Primary Osteomyelitis of the Clavicle in Children.

Osteomyelitis of the clavicle is a rare entity with a broad differential diagnosis and high potential for complications if not diagnosed promptly and treated appropriately. The threshold for surgical intervention should be low to prevent osteonecrosis and bony resorption. In addition, although rare, life-threatening complications have been reported. This report describes primary osteomyelitis of the clavicle that was diagnosed in a 22-month-old girl on her third clinical evaluation after 4 days of symptoms. She presented to a children's tertiary care emergency department with fever and acute pain and swelling of her right shoulder and arm. The diagnosis was confirmed through clinical, laboratory, and imaging studies including ultrasound; these revealed subperiosteal abscess formation, which may have developed in part as the result of a delayed diagnosis from the 2 prior emergency department visits. The patient was treated initially with intravenous antibiotics and underwent therapeutic as well as diagnostic needle-guided tissue aspiration under ultrasound guidance. This ruled out malignancy but was not curative, and the subperiosteal abscess recurred within 24 hours, prompting formal operative irrigation and debridement. The patient was seen for 12-month follow-up and has had no complications or evidence of recurrence. This case emphasizes the need for a high index of suspicion to prevent diagnostic delays as well as the importance of a low threshold for surgical debridement to minimize the potential for complications that could prolong the treatment course. [Orthopedics. 2016; 39(4):e760-e763.].

Subchondral Insufficiency Fracture of Femoral head: Uncommon cause of Hip pain in Elderly.

INTRODUCTION: Subchondral insufficiency fracture (SIF) of femoral head is not very common cause of hip pain. This usually occurs in elderly osteoporotic patients or fatigue fracture in young military recruits. CASE REPORT: We report a case of hip pain in an osteoporotic male which was diagnosed on MRI after the condition was missed by two physicians initially. Patient responded well to conservative treatment and was asymptomatic at one year follow up. CONCLUSION: Purpose of this case is to highlight clinical and radiological features of this entity and to discuss the prognosis and treatment. This case should increase awareness of this rare condition amongst treating physicians. This may facilitate early diagnosis and successful outcome with conservative treatment in selected sub-group of patients having SIF of femoral head.

Tumor like swellings arising from Hoffa's fat pad: A report of three patients.

We report three rare cases of tumor-like conditions arising from Hoffa's fat pad (HFP). Patients were having persistent knee pain, the cause of which was not diagnosed by the general physician, and then were referred to us for knee pain. Magnetic resonance imaging revealed the lesions to be arising from HFP (ganglion cysts and hemangioma), as was suggested by clinical findings. Anatomy, pathology, and radiological features of the Hoffa's disease are described here to increase awareness in orthopedic community of this rare but interesting disease which is often misdiagnosed as meniscal pathology. These cases illustrate that increased cognizance can facilitate timely intervention which will prevent morbidity of the patient.

Screw and wire fixation for Lisfranc fracture dislocations.

PURPOSE: To assess mid-term outcome of screw and wire fixation for Lisfranc fracture dislocations to determine the risk factors of post-traumatic arthritis. METHODS: 15 men and 4 women aged 21 to 58 (mean, 41) years with Lisfranc fractures underwent open/ closed reduction and internal fixation (using screw and wire). Fractures were classified as homolateral (n=7), isolated (n=7), and divergent (n=5). Six patients had open fractures; 8 patients injured 5 tarsometatarsal joints; and 6 patients had pure ligamentous injury. Outcome (pain, function, and cosmesis) was assessed using the Maryland foot score and the American Orthopedic Foot and Ankle Society (AOFAS) score. Weight-bearing radiographs were evaluated for non-union, subluxation, malalignment, and post-traumatic arthritis. RESULTS: Patients were followed up for 24 to 40 (mean, 30) months. Patients with anatomic reduction (n=14) achieved higher mean AOFAS foot score (79.3 vs. 67.5, p=0.0007) and Maryland foot score (80.4 vs. 69.4, p=0.0009) than did patients with non-anatomic reduction (n=5). Post-traumatic arthritis occurred significantly more often in patients with non-anatomic than anatomic reduction (3/5 vs. 1/14, p=0.037). Four patients developed post-traumatic arthritis, one of whom also developed lateral subluxation after implant removal. Two patients developed flat foot. Two patients had severe symptoms that limited function, one of whom underwent an arthrodesis. Two patients with compound fractures developed superficial infections. Three patients had broken screws. CONCLUSION: Anatomic reduction is the main predictor of outcome in patients with Lisfranc fracture dislocations.

Tuberculosis of spine with neurological deficit in advanced pregnancy: a report of three cases.

BACKGROUND CONTEXT: Early decompression in spinal tuberculosis (TB) with complete paraplegia has a better prognosis in relation to the neurological recovery and deformity progression. Advanced pregnancy can complicate this picture in view of the various fetomaternal factors. The prevalent literature is inconclusive regarding the time and extent of surgical intervention. Delay in the surgical intervention may adversely affect the prognosis. PURPOSE: To emphasize the importance of early decompression in spinal TB complicated by neurological deficit in advanced pregnancy. STUDY DESIGN: A case report of three patients to analyze the surgical management of neurological deficit because of spinal TB in pregnancy. OUTCOME MEASURES: Neurological recovery, progression of deformity, healing of the TB lesion, and outcome of the pregnancy. METHODS: Three patients presented with spinal TB with neurological deficit complicating third trimester of pregnancy. The first patient was initially managed conservatively but was operated after a spontaneous abortion. The remaining two patients were managed by urgent Caesarean section followed by spinal decompression and fusion. RESULTS: The first patient who underwent delayed decompression showed good healing of the TB lesion but continued to have spastic paraparesis with kyphosis. This was later managed by repeat decompression and instrumented fusion, without neurological recovery. The other two patients treated by early decompression and fusion showed complete healing with neurological recovery. CONCLUSIONS: Early decompression and instrumented fusion in spinal TB, complicated by neurological deficit in advanced pregnancy, can give good results with respect to neurological recovery, healing of the lesion, and arrest of deformity progression. Neonatal prognosis depends on the fetal maturity. Antitubercular therapy is an essential component of the management; it poses little hazard of inducing congenital anomalies, but possibility of maternal drug toxicity should be considered.

Lisfranc Dislocation having Bimalleolar Fracture with Syndesmotic Injury.

INTRODUCTION: Fracture-dislocations of tarsometatarsal joints are rare. Association of these fractures with ankle injuries is very rare; to our knowledge not reported in the literature. Here, we report a rare case of Tarso-metatarsal (Lisfranc) dislocation with bimalleolar fracture with syndesmotic injury. CASE REPORT: Patient was treated with closed reduction and fixation of Lisfranc injury with combination of screws and k wires and also fixation of bimalleolar and syndesmotic injury. At follow up patient achieved excellent function as assessed by AOFAS (American Orthopaedic Society Foot and Ankle Society Midfoot Score). CONCLUSION: Even though extremely uncommon, early recognition of ankle injuries with uncommon lisfranc fractures & dislocations is important as prompt and simultaneous treatment of both injuries results in excellent clinical outcome.