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these fractures. All patients were young recruits in the age group of 19e24 years and belonged to rural agricultural background. All recruits were hospitalized and thorough clinical and radiological examination was carried out. The chief presenting complaint was pain localized to involved leg which aggravated on exertion. Clinical examination essentially revealed bony thickening and tenderness at the site of the fracture. Radiologically fractures were graded in 6 grades from 0 to V. Grade 0, no findings on radiograph, Grade I, only periosteal reaction seen at fracture site, Grade II, Unicortical break with or without periosteal reaction, Grade III, Bicortical break (complete fracture) without any displacement, Grade IV, complete fracture (Bicortical break) with acceptable fracture displacement, Grade V, Bicortical break (Complete fracture) with unacceptable displacement or complete off ending of fracture fragments. There were 3 (6%) grade 0, 38 (76%) grade I, 3 (6%) grade II and 2 (4%) each of grade III, IV and V fractures. Pain disappeared in 1e8 weeks (Average 3
weeks). Average hospital stay was 4 weeks (range 3 weeks to 2 months). All cases were managed conservatively. Grade 0 and I were managed with rest and crepe bandage only. Grade II and III required PTB/POP for 4 weeks followed by 4 weeks of sick leave whereas grade IV and V were managed with AK/POP for 4 weeks followed by PTB/POP for 6 weeks. 44 (88%) required sick leave for 4 weeks, 3 (6%) for 6 weeks and remaining 3 (6%) did not require sick leave. 3 (6%) were placed in low medical category for 8 weeks. All patients were declared fit and underwent successful training except one who had to be invalided out. Based on clinico-radiological behaviour of the fractures, a new radiological classification has been proposed. Contributed by: Lt Gen K.R. Salgotra, VSM DCIDS (Med), HQ IDS, New Delhi DOI of original article: 10.1016/S0377-1037(12)60021-5.
Letter-2 Dear Sir, I read with interest the article written by Col N. Dash et al regarding stress fractures among recruits. In this connection, I would like to comment that the criteria used for diagnosis of stress# is clinical and plain X-ray which may take several weeks to be positive. We did a study using Bone scans and MRI in the initial diagnosis of stress# and found that Bone scan not only detects early but also detects stress# at sites which are not symptomatic. There was concordance of 95% with MRI and we recommended that MRI to be done in specific cases for better delineation and Bone scans which are
cheap and easily available should be used for early diagnosis of stress#. Ref.: “CORRELATION OF BONE SCINTIGRAPHY AND MAGNETIC RESONANCE IMAGING FOR STRESS INJURIES OF BONE” Col P.G. Kumar, Gp Capt A. Alam, Wg Cdr A.V.S. Anil Kumar, CHAF Bengalurudposter presentation at 57 SNM conf, Utah, USA, 2010 (abstract book). Contributed by: Col P.G. Kumar Sr Adv (Med & Nuclear Med), CH (EC), Kolkata, India DOI of original article: 10.1016/S0377-1037(12)60021-5.
Reply to letters Dear Sir, 1. The authors are grateful to the readers for showing their keen interest in our article.1 The purpose of writing the article to bring focus on this important yet neglected malady affecting our recruits and cadets has been served. 2. The authors also thank the readers for providing us with their work on stress fracture done by them and presented in IOACON. It was unfortunate for us that this work by the readers was not available to us despite our best efforts to search for articles on stress fractures and its classifications. The authors are glad to go through the work of reader and highly appreciate their work. 3. The setting in our study is markedly different than the study by Agrawal et al.2 While their study was done in a tertiary care centre by an orthopaedic surgeon with facilities of bone scan mainly to classify and manage stress fractures, our study which was a prospective community
based design done in a peripheral training centre to study incidence and important factors with just X-ray and general surgical facilities available and hence the difference in the diagnosis, classification and management of stress fractures. 4. The question on our modification of classification given2 is due to the limited investigative modalities available. While in the other study2 had bone scan available, we did not have this desirable facility and hence we combined the Grade 0 and Grade 1 as given in other study2 into single category ie Grade 1. 5. Since the clinical and radiological features of our Grade IV Stress fracture in our study1 are different than those by other study2 and the modalities of management available and expertise available are different, thus the difference in management of Grade IV stress fracture cases. 6. The article had two main objectives.1 Firstly, to highlight the neglected issue of stress fracture and its magnitude and secondly to bring forth important factors associated with
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 8 ( 2 0 1 2 ) 4 0 7 e4 1 1
the stress fractures which were urban residence, vegetarianism and those without prior history of physical activity. 7. The authors fully agree with the contention of the reader that criteria for diagnosing stress fractures should be bone scan and MRI wherever feasible.
references
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2. Agarwal PK. Stress fractures: management using a new classification. Indian J Orthop. 2004;38:112e120.
Col N. Dash (Retd) Ex-Senior Advisor (Surgery), Command Hospital (SC), Pune e 40, India Lt Col A.S. Kushwaha* Associate Professor, Department of Community Medicine, AFMC, Pune e 40, India *Corresponding author. E-mail address:
[email protected]
1. Dash Niranjan, Kushwaha AS. Stress fracturesda prospective study amongst recruits. MJAFI. 2012;68:118e122.
Answer to radiological quiz
Myositis ossificans X-ray shows evidence of periosteal reaction along the medial aspect of lower end of right femur with a relatively radiolucent central area and radiodense periphery and displacement of fat planes in the adjacent soft tissue suggestive of heterotropic bone formation. Diagnosis is myositis ossificans. Non-traumatic myositis ossificans is benign heterotropic ossification characterized by the aberrant formation of bone in extraskeletal soft tissues.1 It is usually confined to a single muscle or muscle group, most commonly in quadriceps, gluteals, small muscles of hand and brachialis. It is most common in active male within the second and third decade of life. It usually occurs after muscle injury such as repeated microtrauma, but it can also occur without previous trauma in patients with burns, neuromuscular disorders, hemophilia, tetanus, and drug abuse.2,3 Myositis ossificans is essentially a proliferative mesenchymal response to an initiating injury to the soft tissue, not necessarily to the muscle, which leads to localized ossification. The mechanism suggested is the abnormal differentiation of fibroblast to bone forming cells under the influence of bone morphogenic protein 2.4 Myositis ossificans is a self limiting condition resolving in about 6 months. It needs to be differentiated
from osteosarcoma. In the acute phase which lasts for upto 3 weeks they should be managed conservatively with compressive dressing, avoidance of additional injury and physiotherapy. The resolution of the lesion correlates with decreasing alkaline phosphate values. The lesion shouldn’t be removed surgically until the lesions have matured as there is high risk of recurrence.
references
1. McCarthy EF, Sundaram M. Heterotopic ossification: a review. Skeletal Radiol. 2005;34:609e619. 2. Hajek VE. Heterotopic ossification in hemiplegia following stroke. Arch Phys Med Rehabil. 1987;68:313e314. 3. Aneiros-Fernandez J, Caba-Molina M, Arias-Santiago S, Ovalle F, Hernandez-Cortes P, Aneiros-Cachaza J. Myositis ossificans circumscripta without history of trauma. J Clin Med Res. 2010;2:142e144. 4. Lounev VY, Ramachandran R, Wosczyna MN, et al. Identification of progenitor cells that contribute to heterotopic skeletogenesis. J Bone Joint Surg Am. 2009;91:652e663.
