Fibrous contracture of muscles following intramuscular injections in adults

Periarticular fibrous muscle contractures in adults from repeated injections in the same site is predictable. The causes of joint contracture in children are many and complex, but in adults it seems certain that this phenomenon is the result of repeated injections of analgesics or other agents into 1 muscle area. Any drug if repeatedly injected locally may cause fibrosis of the muscle and subsequent joint contracture. Five cases of bilateral abduction contracture of the shoulder in adults including the first case of bilateral abduction contractures of shoulder and hip plus bilateral flexion contracture of elbow and extension contracture of a knee are reported. No underlying disease which might predispose to this fibrosis of muscles was noted. The frequency and period of injections were variable over several years. In all patients the interference in activtities of daily living were serious, but the deformities were corrected by release of the fibrous band with relief of discomfort and restoration of joint motion without recurrence. Noting the potential complication of repeated intramuscular injections in one area, this practice should be avoided whenever possible in adults, as well as in children.     

The effect of temperature on potassium chloride contracture in cat myocardium

1. Contracture was induced in cat myocardium by exposure to 140 mM-KC1 In isotonic Tyrode solution. Force of contracture expressed as mg/mm2 (muscle cross-sectional area) falls with increasing cross-sectional area. 2. The effect of temperature on isometric force developed during contracture was evaluated both in normal (untreated) atrial and ventricular muscle and following treatment with sympatholytic drugs. 3. The force of contracture was not significantly affected by sympatholytic drugs at 36 degrees C. 4. In normal atrial and ventricular muscle, force of contracture decreased when the muscle was cooled from 36 to either 29 or 20 degrees C. 5. In atrial muscle, the effect of temperature was not changed by sympatholytic drugs. In contrast, exposure to sympatholytic drugs increased contracture force developed by ventricular muscle at 20 degrees C. Also, contracture force was significantly greater at 20 than at 36 degrees C in ventricular muscle from reserpine-pretreated cats. 6. It is suggested that ventricular muscle becomes more sensitive to the relaxing effects of endogenous catecholamines at temperature is lowered. 7. The differences shown between atrial and ventricular muscle with respect to the effect of temperature and sympatholytic drugs on contracture force may result from the differing amounts of sarcoplasmic reticulum found in these types of cardiac muscle and also from different mechanisms of "excitation-contracture" coupling in atrial and ventricular muscle.     

Chlorocresol, an additive to commercial succinylcholine, induces contracture of human malignant hyperthermia-susceptible muscles via activation of the ryanodine receptor Ca2+ channel

BACKGROUND: A defect in the ryanodine (Ry1) receptor Ca2+ channel has been implicated as one of the possible underlying causes of malignant hyperthermia (MH), a pharmacogenetic disorder characterized by sustained muscle contracture. The disease is triggered by common halogenated anesthetics and skeletal muscle relaxants, such as succinylcholine. This study tested whether the functional properties of the Ry1 receptor Ca2+ channel are affected by chlorocresol, a preservative added to a commercial preparation of succinylcholine (Midarine) and other parenteral compounds. METHODS: In vitro contracture testing was carried out on muscle biopsies from malignant hyperthermia-susceptible (MHS) and -negative (MHN) individual according to the protocol of the European MH group. Ca2+ flux studies on isolated rabbit sarcoplasmic reticulum fractions were measured spectrophotometrically by following the A710-790 of the Ca2+ indicator antipyrylazo III. RESULTS: Chlorocresol causes muscle contracture in MHS muscles at a concentration of 25-50 microM and potentiates the caffeine contracture response in human MHS muscles. Sub-threshold (20 microM) concentrations of chlorocresol increase both the Kd and the Vmax of caffeine-induced Ca2+ release from isolated rabbit terminal cisternae. CONCLUSIONS: These data suggest that, in muscle from MHS individuals, the enhanced Ca2+ released from the sarcoplasmic reticulum may not be due to the effect of succinylcholine alone but rather to the action of the preservative chlorocresol added to the drug.     

