Intramedullary fixation of forearm fractures in adults

The arrangement of the smooth muscle and elastic and collagen fibers of the minor papilla of the human duodenum was studied on 53 duodenopancreatic specimens obtained from adults of both sexes. Methods included stereological analyses of gross anatomical specimens and thick and thin microscopic sections. The muscular and elastic fibers of the minor papilla have a unidirectional arrangement by which the contraction of its smooth muscular fibers causes opening of its orifice allowing the flow of the pancreatic juice into the duodenum. It is not a typical anatomical sphincter.     

Acute Monteggia lesions in children

Twenty-five consecutive acute Monteggia lesions in children were treated during a six-year period. The series included a very rare case of a Type-II Monteggia lesion not previously reported in children. All patients, except one, were treated by closed reduction. In two instances, after a successful reduction the unstable radial head was fixed with a percutaneous Kirschner wire inserted through the capitulum with the elbow flexed 90 degrees. This was done to avoid immobilizing the elbow in an acutely flexed position. On follow-up (average, thirty-four months), all the end results were excellent.     

The pediatric Monteggia fracture

Since Monteggia first described the fracture bearing his name in 1814, the association of radial head dislocation with ipsilateral ulnar fracture has been well described. Monteggia fractures and their variants are often misdiagnosed, however, because of the numerous atypical presentations of this injury in children. This article describes the diagnosis, treatment, and potential pitfalls encountered in the treatment of Monteggia fractures.     

Chronic Monteggia injury in a child

The case of a Monteggia fracture neglected from two years of age and seen at the age of fourteen, is described. A shortening of the affected ulna by three cm and a relative elongation of the radius was found. The function of the arm and elbow joint was remarkably unaffected with nearly full extension and flexion, supination and pronation. The carrying angle was ten degrees on both sides. Based on the literature, it is stressed that diagnosis and treatment of Monteggia lesions should be immediate. Complications in non-treated cases and at late treatment are many, and the results of such treatment dubious. It is thus of great importance that, when dealing with ulnar fracture a radiograph is also taken of the elbow joint to secure immediate diagnosis.     

Patient self-assessment of tibial plateau fractures in 40 older adults

The prevalence of refractory partial seizure Thai patients at Prasat Neurological Institute was retrospectively from patient charts from January 1995-December 1996 and further prospectively analysed. All epileptic patients were screened by direct questions regarding the anti-epileptic drugs (AEDs) regimen, the frequency, nature of seizure attacks and risk factors of seizure. The criteria of clinical refractory partial seizure was defined as partial seizure which cannot be controlled by a combination of at least two AEDs for four weeks. The results were 3,018 cases of total epileptic patients out of 300,008 visits. These were classified as 2,802 cases of generalized seizures (92.8%), 184 cases of partial seizures (6.1%), and 32 cases of unclassified seizures (1.1%). In the partial seizures group, the number of clinical refractory partial seizures was found to be 48 cases (26.1% of partial seizure). We found that the major risk factor of refractory partial seizures was lack of therapeutic AEDs blood level monitoring (64.5% of cases) and the other risk factors were lack of compliance, loss of follow-up but continued medication, concomitant medication, and improper drug storage. AEDs dosage was adjusted until the blood levels were in the therapeutic range, and correction of other risk factors and patient counseling was given. The number of true refractory partial seizures was reduced to 10 cases (5.4% of partial seizure). This procedure revealed that AED blood level monitoring and correction of other risk factors were essential in controlling seizure frequency. Thus, the prevalence of true refractory partial seizure in our study was 3.3 cases of refractory partial seizure per 1,000 cases of the seizure population. We recommend that AEDs blood level monitoring and exclusion of other risk factors should be added to the criteria for the definition of refractory partial seizures. This criteria should be applied when considering the use of new AEDs as an add-on therapy in refractory Thai patients.     

