Medicine Hack

It is the case of a 16-yr old female who came to the emergency department with complaints of low back ache for the past week. She has had similar symptoms in the past but now the intensity is increasing. There is no associated numbness or weakness of extremities. She did not have any weight loss. There was neither urinary nor fecal incontinence. On examination she had an obvious limp. Lumbar spines: mild tenderness lower lumbar spines, no deformity, range of motion was normal, no stigma of spina bifida. Lower limbs length showed a discrepancy of 1.5cm being shorter by 1.5cm on the left side. Left ankle in inversion and with hyperlaxity while left ankle was stiff and with restricted inversion. X-ray of Lumbar Spines showed a spina bifida. Impression of Spina Bifida occulta was made.

It is a fracture that occurs not because of a single violent injury but results from repeated stress. It is commonly seen in athletes and new military or police force recruits. The pathology here is that the rate of microdamage from repeated stress exceeds the rate of repair. Thus there is accumulation of these microdamages and there is eventually a complete fracture across the full width of the bones. Majority of stress fractures occurs in the bones of the lower limbs, notably the metatarsals. Other sites may be the shaft of the tibia or the neck of femur.

It is also called as Gustilo-Anderson classification. It is a well established system to establish the severity of the open fracture. e.g. if you are on night duty and you have to phone the orthopedic surgeon regarding a case, you just have to tell which type it is according to the Gustilo's classification, instead of describing the fracture in details. The classification goes as follows: Typ e I - Puncture wound < 1 cm, minimal contamination, low energy and simple fracture Type II - Laceration > 1 cm; moderate soft tissue damage with adequate bone coverage Type IIIA - Extensive soft tissue damage, often associated with high energy trauma, massive contamination but adequate bone coverage Type IIIB - Extensive soft tissue damage with periosteal stripping and bone exposure, flap coverage is usually required Type IIIC - Arterial injury associated and requiring repair

Bennett's fracture is an unstable intra articular fracture of the base of the first metacarpal bone.  It extends into the carpometacarpal (CMC) joint and is  the most common type of fracture of the thumb. It is nearly always accompanied by some degree of subluxation or frank dislocation of the carpometacarpal joint and this subluxation/dislocation makes the fracture unstable. The mechanism of injury is that when an axial force is applied against a partially flexed metacarpal, there is a resulting fracture of the base of that metacarpal and usually associated with subluxation/dislocation.  This fracture is common in cases of fall on thumb usually from bicycles and punching to a hard object. If intraarticular fractures (such as the Bennett's fractures) are allowed to heal in a displaced position, significant post-traumatic osteoarthritis of the base of the thumb can occur.

Type I – A transverse fracture through the growth plate ( incidence is about 6-7%) Type II – A fracture through the growth plate + metaphysis and sparing the epiphysis (incidence is about 70-75% ) Type III – A fracture through growth plate + epiphysis, sparing the metaphysis (7- 8% incidence) Type IV – A fracture through all three elements growth plate + metaphysis + epiphysis (8-10% incidence) Type V – A compression fracture of the growth plate