An unusual Monteggia equivalent type 1 lesion: Diaphyseal ulna and radius fractures with a posterior elbow dislocation in a child / 中华创伤杂志(英文版)

In this report, we describe an extremely unusual Monteggia equivalent type 1 lesion in a 10-year-old boy following a fall from a height of 1 m. On the plain radiographs, our patient had a particular Monteggia equivalent type 1 injury associating a posterior elbow dislocation with diaphyseal radius and ulna fractures. The patient was treated by closed reduction technique. At six months of follow-up, the fractures were consolidated and the elbow was stable. To our knowledge, only 8 adult cases and one paediatric observation with similar lesions had been reported through medical literature. Therefore, the aim of our case report is to remind this rare entity and also to provide a comprehensive review of the literature related to this uncommon lesion.

fracture risk assessment tool [FRAXTM], where one is in Tunisia?

The fracture risk assessment tool [FRAXTM], published in February 2008, is developed based on the use of clinical risk factors with or without bone mineral density tests. To calculate the FRAX tool in a cohort of Tunisian patients in whom bone mineral density [BMD] was assessed by dual X ray absorptiometry [DXA]; to correlate this score to osteoporotic fracture and to BMD assessment and to propose a threshold for therapeutic intervention. In a cross sectional study of 582 patients older than 40 years, in whom a BMD measurement by DXA has been performed between January 2006 and December 2009, clinical risk factor for osteoporotic fracture and the occurrence of a prior fragility fracture were assessed. The French version of the FRAX tool was used. Threshold for pharmacological intervention was evaluated by ROC curve. Patients were aged 62.3 +/- 10.4 years. They were female in 91.2% of cases. BMD measurement was under 2.5 standard deviation in 53.2%. Osteopenia was noted in 29.2% of cases and BMD was normal in 17.4% of cases. Osteoporotic fractures were observed in 38.2% of cases. Major osteoporotic fractures [FOM] [hip, vertebra, radius] occurred in 82% of cases. The FRAX score calculated with T-score was 8.55 +/- 8.54% for the FOM and 3.02 +/- 6.37% for femoral neck [FN], while it was 7.81 +/- 6.45% for the FOM and 2.58 +/- 3.97% for the FN if calculated without T-score with a significant difference [p <10[3]]. For the patients having T-score under 2.5 SD, FRAX score was 11.39 +/- 10.32% for the FOM and 4.74 +/- 8.13% for the FN if calculated with T-score and it was 9.18 +/- 6.95% for the FOM and 3.19 +/- 4.11% if calculated without T-score. The score FRAX was correlated to BMD [r=0, 53, p <10-3] and to fracture prevalence [p < 10[3]]. The threshold of therapeutic intervention was fixed to 30% for the FOM and 7% for the FN. Our study confirms the usefulness of the FRAX score in the prediction of fracture risk in Tunisian population. The determination of therapeutic threshold intervention requires other prospective and larger studies with medico-economic analyses

[Adult-onset of Still's disease with atypical articular and skin manifestations]

Adult-onset Still's disease [ASD] is an uncommon clinical entity. It is a diagnosis of exclusion, characterized by a clinical triad of intermittent fever spikes, evanescent rash, and either arthralgia or arthritis. Destructive arthritis more commonly affects the hips, wrists, tarsal joints and cervical spine. To report an unusual case of ASD with severe distal interphalangeal destructive arthritis and finger skin vesiculopustules. A 19 years old girl was followed for 2 year-history of ASD with polycyclic articular involvement. She noted, since 2 months, rapid appearance of painful tumefaction in the distal interphalangeal joints [DIP] with maculopustular eruption distributed exclusively on the hands, in front, only of DIP and few proximal interphalangeal joints [PIP]. Further more, she complained of polyarticular active disease. Hands and wrists X-ray showed narrowed distal-interphalangeal joint space of only DIP joints. RMN imaging revealed in addition carpal, metacarpal and PIP articular inflammatory damage. The infectious investigation remained negative. A surgical skin and DIP biopsy specimens showed disseminated micro-abscesses with polynuclear leukocyte dermal infiltration. There was no signs of osteitis. Bacterial and fungal cultures from the pus failed to reveal any causative organisms. Skin lesions gradually disappeared in response to conventional ASD therapy after intensification. Hence, the diagnosis of distal destructive arthritis of ASD associated with atypical neutrophilic dermatosis [Sweet's syndrome] was made. ASD is rare, heterogeneous, with unpredictable evolution. The distal destructive arthritis represents a possible complication. The presence of pustules as atypical cutaneous features of Sweet's syndrome may be seen in severe forms of ASD and clinicians must be alert to the possibility of a misdiagnosis in these cases