The image in the xray belongs to a 34 years old male who suffered fractures of right tibia and fibula in motor vehicle accident
The fracture was successfully managed by closed reduction and internal fixation using locked intramedullary nail.

Related posts:

1. Oblique Fracture Upper End Tibia – Anteroposterior and Lateral Views
2. Xray of Non Union of Shaft of Fibula
3. Xray of Fracture Fibula With Subluxation of Ankle

The xray in picture belongs to 38 years old young man who suffered this injury following a bike accident.

The patient was managed with tibial condylar plates and has his fracture united after 3 months of follow up. Because the injury is near the joint and fracture is oblique, surgery was considered for allowing the patient early mobilisation.

The patient has regained full knee movements.

Related posts:

1. Anteroposterior and Lateral Xarys of Fracture Shaft of Tibia and Fibula
2. Xray Of Comminuted Fracture of Upper End Of Tibia
3. AP and Lateral Views of Intercondylar Fracture of Humerus

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Pressing the  trigger point may cause local tenderness, referred pain, or local twitch response.

The trigger points frequently cause pain that frequently radiates from these points of local tenderness to broader areas, sometimes quite faraway from these points. In spite of being accepted them as a different entity, enough diagnostic criteria and cause of there origin is not known

The term “trigger point” was coined in 1942 by Dr. Janet Travell.

A typical trigger point is said to have following characteristics

• Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection.
• The painful point can be felt as a tumor or band in the muscle, and a twitch response/tenderness/referred pain can be elicited on stimulation of the trigger point.
• Palpation of the trigger point reproduces the patient’s complaint of pain

Not all trigger points may have these classical features though.

Pathophysiology

Exact mechanism is unknown.

The most recent proposed mechanism says  that trigger points are muscle spindles, made over-active by adrenalin stimulation. These very short muscle fibers (< 1 cm in length) called intrafusal muscle fibers  are activated by adrenalin via the sympathetic nervous system.

An event of muscular overload causes a prolonged release of calcium from the sarcoplasmic reticulum (storage unit for the muscle cell) which results in a sticking  cells leading  to a contracture with compression of capillaries and results in an increased local energy demand and local ischemia (loss of blood circulation) to the area. This energy crisis causes the release of chemicals that augment pain.

Types

Trigger points may be of following types

Active & Latent

An active trigger point is one that actively refers pain either locally or to another location

A latent trigger point is one that exists, but does not yet refer pain actively. It may do so when pressure or strain is applied to the myoskeletal structure containing the trigger point.

Key & Satellites

A key trigger point is one that has a pain referral pattern along a nerve pathway that activates a latent trigger point on the pathway, or creates it.

A satellite trigger point is one which is activated by a key trigger point.

Successfully treating the key trigger point often will resolve the satellite and return it from being active to latent, or completely treating it too.

Primary & Secondary.

A trigger point in many cases will biomechanically activate a secondary trigger point in another structure. The original trigger point is called primary trigger point.

Treating the primary trigger point does not treat the secondary trigger point.

What Activates A Trigger Point?

• Acute or chronic muscle overload
• Activation by other trigger points
• Psychological distress
• Direct trauma to the region
• Rradiculopathy ( Pain due to compression /trritation of nerve root
• Smoking

Where Can Trigger points Appear?

• Muscles
• Tendons
• Ligaments
• Skin
• Joint capsule
• Scar tissue.

Diagnosis

Trigger points are diagnosed by clinical history and examination that includes manual palpation. Pain patterns and a taut band or hard nodule guide to the diagnosis. A twitch response can be felt in the muscle by running finger perpendicular to the muscle’s direction. Pressing on an affected muscle can often refer pain.

Treatment

Treatment of trigger points involves  manual massage,  mechanical vibration, pulsed ultrasound, electrostimulation, ischemic compression, local anaesthetics/steroid injection, low Level Laser Therapy and stretching techniques that invoke reciprocal inhibition within the musculoskeletal system.

After trigger points have been deactivated, muscle and fascial stretching should be done by active/passive means stretching to be effective to prevent redevelopment.

Related posts:

1. Myofascial Pain Syndrome As Cause of Neck Pain
2. Approach To Patient With Neck Pain

• Disproportionate dwarfism : One or more body parts arerelatively large or small in comparison to those of a normal adult.
• Proportionate dwarfism: The body appears normally proportioned, but is clearly abnormally small.

