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Avulsion fracture

A fracture is called an avulsion fracture when the injury occurs in a place where a tendon or ligament that attaches to the bone pulls off a piece of the bone. It is common to notice avulsion fractures occur around the pelvis area, though they can occur anywhere in the body. More than adults, children are more prone to avulsion fracture, because a child's bone may give away before the ligament or tendon is injured whereas in adults, ligaments get injured more. Children have an area of bone that grows faster. This area in the skeleton is known as a growth plate. When an injury occurs in children near a growth plate, the tendons or ligaments can pull very hard and it will lead to a fracture of the growth plate. Growth plates are necessary for normal skeletal development of a child and so, avulsion fractures must be treated with utmost care. Surgery is the only option, to align the growth plate and stabilize it. If there is no danger of lasting growth problems and if the avulsion fracture is well aligned, then surgery is not necessary.


Normally, avulsion fractures can be treated without surgery since it is treated as a soft-tissue injury. An avulsion fracture of the hamstring attachment on the pelvis can be treated in the same way as a hamstring tear. Surgery is considered only when the bone is pulled too far from its original position. Some ankle sprains where the damaged ankle ligaments pull off a tiny piece of a bone from the joint are treated like an ankle sprain. Avulsion fractures in children are more complicated.


Avulsion fracture of the pelvis

Teenagers and sports persons are susceptible to a type of pelvic fracture. Often some of the pulled muscles may end in an avulsion fracture not detected earlier. The muscle in the pelvic area tears away a small piece of bone from the top of the hip bone and there may be sudden muscle contractions. The entire pelvic ring is not involved and there is no injury to the internal organs. Avulsion fractures experienced by athletes are stable fractures and will heal without surgery. Elderly persons with osteoporosis are also at a risk for pelvic fracture. It can occur during a fall or when descending stairs. Normally the pelvic ring is not damaged but any of the individual bones of this ring may be fractured. Mostly these pelvic fractures involve high-energy forces. Motor vehicle accident, crush accident and fall are the major causes for this type of fracture. Pelvic fractures can be life-threatening depending on the amount of force involved.


Acute pain, swelling and bruises are symptoms of pelvic injuries. To avoid aggravating the pain, a patient may walk with a bent knee. There may be injuries to other parts of the body like head, legs or the chest, if the injury is due to trauma. Heavy bleeding can lead to shock should be arrested immediately. The doctor will request for X-rays from different angles to find out the exact degree of displacement to the bones. A CT scan will reveal the extent of other injuries. It is routine to examine the blood vessels and nerves to the legs for any damage due to the injuries.

Brachial Plexus Injury

A network of nerves that conveys signals from the spine to arms, hands and shoulders is known as brachial plexus. Brachial refers to an arm and a network of nerves is indicated as plexus. Damage to these nerves causes brachial plexus injuries. A paralyzed arm, lack of muscle control in the arm, wrist or hand are some of the symptoms of brachial plexus injuries. Along with any of these symptoms, there is lack of feeling or sensation in the arm or hand.


Brachial plexus injuries commonly occur during birth but a possibility of this injury occurring at any time cannot be ruled out. When this injury happens during birth, the brachial plexus nerves stretch or tear as a result of an impact of the shoulders of the baby during the birth process. This injury is also known as Erb's Palsy when newborn is affected by it. A more serious condition called global palsy may occur when the injury involves both the upper and lower nerves. A difficult delivery when the baby is very large or if there is a breech or a protracted labor, pose the problem of brachial plexus injury. Brachial Plexus injuries are classified into four types:


  • The most severe type is called avulsion. In this type of the injury, the nerve gets torn from the spine.
  • The other type is called rupture. The nerve is torn in this type, but it occurs at a place other than the spinal attachment.
  • The third type is called neuroma; in this type, a scar tissue will grow around the injury when the nerve tries to heal by itself and this exerts pressure on the injured nerve. It will also prevent the nerve from passing on signals to the muscles.
  • The fourth type is neuropraxia or stretch. Though the nerve gets damaged due to the injury in this type it is not torn. Neuropraxia is the type of brachial plexus injury that occurs very commonly.

Occupational or physical therapy is available for treating brachial plexus injuries and some cases may need surgery. Recovery is not possible for avulsion and rupture injuries unless surgery is done well in time to reconnect the nerves. The potential for recovery differs from patient to patient, if the injury is either neuroma or neuropraxia. Recovery is spontaneous for patients who suffer from neuropraxia.


