Fracture of clavicle Fracture of humerus Osteomyelitis Tennis elbow Frozen shoulder RCT Epulis Dental Carsies Dental cyst Dental fistula Gringivitis Renula
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Here is a structured clinical overview of all 12 topics, drawn from authoritative textbook sources:
Orthopedic & Musculoskeletal Conditions
1. Fracture of the Clavicle
Definition: A break in the clavicle (collarbone), the most frequent fracture in children and accounting for 90% of obstetric fractures.
Sites: Most fractures (about 80%) occur at the middle third. Lateral and medial third fractures also occur.
Mechanisms:
- Birth injury: direct pressure from the symphysis pubis during delivery
- Older children/adults: fall on an outstretched hand (FOOSH), direct trauma to the clavicle or acromion
Clinical Features:
- Pain at the clavicle and shoulder, worsened by neck and arm movement
- Visible deformity, crepitus, and edema over the fracture site
- Proximity to subclavian vessels and brachial plexus - always perform a thorough neurovascular exam, especially in displaced fractures
- Proximal fractures or posterior sternoclavicular displacement can injure the trachea, esophagus, or cause pneumothorax
Investigations:
- Anteroposterior (AP) radiograph - usually sufficient
- Cephalic tilt views (35-40 degrees) for better visualization
- Axial CT for medial clavicle fractures and physeal separation
- Ultrasound for obstetric fractures
Treatment:
- Newborns: no treatment usually needed
- Children/adolescents: sling and swath for 4-6 weeks (nonoperative is standard of care)
- Figure-of-eight splinting is NOT recommended (risk of brachial plexus palsy)
- Absolute indications for surgery: open fractures, neurovascular compromise
- Relative indications: nonunion, malunion, displacement >2 cm
Complications: Nonunion (1-3%), malunion, neurovascular compromise, pneumothorax
- ROSEN's Emergency Medicine; Miller's Review of Orthopaedics 9th Edition
2. Fracture of the Humerus
Types and key features:
Proximal Humerus Fractures:
- 80-90% of humeral growth occurs at the proximal physis - high remodeling potential in children
- Proximal fragments rotate into abduction and external rotation (rotator cuff pull); distal fragments pulled into adduction (pectoralis major/deltoid)
- Gravity can aid reduction
- Classified by Salter-Harris (SH) system: SH I most common under age 5; SH II most common over age 12
- Blocks to closed reduction: long head of biceps tendon, joint capsule, periosteum
Supracondylar Fracture (most common elbow fracture in children):
- Extension type: mechanism is FOOSH with elbow extended
- Risks: anterior interosseous nerve (AIN) injury, brachial artery injury, compartment syndrome
- Classified by Gartland system (I-III)
- Management: undisplaced (Type I) - cast; displaced (Type II/III) - closed reduction and percutaneous pinning (CRPP)
Distal Humerus:
- Complex intra-articular fractures in adults often require open reduction and internal fixation (ORIF)
- Olecranon osteotomy approach commonly used
General Treatment Goals: Anatomic reduction, preservation of neurovascular function, restoration of full range of motion.
- Miller's Review of Orthopaedics 9th Edition; Bailey & Love's Short Practice of Surgery 28th Edition
3. Osteomyelitis
Definition: Inflammation of bone and marrow, virtually always secondary to infection.
Causative Organisms:
- Staphylococcus aureus: most common overall (binds collagen in bone matrix)
- Neonates: Group B Streptococci, E. coli
- Sickle cell disease: Salmonella and gram-negative organisms
- No organism identified in ~50% of cases
Routes of Infection:
- Hematogenous spread (most common in children - metaphysis of long bones)
- Extension from contiguous site
- Direct implantation (open fractures, surgical procedures)
Pathological Changes (Morphology):
- Acute phase: Bacterial proliferation, neutrophilic inflammation, bone cell necrosis within 48 hours. Bacteria spread via Haversian systems to periosteum, causing subperiosteal abscess
- Sequestrum: Dead necrotic bone
- Involucrum: Shell of new reactive bone around the sequestrum
- Rupture of periosteum - soft tissue abscess - draining sinus to skin
- Epiphyseal spread can cause septic arthritis
Clinical Features:
- Acute: fever, malaise, chills, leukocytosis, throbbing pain over affected bone
- Infants: unexplained fever; adults: localized pain
Investigations:
- X-ray: lytic focus + reactive bone formation (takes 7-10 days to appear)
- MRI: most specific and sensitive
- Biopsy + microbial culture
Treatment: Antibiotics + surgical drainage (usually curative)
Complications of chronic osteomyelitis: Pathologic fracture, secondary (reactive) amyloidosis, endocarditis, sepsis, squamous cell carcinoma in draining sinus tracts
- Robbins & Kumar Basic Pathology
4. Tennis Elbow (Lateral Epicondylitis)
Definition: Degenerative tendinopathy at the origin of the Extensor Carpi Radialis Brevis (ECRB) at the lateral humeral epicondyle. It is a degenerative, not inflammatory, process.
