Isolated fractures of the lesser trochanter in children

In a retrospective study of 1126 children with fractures of the proximal third of the femur, three children were found to have isolated fractures of the lesser trochanter. This fracture occurred from a fall in one child and following sporting activities, without a history of injury, in the others. In the latter children, the clinical presentations were similar to those of children with transient synovitis of the hip or Perthes disease. In each child, plain radiographs showed an avulsion fracture of the bony portion of the lesser trochanter. Early and complete recovery followed symptomatic treatment even when there was marked proximal displacement of the avulsed segment of the lesser trochanter.     

A case of intestinal amebiasis]

An avulsion fracture of the insertion of the extensor carpi radialis longus tendon is rare. There have been only five reports of this injury in the literature [1, 2, 4]. We describe an additional case in which open reduction with internal fixation gave a satisfactory result.     

Adrenoceptors in the hepatic tissues in cirrhotic rats and cirrhotic patients with portal hypertension]

Phalangeal dislocations of toes are extremely rare in childhood and usually can be treated by closed reduction. We present a proximal interphalangeal dislocation of the fourth toe with an irreducible avulsion fracture of the middle phalanx requiring open reduction. To our knowledge concomitant avulsion fractures in this condition have not been reported thus far in pediatric patients. The pathological mechanism of this injury is discussed, and the significance of the plantar plate for joint stability is emphasized.     

Tibial tuberosity avulsion associated with patellar tendon avulsion

We report an adolescent boy with avulsion of the tibial tuberosity associated with avulsion of the patellar tendon. He underwent open reduction and internal fixation of his bone injury and the patellar tendon was successfully reattached. The boy experienced a full recovery.     

Isolated avulsion fracture of the lesser tuberosity of the humerus. Apropos of a case

PURPOSE OF THE STUDY: The authors report a rare case of an isolated avulsion fracture of the lesser tuberosity of the humerus in an adult. The aim of the study was to highlight diagnostic features as well as surgical treatment. MATERIAL: A 31 year old woman presented an isolated avulsion fracture of the lesser tuberosity of the humerus. Physical exam, standard radiographs of the shoulder as well as a computed tomographies (CT) were obtained. METHODS: An assessment was made of the patient's complaints, signs and symptoms, diagnosis, surgical treatment, physical therapy and follow-up. Final clinical results were evaluated according to external rotation and muscular strength of the shoulder. RESULTS: The diagnosis was evoked on standard radiographs of the shoulder and confirmed by CT. The patient was operated on the 8th day following trauma and pendular physical therapy was initiated on the third day postoperatively. The patient recovered her daily activities from the 6th week and was back at work by the end of the 2nd month. Follow up at 12 months showed a painless shoulder with external rotation at 50 degrees in adduction and 70 degrees in abduction. Muscular strength was identical to the contralateral side. No antero-medial impingement was detected due to the hardware. DISCUSSION: This observation illustrates the rare aspect of this fracture, already recognized in literature. The fracture mechanism remains unknown. We agree with Haas, Ross and Love that it might be due to a forced external rotation of the shoulder at 60 degrees of abduction. We highlight the role of the "axillary view" and of the magnetic resonance imaging (MRI) in the diagnostic approach. Treatment is surgical by open reduction and internal fixation of the detached fragment. CONCLUSION: Treatment must be surgical whenever there is a slight displacement of the detached fragment, to prevent non union, mal union or an antero-medial impingement that might limit mobility and muscular strength.     

Serratus anterior dysfunction. Recognition and treatment

Recognition of scapular winging may be difficult, and potential errors in treatment can result. Such treatment errors may cause morbidity for the patient. In addition, electrical evidence of long thoracic nerve injury usually is required to confirm the etiology of scapular winging as being caused by serratus anterior dysfunction. Although various conditions may result in scapular winging, primary serratus anterior dysfunction can be treated effectively by transfer of the pectoralis major tendon; however, this surgical approach sometimes may given an unacceptable cosmesis, and there may be local morbidity to the donor site of the iliotibial band graft that is used to augment the tendon transfer. The authors report eight patients with primary chronic scapulothoracic winging refractory to conservative treatment. Five of these patients had an incorrect diagnosis, and this resulted in 17 surgical procedures without resolution of their pain or improvement of function. Of the eight patients who required additional surgery to stabilize the scapula, only five patients had an electromyographic study that showed long thoracic nerve palsy, although all patients had profound scapulothoracic winging. All patients underwent a modified pectoralis major transfer with autogenous semitendinosus and gracilis tendon augmentation using two small incisions. Although one patient had a postoperative infection develop, the remaining seven patients had resolution of their winging, improved function, and satisfactory cosmesis.     

