A club foot

8/6/2019 A club foot

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A club foot, orcongenital talipes equinovarus (CTEV),[1]

is a congenital deformity involvingone foot or both.

[2]The affected foot appears rotated internally at the ankle. TEV is classified

into 2 groups: Postural TEV or Structural TEV.

Without treatment, persons afflicted often appear to walk on theirankles, or on the sides of their

feet. It is a commonbirth defect, occurring in about one in every 1,000 live births.Approximately 50% of cases of clubfoot are bilateral. In most cases it is an isolated dysmelia.This occurs in males more often than in females by a ratio of 2:1. A condition of the same name

appears in animals, particularly horses.

Contents

[hide]

y 1 Deformitiesy 2 Causesy 3 Prenatal Screeningy 4 Treatment

o 4.1 Non-surgical treatment and the Ponseti Methodo 4.2 Surgical treatment

y 5 Famous peopley 6 In literaturey 7 In non-human animalsy 8 Referencesy 9 External links

[edit] Deformities

The deformities affecting joints of the foot occur at three joints of the foot to varying degrees.

They are[2]

y Inversion at subtalar jointy Adduction at talonavicular joint andy equinus at ankle joint, that is, aplantarflexed position, making the foot tend towards toe

walking.[3]

The deformities can be remembered using the mnemonic, "InAdEquate" forInversion,Adduction and Equinus.

[2]

[edit] Causes

There are different causes for clubfoot depending on what classification it is given. Structural

cTEV is caused by genetic factors such as Edwards syndrome, a genetic defect with three copies


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of chromosome 18. Growth arrests at roughly 9 weeks and compartment syndrome of theaffected limb are also causes of Structural cTEV. Genetic influences increase dramatically with

family history. It was previously assumed that postural cTEV could be caused by externalinfluences in the final trimester such as intrauterine compression from oligohydramnios or from

amniotic band syndrome. However, this is countered by findings that cTEV does not occur more

frequently than usual when the intrauterine space is restricted.

[4]

Breech presentation is alsoanother known cause.[citation needed] cTEV occurs with some frequency in Ehlers Danlos Syndromeand some other connective tissue disorders, such as Loeys-Dietz Syndrome (see www.loeys-

dietzsyndromecanada.org). TEV may be associated with other birth defects such as spina bifidacystica.

[edit] Prenatal Screening

Screening for club foot prenatally is a debatable topic. However, this is commonly done as it iseasily identified using a ultrasound scan. Most fetuses undergo a 20 weeks gestation fetal

abnormality scan[5]

in which club foot is one of the abnormalities that can be picked up. Some

doctors have argued that club foot may occasionally be associated with a syndromic disease andshould therefore be screened. If no syndromic association is found prenatally, most fetuses withclub foot are born and can live a normal life with medical treatment.

[edit] Treatment

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removed. (December 2009)

Clubfoot is treated with manipulation bypodiatrists,physiotherapists, orthopedic surgeons,specialist Ponseti nurses, ororthotists by providing braces to hold the feet in orthodox positions,serial casting, or splints called knee ankle foot orthoses (KAFO). Other orthotic options include

Dennis-Brown bars with straight last boots, ankle foot orthoses and/or custom foot orthoses(CFO). In North America, manipulation is followed by serial casting, most often by the Ponseti

Method. Foot manipulations usually begin within two weeks of birth. Even with successfultreatment, when only one side is affected, that foot may be smaller than the other, and often that

calf, as well.

Extensive surgery of the soft tissue or bone is not usually necessary to treat clubfoot; however,

there are two minimal surgeries that may be required:

1. Tenotomy (needed in 80% of cases) is a release (clipping) of the Achilles tendon minorsurgery local anesthesia

2. Anterior Tibial Tendon Transfer (needed in 20% of cases) where the tendon is movedfrom the first ray (toe) to the third ray in order to release the inward traction on the foot.