Clinical presentations, differential diagnosis and management of obstetric brachial palsy

INTRODUCTION: The brachial plexus originates from C5 to T1 spinal segments. The brachial plexus includes the ventral ramus, trunks, divisions, cords and branches. DEVELOPMENT AND CONCLUSIONS: Brachial plexus injuries produce clinical syndromes. The Duchenne-Erb syndrome is the most frequent presentation of obstetric brachial plexus injury. The differential diagnosis of brachial plexus palsy include decreased arm movements due to pain, or weakness caused by a lesion of the nervous system outside in the brachial plexus, or by a lesion in the brachial plexus due to non-obstetrical causes. Management of these patients initially includes considering the possibility of clavicular and humeral fractures and posterior subluxation of the shoulder; and subsequently considering the possibilities of subscapularis muscle contraction or posterior shoulder subluxation in patients that develop internal rotation contracture of the shoulder; or flexion, pronation or supination contracture in patients with forearm deformation. Treatment consist of physical therapy, administration of botulinum toxin, electrical stimulation, neurolysis, nervatization, removal of neuromas and nerve grafting, treatment of fractures and subluxation, release of muscle contracture and tendon transplantation.     

Salivary cortisol: a non-invasive measure of hypothalamo-pituitary-adrenocortical activity in the squirrel monkey, Saimiri sciureus

STUDY OBJECTIVES: To study the in vitro effects of the serotonin2 (5-HT2) receptor agonist 1-(2.5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI) in skeletal muscle specimens from malignant hyperthermia-susceptible (MHS) and normal (MHN) patients following pretreatment with the 5-HT2 receptor antagonist ritanserin. DESIGN: Prospective study. SETTING: Malignant hyperthermia (MH) laboratory at a university hospital. PATIENTS: 41 patients undergoing in vitro contracture test for diagnosis of MH susceptibility. INTERVENTIONS: Skeletal muscle biopsies in adult patients were performed with a 3-in-1 nerve block with 40 ml prilocaine 1%. In children, general anesthesia was induced with 50 micrograms/kg alfentanil intravenously (i.v.) and 2 to 2.5 micrograms/kg propofol i.v. and maintained with a continuous infusion of propofol (< or = 150 micrograms/kg/min) and nitrous oxide (66%) in oxygen. MEASUREMENTS AND MAIN RESULTS: Patients were first classified as MHS or MHN by the in vitro contracture test according to the European MH protocol. Surplus muscle specimens of 21 MHS and 20 MHN patients were used in this study. At first, DOI was added to the organ bath at a concentration of 0.02 mM. In the second part of the study, muscle specimens were preincubated with ritanserin 0.01 mM for 10 minutes before DOI 0.02 mM was added to the bath. Muscle specimens from all patients developed contractures after administration of DOI. The onset of contractures was significantly faster in MHS muscles, and the magnitude of contracture was significantly greater than in MHN. The muscle twitch decreased significantly in both groups after DOI. After pretreatment with ritanserin, start of contracture was significantly delayed in MHS muscles. MHN muscles failed to develop contractures. The maximum level of contracture was significantly reduced in MHS. Muscle twitch decreased also in both MHS and MHN groups. CONCLUSIONS: The findings may indicate that stimulation of 5-HT2 receptors is involved in MH induction. Furthermore, 5-HT2 receptor antagonists could possibly be effective in preventing MH. Additional studies are required to determine if administration of 5-HT2 receptor antagonists could be of additional value in the treatment or prevention of anesthetic-induced MH.     

Breast conservation therapy after augmentation mammaplasty: is it appropriate?

