Avulsion of the tibial spine.

The anterior cruciate ligament (ACL) attaches to the anterior tibial spine. Excessive tension in this ligament causes an avulsion fracture. This can arise from a hyperextension injury. It can also arise in the same way as an ACL tear, from a twisting force on the knee when bent.

Yes, this injury is nearly always seen in the 8-16 age range. It can be considered an equivalent to an ACL tear in an adult. It is particularly associated with boys and bikes!

Yes, the best imaging would be x-ray, AP Pelvis and frog lateral (heels together, knees ‘flopped’ open – more details below). This is unlikely to be septic arthritis or transient synovitis because of the duration, so ultrasound (for a joint effusion) is less likely to be helpful.

Her images are shown:

Loss of the growth plate width and flattening of the femoral head. This is consistent with Perthes Disease.

In Perthes disease, or avascular necrosis, the blood supply to the epiphysis is inadequate resulting in softening and necrosis of the femoral head. It occurs in children aged 4 – 10yrs. It is 5 times more common in boys than girls, but girls have a worse prognosis.

Symptoms include hip, knee or groin pain and limping. If untreated, muscles on the affected side become wasted, the leg shortens and there is a reduction in range of movement.

Osteosarcoma – a primary malignant bone tumour, the most common bone tumour of childhood. Teenage boys most commonly affected.

Slipped upper femoral epiphysis (SUFE) – The upper femoral epiphysis slips backwards and downwards at the growth plate between the head and neck of the femur. The epiphysis appears widened on xray. Peak age 13 years, affects boys 3 times more often than girls.

Further information
www.perthes.org.uk
www.noc.nhs.uk/paediatricorthopaedics/information/conditions/perthes-disease.aspx

The chest X-ray shows a large right sided pleural effusion. There is also some patchy consolidation on the left. Potential causes of this effusion could be:

• Haemothorax
• Parapneumonic effusion
• Empyema (pleural infection)

This is clearly an empyema. Empyema is the presence of pus within the pleural space.

British Thoracic Society guidance recommends
• Commencing antibiotics – the most common pathogens in community acquired pleural infection are Gram positive aerobic organisms such as Streptococcal species and Staph. aureus. Anaerobes are also commonly found.
• Sending a sample of fluid for testing pH, microscopy, culture and sensitivities
• Sending blood cultures for analysis
• Inserting a chest tube if there is frank pus or sample pH is <7.2
• Early involvement of a respiratory physician or thoracic surgeon
• Thromboprophylaxis should be given unless contraindicated

Further reading:
British Thoracic Society guideline: Management of pleural infection in adults: British Thoracic Society pleural disease 2010
http://www.brit-thoracic.org.uk/Portals/0/Guidelines/PleuralDiseaseGuidelines/Pleural%20Guideline%202010/Pleural%20disease%202010%20pleural%20infection.pdf

The CXR shows a right-sided pleural effusion. This plus the pericardial effusion and ascites makes TB most likely.

This CT confirms the effusion, and also shows that the patient has ‘miliary mottling’ (small patches of consolidation a few millimetres across), indicating the condition known as miliary TB.

TB was confirmed on microscopy of his ascites.

TB exposure is common, but 90% only develop ‘latent TB’, remaining well, but becoming tuberculin positive. Most clinically evident adult pulmonary TB is ‘post primary’, arising from reactivation of latent bacteria in the lungs. If the enlarging TB granuloma breaks into a branch of the pulmonary vein then bacteria may be seeded into the circulation and hence throughout the body, to the brain, liver, spleen, lymphatics etc. In an individual with low immunity this may cause miliary TB. It has a high mortality, 100% if not treated, 10% if treated. Half of miliary TB cases probably die undiagnosed.

TB has been on the rise in the UK for many years, although the rise is slowing. Half of the UK cases are in London, and three-quarters of cases are in immigrants. However locally acquired disease does occur, with an incidence of about 4 per 100,000 per year. BCG has been shown to be quite protective in the UK, although it has not been so effective in many other countries. Nevertheless it is widely protective against the most dangerous types – miliary TB and TB meningitis. Multi-drug resistant TB is a growing concern, although only present in 2% of new cases in the UK. The ethics of compulsory isolation and treatment of such patients has been much debated. The WHO has accepted that this may be necessary as a ‘last resort’.

