Medicurio

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internal derangement of the knee (IDK) is a chronic condition that interferes with normal knee joint function. Several things can cause it, such as injured ligaments, loose pieces of bone or cartilage in the knee joint, or a torn meniscus.

Over time, it can cause pain, instability, and limited knee flexibility. Keep reading to learn more about the symptoms of IDK and how to treat it.

CLASSIFICATION

The normal knee joint has two collateral ligaments, two cruciate ligaments and two semilunar cartilages (menisci). Any of these may be involved in a derangement,some being more easily damaged than others. In some instances more than one structure is disrupted.

The following disorders may be met with

.Sprain or tear of the medial collateral ligament.

.Sprain or tear of the lateral collateral ligament.

.Partial or complete rupture of the anterior cruciate ligament.

.Rupture of the posterior cruciate ligament.

.Tear of the medial semilunar cartilage.

This may take the form of a longitudinal spilt (bucket handle tear), or an anterior or posterior horn tear.

.Tear of the lateral semilunar cartilage. The same variations occur as with amedial cartilage tear.

.Tear of a degenerate meniscus.

.Cyst of a semilunar cartilage, usually the lateral.

3.9.Congenital discoid meniscus, usually the lateral.

4.The commonest derangement met with is injury to the medial collateral ligament.The medial meniscus and anterior cruciate ligament are next in frequency. Thelateral ligament, lateral meniscus and posterior cruciate ligament are less liable todamage.

causes

Sudden injuries — such as a blow to your knee or twisting your knee — and gradual damage from repeated stress on your knee can both cause IDK. Examples of repeated stress include:

• climbing stairs
• crouching or squatting
• heavy lifting
• carrying too much weight

Your meniscus can also tear slowly over time. During the process, small pieces of cartilage can break off from your meniscus, leaving a frayed end and loose bodies floating around in your knee joint.

Physical trauma is the cause of the vast majority of IDKs. The mechanics of the knee are such that individual derangements tend to be caused by particular types oftrauma, although severe injuries may produce multiple derangements; for example,a particular rotational injury may tear the medial ligament, medial meniscus and anterior cruciate ligament.

.The majority of acute knee injuries result from a valgus and/or twisting strain. Mos tcommonly, they involve the medial joint structures and the anterior cruciate ligament.

.The type of physical trauma causing IDK may be a sports injury, a road traffic accident or an occupational stress; by far the most common at the present time is a sports injury, usually from participation in contact sports. Professional soccer players are especially prone to suffer IDKs.

The most frequent cause of damage to the medial collateral ligament is forced valgus injury to the knee; this occurs in sportsmen when the athlete is hit from the lateral side and the knee is driven medially. Thus, it is most often found in contact sports, such as soccer, rugby and ice hockey.

Lateral collateral ligament injuries are much less common, as varus stress to the knee occurs much less frequently than valgus stress. They are usually caused by extreme violence, such as road traffic accidents.

.Anterior cruciate ligament injury occurs from forced valgus stress to the fully extended knee. It is found in sports such as soccer, rugby, netball and basketball; it is also common in skiing.

.Posterior cruciate ligament injury is liable to occur in motor car accidents caused by high velocity trauma, with posterior dislocation of the tibia on a flexed knee, as in a dashboard impact. It is a relatively uncommon sporting injury, but may occur in sports where there is frontal impact.

.Meniscus tears occur when substantial rotational stresses are applied to the flexed knee. They are particularly common in footballers, when the player is tackled from the side; they are also liable to occur in other sports, such as hockey, tennis, badminton, squash and skiing.

Occupational trauma is a recognised cause of meniscal injuries. It occurs in men who work in a squatting position, and used to be well known in miners prior to full mechanisation. Workers in jobs involving kneeling and twisting, such as carpetfitters and electricians, are at risk of meniscal damage.

Age-related degeneration of a semilunar cartilage may be met with in an older patient, say over age 50. It may present as spontaneous occurrence of knee pain without any history of injury.

Meniscal cysts often appear to follow an injury, and there may be a history oftrauma in the past. If there is a previous history of direct injury at the site of the cyst, a traumatic origin could not be denied. However, in most instances the aetiology is obscure. Some meniscal cysts appear to be congenital.

Discoid lateral meniscus is a true congenital malformation and is more liable toinjury than is a normal meniscus. The condition frequently presents with symptoms in early childhood.

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symptoms

In addition to pain and discomfort, knee locking is one of the more common symptoms of IDK. Your quadriceps and hamstrings, two muscles above your knee joint, may freeze in position. They might also give out at the same time, causing your knee to buckle.

Additional symptoms depend on the underlying cause of IDK:

• Meniscus tear. After some initial pain and swelling, you may start to feel pain when flexing or turning your knee. The pain may go away when you bend your knee. You might also find it hard to fully extend your knee.
• Ligament tear. Depending on the ligaments involved, you’ll feel pain in your inner or outer knee. You may also notice some swelling around the affected ligament. Until the ligament is repaired, you’ll likely have some knee instability as well.
• Loose bodies. Knee injuries and normal wear and tear can cause bits of cartilage or bone to break loose within your knee joint. As they move around in the joint, you might feel pain in different parts of your knee.

diagnosis

It’s important to see your doctor if you notice knee pain or stiffness that doesn’t go away after a day or two. To figure out what’s causing the pain, they’ll start by asking you about any recent injuries or other symptoms you’ve been having. They’ll likely move your knee into several positions while asking if you feel any pain.

Depending on the results of your exam, you may also need an MRI scan to give your doctor a view of the soft tissue inside your knee. This will help them see any signs of a torn meniscus. They may also use a knee X-ray to check for bone damage.

treatment

There are several treatment options for IDK, depending on the underlying cause and your overall health. Treatment also depends on your daily activity level. For example, if you’re an athlete, you may want to opt for more invasive surgery that will help your knee endure ongoing stress.

Nonsurgical

IDK doesn’t always require surgery. For minor tears, try following the RICE protocol, which stands for:

• Rest.Give your knee a day or two of rest. During this time, try to avoid putting pressure on it as much as possible.
• Ice.Apply an ice pack to your knee for 20 minutes at a time. Do this up to four times a day. Consider investing in a reusable ice pack, which you can find on Amazon. Look for a flexible one that you can wrap around your entire knee for maximum benefit.
• Compression.Wrap your knee with an elastic bandage to reduce swelling. Just make sure you don’t wrap it too tightly, which could interfere with your circulation.
• Elevation.Try to prop your knee up on some pillows as much as possible for a few days.

Your doctor might also suggest wearing a knee brace, which you can find on Amazon, to help support and stabilize the joint as you heal. Look for one that’s labelled as “level 2” to make sure it provides enough support. Physical therapy can also help to strengthen the muscles around your knee to improve flexibility and range of motion.

Surgery

If you do need surgery, you might be able to opt for minimally invasive arthroscopic surgery. This involves making a few small incisions and inserting small tools through them to repair damage to your meniscus or to remove loose bodies. This is usually an outpatient procedure involving six to eight weeks of recovery time.

If you’re injury is more severe or you regularly put a lot of stress on your knee, you may need a more invasive procedure to repair a torn ligament. This usually involves taking a tendon from your hamstrings or other area and sewing it to the torn ligament to help restore its function. Following a procedure like this, you may need to use crutches for a week or two to keep pressure off your knee. It may take up to a year to fully recover.

Following any type of knee procedure, your doctor will likely recommend you follow up with a physical therapy program to rebuild muscle and improve strength.

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Amputation is the removal of an extremity by trauma, prolonged constriction, medical illness or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, amputation of the hands, feet or other body parts is, or was used as a form of punishment for people who committed crimes. Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury.

causes

There are many reasons an amputation may be necessary. The most common is poor circulation because of damage or narrowing of the arteries, called peripheral arterial disease. Without adequate blood flow, the body’s cells cannot get oxygen and nutrients they need from the bloodstream. As a result, the affected tissue begins to die and infection may set in.

Other causes for amputation may include:

• Severe injury (from a vehicle accident or serious burn, for example)
• Cancerous tumor in the bone or muscle of the limb
• Serious infection that does not get better with antibiotics or other treatment
• Thickening of nerve tissue, called a neuroma
• Frostbite

Congenital

• Congenical limb deficiency 
• Phocomelia: “a congenital deformity in which the limbs are extremely shortened so that the feet and hands arise close to the trunk”

Acquired

• Vascular
  • Ischaemia
  • Diabetes
  • Frostbite
  • Arterial insufficiency leading to death or decay of body tissue (gangrene)
  • Chronic leg ulcer leading to septicemia.
• Infection e.g. Bone infection (Osteomyelitis)
• Malignant tumours e.g. sarcoma (cancer of the connective tissue)
• Trauma (limb buried under / crushed by heavy object, limb damaged by car accident, stabbing, gunshot, animal bite etc.); in some cases leading to
  • Traumatic amputation: a physical (non-surgical) separation of the limb in the course of the traumatic event

The Amputation Procedure

An amputation usually requires a hospital stay of five to 14 days or more, depending on the surgery and complications. The procedure itself may vary, depending on the limb or extremity being amputated and the patient’s general health.

Amputation may be done under general anesthesia (meaning the patient is asleep) or with spinal anesthesia, which numbs the body from the waist down.

When performing an amputation, the surgeon removes all damaged tissue while leaving as much healthy tissue as possible.

A doctor may use several methods to determine where to cut and how much tissue to remove. These include:

• Checking for a pulse close to where the surgeon is planning to cut
• Comparing skin temperatures of the affected limb with those of a healthy limb
• Looking for areas of reddened skin
• Checking to see if the skin near the site where the surgeon is planning to cut is still sensitive to touch

During the procedure itself, the surgeon will:

• Remove the diseased tissue and any crushed bone
• Smooth uneven areas of bone
• Seal off blood vessels and nerves
• Cut and shape muscles so that the stump, or end of the limb, will be able to have an artificial limb (prosthesis) attached to it.

The surgeon may choose to close the wound right away by sewing the skin flaps (called a closed amputation). Or the surgeon may leave the site open for several days in case there’s a need to remove additional tissue.

The surgical team then places a sterile dressing on the wound and may place a stocking over the stump to hold drainage tubes or bandages. The doctor may place the limb in traction, in which a device holds it in position, or may use a splint.

Initially, the arterial and venous supply are ligated to prevent hemorrhage (bleeding). The muscles are transected and the bone is sawed through with an oscillating saw. Sharp and rough edges of the bone are filed down, skin and muscle flaps are then transposed over the stump.

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Distal stabilisation of the muscles is recommended, allowing for effective muscle contraction and reduced atrophy. This in turn allows for a greater functional use of the stump and maintains soft tissue coverage of the remnant bone. Muscles should be attached under similar tension to normal physiological conditions.

• myodesis: the muscles and fascia are sutered directly to the distal residual bone for better prosthetic control
• myoplastic: suture to opposite muscle in the residual limb to to each other and to the periosteum or to the distal end of the cut bone for weight bearing purposes

Ideal Stump

1. Skin flaps: skin should be mobile, sensation intact, no scars
2. Muscles are divided 3 to 5 cm distal to the level of bone resection
3. Nerves are gently pulled and cut cleanly, so that they retract well proximal to the bone level to reduce the complication of neuroma

Levels of Amputation

Transfemoral AmputationUpper Limb

• Forequarter
• Shoulder Disarticulation (SD)
• Transhumeral (Above Elbow AE)
• Elbow Disarticulation (ED)
• Transradial (Below Elbow BE)
• Hand/ Wrist Disarticulation
• Transcarpal (Partial Hand PH)

Lower Limb

• Hemipelvectomy
• Hip Disarticulation (HP)
• Transfemoral TF (Above Knee AKA)
• Knee Disarticulation (KD)
• Transtibial TT (Below Knee BKA)
• Ankle Disarticulation
• Symes
• Partial Foot PF (Chopart)
• Toe amputation

Special Investigations

Doppler Ultrasound

• X-rays
• CT scan
• Angiogram (outlines blood vessels)
• Doppler ultrasound (occlusion of vessels)
• Venogram and arteriogram
• Radioactive dye injected into the blood
  

Arterial Insufficiency

• Surgery to improve circulation
• Bypass grafts (autogenous graft uses a vein to bypass the obstructed area)
• Synthetic grafts

Management

Please find below links to more detailed pages on the management of amputees

• Pain Management
• Pre-Fitting Management of the Patient with a Lower Limb Amputation
• Post-fitting Management
• Prosthetic Rehab
• High level Rehab
• Clinical Guidelines: Mental Health Amputees

Buerger’s Exercises

• Stimulates collateral blood flow in the patient’s leg
• It is performed for 20 min.
• The leg is elevated until the toes go white, then lowered, then level
• Repeat 2-3 times to improve collateral circulation

Connective Tissue Massage

Dynamic Stump Exercises

Balance and Gait Retraining

• Improve static and dynamic balance
• Use parallel bars, walking frame then Crutches (in that order)
• Therapist stands on the amputation side, using a belt around the patient’s waist to support
• Rest if the patient feels tired

Short Wave Diathermy (SWD)

Through the pelvis to warm the arteries (contraindicated in patients with arterial insufficiency because the warmth leads to increased metabolism, causing a greater demand for nutrients, which are not available)

Post-operative Care

• Maintain function in the remaining leg and stump to maintain peripheral circulation
• Maintain respiratory function (important with smokers and those patients under general anaesthesia)
• Prepare for mobility rehabilitation

Stump care

• For hygiene and skin care see handout on amputations
• A hip flexion contracture may develop because of elevation to reduce swelling
• Stump bandaging is done to ‘cone’ the stump, thereby preventing oedema, which occurs because there is no muscle pump and the stump hangs
• Swelling must be prevented to allow proper attachment of the prosthesis, and the prevention of pressure sores
• The stump sock is put on first, then the prosthesis
• The prosthesis must be cleaned and maintained (children who are still growing, grow out of their prostheses)

Mobility Aids

• The choice of mobility aids depends on the level of fitness, strength, balance skills of the individual:
  • Walking frame
  • Axillary crutches
  • Elbow crutches
  • Walking stick 
• For bilateral lower limb amputees a wheelchair is often indicated (high energy expenditure during gait with prostheses)

Complications

Some of the most common complications associated with amputation include;

• Oedema
• Wounds and infection
• Pain (phantom limb)
• Muscle weakness and contractures
• Joint Instability
• Autonomic dysfunction

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Congenital pseudarthrosis of the tibia (CPT) refers to nonunion of a tibial fracture that develops spontaneously or after a minor trauma. A pseudarthrosis is defined as a “false joint” and is a break in the bone that fails to heal on its own. The pseudarthrosis usually develops within the first two years of life; however, there have been reported cases of CPT development before birth as well as later in life.

Congenital pseudarthrosis of the tibia is a shin bone fracture in children that has not healed. It normally presents before a child turns two years old. Typically, the child gets a shin bone fracture that either happens spontaneously, or results from when the child experiences a minor trauma, and the fracture will not heal. It is a rare condition that occurs in 1 out of every 250,000 children.

It stems from the periosteum, a membrane that covers the bone, being abnormal and preventing proper bone healing. Since the bone has not healed correctly, it is unstable and there is mobility at the false joint which should be solid, stable bone. As a result, many patients have an unstable leg, making function difficult.

Classification Systems

Classification systems of CPT based on onset, mobility, and x-rays have been proposed. Difficulties of classification, however, have arisen because the condition includes different clinical and pathological entities each with a different history and prognosis. For example, classification systems based on the appearance of the tibia can become confusing since the appearance can change during treatment.

Dr. Paley, in conjunction with Dr. El-Rosassy, developed a classification system designed to indicate prognosis and treatment. The El-Rosassy-Paley classification system divides CPT into three types based on two criteria: the geometry of the bone ends and how mobile they are—that is, whether the bone ends at the pseudarthrosis are thick and stiff or thin and mobile. Another important consideration in the El-Rosassy-Paley classification is whether the patient has undergone a previous, unsuccessful surgery.

Type 1

• Atrophic (narrow) bone ends
• Mobile pseudarthrosis
• No previous surgery

Type 2

• Atrophic (narrow) bone ends
• Mobile pseudarthrosis
• Previous unsuccessful surgery

Type 3

• Hypertrophic (wide) bone ends
• Stiff pseudarthrosis

Congenital pseudarthrosis of the tibia remains one of the most challenging and misunderstood conditions in orthopedics. The difficulty of treatment lies in the weak healing power at the fracture site, a tendency to refracture after treatment, and the difficulty of stabilizing small osteoporotic bone fragments in small children. Even in cases where a union has been achieved, there is a difficulty in maintaining it. Frequently, the end result is a frustrated child and family who have been through multiple failed surgeries and remain with a limb that is short, deformed, and almost functionless. For this reason, many orthopedic surgeons recommend amputation, particularly after a third failed surgery.

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Who gets congenital pseudarthrosis of the tibia?

Congenital pseudarthrosis of the tibia is often associated with neurofibromatosis (NF-1) which has many other serious potential manifestations. However, congenital pseudarthrosis of the tibia is also seen in fibrous dysplasia, osteofibrous dysplasia and cleidocranial dysostosis. A significant percentage remain without a known cause (“idiopathic”).

How is congenital pseudarthrosis of the tibia diagnosed?

Congenital pseudarthrosis of the tibia is typically identified with X-rays and physical examination. Patients who are deemed high risk (e.g., patients with neurofibromatosis) may have screening X-rays performed in early childhood. In some cases, the first sign is a deformity in the leg or a fracture that occurred with minimal trauma.

What will happen during a clinic visit for congenital pseudarthrosis of the tibia?

The doctor will evaluate the patient for neurofibromatosis, a genetic disorder that causes tumors to form on nerve tissue which occurs in 40-50% of patients. The doctor will also ask for a history of previous fractures and examine the leg to determine the range of motion of the false joint. X-rays will be taken to determine the quality of the bone, the condition of the joints, the amount of limb length discrepancy and the severity of any bone abnormalities.

How is congenital pseudarthrosis of the tibia treated?

The primary treatment goal of congenital pseudarthrosis of the tibia is to achieve union of the shin bone (tibia) and to maintain that union. Treatment also addresses the resulting limb length discrepancies and bone deformities. To treat congenital pseudarthrosis of the tibia, the International Center for Limb Lengthening has a combined multimodal, comprehensive treatment program that addresses both the biological and mechanical issues. Many doctors use various elements of our protocol, but we strongly believe that the combined multimodal approach is the most effective.

What happens in surgery for congenital pseudarthrosis of the tibia?

1. Two to four weeks before surgery, the patient receives a bisphosphonate infusion from our endocrinologist. Bisphosphonates  inhibit cells responsible for breaking down bone. It is used to prevent resorption (melting away) of bone graft and to improve local healing response. This can take place in Baltimore or for patients from further away, it can be done closer to home by a local endocrinologist.
2. In the operating room, the abnormal periosteum is removed from the tibia and fibula (both bones in the lower leg), and the pencil tip ends of the tibia and fibula are slightly trimmed to allow straightening of the leg with stable bone contact to optimize healing.
3. The tibia is stabilized with intramedullary rods (inside the canal of the bone), and the fibula is stabilized with wires. Newer intramedullary rods have allowed surgeons to avoid crossing and damaging the ankle joint during fixation of almost all cases.
4. Healthy periosteum and a bone graft are harvested from the pelvis usually on the same side as the tibia pseudarthrosis.
5. The healthy periosteum, bone graft, and bone morphogenic protein (BMP) are placed in between and around the tibia and fibula bones, generating a large cross-sectional surface area for optimal healing. BMP is a naturally occurring cell signaling molecule that drives bone formation. When used in CPT treatment, it helps increase bone formation in the early stages. This is an off-label use of BMP in the United States (not approved by the FDA for this use). While healing can occur without BMP, it is an important component of the International Center for Limb Lengthening’s multi-faceted approach.
6. In some cases, an external fixator is applied to the leg to provide rotational stability and to compress the bone ends while they knit. In most cases, an internal plate is used to control the newly realigned limb. In the past, external fixators were a necessity. The combination of the newer ankle-sparing intramedullary rods and improved internal plates gives surgeons another option to maintain improved ankle motion. Your doctor will assess which treatment is best for your child’s unique needs and circumstances.
7. Once healing has occurred (typically evident by 2 months, and strong by 3-4 months), activity restrictions are lifted, and children can return to normal activities. A plastic leg brace called an ankle foot orthosis (AFO) is worn on the leg under clothing for additional protection.
8. If an external fixator was used and healing of the tibia has been achieved, then the frame stays on for 3-4 months.
9. If a proximal lengthening is being performed at the same time, then the frame is in place for 4-6 months. In the external fixation device, the patient is allowed to bear weight as soon as they would like after surgery. After the frame is removed, a long leg cast is placed for 4 weeks. After 4 weeks, the cast is removed and a brace is used for 2-3 months or longer.
10. If a plate was used instead, the plate is removed 6-12 months after the initial surgery, while the rods remain inside to act as “rebar” to strengthen the newly healed leg and prevent refracture.
11. After either method is used, regular monitoring of the bone is required on an annual basis. The internal rod may needs to be swapped out every 3-4 years during childhood as the leg grows longer to keep providing protection against refracture.

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Congenital diaphragmatic hernia (CDH) occurs when the diaphragm, the muscle that separates the chest from the abdomen, fails to close during prenatal development. This opening allows contents of the abdomen (stomach, intestines and/or liver) to migrate into the chest, impacting the growth and development of the lungs. The lungs will be smaller than expected (pulmonary hypoplasia), and will have less developed blood vessels. This causes high blood pressure in the lungs (pulmonary hypertension).

CDH is one of the most common major congenital anomalies, occurring in 1 of every 2,500 – 3,000 live births. CDH can occur on the left or right side, or rarely on both sides. Newborns affected with CDH will require immediate care at delivery, so early and accurate diagnosis is important.

causes

The cause of CDH is unknown. Typically CDH is an isolated finding although it can occur along with heart disease or a genetic abnormality which can lead to additional complications.

Genetic researchers are using innovative techniques to try to find the potential underlying genetic etiology of CDH. Identifying the genetic cause(s) of CDH will allow our clinicians to better manage and counsel families with an affected child.

Signs and symptoms of CDH

CDH is typically discovered during a routine prenatal ultrasound. The sonographer may notice stomach, intestine, or liver in your baby’s chest where the lungs should be. The baby’s heart may also be pushed to one side by the extra organs in the chest.

diagnosis

CDH is typically detected through a routine ultrasound, which allows doctors to check the position of your baby’s lungs and heart. Following the initial diagnosis, at 22 to 28 weeks of gestation, the SSM Health St. Louis Fetal Care Institute team performs a focused ultrasound, a fetal MRI, and a fetal echocardiogram (echo) to assess the severity of the CDH. We also offer genetic testing to determine if a chromosomal abnormality has caused the CDH. In some situations, additional testing will be required throughout the pregnancy.

The team uses several measurements to understand how the CDH will affect the baby. We measure the lung-to-head ratio (LHR), the liver position, the total lung volume, and the response of the fetal lungs to oxygen. Additionally, we look for any abnormalities that suggest a genetic cause. This critical assessment can often provide insight into the severity of the CDH.

Every case and every outcome is different; however, the liver position and lung-to-head ratio can often be a predictor of the severity of the CDH. “Liver up” means that the liver has migrated through the hole in the diaphragm into the chest cavity, while “liver down” means that it is below the hole in the diaphragm, sitting in the normal position in the abdomen.

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What happens at delivery?

Most babies with less severe CDH can be delivered vaginally at full-term, unless there are obstetric indications for cesarean delivery. It is best for these babies to be delivered at a medical center where there is access to a team of pediatric surgeons and neonatologists, along with an established Neonatal Intensive Care Unit (NICU),

At birth, the neonatology team will assess your baby. If necessary, a breathing tube will be inserted and a nasogastric tube will be inserted into the stomach to prevent air from building up in the stomach and intestines. Most babies with CDH will go to SSM Health Cardinal Glennon Children’s Hospital for intensive monitoring prior to surgery.

In severe cases of CDH, we may recommend a special delivery procedure, called an EXIT procedure. If your baby has the signs of a severe CDH, we can discuss the full range of options to care for your baby.

What care is provided after delivery?

The care of babies with CDH can be quite complex, with frequent blood tests, x-rays and machines that are helping to support your baby. Our team will involve and inform our parents about all of the various aspects of their baby’s care. We encourage parents to ask questions to better understand how their baby is responding.

When babies with CDH arrive in the NICU they begin the observation stage of their care until they are ready for hernia repair surgery. In many situations they are kept on a ventilator and given sedation to keep them calm and pain free. Intravenous fluids and nutritional support are also provided. Your baby will not be able to eat until after surgery. If they choose, mothers can pump and store their breast milk until the baby can eat.

Most CDH babies suffer from high blood pressure in the lungs, called pulmonary hypertension. This problem can be quite serious and can delay surgical repair of the diaphragm. Before repair surgery, your baby will be monitored for pulmonary hypertension, and treatments will be started to reduce its severity. For instance, inhaled nitric oxide is often used to help open up the blood vessels in the lungs, decreasing the blood pressure and allowing for better oxygen delivery.

CDH babies typically undergo surgery to repair the hole in their diaphragm once pulmonary hypertension has subsided. The CDH team will work together with you to develop the optimal care plan for you and your baby.

During surgery, the surgeons will assess the size and location of the defect to determine which type of closure is required. During the CDH repair procedure a small incision in made under the rib cage to give the surgeon access to the diaphragm and misplaced organs. The surgeon will gently reposition the organs in the abdomen, and close the hole in the diaphragm. Smaller hernias may be repaired with stitches, but larger defects require a medical patch.

After surgery, your baby will return to the NICU to recover and heal. The stress of the surgery may cause your baby’s condition to initially get worse before it gets better, and treatment may require additional sedation, ventilation, blood pressure medications or ECMO.

The amount of time spent in the NICU after surgery varies from patient to patient depending on the severity of their case. The CDH team will work to wean your baby off the ventilator and pain medications as quickly as possible, and to get them eating and gaining weigh

Management of CDH during pregnancy

After all testing is complete, our team, led by a maternal-fetal medicine specialist and a pediatric surgeon both with experience managing pregnancies affected by CDH, meets with you and your family. Together we review imaging and test results, discuss the diagnosis, explain treatment options and potential outcomes, and answer any questions you may have.

You will typically be seen every four weeks for follow up until later in pregnancy when you’ll be seen more frequently by an obstetrical team experienced in managing pregnancies affected by CDH and led by a maternal-fetal medicine specialist. During your follow up ultrasounds the lung measurements will be updated, your baby’s growth will be carefully watched, and the amount of amniotic fluid around the baby will be measured. Weekly testing begins at 34 weeks to closely monitor fetal well-being.

At this time, relocation is necessary if you live more than one hour away from our center. You will need to relocate sooner if you undergo prenatal intervention, if extra fluid develops around your baby (polyhydramnios), or if there are signs of preterm labor. This will ensure that you are nearby in the event labor occurs or delivery is indicated earlier than expected. Our social workers will help coordinate housing options based upon your family’s needs.

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Infectious arthritis is an infection in a joint. It may also be referred to as septic arthritis. It occurs when an infection caused by a bacteria or virus spreads to a joint or the fluid surrounding the joint. This fluid is called the synovial fluid. This infection usually begins in another area of the body and spreads through the bloodstream to the joint tissue. The infection may also enter the body through surgery, open wounds, or injections.

Infectious arthritis usually only occurs in one joint. The condition typically affects a large joint such as the knee, hip, or shoulder. It occurs more often in children, older adults, and people who use illegal drugs.

Septic arthritis is a painful infection in a joint that can come from germs that travel through your bloodstream from another part of your body. Septic arthritis can also occur when a penetrating injury, such as an animal bite or trauma, delivers germs directly into the joint.

Infants and older adults are most likely to develop septic arthritis. People who have artificial joints are also at risk of septic arthritis. Knees are most commonly affected, but septic arthritis also can affect hips, shoulders and other joints. The infection can quickly and severely damage the cartilage and bone within the joint, so prompt treatment is crucial.

Treatment involves draining the joint with a needle or during surgery. Antibiotics also are usually needed.

Causes

Septic arthritis can be caused by bacterial, viral or fungal infections. Bacterial infection with Staphylococcus aureus (staph) is the most common cause. Staph commonly lives on even healthy skin.

Septic arthritis can develop when an infection, such as a skin infection or urinary tract infection, spreads through your bloodstream to a joint. Less commonly, a puncture wound, drug injection, or surgery in or near a joint — including joint replacement surgery — can give the germs entry into the joint space.

The lining of your joints has little ability to protect itself from infection. Your body’s reaction to the infection — including inflammation that can increase pressure and reduce blood flow within the joint — contributes to the damage.

Symptoms

Septic arthritis typically causes extreme discomfort and difficulty using the affected joint. The joint could be swollen, red and warm, and you might have a fever.

If septic arthritis occurs in an artificial joint (prosthetic joint infection), signs and symptoms such as minor pain and swelling may develop months or years after knee replacement or hip replacement surgery. Also, a loosening of the joint may occur, which causes pain while moving the joint or while putting weight on the joint. Typically, the pain goes away when at rest. In extreme cases, the joint may become dislocated.

The symptoms of infectious arthritis can vary depending on your age and the medications you’re taking. The symptoms may include:

• severe pain that worsens with movement
• swelling of the joint
• warmth and redness around the joint
• a fever
• chills
• fatigue
• weakness
• decreased appetite
• a rapid heart rate
• irritability

Diagnosis

Your doctor will examine your joint and ask you questions about your symptoms. If they suspect you have infectious arthritis, they may order additional tests.

An arthrocentesis is a test frequently used to diagnose this condition. It involves inserting a needle into the affected joint to take a sample of synovial fluid. The sample is sent to the lab to be examined for color, consistency, and the presence of white blood cells and bacteria. The information from this test can tell your doctor if you have an infection in the joint and what is causing the infection.

Your doctor may also take a blood sample from you. This is another way to check your white blood cell count and to determine if any bacteria are present in your bloodstream. This information can help your doctor determine the severity of the infection.

Imaging tests may also be ordered to confirm the presence of infection. These tests can also help your doctor see if your joint has been damaged by the infection. Imaging tests used for infectious arthritis include:

• X-rays
• MRI scans
• CT scans
• nuclear scans

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Risk factors

Risk factors for septic arthritis include:

• Existing joint problems. Chronic diseases and conditions that affect your joints — such as osteoarthritis, gout, rheumatoid arthritis or lupus — can increase your risk of septic arthritis, as can previous joint surgery and joint injury.
• Having an artificial joint. Bacteria can be introduced during joint replacement surgery, or an artificial joint may become infected if germs travel to the joint from a different area of the body through the bloodstream.
• Taking medications for rheumatoid arthritis. People with rheumatoid arthritis have a further increase in risk because of medications they take that can suppress the immune system, making infections more likely to occur. Diagnosing septic arthritis in people with rheumatoid arthritis is difficult because many of the signs and symptoms are similar.
• Skin fragility. Skin that breaks easily and heals poorly can give bacteria access to your body. Skin conditions such as psoriasis and eczema increase your risk of septic arthritis, as do infected skin wounds. People who regularly inject drugs also have a higher risk of infection at the site of injection.
• Weak immune system. People with a weak immune system are at greater risk of septic arthritis. This includes people with diabetes, kidney and liver problems, and those taking drugs that suppress their immune systems.
• Joint trauma. Animal bites, puncture wounds or cuts over a joint can put you at risk of septic arthritis.

Having a combination of risk factors puts you at greater risk than having just one risk factor does.

When to see a doctor

See your doctor if you have severe pain in a joint that comes on suddenly. Prompt treatment can help minimize joint damage.

If you have an artificial joint, see your doctor if you experience pain while using the joint.

Complications

If treatment is delayed, septic arthritis can lead to joint degeneration and permanent damage. If septic arthritis affects an artificial joint, complications may include joint loosening or dislocation.

Treatment

Prescription Drugs

Treatment for infectious arthritis caused by a bacteria usually begins with antibiotics to kill the bacteria causing the infection. Your doctor will use the information from your tests to choose an antibiotic that’s effective for the type of bacteria present in your joint. The infection needs to be treated promptly and aggressively to prevent osteoarthritis and damage to your joint. As a result, your doctor may order intravenous antibiotics, which are given through your veins. This treats the infection more quickly than oral antibiotics. Most people begin to feel better within 48 hours of their first antibiotic treatment.

Your doctor may also prescribe oral antibiotics to treat the infection. Oral antibiotics for infectious arthritis usually need to be taken for six to eight weeks. It’s important to take the entire course of antibiotics to treat the infection effectively.

Your doctor will prescribe antifungal medication instead of antibiotics if a fungus is causing your infection.

Infectious arthritis caused by a virus doesn’t require medication.

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Synovial Fluid Drainage

Many people with infectious arthritis need to have their synovial fluid drained. This is done to remove the infected fluid, ease pain and swelling, and prevent further damage to the joint. Synovial fluid is often drained using arthroscopy, but it can be done in an open surgical procedure.

With arthroscopy, your doctor will make several small incisions near the affected joint. Then, they’ll insert a small tube containing a camera into the incision. Your doctor will use the camera image to guide them in suctioning the infected fluid from your joint. Usually, a drain or tube will be inserted and left in the joint to keep the joint from swelling again. This drain is then removed in a few days.

Sometimes, a doctor can use a small needle to remove infected fluid without requiring surgery. This is called arthrocentesis. This procedure often has to be repeated over the course of several days to ensure the fluid has been removed.

Other Treatment Options

Most cases of infectious arthritis require surgery, such as arthroscopy or an open procedure, to wash out the joint. On occasion, surgery is required to remove any damaged sections of the joint or replace the joint, but this is only done after the infection has been treated.

Other treatment methods to reduce pain may be used along with treatment for the infection. These methods include:

• using nonsteroidal anti-inflammatory drugs
• resting the joint
• splinting the affected joint
• going to physical therapy

Physical Therapy Management

Patients with septic arthritis are usually managed initially in the inpatient hospital setting and require an interprofessional team of caregivers including the primary care provider, physical and occupational therapist, nurses and wound care team. At the time of discharge, some patients can return home while others with increased debility may need ongoing physical therapy at either an acute or subacute rehabilitation facility. The social workers in the hospital help to ensure a smooth transition from inpatient to outpatient care..

The initial treatment of infectious arthritis is outside of the scope of physical therapy. It is important, first, for the physical therapist to recognize the signs and symptoms of the infection and refer out for other medical treatment. Subjective history, in combination with the physical therapist’s objective findings, is important in order to recognize the risk factors that make septic arthritis the likely diagnosis. It is important to immobilize the joint in this stage to best manage the patient’s pain and to decrease the likelihood of doing further damage to the joint until proper treatment can occur. 

Once the patient receives a round of antibiotic treatment in combination with either joint aspiration, debridement, or arthroscopy, the patient may then be referred back to physical therapy including

• educate on how to properly protect the affected joint.
• Gentle mobilization of the infected joint can begin if the patient is responding well following 5 days of medical treatment.
• Once the infection is well-managed, current evidence states the patient will usually respond best to aggressive physical therapy to allow maximum post-infection functioning.
• Physical therapy needs to consist of allowing the joint to be in its functional position and positioning the joint to allow passive range of motion activities. 

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Tuberculous synovitis frequently presents as a monoarthritis of weight-bearing joints such as the hip, knee, or ankle. Owing to its low incidence in developed countries, the diagnosis is often delayed for months to years. Early diagnosis with a synovial biopsy permits prompt antituberculous therapy and substantially improves the prospect of preservation of joint structure and function. Initial treatment typically includes combination therapy with four drugs (isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol) because of the frequency of isoniazid resistance. Antimicrobial therapy should be of at least 9 months’ duration, longer in immunocompromised hosts. Partial synovectomy and other surgical procedures should be restricted to joints with severe cartilage destruction, large abscesses, joint deformity, multiple drug resistance, or atypical mycobacteria.

Tubercular bacilli reach the joint space via the blood stream through subsynovial vessels, or indirectly from epiphyseal (more common in adults) or metaphyseal (more common in children) lesions, which erode into the joint space. Articular cartilage destruction begins peripherally and the weightbearing surfaces are preserved for a few months, providing the potential for good functional recovery with effective treatment in patients with early disease.

The disease may start in bone or in the synovial membrane, but one rapidly infects the other. The initial focus starts in the metaphysis in childhood or at the end of the bone in adults. An example of articular tuberculosis of the typical osseous areas of predilection for hip disease.

Osseous Changes and Tubercular Sequestra

After the infection, marked hyperemia and severe osteoporosis occur. The softened bone easily yields under the effect of gravity and muscle action, leading to compression, collapse, or deformation. Necrosis also may be caused by ischemic infarction of segments of bone.

Sequestration gives the appearance of coarse sand and rarely produces a radiologically visible sequestrum. Because of loss of nutrition, the adjacent articular cartilage or the intervening disc degenerate and also may become separated as sequestra. Some of the radiologically visible smaller sequestra in tuberculous cavities may result from calcification of caseous matter.

The Future Course of Tubercle

Before the availability of antitubercular drugs, the 5–year followup mortality of patients with osteoarticular tuberculosis was approximately 30.Modern antitubercular agents have changed the outlook considerably. Depending on the sensitivity pattern, host resistance, and the stage of the lesion at the inception of treatment, the tuberculous lesion may behave as follows. It may resolve completely; the disease may heal with residual deformity and loss of function; the lesion may be walled off completely and the caseous tissue may calcify; low-grade chronic fibromatous granulating and caseating lesion may persist (grumbling disease); and the infection may spread locally by contiguity and systematically by the blood stream

DIAGNOSIS OF TB INFECTION

Methods

Tuberculin Skin Test (TST)

Interferon Gamma Release Assays (IGRAs)

Enzyme-Linked Immunosorbent Assays (ELISA)

Bacteriology

Radiology

Computed Tomography (CT)

Magnetic Resonance Imaging (MRI)

Polymerase Chain Reaction (PCR)

Synovial fluid examination

Synovial biopsy

Blood

A relative lymphocytosis, low hemoglobin, and increased erythrocyte sedimentation rate often are found in patients with the active stage of disease. An increased erythrocyte sedimentation rate, however, is not necessarily proof of activity of the infection. Its repeated estimation at 3- to 6-month intervals gives an index of the activity of the disease.

Mantoux Test

As a rule, a positive reaction is present in a patient infected with tuberculosis for more than 1 month. A negative test, in general, rules out the disease. The tuberculin test rarely may be negative although active tuberculosis is present, such as in immune deficiency states.

Biopsy

Whenever there is doubt (particularly in the early stages) it is mandatory to prove the diagnosis by obtaining a biopsy specimen of the diseased tissue (granulations, synovium, bone, lymph nodes, or margins of tuberculous ulcers). Microscopic examination of an aspiration, core biopsy, needle biopsy, or open biopsy will reveal typical tubercles in patients who are not treated. Epithelioid cells surrounded by lymphocytes, even without central necrosis or peripheral foreign-body giant cells, are adequate histologic evidence of tuberculosis in a patient who is suspected to have the disease. At the time of open biopsy of a joint or bone, the orthopaedic surgeon should do therapeutic synovectomy or curettage. The infections of bone and joint that present as granulomatous lesions in order of frequency are tuberculosis, mycotic infection, brucellosis, sarcoidosis, and tuberculoid leprosy.

Guinea Pig Inoculation

The tuberculous pus, joint aspirate, or diseased material may be injected intraperitoneally into a guinea pig. Examination in positive cases shows tubercles on the peritoneum 5 to 8 weeks later. Although it currently is not considered a cost-effective test, it perhaps is the most reliable proof of tuberculosis.

Smear, Culture, and Serology

The material prepared for guinea pig inoculation also may be submitted for smear and culture examination for acid-fast bacilli. In superficial joints, one may be able to aspirate synovial fluid. Analysis of synovial fluid does not provide pathognomonic information; however, in general the leukocyte count is elevated to approximately 20,000 mm³, there is a lowered glucose level, and poor mucin. Clear synovial aspirate is not an appropriate material for microbiologic investigation; however, it is an excellent material for polymerase chain reaction and nucleic acid probes.

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Principles of Treatment of Osteoarticular Tuberculosis

Modern drugs promote the healing of sinuses, ulcers, and abscesses in patients previously unresponsive to extensive surgery. They also eliminate the danger of postoperative miliary and meningeal disease caused by dissemination of the tuberculous infection.

Death caused by uncontrolled disease, meningitis, miliary tuberculosis, amyloidosis, paralysis, and crippling now is rare. If a patient is diagnosed early and treated vigorously, healing can be accomplished without residual joint ankylosis or deformity.

With the use of modern drugs, the indications for surgery have become universally more selective and directed toward the prevention and correction of deformities, and the improvement in function of the diseased joints. At the stage of tuberculous arthritis, if abscess formation has not occurred, the natural outcome generally is a fibrous ankylosis. If an abscess discharges and sinuses develop, the outcome may be a bony ankylosis. The prognosis in articular tuberculosis depends on the stage of the disease. when the specific treatment is started. Concomitant disease must be treated and hospitalization is necessary only for patients with complications, or for patients requiring traction under supervision to correct deformities.

Category of treatment	Category of TB cases	Anti-TB drug regimens
Intensive phase	Continuation phase
I	New Patient Regimen New smear-positive PTB Smear-negative PTB with extensive Parenchymal involvement Severe forms of EPTB other than TB meningitis	2HRZE	4HR
II	New Patient Regimen Smear-negative PTB without extensive P Parenchymal involvement Less severe forms of EPTB (e.g., TB cervical adenitis)	2HRZ	4HR
III	New Patient Regimen TB meningitis	2HRZSa	4HR
IV	Retreatment regimen Previously treated smear-positive PTB (relapse, treatment after interruption or treatment failure) If low risk for MDR-TB or risk unknown, continue with retreatment regimen If high risk for MDR-TB, use MDR-TB regimen below	2HRZES/1HRZE	5HRE
V	MDR Regimen MDR-TB	Individualized regimens

Table 2: Treatment regimens for tuberculosis recommended by the WHO . Other regimens are recommended for the treatment of TB meningitis, including replacing streptomycin with ethionamide and treating for 9-12 months.
E: Ethambutol; EPTB: Extra-Pulmonary Tuberculosis; H: Isoniazid; HIV: Human Immunodeficiency Virus; MDR-TB: Multi-Drug Resistant Tuberculosis; PTB: Pulmonary Tuberculosis; R: Rifampicin; S: Streptomycin; Z: Pyrazinamide; 2HRZ 4HR: Denotes a Two-month Intensive Phase of Daily Isoniazid, Rifampicin, and Pyrazinamide followed by a Four-month Continuation Phase of Daily Isoniazid and Rifampicin  

Rest, Immobilization, and Braces

In the active stage of disease, the joints are rested in the position of function using removable splints. Prolonged immobilization can lead to spontaneous ankylosis when joints are grossly destroyed. Patients with early disease are allowed 1 to 2 hours of intermittent, guarded active and assisted exercises while taking antitubercular drugs, with the aim of retaining a useful range of movement in the functional arc of the involved joint. Traction helps to correct deformity and to rest the diseased part. Gradual ambulation is encouraged with the help of suitable braces approximately 3 months after the start of treatment while healing is progressing. As the disease heals and pain subsides, weightbearing and activity are permitted. If there is steady progress, activity is increased within the limits of discomfort. The use of a brace is discontinued gradually after approximately 2 years.

Treatment of Abscess, Effusion, and Sinus

Palpable and large joint effusions are aspirated and 1000 mg of streptomycin alone or combined with injectable isoniazid (300 mg) is instilled at each aspiration. Local concentrations of antibiotics after parenteral administration may make this local instillation unnecessary. Open drainage of an abscess is indicated if aspiration fails. Radiologically visible paravertebral abscess shadows do not need to be drained, unless decompression is done in patients with paraplegia or when diseased vertebrae are debrided. A prevertebral abscess in the cervical region is drained if it causes difficulty in swallowing or breathing. Drainage of a large paravertebral abscess also may be considered when its radiologic size increases markedly despite treatment.

A majority of ulcers and sinuses heal within 6 to 12 weeks under the influence of systemic antitubercular drugs. Less than 1% of patients with sinuses require longer treatment and excision of the tract, with or without debridement. Sinus ramification always is greater than can be appreciated and complete surgical excision therefore is impractical.

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Antitubercular Chemotherapy

Combination chemotherapy should be used for an adequate length of time. Most of the antitubercular drugs potentially are toxic and resistance or intolerance to the drugs should be suspected when a patient fails to respond.

Multidrug Resistant Tuberculosis and Patients Who do not Respond

If the disease is caused by organisms resistant to isoniazid and rifampicin (multidrug resistant tuberculosis), if the disease is not controlled within 4 to 5 months, or if despite multidrug therapy, more active tuberculous lesions appear, one has to resort to second line drugs or potential antituberculous drugs. The situation is desperate in patients who do not respond. Immunomodulation in conjunction with drugs may be used in such patients. A favorable response was reported in approximately 85% of patients.

Pending the availability of better immunomodulation techniques.the current author has evolved the following outline during the past 12 years to upgrade cell-mediated immunity. In brief, 150 mg of levamisol is given at night for 3 days at weekly intervals for a total of 45 tablets. Four injections are administered once a month. The first and second infections are 0.1 mL intradermal (Bacillus Calmett-Guérin) injections and the third and fourth are intramuscular DPT injections (diphtheria vaccine + tetanus vaccine + Bordetella pertussis 20,000 million per 0.5 mL).

Surgery in Patients with Tuberculosis of Bones and Joints

No surgery is a substitute for a prolonged course of antitubercular drugs. A trial of conservative treatment is justified in most patients before surgery is contemplated. Nonoperative treatment usually is adequate in patients with pure synovial tuberculosis, low-grade or early arthritis of any joint, and even advanced (Stage III or IV) arthritis, especially in the upper extremity.

Surgery only should be considered once the general condition of the patient is stabilized by drug therapy, before the development of drug resistance. In general, a minimum of 1 to 4 weeks of therapy is advisable before any major surgical intervention.

Relapse of Osteoarticular Tuberculosis or Recurrence of Complications

The incidence of relapse or recurrence is unknown because these complications may occur at any period during the lifetime of a patient, whether the initial treatment included excisional surgery. Reactivation may occur in 2% to 5% of patients as late as 20 years or more after apparent healing.

The causes of reactivation include prolonged use of systemic cortisone therapy, malnutrition, the development of diabetes or an immune deficiency state, or a surgical procedure or injury to the previously infected area. Dormant bacilli persisting in tissue for years may start multiplying under such circumstances.

Tuberculosis of the Spine

Vertebral tuberculosis accounts for 50% of all cases of skeletal tuberculosis. In the majority of patients, the disease typically started in the paradiscal region. Narrowing of the disc often is the earliest radiologic finding. Any reduction in disc space, if it is associated with a loss of definition of the paradiscal margins of the vertebrae, suggests tuberculosis and occurs before the appearance of frank osseous destruction. These changes usually are evident only after infection has been present for 3 to 6 months, although advanced imaging may detect changes at approximately 6 weeks.

Most cases of tuberculosis of the spine heal without surgical intervention. However, uncertainty about the diagnosis, progressive bone destruction, and neurologic symptoms despite chemotherapy are definite indications for surgery in the active stage of disease.

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Pott’s Disease, also known as tuberculosis spondylitis, is a rare infectious disease of the spine which is typically caused by an extraspinal infection. Pott’s Disease is a combination of osteomyelitis and arthritis which involves multiple vertebrae.  The typical site of involvement is the anterior aspect of the vertebral body adjacent to the subchondral plate and occurs most frequently in the lower thoracic vertebrae. A possible effect of this disease is vertebral collapse and when this occurs anteriorly, anterior wedging results, leading to kyphotic deformity of the spine.  Other possible effects can include compression fractures, spinal deformities and neurological insults, including paraplegia

Tuberculosis is an extremely infectious disease caused by the bacterium Mycobacterium tuberculosis. It’s one of the top-10 causes of death worldwide. Tuberculosis (TB) is most common in developing countries, but more than 9,000 cases were reported in the United States in 2016. Tuberculosis is preventable, and if it’s contracted and discovered early, it’s generally treatable.

TB primarily affects the lungs, but in some cases it can spread to other parts of the body. When TB spreads, it’s referred to as extrapulmonary tuberculosis (EPTB). One form of EPTB is bone and joint tuberculosis. Bone tuberculosis is simply a form of TB that affects the spine, the long bones, and the joints.

In the United States, only about 3 percent of all TB cases affect the musculoskeletal system. Of those cases, the spine is most commonly affected. Therefore, if you have bone TB, you are more likely to have it in or on your spinal column. However, bone TB could potentially affect any bone in your body. A common form of spinal bone TB is known as Pott’s disease.

Prevalence

Incidence
In 2005, there were 8.8 million new patients with tuberculosis (TB) all over the world, and of these, 7.4 million were in Asia and sub-Saharan Africa. Involvement of the spine reportedly occurs in less than 1-2% of patients who contract TB. Although the incidence of tuberculosis increased in the late 1980’s to early 1990’s, the total number of cases has decreased in recent years. In the United States, bone and soft tissue tuberculosis accounts for approximately 10% of extrapulmonary TB cases and between 1% and 2% of total cases. Of these cases, Pott’s disease is the most common manifestation of musculoskeletal TB, accounting for approximately 40-50%. Internationally, approximately 1-2% of total tuberculosis cases are attributable to Pott’s disease.

Ethnicity
Data from the United States show that musculoskeletal tuberculosis primarily affects African Americans, Hispanic Americans, Asian Americans, and foreign-born individuals.  The number of patients with TB spondylitis in Japan also declined to 233 in 2005 from 734 in 1978 and 276 in 2001.

Gender
Although some studies have found that Pott’s disease does not have sexual predilection, the disease is more common in males. The male to female ratio is reportedly 1.5-2:1.

Age
In the United States and other developed countries, Pott’s disease occurs primarily in adults. In underdeveloped countries which have higher rates of Pott’s disease, involvement in young adults and older children predominates.

causes

Tuberculosis is normally spread from person to person through the air. After you contract tuberculosis, it can travel through the blood from the lungs or lymph nodes into the bones, spine, or joints. Bone TB typically begins due to the rich vascular supply in the middle of the long bones and the vertebrae.

Bone tuberculosis is relatively rare, but in the last few decades the prevalence of this disease has increased in developing nations partially as a result of the spread of AIDS. While rare, bone tuberculosis is difficult to diagnose and can lead to severe problems if left untreated.

Characteristics/Clinical Presentation

Spinal Involvement

• Lower thoracic vertebrae is the most common area of involvement (40-50%), followed by the Lumbar spine (35-45%)
• Approximately 10% of Pott’s disease cases involve the cervical spine.
• The thoracic spine is involved in about 65% of cases, and the lumbar, cervical and thoracolumbar spine in about 20%, 10% and 5%, respectively
• The atlanto-axial region may also be involved in less than 1% of cases

Physical Findings

• Localized Tenderness
• Muscle Spasms
• Restricted Spinal Motion
• Spinal Deformity
• Neurological Deficits

Back Pain

Back pain is the earliest and most common symptom. Patients with Pott’s disease usually experience back pain for weeks before seeking treatment and the pain caused by spinal TB can present as spinal or radicular. Although both the thoracic and lumbar spinal segments are nearly equally affected, the thoracic spine is frequently reported as the most common site of involvement. Together, thoracic and lumbar involvement comprise of 80-90% of spinal TB sites.

Neurological Signs

Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with the following: 

• Paraplegia
• Paresis
• Impaired sensation
• Nerve root pain
• Cauda equina syndrome

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Spinal Deformities

Almost all patients with Pott’s disease have some degree of spine deformity with thoracic kyphosis being the most common.

Constitutional Symptoms

• Fever
• Night sweats
• Weight loss 
• Malaise

Cervical Spinal TB

Cervical spine TB is a less common presentation occurring in approximately 10% of cases, but is potentially more serious because severe neurological complications are more likely. This condition is characterized by cervical pain and stiffness and symptoms can also include torticollis, hoarseness, and neurological deficits. Upper cervical spine involvement can cause rapidly progressive symptoms and neurologic manifestations occur early, ranging from a single nerve palsy to hemiparesis or quadriplegia. Retropharyngeal abscesses occur in almost all cases. In lower cervical spine insults, the patient can present with dysphagia or stridor.

Presentation in People Infected with HIV

The clinical presentation of spinal tuberculosis in patients infected with the human immunodeficiency virus (HIV) is similar to that of patients who are HIV negative; however, spinal TB seems to be more common in persons infected with HIV.

Asymptomatic Presentation

62-90% of patients with Pott’s disease are reported to have no evidence of extraspinal tuberculosis, further complicating a timely diagnosis.

Diagnostic Tests/Lab Tests/Lab Values

The Mantoux Test (Tuberculin Skin Test)
Injection of a purified protein derivative (PPD). Results are positive in 84-95% of patients with Pott’s disease who are not infected with HIV.

Erythrocyte Sedimentation Rate (ESR)
ESR may be markedly elevated (>100 mm/h)

Microbiology Studies
Microbiology studies are used to confirm diagnosis. Bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft tissue structures; however, these study findings are positive in only about 50% of the cases.

Radiography
Radiographic changes associated with Pott’s disease present relatively late. The following are radiographic changes characteristics of spinal tuberculosis on plain radiography:

• Lytic destruction of anterior portion of vertebral body
• Increased anterior wedging
• Collapse of vertebral body
• Reactive sclerosis on a progressive lytic process
• Enlarged psoas shadow with or without calcification
• Vertebral end plates may be osteoporotic
• Intervertebral disks may be shrunk or destroyed
• Vertebral bodies show variable degrees of destruction
• Fusiform paravertebral shadows suggest abscess formation
• Bone lesions may occur at more than one level

CT Scanning
CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk collapse, and disruption of bone circumference. Low contrast resolution provides a better assessment of soft tissue, particularly in epidural and paraspinal areas. CT scanning reveals early lesions and is more effective for defining the shape and calcification of soft tissue abscesses which is common in TB lesions.

MRI
MRI is the criterion gold standard for evaluating disk-space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissue and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments. MRI is also called the most effective imaging study for demonstrating neural compression. MRI findings useful to differentiate tuberculosis spondylitis from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and well-defined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis.

               MRI of the thoracic spine (T2-weighted, sagittal reconstruction). The dorsal fluid collection suggests a 

          paravertebral abscess (large arrow) just above the fractured and operated third thoracic vertebra (small arrow)

Biopsy
Use of a percutaneous CT-guided needle biopsy of bone lesions can be used to obtain tissue samples. This is a safe procedure that also allows therapeutic drainage of large paraspinal abscesses.

Polymerase Chain Reaction (PCR)
PCR techniques amplify species-specific DNA sequences which is able to rapidly detect and diagnose several strains of mycobacterium without the need for prolonged culture. They have also been used to identify discrete genetic mutations in DNA sequences associated with drug resistance

Bone tuberculosis treatment

While bone tuberculosis can lead to some painful side effects, the damage is usually reversible when treated early with the right regimen of medications. In many cases, spinal surgery is necessary, such as a laminectomy (where a part of the vertebrae is removed).

Medications are the first line of defense for bone tuberculosis, and the course of treatment can last anywhere from 6–18 months. Treatments include:

• antituberculosis medications, such as rifampicin, isoniazid, ethambutol and pyrazinamide
• surgery

Medications

The duration of treatment is somewhat controversial. Although some studies favor 6 to 9 month course, traditional courses range from 9 months to longer than 1 year. The duration of therapy should be individualized and based on the resolution of active symptoms and the clinical stability of the patient.

The main drug class consists of agents that inhibit growth and proliferation of the causative bacteria. Isoniazid and rifampin should be administered during the whole course of therapy. Additional drugs are administered during the first two months of therapy and these are generally chosen among the first-line drugs which include pyrazinamide, ethambutol, and streptomycin. The use of second-line drugs is indicated in cases of drug resistance.

Isoniazid (Laniazid, Nydrazid)
Highly active against Mycobacterium tuberculosis. Has good GI absorption and penetrates well into all body fluids and cavities.

Rifampin (Rifadin, Rimactane)
For use in combination with at least one other antituberculous drug; inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur.

Pyrazinamide
Bactericidal against M tuberculosis in an acid environment (macrophages). Has good absorption from the GI tract and penetrates well into most tissues, including CSF.

Ethambutol (Myambutol)
Has bacteriostatic activity against M tuberculosis. Has good GI absorption. CSF concentrations remain low, even in the presence of meningeal inflammation.

Streptomycin
Bactericidal in an alkaline environment. Because it is not absorbed from the GI tract, must be administered parenterally. Exerts action mainly on extracellular tubercle bacilli. Only about 10% of the drug penetrates cells that harbor organisms. Enters the CSF only in the presence of meningeal inflammation. Excretion is almost entirely renal.

Physical Therapy Management (current best evidence)

Patients with Pott’s disease often undergo spinal fusion or spinal decompression surgeries to correct their structural deformity and prevent further neurological complications. There are no established guidelines which dictate treatments that will yield positive outcomes in such patients.  However, treatment regimens should address each patient individually, focusing on any impairments, functional limitations and/or disabilities with which they present.

PT Managment Post-Spinal Decompression Surgery

• Spinal Stabilization Exercises
• Maitland
• Back School
• Exercise and Strengthening

When compared with other physical therapy treatments and self-managment, spinal stabilization exercises were found to produce significantly more positive ratings in global outcomes. Pain and disability, however, did not show significant improvement when compared to the other two treatment options.

PT Managment Post-Spinal Fusion Surgery

• TENS (Transcutaneous Electrical Neuromuscular Stimulation)
• Aquatic Therapy
• Overground Training (Walking Program)
• Aerobic Exercise
• Trunk Strengthening

Studies examining the use of TENS have shown higher frequencies are more effective in decreasing neuropathic pain. Aerobic exercise, PT, and trunk strengthening interventions have all attained significant decreases in pain, psychological distress and disability.