Of course, each case is different, but in most cases extensive surgery is not needed to treat

clubfoot. Extensive surgery may lead to scar tissue developing inside the child's foot. The


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scarring may result in functional, growth and aesthetic problems in the foot because the scarredtissue will interfere with the normal development of the appendage. A child who has extensive

surgery may require on average two additional surgeries to correct the issues presented above.

In stretching and casting therapy the doctor changes the cast multiple times over a few weeks,

gradually stretching tendons until the foot is in the correct position of external rotation. The heelcord is released (percutaneous tenotomy) and another cast is put on, which is removed after threeweeks. To avoid relapse a corrective brace is worn for a gradually reducing time until it is only at

night up to four years of age.

[edit] Non-surgical treatment and the Ponseti Method

Main article: Ponseti Method

Treatment for clubfoot should begin almost immediately to have the best chance for a successful

outcome without the need for surgery. Over the past 10 to 15 years, more and more success has

been achieved in correcting clubfeet without the need for surgery. The clubfoot treatment methodthat is becoming the standard in the U.S. and worldwide is known as the Ponseti Method.

[6]Foot

manipulations differ subtly from the Kite casting method which prevailed during the late 20th

century. Although described by Dr. Ignacio Ponseti in the 1950s, it did not reach a wideraudience until it was re-popularized around 2000 by Dr. John Herzenberg in the USA and in

Europe and Africa byNHS surgeon Steve Mannion while working in Africa. Parents of childrenwith clubfeet using the Internet

[7] also helped the Ponseti gain wider attention. The Ponseti

method, if correctly done, is successful in >95% of cases[8]

in correcting clubfeet using non- orminimal-surgical techniques. Typical clubfoot cases usually require 5 casts over4 weeks.

Atypical clubfeet and complex clubfeet may require a larger number of casts. Approximately

80% of infants require an Achilles tenotomy (microscopic incision in the tendon requiring only

local anesthetic and no stitches) performed in a clinic toward the end of the serial casting.

Throughout the past decade, physicians at Texas Scottish Rite Hospital for Children have beenstudying the effectiveness of both the Ponseti casting method and the French functional (physical

therapy) method of stretching, massaging and taping and comparing the results with patients whohave undergone surgery. Results of these studies have been presented at national and

international conferences, such as the Pediatric Orthopaedic Society of North America annualmeeting, the International Clubfoot Symposium, Brandon Carrell Visiting Professorship and the

American Academy of Orthopaedic Surgeons annual meeting, and have been published in theJournal of Pediatric Orthopaedics.

[9]

After correction has been achieved, maintenance of correction may require the full-time (23hours per day) use of a splintalso known as a foot abduction brace (FAB)on both feet,

regardless of whether the TEV is on one side or both, for several weeks after treatment. Part-time

use of a brace (generally at night, usually 12 hours per day) is frequently prescribed for up to 4years. Without the parents' participation, the clubfoot will almost certainly recur, because the

muscles around the foot can pull it back into the abnormal position. Approximately 20% ofinfants successfully treated with the Ponseti casting method may require a surgical tendontransfer after two years of age. While this requires a general anesthetic, it is a relatively minor


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surgery that corrects a persistent muscle imbalance while avoiding disturbance to the joints of thefoot.

The developer of the Ponseti Method, Dr Ignacio Ponseti, was still treating children with clubfeet

(including complex/atypical clubfeet and failed treatment clubfeet) at the University of Iowa

Hospitals and Clinics well into his9

0s. He was assisted by Dr Jose Morcuende, president of thePonseti International Association.

The long-term outlook[10] for children who experienced the Ponseti Method treatment iscomparable to that of non-affected children.

Watch a Video on the Ponseti Method

Botox is also being used as an alternative to surgery. Botox is the trade name for BotulinumToxin type A. a chemical that acts on the nerves that control the muscle. It causes some

paralysis(weakening) of the muscle by preventing muscle contractions (tightening). As part of

the treatment for clubfoot, Botox is injected into the childs calf muscle. In about 1 week theBotox weakens the Achilles tendon. This allows the foot to be turned into a normal position, overa period of46 weeks, without surgery.

