The tears occur in multiple planes .
A 34 year old male has a long history of several subacute attacks of self-limited inflammatory arthritis. Crystals have been retrieved from a joint aspirate. Radiography of his knee is likely to demonstrate: a) subperiosteal thickening b) marginal articular erosions c) central articular erosions d) chondrocalcinosis e) subchondral bony sclerosis
The correct answer is D
Explanation Chondrocalcinosis is simply the term for the finding of radio-opaque crystals in hyaline or fibrocartilage. These salts may consist of calcium pyrophosphate dihydrate, dicalcium phosphate dihydrate or hydroxyapatite. Crystals may also be deposited in bursae, capsules, ligaments and tendons. Chondrocalcinosis may accompany a variety of diseases, but is not a disease entity merely a physical sign thereof. Used properly, the term pseudogout refers to the clinical syndrome of one or more acute or subacute attacks of self-limited inflammatory arthritis caused by crystal-induced synovitis, proven by recovery of the crystals from a joint aspirate. Most people with chondrocalcinosis never have a single acute episode of pseudogout.
CPPD crystal deposition disease is the general term that encompasses chondrocalcinosis, pseudogout, a distinctive arthropathy and a host of variations. During acute attacks (pseudogout) of crystal-induced synovitis, the usual radiological findings are soft-tissue oedema and joint effusion. Chondrocalcinosis may or may not be present. The cartilage and articular bone are often normal. The chronic arthropathy is more distinctive. It is most frequent in the patellofemoral, radiocarpal metacarpophalangeal and elbow joints.
Although the findings superficially resemble osteoarthritis, there are several important differences beyond the unique distribution. The arthropathy is characterized by cartilage loss, multiple subchondral cystic rarefactions, structural collapse of the articular surface, and the presence of many small intra-articular fragments, all without much bone sclerosis. In addition to the usual target sites, these changes may be observed in the hips, knees and sacroiliac joints. Chondrocalcinosis, which does not have to accompany the arthropathy, is seen most commonly in the large joints such as the knee, hip and shoulder as well as the symphysis pubis.
Most common form of generalized osteoporosis. As a person ages, the bones lose density and become more brittle, fracturing more easily and healing more slowly. Many elderly persons are also less active and have poor diets that are deficient in protein. Females are affected more often and more severely than males, as postmenopausal women have deficient gonadal hormone levels and decreased osteoblastic activity.
Osteoporosis of aging. Generalized demineralization of the spine in a postmenopausal woman. The cortex appears as a thin line that is relatively dense and prominent (picture-frame pattern).
Pain over the thumb side of the wrist is the primary symptom of DeQuervain's tenosynovitis. It may occur "overnight" or gradually, and it may radiate into the thumb and up into the forearm. It is worse with the use of the hand and thumb, especially with any forceful grasping, pinching or twisting. Swelling over the thumb side of the wrist may be present, as well as some "snapping" when the thumb is moved. Due to the pain and swelling , there may be some decreased thumb motion.
Besides pain and swelling over the first dorsal compartment, having a positive Finkelstein's test is a good indication that the patient has the problem. In this test, the patient makes a fist with the thumb placed under the little finger and bends the wrist. The test is mildly painful to many of us, but to someone with De Quervain's stenosing tenosynovitis, it is very painful.
A 42-year-old carpenter presents with wrist pain and grip weakness. On exam he is found to have pain over the radial aspect of the wrist that is aggravated by flexing the thumb and applying ulner flexion. The most likely diagnosis is
A) carpal tunnel syndrome
B) scaphoid fracture
C) de Quervain's tenosynovitis
D) boxer's fracture
E) hamate fracture
Answer and Discussion
The answer is ( C ). The combination of wrist pain and grip weakness is characteristic of de Quervain's tenosynovitis. The pain is generally located on the radial aspect of the wrist and reproduced with direct palpation of the involved tendons. Pain is aggravated by passively stretching the thumb tendons over the radial styloid in thumb flexion (the Finkelstein maneuver).
Bowleg (or genu varum) is a condition where the legs are bowed outwards in the standing position. The bowing usually occurs at or around the knee, so that on standing with the feet together, the knees are far apart.
Knock-knee (or genu valgum) is a condition where the legs are bowed inwards in the standing position. The bowing usually occurs at or around the knee, so that on standing with the knees together, the feet are far apart.
Bow-Legs This is almost always caused by softening of the bones, as in rickets. The bending occurs in the bones of both the leg and thigh, and the location of the point of greatest bending is sometimes low down toward the ankles or close up to the knee-joint, or the whole diaphysis of the bones may be curved. They are often curved anteroposteriorly as well as laterally.
Knock-knee (Genu Valgum). This condition has its point of bending most marked at the knee-joint. When caused by rickets the joint surfaces are often not much altered and the deformity is produced by a bending of the tibia or femur close to the joint; hence when an osteotomy is performed just above the condyles of the femur the joint is again brought level and resumes its functions normally.
Most people have some degree of bowleg or knock-knee and is considered within the limits of normal structure and function. During development in the first few years of life, because of rapid and differential growth around the knees, most children are bowlegged from birth till age 3, then become knock-kneed till age 5, then straighten up by age 6 or 7. In most children, even as they grow through these phases, the bowleg and knock-knee are not severe, and do not engender concern on the part of the parents. In some instances, the bowleg or knock-knee gets quite obvious, and becomes worrisome for the parents.
There are, of course, more serious causes of bowleg and knock-knee. They include the following: 1. Blount’s disease - a condition of severe bowleg that occurs usually in black children that is progressive, and may require surrgery. 2. Growth disturbance - or epiphyseal dysplasia, which may be a part of a generalized bone growth disturbance. 3. Post-trauma - where injury to the knee causes damage to the growth plate (also called the epiphyseal plate) and abnormal growth around the knee. 4. Rickets. Lack of vitamin D intake, or inability to metabolize Vitamin D due to kidney disease can cause growth disturbance of the bones in the body, including the knee.