Dwarfism is not necessarily a disorder. It can be a naturally occurring consequence of a person’s genetics.

Dwarfism can be classified by the location of the shortness or the structure causing it.

Location

In this proximal portion upper arm/thigh are taken as  root, leg/forearm as middle part and hands/feet as end. Accordingly dwarfism can be

• Rhizomelic : Involving bones of the upper arm or thigh
• Mesomelic  : Involving bones of the forearm or leg
• Acromelic  : Involving  bones of hands and feet.
• Micromelic : Entire limbs are shortened

Source

Achording to source dwarfism can be due disorders of  of cartilage, bone, vertebrae

Examples areachondroplasia, osseous dysplasia, chondrodystrophy etc.

Physical and Mental Effects of Dwarfism

They can vary according to the specific disease and may include

• Abnormal bone alignment
• Nerve compression
• Early degenerative joint disease
• Exaggerated lordosis or scoliosis
• Constriction of spinal cord or nerve roots can cause pain and disability.
• Reduced thoracic size can restrict lung growth and reduce pulmonary function.
• Disordered function of other organs

Mental Effects

They also vary according to the specific underlying syndrome. In most cases mental function is not impaired in any way. But some syndromes can affect the cranial structure and growth of the brain, severely impairing mental capacity.

Achondroplasia and growth hormone deficiency  are responsible for the majority of dwarfism cases.

The treatment and care depends on the effects and underlying cause, if treatable.

Skeletal Dysplasias Causing Short Limbs

Related posts:

1. Metatropic Dwarfism
2. Leri Weill Dyschondrosteosis
3. Achondroplasia

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• Leri Weill Dyschondrosteosis
• Pseudoachondroplastic Spondyloepiphysial Dysplasis or Mucopolysaccharidosis VI
• Mucopolysaccharidoses and Mucolipidoses
• Metatropic Dwarfism
• Hunter Syndrome-Type A

• Variable short stature
• Short forearms,
• Tibial/fibular shortening.

The height of these patients is usually is less than 25th percentile. The features become more  pronounced clinically during adolescence.

No other abnormalities are commonly associated.

Forearm shortening is  bilateral and appears almost identical to that in primary MD. One of the differentiating features is that  that the proximal radius is involved in patients with Leri Weill dyschondrosteosis whereas it is  not involved in primary Madelung deformity.

Both dyschondrosteosis and Madelung deformity are transmitted in an autosomal dominant fashion and the diseases are more predominant in  females.

This condition needs to differentiated in bilateral Madelung deformity. Many children with unilateral and bilateral Madelung deformity have normal stature and no other characteristic of dyschondrosteosis.

It apears that while they may be related but are separate entities.  In primary Madelung deformity without Leri Weill dyschondrosteosis the height of the child is above the 25th percentile in height and there would be no family  history of dyschondrosteosis.

A patient who is less than 5 feet tall at skeletal maturity with involvement of the proximal radius with relatively short tibia and fibula is likely to have Leri Weill dyschondrosteosis.

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1. Madelung Deformity
2. Skeletal Dysplasias Causing Short Limbs
3. Types of Dwarfism

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• Types of Dwarfism
• Pseudoachondroplastic Spondyloepiphysial Dysplasis or Mucopolysaccharidosis VI
• Mucopolysaccharidoses and Mucolipidoses
• Madelung Deformity
• Hunter Syndrome-Type A

The xrays are of 37 years old male who sustained injury in a fall following motor vehicle accident.

Upper one is AP (antero-posterior) view and lower one is lateral view.

This patient was managed by open reduction and internal fixation using reconstruction plates.

Related posts:

1. Oblique Fracture Upper End Tibia – Anteroposterior and Lateral Views
2. Xray of Intercondylar Fracture of Humerus
3. Xray of Fracture Lateral Condyle of Humerus

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• Xray of Supracondylar Fracture of Humerus In A Child
• Xray of Comminuted Fracture of Patella
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• Oblique Fracture Upper End Tibia – Anteroposterior and Lateral Views

The inorganic is mainly crystalline mineral salts and calcium and the organic part of matrix is mainly composed of Type I collagen.

Woven and lamellar bone are termed on microscopic differentiation of the bone.

On microspoe, two types of bone can be identified.