Mid-clavicle fractures in adults: end result study after conservative treatment

OBJECTIVE: The aim of the present study was to analyze the long-term outcome of mid-clavicle fractures in adults and to evaluate the clinical importance of displacement and fracture comminution. DESIGN: Two hundred twenty-five mid-clavicular fractures that had been nonsurgically treated at Malm? University Hospital were retrospectively evaluated, both clinically and radiographically, an average of seventeen years after injury. There were seventy-one undisplaced fractures, sixty-nine displaced two-fragment fractures, and eighty-five displaced and comminuted fractures. The average patient age at the time of trauma was thirty-three years (range 15 to 70 years). Patients were interviewed, and careful clinical and radiological examination of their shoulders was performed. Two patients had experienced transient neuritis, and another two underwent operative treatment because of progressive neuropathy. SETTING: All 225 consecutive patients were treated primarily at the Malm? University Hospital, which serves the Malm? city population (250,000). PATIENTS/PARTICIPANTS: Since the beginning of this century, all radiographs taken at the Malm? University Hospital have been classified and filed for easy retrieval. In this retrospective study, all patients treated between 1970 and 1979 were identified, and those still living were called for follow-up examination. INTERVENTION: Of the 225 fractures reviewed, 197 fractures were originally treated with a figure-of-eight splint for an average period of three weeks without any attempt to reduce the displaced fractures; twenty-four patients were allowed immediate free shoulder mobilization. MAIN OUTCOME MEASUREMENTS: Clinical rating and healing were the main outcome measurements. RESULTS: At follow-up, 185 shoulders were asymptomatic. Thirty-nine shoulders had moderate pain and were rated as fair, and one patient was rated as poor. One hundred twenty-five of the fractures had healed normally, fifty-three were malunited with persistent fracture displacement, and seven were nonunions; nonunion was significantly more prevalent in cases with displaced fractures. Forty malunited fractures and three nonunions were rated as good. CONCLUSIONS: This review demonstrates that few patients with fractures of the mid-part of the clavicle require operative treatment.     

Factors predicting fractures during falling impacts among home-dwelling older adults

OBJECTIVE: To investigate the predictors of fractures during falling impacts among home-dwelling older adults. DESIGN: A case-control study within a prospective, population-based survey. SETTING: Five rural municipalities in northern Finland. PARTICIPANTS: The study population consisted of all home-dwelling persons aged 70 or older living in these five municipalities (n = 790 (85%)). The cases for this study were those with fracture, using the first fracture (n = 82) in the analyses, during a follow-up period of 4 years. Controls (n = 82) were selected from among the persons who suffered soft tissue injuries; matching was by age, sex, and location of the first injury during the period. MEASUREMENTS: During a 4-year follow-up period, all falls in the population were recorded using fall diaries, telephone interviews, and information from medical records. Risk factors for fractures during the 4-year follow-up were determined according to the number and severity of previous falls, circumstances and place of falls, disease history, use of medicines, symptoms, clinical examinations and tests, nutritional status, functional abilities and social and health behavior. Cross-tabulations for categorial variables, paired t tests for the means of continuous variables, and conditional logistic regression analysis were performed. RESULTS: According to the bivariate analyses, the risk factors for falls resulting in a fracture were frequent fear of falling, abnormal heel-shin test, reduced knee extension strength, reduced grip strength, poor distance visual acuity, low supine pulse rate, inability to carry a 5-kg load 100 meters, not doing heavy outdoor work, and no habitual exercise. A limited amount of social participation was associated negatively with fracturing. Conditional logistic regression analysis showed that the risk factors for fracture-causing falls were frequent fear of falling (OR 2.50; CI 1.11-5.65), reduced knee extension strength (OR 3.38; CI 1.00-11.4), and poor distance visual acuity (OR 3.45; CI 1.13-10.6), whereas limited social participation (OR 0.29; CI 0.11-0.79) protected against the occurrence of fractures. CONCLUSION: Impaired perception, muscle strength, and psychological and social functioning may influence fracture risk during injurious fall impacts. Studies with larger sample sizes are needed to confirm this and to examine the circumstances and mechanisms contributing to the fracture risk during falls via these risk factors.     