It needs to be decided whether this lady has the capacity to make her own decision to leave hospital without treatment.

Mental capacity is the ability of an individual to make decisions about specific aspects of their life. Assessing capacity has now been formalised in UK law – the Mental Capacity Act 2005, which came into force on the 1st October 2007.

Patients must be assumed to have capacity, unless there is a reason to doubt this. This doubt would arise from: ‘signs, symptoms or behaviours that indicate impairment or disturbance in the functioning of their mind or brain (either permanent or temporary). In which case the clinician would assess decision making capacity by considering whether the patient can:

• Understand information given to them

• Retain information long enough to make a decision

• Weigh up the information available to make the decision

• Communicate their decision The patient lacks capacity if unable to do one or more of these 4 things.

There was reason to doubt this patient’s capacity as she was believed to under the influence of alcohol, affecting her judgement. Applying the four questions above, she did not demonstrate that she could do any of them. Thus she lacks capacity. Therefore she could have been given treatment that was deemed to be in her best interests.

Any decisions regarding capacity should be made by a senior healthcare professional (e.g. Consultant or Registrar) and clearly documented in the notes. Decisions or actions taken for people who lack capacity should be options that least restrict basic rights and freedoms. All relevant options should be considered before a final decision is reached.

No. This lady is not showing any signs of a mental heath disorder and so cannot be sectioned under the Mental Health Act (UK).

The Mental Capacity Act has broad scope and provides a legal framework for acting and decision making which applies in many situations when patients are unable to make decisions and act for themselves.

The Mental Health Act provides much narrower legal authority for the admission to hospital and treatment (where appropriate without consent) of people with a mental disorder because of the risk posed to themselves or others.

Treatment under the Mental Health Act is excluded from the scope of the Mental Capacity Act. Compulsory treatment under the Mental Health Act is not an option if the individual needs treatment only for a physical illness or disability. However the Mental Capacity Act can be applied to people subject to the Mental Health Act (with some exceptions).

Further reading:
The Mental Capacity Act 2005 (UK)
http://www.legislation.gov.uk/ukpga/2005/9/pdfs/ukpga_20050009_en.pdf

Medical Defence Union (UK) Guidance on the Mental Capacity Act
http://www.themdu.com/guidance-and-advice/latest-updates-and-advice/the-mental-capacity-act-2005

Resources from the General Medical Council (UK) on working with the Mental Capacity Act
http://www.gmc-uk.org/guidance/mental_capacity_act.asp

According to UK national guidelines (NICE) a patient with a post traumatic seizure should receive a CT brain within an hour.

A large extradural haematoma(EDH)  in the left frontal region with limited mass effect and displacement of the ventricles. He had surgical evacuation of the haematoma, and recovered well.

The haematoma would have taken time to develop. The unconsciousness would have been caused by the direct brain trauma. Most, but not all, EDHs are associated with skull fractures, and require time for the haematoma to enlarge sufficiently to cause symptoms. This patient did not suffer raised intracranial pressure, as the haematoma did not become large enough. Had he done so, his consciousness would have declined again, and he would have demonstrated the classic ‘lucent interval’ seen in less than a quarter of EDHs.

Yes. The dura is more adherent to the skull in older patients, so that a haematoma is less able to collect between the skull and the dura. Most extradurals happen in children and adults up to the 20s.

His knee x-ray shows a transverse fracture of the patella.

a. Direct blow to the knee, most common cause
b. Indirect. Quadriceps contracts and pulls the patella apart, as in this patient

Initial: Analgesia, Immobilisation
Definitive: Specialist input, Surgery, Physiotherapy post operatively

Below are his intraoperative images:

Links:

www.orthopedics.about.com/od/brokenbones/a/patella.htm

www.wheelessonline.com/ortho/fractures_of_the_patella