These bones differ in the pattern of collagen forming the osteoid.

Woven bone

Woven bone is characterised by haphazard organisation of collagen fibers and is mechanically weak.

Woven bone is produced when osteoblasts produce osteoid rapidly.

It is present in

• All feta bones initially when the bone is laid down. Later it gets replaced by lamellar bone.
• After fractures  the initial bone that unites the fracture is woven bone. It too gets replaced by lamellar bone.
• Paget’s disease.

Woven bone is weaker, with a smaller number of randomly oriented collagen fibers, but forms quickly. It has been named due to woven appearance of fibrous matrix [see figure]

Woven Bone Matrix

Lamellar bone

Lamellar bone has a regular parallel alignment of collagen into sheets (lamellae) and is mechanically strong.  It is highly organized in concentric sheets with a much lower proportion of osteocytes to surrounding tissue. Lamellar bone is stronger and filled with many collagen fibers parallel to other fibers in the same layer (osteons).

In cross-section, the fibers run in opposite directions in alternating layers. This kind o structural arrangement assists in the bone’s ability to resist torsion forces.

Note: A microscope is necessary to differentiate between the two.

Related posts:

1. How Does Bone Fracture Healing Occur!
2. A Look Into The Cells That Constitute Bone
3. Collagen In The Bone

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• Primary and Secondary Bone healing In Relation To Fractures
• Xray of Operated Fracture Lateral Condyle In A Child
• Xray of Intercondylar Fracture of Humerus
• Xray of Fracture of Medial Malleolus of Tibia
• Xray of Fracture Lateral Condyle of Humerus

The man also had quadriplegia.

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Each osteon consists of concentric layers, or lamellae, of compact bone tissue that surround a central canal, the Haversian canal.

The Haversian canal contains the bone’s nerve and blood supplies.

Osteoblasts form the lamellae sequentially, from the most external inward toward the Haversian canal.

Some of the osteoblasts develop into osteocytes, each living within its own small space also known as lacuna.

Osteocytes make contact with the cytoplasmic processes of their counterparts via a network of small canals, or canaliculi. This network facilitates the exchange of nutrients and metabolic waste.

The space between osteons is occupied by interstitial lamellae, which are the remnants of osteons that were partially resorbed during the process of bone remodelling.

Osteons are connected to each other and the periosteum by oblique channels called Volkmann’s canals.

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2. A Look Into The Cells That Constitute Bone
3. Blood Supply of Bones

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• Woven Bone and Lamellar Bone

In this kind of healing callus is not formed at all and  requires rigid stabilization with or without compression of the bone ends.

Rigid stabilization suppresses the formation of a callus in either cancellous or cortical bone .

Because most fractures are  managed in a way that results in some degree of motion, primary healing per se is rare.

Primary bone healing can be divided into gap healing and contact healing. Union occurs in both types.

Gap Healing

Gap healing occurs in two stages.

Firstly, the width of the gap is filled by direct bone formation. An initial scaffold of woven bone is laid down, followed by formation of  lamellar bone as support. The orientation of the new bone formed in this first stage is transverse to that of the original lamellar bone orientation.

In the second stage, which happens after several weeks, longitudinal Haversian remodeling reconstructs the necrotic fracture ends and the newly formed bone to replace the woven bone  with osteons of the original orientation. In the end, the normal bone structure results.

Contact Healing

Contact healing occurs where fragments are in direct apposition and osteons can grow across the fracture site, parallel to the long axis of the bone.

When fracture fragments are in contact, osteoclasts on one side of the fracture undergo a tunneling resorptive response, forming cutting cones that cross the fracture line.

This tunnelling  allows the penetration of capillaries and eventually the formation of new haversian systems. These blood vessels are then accompanied by endothelial cells and osteoprogenitor cells for osteoblasts leading to the production of osteons across the fracture line  eventually leading to regeneration of the normal bone architecture.

Secondary bone healing

It occurs when there is no rigid fixation of the fractured bone ends, which leads to the development of a fracture callus. It includes an inflammatory phase, a reparative phase, and a remodeling phase.

More about this type of healing can be found in following article

How Does Bone Fracture Healing Occur

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1. How Does Bone Fracture Healing Occur!
2. Factors Affecting Fracture Healing
3. Factors Influencing Fracture Healing

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