Month: July 2015

Differential Diagnosis: Perthes’ Disease

by

A number of the patients admitted to Stannington were mistakenly given an initial diagnosis of tuberculosis or were found upon examination to be non-tuberculous and were instead allocated an alternative diagnosis. Perthes’ Disease was the most common differential diagnosis assigned to the bones and joints in Stannington, affecting the hip joint this condition was often mistaken as tuberculous-arthritis of the hip.

Perthes’ Disease, a condition that usually affects children between the ages of 4 and 10, is a condition where the blood supply to the femoral head is temporarily lost. This causes the bone at the epiphysis of the femur to soften and breakdown, known as necrosis, giving the femoral head a flattened appearance.

Patient 88/38, a 6 year old boy, is one example of a patient from Stannington with Perthes’ Disease, in this case affecting the left hip. Admitted to Stannington on 31st October 1941, clinical notes read:

‘L. hip – some wasting thigh muscles. Some limitation flexion. Hip in good position.’

FIGURE 2: HOSP-STAN-07-01-02-569_03
FIGURE 2: HOSP-STAN-07-01-02-569_03
Figure 1: HOSP-STAN-07-01-02-569_02
Figure 1: HOSP-STAN-07-01-02-569_02

 

 

 

 

 

 

 

 

This is supported by the radiographs for the patient, figures 1 and 2 respective of date, and x-ray report:

‘13/11/1941 – Hip – flattened epiphysis has progressed since last x-ray 15/09/1941. Perthes’ Disease

20/11/1941 -Marked flattening of epiphysis L. hip. Some softening of neck. Definite Perthes’ Disease.’

 

By comparison, tuberculosis of the hip (see posting from 08/12/2014) results in the gradual destruction of the hip joint beginning with a reduction in the joint space between the femoral head and the acetabulum, leading to possible porosity and eburnation in the affected bones and the possibility of pathological dislocation, deformity and loss of use in the affected joint. Even after the disease has reached quiescence it is possible that the individual will suffer with ongoing osteoarthritis or ankyloses.

FIGURE 3: HOSP-STAN-07-01-02-591_03
FIGURE 3: HOSP-STAN-07-01-02-591_03

Figure 2, above, is of patient 88/38 with Perthes’ Disease, which can be compared with figure 3, patient 89/21, an individual with TB of the right hip. From the images, note the difference between the Perthes’ Disease where the femoral head becomes flattened and the epiphysis appears to pull away from the metaphysis but generally keeps its ‘ball and socket’ joint appearance with the pelvis compared to the loss of definition of a clear joint with the tuberculous hip, which shows loss of joint space and rarefaction.

 

For further radiographic images check out the Radiographs from Stannington Flickr Stream athttps://www.flickr.com/photos/99322319@N07/sets/72157648833066476/

 

Sources

The Perthes’ Association (2011). ‘What is Perthes’ Disease?’ http://www.perthes.org.uk/what-is-perthes-disease/

This Week in World War One, 2nd July 1915

by

Berwick Advertiser title 1915

BERWICK ADVERTISER, 2ND JULY 1915

 

BERWICK BOY SCOUTS FIELD DAY

 

On Midsummer Holiday Berwick-upon-Tweed Boy Scouts had a combined outing to Chain Bridge. The patrols from Tweedmouth and Spittal joined Berwick boys at Headquarters, Palace Green, where arrangements were completed for the march. Headed by a patrol leader bearing the Troop

Berwick Advertiser 2 July 1915, Boy Scout
Berwick Advertiser 2 July 1915, Boy Scout

flag, the procession passed through the town and made quite a good show, the treck-cart party coming up close behind, and being followed by the Cyclist Scouts.

After a halt at Cantie’s the troop resumed their march and reached Chain Bridge in time to have bathing parade before dinner. The afternoon was pleasantly spent, and after tea, a football match, Berwick versus Tweedmouth and Spittal, was played off, resulting in a victory for the latter.

The weather was glorious up to this point, but the thunder-storm which broke as the boys were on their way to Velvet Hall Station literally put the damper on them. However, they were very happy, and quite enjoyed the day’s outing.

Altogether, 134 boys were present at the outing, the Scoutmasters in charge being Messrs Clements, Turnbull, Moore and Edward Smith. Mr T. Boal very kindly acted as Scoutmaster for the day, and to him and to Mr Bell, farmer, Bankhead, who kindly placed a field at the disposal of the Scouts, as well as to Mr T. C. Smith, Castle Terrace, who provided prizes, the thanks of the Scouts’ Association are heartily tendered.

 

Berwick Advertiser 2 July 1915, Playhouse Advert
Berwick Advertiser 2 July 1915,
Playhouse Advert

 

 

SUNDAY SCHOOL TRIP

 

On Tuesday afternoon the children attending the E.P. Church, Tweedmouth, had their annual trip to Greenlaw Farm, Foulden. The farmer, Mr James Renton, and family, seem to look forward to the coming of the children and their friends with pleasure, and to find special delight in making preparations for their entertainment. As the long procession of carts, kindly supplied by Messrs Peter Edgar, Camphill; David and James Renton, Spittal Hall; Mrs Marshall, Tweedmouth; Mr Cowe, Baldersbury; and Mrs Waite, Castlehill, passed along the youngsters broke away from the monotony and depression of the time-making all within reach of their voices forget for a little the worries and anxieties of the war. Once on the field there was a rush to the liberty to scamper and play and amuse themselves without restraint. After tea, served by the teachers, the games and races were resumed with vigour, and kept going till a few loud claps of thunder intimated that it was time to quit. Before leaving, to show how much they felt indebted to Mr and Mrs Renton and family for the invitation to their place, for the milk they supplied for the tea, and for their kindness and efforts to make the trip a success, three hearty cheers were given. The return journey, after a most enjoyable afternoon in the open, was completed without a mishap. The teachers beg to thank very sincerely Mr P. Edgar for his assistance on the field; Mr P. Boston for the use of the infuser; the ladies who gave the nuts and sweets; those who provided the carts, and all who contributed towards the children’s enjoyment.