Breast conservation therapy, consisting of lumpectomy, axillary node dissection, whole-breast irradiation, and a boost to the tumor bed, is an increasingly popular option for the treatment of breast cancer. Among patients with stage I and stage II disease, breast conservation therapy yields survival rates equivalent to those for mastectomy. The cosmetic results of radiotherapy are usually good, and this approach preserves an intact, sensate breast. Most studies on breast conservation therapy, however, have been performed in nonaugmented patients. Relatively little has been published regarding breast conservation therapy in the presence of silicone implants. Between 1981 and 1994, we treated 33 augmented patients with breast conservation therapy. Among 26 individuals for whom complete follow-up data were available, 17 (65 percent) developed significant capsular contracture on the irradiated side. Thus far 8 patients with radiation-induced contracture have undergone corrective surgery. In our experience, augmented breast cancer patients treated with breast conservation therapy have less satisfactory cosmetic results than nonaugmented women. In addition, mammographic follow-up, critical for identifying local recurrence, may be impaired by the presence of an implant and capsular contracture. On the basis of these considerations, breast conservation therapy may be less than optimal in augmented cancer patients unless explantation is performed before treatment.     

Effect of chlorocresol vs caffeine on muscle contracture in malignant hyperthermia susceptible patients

The phenotype of susceptibility to malignant hyperthermia (MHS); can only be detected reliably by the in vitro caffeine-halothane contracture test (CHCT). Enhanced sensitivity of the calcium-induced calcium release mechanism is responsible for the exaggerated contracture response of skeletal muscle fibers from MHS patients to halothane and caffeine. Chlorocresol was demonstrated to be a potent activator of Ca++ release from skeletal muscle sarcoplasmic reticulum. This effect is probably mediated through action on a ryanodine sensitive Ca++ release channel known to be more sensitive in MH. We studied the effect of chlorocresol on the mechanical contracture response of skeletal muscle from patients presenting for the in vitro CHCT. Chlorocresol induces contracture response in a concentration 1/200 of that of caffeine in muscle strips from MH patients. By adding chlorocresol to the protocol of the CHCT, there is clearer discrimination between the responses of MH patients and normal subjects can be achieved.     

Fiber-type caffeine sensitivities in skinned muscle fibers from humans susceptible to malignant hyperthermia

BACKGROUND: The response to contracture tests may depend upon the relative proportion of muscle fiber types within the muscle specimen. To determine whether a difference in fiber-type caffeine sensitivities exists between malignant hyperthermia susceptible (MHS) and malignant hyperthermia-nonsusceptible (MHN) skeletal muscle, we compared the fiber-type caffeine sensitivities in chemically skinned muscle fibers dissected from vastus lateralis muscle from 15 MHS and 16 MHN patients. METHODS: Muscle fiber type was determined in each fiber by the difference in strontium-induced tension measurements and in 36 fibers, after contracture testing, by ATPase enzyme histochemistry. Caffeine sensitivity was defined as the threshold concentration inducing more than 10% of the maximal tension obtained with a calcium 1.6 x 10(-2) mM solution. RESULTS: Significant difference in the mean (+/- SD) caffeine sensitivity was found between type I MHS fibers (2.63 +/- 0.85 mM) versus type II MHS fibers (3.47 +/- 1.2 mM) and between type I MHN fibers (5.89 +/- 1.8 mM) versus type II MHN fibers (10.46 +/- 2.6 mM). The mean (+/- SD) caffeine sensitivities for a given muscle fiber type (I or II) were different between groups of MHS and MHN patients. Both type I and II MHS fibers had significantly lower caffeine sensitivities, and this increase in caffeine sensitivity was significantly smaller in type I than in type II fiber. CONCLUSIONS: The current study indicates that a truly MHS patient cannot have a false-negative result solely related to abnormal type II fibers contained in a given muscle strip. Although the occurrence of a very high proportion of type I fibers in MHN human muscle could result in a false-positive contracture outcome, such an occurrence is expected to be rare.     

The adenosine triphosphate (ATP) depletion test: comparison with the caffeine contracture test as a method of diagnosing malignant hyperthermia susceptibility

The adenosine triphosphate (ATP depletion ratio, which is the ratio [ATP] in skeletal muscle equilibrated with carbogen and 4% halothane for 30 minutes divided by [ATP] in skeletal muscle equilibrated with carbogen alone for 30 minutes is less than normal in most but not in all rigid MHS patients. The ratio is normal in non-rigid MHS patients. This diagnostic tool is, therefore, useful in the diagnosis of rigid MH. It is not, however, such a sensitive diagnostic parameter as the caffeine contracture test.     

