Le Fort Classification of facial fractures

In 1901 ;René Le Fort (1869-1951),French surgeon, reported his work on cadaver skulls that were subjected to blunt forces of various magnitudes and directions. He concluded that predictable patterns of fractures follow certain types of injuries. Three predominant types were described.


Le Fort I fractures (horizontal) may result from a force of injury directed low on the maxillary alveolar rim in a downward direction. The fracture extends from the nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates.

Le Fort II fractures (pyramidal) may result from a blow to the lower or mid maxilla. Such a fracture has a pyramidal shape and extends from the nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates.

Le Fort III fractures (transverse), also termed craniofacial dysjunctions, may follow impact to the nasal bridge or upper maxilla. These fractures start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the sphenoid.

Histopathology of Osteosarcoma

ABC of Spinal cord trauma

Spinal cord trauma is potentially the most devastating consequence of injury to the spine. This well-established, practical guide provides a detailed overview from the scene of the accident to rehabilitation and discharge from hospital care. This latest edition has been substantially rewritten to include the most recent developments in practical management of patients with potential spine injury and risk-minimisation techniques. There is also a new chapter on spinal cord injury in developing countries.

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Ambulation Algorithm

FOOTNOTES:
1. Non-weight bearing: Patient is unable to bear weight through both lower extremities or weight-bearing through both lower extremities is contraindicated.

2. Partial weight bearing: This will include situations where the patient may be allowed: a) Limited weight bearing on one lower extremity and full weight bearing on the other extremity; b) Partial weight bearing through both lower extremities.

3. Safety risks may include: decreased cognition; decreased ability to cooperate/ combativeness; medical stability.

4. Factors that contribute to low safety risk: a) Lack of combativeness; b) Ability to follow commands; c) Medical stability; d) Experience with the assistive device.

5. Factors that contribute to high safety risk: a) Combativeness; b) Lack of ability to follow commands; c) Medical instability; d) Lack of experience with
the assistive device, e) neurological deficits.

Anterior Sternal Dislocation

An 83-year-old man was admitted to the acute medical ward after having fallen down in his home. On admission he was confused and agitated.

Physical examination revealed a swelling with bruising over his right sternoclavicular joint (Panel A) and periorbital bruising. He had a white-cell count of 14×103 per cubic millimeter, a C-reactive protein level of 56 mg per liter, and a urinalysis that was positive for a urinary tract infection. A social history was taken and revealed no suggestion of abuse. Radiography of the chest (Panel B) showed a right sternoclavicular dislocation, which was clinically confirmed to be anterior.
Anterior sternoclavicular dislocations often result from an indirect force to the shoulder, rotating the shoulder posteriorly. The physician must always consider the possibility of abuse having caused this type of injury. The patient was treated for his urinary tract infection. His anterior sternoclavicular dislocation was treated conservatively. The confusion resolved, and after a short period of rehabilitation, he regained good function of his right upper limb.

Diagram of meniscal tear patterns

Meniscal injuries can be classified according to their tear patterns. A vertical or longitudinal tear occurs in line with the circumferential fibers of the meniscus . If long enough, this tear is known as a bucket-handle tear. At arthroscopy, the bucket-handle tear may be seen as being attached anteriorly and posteriorly. Alternatively, it may be detached at either end or transected in the middle with unstable anterior and posterior flaps. A bucket-handle tear may displace into the intercondylar notch, where it may cause true locking of the knee joint.

(A) Vertical or longitudinal (Bucket-handle), (B) Flap or Oblique, (C) Radial or Transverse, (D) Horizontal, (E) Complex degenerative.

-Oblique tears are also known as flap or parrot beak tears and are perhaps the most common . These occur generally at the junction of the posterior and middle thirds.

-Radial tears occur in a similar location. They extend from the inner free margin toward the periphery . If such a tear reaches the periphery, it transects the meniscus and renders the hoop stress-distributing capacities of the meniscus useless. Such a tear is the functional equivalent of a total meniscectomy.

-Horizontal cleavage tears usually occur in older individuals. They extend from the inner free margin peripherally to the intrameniscal substance where myxoid degeneration may be present. These tears divide the meniscus into superior and inferior flaps, either of which may be unstable

-Complex degenerative tears occur in older patients. Osteoarthritic changes may be visible on plain radiographs, and chondromalacia of the articular surfaces is commonly encountered. The tears occur in multiple planes .

