Question 1

Colle's fractures represent over 90% of distal radius fractures. They display the classic 'dinner fork deformity' on x-ray.

The definition of a Colle's fracture is:

• a fracture within 2.5cm of the wrist joint
• dorsal angulation
• dorsal displacement
• radial displacement
• impaction
• frequently associated with an ulnar styloid fracture

Question 2

On examination a palpable 'olive' mass is felt in the right upper quadrant.

What is the most likely diagnosis?

All of the above diagnoses should be considered in an infant presenting with vomiting or regurgitation. However, the history above is consistent with pyloric stenosis.

Pyloric stenosis typically presents between 2 and 8 weeks of age. It is four times more common in males, particularly first borns, and may be associated with a family history. Classic features are:

• Non-bilious projectile vomiting
• Constant hunger despite feeding
• Weight loss or poor weight gain
• A hypochloraemic metabolic alkalosis with low plasma potassium (from vomiting stomach contents)
• Signs of dehydration (eg. decreased urine output, poor skin turgor)

Examination of the abdomen often reveals an 'olive' mass in the RUQ.

Clinical diagnosis may be made by using a test feed – the baby is given a milk feed, and the abdomen examined: visible gastric peristalsis is seen as a wave moving left to right across the abdomen. If the abdomen is distended, this may be difficult to appreciate. Ultrasound is the primary imaging modality to confirm the diagnosis.

Treatment is initially with correction of fluid and electrolytes abnormalities followed by pyloromyotomy.

Question 3

A Monteggia fracture is best described as a fracture of the:

The mechanism of injury for a Monteggia fracture is usually following a direct blow to the arm OR forced pronation (e.g. a fall on an outstretched arm accompanied by rotation of the trunk)

The definition of a Monteggia fracture is "a fracture of the ulna with dislocation of the head of the radius".

Question 4

What diagnosis would be your primary concern?

Henoch-Schonlein purpura (HSP) usually occurs between the ages of 3 and 10 years. It is more common in males, has a peak in winter, and is often preceded by a URTI. The characteristic features include:

• Symmetrical purpuric rash, commonly over the buttocks and extensor surfaces of arms and legs, with sparing of the trunk.
• Arthralgia
• Periarticular oedema
• Colicky abdominal pain

Over 80% of patients with HSP have either microscopic or macroscopic haematuria or mild proteinuria at presentation. The disease is usually self-limiting, but nephrotic syndrome is a rare complication.

Question 5

The following EEG was obtained:

(Reprinted with permission from eMedicine.com.)

What diagnosis would you consider?

The EEG above shows hypsarrhythmia – a chaotic background of high-voltage dysrhythmic slow-wave activity with multi-focal spike and wave discharges. This EEG is characteristic of 'West syndrome' or infantile spasms.

West syndrome usually presents between the age of four and six months, with males and female equally affected. The spasms described in the case above are characteristic of the disease. Other features of the disease include impaired social interaction and developmental regression. Prognosis is poor with most infants showing loss of skills and later learning disability or epilepsy.

For more details see: eMedicine.com - Infantile Spasm (West Syndrome).