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Volkmann contracture is a deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm. The condition is also called Volkmann ischemic contracture.

A Volkmann’s contracture is deformity of the hand, fingers, and wrist which occurs as a result of a trauma such as fractures, crush injuries, burns and arterial injuries. Following this trauma, there is a deficit in the arterio-venous circulation in the forearm which causes a decreased blood flow and hypoxia can lead to the damage of muscles, nerves and vascular endothelium. This results in a shortening (contracture) of the muscles in the forearm.

Causes

Volkmann contracture occurs when there is a lack of blood flow (ischemia) to the forearm. This occurs when there is increased pressure due to swelling, a condition called compartment syndrome.

Injury to the arm, including a crush injury or fracture, can lead to swelling that presses on blood vessels and decreases blood flow to the arm. A prolonged decrease in blood flow injures the nerves and muscles, causing them to become stiff (scarred) and shortened.

When the muscle shortens, it pulls on the joint at the end of the muscle just as it would if it were normally contracted. But because it is stiff, the joint remains bent and stuck. This condition is called a contracture.

In Volkmann contracture, the muscles of the forearm are severely injured. This leads to contracture deformities of the fingers, hand, and wrist.

There are three levels of severity in Volkmann contracture:

• Mild — contracture of 2 or 3 fingers only, with no or limited loss of feeling
• Moderate — all fingers are bent (flexed) and the thumb is stuck in the palm; the wrist may be bent stuck, and there is usually loss of some feeling in the hand
• Severe — all muscles in the forearm that both flex and extend the wrist and fingers are involved; this is a severely disabling condition. There is minimal movement of the fingers and wrist.

Conditions that can cause increased pressure in the forearm include:

• Animal bites
• A forearm fracture
• Bleeding disorders
• Burns
• Injection of certain medicines into the forearm
• Injury of the blood vessels in the forearm
• Surgery on the forearm
• Excessive exercise — this would not cause severe contractures

Signs and symptoms

The clinical presentation includes the five Ps:

• Pain (earliest manifestation), especially accentuated by passive stretching
• Pallor
• Pulselessness
• Paresthesias
• Paralysis

Additional useful findings are as follows:

• Firmness of the tissues on palpation
• Induration of the forearm

The clinical presentation of Volkmann`s contracture includes what is commonly referred to as the 5 Ps. These are pain, pallor, pulselessness, paresthesias, and paralysis. Pain is the earliest sign

Special findings:

• Bleach view at the level of the skin (pallor).
• The wrist is in palmar flexion
• Clawed fingers
• Pain occurs with passive stretching of the flexor
• Palpation of the affected region creates persistent pain (pain)
• It is possible that the pulsations can not be felt in the swollen arm, mainly in the distal part (pulselessness).
• There are also neurological limitations noticeable from the muscles that pinch the neural pathways, there is a decreased sensation (paresthesia) and there is an observable motor deficit (paresis)

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Diagnostic Procedures

Pressure monitoring

Intracompartmental pressure (ICP) can be measured by several means including:

• Wick catheter
• Simple needle manometry
• Infusion techniques
• Pressure transducers
• Side-ported needles

Critical pressure for diagnosing compartment syndrome is unclear

Different authors consider surgical intervention if:

• Absolute ICP greater than 30 mmHg
• Difference between diastolic pressure and ICP greater than 30 mmHg
• Difference between mean arterial pressure and ICP greater than 40 mmHg

Differential Diagnosis

Pseudo-Volkmann’s contracture

Examination

For a Volkmann’s contracture, the findings are specific as described in the clinical presentation subheading above. The main physical picture that we see is a neurological deficit that occurs in the nerves that pass in the affected regions. The flexion of the wrist is a result of contracture and a loss of innervation.

The deformity seen in this condition can be divided into different levels of severity:

1. MILD: Flexion contracture of 2 or 3 fingers with no or limited loss of sensation
2. MODERATE: All fingers are flexed and the thumb is oriented in the palmar orientation. The fist, in this case, can remain permanently flexed and there is usually a loss of sensation in the hand.
3. SERIOUS: All muscles in the forearm (flexors and extensors) are involved. This is a serious limiting condition.

An objective test to evaluate the ischemia and the pressure in a muscle compartment is an invasive test. It measures the absolute pressure in the compartment of the muscle. This is also called the intracompartimental pressure monitoring (ICP)

Medical Management

Prevention is the best management in this condition. However, there are times, that surgical intervention will be indicated. The majority of Volkmann’s contractures are caused by a supracondylar fracture, and it is essential that all steps are taken to improve the healing of the fracture. When there is an intra-compartment pressure (ICP) of >30 mmHg,an urgent fasciotomy is recommended to avoid further complications, Raised ICP threatens the viability of the limb and compartment syndrome (CS) represents a true medical emergency. Thus, the need for decompression by removal of all dressing down to the skin, followed by fasciotomy- Surgical opening of the fascia around the muscles to make more place for the structures inside. This is done to prevent the onset of Volkmann’s contractures.

In moderate Volkmann’s contracture, tendon slide and neurolysis surgery should be performed (median and ulnar) along with extensor transfer procedures.

Finally, in severe cases of Volkmann’s contracture, debridement of injured muscle may be performed with releases of scar tissue and salvaging procedures. Range of motion and function after injury are improved by physical and occupational therapy.

Physiotherapy Management

After the surgery, it is important to ensure that the mobility is recovered by:

• Passive stretching techniques
• Range of motion exercises to enhance soft tissue elasticity.

Another part of the therapy programme involves activating and strengthening the weak agonist to ensure equilibrium in agonist and antagonist pull during joint movement.

Progressive Splinting, passive stretching and tendon gliding, as well as massage can be used in mild to moderate cases of Volkmann’s contracture.

By the use of an electromyographic device, the patient can train its affected muscles with cooperativity. The patient is more alert and there is more interaction between the patient and the therapist.

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Monteggia fracture-dislocations consist of a fracture of the ulnar shaft with concomitant dislocation of the radial head. The ulnar fracture is usually obvious, whereas the radial head dislocation can be overlooked, with potentially serious functional and medico-legal ramifications. 

The eponym Monteggia fracture is most precisely used to refer to a dislocation of the proximal radioulnar joint (PRUJ) in association with a forearm fracture, most commonly a fracture of the ulna. These injuries are relatively uncommon, accounting for fewer than 5% of all forearm fractures. The mechanism of injury is most often a fall on an outstretched hand.

The ulna fracture is usually clinically and radiographically apparent. Findings associated with the concomitant radial head dislocation are often subtle and can be overlooked. The keys to successful diagnosis of a Monteggia fracture are clinical suspicion and radiographs of the entire forearm and elbow. Properly assessing the nature of this injury in a timely fashion is imperative in order to prevent permanent disability or limb dysfunction.

Anatomy

The annular and radial collateral ligaments stabilize the radial head. These ligaments stretch or rupture during radial head dislocation. The radial head articulates with the humeral capitellum and the radial notch of the proximal ulna. The radius and ulna are closely invested by the interosseous membrane, which accounts for the increased risk of displacement or injury to the radius when the ulna fractures.

The distal ulna and radius also articulate at the DRUJ. The ulna provides a stable platform for rotation of the radius and forearm. The ulna and interosseous membrane also may provide stable platforms for dislocation of the proximal radius, leading to the Monteggia fracture.

The posterior interosseous nerve travels around the neck of the radius and dives under the supinator as it courses into the forearm. The median and ulnar nerves enter the antecubital fossa just distal to the elbow. The close proximity of these nerves may lead to injuries when a Monteggia fracture occurs. Neural injuries are generally traction injuries and result from stretching around the displaced bone or from energy dispersed during the initial injury.

Etiology

Monteggia fractures are primarily associated with falls on an outstretched hand with forced pronation. If the elbow is flexed, the chance of a type II or III lesion is greater. In some cases, a direct blow to the forearm can produce similar injuries.

Evans in 1949 and Penrose in 1951 studied the etiology of Monteggia fractures on cadavers by stabilizing the humerus in a vise and subjecting different forces to the forearm. Penrose considered type II lesions a variation of posterior elbow dislocation. Bado believed that the type III lesion, the result of a direct lateral force on the elbow, was primarily observed in children.

In essence, high-energy trauma (eg, a motor vehicle collision) and low-energy trauma (eg, a fall from a standing position) can result in the described injuries. A high index of suspicion, therefore, should be maintained with any ulna fracture.

Pathophysiology

The forearm structures are intricately related, and any disruption to one of the bones affects the other. The ulna and radius are in direct contact with each other only at the PRUJ and the DRUJ; however, they are unified along their entire length by the interosseous membrane. This allows the radius to rotate around the ulna. When the ulna is fractured, energy is transmitted along the interosseous membrane, displacing the proximal radius. The end result is a disrupted interosseous membrane proximal to the fracture, a dislocated PRUJ, and a dislocated radiocapitellar joint.

Radial head dislocation may lead to radial nerve injury. The posterior interosseous branch of the radial nerve, which courses around the neck of the radius, is especially at risk, particularly in Bado type II injuries. Injuries to the anterior interosseous branch of the median nerve and the ulnar nerve also have been reported. Most nerve injuries are neurapraxias and typically resolve over a period of 4-6 months. Splinting of the wrist in extension and finger range-of-motion (ROM) exercises help prevent contractures from developing while the patient awaits resolution of the nerve injury.

Classification

In 1814, Giovanni Battista Monteggia of Milan first described this injury as a fracture to the proximal third of the ulna with associated anterior dislocation of the radial head. Interestingly, he described this injury pattern in the pre-Roentgen era solely on the basis of the history of injury and the physical examination findings. However, this particular fracture pattern only accounts for about 60% of these types of injuries.

