Camptodactyly

 

Camptodactyly is a fixed flexion deformity at the PIP joint of the little finger. The condition is an autosomal dominant trait involving permanent flexion of the little finger. Camptodactyly may also be bilateral affecting multiple digits. Unilateral 1/3 of the time and bilateral 2/3 of the time. Camptodactyly occurs in less than 1% of the population, and it may be associated with several congenital syndromes. Camptodactyly may be caused by abnormal lumbricals and flexor digitorum superficialis insertion. Severe camptodactyly may cause difficulty in grasping objects. Clinodactyly is congenital curvature of the digit in the radioulnar plane. Treatment should be done early with splinting, passive stretching, and physical therapy. Surgery may be needed if the deformity is flexible, the patient may need tenotomy or tendon transfer. If the deformity is severe and fixed, the patient may need osteotomy or arthrodesis.

Female Athlete Triad

 

Female athlete triad is a condition that affects female athletes such as gymnasts, dancers, or athletes with weight classifications such as body builders. It is a syndrome in which amenorrhoea, osteoporosis, and insufficient caloric intake affects certain groups of athletes. Each component of the female athlete triad can occur from mild to severe. Not all components need to be present, but if one component is found, the doctor should check for the others. If you find a healthy, young female with stress fractures, ask about her eating habits. The physician should examine the relationship between the different components of the triad. The athlete will try to restrict their diet in order to maintain lower body fat, and that may cause an imbalance of energy (low caloric intake). This restriction of the athlete’s caloric intake will lead to negative energy balance. Amenorrhoea results from energy imbalance. Insufficient caloric intake is the most common cause of amenorrhoea in female athletes, and it may or may not be associated with eating disorders. Eating disorders can affect the brain’s regulation of the ovaries. This may cause an absence of the menstrual cycle (amenorrhoea). It occurs in about 65% of athletes such as runners and ballet dancers. There are two types of amenorrhoea: primary and secondary. Primary amenorrhoea occurs when menstrual cycles never start. Secondary amenorrhoea occurs when there is no menses for 6 months or absence of 3 or more consecutive menstrual cycles. Osteoporosis will lead to bone fragility and often manifest as stress fractures. 90% of bone mineral content occurs by the end of adolescence. The first step in treatment is recognition of the disorder. Treatment includes prevention, correction of the energy deficit, increase dietary calcium and vitamin D, maintaining bone mass, resume normal menstrual function, and reduce training intensity. The patient will need a multidisciplinary team including an athletic trainer, a nutritionist, a psychologist, and a physician. Female patient with a history of stress fracture should undergo a workup. This includes obtaining a menstrual cycle history, nutritional consult, bone density, and psychological consult for eating disorder.

Osteonecrosis of the Hip

 

Transient osteoporosis of the femoral head is not an osteonecrosis of the femoral head. In transient osteoporosis, the symptoms are usually more than the x-ray findings. It usually affects pregnant women, and it also affects men during the 5^th decade of life. On x-ray, you probably will not find much. You may find osteopenia. The signal changes will involve the femoral head and extend into the neck, and may include the trochanteric area. In transient osteoporosis, there is no double density which is seen in the MRI patients with osteonecrosis. Transient osteoporosis is not a tumor, it is not an osteonecrosis, and it does not need surgery. Osteonecrosis may be bilateral in about 80% of patients. Check the other hip even if the patient is asymptomatic. Early diagnosis and treatment may improve the chances for success of a head preserving surgical procedure, such as core decompression or bone grafting. In late stages of osteonecrosis, the femoral head collapses and cannot be saved. For the patient to have a good outcome, the femoral head will need to be replaced at this late stage. MRI is usually the study of choice, especially when the patient has persistent hip pain and the radiographs are negative and the diagnosis of osteonecrosis of the femoral head is suspected, especially if the patient has risk factors. On the T1 MRI, there will be a well-defined band of low signal intensity usually within the superior anterior portion of the femoral head. Decreased signal from the ischemic marrow, and there is a single band-like area of low signal intensity (crescent sign). The crescent sign represents the reactive interface between the necrotic and reparative zone. The single line density demarcates the normal from the ischemic bone. Double line sign is seen in T2 images. The subcortical lesion on T2 shows two lines: low signal intensity line and high signal intensity line. The lesion will show a high signal intensity inner border with a low signal intensity peripheral rim (double line). The high signal intensity represents hyper vascular granulation tissue. The size of the lesion is the most important factor in determining the development of symptoms and the progression of the disease. The best prognosis occurs in a small lesion with sclerotic margins. The presence of bone marrow edema on the MRI is predictive of worsening of the pain and future progression of the disease. Multifocal osteonecrosis is a disease involving three or more sites such as the hip, the knee, the shoulder and the ankle, occurs in about 3% of patients. A patient that presents with osteonecrosis at a site other than the hip should undergo MRI of the hip to rule out the asymptomatic lesion in the femoral head.