Histology: Angiofibroblastic hyperplasia (no true inflammatory cells)
Mechanism: Precipitated by repetitive wrist extension and forearm rotation. More often associated with occupation than racket sports.
Clinical Features:
- Lateral elbow pain, worse with resisted wrist extension (elbow extended, forearm pronated)
- Grip strength diminished with elbow extended vs. flexed at 90 degrees
- Tenderness over the lateral epicondyle
Treatment:
- Nonoperative (primary approach): Rest, avoidance of aggravating activities, NSAIDs, counterforce (tennis elbow) brace, physiotherapy (ice, heat, ultrasound, iontophoresis)
- Corticosteroid injection: efficacy is controversial; no clear benefit
- Operative: For recalcitrant cases after prolonged conservative management fails; open and arthroscopic approaches show equivalent results. Arthroscopic release allows return to work in 2-3 weeks.
- Miller's Review of Orthopaedics 9th Edition; Campbell's Operative Orthopaedics 15th Ed 2026
5. Frozen Shoulder (Adhesive Capsulitis)
Definition: Characterized by pain and restricted glenohumeral joint motion - particularly external rotation - due to inflammation and fibrosis of the joint capsule.
Epidemiology: Typically ages 40-70 years; nondominant side more affected; more common in females.
Causes:
- Majority are idiopathic
- Associated conditions: diabetes mellitus, thyroid disease (disproportionately affected)
- Other: trauma, chest/breast surgery, prolonged immobilization
Pathology:
- Essential lesion: coracohumeral ligament (CHL) and rotator interval capsule
- Histology: inflammation and fibrosis with dense type III collagen matrix containing fibroblasts and myofibroblasts (resembles Dupuytren disease)
Clinical Stages:
- Painful phase (freezing)
- Stiffening phase (frozen)
- Resolution phase (thawing)
Diagnosis:
- Clinical: insidious onset of pain followed by selective loss of external rotation, then global ROM loss
- Active ROM = Passive ROM (unlike rotator cuff tear)
- Differential: glenohumeral OA, locked posterior dislocation - X-ray must be done first
- MRI: thickened capsule, obliteration of subcoracoid fat triangle, rotator interval synovitis
- Arthrography: loss of normal axillary recess (reduced joint volume)
Treatment:
- ~90% respond to nonoperative treatment: physical therapy, corticosteroid injection, NSAIDs
- Distention arthrography (hydrodilatation) occasionally used
- After 12-16 weeks of failed conservative treatment: arthroscopic capsular release
- Note: axillary nerve is at risk during this procedure
- Miller's Review of Orthopaedics 9th Edition; Goldman-Cecil Medicine
6. Rotator Cuff Tear (RCT)
Definition: Tear of one or more of the four rotator cuff tendons (supraspinatus most commonly), either partial or complete.
Classification by size:
- Small: ≤1 cm
- Medium: 1-3 cm
- Large: 3-5 cm
- Massive: >5 cm
Etiology:
- Acute traumatic tear (often superimposed on degenerative tissue)
- Chronic degenerative (most common) - gradual degeneration without recalled trauma
Clinical Features:
- Shoulder pain, weakness on abduction, loss of motion
- Drop-arm sign: Inability to maintain 90° of passive shoulder abduction - seen in large/massive tears
Investigations:
- MRI: preferred imaging test
Treatment:
- Small/incomplete tears: rest, physical therapy, NSAIDs; subacromial corticosteroid injection (1 mL methylprednisolone 40 mg/mL)
- Surgical repair: indicated in younger patients or large/massive tears failing conservative management
- Goldman-Cecil Medicine; Campbell's Operative Orthopaedics 15th Ed 2026
Dental / Oral Conditions
7. Epulis
Definition: A clinical term meaning any benign lesion situated on the gingiva. Most are reactive processes showing fibrosis, inflammation, and vascular proliferation on biopsy.
Giant Cell Epulis (Peripheral Giant Cell Granuloma):
- Solitary, bluish-red tumor, 10-20 mm
- Located on gingiva between or around deciduous bicuspids and incisors
- May be induced by dental implants
- Associated with cherubism (autosomal dominant inherited syndrome)
- Histologically resembles giant cell tumor of the tendon sheath
- Andrews' Diseases of the Skin, Clinical Dermatology
8. Dental Caries
Definition: A dynamic, multifactorial, bacterial disease of teeth resulting from acid dissolution of calcified dental tissue, creating an imbalance between demineralization and remineralization.