Transnasal endoscopic approach to expose the medial rectus from the annulus of Zinn to the penetration of Tenon''s capsule

Conventional strabismus surgery employs a conjunctival incision to gain access to Tenon's space where a wide variety of procedures are routinely performed on the tendon and anterior aspect of the extraocular muscles. Recently, transnasal endoscopic surgical techniques have gained acceptance as effective means of decompressing the medial wall and floor of the orbit in patients with thyroid-related orbitopathy. The orbital surface of the medial rectus and inferior rectus are exposed from the annulus of Zinn to a position close to where the muscles penetrate Tenon's capsule. In theory, this technique also provides the exposure necessary to locate and retrieve a "lost" medial rectus when the usual sub-Tenon's approach fails to recover the muscle. Cadaver studies demonstrate the feasibility of exposure and suture placement in the stump of a lost medial rectus with passage of the suture through Tenon's capsule to transmit the force of the muscle to the globe, provided that the lost muscle is retrieved before severe contracture develops.     

The gastrocnemius muscle flap in the correction of severe flexion contracture of the knee

Extreme flexion contracture of the knees due to extra-articular contracture of the knee joints is a frequent deformity in catastrophic neurological lesions such as multiple sclerosis, meningomyelocoele, paraplegia, quadriplegia, and cerebral spastic paralysis. Such gross knee contractures together with the coexisting hip flexion contractures create a severe nursing problem. Adequate perineal hygiene and positioning are very difficult to achieve and thus pressure sores frequently develop in these bed-ridden patients in spite of devoted nursing care. The orthopaedic surgeon can help alleviate the plight of these unfortunate victims: first the hip joint contractures are released by the classical methods and then, at the same session, the knee contractures: a simple one stage procedure is described. Primary cover of the large popliteal skin defect is achieved by a gastrocnemius versatile muscle flap, which is itself covered by a free split skin graft. An illustrative case is described.     

4-chloro-m-cresol-induced contractures of skeletal muscle specimen from patients at risk for malignant hyperthermia

PURPOSE: 4-chloro-m-cresol (4-CmC), commonly used as preservative, has been shown to induce contractures in skeletal muscle specimens from individuals susceptible to malignant hyperthermia (MH). It has been suggested that a defect of the calcium release channel of the skeletal muscle sarcoplasmic reticulum (ryanodine receptor) in MH susceptible (MHS) patients could be responsible for this phenomenon. 4-CmC was found to be a potent activator of ryanodine receptor-mediated Ca2+ release. The aim of this study was to determine the in vitro effects of 4-CmC on muscle specimens from MHS and normal (MHN) patients, and whether contracture testing with different concentrations of 4-CmC could result in a more precise discrimination between MHS and MHN. METHODS: In this prospective study muscle biopsies were obtained from 40 patients with clinical suspicion of MH. The patients were first classified by the in vitro contracture test (IVCT) according to the European MH protocol. After MH classification, surplus muscle specimens were subjected to the 4-CmC study. RESULTS: Cumulative administration of 4-CmC (25, 50, 75, 100, 150, and 200 mumol/l) produced contractures in a concentration-dependent manner. However, contractures developed significantly earlier and were greater in MHS (n = 17) than in MHN specimens (n = 23). After bolus administration of 50, 75, and 100 mumol/l 14-CmC MHS specimens developed distinct muscle contractures. In contrast, in MHN specimens only 100 mumol/l 4-CmC produced contractures. All contracture levels following bolus administration of 100 mumol/l 4-CmC were attained significantly earlier in MHS than in MHN. There was no overlapping in the range of times between both groups. CONCLUSION: In vitro contracture testing with 4-CmC seems to be a specific method to distinguish between MHS and MHN patients. However, the question whether 4-CmC is an MH-triggering agent is not completely solved. 4-CmC is a preservative within a large number of commercially available preparations (e.g. insulin, hormones, etc.). Regarding the results of contracture testing with 4-CmC it has been suggested that 4-CmC possibly represents a high-risk agent for MHS individuals. To reduce the risk of MH in susceptible patients due to administration of chlorocresols, we recommend avoiding preparations containing the preservative 4-CmC.     