The weakness from a Botox injection usually lasts from 36 months. (Unlike surgery it has no

lasting effect). Most club feet can be corrected with just one Botox injection. It is possible to doanother if it is needed. There is no scar or lasting damage. BC Women and Childrens Hospital

[edit] Surgical treatment

This section needs additional citations for verification.

Please help improve this article by adding reliable references. Unsourced material may be challenged andremoved. (December 2009)

On occasion, stretching, casting and bracing are not enough to correct a baby's clubfoot. Surgery

may be needed to adjust the tendons, ligaments and joints in the foot/ankle. Usually done at 9 to12 months of age, surgery usually corrects all clubfoot deformities at the same time. After

surgery, a cast holds the clubfoot still while it heals. It is still possible for the muscles in thechild's foot to try to return to the clubfoot position, and special shoes or braces will likely be used

for up to a year or more after surgery. Surgery will likely result in a stiffer foot than nonsurgicaltreatment, particularly over time.

Without any treatment, a child's clubfoot will result in severe functional disability, however withtreatment, the child should have a nearly normal foot. He or she can run and play without painand wear normal shoes. The corrected clubfoot will still not be perfect, however; a clubfoot

usually stays 1 to 1 sizes smaller and somewhat less mobile than a normal foot. The calfmuscles in a leg with a clubfoot will also stay smaller.

[edit] Famous people


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The club-foot, by Jos de Ribera.

Many notable people have been born with one or both feet in "clubbed" condition, includingRoman emperorClaudius, Egyptian pharaoh Tutankhamun, statesman Prince Talleyrand, Civil

War politician Thaddeus Stevens, comedian Damon Wayans, actorGary Burghoff, and Eric TheMidget from The Howard Stern Show, football players Steven Gerrard and Miguel Riffo, sledge

hockey playerMatt Lloyd, a Paralympian, mathematician Ben Greenberg, and filmmaker

Jennifer Lynch.

The British Romantic poet George Gordon, Lord Byron had a clubfoot, which caused him much

humiliation.

Comedian, musician, and actorDudley Moore was born with a club foot. This was mostlyunknown to the public as he wore one shoe with a slightly bigger sole to compensate when

walking.

The figure ice-skaterKristi Yamaguchi was born with a clubfoot, and went on to win figure

skating gold in 1992. The soccer starMia Hamm was born with the condition. Baseball pitcher

Larry Sherry, the 1959 World Series MVP, was born with club feet,[2] as was pitcherJim Mecir,and both enjoyed long and successful careers. In fact, it was suggested in the bookMoneyballthat Mecir's club foot contributed to his success on the mound; it caused him to adopt a strange

delivery that "put an especially violent spin" on his screwball, his specialty pitch. The SanFrancisco Giants held the record as the team with the all-time highest number of players with

clubbed feet as of July 2010, and Freddy Sanchez, one of its infielders, cites his ability toovercome the defect as a reason for his success.

[11]Tom Dempsey of theNew Orleans Saints,

born with a right club foot and no toes (this was his kicking foot), kicked an NFL record 63-yard


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(58 m) field goal. This kick became famous as the longest NFL field goal in history. FormerNFL quarterbackTroy Aikman beat being born with a clubfoot to enjoy a productive Hall of

Fame career.[12]

TheNaziPropaganda MinisterJoseph Goebbels had a right clubfoot (possibly incurred after

birth as a complication ofosteomyelitis),

[13]

a fact hidden from the German public by censorship.Because of this malformation, Goebbels needed to wear a leg brace. That, plus his short stature,led to his rejection for military service in World War I.

De Witt Clinton Fort, who served in the Confederate Army as a captain, was born with a

clubfoot, and he was known during the American Civil War as Captain "Clubfoot" Fort, C.S.A.

