Ravitch Procedure



Some contend that Ravitch is indicated when a Nuss has failed or is contraindicated.

The Ravitch procedure involves an incision across the chest and the removal of the cartilage that causes the defect. The sternum is then placed in the normal position. If treated for pectus excavatum, a small bar is then inserted under the sternum to hold it in the desired position.

The cartilage will regenerate over the next 4-6 weeks, causing the sternum to be in a fixed position. A small drain may be placed at the site of the operation to prevent a fluid collection.

Triplane fracture

Triplane or triplanar fractures are of the distal tibia only occurring in adolescents. As the physiological closure of the physeal plate begins medially, the lateral (open) physis is prone to this type of fracture. The name is due to the fact of the fracture expanding both in frontal and lateral as well as transverse planes. Most authors regard it as a type IV Salter-Harris fracture.

  • a vertical fracture through the epiphysis
  • a horizontal fracture through the physis
  • an oblique fracture through the metaphysis




Pulmonary Artery Aneurysm



This is a really snazzy case of a pulmonary artery aneurysm. The clinical indication was dissection of the pulmonary artery, which may be present. Pulmonary arterial webs are probably more common but there is definitely an “cobweb sign” in the main pulmonary artery. Whether this represents an intimal flap or a pulmonary web is probably immaterial given the size of the pulmonary artery which measures up to 10 cm.

The pulmonary valve annulus appears diminutive as does the aorta and this probably represents congenital heart disease with pulmonary stenosis and an intra-cardiac shunt lesion. There is a massive pericardial effusion which is probably due to the CHF. The lungs demonstrate diffuse pulmonary edema which is both interstitial and alveolar. Given all these findings, tamponade physiology seems likely.

Bonus round findings include calcification of the walls of the pulmonary artery which is a finding of irreversibility associated with Eisenmenger pathophysiology.