A case of Inflammatory Arthritis

A 34 year old male has a long history of several subacute attacks of self-limited inflammatory arthritis. Crystals have been retrieved from a joint aspirate. Radiography of his knee is likely to demonstrate:

a) subperiosteal thickening
b) marginal articular erosions
c) central articular erosions
d) chondrocalcinosis
e) subchondral bony sclerosis

The correct answer is D

Explanation
Chondrocalcinosis is simply the term for the finding of radio-opaque crystals in hyaline or fibrocartilage. These salts may consist of calcium pyrophosphate dihydrate, dicalcium phosphate dihydrate or hydroxyapatite. Crystals may also be deposited in bursae, capsules, ligaments and tendons.
Chondrocalcinosis may accompany a variety of diseases, but is not a disease entity merely a physical sign thereof. Used properly, the term pseudogout refers to the clinical syndrome of one or more acute or subacute attacks of self-limited inflammatory arthritis caused by crystal-induced synovitis, proven by recovery of the crystals from a joint aspirate. Most people with chondrocalcinosis never have a single acute episode of pseudogout.

CPPD crystal deposition disease is the general term that encompasses chondrocalcinosis, pseudogout, a distinctive arthropathy and a host of variations. During acute attacks (pseudogout) of crystal-induced synovitis, the usual radiological findings are soft-tissue oedema and joint effusion. Chondrocalcinosis may or may not be present. The cartilage and articular bone are often normal. The chronic arthropathy is more distinctive. It is most frequent in the patellofemoral, radiocarpal metacarpophalangeal and elbow joints.

Although the findings superficially resemble osteoarthritis, there are several important differences beyond the unique distribution. The arthropathy is characterized by cartilage loss, multiple subchondral cystic rarefactions, structural collapse of the articular surface, and the presence of many small intra-articular fragments, all without much bone sclerosis. In addition to the usual target sites, these changes may be observed in the hips, knees and sacroiliac joints. Chondrocalcinosis, which does not have to accompany the arthropathy, is seen most commonly in the large joints such as the knee, hip and shoulder as well as the symphysis pubis.

Osteoporosis of aging (senile or postmenopausal osteoporosis)

Most common form of generalized osteoporosis. As a person ages, the bones lose density and become more brittle, fracturing more easily and healing more slowly. Many elderly persons are also less active and have poor diets that are deficient in protein. Females are affected more often and more severely than males, as postmenopausal women have deficient gonadal hormone levels and decreased osteoblastic activity.

 Osteoporosis of aging. Generalized demineralization of the spine in a postmenopausal woman. The cortex appears as a thin line that is relatively dense and prominent (picture-frame pattern).

Finkelstein's test to diagnose DeQuervain's tenosynovitis

Pain over the thumb side of the wrist is the primary symptom of DeQuervain's tenosynovitis. It may occur "overnight" or gradually, and it may radiate into the thumb and up into the forearm. It is worse with the use of the hand and thumb, especially with any forceful grasping, pinching or twisting. Swelling over the thumb side of the wrist may be present, as well as some "snapping" when the thumb is moved. Due to the pain and swelling , there may be some decreased thumb motion.

Besides pain and swelling over the first dorsal compartment, having a positive Finkelstein's test is a good indication that the patient has the problem. In this test, the patient makes a fist with the thumb placed under the little finger and bends the wrist. The test is mildly painful to many of us, but to someone with De Quervain's stenosing tenosynovitis, it is very painful.

Characteristic complaint of de Quervain's tenosynovitis

A 42-year-old carpenter presents with wrist pain and grip weakness. On exam he is found to have pain over the radial aspect of the wrist that is aggravated by flexing the thumb and applying ulner flexion. The most likely diagnosis is

• A) carpal tunnel syndrome
• B) scaphoid fracture.................

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Knock-Knee And Bow-Legs

Bowleg (or genu varum) is a condition where the legs are bowed outwards in the standing position. The bowing usually occurs at or around the knee, so that ........

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McMurrays test

McMurray's test is performed with the patient lying flat (non-weight bearing) and the examiner bending the knee. A click is felt over the meniscus tear as the knee is brought from full flexion to 90 degrees of flexion.

Basic surface anatomy knee

Simple identification of Giant cell tumor in X-ray

Lytic lesion in the end of a long bone of a young adult after epiphyseal closure. Usually asymptomatic, but may be associated with intermittent dull pain and a palpable tender mass and predispose to pathologic fracture. Approximately 20% are malignant (best seen as tumor extension through the cortex and an associated soft-tissue mass on CT). There is much overlap in the radiographic appearance of benign and malignant lesions.

Imaging Findings :

Eccentric lucent metaphyseal lesion that may extend to the immediate subarticular cortex of a bone but does not involve the joint. Expansion toward the shaft produces a well-demarcated lucency, often with cortical expansion but without a sclerotic shell or border. Typically involves the distal femur, proximal tibia, distal radius, or ulna.

Giant cell tumor of the distal femur. Typical eccentric lucent lesion in the metaphysis extends to the immediate subarticular cortex. The surrounding cortex, though thinned, remains intact.

Malignant giant cell tumor. The tumor has caused cortical disruption, extends outside the host bone, and has an illdefined margin.

Lipoma arborescens (what`s it !!!)

Lipoma arborescens is a rare case affecting the synovial linings of the joints and bursae, with 'frond like' depositions of fatty tissue. They account for less than 1% of all lipomatous lesions.

Clinical presentation
Clinically presented by painless joint swelling, frequently with effusion, typically in the 5th - 7th decades. Usually these lesions are sporadic, however they can be seen in the setting of osteoarthritis, collagen vascular disorders or previous trauma.

The most common site of involvement is suprapatellar bursa of knee joint, and the disorder is usually unilateral . Occasional reports of hip, shoulder, wrist elbow are also reported. Other joint involvement is uncommon. Involvement of tendon sheath is even rarer.

Treatment and prognosis
The condition is benign and is cured by synovectomy. Recurrence is uncommon

For MRI images (of ankle involvement):

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Spirotome Bone biopsy for osteolytic lesions under CT guidance

Soft tissue biopsy from osteolytic lesions is a challenge for the interventionist. The Spirotome Bone is conceived for this intervention. The procedure is straigthforward and produces tissue specimens of high quality in sufficient amounts to allow quantitative molecular biology.

Chest X-rays of the Kyphotic Patient

The radiographer has, by force of habit, angled the X-ray tube caudally for the AP sitting projection. This is a positioning trap in bedside radiography of kyphotic patients. The result is extreme foreshortening of the chest. Even the use of a horizontal ray would have resulted in significant foreshortening of the lung fields (see the lateral image).

This is a lateral chest image taken on a patient with a moderately severe thoracic kyphosis. A triangular positioning sponge has been placed behind the patient. Note that the patient's chest is angled forward considerably and this position is associated with the patient's thoracic kyphosis.

Vertebroplasty with Procedure Demonstration

What is Vertebroplasty :

The vertebral column or backbone tends to get weak as a person gets old. This is more common in women since female hormones are necessary for normal mineralization. The weak bones in the spine collapse, producing painful fractures. Till a few years ago the only treatment that was available for condition was a major surgery. However thanks to interventional radiology today a fractured bone of the spine can be strengthened by injecting a specialized medical cement ( bone cement) into the diseased vertebral body .

Procedure Demonstration :

Stryker Vertebroplasty uses a specially formulated acrylic bone cement to stabilize and strengthen the fracture and vertebral body. Its done on an outpatient basis and requires only a local anesthetic and mild sedation, eliminating the complications that may result from open surgery and general anesthesia. Stryker Vertebroplasty is considered a minimally invasive procedure because it is done through a small puncture in the patients skin (as opposed to an open incision). Technically simple, it usually takes about 30 minutes to complete.

Using sterile technique and fluoroscopic visualization, a 10-, 11- or 13- gauge needle is advanced into the fractured vertebra using a transpedicular approach. Bi-pedicular needle placement is recommended. Once the needles are in the correct position, bone cement is slowly injected into the vertebral body, diffusing throughout the intertrabecular marrow space and creating an internal cast that stabilizes the bone.

Following the procedure, patients lie flat on their back for a short period of time as the cement continues to harden. They may then go home. Almost all patients undergoing Stryker Vertebroplasty experience 90% or better reduction in pain within 24-48 hours and increased ability to perform daily activities shortly thereafter.

Scoliosis Assessment

Compact and Spongy Bones

The bone tissue has 2 types of differ in density......> compact and spongy

1-Compact Bone:

Compact bone consists of closely packed "osteons or haversian systems". The osteon consists of a central canal called the osteonic (haversian) canal, which is surrounded by ............

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