Kicking it.

 Young bloke presents after footy practice last week. Kicking when had sudden pain in his right groin. Did what most do and ignored but still painful and has not improved with rest.

He had been reviewed by the team physio and given a diagnosis of a sprain and persisted playing through his pain.

O/E
Fit young man.
Tender on even passive motion at the hip. Power of hip flexion and knee extension both reduced due to pain.

Clinical suspicion leads you to order a pelvic X-ray.

HIP

 

HIP 2
The above films show an avulsion fracture of the Anterior inferior iliac spine. with minor separation.

 

Avulsion fractures of the pelvis.

Points to remember:

Pelvic avulsion fractures are seen in patients aged 14 to 25.

This fracture is due to forced hip flexion often eccentric breaking the physis.

Most common are Ischial tuberostiy approx 50% (sprinters/tennis players)

Anterior inferior iliac spine (15-20%) (kicking as above)

Anterior superior iliac spine (15-20%) (also sprinting)

Treatment is conservative unless significant (1.5cm+) seperation has occured. very important to slowly return to activity as re-injury is common.

I have a low threshold for imaging young atheletes with injuries sustained at times of maximum effort as these fractures are common and do follow a different course to a standard sprain. (slower and more painful generally)

A beautiful summary image of these fractures from learning radiology

IMG_0273-0.JPG

Refs: http://www.learningradiology.com/archives06/COW%20205-Ischial%20Avulsion%20Fx/avulseischiumcorrect.htm

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2465275/

An Awful case and pun.

A 70yo woman presents to ED with the following lesions which have been present for 2 weeks now and have steadily progressed from small raised areas into the large, painful areas seen below with moderate amounts of necrosis.

The patient had presented to ED a week earlier and was given a presumptive diagnosis despite the lack of obvious exposure. some antibiotics given for probable secondary infection at that time.

She has no history of major diseases of any kind other than well controlled hypertension (on metoprolol)

 No allergies.

photo_1

She is a keen gardener who has a pet dog. She has not visited any farms or abattoirs in the recent past.

 

photo_2   photo_5 photo_4

Further advice was sought from dermatology (email photos sent) which received the following reply:

“Hi
Thanks for these excellent photos of Orf, probably acquired via contact with a sheep, goat or other animal. Symptomatic management with a topical antiseptic such as Betadine dressings and analgesics is correct.”

Orf is a parapox virus which is passed amongst sheep, goats and a number of other animals (including red squirrels apparently)

It causes lesions like those shown but often much less impressive with papules which often burst releasing purulent (and infective) material.

Most people effected by orf are shearers, farmers and of concern to myself is children with pet lambs.

 kids feeding the lambs

Orf is something that presents reasonably frequently to GP land here in rural(ish) NZ. Many of the people most at risk for orf often treat themselves. Stories of shearers curetting their own lesions abound.

Follow up (2 weeks later)

As you can see most of the lesions have improved significantly with almost complete resolution of some of the later lesions which never ruptured.

photo_4 b photo_3 b photo_1 b

Final  follow-up 8-10 weeks post initial presentation:

I’ve since seen the patient at the supermarket and can confirm complete resolution without any scarring of all of the lesions. She now gardens with gloves on and thinks the only possible exposure was something her dog must have rolled in.

One of the best going cases of Orf I have seen. It can be much more aggressive in those with immunocompromised but as mentioned earlier the patient is very fit and well with no major health issues.

So there you have it one Orful case… *drops mic*

PS. Sorry I Haven’t posted in ages. Will do better in future. :)

References: 

http://lifeinthefastlane.com/what-is-orf/

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