Tutankhamun had a club foot and a cleft palate, and it is likely that he needed a cane to walk.[14]

[edit] In literature

y The main character, Philip Carey, in W. Somerset Maugham's novel OfHuman Bondage,has a club foot, a central theme in the work.

y Hippolyte Tautain, the stable man at the Lion D'Or public house in Gustave Flaubert'snovelMadame Bovary is unsuccessfully treated for clubfoot by Charles Bovary, leading

to the eventual amputation of his leg.y Charlie Wilcox, the main character in Sharon McKay's novel Charlie Wilcox had a club

foot.y In Yukio Mishima's seminal novel The Temple ofthe Golden Pavilion the character

Kashiwagi has club feet which parallels the stutter of the main character, Mizoguchi.y In David Eddings'Malloreon series, Senji the sorcerer has a club foot.y In Caroline Lawrence's Roman Mysteries series, a character called Vulcan the blacksmith

appears in the book "The Secrets of Vesuvius". He reveals that he gained the nicknamebecause of his club foot.

y In Bernard Cornwell's "Warlord Chronicles," Mordred, King of Dumnonia, has a clubfoot that is often used as a symbol for his ugliness and weakness as a ruler.

y In Daniel Keyes' Flowers for Algernon Gimpy, one of Charlie's co-workers at the bakery,has a club foot.

y In Heinrich von Kleist's play The Broken Jug, the main character Judge Adam has a clubfoot, betraying him as the culprit who broke the jug.

[edit] In non-human animals


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Apparent club foot, thought to be from post-natal environmental conditions, not congenital

Severe club foot in apony, probably congenital in origin

Left hoof normal, right hoof possible grade one club foot

Club feet occur in other animals, notably equines. The condition is characterized by a strongly

uprightpastern and a corresponding rotation of the coffin bone in the hoof. The condition often

affects only one foot. Severity varies, with some animals usable for work or riding, and othersunsound for life. Careful farrierwork on the hooves can lessen the severity of many cases, and in


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certain circumstances surgery may be beneficial. The visible outward appearance of a club foothas different possible origins that include a genetic predisposition to the condition, a congenital

defect formed while the animal is in the womb, or problems with diet and bone developmentduring the early post-natal period. Certain horse breeds appear to be more predisposed to the

condition than others, but research has yet to identify the genes involved.

A grading scale exists to assess the severity of club feet, which are caused by a deep digitalflexor contraction syndrome. When the muscle fibers of the upper leg's deep ditigal flexor

muscle contract excessively, this affects the tendon of the same name that comes off of thismuscle group and attaches at the bottom of the coffin bone. A constant upward pull by the

tendon on the coffin bone and other structure of the horse's hoof creates the condition. Whilemany young foals are born with somewhat upright pasterns, the condition may resolve naturally

or with minimal intervention if begun early. However, some cases are so severe that more drastictreatment may be required

Definition

Clubfoot is when the foot turns inward and downward. It is a congenital condition, which meansit is present at birth.

Symptoms

The physical appearance of the foot may vary. One or both feet may be affected.

The foot turns inward and downward at birth, and is difficult to place in the correct position. Thecalf muscle and foot may be slightly smaller than normal

Causes & Risk Factors

Clubfoot is the most common congenital disorder of the legs. It can range from mild and flexible

to severe and rigid.

The cause is not known, but the condition may be passed down through familiesin some cases. Risk factors include a family history of the disorder and being

male. The condition occurs in about 1 out of every 1,000 live births. Tests &

Diagnostics

The disorder is identified during a physical examination. A foot x-ray may be done.


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Foot X-RayAn extremity x-ray is an image of the hands, wrist, or feet, or all of these areas. The term

"extremity" often specifically refers to a human hand or foot. X-rays are a form of radiation thatpenetrate the body to form an image on film. Structures... More

ADAM

History and Physical ExamDuring a physical examination, a health care provider studies a patient's body to determine the

presence or absence of physical problems. A typical physical examination includes: Inspection(looking at the body; Palpation (feeling the body with ha... More

ADAM

X-RayX-rays are a form of electromagnetic radiation, just like visible light. In a health care setting, a

machines sends are individual x-ray particles, called photons. These particles pass through thebody. A computer or special film is used to record...

