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Posted on: October 12th, 2016 by admin No Comments

Mallet finger is an injury to the thin tendon that straightens the end joint of a finger or thumb. Although it is also known as “baseball finger,” this injury can happen to anyone when an unyielding object (like a ball) strikes the tip of a finger or thumb and forces it to bend further than it is intended to go. As a result, you are not able to straighten the tip of your finger or thumb on your own.


With a mallet finger injury, the fingertip droops and cannot be actively straightened.


Tendons are tissues that connect muscles to bone. The muscles that move the fingers and thumb are located in the forearm. Long tendons extend from these muscles through the wrist and attach to the small bones of the fingers and thumb.

The extensor tendons on the top of the hand straighten the fingers. The flexor tendons on the palm side of the hand bend the fingers.


The extensor tendons straighten the fingers and thumb through a very complex arrangement.


In a mallet injury, when an object hits the tip of the finger or thumb, the force of the blow tears the extensor tendon. Occasionally, a minor force such as tucking in a bed sheet will cause a mallet finger.

The injury may rupture the tendon or pull the tendon away from the place where it attaches to the finger bone (distal phalanx). In some cases, a small piece of bone is pulled away along with the tendon. This is called an avulsion injury.


(Top) A rupture of the extensor tendon. (Bottom) A fragment of the distal phalanx has pulled away with the tendon.

The long, ring, and small fingers of the dominant hand are most likely to be injured.

The finger is usually painful, swollen, and bruised. The fingertip will droop noticeably and will straighten only if you push it up with your other hand.

Risk for Infection

It is very important to seek immediate attention if there is blood beneath the nail or if the nail is detached. This may be a sign of a cut in the nail bed, or that the finger bone is broken and the wound penetrates down to the bone (open fracture). These types of injuries put you at risk for infection.

First Aid

To relieve pain and reduce swelling, apply ice to your finger immediately and keep your hand elevated above your heart.

Doctor Examination

A mallet finger injury requires medical treatment to ensure the finger regains as much function as possible. Most doctors recommend seeking treatment within a week of injury. However, there have been cases in which treatment was delayed for as long as a month after injury and full healing was still achieved.

Physical Examination

After discussing your medical history and symptoms, doctor will examine your finger or thumb. During the examination, doctor will hold the affected finger and ask you to straighten it on your own. This is called the mallet finger test.


During a mallet finger test, doctor determines whether you can straighten your fingertip without assistance.


Doctorwill most likely order x-rays of the injury. If a fragment of the distal phalanx was pulled away when the tendon ruptured, or if there is a larger fracture of the bone, it will appear in an x-ray. An x-ray will also show whether the injury pulled the bones of the joint out of alignment.


This x-ray shows that a piece of the distal phalanx bone broke away with the tendon.


Mallet finger injuries that are not treated typically result in stiffness and deformity of the injured fingertip. The majority of mallet finger injuries can be treated without surgery.
In children, mallet finger injuries may involve the cartilage that controls bone growth. The doctor must carefully evaluate and treat this injury in children, so that the finger does not become stunted or deformed.

Nonsurgical Treatment

Most mallet finger injuries are treated with splinting. A splint holds the fingertip straight (in extension) until it heals.


There are several types of splints used to treat mallet finger, many of them fabricated by hand therapists.

To restore function to the finger, the splint must be worn full time for 8 weeks. This means that it must be worn while bathing, then carefully changed after bathing. As the splint dries, you must keep your injured finger straight. If the fingertip droops at all, healing is disrupted and you will need to wear the splint for a longer period of time.


When removing the splint for cleaning and drying, the fingertip must stay in extension.


A temporary splint is applied with two pieces of tape.

Because wearing a splint for a long period of time can irritate the skin, your doctor may talk with you about how to carefully check your skin for problems. Your doctor may also schedule additional visits over the course of the 8 weeks to monitor your progress.

For 3 to 4 weeks after the initial splinting period, you will gradually wear the splint less frequently — perhaps only at night. Splinting treatment usually results in both acceptable function and appearance, however, many patients may not regain full fingertip extension.

For some patients, the splinting regimen is very difficult. In these cases, the doctor may decide to insert a temporary pin across the fingertip joint to hold it straight for 8 weeks.

Surgical Treatment

Doctor may consider surgical repair if there is a large fracture fragment or the joint is out of line (subluxed). In these cases, surgery is done to repair the fracture using pins to hold the pieces of bone together while the injury heals.

It is not common to treat a mallet finger surgically if bone fragments or fractures are not present. Surgical treatment of the damaged tendon usually requires a tendon graft — tendon tissue that is taken (harvested) from another part of your body — or even fusing the joint straight.


Posted on: October 11th, 2016 by admin No Comments

The posterior cruciate ligament is located in the back of the knee. It is one of several ligaments that connect the femur (thighbone) to the tibia (shinbone). The posterior cruciate ligament keeps the tibia from moving backwards too far.