Pathophysiology of changes in absolute lung volumes

Changes in absolute lung volumes are common in lung disease and result in significant impacts on gas exchange, respiratory muscle function, the sensation of dyspnoea, and limitations to maximal exercise. Though our knowledge regarding the magnitude and determinants of changes in lung volumes in health and disease has increased in the past 20 years, a number of important questions remain unanswered. Consideration of the limitations of specific methods for measuring lung volumes is essential when analysing published studies regarding absolute lung volumes in infants, children and adults. Though functional residual capacity is most commonly measured in children and adults with the subject awake and at rest, increasingly attention is being directed to making these measurements under clinically more relevant conditions (e.g. during exercise, sleep, anesthesia, or mechanical ventilation). The relationships between dynamic changes in functional residual capacity, flow limitation during tidal breaths, sensation of dyspnoea and exercise limitation are important to understand, and are the focus of current and future research. Improved understanding of these relationships may lead to improvements in therapy of patients with acute and chronic lung disease and are likely to be particularly important for evaluating the efficacy of and optimal patient selection for new modes of therapy, such as lung volume reduction surgery.     

Tissue radiation dosages using the RVG-S with and without niobium filtration

Twenty-five free tissue transfers for reconstruction after lower limb trauma or release of scar contractures were performed in 23 children over an 8-year period. The ages ranged from 2 to 14 years (mean 7.1 years). Fourteen (61%) patients had major associated injuries. The reconstruction sites were all in the distal leg. The overall vascular success rate was 96%. Three patients underwent re-explorations because of vascular insufficiency. One flap failed and two were salvaged. The causes of vascular complications were considered to be inadequate debridement of an avulsed vessel, venous kinking and inadequate protection of the vascular pedicle. The three cases with vascular insufficiency were children with associated injuries on the ipsilateral leg proximally. Postoperative complications were not uncommon (28%). Six of the seven complications occurred in patients with major associated injuries. The mean follow-up was 57 months. Long-term problems such as a limping gait, frequent flap ulcers, toe contracture or a bulky flap were common. Our results suggest that free tissue transfer is reliable and safe for the reconstruction of major leg injuries in children. Associated injuries proximal to the reconstructed defects on the ipsilateral leg predispose to more vascular complications. Since postoperative complications and long-term morbidity are common in children, special precautions should be taken with the preoperative assessment, planning, execution of surgery and postoperative care to achieve better results.     

Congenital extension contracture of metacarpophalangeal joints

We report a case of congenital extension contracture of the fifth metacarpophalangeal joints in a 15-year-old boy who had no associated anomalies and was successfully treated by surgery. Congenital extension contracture of bilateral metacarpophalangeal joints has not been reported previously, and the entity can be considered to be a new subgroup of distal arthrogryposis with congenital distal limb contracture.     

EDP recipe adjustment by percentage method in a college foodservice system

In a free muscle transfer, great care must be taken in selecting the muscle to be grafted. We have found the pectoralis major to be a good donor muscle. Although most muscles are not nourished by a single artery and a few veins, the vessels which enter the pectoralis major muscle with the nerves are the main nutrient vessels, and these vessels alone can adequately nourish this muscle. Neurorrhaphy should be performed at a site as close as possible to the muscle. Good indications for free muscle transfer are cases in which a flexor muscle has become necrotic, while the extensor muscle is viable--for example, if the flexor muscle has sustained traumatic crushing injury or if there is a Volkmann's contracture.     