Treatments

Treatment may involve moving the foot into the correct position and using a cast to keep it there.This is often done by an orthopedic specialist. Treatment should be started as early as possible --

ideally, shortly after birth -- when reshaping the foot is easiest.

Gentle stretching and recasting occurs every week to improve the position of the foot. Generally,five to 10 casts are needed. The final cast remains in place for3 weeks. After the foot is in the

correct position, a special brace is worn nearly full time for3 months. Then it is used at night andduring naps for up to 3 years.

Often, a simple outpatient procedure is needed to release a tightened Achilles tendon.

Some severe cases of clubfoot will require surgery if other treatments do not work, or if theproblem returns. The child should be monitored by a doctor until the foot is fully grown. See:

Clubfoot repair

Complications

Some defects may not be completely fixed. However, treatment can improve the appearance andfunction of the foot. Treatment may be less successful if the clubfoot is linked to other birth

disorders.


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Definition

If more pressure is put on a bone than it can stand, it will split or break. A break of any size is

called a fracture. If the broken bone punctures the skin, it is called an open fracture (compoundfracture).

A stress fracture is a hairline crack in the bone that develops because of repeated or prolongedforces against the bone.

Alternative Names

Bone - broken; Fracture; Stress fracture

Considerations

It is hard to tell a dislocated bone from a broken bone. However, both are emergency situations,and thebasic first aid steps are the same.

Causes

The following are common causes of broken bones:

y Fall from a heighty Motor vehicle accidentsy Direct blowy Child abusey Repetitive forces, such as those caused by running, can cause stress fractures of the foot,

ankle, tibia, or hip

Symptoms

y A visibly out-of-place or misshapen limb or jointy Swelling,bruising, or bleedingy Intense painy Numbness and tinglingy Broken skin with bone protrudingy Limited mobility or inability to move a limb

First Aid

1. Check the person's airway and breathing. If necessary, call 911 and begin rescuebreathing, CPR, orbleeding control.

2. Keep the person still and calm.


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y There is a suspected broken bone in the head, neck, or back.y There is a suspected broken bone in the hip, pelvis, or upper leg.y You cannot completely immobilize the injury at the scene by yourself.y There is severe bleeding.y An area below the injured joint is pale, cold, clammy, or blue.y

There is a bone projecting through the skin.

Even though other broken bones may not be medical emergencies, they still deserve medical

attention. Call your health care provider to find out where and when to be seen.

If a young child refuses to put weight on an arm or leg after an accident, won't move the arm orleg, or you can clearly see a deformity, assume the child has a broken bone and get medical help.

Prevention

y Wear protective gear while skiing, biking, roller blading, and participating in contactsports. This includes helmets, elbow pads, knee pads, and shin pads.

y Create a safe home for young children. Gate stairways and keep windows closed.y Teach children how to be safe and look out for themselves.y Supervise children carefully. There is no substitute for supervision, no matter how safe

the environment or situation appears to be.

y Prevent falls by not standing on chairs, counter tops, or other unstable objects. Removethrow rugs and electrical cords from floor surfaces. Use handrails on staircases and non-

skid mats in bathtubs. These steps are especially important for the elderly.

Introduction to fracture

Bones form the skeleton of the body and allow the body to be supported against gravity and to

move and function in the world. Bones also protect some body parts, and the bone marrow is theproduction center for blood products.

Bone is not a stagnant organ. It is the body's reservoir of calcium and is always undergoing

change under the influence of hormones. Parathyroid hormone increases blood calcium levels byleeching calcium from bone, while calcitonin has the opposite effect, allowing bone to accept

calcium from the blood.

What causes a fracture?

When outside forces are applied to bone it has the potential to fail. Fractures occur when bonecannot withstand those outside forces. Fracture, break, or crack all mean the same thing. One


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term is not better or worse than another. The integrity of the bone has been lost and the bonestructure fails.