Late treatment of brachial plexus palsy secondary to birth injuries: rotational osteotomy of the proximal part of the humerus

We retrospectively reviewed the results of rotational osteotomy that had been performed distal to the surgical neck of the humerus in twenty-two patients who had sustained an injury of the brachial plexus at birth. Eighteen patients had a lesion of the superior trunk of the brachial plexus (the fifth and sixth cervical nerve roots), and four had involvement of the entire brachial plexus. The patients ranged in age from four to seventeen years old (average age, ten years and three months old) at the time of the operation. The average duration of follow-up was fourteen years (range, two to thirty-one years). Preoperatively, the patients had been unable to perform self-care activities, such as grooming, feeding, and washing themselves, because of limited active external rotation or fixed internal rotation of the shoulder. All patients had decreased strength of the lateral rotator and abductor muscles and normal strength of the subscapularis and pectoralis major muscles. Radiographs showed some flattening of the humeral head, and four patients had posterior subluxation of the humeral head. A lateral rotational osteotomy of the proximal part of the humerus was performed between the insertions of the subscapularis and pectoralis major muscles. The site of the osteotomy was stabilized with catgut sutures in the periosteum in ten patients and with one or two staples in twelve. The extremity was immobilized in a plaster shoulder-spica cast for six weeks. At the latest follow-up evaluation, the average increase in active abduction was 27 degrees (range, 0 to 60 degrees) and the average increase in the arc of rotation was 25 degrees (range, 5 to 85 degrees). Supination of the forearm also had increased commensurate with the increase in external rotation. The appearance of the extremity had improved as well.     

Acute disruption of the posterior tibial tendon associated with open-fracture dislocation of the ankle

A 27-year-old man with a high-energy, open-fracture dislocation of the ankle underwent debridement and open reduction of his injuries. During surgery a disruption-laceration of the posterior tibial tendon at the level of the fracture of the medial malleolus was found. Repair required location of the proximal muscle and tendon and controlled traction of the musculotendinous unit from its retracted position. Common aspects in the nine previously reported instances of this lesion include relatively high energy of the injury and the fracture type, a transverse fracture in the medial malleolus. Unique to this case was the open injury.     

Avulsion fracture of the anteromedial bundle of the anterior cruciate ligament

The avulsion fracture of the tibial attachment site of the anterior cruciate ligament is relatively rare among adults. Although partial avulsion fracture of this site is very rare, complex forces exerted on the knee joint could produce this type of fracture. We report on an adult patient with an avulsion fracture of the attachment site of anteromedial bundle of the anterior cruciate ligament associated with injuries of lateral and medial collateral ligament and fibular fracture. We speculate varus stress in a flexed knee coupled with rotation between the femur and tibia caused this type of injury.     

Shoulder muscle moment arms during horizontal flexion and elevation

The instantaneous muscle moment arms of 10 shoulder muscles including the three portions of the deltoid and the rotator cuff and scapulohumeral muscle groups during four specified glenohumeral motions were calculated. Moment arm values were derived from a plot of tendon excursion versus glenohumeral joint rotation angle during horizontal flexion along the 90 degrees elevation plane and elevation in the sagittal, scapular, and coronal planes. The deltoid had the largest moment arm in elevation. The anterior deltoid has a larger moment arm in the anterior planes, whereas the midportion is greater in the scapular and coronal planes. The muscles with the largest depressor (adductor) moment arms are the pectoralis major, latissimus dorsi, and teres major. Contrary to the findings of other investigators, the supraspinatus and infraspinatus have a smaller potential elevation torque in the scapular plane than has been previously reported. Furthermore the subscapularis may potentially be a more important elevator in the scapular plane than either the supraspinatus or infraspinatus, especially in the latter phases of motion. The pectoralis major has the largest horizontal flexion moment arm with the humerus elevated 90 degrees, whereas the posterior deltoid and infraspinatus have the largest horizontal extension moment arms in this plane.     