Importance of tenotomy of the adductors in the treatment of cerebral palsy manifestations in the lower extremities

The authors evaluate 303 tenotomies of adductors performed in patients with cerebral palsy (CP) in 1970-1992. They emphasize the correct diagnosis of adduction contracture of the hip joint and correct treatment, incl. early surgery, not only because of the influence of adductors on standing and gait but also on the development of the hip joint in children. The authors draw attention to the increased incidence of subluxations and luxations of the hip joint in recent years in children with CP who were not operated or where the muscular balance and contractures of the hip joint were not modified. They emphasize the fact that in children where tenotomy of the adductors was performed in time before the age of 8 years, with a single exception luxation did not develop. In the authors' opinion tenotomy at the age of cca 11 years is an essential operation but in view of the development of skeletal changes it is late. The authors recommend to pay increased attention to the problem of adductors in CP as regards diagnosis and technical aspects of the operation.     

Infrapatellar contracture syndrome. Diagnosis, treatment, and long-term followup

Infrapatellar contracture syndrome is an uncommon but recalcitrant cause of reduced range of motion after knee surgery or injury. The results and conclusions presented here are based on a retrospective clinical study evaluating the long-term outcome in 75 patients who developed infrapatellar contracture syndrome. These 75 patients (76 knees) were evaluated at an average followup of 53 months after the index (inciting) procedure or injury. Comparing subgroups within the study population, factors that correlated with poorer results or more severe infrapatellar contracture syndrome were found to be acute anterior cruciate ligament repair or reconstruction, the use of patellar tendon autograft for anterior cruciate ligament reconstruction, nonisometric graft placement, multiple surgical procedures, use of closed manipulation, and the development of patella infera. We concluded that appropriate procedures can substantially increase the range of motion in patients with infrapatellar contracture syndrome. However, residual functional morbidity persists in many patients, and the outcome, as determined by subjective knee function scores, is only fair. The natural history of an anterior cruciate ligament-deficient knee appears to be more benign than the natural history of a knee that develops infrapatellar contracture syndrome.     

0.9% sodium chloride injection with and without heparin for maintaining peripheral indwelling intermittent-infusion devices in infants

PURPOSE: Tachypnea in children is associated with respiratory disorders and nonrespiratory disorders such as cardiac disease, metabolic acidosis, fever, pain, and anxiety. Pulmonary embolism is seldom considered by pediatricians as a cause of tachypnea. PATIENTS AND METHODS: Three children of various ages with persistent tachypnea are described: a girl after orthopedic surgery for kyphoscoliosis, a boy with nephrotic syndrome, and a neonate with Hirschsprung disease. Other causes of tachypnea were diagnosed and treated before pulmonary embolism was considered. RESULTS: Ventilation-perfusion scanning appeared to be highly probable for pulmonary embolism in these patients. Anticoagulant therapy was started. CONCLUSION: Pulmonary embolism should be kept in mind in children with tachypnea, especially when other risk factors for venous thromboembolism are present, to avoid delay in anticoagulant treatment and a fatal outcome.     

Natural history of uncorrected flexion contractures following total knee arthroplasty

Over a 2-year period, 29 patients were identified that had preoperative flexion contractures less than 30 degrees and were not fully corrected to neutral following total knee arthroplasty. They were followed after surgery at 3, 6, and 12 months, and yearly thereafter with complete clinical and roentgenographic examinations to determine the natural history of the flexion contracture and its effect on the clinical outcome. The mean age of the 10 women and 19 men was 66 years (range, 47-80 years). The mean preoperative flexion contracture was 11 degrees (range, 5 degrees-30 degrees). The mean follow-up period was 33 months (range, 24-60 months). The mean values of the flexion contractures at each follow-up period were; immediately after surgery, 10.5 degrees; at 3 months, 5 degrees; at 6 months, 2 degrees; at 12 months, 1 degree; and at 24 months, 1 degree (P < .0001). Resolution of the flexion contracture did not vary between patients under and over the age of 65 years. There was no statistically significant difference in the residual flexion contracture when knees with preoperative contractures from 0 degrees to 14 degrees and 15 degrees to 30 degrees were compared. The clinical outcome was not affected by the residual flexion contracture after 6 months of follow-up evaluations. Significant improvements can occur after surgery with rehabilitation, and it appears that complete intraoperative correction is not necessary. There appears to be no difference in the natural history of flexion contractures with regard to age or severity up to 30 degrees.