Broken bones hurt for a variety of reasons including:

yThe nerve endings that surround bones contain pain fibers and and these fibers becomeirritated when the bone is broken or bruised.

y Broken bones bleed, and the blood and associated swelling (edema) causes pain.y Muscles that surround the injured area may go into spasm when they try to hold the

broken bone fragments in place, and these spasms cause further pain.

Often a fracture is easy to detect because there is obvious deformity. However, at times it is noteasily diagnosed. It is important for the physician to take a history of the injury to decide what

potential problems might exist. Moreover, fractures don't always occur in isolation, and theremay be associated injuries that need to be addressed.

Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces on the

bone may determine what type of injury that occurs. Descriptions of fractures can be confusing.They are based on:

y where in the bone the break has occurred,y how the bone fragments are aligned, andy whether any complications exist.

The first step in describing a fracture is whether it is open or closed. If the skin over the break isdisrupted, then an open fracture exists. The skin can be cut, torn, or abraded (scraped), but if the

skin's integrity is damaged, the potential for an infection to get into the bone exists. Since thefracture site in the bone communicates with the outside world, these injuries need to be cleaned

out aggressively and many times require anesthesia in the operating room to do the jobeffectively.

Next, there needs to be a description of the fracture line. Does the fracture line go across the

bone (transverse), at an angle (oblique) or does it spiral? Is the fracture in two pieces or is itcomminuted, in multiple pieces?


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Finally, the fracture's alignment is described as to whether the fracture fragments are displaced or

in their normal anatomic position. If the bones fragments aren't in the right place, they need to bereduced or placed back into their normal alignment.

What are common types of fractures?

Stress fracture

A stress fracture is an overuse injury. Because of repeated micro-trauma, the bone can fail to

absorb the shock that is being put upon it and become weakened. Most often it is seen in thelower leg, the shin bone (tibia), or foot. Athletes are at risk the most, because they have repeatedfootfalls on hard surfaces. Tennis players, basketball players, jumpers, and gymnasts are

typically at risk. A March fracture is the name given to a stress fracture of the metatarsal or longbones of the foot. (It is named because it often occurs in soldiers who are required to march long

distances.)

Diagnosis is made by history and physical exam, though on occasion a bone scan may be done toconfirm the diagnosis.

Treatment is conservative, rest, ice, and anti-inflammatory medication like ibuprofen. These

fractures can take six to eight weeks to heal (as long as the fracture can be seen on x-ray). Tryingto return too quickly can cause re-injury, and may also allow the stress fracture to extend through

the entire bone.

Shin splints may have very similar symptoms as a stress fracture of the tibia but they are due to

inflammation of the lining of the bone, called theperiosteum. Shin splints are caused by overuse,especially in runners, walkers, dancers, including those who do aerobics. Muscles that run

through the periosteum and the bone itself may also become inflamed.


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Treatment is similar to a stress fracture and physical therapy can be helpful.

Compression fracture

As people age, there is a potential for the bones to develop osteoporosis, a condition where bones

lose their calcium content. This makes bone more susceptible to breaking. One such type ofinjury is a compression fracture to the spine, most often the thoracic or lumbar spine. Since weare an upright animal, if the bones of the back are weaker than the force of gravity these bones

can crumple. Pain is the major complaint, especially with movement.

Compression injuries of the back may or may not be associated with nerve orspinal cord injury.An x-ray of the back can reveal the bone injury, however, sometimes a CT scan orMRI will be

used to insure that no damage is done to the spinal cord.

Treatment includespain medication and often a back brace. Some compression fractures can also

be treated with vertebroplasty. Vertebroplasty involves inserting a glue-like material into the

center of the collapsed spinal vertebra in order to stabilize and strengthen the crushed bone. Theglue (methylmethacrylate) is inserted with a needle and syringe through anesthetized skin intothe midportion of the vertebra under the guidance of specialized x-ray equipment. Once inserted,

the glue soon hardens, forming a cast-like structure with the locally broken bone.

