Pathophysiology of Paget's disease (Osteitis deformans)

To contact us Click HERE

BASIC PHYSIOLOGY OF NORMAL BONE RESORPTION AND FORMATION :


*Osteoclast maturation is regulated by various factors, such as Receptor Activator of Nuclear Factor-kappaB (NF-kappaB) Ligand (RANKL). RANKL can exist as a soluble form and binds to the osteoclast receptor RANK.
*This binding activates osteoclast differentiation via the translocation of NF-kappaB into the nucleus by intermediates such as Tumor Necrosis Factor (TNF) Receptor-Associated Factor 6 (TRAF6).
*RANKL signals can be blocked by a soluble RANKL-binding decoy receptor, osteoprotegerin (OPG), produced by osteoblasts.
*Vacuolar H+-ATPase pump (H+), matrix metalloproteinase (MMP), Cathepsin K and Tartrate-Resistant Acid Phosphatase (TRAcP) are involved in osteoclast activity.

*This picture above helps us in understanding the pathophysiology behind PAGET'S disease :

*PATHOPHYSIOLOGY OF PAGET'S DISEASE:
- The principal abnormality in Paget disease is the increased number and activity of osteoclasts. - Pagetic osteoclasts are large, increased 10- to 100-fold in number, and have a greater number of nuclei (as many as 100 compared to 3–5 nuclei in the normal osteoclast). - The overactive osteoclasts may create a sevenfold increase in resorptive surfaces and an erosion rate of 9 microg/d (normal is 1 microg/d).
- Several causes for the increased number and activity of pagetic osteoclasts have been identified: (1) Osteoclastic precursors are hypersensitive to 1,25(OH)₂D₃; (2) Osteoclasts are hyperresponsive to RANK ligand (RANKL), the osteoclast stimulatory factor that mediates the effects of most osteotropic factors on osteoclast formation; (3) Marrow stromal cells from pagetic lesions have increased RANKL expression; (4) Osteoclast precursor recruitment is increased by interleukin (IL) 6, which is increased in the blood of patients with active Paget disease and is overexpressed in pagetic osteoclasts; (5) Expression of the proto-oncogene c-fos, which increases osteoclastic activity, is increased; and (6) The antiapoptotic oncogene Bcl-2 in pagetic bone is overexpressed. Numerous osteoblasts are recruited to active resorption sites and produce large amounts of new bone matrix. As a result, bone turnover is high and bone mass is normal or increased, not reduced.
- The characteristic feature of Paget disease is increased bone resorption accompanied by accelerated bone formation. - An initial osteolytic phase involves prominent bone resorption and marked hypervascularization. - Radiographically, this manifests as an advancing lytic wedge, or "blade of grass" lesion. - The second phase is a period of very active bone formation and resorption that replaces normal lamellar bone with haphazard (woven) bone. - The mosaic pattern of woven bone is structurally inferior and can bow and fracture more readily. - At the same time, fibrous connective tissue may replace normal bone marrow. - In the final sclerotic phase, bone resorption declines progressively and leads to a hard, dense, less vascular pagetic or mosaic bone, which represents the so-called burned-out phase of Paget disease. - All three phases may be present at the same time at different skeletal sites.

*Acutely marginated bone demineralization during lytic phase in skull - OSTEOPOROSIS CIRCUMSCRIPTA.
*Acutely marginated demineralization of long bones - BLADE OF GRASS SIGN and FLAME SHAPED MARGIN.
*Mixed lytic and sclerotic phase in spine - PICTURE FRAME VERTEBRAE
*Mixed lytic and sclerotic phase in skull - COTTON WOOL SKULL.

Haglund's deformity (Pump Bump)

To contact us Click HERE

*A Haglund deformity, or pump bump, is caused by chronic inflammation of the adventitious superficial pretendinous Achilles bursa that separates the Achilles tendon from the overlying skin.

*According to Jones, this bursa is present in about 50% of patients. This pretendinous bursitis usually is caused by chronic irritation from a shoe heel counter, and modification of shoe wear usually relieves symptoms. This deformity usually occurs in young women in their 20s or 30s. Surgery is infrequently required.