An injury to the posterior cruciate ligament requires a powerful force. A common cause of injury is a bent knee hitting a dashboard in a car accident or a football player falling on a knee that is bent.


Two bones meet to form your knee joint: your thighbone (femur) and shinbone (tibia). Your kneecap sits in front of the joint to provide some protection.

Bones are connected to other bones by ligaments. There are four primary ligaments in your knee. They act like strong ropes to hold the bones together and keep your knee stable.

anatomyNormal knee anatomy, front view

Collateral ligaments. These are found on the sides of your knee. The medial collateral ligament is on the inside and the lateral collateral ligament is on the outside. They control the sideways motion of your knee and brace it against unusual movement.

Cruciate ligaments. These are found inside your knee joint. They cross each other to form an “X” with the anterior cruciate ligament in front and the posterior cruciate ligament in back. The cruciate ligaments control the back and forth motion of your knee.

The posterior cruciate ligament keeps the shinbone from moving backwards too far. It is stronger than the anterior cruciate ligament and is injured less often. The posterior cruciate ligament has two parts that blend into one structure that is about the size of a person’s little finger.


Injuries to the posterior cruciate ligament are not as common as other knee ligament injuries. In fact, they are often subtle and more difficult to evaluate than other ligament injuries in the knee.

Many times a posterior cruciate ligament injury occurs along with injuries to other structures in the knee such as cartilage, other ligaments, and bone.


A complete tear of the posterior cruciate ligament, back view.

Injured ligaments are considered “sprains” and are graded on a severity scale.

Grade 1 Sprains. The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly stretched, but is still able to help keep the knee joint stable.

Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose. This is often referred to as a partial tear of the ligament.

Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable.
Posterior cruciate ligament tears tend to be partial tears with the potential to heal on their own. People who have injured just their posterior cruciate ligaments are usually able to return to sports without knee stability problems.


An injury to the posterior cruciate ligament can happen many ways. It typically requires a powerful force.

  • A direct blow to the front of the knee (such as a bent knee hitting a dashboard in a car crash, or a fall onto a bent knee in sports)
  • Pulling or stretching the ligament (such as in a twisting or hyperextension injury)
  • Simple misstep


The typical symptoms of a posterior cruciate ligament injury are:

  • Pain with swelling that occurs steadily and quickly after the injury
  • Swelling that makes the knee stiff and may cause a limp
  • Difficulty walking
  • The knee feels unstable, like it may “give out”

Doctor Examination

During your first visit, doctor will talk to you about your symptoms and medical history.

During the physical examination, your doctor will check all the structures of your injured knee, and compare them to your non-injured knee. Your injured knee may appear to sag backwards when bent. It might slide backwards too far, particularly when it is bent beyond a 90° angle. Other tests which may help your doctor confirm your diagnosis include X-rays and magnetic resonance imaging (MRI). It is possible, however, for these pictures to appear normal, especially if the injury occurred more than 3 months before the tests.

X-rays. Although they will not show any injury to your posterior cruciate ligament, X-rays can show whether the ligament tore off a piece of bone when it was injured. This is called an avulsion fracture.


MRI. This study creates better images of soft tissues like the posterior cruciate ligament.


Sagittal and coronal T2-weitghted magnetic resonance images of the knee, showing upward displacement of the PCL insertion at the tibia (a) and the displaced fragment of the lateral tibial condyle (b and c).


Nonsurgical Treatment

If you have injured just your posterior cruciate ligament, your injury may heal quite well without surgery Your doctor may recommend simple, nonsurgical options.
RICE. When you are first injured, the RICE method – rest, ice, gentle compression and elevation — can help speed your recovery.

Immobilization. Your doctor may recommend a brace to prevent your knee from moving. To further protect your knee, you may be given crutches to keep you from putting weight on your leg.

Physical therapy. As the swelling goes down, a careful rehabilitation program is started. Specific exercises will restore function to your knee and strengthen the leg muscles that support it. Strengthening the muscles in the front of your thigh (quadriceps) has been shown to be a key factor in a successful recovery.

Surgical Treatment

Your doctor may recommend surgery if you have combined injuries. For example, if you have dislocated your knee and torn multiple ligaments including the posterior cruciate ligament, surgery is almost always necessary.

Rebuilding the ligament. Because sewing the ligament ends back together does not usually heal, a torn posterior cruciate ligament must be rebuilt. Your doctor will replace your torn ligament with a tissue graft. This graft is taken from another part of your body, or from another human donor (cadaver). It can take several months for the graft to heal into your bone.

Procedure. Surgery to rebuild a posterior cruciate ligament is done with an arthroscope using small incisions. Arthroscopic surgery is less invasive. The benefits of less invasive techniques include less pain from surgery, less time spent in the hospital, and quicker recovery times.

Surgical procedures to repair posterior cruciate ligaments continue to improve. More advanced techniques help patients resume a wider range of activities after rehabilitation.