Rib fracture

The ribs are especially vulnerable to injury and are prone to breaking due to a direct blow. Rib x-rays are rarely taken as it doesn't matter if the rib is broken or just bruised. A chest x-ray is

usually taken to make certain there is no collapse or bruising of the lung.

When we breathe, it is like a bellows. We inhale air into our lungs and the ribs move out and thediaphragm moves down. When a person has a rib injury, the pain associated with it makes

breathing difficult, and the person has a tendency to not take deep breaths. If the lung underlyingthe injury does not expand, it is at risk for infection. The person is then susceptible topneumonia

(lung infection),which is characterized by fever, cough, and shortness of breath.

As opposed to other parts of the body that can rest when they are injured, it is very important to

take deep breaths to prevent pneumonia when rib fractures are present. The treatment for bruisedand broken ribs is the same: ice to the chest wall, ibuprofen as an anti-inflammatory, deep

breaths and pain medication. Even if all goes well, there will be significant pain for four to sixweeks.

With lower rib fractures, there may be concern about organs in the abdomen that the ribs protect.

The liver is located under the ribs on the right side of the chest, and the spleen under the ribs onthe left side of the chest. Many times your doctor may be more worried about abdominal injury

than about the broken rib itself. Ultrasound or CT scan may help diagnosis intra-abdominalinjuries.

Skull fracture


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With the wide availability of CT scans, skull x-rays are rarely taken to diagnose head injury. If ahead injury exists, the physician will feel or palpate the scalp and skull to determine if there may

be a skull fracture. He will also look into the ears to see if there is blood behind the ear drummand he will also complete a neurologic examination.

The skull is a flat, compact bone and it takes significant force to break it. If a skull fractureexists, there is an increased likelihood of bleeding in the brain, especially in children. There areguidelines that are available to decide whether a CT scan is indicated (needed).

Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed

disorientation in patients with a GCS (Glasgow Coma Score) score of 13-15. With minor headinjury, the following risk groups are considered when evaluating need for CT brain scan:

High riskfor potential neurosurgical operation

y Abnormal neurologic exam within two hours after injuryy Suspected open or depressed skull fracturey Any sign of basal skull fracture (blood behind the ear drum, blackened eyes, clear fluid

running from the ears, or bruising behind the ear)

y Vomiting - two episodesy 65 years of age or older

Medium risk(for brain injury on CT)

y Amnesia before impact - more than 30 minutesy Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor

vehicle, fall from height greater than 3 feet or five stairs)

Fracture in children

Children can break bones and yet have normal x-rays. Fractures appear as clear lines through thebone on an x-ray through the bone. If calcium hasn't yet accumulated in the repairing bone, the

break may not be apparent. This lack of calcification happens in two ways.

1. Bones mature at different times in a child's development and while the bony structure isthere, it may have more cartilage than calcium.

2. The second situation is associated with growth plates. Each bone has an area where cellactivity is maximal and where the bone grows. These areas appear as lucent lines on x-


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ray. It may be one of the weaker points in the bone as well, and a fracture through thegrowth plate may not be seen.

The doctor needs to match the history and physical exam with what is seen on x-ray to make to a

diagnosis. Sometimes, the child is placed in a cast for a period of time to protect the broken limb.

As fractures heal, the body lays down extra calcium as building material and then remodels it tonormal shape. After7-10 days, there may be evidence on x-ray of the healing calcium to confirmthe fracture.

Growth plate fractures are classified by Salter-Harris category. When a break occurs through the

growth plate, it can involve different parts of the bone on each side of the plate. It is importantthat these fractures are aligned properly so that the bone grows properly as the child ages. For

more, please read the Growth Plate Fractures in Children article.

Children are more flexible than adults until the calcium completely solidifies their bone. If you

think of an arm or leg bone as tubular, sometimes only one side of the bone breaks, just like an

immature branch on a tree. This is referred to as a greenstickfracture, and may need to be "set"so that it heals properly. Sometimes the bones can bend but not break because they are so pliable.This is called a plastic deformity and again will need to be set or aligned to allow proper healing.

How is a fracture diagnosed?