Epidemiology of fractures in 15,000 adults: the influence of age and gender

The effect of iron deprivation on the expression of outer membrane proteins and the ability to use heme as an iron source by uropathogenic Proteus mirabilis, Pr 6515, was studied. Examination of iron-restricted bacteria showed three outer membrane proteins ranging from 66 to 75 kDa to be affected by iron restriction, as well as a newly expressed 64-kDa protein. These proteins were induced within 15 minutes of iron-deprivation. The strain grew in the presence of ferric citrate, hemin and hemoglobin as iron sources, but could not use transferrin, lactoferrin or siderophores from exogenous sources. The 64- and 66-kDa proteins showed hemin-binding activity by affinity chromatography, and both reacted in Western blots with sera from mice transurethrally infected with the same strain. We suggest that P. mirabilis expresses iron-regulated outer membrane proteins that could be involved in heme uptake and may have a role in pathogenesis.     

Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients

We examined the frequency of associated chondral and ligament lesions in distal fractures of the radius in young adults (men 20-60 years, women 20-50 years). Fifty initially displaced fractures were examined arthroscopically. Chondral lesions were found in 16 patients (32%). All patients but one were found to have a ligamentous injury in the wrist. No major instability was found. The most frequent ligament tear was the triangular fibrocartilage complex in 39 cases (78%), with a statistical correlation to ulnar styloid fractures. The scapholunate ligament was partially or totally torn in 27 cases (54%). No correlation was found between specific fracture type and pattern of ligament injury. Chondral and ligamentous lesions were frequent and may explain poor outcomes after seemingly well-healed distal fractures of the radius. The ligament lesions should also be kept in mind when early mobilization of the distal fracture of the radius is considered.     

Controversies in acetabular fractures

Open reduction and internal fixation has become the standard of care for the treatment of most displaced acetabular fractures. As surgical techniques have become refined, long term results of surgical fixation have improved. During the past 10 to 15 years, several controversies have surfaced in the orthopaedic literature regarding the treatment of acetabular fractures. The recent literature regarding acetabular fixation was reviewed. Controversies include the most efficacious surgical approach for complex acetabular fractures; the effectiveness of intraoperative sciatic nerve monitoring; the most effective method of prophylaxis against deep vein thrombosis; and the indications for and method of prophylaxis against heterotopic bone formation.     

Carpal fractures in children

This study addresses the likelihood of false negative urine pregnancy test results, due to physiological urine dilution as described in some anecdotal reports. In this prospective study 320 pregnancy tests were performed on urine samples of varying concentrations obtained from 40 women, with suspected complications of early pregnancy, who had presented for ultrasound scans. Four different pregnancy tests were used and serum betahCG levels were measured quantitatively. Despite a mean fivefold increase in urine dilution, the pregnancy tests with low betahCG detection limits maintained maximal sensitivity. The detection of betahCG in dilute urine was adversely affected by using pregnancy tests with higher betahCG detection limits and these tests should be used with caution when assessing gynaecological emergencies.     

Avulsion fractures in athletes

34 cases of avulsion fractures are described. Each fracture took place during athletic training or competition. Excepting six sportsmen participating in a general fitness programme, every patient was an active competitive athlete. There were six women and 28 men; their average age was 20.1 years, raised by a few middle-aged "fitness sportsmen". Most avulsion fractures took place in sprinters and hurdlers; next were middle and long distance renner, footballers, fitness joggers, skiers and ice-hockey players. The most usual location of a fracture was the anterior pelvic spines; avulsion fractures were also detected in various parts of lower limbs. There were fewer avulsion fractures in the area of the trunk and upper extremities. Roetgenologically, the diagnosis of an avulsion fracture is generally easy to make. However, the diagnosis is facilitated by knowing the mechanism of the injury, the technique of the athletic event, and some of the training methods. Generally, a fracture heals well, even if it requires both sufficient immobilisation and some delay in resuming physical exertion.     

Stress fractures in athletes

Stress fractures are one of the most common overuse injuries seen in athletes, accounting for up to 20% of all injuries presented to sports medicine clinics. Runners are particularly prone to these injuries, however, it is difficult to predict injury as there is usually a critical interplay between the athlete's biomechanical predisposition, training methods, and other factors such as diet, and muscle strength and flexibility. This article will discuss the key clinical findings for the majority of stress fractures encountered in a sports medicine practice. A classification scheme will also be described that will allow the clinician to make appropriate treatment decisions based on the degree of risk for each injury.