Whether your treatment involves surgery or not, rehabilitation plays a vital role in getting you back to your daily activities. A physical therapy program will help you regain knee strength and motion. If you had surgery, physical therapy will begin 1 to 4 weeks after your procedure.

How long it takes you to recover from a posterior cruciate ligament injury will depend on the severity of your injury. Combined injuries often have a slow recovery, but most patients do well over time.

If your injury requires surgery, it may be several weeks before you return to a desk job – perhaps months if your job requires a lot of activity. Full recovery typically requires 6 to 12 months.

Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.


Posted on: September 25th, 2016 by admin No Comments


Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood to the round head of the femur (thighbone) is temporarily disrupted. Without an adequate blood supply, the bone cells die, the process is called avascular necrosis or osteonecrosis. This disease otherwise known as “Legg-Calve-Perthes syndrome”



There are four stages in Perthes Disease:

    • INITIAL/Necrosis: In this stage of the disease, the blood supply to the femoral head is disrupted and bone cells die. The area becomes intensively inflamed and irritated and your child may begin to show signs of the disease, such as a limp or different way of walking. The initial stage may last for several months.


In the FIRST STAGE of Perthes disease, the bone in the head of the femur slowly dies.

  • Fragmentation: Over a period of 1 to 2 years, the body removes the dead bone and quickly replaces it with an initial, softer bone. It is during this phase that the bone is in weaker state and the head of the femur is more likely to break apart and collapse.
  • Reossification: New, stronger bone develops and begins to shape in te head of femur. The Reossification stage is often the longest stage of the disease and can last a few years.
  • Healed: In this stage, the bone growth is complete and the femoral head has reached its final shape. How close the shape is to round will depend on several factors, including the extent of damage that took place during the fragmentation phase, as well as the child’s age at the onset of disease, which affects the potential for bone regrowth.

                                                 Lateral Pillar (HERRING) CLASSIFICATION:



The cause of Perthes disease is not known. Some recent studies indicate that there may be a genetic link to the development of Perthes, but more research need to be conducted.


One of the earliest signs of Perthes is a change in the way our child walks and runs. This often most apparent during sport activities. Your child may limp, or develop a peculiar running style. Other common symptoms may include:

  • Pain in the hip or groin or in other parts of the leg, such as the thigh or knee (called “referred pain”).
  • Pain that worsens with the activity and is relived with rest.
  • Painful muscle spasms that may be caused by irritation around the hip.

Depending upon your child’s activity level, symptoms may come and go over a period of weeks or even months before a doctor visit is considered.


After discussing your child’s symptoms and medical history doctor will conduct a thorough physical examination.

  • PHYSICAL EXAMINATION TESTS:Doctor will assess your child’s range of motion in the hip. This disease usually causes limitation in the movements (typically limits the ability to move the leg

away from the body {abduction}, and twist the leg toward the inside of the body {internal rotation}).

  • X-Rays: Perthes can be diagnosed with X-rays study of the hip. X-rays will show the condition of the femoral head.


In this x-ray, Perthes disease has progressed to a collapse of the femoral head (arrow). The other side is normal.


The goal of the treatment is to relieve painful symptoms, protect the shape of the femoral head and restore normal hip movement. If left untreated, the femoral head can deform and not fit well within the acetabulum, which can lead to further hip problems in adulthood.

There are many treatment options for Perthes disease. Doctor will consider several factors when developing a treatment plan for your child, including:

  • Your child’s age. Younger children (age 6 and below) have a greater potential for developing new, healthy bone.
  • The degree of damage to the femoral head. If more than 50% of the femoral head has been affected by necrosis, the potential for regrowth without deformity is lower.
  • The stage of disease at the time your child is diagnosed. How far along your child is in the disease process affects which treatment options your doctor will recommend.
  • Observation. For very young children (those 2 to 6 years old) who show few changes in the femoral head on their initial x-rays, the recommended treatment is usually simple observation. Doctor will regularly monitor your child using x-rays to make sure the regrowth of the femoral head is on track as the disease runs its course.
  • Anti-inflammatory medications.  Painful symptoms are caused by inflammation of the hip joint. Anti-inflammatory medicines are used to reduce inflammation, and doctor may recommend them for several months. As your child progresses through the disease stages, doctor will adjust or discontinue dosages.
  • Limiting Activity.  Avoiding high impact activities, such as running and jumping, will help relieve pain and protect the femoral head. Doctor may also recommend crutches or a walker to prevent your child from putting too much weight on the joint.
  • Physical therapy exercises.  Hip stiffness is common in children with Perthes disease and physical therapy exercises are recommended to help restore hip joint range of motion. These exercises often focus on hip abduction and internal rotation. Parents are often needed to help the child complete the exercises
  • Hip abduction. The child lies on his or her back, keeping knees bent and feet flat. He or she will push the knees out and then squeeze the knees together. Parents should place their hands on the child’s knees to assist with reaching a greater range of motion.
  • Hip rotation. With the child on his or her back and legs extended out straight, parents should roll the entire leg inward and outward.
  • Casting and bracing. If range of motion becomes limited or if x-rays or other image scans indicate that a deformity is developing, a cast or brace may be used to keep the head of the femur in its normal position within the acetabulum.


Petrie casts keep the legs spread far apart in an effort to maintain the hips in the best position for healing.

  • Arthrogram. During the procedure, doctor will take a series of special x-ray images called arthrograms to see the degree of deformity of the femoral head and to make sure he or she positions the head accurately. In an arthrogram, a small amount of dye is injected into the hip joint to make the anatomy even easier to see.
  • Tenotomy. In some cases, the adductor longus muscle in the groin is very tight and prevents the hip from rotating into the proper position. Doctor will perform a minor procedure to release this tightness called a tenotomy before applying the Petrie casts. During this quick procedure, your doctor uses a thin instrument to make a small incision in the muscle.

After the cast is removed, usually after 4 to 6 weeks, physical therapy exercises are resumed. Your doctor may recommend continued intermittent casting until the hip enters the final stage of the healing process


Doctor may recommend surgery to re-establish the proper alignment of the bones of the hip and to keep the head of the femur deep within the acetabulum until healing is complete. Surgery is most often recommended when:

  • Your child is older than age 8 at the time of diagnosis. Because the potential for deformity during the reossification stage is greater in older children, preventing damage to femoral head is even more critical.
  • More than 50% of the femoral head is damaged. Keeping the femoral head within the rounded acetabulum may help the bone grow into a functional shape.
  • Nonsurgical treatment has not kept the hip in correct position for healing.

The most common surgical procedure for treating Perthes disease is an osteotomy. In this type of procedure, the bone is cut and repositioned to keep the femoral head snug within the acetabulum. This alignment is kept in place with screws and plates, which will be removed after the healed stage of the disease.


An osteotomy of the femur places the femoral head in a better position to heal

In many cases, the femur bone is cut to realign the joint. Sometimes, the socket must also be made deeper because the head of the femur has actually enlarged during the healing process and no longer fits snugly within it. After either procedure, the child is usually placed in a cast for 6 to 8 weeks to protect the alignment.

After the cast is removed, physical therapy will be needed to restore muscle strength and range of motion. Crutches or a walker will be necessary to reduce weight bearing on the affected hip. Doctor will continue to monitor the hip with x-rays through the final stages of healing.


Posted on: September 20th, 2016 by admin No Comments


Any material used to support a fracture is known as splint.

  • Unconventional.
  • Conventional.


  • Temporary immobilization of sprains, fractures and reduced dislocations.
  • Control pain
  • Prevention of further soft tissue or neurovascular injuries.



  • Ladder splint.
  • Used temporary splint for fractures during transportation.
  • Made of 2 thick parallel wires with interacting wires.
  • Can be bent into different shapes.


  • Initially used for immobilization for tuberculosis of the knee.




  • ADVANTAGES: Angle of traction can be changed without changing traction arrangements. Simultaneous tractions possible.
  • DISADVANTAGE: Not suitable for transportation.









  • Splint should be properly applied, well-padded at bony prominences and at the fracture sites.
  • Bandage of the splint shouldn’t be too tight nor too loose.
  • Patient should be encouraged to actively exercise the muscles and the joints inside the splint as much as permitted.
  • Any compression of nerve or vessel should be detected early and managed accordingly.
  • Daily checking and adjustments should be made.






Traction is a method of restoring alignment to a fracture through gradual neutralization of muscular forces.


  • Reduction of fractures and dislocations.
  • Immobilizing painful and inflamed joint.
  • Preventing deformities.
  • Correction of soft tissue contractures.



Counter traction is provided by the part of the body.


Weight of the body under influence of gravity provides counter-traction.



  • Skin traction:
  • Adhesive/non adhesive strap is applied on the skin and traction is applied.
  • Acts over large area.
  • Maximum weight permissible 6-7kg.


  • Skeletal traction:

Traction applied through pin/wire driven through bone.


AGE Children Adults
APPLIED WITH Adhesive plaster Pin,wire
SITE Below knee Upper tibial pin traction
Wt.PERMITTED 3-4 kg 20kg
DURATION Short long


  • Over distraction.
  • Loss of position.
  • Pressure sores.
  • Tin track infection.
  • Injury to vessels or nerves.


  • Traction should be made comfortable.
  • Proper functioning of traction unit must be ensured.
  • Sensation over toes and fingers should be normal.
  • Proper position of fracture ensured by taking check x-rays in traction.
  • Physiotherapy of limb should be continued to minimize muscle strength(wasting).


Posted on: September 15th, 2016 by admin No Comments

Smith’s Fractures is also known as a Goyrand Fracture in French literature. Smith’s fracture is palmarly displaced distal radius fracture. It is referred to as “GARDEN SPADE” deformity. Smith’s fracture is a reversed Colles fracture.



Smith’s fracture account for less than 3% of all fractures of the radius and ulna and have a bimodal distribution: young males (most common) and elderly females.


Smith’s fractures usually occur in one of the 2ways:

  1. A fall onto a flexed wrist
  2. Direct blow to the back of the wrist




  1. Typically acute pain in the wrist from an impact or a fall.
  2. Tenderness in the affected area.
  3. Pain is felt while moving the wrist.
  4. Development of swelling.
  5. Wrist may become deformed.
  6. Appearance of hand being downwards.
  7. Fractured may develop a cracking noise.
  8. Symptoms of fever few hours after injury.


SMITH’S FRACTURE can be broadly be classified into two types.


This is frequently called as mild fracture. The treatment for this condition is casting. Once the problem is diagnosed immediate attention must be given. The area of the fracture gets healed in few weeks.


This type of fracture is very severe in nature. Displaced generally leads to very serious and dangerous damage to the bone. In this condition the joint of the wrist is often displaced forward creating discomfort over the wrist while moving in some angles.

Types of SMITH’S FRACTURE classified based on the type of injury.




  1. X-ray of the wrist.
  2. CT/MRI in rare cases




Smith’s Fractures can be treated with manipulation and reduction.


Conservatives measures involve closed reduction with use of local anesthesia and then casting of hand to thumb. It takes about 10 weeks for complete recovery, which involves period of immobilization for about a month and then splinting for 6 weeks.


Surgery is needed in majority of cases with Smiths Fracture as the deformity cannot be treated with nonsurgical means. This method is termed as OPEN REDUCTION.
This is done by creating an incision for interpretation of fracture and to get it back to its normal place. This at times requires pins, screws, etc for fixation.


This is essential for everyone for appropriate healing and normalizes function of wrist and hand can include:

  1. Joint mobilization.
  2. Soft tissue massages.
  3. Electrotherapy.
  4. Ice and heat.
  5. Therapy focusing on improving the strength.
  6. Activity modifications.
  7. Attempts at returning to activity.


Posted on: September 10th, 2016 by admin No Comments


Scoliosis is a lateral (toward the side) curvature in the normally straight vertical line of the spine. When viewed from the side, the spine should show a mild roundness in the upper back and shows a degree of swayback (inward  curvature) in the lower back. When a person with a normal spine is viewed from the front or back, the spine appears to be straight. When a person with scoliosis is viewed from the front or back, the spine appears to be curved.


What Causes Scoliosis?

There are many types and causes of scoliosis, including:

  1. Congenital Scoliosis. Caused by a bone abnormality present at birth.
  2. Neuromuscular Scoliosis. A result of abnormal muscles or nerves. Frequently seen in people with spina bifida or cerebral palsy or in those with various conditions that are accompanied by, or result in, paralysis.
  3. Degenerative Scoliosis. This may result from traumatic (from an injury or illness) bone collapse, previous major back surgery, osteoporosis (thinning of the bones).
  4. Idiopathic Scoliosis. The most common type of scoliosis, idiopathic scoliosis, has no specific identifiable cause. There are many theories, but none have been found to be conclusive. There is, however, strong evidence that idiopathic scoliosis is inherited.


Who Gets Scoliosis?

Approximately 2% to 3% of Americans at age 16 have scoliosis. Less than 0.1% have spinal curves measuring greater than 40 degrees, which is the point at which surgery becomes a consideration. Overall, girls are more likely to be affected than boys. Idiopathic scoliosis is most commonly a condition of adolescence affecting those ages 10 through 16. Idiopathic scoliosis may progress during the “growth spurt” years, but usually will not progress during adulthood.


How is Scoliosis Diagnosed?

Most scoliosis curves are initially detected on school screening exams, by a child’s pediatrician or family doctor, or by a parent. Some clues that a child may have scoliosis include uneven shoulders, a prominent shoulder blade, uneven waist, or leaning to one side. The diagnosis of scoliosis and the determination of the type of scoliosis are then made by a careful bone exam and an X-ray to evaluate the magnitude of the curve.


What is the treatment for Scoliosis?

The majority of adolescents with significant scoliosis with no known cause are observed at regular intervals (usually every four months to six months), including a physical exam and a low-radiation X-ray.


Treatments for Scoliosis Include:



Bracing is the usual treatment choice for adolescents who have a spinal curve between 25 degrees to 40 degrees — particularly if their bones are still maturing and if they have at least 2 years of growth remaining.
The purpose of bracing is to halt progression of the curve. It may provide a temporary correction, but usually the curve will assume its original magnitude when bracing is eliminated.



Those who have curves beyond 40 degrees to 50 degrees are often considered for scoliosis surgery. The goal is to make sure the curve does not get worse, but surgery does not perfectly straighten the spine. During the procedure, metallic implants are utilized to correct some of the curvature and hold it in the correct position until a bone graft, placed at the time of surgery, consolidates and creates a rigid fusion in the area of the curve. Scoliosis surgery usually involves joining the vertebrae together permanently– called spinal fusion.


Posted on: September 6th, 2016 by admin No Comments



A cervical rib is an extra rib that forms above the normal first rib, growing from the base of the neck just above the collarbone. The defect is present at birth, but usually not noticed until later in life.

It may be a fully-formed bony rib or just a thin strand of tissue fibers, which will not always show up on any X-ray or MRI scans you may have. If the extra rib is only partially formed, it may either end in a swelling that shows as a lump in the neck or it may tail off into a fibrous band of tissue that connects to the first proper rib.

A cervical rib can sometimes squash one of the nearby blood vessels or nerves, causing problems such as neck pain and numbness in the arm. These symptoms are collectively known as thoracic outlet syndrome.

Thoracic Outlet Syndrome


Not all people with a cervical rib will develop thoracic outlet syndrome, and thoracic outlet syndrome can also be caused by other conditions.

Two major blood vessels (the subclavian artery and subclavian vein) and a bunch of nerves called the brachial plexus pass over the cervical rib. They run through a narrow space at the base of the neck towards the armpit and arm.

A cervical rib will only cause any symptoms if it is squashing these blood vessels or nerves.

Symptoms of Thoracic Outlet Syndrome


If the extra rib does press on a vessel or nerve, you may have any of the following symptoms:

    1. pain in the shoulder and neck, which spreads into the arm – this may come and go or be constant
    2. moments where you lose feeling and have weakness or tingling in the affected arm and fingers
    3. moments where you can’t carry out fine hand movements, such as doing up buttons Raynaud’s phenomenon, where the blood vessels go into a temporary spasm, affecting blood supply to the fingers and toes (turning them white)
    4. a blood clot forming in the artery supplying the hand, which can affect the blood supply to the fingers, causing small patches of red or black discolouration
    5. swelling in the affected arm (although this is rare)

These symptoms vary widely from person to person: they may be mild or severe, be persistent or come and go.
Thoracic outlet syndrome usually starts between the ages of 20 and 50 years old, and women are more likely than men to have it.



Most people diagnosed with a cervical rib will find their symptoms get better with time, without treatment. Your GP may refer you to a physiotherapist for shoulder exercises designed to stretch and strengthen the neck region and correct any poor posture. The area may be massaged to release any tight or shortened neck tissues. A referral to an occupational therapist may also be useful, for advice on techniques to protect your back and neck while at work.

To relieve any pain and inflammation, your doctor may prescribe you an NSAID painkiller such as naproxen or diclofenac. If you develop thoracic outlet syndrome you may also be prescribed thrombolytic to break up any blood clots, and anticoagulantsto prevent further clots developing. If the above measures don’t help and the symptoms persist, you may wish to consider surgical treatment to remove the extra rib, although this is often a last resort.


Posted on: April 18th, 2016 by admin No Comments


Osgood-Schlatter disease is a common cause of knee pain in growing adolescents. It is an inflammation of the area just below the knee where the tendon from the kneecap (patellar tendon) attaches to the shinbone (tibia).

Osgood-Schlatter disease most often occurs during growth spurts, when bones, muscles, tendons, and other structures are changing rapidly. Because physical activity puts additional stress on bones and muscles, children who participate in athletics — especially running and jumping sports – are at an increased risk for this condition. However, less active adolescents may also experience this problem.




Painful symptoms are often brought on by running, jumping, and other sports-related activities. In some cases, both knees have symptoms, although one knee may be worse than the other.

  • Knee pain and tenderness at the tibial tubercle
  • Swelling at the tibial tubercle
  • Tight muscles in the front or back of the thigh



Treatment for Osgood-Schlatter disease focuses on reducing pain and swelling. This typically requires limiting exercise activity Untill the patient can enjoy activity without discomfort or significant pain afterwards. In some cases, rest from activity is required for several months, followed by a strength conditioning program. However, if the patient does not have a large amount of pain or a limp, participation in sports may be safe to continue.

  • Stretching exercises. Stretches for the front and back of the thigh (quadriceps and hamstring muscles) may help relieve pain and prevent the disease from returning.
  • Non-steroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.

Wound dehiscence

Posted on: April 16th, 2016 by admin No Comments


Its is an surgical complication. In which wound ruptures along surgical suture and also known as abdominal wound dehiscence. Its describe partial or complete post-operative separation of an abdominal wound closure.


  • It is an sub-acute infection.
  • Infection at the wound area.
  • Injury to the wound area.
  • Pressure on the sutures.
  • Weak tissue or muscle at the wound area.



  • Bleeding
  • Pain
  • Swelling
  • Redness
  • Fever
  • Opened wound
  • Broken suture


Risk Factor

  • Obesity
  • Hypertension
  • Over aged
  • Usually in female
  • Poor nutrition
  • Diabetes mellitus
  • Smoking
  • Surgical error
  • Long term use of corticosteroids.
  • Incorrect suture technique used to close operative area.


Wound Complication

  • Wound infection.
  • Chronic wound.
  • Hematoma.



  • Drug theraphy.
  • Antibiotics.
  • Medical treatment.
  • Surgical intervention.
  • Surgical removal of contaminated dead tissue.
  • Re-suturing.