*The following technique is recommended if conservative measures fail :

1. Place the patient prone. After administration of general or local anesthesia, make a longitudinal lateral incision 1 cm lateral to the Achilles tendon, extending distally from 3 to 4 cm proximal to the superior tuberosity of the calcaneus to 2 to 3 cm distal to the superior tuberosity of the calcaneus.

2. Plantar flex the ankle joint and by sharp and blunt dissection, identify the Achilles tendon.

3. Place a right-angle retractor between the Achilles tendon and posterior and superior borders of the calcaneal tuberosity. With the foot plantar flexed, this usually affords enough exposure to remove the superior border of the calcaneal tuberosity without raising any of the Achilles tendon off the calcaneus. However, the Achilles tendon has such an extensive insertion into the posterior and plantar aspect of the calcaneal tuberosity that raising a 1- to 2-cm-long portion of the tendon may be necessary to resect the bone adequately.

4. Remove the superior aspect of the tuberosity with a microsagittal saw or an osteotome. Placement of several drill holes along the proposed osteotomy site makes this resection easier.

5. If an area of ossification remains, split the Achilles tendon in a coronal plane distally with the anterior third or half to free up enough to excise the calcified tendon.

6. Lavage the wound and close in layers.

7. Apply a well-padded, short leg, non–weight bearing cast with the ankle in approximately 20 degrees of plantar flexion.

AFTER TREATMENT:
*The cast and sutures are removed at 3 weeks. The sutures may be removed earlier if indicated, but the non–weight bearing cast remains on for 3 weeks. Then a removable weight bearing cast boot is applied, and active plantar flexion and dorsiflexion exercises are begun. It is important in the preoperative counseling to explain to a young woman with a pump bump that it might be 3 to 6 months before she can wear a stylish shoe and that there is no guarantee that she will ever be able to do so comfortably.

Bohler's angle ( Tuber joint angle )

To contact us Click HERE

 -Bohler's angle also called as the Tuber joint angle, measures the angular relationship between talus and calcaneum. This angle is formed by two lines . first line is drawn from the posteriosuperior margin of the calcaneal tuberosity through the tip of the posterior facet of the subtalar joint. second line is drawn from the tip of the posterior facet through the superior margin of the anterior process of the calcaneum.-Normally this angle ranges between 20 and 40 degrees.-Flattening of this angle is a classic x-ray sign of depressed fracture of calcaneum. P.S : The image is not my original work and has been taken from the wikimedia commons project and the author is Gilo1969.

Phalen's test

To contact us Click HERE

Place the backs of both of your hands together and hold the wrists in forced flexion for a full minute. (Stop at once if sharp pain occurs) . If this produces numbness or "pins and needles" along the thumb side half of the hand, you most likely have Median nerve entrapment (Carpal Tunnel Syndrome). Examination by a health care professional familiar with these conditions is the way to be sure of the diagnosis and get proper treatment.

Chopart's fracture

To contact us Click HERE

The foot is generally divided into the

• Hindfoot
• Calcaneus
• Talus
• Midfoot
• Cuboid
• Navicular
• Three cuneiforms
• Forefoot
• Metatarsals
• Phalanges
• The articulation between the hindfoot and the midfoot (midtarsal joint) is frequently referred to as Chopart’s joint
• Named after surgeon who performed amputations at the calcaneocuboid, talonavicular joint
• The articulation between the midfoot and the forefoot is referred to as the Lisfranc joint.
  
• Named after French surgeon Francois Chopart (1743–1795) who performed amputations of the foot at this level
• This type of amputation renders the ankle joint unstable as almost all of the points of insertion of the ankle tendons have been remove

• All dislocations of the foot are relatively uncommon with the Lisfranc fracture-dislocation being the most common
• Most are due to falls from a height or motor vehicle accidents
• Males are more likely to have foot dislocations than females
  