When you arrive for medical care, the doctor will take a history of the injury. Where, when, and

why did the injury occur? Did the person trip and fall, or did they pass out before the fall? Arethere other injuries that take precedence over the fracture? For example, a person who falls and

hurts their wrist because they had a stroke orheart attackwill have their fracture care delayed toallow care for the life threatening illness. The injured area will be examined and a search will

happen for potential associated injuries. These include damage to skin, arteries and nerves.

Pain control is a priority and many times, pain medication will be prescribed before the diagnosisis made. If the doctor believes that an operation is likely, pain medication will be given through

an intravenous (IV) line or by an injection into the muscle. This allows the stomach to remainempty for potential anesthesia.

A decision will be made whether x-rays are required, and which type of x-ray should be taken tomake the diagnosis and better assess the injury. There are guidelines in place to help doctors

decide if an x-ray is necessary. Some include the Ottawa ankle and knee x-ray rules.

The body is three dimensional, and plain film x-rays are only two dimensional. Therefore, two orthree x-rays of the injured areas may be taken in different positions and planes to give a true

picture of the injury. Sometimes the fracture will not be seen in one position, but is easily seen inanother.

There are areas of the body where one bone fracture is associated with another fracture at a more

distant part. For example, the bones of the forearm make a circle and it is difficult to break justone bone in that circle. Think of trying to break a pretzel in just one place, it is difficult to do.


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Therefore broken bones at the wrist may be associated with an elbow injury. Similarly, an ankleinjury can be accompanied by a knee fracture. The doctor may x-ray areas of the body that don't

initially appear to be injured.

Occasionally, the broken bone isn't easily seen, but there may be other signs that a fracture

exists. In elbow injuries, fluid seen in the joint on x-ray is an indicator of a subtle fracture. Andin wrist injuries, fractures of the scaphoid or navicular bone may not show up on x-ray for one totwo weeks, and diagnosis is made solely on physical examination with swelling and tenderness

over the snuffbox at the base of the thumb.

In children, bones may have numerous growth plates that can cause confusion when reading anx-ray. Sometimes, the doctor will choose to x-ray the opposite arm or leg to determine what

normal is for the child before deciding whether a fracture exists.

What is the treatment of a fracture?

Initial treatment for fractures of the arms, legs, hands and feet in the field include splinting theextremity in the position it is found, elevation and ice. Immobilization will be very helpful withinitial pain control. For injuries of the neck and back, many times, first responders or paramedics

may choose to place the injured person on a long board and in a neck collar to protect the spinalcord from potential injury.

Once the fracture has been diagnosed, the initial treatment for most limb fractures is a splint.

Padded pieces of plaster or fiberglass are placed over the injured limb and wrapped with gauzeand an elastic wrap to immobilize the break. The joints above and below the injury are

immobilized to prevent movement at the fracture site. This initial splint does not go completelyaround the limb. After a few days, the splint is removed and replaced by a circumferential cast.

Circumferential casting does not occur initially because fractures swell (edema). This swellingwould cause a build up of pressure under the cast, yielding increased pain and the potential for

damage to the tissues under the cast.

Surgery

Surgery on fractures are very much dependent on what bone is broken, where it is broken, and

whether the orthopedic surgeon believes that the break is at risk (for staying where it is) once thebone fragments have been aligned. If the surgeon is concerned that the bones will heal

improperly, an operation will be needed. Sometimes bones that appear to be aligned normally aresplinted, and at a recheck appointment, are found to be unstable and require surgery.

Surgery can include closed reduction and casting, where under anesthesia, the bones are

manipulated so that alignment is restored and a cast is placed to hold the bones in that alignment.Sometimes, the bones are broken in such a way that they need to have metal hardware inserted to

hold them in place. Open reduction means that, in the operating room, the skin is cut open andpins, plates, or rods are inserted into the bone to hold it in place until healing occurs. Depending

on the fracture, some of these pieces of metal are permanent (never removed), and some aretemporary until the healing of the bone is complete and surgically removed at a later time.


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