  • To reduce stress on the wound edges.
  • Diabetes should to be control.
  • Cover the suture with sterile strips.
  • Use the antibiotics and clean the wound regularly.

A Case Report on Metal On Metal (Alval) Reaction Revision Hip Arthroplasty Done In 2 Stage Procedure

Posted on: March 17th, 2016 by admin No Comments


A 64 yrs old female was admitted on 21/06/2013 for Pain in left hip since March 2013(3 and ½ months). She also complained of inability to walk since 15 days. Patient was operated for FRACTURE NECK OF FEMUR 6yrs back and was alright for 2 yrs. After that vague pain started in her left Hip. Clinically left lower limb was short. Active straight leg test not possible. Movements of hip painful and limited. The recent X-Ray showed Dislocation of Hip Lt. Side. Planned for revision hip surgery.

Left hip was explored. There was no glutei muscle seen. The entire area was filled with ALVAL fluid. Acetabular Cup was removed with less difficulty. The coral stem was also removed. The upper one third of femur was Avascular. The further procedure was deferred for allowing the soft tissue to resolve. The entire ALVAL tissue was curetted as much as possible. So the surgery was not preceded.

During the second stage procedure, Revision hip with constrained hip system was done.


There are ongoing concerns regarding metal wear debris following the use of metal-on-metal (MoM) bearings for hip surface and total arthroplasty. A Type IV Hypersensitivity reaction to MoM articulations has previously been identified (aseptic lymphocyte dominated vasculitis associated lesion, ALVAL) but little is known of its incidence, diagnosis or management. Persisting groin pain in MoM patients may be undiagnosed ALVAL.

ALVAL- (Aseptic Lymphocyte Dominated Vasculitis Associated Lesion) is a medical reaction triggered by a soft tissue reaction in the body causing pain and inflammation and, where present, has affected some patients with metal on metal implants

Metallosis, another known complication is a medical condition resulting from a build-up of metallic debris in the surrounding soft tissue of the body. It has been reported that Metallosis can occur in patients with metal transplants and that these metal particles have been strongly linked to tissue damage, tumours, including Pseudo-tumours (an accumulated mass of inflamed tissue formed as a reaction to an irritant), high metal ion blood counts and blood poisoning.

ALVAL and Metallosis, when present in patients who had received metal on metal hip replacements are thought to be caused by incorrect placement of certain hip components in the patient, causing additional wear on these components. The hip resurfacing device functions as a metal bearing made of high carbon, cobalt and chromium alloys. If a patient is fitted with one of these implants, and the components are not aligned properly, then this malalignment of the bearing results in much more wear in that area, potentially causing a high- metal ion level as the debris and particles ( generated from the friction and wear of the metal components against one another) are released into the patient’s blood stream.

Current-generation MOM implants are made of cobalt-chromium alloys. A few authors have reported on an unusual mode of failure of these implants that is associated with a localized hypersensitivity reaction and immunologic response to metal wear debris: aseptic lymphocytic vasculitis associated lesion (ALVAL). The reported presenting features of ALVAL include early postoperative groin pain, radiographic loosening and osteolysis, recurrent dislocations, and periprosthetic fractures.

Case Report:

This is a single case reporting of a 64 years old female who was admitted for pain in her left hip since 3 and ½ months. She also complained of inability to walk since 15 days. Patient had a fall before 6 years and was diagnosed to have Fracture Neck of Femur. She was advised for Total Hip Metal on Metal prosthesis. She was operated with the same 6 years back. Initial 2 years after surgery she was completely alright doing all her routine activities. After 2 years she started to experience some vague pain over her operated hip. Initially the pain was vague but it increased progressively with days. She managed the pain with some analgesics and continued her routine activities.

Recently since 3 and ½ months she complaints of severe pain in her Left hip (old operated hip) followed by inability to walk since 15 days. On examination the Left Lower limb was shortened. The Active straight leg test was not possible. Greater trochanter was prominent on palpation. Range of movements was painfully restricted.

Clinical and radiological examination revealed Posterior dislocation of hip, loosening of the Cup & Osteolysis of the superior part of acetabulum and lateral cortex. So Decided to explore and proceed for revision hip.

  Stage 1 Procedure:

Under SA, with pt. in Rt. Lateral position with Lt. hip facing up, the hip was exposed by lateral approach.

There was no muscle tissue, namely the glutei which was found necrosed and fibrosed. The necrosed tissue was brittle and greyish in colour. The same was excised as much as possible.

The upper end of the femur was not having any muscle attachment and it was avascular.

The trochanteric region was curetted which was filled with necrotic tissue. The head was removed from the stem. It was not shiny.

The acetabulum was covered with thick whitish fibrous tissue which was not bleeding on cut. The granulation and fibrous tissue was cleared and cup exposed. There was erosion of Acetabular wall superiorly. It was tapped out gently and removed. The granulation tissue was curetted out till it started oozing in the floor of acetabulum.