Impalement injury of the colon, iliac vein and sacrum--a rare combination in penetrating abdominal trauma. A case report

We report on the treatment of a patient who sustained a penetrating abdominal wound with injury of the left common iliac vein, the sigmoid colon and the sacrum in a motorbike accident. The left iliac vein injury was treated using a Gore-Tex vein patch and an A-V fistula. The colon was restored after an intraoperative washout. The punched fragment of the sacrum was removed. An additional fracture of the proximal left humerus was managed with an osteosynthesis in a second operation. The principles of management of combined colon and vascular injuries are discussed and a short review of the literature is given.     

Suppression of reperfusion arrhythmias by preconditioning is inhibited by an ATP-sensitive potassium channel blocker, 5-hydroxydecanoate, but not by protein kinase C blockers in the rat

Nine children sustained a second fracture of the distal humerus after union of an ipsilateral supracondylar fracture which had healed with cubitus varus. There were eight boys and one girl with a mean age of five years (1 to 8) at the time of the second fracture which occurred at a mean of 1.5 years after the first. In all patients, the second fracture was an epiphyseal injury of the distal humerus, either associated with a fracture of the lateral metaphysis below the site of the previous supracondylar fracture, or a fracture-separation of the entire distal humeral epiphysis. This suggests that the physis and epiphysis tend to be more subject to injury than the metaphysis of the distal humerus in children who have had a previous supracondylar fracture with varus malunion.     

Xenobiotics or biological response modifiers? Methotrexate remains the anchor drug for rheumatoid arthritis

In avulsion amputations of the digits, soft-tissue injuries are extensive and often require tendon, nerve, and vessel transfers or grafts. The functional results of such digital replantations are frequently less than ideal. Therefore, avulsion amputation of a single digit proximal to the insertion of the flexor digitorum superficialis has been a contraindication to replantation, because the anticipated poor functional result may interfere with overall hand function, and is not worth the sacrifice of a tendon, nerve, or vessel from another digit or transfer. The authors report a patient with avulsion amputation of the middle finger at the proximal interphalangeal joint. The digit was replanted successfully without any tissue transfers other than a radial digital artery from the ring finger. The functional results were good, and the authors believe that good functional and cosmetic results can be achieved in select patients with isolated digital avulsions, provided that an experienced hand microsurgeon and a skillful hand therapist are available for a compliant patient.     

Demonstration of avulsion of the triceps tendon in an adolescent by magnetic resonance imaging

Avulsion of the triceps tendon is an uncommon injury typically occurring in skeletally mature individuals. Although the diagnosis can be suggested by the physical findings and initial radiographs, it may be missed, especially when severe swelling of the soft tissues prevents an accurate physical examination and the radiographs do not show a small fragment of bone accompanying the avulsed tendon. This report describes an avulsion of the triceps tendon in an adolescent boy. Magnetic resonance imaging was useful in confirming the diagnosis.     

Irreducible anterior shoulder dislocation with fracture of the greater tuberosity

The combination of an anterior shoulder dislocation and an avulsion fracture of the greater tuberosity can usually be reduced by closed methods. This report describes a patient requiring open reduction and division of the subscapularis tendon before reduction of the glenohumeral dislocation could be achieved.     

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.     

Closed management and percutaneous fixation of unstable proximal humerus fractures

BACKGROUND: In dealing with displaced proximal humerus fractures, there is still much controversy in treatment modalities. The latest investigations emphasize the concept of minimal exposure and rigid fixation. METHODS: The technique of closed reduction and percutaneous fixation with cannulated screws and k-pins was performed on 19 patients with two- and three-part proximal humerus fractures. The outcomes were evaluated with a mean follow-up of 21 months. RESULTS: All except one case had a solid union of the fracture. