DOCSLIB.ORG

Orthopedic Follow-Up Evaluations: Identifying Complications Duane A

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Orthopedic Follow-Up Evaluations: Identifying Complications Duane A PEER REVIEWED RECOVERY & REHAB ORTHOPEDIC FOLLOW-UP EVALUATIONS: IDENTIFYING CoMPLICATIONS Duane A. Robinson, DVM, PhD University of California–Davis rthopedic procedures, whether BONE HEALING tions, immediately after fracture occur- performed on an elective or In veterinary medicine, the majority of rence, bone union begins by: Ourgent/emergent basis, are fractures heal via stabilization of frac- • Accumulation of blood from perios- common in small animal veterinary ture fragments by development of a teal, endosteal, and marrow sources, patients. In many instances, definitive callus, followed by endochondral ossi- which forms a fracture hematoma treatment occurs at a referral center, fication, which results in formation of • Development of a soft tissue envelope, with postoperative follow-up taking new bone. More specifically, healing of which surrounds the fracture site and place at the primary care clinic. bone can occur via direct (primary)— delivers the needed blood supply to During the recovery period, the pri- divided into gap or contact healing— the healing bone until the endosteal, mary care veterinarian needs to be able or indirect (secondary) bone healing.1,2 periosteal, and marrow blood sup- to identify complications in order to in- ply sources are reestablished. tervene as soon as possible. This article Direct Bone Healing The phase described above is the reviews basic guidelines and provides Clinically, direct (primary) healing oc- tools regarding identification of com- curs via a combination of contact and plications that may occur in adult pa- gap healing,1 and requires rigid inter- tients recovering from orthopedic pro- nal fixation. cedures. Contact direct healing describes sit- uations in which: COMMON ORTHOPEDIC • Fracture/osteotomy surfaces are in PROCEDURES direct contact Stabilization techniques for rupture of • Interfragmentary motion is not pres- the cranial cruciate ligament are un- ent doubtedly one of the most common • Fragments are usually under com- orthopedic procedures performed on pression. an elective basis; these procedures in- Gap direct bone healing occurs clude: when an interfragmentary gap of < 1 • Tibial plateau leveling osteotomy mm is present. (TPLO) • Tibial tuberosity advancement (TTA) Indirect Bone Healing • Lateral imbrication suture (lateral Indirect (secondary) bone healing is femoral fabellotibial suture). common in patients with nonrecon- The TPLO and TTA procedures re- structable fracture configurations, in quire an osteotomy and normal bone which biologic fixation (biological os- healing for a successful outcome. teosynthesis) methods are used. These Fracture repairs are a group of ortho- methods minimize the extent to which Figure 1. Radiograph of comminuted pedic procedures that are particularly the fracture site/callus and its blood radius and ulna fracture at time of injury challenging because normal healing is supply are approached and disturbed (A) and approximately 8 weeks later, dependent on a multitude of factors. (Figure 1). Examples of biologic fixa- after removal of failed external fixator (B). For example: tion methods include the use of mini- This fracture is an example of a delayed • What was the fracture configuration? mally traumatic surgical approaches union; note extensive callus formation. • What repair method was used? (eg, closed alignment using an intra- While fracture is not healed, it also • What is the patient’s signalment? medullary pin), external fixator sys- provides an excellent example of indirect • Are any comorbidities present and, if tems, and cancellous bone grafting. (secondary) bone healing. Courtesy UC– so, will they affect fracture healing? Under indirect bone-healing condi- Davis VMTH tvpjournal.com September/October 2014 Today’s Veterinary Practice 71 | RECOVERY & REHAB reactive phase, which includes the inflammatory and gran- body reduces strain is to increase the original gap length ulation phases, and it is followed by the reparative and re- by osteoclastic resorption.1,2 Therefore, during an early (ie, modeling phases. While the initial phases are relatively 6–8 weeks after repair) follow-up radiograph, the fracture short lived, the remodeling phase may continue for years.1 Interfragmentary Strain Bone healing is also influenced by interfragmentary strain—a measure of the deformation that occurs in the area between fracture ends (Figure 2). The smaller the gap between the fragments, the greater the amount of strain that will occur with a given degree of deformation. Bone formation requires low strain levels. Orthopedic implants (ie, plate and screw, interlocking nail) are designed to decrease the amount of deformation at the fracture ends. Limiting the amount of deformation decreases interfragmentary strain, which is important be- cause, in order for bone formation to occur via gap direct Figure 2. Strain is the change in gap length divided by bone healing, the strain in the fracture gap must be less than original gap length. This graphical depiction of strain 2% (Figure 2).1 demonstrates how osteoclastic resorption increases The clinical manifestation of this concept is somewhat the initial fracture gap and, as a result, decreases counterintuitive. For example, one method by which the interfragmentary strain to a point where bone will form. TABLE 1. Failure to Achieve Clinical Union of Fragments: Definition, Clinical Signs, & Approach DEFINITION CLINICAL SIGNS APPROACH DELAYED Fracture in which healing is 8- to 12-weeks postrepair: Every 4 to 6 weeks: UNION prolonged, but is anticipated • No instability at fracture site • Physical examination to eventually occur • Minimal to no pain on palpation of • Radiographic evaluation fracture site • Minimal lameness; any lameness present should be improving NONUNION Fracture that fails to heal regardless of time since repair Viable Fracture typically affected by • Clinical instability may be noted at • Rigid fixation (required) motion and/or lack of ade- fracture site; with loose implants, • Removal of fibrous tissue at fracture quate mechanical stability; may be gross instability site following are present: • Significant pain on palpation, or • Restoration of medullary cavity • Adequate biologic with use of limb • Implant removala environment • Worsening lameness • Bone graft • Healing response • Migrating broken implants may • Culture of bone/implants; treatment • Excessive callus formation protrude through skin based on results around fracture site • Muscle atrophy and/or stiffness Nonviable Fracture that fails to heal • Instability may be noted at the • Prevention often easier than repair accompanied by cessation fracture site • Surgery to remove any fibrous/other of osteogenic activity; • Pain on palpation of surgery site tissue present within fracture; minimal fracture site is avascular and and with limb use soft tissue damage, graft, and rigid biologically inactive • Static nonweight-bearing lame- fixation are keyb ness typical • Culture of bone and implants; • Fistula/draining tract may be pres- treatment directed by culture results ent (necrotic cases) • If infected, consider sterile • Severe muscle atrophy antimicrobial impregnated material • Significant loss of joint mobility/ (ie, polymethylmethacrylate, plaster of range of motion Paris beads) MALUNION Fracture that heals but normal • Mild cases: May be difficult to Goal of treatment is to restore limb to form and function of limb is detect any abnormality clinically normal angular and torsional anatomy; not restored • Severe cases: Angular or torsional new bone formation that occurs during deformity apparent and originates healing can distort normal anatomy; thus, at fracture site thorough planning and, in some cases, 3-dimensional planning via CT imaging necessary a. For example, if converting from external fixator to plate, remove all fixator components b. Surgery involves (1) opening medullary cavity; (2) en bloc removal of affected bone ends, compression of ends using plate and screw fixa- tion (optimal); (3) autologous and/or allogeneic bone graft (essential); (4) if available, consider rhBMP-2 72 Today’s Veterinary Practice September/October 2014 tvpjournal.com RECOVERY & REHAB | NS O TI gap may be wider than it was initially, but this is considered COMPLICATIONS OF BONE HEALING CA normal (Figure 3). However, if such a gap is noted during Despite veterinarians’ best efforts, complications occur in LI subsequent radiographic evaluations, it is considered a com- bone healing, resulting in increased morbidity for patients plication in healing. and increased economic burden for clients.3 Examples of OMP As it heals, an unstabilized fracture or a fracture that is such complications include: being addressed using indirect (secondary) bone healing can • Failure to achieve functional clinical union of fragments YING C decrease strain by both formation of a fracture callus (which (Tables 1 and 2) F stabilizes the fracture and, therefore, decreases deformation) • Osteomyelitis 1,2 and osteoclastic resorption. • Bone-implant construct failure (construct can fail due to ENTI problems with the implant or bone, or implant attach- ID ment to the bone) NS: • O A B Fracture disease (eg, atrophy, stiffness, adhesions). For most orthopedic cases, follow-up clinical evaluations TI with radiographs are generally recommended 6 to 8 weeks UA after surgery; further follow-up depends on the specific L needs of the patient. However, in situations with precarious EVA fixations or concern regarding client compliance after sur- P gery, radiographs
Load more

Recommended publications
  • Systemic Therapy of Mscs in Bone Regeneration: a Systematic Review and Meta-Analysis Jingfei Fu, Yanxue Wang, Yiyang Jiang, Juan Du, Junji Xu* and Yi Liu*
    Fu et al. Stem Cell Research & Therapy (2021) 12:377 https://doi.org/10.1186/s13287-021-02456-w REVIEW Open Access Systemic therapy of MSCs in bone regeneration: a systematic review and meta-analysis Jingfei Fu, Yanxue Wang, Yiyang Jiang, Juan Du, Junji Xu* and Yi Liu* Abstract Objectives: Over the past decades, many studies focused on mesenchymal stem cells (MSCs) therapy for bone regeneration. Due to the efficiency of topical application has been widely dicussed and systemic application was also a feasible way for new bone formation, the aim of this study was to systematically review systemic therapy of MSCs for bone regeneration in pre-clinical studies. Methods: The article search was conducted in PubMed and Embase databases. Original research articles that assessed potential effect of systemic application of MSCs for bone regeneration in vivo were selected and evaluated in this review, according to eligibility criteria. The efficacy of MSC systemic treatment was analyzed by random effects meta-analysis, and the outcomes were expressed in standard mean difference (SMD) and its 95% confidence interval. Subgroup analyses were conducted on animal species and gender, MSCs types, frequency and time of injection, and bone diseases. Results: Twenty-three articles were selected in this review, of which 21 were included in meta-analysis. The results showed that systemic therapy increased bone mineral density (SMD 3.02 [1.84, 4.20]), bone volume to tissue volume ratio (2.10 [1.16, 3.03]), and the percentage of new bone area (7.03 [2.10, 11.96]). Bone loss caused by systemic disease tended to produce a better response to systemic treatment (p=0.05 in BMD, p=0.03 in BV/TV).
    [Show full text]
  • Delayed Massive Hemothorax Requiring
    Clin Exp Emerg Med 2018;5(1):60-65 https://doi.org/10.15441/ceem.16.190 Case Report Delayed massive hemothorax requiring eISSN: 2383-4625 surgery after blunt thoracic trauma over a 5-year period: complicating rib fracture with sharp edge associated with diaphragm injury Received: 26 September 2017 Revised: 28 January 2018 Sung Wook Chang, Kyoung Min Ryu, Jae-Wook Ryu Accepted: 20 February 2018 Trauma Center, Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital, Cheonan, Korea Correspondence to: Jae-Wook Ryu Department of Thoracic and Cardiovascular Surgery, Dankook Delayed massive hemothorax requiring surgery is relatively uncommon and can potentially be University Hospital, 201 Manghyang-ro, Dongnam-gu, Cheonan 31116, Korea life-threatening. Here, we aimed to describe the nature and cause of delayed massive hemotho- E-mail: [email protected] rax requiring immediate surgery. Over 5 years, 1,278 consecutive patients were admitted after blunt trauma. Delayed hemothorax is defined as presenting with a follow-up chest radiograph and computed tomography showing blunting or effusion. A massive hemothorax is defined as blood drainage >1,500 mL after closed thoracostomy and continuous bleeding at 200 mL/hr for at least four hours. Five patients were identified all requiring emergency surgery. Delayed mas- sive hemothorax presented 63.6±21.3 hours after blunt chest trauma. All patients had superfi- cial diaphragmatic lacerations caused by the sharp edge of a broken rib. The mean preoperative chest tube drainage was 3,126±463 mL. We emphasize the high-risk of massive hemothorax in patients who have a broken rib with sharp edges.
    [Show full text]
  • Effect of Freeze-Dried Bovine Bone Xenograft on Tumor Necrosis Factor- Alpha Secretion in Human Peripheral Blood Mononuclear Cells
    Asian Jr. of Microbiol. Biotech. Env. Sc. Vol. 20 (December Suppl.) : 2018 : S88-S92 © Global Science Publications ISSN-0972-3005 EFFECT OF FREEZE-DRIED BOVINE BONE XENOGRAFT ON TUMOR NECROSIS FACTOR- ALPHA SECRETION IN HUMAN PERIPHERAL BLOOD MONONUCLEAR CELLS AHMAD K.M. HUMIDAT1, DAVID B. KAMADJAJA2,3*, CHRIST BIANTO1, ANINDITA Z. RASYIDA1, PURWATI3 AND ACHMAD HARIJADI2 1Residency Program, Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia. 2Department of Oral Maxillofacial Surgery, Faculty of Dental Medicine, Universitas Airlangga, Surabaya,Indonesia. 3Stem Cell Research and Development Center, Universitas Airlangga, Surabaya, Indonesia (Received 25 September, 2018; accepted 15 November, 2018) Key words: Tumor Necrosis Factor , Freeze Dried Bovine Bone Xenograft, Human peripheral blood mononuclear cell. Abstract– Alveolar bone augmentation requires the use of bone graft particles to promote bone formation. Freeze-dried bovine bone xenograft (FDBBX) is a type of bone substitute may be potential as an alternative to autogenous bone graft. However, since it is xenogeneic material, it may trigger body’s immune response and cause early resorption of the graft. Tumor Necrosis Factor- (TNF-) is a cytokine which is released rapidly after trauma or infection and is one of the most abundant mediators in inflammation tissue. The immune system and immune response play a very important role in the concept of bone healing. Human peripheral blood mononuclear cells (hPBMCs) is a critical component of the immune system which release TNF-. This study aims to evaluate FDBBX effect on the secretion of TNF-á in hPBMCs culture. hPBMC cultures were divided into two groups. In experimental groups, the cell was cultured in FDBX conditioned medium of 2.5% dilution while in control group, basic medium was used.
    [Show full text]
  • Accuracy of Diagnosis of Distal Radial Fractures by Ultrasound Ahmad Saladdin Sultan, Muddather Abdul Aziz, Yakdhan Z
    The Egyptian Journal of Hospital Medicine (October 2017) Vol. 69 (8), Page 3115-3122 Accuracy of Diagnosis of Distal Radial Fractures by Ultrasound Ahmad Saladdin Sultan, Muddather Abdul Aziz, Yakdhan Z. Alsaleem Mosul Teaching Hospital, Emergency Medicine Department, Mosul, Iraq Corresponding author: Ahmad Saladdin <[email protected] ABSTRACT Background: although distal radial fracture account up to 20% of all fractures, it forms the most common fracture in upper extremities. Distal radial fracture has six types the most common one is Colle's fracture. The gold standard for diagnosis of distal radial fracture is conventional radiograph. Despite using ultrasound in tendon rupture, localizing foreign bodies, ultrasound started to be used for diagnosing bone fracture especially distal radius. Aim of the work: this study aimed to detect the accuracy of ultrasound in the diagnosis of distal radial fracture. Patients and methods: this was a selective prospective case series study in the Emergency Department, Al-Jumhoori Teaching Hospital,78 patients were included in this study, their age ranged between 6-45 years with mean age 17.1. 59 were males and 19 females. Duration of the study was one year (January2013 - January 2014). Results: by analyzing data of 78 patients for distal radial fracture ultrasound and comparing the results with the gold standard conventional radiograph we found that sensitivity of ultrasound in detecting fracture was 95.5%, specificity 100%, accuracy 96.15%, positive predictive value 100% and negative predictive value 80%. Conclusion: results of the current work demonstrated that ultrasound can be considered as a promising alternative to routine radiograph in diagnosis of the distal radial fractures and the horizon still open for further studies of use of ultrasound in diagnosis of other types of fractures.
    [Show full text]
  • Interactions Between Bone and Immune Systems: a Focus on the Role of Inflammation in Bone Resorption and Fracture Healing
    PERIODICUM BIOLOGORUM UDC 57:61 VOL. 116, No 1, 45–52, 2014 CODEN PDBIAD ISSN 0031-5362 Interactions between bone and immune systems: A focus on the role of inflammation in bone resorption and fracture healing Abstract TOMISLAV KELAVA1,2 ALAN ŠUĆUR1,2 Functional interactions between the immune system and bone tissues are SANIA KUZMAC2,3 reflected in a number of cytokines, chemokines, hormones and other media- 2,3 VEDRAN KATAVIĆ tors regulating the functions of both bone and immune cells. Investigations 1 Department of Physiology and Immunology of the mechanisms of those interactions have become important for the un- University of Zagreb School of Medicine derstanding of the pathogeneses of diseases like inflammatory arthritis, in- [alata 3b, Zagreb-HR 10000, Croatia flammatory bowel disease, periodontal disease and osteoporosis. This review 2 Laboratory for Molecular Immunology first addresses the roles of the inflammatory mediators and mechanisms by University of Zagreb School of Medicine which they cause inflammation-induced bone loss. In the second part of the [alata 12, Zagreb-HR 10000, Croatia review we stress the importance of proinflammatory mediators for normal 3 Department of Anatomy fracture healing. Defective bone remodeling underlying different patho- University of Zagreb School of Medicine logical processes may be caused by disturbed differentiation and function of [alata 3b, Zagreb-HR 10000, Croatia either osteoclast or osteoblast lineage cells. Understanding of the mechanisms governing enhanced differentiation and activation
    [Show full text]
  • Diagnosis and Treatment of Intramedullary Osteosclerosis
    Abe et al. BMC Musculoskeletal Disorders (2020) 21:762 https://doi.org/10.1186/s12891-020-03758-5 CASE REPORT Open Access Diagnosis and treatment of intramedullary osteosclerosis: a report of three cases and literature review Kensaku Abe, Norio Yamamoto, Katsuhiro Hayashi, Akihiko Takeuchi* , Shinji Miwa, Kentaro Igarashi, Takashi Higuchi, Yuta Taniguchi, Hirotaka Yonezawa, Yoshihiro Araki, Sei Morinaga, Yohei Asano and Hiroyuki Tsuchiya Abstract Background: Intramedullary osteosclerosis (IMOS) is a rare condition without specific radiological findings except for the osteosclerotic lesion and is not associated with family history and infection, trauma, or systemic illness. Although the diagnosis of IMOS is confirmed after excluding other osteosclerotic lesions, IMOS is not well known because of its rarity and no specific feature. Therefore, these situations might result in delayed diagnosis. Hence, this case report aimed to investigate three cases of IMOS and discuss imaging findings and clinical outcomes. Case presentation: All three cases were examined between 2015 and 2019. The location of osteosclerotic lesions were femoral diaphyses in the 60-year-old man (Case 1) and 41-year-old woman (Case 2) and tibial diaphysis in the 44-year-old woman (Case 3). All cases complained of severe pain and showed massive diaphyseal osteosclerotic lesions in plain radiograms and computed tomography (CT) scans. Cases 2 and 3 were examined using the triphasic bone scan, and a fusiform-shaped intense area of the tracer uptake on delayed bone image was detected in both cases without (Case 2) or slightly increased vascularity (Case 3) on the blood pool image, which was reported as a specific finding of IMOS.
    [Show full text]
  • Treatment of Common Hip Fractures: Evidence Report/Technology
    This report is based on research conducted by the Minnesota Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA 290 2007 10064 1). The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment. This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. Evidence Report/Technology Assessment Number 184 Treatment of Common Hip Fractures Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Contract No. HHSA 290 2007 10064 1 Prepared by: Minnesota Evidence-based Practice Center, Minneapolis, Minnesota Investigators Mary Butler, Ph.D., M.B.A. Mary Forte, D.C. Robert L. Kane, M.D. Siddharth Joglekar, M.D. Susan J. Duval, Ph.D. Marc Swiontkowski, M.D.
    [Show full text]
  • Bone Healing
    BONE HEALING How Does a Bone Heal? Bone generally takes 6 to 8 weeks ll broken bones go through the to heal to a significant degree. In A same healing process. This general, children's bones heal faster is true whether a bone has been than those of adults. The foot and cut as part of a surgical procedure ankle surgeon will determine when or fractured through an injury. the patient is ready to bear weight The bone healing process Inflammation on the area. This will depend on the has three overlapping stages: location and severity of the fracture, inflammation, bone production, the type of surgical procedure and bone remodeling. performed, and other considerations. • Inflammation starts immediately after the bone is fractured and What Helps Promote lasts for several days. When Bone Healing? the bone is fractured there is If a bone will be cut during a bleeding into the area, leading planned surgical procedure, some to inflammation and clotting of steps can be taken pre-and post- blood at the fracture site. This operatively to help optimize healing. provides the initial structural Bone production The surgeon may offer advice on diet stability and framework for and nutritional supplements that are producing new bone. essential to bone growth. Smoking • Bone production begins when cessation, and adequate control the clotted blood formed by of blood sugar levels in diabetics, inflammation is replaced with are important. Smoking and high fibrous tissue and cartilage glucose levels interfere with bone (known as “soft callus”). As healing. healing progresses, the soft For all patients with fractured callus is replaced with hard bones, immobilization is a critical bone (known as “hard callus”), Bone remodeling part of treatment, because any which is visible on x-rays several movement of bone fragments slows weeks after the fracture.
    [Show full text]
  • (Osgood- Schlatter Disease): a Review
    Open Access Review Article DOI: 10.7759/cureus.780 Apophysitis of the Tibial Tuberosity (Osgood- Schlatter Disease): A Review Raju Vaishya 1 , Ahmad Tariq Azizi 2 , Amit Kumar Agarwal 1 , Vipul Vijay 1 1. Orthopaedics, Indraprastha Apollo Hospitals 2. Orthoapedics, Herat Regional Hospital, Herat, Afghanistan Corresponding author: Amit Kumar Agarwal, [email protected] Abstract Osgood-Schlatter disease (OSD) is a condition in which the patellar tendon insertion on the tibial tuberosity becomes inflamed. It is a well-known condition in late childhood characterized by pain and a bony prominence over the tibial tuberosity. The pain is usually exacerbated by physical activities like running, jumping, and climbing stairs. In the acute stage, the margins of the patellar tendon become blurred in radiographs due to the soft tissue swelling. After three to four months, bone fragmentation at the tibial tuberosity is viewed. In the sub-acute stage, soft tissue swelling resolves, but the bony ossicle remains. In the chronic stage, the bone fragment may fuse with the tibial tuberosity which can appear normal. The primary goal in the treatment of OSD is the reduction of pain and swelling over the tibial tuberosity. The patient should limit physical activities until the symptoms are resolved. In some cases, the patient should restrict physical activities for several months. The presence of pain with kneeling because of an ossicle that does not respond to conservative measures is the indication for surgery. In these cases, the removal of the ossicle, surrounding bursa, and the bony prominence is the treatment of choice. Categories: Orthopedics Keywords: tibial tuberosity, osgood-schlatter disease, apophysitis Introduction And Background Osgood-Schlatter disease (OSD, also called Lannelongue’s disease) is a condition in which the patellar tendon insertion on the tibial tuberosity becomes inflamed [1-2].
    [Show full text]
  • Knee Pain in Children, Part II: Limb- and Life-Threatening Conditions, Hip Pathology, and Effusion
    Knee Pain in Children, Part II: Limb- and Life-threatening Conditions, Hip Pathology, and Effusion Michael Wolf, MD* *Pediatrics and Orthopedic Surgery, St Christopher’s Hospital for Children, Philadelphia, PA. Practice Gap Clinicians who evaluate knee pain must be able to recognize limb- and life-threatening conditions, hip pathology, or joint effusion and pursue the appropriate management. Objectives After reading the article, the reader should be able to: 1. Describe the presentation and treatment of common limb- and life-threatening conditions that can cause knee pain in children. 2. Delineate how hip pathology can contribute to knee pain in children and how such conditions should be diagnosed and treated. 3. Explain the diagnosis and treatment of conditions that may cause effusion in conjunction with knee pain in children. INTRODUCTION As noted in the first part of this three-part review of knee pain in children, the clinician can use the information gained from the history and physical examination in an algorithm to establish a working diagnosis and direct subsequent evaluation and management. The initial priorities are to identify emergent limb- and life-threatening conditions, hip pathology, or effusion (Table). LIMB- AND LIFE-THREATENING CONDITIONS Bacterial Infections Septic Arthritis. The knee is the most common site of septic arthritis in children. Usually, septic arthritis is characterized by the acute onset of steadily progressive knee pain with fever and a physical examination demonstrating effusion, warmth, AUTHOR DISCLOSURE Dr Wolf has disclosed fi erythema, and limited motion. Concern for septic bacterial arthritis in children no nancial relationships relevant to this article. This commentary does not contain a warrants emergent evaluation, including knee radiographs (anteroposterior [AP] discussion of an unapproved/investigative and lateral) and laboratory studies (complete blood cell [CBC] count with use of a commercial product/device.