• Chopart Fracture

• Chopart fracture-dislocation involves the midtarsal joints (talonavicular and calcaneocuboid joints)
• Typically caused by falls from a height, motor vehicle accidents and severe twisting injuries such as can occur in basketball players who land on a plantar-flexed and inverted foot
• Usually result from severe trauma
• Most commonly, there is medial displacement of the distal fragments (80%)
• The foot is displaced inward and upward
• But displacement in other directions can occur
• Eversion injuries result in lateral dislocations
• There are frequently associated fractures of the calcaneus, cuboid and navicular
• A small percentage are open
• The talus remains in the ankle mortise

Chopart's fracture dislocation. Black arrow points to talus which is dislocated from navicular (yellow
arrow) at talonavicular joint. Calcaneus (blue arrow) is dislocated from the cuboid (red arrow), which is also fractured. The dislocation is at the calcaneocuboid joint. This is an uncommon dislocation.
The forefoot is usually displaced medially rather than laterally as in this case.

• Prognosis

• Prompt reduction and early range of motion generally result in favorable outcome
• High impact injuries with greater soft tissue compromise and associated fractures worsen prognosis

.

Diagram of Chopart's fracture-dislocation from Radiographics.

To contact us Click HERE

Can You Claim Groceries on Your Taxes?

• 
  
• Share
• RSS
• Email

There are some situations where groceries are tax-deductible.

Everyone can claim groceries on their taxes. However, most of the time, the IRS sends a very personal note indicating the deduction was disallowed and requesting more money. There are some situations where groceries could become a legitimate expense. This doesn't mean the IRS will accept it immediately. It simply means you have justification to believe it's legitimate and not a frivolous deduction.

Purpose

One of the biggest factors in deciding whether groceries were deductible is the purpose for the groceries. If it was just to feed your family, don't even think of it. Everyone has to eat, even if it seems your kids have a tapeworm and they eat more food than others, it's still not deductible. Don't think about naming the tapeworm you believe your child has and using it as an exemption, either.

Charity

If you purchased food to donate to a food bank or donated the food to another organization that gives to needy families, you have a good shot at receiving the deduction. Charitable donations are deductible on your itemized deductions. If you do random acts of kindness and simply leave a food basket on the doorstep of a needy neighbor, you can't deduct the groceries. It must go to a qualified tax-exempt organization if you want the IRS to allow it.

Educator Expense

There are many types of work situations in which your groceries could be legitimate deductions. For instance, if you're a schoolteacher and you decide the class needs to make cookies for old people for Christmas, the purchase of the groceries is work-related and not for personal use. Educators don't have to itemize to receive the deduction. On the 2009 tax form, line 23, you could put up to $250 of qualified expenses paid for classroom supplies without itemizing.

Other Jobs

If you threw a lavish dinner party in your home for clients or your staff, you can deduct the cost of the groceries you used for the party. The IRS isn't unreasonable. They don't want an exact count on the number of shrimp each person ate but you have to be accurate in your records. For instance, if you had a client over for dinner and deduct $300 for the groceries, the IRS might just raise an eyebrow and require receipts and more information. If you own the business and file Schedule C, show it as a deduction on that schedule under business entertainment. If you are an employee, use the itemized schedule and list it under miscellaneous expenses.

Oxygen Higher at Acupuncture Points – New Research

To contact us Click HERE
New research has discovered that oxygen levels are higher at acupuncture points. Using a 25 micron amperometric oxygen microsensor, researchers measured the partial oxygen pressure of the distal left Acupuncture pO2forearm of humans. Oxygen levels were significantly higher at the acupuncture points in the measured region: LU9 (Taiyuan), LU8 (Jingqu), PC7 (Daling), PC6 (Neiguan), HT7 (Shenmen), HT6 (Yinxi), HT5 (Tongli), and HT4 (Lingdao). The researchers note that this correlation provides information on the physiology of acupuncture points.
The researchers conducted this human study after a clinical investigation of rabbits measured higher partial oxygen pressure at acupuncture points ST36, ST37, CV16 and CV17 compared with the surrounding regions of the acupoints. The researchers note that their human study uses tiny oxygen sensors and is therefore noninvasive. In addition, they conclude that this research provides “clearer evidence on the strong pO₂ (partial oxygen pressure)-acupuncture point correlation….” The researchers note that their investigation may “verify the physical existence of acupuncture points….”