A new born affected with this injury will not be able to move the arm and will keep its arm stiff at its side. A more severe injury in an infant is indicated by a droopy eyelid on the affected side. The doctor will look for any damage to the bones and joints of the shoulder and the neck by ordering a x-ray or MRI. EMG is conducted to determine the presence of nerve signals in the muscles of the upper arm.

Since recovery is possible without surgery, most infants affected by Erb's palsy or brachial plexus injury will be examined after a month again. This is to confirm the extent of recovery of the nerves. The doctor will repeat this examination after two more months. For complete recovery, it may take even up to two years. The doctor may suggest a range of motion exercises that are most important to keep the infant's joints from getting stiff.


Ingrown Toenail

A common foot problem, ingrown toenails or onychocryptosis can be very painful and need to be treated by a chiropodist. If a splinter or the whole nail exert pressure against the skin on any or both sides of the nail, it will result in an ingrown toenail. If this pressure is prolonged, it can cause swelling, infection, and irritation of the skin and pain. An injury to the toe can also cause acute ingrown toenails. In a chronic condition, it lasts for a long time. Though it is the large toe that is affected normally, the other toes are sometimes affected.


Ingrown toenail can be the result of an abnormality of the soft tissue on the side of the nail. It may also be a result of laxity of the skin due to certain rare diseases. Wearing tight fitting shoes normally leads to soft tissue abnormality. Overcrowding of the toes because of these shoes will result in pushing the soft tissue against the sides of the nail. Nail abnormalities is another widespread factor for ingrown toenails.


During the developmental stages of the foot, wearing shoes that are very narrow or short can lead to bunching of the toes that causes the nail to curl into the skin and cause ingrown toenails. If a person cuts the toenail short and curved, it may result in the edges turning in. Sometimes advancing age, poor blood circulation at the extremities due to blockage in blood vessels may also cause curved nails. Ingrown toenails can also be caused by bone spurs beneath the nail, or a direct hit on the nail, or due to multiple infections and certain drugs like Indinavir; but these are not very common.


Trauma that is caused by stubbing the toenail or dropping heavy objects on the toe will injure the flesh and this condition makes the nail to grow irregularly. This nail may also press into the flesh. For some people, there is a tendency of the nails to grow inwardly because they are genetically prone to nail problems and nail deformities. Ingrown toenails are categorized as three stages.


I Stage: Painful to the touch, the skin on both sides of the nail appears red due to inflammation or irritation. This condition may not be due to infection.


II Stage: The skin may bulge over the side of the nail and this may be due to infection. There may be oozing of a clear fluid or pus in the affected area.


III Stage: The infection may try to heal itself if the infection had been there for a prolonged time. By forming granulation tissue, the infection tries to heal, but that will add to the problem by making the tissues bleed easily. These tissues also move over the nail edge.


Clinically ingrown toenails can be diagnosed by looking at their appearance. The presence of pus indicates bacterial infection and should be determined by a culture test. Infections might have spread to the bone or joint space at times and with a x-ray, the physician can rule out this possibility which is rare. Diabetics are more prone to this condition and so should pay proper attention to their feet. These people lose sensation in their feet if they develop peripheral neuropathies.


The treatment of ingrown toenails depends upon its stage. Warm soaks, cutout shoe and elevation of the toenail with a cotton swab are some of the measures taken for stage one. Though the symptoms may improve soon, there will be complete cure only after a few weeks. Along with warm soaks, oral antibiotics are given for stage two ingrown toenails. Surgical options are there to remove a portion of the toenail if it is extremely painful.


If the condition has reached the third stage then partial or full toenail removal is the only way. This procedure is known as partial nail avulsion (PNA). This procedure involves removal of the section of the ingrown nail after injecting the toe with a local anesthetic. It will take 4-6 weeks for the site to heal after this surgery which is very common and painful.


How to prevent ingrown toenails?


1. Cut the nails straight across; do not cut the nails along a curve or very short.
2. Use foot wear that fits well. Shoes that are small in size or width will aggravate any problem that already exists with a toenail.
3. Prevent injuries to the toes by wearing shoes almost always during working or playing.
4. It is a myth that a V cut at the end of the ingrown nail will help the edge of the nail grows together. Only the growing area at the base of the toe determines the shape of the nail and it is not the end of the nail that determines it. It takes almost up to one year for a toenail to grow and this method will in no way hurry the growth.


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Collection of Pages - Last revised Date: November 19, 2019