CTEV : congenital talipes equino varus ( club foot )

INTRODUCTION :

Clubfoot can be classified as (1) postural or positional or (2) fixed or rigid. Postural or positional clubfeet are not true clubfeet. Fixed or rigid clubfeet are either flexible (ie, correctable without surgery) or resistant (ie, require surgical release, though this is not entirely true according to the Ponseti experience^{1, 2, 3}).
The Pirani, Goldner, Di Miglio, Hospital for Joint Diseases (HJD), and Walker classifications have been published, but no classification system is

Gustilo's classification of open fractures

Gustilo Classification
I	Low energy, wound less than 1 cm
II	Wound greater than 1 cm with moderate soft tissue damage
III	High energy wound greater than 1 cm with extensive soft tissue damage
	IIIA	Adequate soft tissue cover
	IIIB	Inadequate soft tissue cover
	IIIC	Associated with arterial injury

Enneking staging of bone tumors

Enneking System for Staging Benign and Malignant Musculoskeletal Tumors

BENIGN

1.    Latent

2.    Active

3.    Aggressive

MALIGNANT

Stage	Grade	Site	Metastases
IA	Low	Intracompartmental	None
IB	Low	Extracompartmental	None
IIA	High	Intracompartmental	None
IIB	High	Extracompartmental	None
III	Any	Any	Regional or distant metastases

Mangled Extremity Severity Score

*LIMB SALVAGE Vs AMPUTATION :

*To predict which limbs will be salvageable after trauma, available scoring systems include the predictive salvage index, the limb injury score, the limb salvage index, the mangled extremity syndrome index, and the mangled extremity severity score. Of these, the Mangled extremity severity score was found to be most useful.

*This system, which is easy to apply, grades the injury on the basis of the energy that caused the injury, limb ischemia, shock, and the patient's age.

*The system was subjected to retrospective and prospective studies, with a score of 6 or less consistent with a salvageable limb. With a score of 7 or greater, amputation was the eventual result.

*Although we do not strictly follow these guidelines in all patients, we do calculate and document a mangled extremity severity score in the chart whenever we are considering primary amputation versus a complicated limb salvage.

*Mangled Extremity Severity Score

Type	Characteristics	Injuries	Points
1	Low energy	Stab wounds, simple closed fractures, small-caliber gunshot wounds	1
2	Medium energy	Open or multiple-level fractures, dislocations, moderate crush injuries	2
3	High energy	Shotgun blast (close range), high-velocity gunshot wounds	3
4	Massive crush	Logging, railroad, oil rig accidents	4
Shock Group
1	Normotensive hemodynamics	BP stable in field and in OR	0
2	Transiently hypotensive	BP unstable in field but responsive to intravenous fluids	1
3	Prolonged hypotension	Systolic BP <90 mm Hg in field and responsive to intravenous fluid only in OR	2
Ischemia Group
1	None	Pulsatile limb without signs of ischemia	0[*]
2	Mild	Diminished pulses without signs of ischemia	1[*]
3	Moderate	No pulse by Doppler, sluggish capillary refill, paresthesia, diminished motor activity	2[*]
4	Advanced	Pulseless, cool, paralyzed, and numb without capillary refill	3[*]
Age Group
1	<30 y		0
2	>30 – <50 y		1
3	>50 y		2

BP, blood pressure; OR, operating room.

*	Points × 2 if ischemic time exceeds 6 hours

Differences between Gout and Pseudogout

GOUT	PSEUDOGOUT
1.       Smaller joints	1.       Large joints
2.       Intense pain	2.       Moderate pain
3.       Joint inflamed	3.       Joint swollen
4.       Hyperuricemia	4.       Chondrocalcinosis
5.       Uric acid crystals	5.       Calcium pyrophosphate crystals
6.       Rod shaped crystals	6.       Rectangular shaped crystals
7.       Negatively bisfringent	7.       Positive bisfringence

Causes of Pseudoarthrosis

*Pseudoarthrosis is a false joint, that may develop after a fracture that has not united properly.

*It may be idiopathic.

*Causes of Pseudoarthrosis (in decreasing order of frequency are) :
1. Non union of a fracture - including pathological fracture.
2. Congenital - in the middle to lower third of the tibia with or without fibula. 50% present in the first year. Later there may be cupping of the proximal bone and pointing of the distal bone end.
3. Neurofibromatosis - seen in 50% of patients with pseudoarthrosis.
4. Osteogenesis imperfecta
5. Cleidocranial dysplasia - congenitally in the femur
6. Fibrous dysplasia
7. Ankylosing spondylitis - in the fused bamboo spine .

Causes of Osteolytic and Osteoblastic metastases

*Causes of Osteolytic metastasis :
- Kidney (expansile) and Thyroid : Expansile lytic osseous metastasis are characteristic of Renal cell carcinoma (kidney) and Thyroid .
- Lung
- Gastrointestinal tract (GIT)
- Breast (occasionally)
- Less commonly melanoma, carcinoma of bronchus and pheochromocytoma may also present with Expansile lytic lesions.

*Causes of Osteoblastic metastasis :
- Prostate
- Breast (may be mixed)
- Seminoma
- Carcinoid 
- Neurogenic tumors
- Uterus  - Ovary