Sever’s Disease

Sever’s disease is a common cause of heel pain in children between the ages of 9 and 12 years. The pain is due to calcaneal apophysitis occurring due to repetitive and continuous traction on the calcaneus from the Achilles tendon. The apophysis is not part of a joint and has muscle or tendon attachments. This traction apophysitis may lead to stress fractures, pain and tenderness over the heel.

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Sever’s disease is similar to Osgood-schlatter disease of the tibial tubercle.

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Patients are usually young athletes presenting with heel pain that increases with activities. Upon examination there could be swelling, tenderness, warmth and/or redness on the back of the heel where the Achilles tendon inserts.

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Plain lateral X-rays may show sclerosis or fragmentation of the calcaneal tuberosity. Sclerosis is not specific for this condition.

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Fragmentation of the calcaneal tuberosity on the other hand, is more common in patients with Sever’s disease relative to the general population.

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Remember that Sever’s disease is a clinical diagnosis. X-rays may show other causes of pain such as tumors, fractures, infections or cysts. MRI is not commonly used, but can help rule out calcaneal stress fractures or osteomyelitis.

Sever’s disease is a self-limiting condition that usually resolves with time. Treatment usually consists of NSAID, Achilles tendon stretching exercises, and activity modifications and in severe condition a short leg walking cast can be used.

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Heat Illness in Athletes

As summer approaches, athletes, coaches and other individuals will need to be aware of heat-related illnesses. Heat illnesses include a spectrum of conditions ranging from heat syncope, heat cramps and heat exhaustion to the more severe heat stroke.

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Heat Syncope (fainting) is a form of orthostatic hypotension that is related to dehydration. It occurs due to inadequate cardiac output and hypotension. It also occurs with standing quickly after sitting or lying down for prolonged durations in the heat. Symptoms include fainting, dizziness and light-headedness. Treatment includes oral rehydration (water, juice or sports drinks) and placing the patient flat on the ground in a cool area with slight elevation of the legs to push the blood back to the vital organs such as the brain.

Heat Cramps are painful muscle cramps that occur due to decreased sodium heat2.pngconcentration in the blood. The patient’s core temperature is usually not elevated. Sodium may decrease when salts are lost in sweat or with excessive water intake that does not include electrolytes leading to a situation called dilutional hyponatremia. Symptoms include painful muscle cramps occurring commonly in the abdominal muscles, arms, legs and thighs. Treatment includes rest, cooling and IV fluids or oral rehydration with fluids rich in electrolytes (sports drinks and juices) to replenish the sodium stores. Prevention could be achieved by consumption of fluids high in electrolytes before strenuous activities.

heat3Heat Exhaustion is the most common heat illness. The body temperature becomes elevated but is less than 40°C. The core body temperature is best measured rectally. The signs and symptoms of heat exhaustion include profuse sweating, core body temperature lower than 40°C, weakness and fatigue, cramping, headaches, nausea and vomiting,  fainting, hypotension, increased heart rate, and fast shallow breathing. Treatment includes rest, IV fluids or oral rehydration and rapid cooling by whole-body immersion in an ice bath.

Heat Stroke is the most severe form of heat illness. It is a medical emergency that needs immediate attention. The patient should be transported to the hospital as soon as possible. Heat strokes occur due to failure of the body’s normal thermoregulatory mechanism. If treatment is not started promptly, end-organ failure and ultimately death may occur. Heat strokes have a high mortality rate and require quick reduction of the patient’s temperature. The three characteristic features of this condition are a lack of sweating, core body temperature above 40°C (best measured rectally) and an altered mental status. Additional signs and symptoms include hot, dry skin, disorientation, confusion and hallucinations, headache and slurred speech. This is a serious medical emergency that requires rapid core body temperature reduction. The patient should have close monitoring of airway, breathing and circulation. The physician should implement basic life support and ACLS protocols. Rapid cooling by whole-body immersion in an ice bath will be utilized as well as IV fluids.

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Hamate Fractures

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Fractures of the hamate bone are rare, difficult to diagnose, and routine x-rays may not show the fracture. Hamate fractures are classified as either a hook fracture or as a body fracture.

Hamate hook fractures are usually seen in individuals who participate in sports which involve a racquet, baseball bat, or from swinging a golf club.

Swinging of the golf club may cause a hook fracture of the Hamate bone. Missing the fracture can lead to persistent pain from nonunion.

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Hamate body fractures are associated with axial force trauma, such as a fist striking a hard object, a fall, or from crushing injuries. It may also be accompanied by 4th and 5th metacarpal subluxation. Coronal fractures are the most common type of Hamate body fractures.

There are three types of coronal fractures; Type A (large piece), Type B (moderate piece) and Type C (avulsion). Make sure to watch out for subluxation of the joint due to pull from the Extensor Carpi Ulnaris.

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Hook fractures of the Hamate are best seen by carpal tunnel or supination x-ray views. For hamate fractures, CT scan is the best study. A 30° pronated view is helpful for body fractures.

Clinical Evaluation

Pain will be present, especially with axial loading of the ring and little finger or by grasping an object. The patient will have dismissed grip strength. They may have ulnar and median nerve neuropathy symptoms. The most common findings are pain and tenderness on the ulnar side of the wrist, distal to the wrist joint.

The pull test has been recently described. This is when the palm of the hand is placed into supination, the wrist is in full ulnar deviation, and the fingers of the patient should be flexed. The examiner pulls on the ulnar two digits with the patient resisting the pull. A positive test with pain in the area of the hook indicates a fractures hook of hamate injury. Pain may also be felt due to compression of the ulnar nerve in the Guyon Canal.

Treatment                        

Early immobilization for acute fractures with short arm splint for 6 weeks will be used to avoid a nonunion. For symptomatic nonunion, excision of the fracture fragment will be needed.

Types A and B require open reduction and internal fixation, in addition to stabilization of the joint if needed. Type C requires closed reduction and percutaneous pinning of the fragment for stabilization of the joint. If a closed reduction of the joint is not adequate, open reduction and stabilization of the joint should be done. A displaced fragment with subluxation requires reduction of the joint and stabilization of the joint with K-wires or fixation of the fragment.

When a 4th or 5th carpometacarpal dislocation occurs, one should make special effort to find a coronal fracture of the hamate.

 

 

 

Marjolin’s Ulcer

Marjolin’s ulcer is a malignant tumor that usually develops into squamous cell sarcoma inside of an osteomyelitis sinus tract.

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Fungating soft tissue mass that increases in size and has a foul smell in addition to x-rays that show chronic osteomyelitis that may indicate malignant transformation. It usually takes a long time to develop (about 20 – 30 years).

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This tumor usually occurs in the lower extremity and can occur in association with burns, decubitus ulcer and venous ulcer. The skin lesion appears more aggressive with more metastasis (it also can spread to the lymph nodes). There is more recurrence than other types of skin cancers and it is associated with a high mortality rate.

The treatment is usually an amputation. Preservation of the extremity function through a wide resection may not be possible.

Difference between Marjolin’s ulcer and Mandura foot:

Majorlin’s ulcer is a malignant slow growing squamous cell carcinoma that usually develops inside of an osteomyelitis sinus tract. Mandura foot is localized swelling with multiple discharging sinuses (usually fungus). The discharge is grain filled or granular.

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