Key Organism: Streptococcus mutans (most notable, not exclusive)
Four Interacting Factors (Keyes' Tetrad):
| Factor | Role |
|---|---|
| Dental plaque | Microbial biofilm; creates microenvironment favoring demineralization |
| Substrate | Cariogenic substrates: refined carbohydrates especially sucrose |
| Dental tissues | Anatomy (fissures, pits) favoring plaque accumulation |
| Saliva | Protective: cleansing, antibacterial, remineralization |
Pathophysiology:
- Acid dissolves enamel along prism sheaths (initial enamel lesion - reversible, no cavitation)
- Reaches enamel-dentine junction - cavitation begins
- Dentine: acid dissolution, proteolysis, bacterial invasion via dentinal tubules
- Pulp involvement - pulpitis (infection and inflammation of the pulp)
Diagnosis: Clinical visual/tactile inspection + dental radiographs
Treatment:
- Preventive: regular brushing, flossing, reducing cariogenic substrates, fluoride
- Operative (once cavitation + dentine involvement): removal of carious tissue + restoration
- Scott-Brown's Otorhinolaryngology Head & Neck Surgery
9. Dental Cysts
Radicular Cyst (Periapical Cyst)
- Most common inflammatory odontogenic cyst
- Arises at the apex (or lateral aspect) of a non-vital tooth
- Consequence of pulp infection, necrosis, and chronic periapical granuloma formation
- Key diagnostic criterion: associated tooth must be non-vital
- Residual cyst: if culprit tooth is extracted and cystic remnant remains
- Treatment: Root canal treatment or extraction ± surgical enucleation for larger cysts
Dentigerous Cyst (Follicular Cyst)
- Most common developmental odontogenic cyst; most common jaw cyst in children
- Arises around the crown of an unerupted tooth, wall attached at the cervical margin
- Usually unilocular; may be multilocular
- Radiograph: follicular radiolucency >4 mm from tooth surface raises suspicion
- Differential: ameloblastoma, odontogenic keratocyst (can also involve unerupted teeth)
- Treatment: Marsupialization or enucleation, with bone grafting for large defects
- Scott-Brown's Otorhinolaryngology Head & Neck Surgery
10. Dental Fistula (Dentoalveolar Abscess / Dental Sinus)
Definition: A dental fistula (also called a sinus tract or "gum boil") forms when infection from a periapical abscess tracks through bone and soft tissue to drain at the skin or oral mucosa surface.
Pathophysiology:
- Untreated caries → pulpitis → pulp necrosis
- Infection spreads via apical foramen into periapical tissues → acute dentoalveolar abscess
- Pus under pressure ruptures the periosteum, forms a subperiosteal abscess, then tracks to the gingival surface or skin, creating a fistulous tract
Clinical Features:
- Pain, swelling, erythema, and suppuration localized to the affected tooth
- A small opening (parulis/gum boil) on the gingiva through which pus intermittently drains
- In chronic cases, the tract may be painless
Treatment:
- Surgical drainage is the management of choice: incision and drainage + elimination of source (root canal treatment or extraction)
- Antimicrobials: limited to spreading/severe infections
- Antibiotic use alone without source control is not recommended
- Scott-Brown's Otorhinolaryngology Head & Neck Surgery
11. Gingivitis
Definition: Inflammation of the gingiva (squamous mucosa) and associated soft tissues surrounding teeth.
Cause: Poor oral hygiene leading to accumulation of dental plaque and calculus (tartar) between and on tooth surfaces. Dental plaque is a sticky biofilm of bacteria, salivary proteins, and desquamated epithelial cells.
Epidemiology: Occurs at any age; most prevalent and severe in adolescence (present in 40-60% of adolescents), after which incidence tapers.
Clinical Features: Erythema, edema, and bleeding of the gingiva
Progression: If untreated, can progress to periodontitis - affecting the periodontal ligaments, alveolar bone, and cementum, ultimately causing tooth loss. Organisms closely associated with periodontitis include Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Prevotella intermedia.
Treatment and Reversibility: Gingivitis is reversible with regular brushing, flossing, and periodic professional cleaning (scaling and polishing). Unlike periodontitis, the damage is not permanent.
- Robbins & Kumar Basic Pathology; Robbins, Cotran & Kumar Pathologic Basis of Disease
12. Ranula
Definition: A cystic lesion arising from extravasation of saliva, following trauma or obstruction of the sublingual gland or its ducts. The name comes from the Latin rana (frog) - it causes croaking speech and the swelling resembles a frog's belly.
Epidemiology: Prevalence ~0.2 per 1000 people. Typically detected in the second decade of life. Slight female predisposition. Increased occurrence in HIV-infected individuals (blockage by peri-ductal fibrosis).
Classification:
- Simple (intraoral) ranula: Lies above the mylohyoid muscle; presents as a soft, blue-tinged swelling on the floor of the mouth
- Plunging (deep) ranula: Extends below the mylohyoid; presents as a painless persistent or recurrent neck swelling; rarely may spread to the upper chest; respiratory obstruction is rare
Diagnosis: Clinical + radiological imaging for soft-tissue swelling (ultrasound/MRI); FNAB cytology may be used.
Treatment:
- Multiple surgical approaches (success rates vary widely)
- Excision of the sublingual gland is associated with the lowest recurrence rate (gold standard), though risks include lingual nerve injury, Wharton duct injury/stenosis, bleeding, and hematoma
- Marsupialization alone has high recurrence
- A medical approach using oral nickel gluconate has been described (promotes enzymatic and tissue repair in salivary glands) with promising early results
- Scott-Brown's Otorhinolaryngology Head & Neck Surgery
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