More than 150 years later, in 1967, Bado coined the term Monteggia lesion and classified the injury into the following four types:

• Type I – Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head
• Type II – Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head
• Type III – Fracture of the ulnar metaphysis with lateral dislocation of the radial head
• Type IV – Fracture of the proximal or middle third of the ulna and radius with anterior dislocation of the radial head

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Treatment and prognosis

All four types of Monteggia fracture-dislocations (see Bado classification) are treated with open reduction and internal fixation of the ulna and radius in type 4. Usually anatomical reduction of the ulna allows for a closed reduction of the radial head.  Types I, III, IV are cast at 110 degrees of flexion, whereas type II is cast at 70 degrees of flexion ^4,6.

In the pediatric population, treatment depends on the type of ulnar fracture: ^7,8

• bowing/greenstick fracture: closed reduction of the ulnar bow and casting. If reduction of the radial head is not possible open osteotomy and fixation of the ulna may be required
• complete transverse/short oblique fracture: closed reduction and intramedullary fixation
• long oblique/comminuted fracture: open reduction and internal fixation

The prognosis is significantly decreased by delayed diagnosis and treatment.

Approach Considerations

Pain should be managed as needed in the immediate period. If the fracture is open, the status of the patient’s tetanus immunization should be determined and addressed as indicated. Intravenous (IV) antibiotics should be administered to patients with open fractures. Open wounds should be irrigated with sterile saline solution and dressed with sterile, moist gauze. The radial head should be reduced in the emergency department (ED) if possible.

Nonoperative treatment is successful for most Monteggia injuries in children, for the following reasons :

• The majority of the fractures are inherently stable
• Children require a shorter time for both the osseous and the ligamentous injuries to heal
• Children have little trouble regaining motion lost through stiffness, despite immobilization of the fractures for the duration of the initial healing period (3-6 weeks)
• The potential may exist for remodeling of mild residual angular deformities (< 10°)

Indications for treatment of Monteggia fractures are based on the specific fracture pattern and the age of the patient (ie, pediatric or adult).  Although most pediatric fracture patterns can be managed conservatively with closed reduction and long arm casting, most adult fractures require open reduction and internal fixation (ORIF).  Few contraindications for surgery exist. Once the radial head is reduced in closed injuries, surgical treatment may be delayed until the patient is stable and the surgery may be performed in a more elective fashion.

Surgical Therapy

Open fractures require emergency surgical consultation. The initial treating physician may reduce the radial head dislocation and splint this fracture. Otherwise, an orthopedic surgeon should be consulted immediately to reduce the radial head. Anatomic reduction of the ulna is usually required before radial head reduction. Unless the fracture is open, surgical treatment is performed on an elective basis. Whereas most adults require operative treatment, most pediatric fractures are treated with closed reduction.

Operative fixation of complete fractures of the ulna with proximal radioulnar joint (PRUJ) dislocation is recommended in children. The complete disruption of bone continuity is likely to be associated with substantial soft-tissue trauma in these injuries. Shortening and angulation of complete fractures after cast immobilization is not uncommon. Anatomic reduction of the ulnar fracture and radial head often requires operative treatment.

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Diagnostic Procedures

Displaced Supracondylar fracture in X-ray

Radiographs should include true AP of distal humerus (not elbow) and true lateral elbow views.If there is only minimal or no displacement these fractures can be occult on radiographs. The only sign will be a positive fat pad sign.

On lateral view

The lateral view also allows assessing the degree of displacement and the integrity of the posterior cortex.

On the lateral view, the following radiological parameters are looked for: (a) Anterior humeral line; (b) Coronoid line; (c) Fish tail sign; (d) Fat pad sign; (Anterior and Posterior).

Anterior Humeral Line Abnormal

Anterior humeral line to capitulum orientation on a lateral view

• Normal elbow – line continues the anterior cortical of the humerus and should traverse the capitulum in its middle third line.
• Extension type injury: capitulum posterior to line
• Flexion type injury: capitulum anterior to the line

On AP view

It helps to evaluate the direction of displacement, the presence of varus or valgus alignment, and the extent of the fracture comminution.

The Baumann angle (Humeral capitular angle) on AP view

• Angle between linea perpendicular to longthe axis of humeral shaft and the physeal line of the capitulum, isused to assess varus or valgus alignment of the distal humerus.
• Normal range – 64º to 82º degrees
• Decrease in angle – varus angulated fracture with possible medial column comminution

The Ulnohumeral angle or radiological carrying angle on AP view

• The angle formed by the diaphyseal axis of the humerus and the axis of the proximal third of the ulna.
• It is also used to assess varus or valgus deformity and it is more accurate and useful than Baumann’s angle 

Management / Interventions

Medical

Management of supracondylar fracture is determined based on the type of fracture based on Modified Gartland Classification.

Type I ( Non-displaced fracture)

• Immobilization with a long-arm cast or splint.
• With elbow flexion up to 80° to 90° and mid pronation-supination are well toleratable for ~3weeks.
• Flexion of the elbow within the cast should not pass 90° because it can increase forearm pressures and impede distal vascular flow.
• Radiographic check at 1 and 2 weeks

Types II

• A closed reduction(CR) and percutaneous pinning fixation is recommended than CR and immobilization as the risk of complication are low. Pins are removed in the hospital approximately three weeks after surgery.

Type III and Type IV

• Closed reduction and percutaneous pinning is the gold standard for all displaced fractures and is widely used in Type III and IV fractures.
• Open reduction is indicated:

1. When the surgeon is not able to reduce the fracture by closed means
2. When there is soft-tissue entrapment (i.e. muscle, median nerve, brachial artery) or
3. When a cold hand remains without perfusion after an attempt at closed reduction has been performed.

There is an increased incidence of infection, stiffness, and myositis ossificans in open reduction. The anterior approach is the most widely used approach for open reduction mainly when vascular repair is necessary. The lateral approach is standard for elbow surgery but in supracondylar fracture increases the risk of radial nerve injury and stiffness. The bilaterotricipital posterior approach (Alonso-Llames approach) is not recommended as it has a high rate of complications described, such as stiffness, unsightly scarring and risk of trochlea osteonecrosis.

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Physiotherapy Management

Physiotherapy treatment is vital in all patients with a supracondylar fracture to hasten healing and ensure an optimal outcome. The goal of physiotherapy treatment is:

• To achieve painless and full mobility of the elbow joint.
• To enhance healing process.
• To strength the affected musculature.
• To improve overall functional abilities of children.
  

Outcome measures that can be used to compare and evaluate the outcome of treatment are :

• Numerical pain rating scale (NPRS)/ Faces Pain Scale
• Range of motion- Goniometry
• Manual muscle testing ( MMT)
• ASK-p (Activities Scale for Kids-performance version)
• Flynn’s criteria include two factors ‘cosmetic factor’ (loss of carrying angle) and ‘Functional factor’ (motion loss in degrees).
• Neuro-vascular assessment is must post-operatively and during rehabilitation.

Evidence

The physical therapy management in the pediatric population is very controversial, in both its effect and its necessity. A randomized controlled trial was done by Schmale et al. in 2014, had shown that children with supracondylar fracture treated with either casting or CR with percutaneous pining followed by casting were not benefited by a short course of physical therapy (six sessions of physical therapy performed over a five-week period beginning the week after cast removal) in terms of either return of function or motion.Supporting the above study, another study was done in 2018, also shows that children managed with CR for uncomplicated supracondylar fracture with immobilization for three weeks regain their functional ROM within 12 weeks of mobilization by themselves, with no added benefit from physiotherapy.

Physiotherapy treatment has not shown significant difference, it may be due to the involvement of children of a ( 5- 10 years) in more involved in daily household activities from an early period and urge for a motion for playing. It would be either affected as the therapist may have been unduly aggressive or unduly conservative while providing treatment.

On the contrary, in a more severe type of injury with neurovascular involvement and in an adult patient, physiotherapy treatment has a significant role.And in the pediatric population, evidence has been lacking to address the strength of upper extremity as an outcome after physiotherapy treatment.

Therefore,

• Optimal loading(pain-free activities based on a child) is very necessary for the pediatric population with supracondylar fracture as pain aggravating activities may delay the healing process and cause further damage as they are in the growing phase.
• Thus, active exercise and active involvement in sports and ADLs are recommended rather than passive joint mobilization and stretching exercises.
• Those activities such as lifting, weight-bearing, or pushing activities that pose large amounts of stress through the humerus should also be avoided in the initial week after immobilization removable.
• Progressive strengthening exercises can be addressed.

Advice and Exercises During the Immobilization Period

• Normally elbow is immobilized for 3 weeks so, during that period, adjacent joints ( Shoulder joint and wrist joint and hand) should be kept moving active or active-assisted exercises frequently in a day.
• Elbow shouldn’t be moved and used of arm sling should be proper.
• Postural training( sitting upright with relaxed shoulder and retraction of the scapula) should be taught.

1-2 Weeks After Removal of Cast

• Hot fermentation can be used to ease joint stiffness.
• Gentle soft tissue release can be done in arm and forearm musculature.
• Gentle active and active-assisted exercises using a wand and be taught in pain- free limit- frequently in a day.
• Isometric exercises for arm and forearm musculature can be addressed.
• Educate parents and child to use the affected hand to use in daily activities like brushing, writing, eating, dressing, etc.
• Avoid weight lifting and pushing activities.

Advice and Exercise After 2 Weeks of Cast Removal

• Progressive and interactive range of motion exercise and strengthening exercise should be addressed eg: passing a ball, dressing and undressing clothes.

Conclusion

• Supracondylar fractures of the humerus are the most frequent fractures in children with a peak incidence at the ages of five to eight years.
• FOOSH is the most mechanism of injury of Supracondylar fracture of the humerus.
• The Neurovascular assessment is must pre and post-operatively.
• Closed reduction with percutaneous pinning is the recommended medical management for displaced fracture without neurovascular involvement.
• Active exercise is recommended in pediatric elbow fracture rather than passive treatment.

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