    [Show full text]
  • Biology of Bone Repair
    Biology of Bone Repair J. Scott Broderick, MD Original Author: Timothy McHenry, MD; March 2004 New Author: J. Scott Broderick, MD; Revised November 2005 Types of Bone • Lamellar Bone – Collagen fibers arranged in parallel layers – Normal adult bone • Woven Bone (non-lamellar) – Randomly oriented collagen fibers – In adults, seen at sites of fracture healing, tendon or ligament attachment and in pathological conditions Lamellar Bone • Cortical bone – Comprised of osteons (Haversian systems) – Osteons communicate with medullary cavity by Volkmann’s canals Picture courtesy Gwen Childs, PhD. Haversian System osteocyte osteon Picture courtesy Gwen Childs, PhD. Haversian Volkmann’s canal canal Lamellar Bone • Cancellous bone (trabecular or spongy bone) – Bony struts (trabeculae) that are oriented in direction of the greatest stress Woven Bone • Coarse with random orientation • Weaker than lamellar bone • Normally remodeled to lamellar bone Figure from Rockwood and Green’s: Fractures in Adults, 4th ed Bone Composition • Cells – Osteocytes – Osteoblasts – Osteoclasts • Extracellular Matrix – Organic (35%) • Collagen (type I) 90% • Osteocalcin, osteonectin, proteoglycans, glycosaminoglycans, lipids (ground substance) – Inorganic (65%) • Primarily hydroxyapatite Ca5(PO4)3(OH)2 Osteoblasts • Derived from mesenchymal stem cells • Line the surface of the bone and produce osteoid • Immediate precursor is fibroblast-like Picture courtesy Gwen Childs, PhD. preosteoblasts Osteocytes • Osteoblasts surrounded by bone matrix – trapped in lacunae • Function
    [Show full text]
  • Distal Radius Fracture
    Distal Radius Fracture Osteoporosis, a common condition where bones become brittle, increases the risk of a wrist fracture if you fall. How are distal radius fractures diagnosed? Your provider will take a detailed health history and perform a physical evaluation. X-rays will be taken to confirm a fracture and help determine a treatment plan. Sometimes an MRI or CT scan is needed to get better detail of the fracture or to look for associated What is a distal radius fracture? injuries to soft tissues such as ligaments or Distal radius fracture is the medical term for tendons. a “broken wrist.” To fracture a bone means it is broken. A distal radius fracture occurs What is the treatment for distal when a sudden force causes the radius bone, radius fracture? located on the thumb side of the wrist, to break. The wrist joint includes many bones Treatment depends on the severity of your and joints. The most commonly broken bone fracture. Many factors influence treatment in the wrist is the radius bone. – whether the fracture is displaced or non-displaced, stable or unstable. Other Fractures may be closed or open considerations include age, overall health, (compound). An open fracture means a bone hand dominance, work and leisure activities, fragment has broken through the skin. There prior injuries, arthritis, and any other injuries is a risk of infection with an open fracture. associated with the fracture. Your provider will help determine the best treatment plan What causes a distal radius for your specific injury. fracture? Signs and Symptoms The most common cause of distal radius fracture is a fall onto an outstretched hand, • Swelling and/or bruising at the wrist from either slipping or tripping.
    [Show full text]