 

LOCAL OFFICER WOUNDED

Lieut F.W Smail

 

Mr H.R. Smail, proprietor of the “Berwick Advertiser,” received word by telegram on Wednesday evening that his second son, Lieut. F.W. Smail had been wounded on Monday, but the nature of the wound is not stated.

Lieut. Smail was educated at Berwick Grammar School and Loretto School, Musselburgh, and afterwards was a student farmer. A year or two ago he entered the tenancy of Linton Burnfoot Farm, Kelso. A year before the outbreak of war he was a trooper in the Lothians and Border Horse, and from that regiment he transferred to the 7th N.F. as second lieutenant. He was keen and enthusiastic in the discharge of his duties, and before the 7th N.F. left for the front he was promoted 1st Lieutenant. His eldest brother, Captain H. R. Smail, is in the same regiment.

A letter we have received as we go to press states that Lieut. Smail was caught by a sniper while in the trenches at night. The bullet struck him on the back of the head, and he was carried from the trench unconscious. The wound is described as serious.

Lieut F.W Smail Dies From His Wounds

 

Berwick Cemetery, North Road, Berwick-upon-Tweed, where 1st Lieutenant Frank Weddell Smail is buried
Berwick Cemetery, North Road, Berwick-upon-Tweed, where 1st Lieutenant Frank Weddell Smail is buried

 

SMAIL, Lt. Frank Weddell. “D” Coy. 1st/7th Bn. Northumberland Fusiliers. Died 1st Dec., 1915 of wounds received near Wulverghem on 27th June. Age 23. Son of Henry Richardson Smail, of Berwick-on-Tweed. A.C. 412. Acknowledgement – Grave Registration Documents-Registers – CWGC

 

Surgical Procedures – Osteotomy

by

Patient 91/10 was a 15 year old boy admitted to Stannington on 31st October 1941, a letter attached to his discharge report alludes to him having been transferred to Stannington from Newcastle. His initial examination notes reveal he had some tightness over the abdominal area and the right hip was in a state of 45° flexion with some adduction, slight exterior rotation and wasted muscle. Signs of two previous sinuses were also present on the right thigh. The patient had previously been admitted to Stannington from August 1936 until February 1939 when he was discharged in a splint which he wore until the age of 13 prior to his second admission and his hip became flexed; unfortunately we do not hold records for patients this early on and as such have no further details about his previous stay. Figures 1 and 2 are two of the radiographs of his first stay in Stannington, the first showing some tuberculous activity in the lungs and the second showing tuberculous involvement in the right hip joint.

FIGURE 1: HOSP-STAN-07-01-02-686_12
FIGURE 1: HOSP-STAN-07-01-02-686_12
FIGURE 2: HOSP-STAN-07-01-02-686_10
FIGURE 2: HOSP-STAN-07-01-02-686_10

 

 

 

 

 

 

 

 

 

This boy was diagnosed with 3rd stage TB of the right hip and was put forward for a surgical procedure known as an osteotomy. An osteotomy, known as ‘bone cutting’, is a procedure whereby the bone near a damaged joint is cut to realign load bearing surfaces. In the case of patient 91/10 a right femoral osteotomy was performed on the proximal femur to better align it with the acetabulum (socket) of the pelvis, most likely to improve functionality of the limb.

Initial notes on this patient from early 1942 are vague referring to the levels of flexion and adduction in the hip joint but little else. The x-ray report prior to the osteotomy note that no infection is active in the lungs and that there was firm ankyloses in the hip. The osteotomy took place on 13th February 1942.

 

FIGURE 3: HOSP-STAN-07-01-02-686_05
FIGURE 3: HOSP-STAN-07-01-02-686_05
FIGURE 4: HOSP-STAN-07-01-02-686_04
FIGURE 4: HOSP-STAN-07-01-02-686_04

 

 

 

 

 

 

 

 

 

 

Figures 3 and 4, respectively, show the patient’s condition before and after the osteotomy was carried out. Figure 3 shows tuberculous infection in the hip joint, affecting the femoral head with some acetabulum involvement. The right hip appears on a slant in comparison to the left sitting higher up, this could potentially have caused the patient to have limp. Figure 4, taken on 14th April 1942, shows the results of the osteotomy, where the femoral head has been repositioned with the aim of realigning the hip joint.

Following the procedure, recovery appears to have gone relatively smoothly. A plaster splint was applied to the patient on 3rd March 1942 where it was noted that the femur had ‘40° abduction – no change’.

No complications are outlined within the notes and the x-ray reports state that there was:

                        ‘14/4/42 –            Good bony union after osteotomy. Position satisfactory.

                        17/7/42 –            Chest no change.

                                                   Hip – osteotomy satisfactory good ankylosis.’

 

By June 1942 the patient was capable of standing and putting weight on the right leg and is noted to be walking well by mid-July, meriting the osteotomy a great success. The patient was discharged on the 24th July 1942 as quiescent after a 38 week stay at Stannington. The final surgical outcome can be seen in Figure 5.

FIGURE 5: HOSP-STAN-07-01-02-686_14
FIGURE 5: HOSP-STAN-07-01-02-686_14

 

To see more radiographic images from Stannington, have a look at our Flickr Stream https://www.flickr.com/photos/99322319@N07/sets/72157648833066476

Sources:

Tuli, S.M (2004) Tuberculosis of the Skeletal System: Bones, Joints, Spine and Bursal Sheaths. Jaypee Brothers Publishers.

+ More