The fibrous tissue was excised as much as possible. The upper end of the femur was osteotomized in form of window and stem was removed. There was no bleeding in the medullary canal. A portion of the bone was taken for biopsy. Good wash was given and the window was closed with stainless steel wire. Wound closed in layers with DT. Foam traction was given. Curetted material from acetabulum and gluteal region was sent for

  1. Culture sensitivity
  2. Histo pathological examination

Fig.3 Glutei found necrosed & fibrosed which is brittle &           Fig.4 Upper end of femur without any muscle attachment

Greyish white in colour (ALVAL)                                                       and found Avascular

Fig.5 Fibrosed being excised as much as possible                           Fig.6 Removed MOM Prosthesis

Fig.7 X-ray taken after Stage 1 procedure

Reasons for 2 Stage procedure:


The entire hip area was occupied by greyish brittle soft tissue (ALVAL Lesion). No delineation of the soft tissue namely the gluteus medius and the rotators. The entire muscles are necrosed.


As the earlier clinical, radiological and lab investigation do not reveal any evidence of infection, the materials were sent for to conform,

  1. No infection.
  2. Evidence of metal arthrosis (ALVAL).


The upper third of the femur was found Avascular.

So the surgery was not preceded.

The patient after the Stage 1 procedure was put on foam traction allowing soft tissues to resolve.

Fig.8 Histo pathological Report                                                   Fig.9 Microbiological Report

Now, as there is no evidence of infection, both culture and Histo pathological study and it is decided to revise the surgery with

  1. Constrained acetabulum.
  2. Proximal femur reconstruction.
  3. Solution to prevent loosening or rotation of stem.

Stage 2 Procedure:

Under GA, with Patient in Right lateral position with Left hip facing up, with the same incision left hip region was exposed. The upper end of femur looks better than what it was earlier. The acetabulum was cleaned & reamed up to 48mm. 48 shell was driven home with good version & 40 degrees abduction. The cup fixation was augmented with 3 screws. Trail liner was fixed & was found satisfactory.

Femur- The Greater Trochanter absent. Having Lesser Trochanter as a land mark, the femoral canal was reamed up to 14.5. The trail 15 stem with Calcar trial reduction was done with 0 size head. It was stable & satisfactory.

Hip dislocated. The trial stem removed & fixed with 15 size solution stem. 0 size trial head as fixed to the solution stem & hip reduced & found hip was stable. The trail liner was removed & replaced with constrained liner and it was stable. The selected 28 size head was fixed to the stem.

The augmenting liner was held to the neck. The liner was well cleaned. The groove in the constrained liner was cleaned & found satisfactory. The hip is reduced & keeping the head & neck perpendicular to the cup it was tapped nicely so that the head was driven in. Now the head is in good place. The augmenting ring was driven in to the groove of the liner. It was holding nicely. Hip movements tested & are stable. The window of the upper end of femur was placed back and held with S.S wire. Wound wash was given. The soft tissue was double breasted over the prosthesis. The rest of the wound is closed in layers with DT.

Fig.10 Upper end of Femur with good vascularity                           Fig.11 Constrained acetabulum in place

Fig.12 Upper end of femur reconstructed and trail fitting done       Fig.13 Femoral implant in place with constrained


Fig.14 Fitting of the selected Constrained Hip system                   Fig.15 Revised THA

Fig. 16 X-ray taken immediately after second stage Procedure


After the second stage procedure, patient was very comfortable with minimal pain and improved. Patient retained the abduction and adduction movements. Active mobilization of Non- weight bearing walking with walker was started on the 3rd post operative day. Alternate day dressing of the wound was done. The wound seemed very healthy. With all the above improvement it was decided to discharge the patient on the 7th day after dressing.

On the 7th day, there was slight ooze from the postero-lateral aspect of the wound. Immediately 2 sutures were removed and the ooze was cleaned. Good wound wash was given. Dressing was done. The ooze seemed to be serous discharge. It was sent for culture and sensitivity. The stay of the patient in the hospital was prolonged. The reports came out negative for any growth. It was proved to be serous discharge, probably because of the reaction of the soft tissues to the Metal. Everyday dressing was done. The surrounding wound healed well, but wound gaping was present in the postero-lateral aspect and serous discharge continued to ooze out.

Apart from the serous discharge, the patient recovered very well. She was comfortable with minimal pain. She was able to do Non- weight bearing walking with walker. On the 14th day post operatively, all the sutures were removed and patient was decided to be discharged from the hospital. The surrounding wound was very healthy. But still everyday dressing was done at home. She was reviewed periodically at the hospital and the serous discharge was sent to lab for culture and sensitivity periodically.

After 1 month postoperatively, the patient was called for review. Serous discharge has reduced to about 50% when compared to the earlier condition. Patient was made to do weight bearing walking with walker. She was very comfortable walking without any pain. Her movements over her hip and knee were restored. Continuous follow-up of the patient was done. Patient at present is very comfortable.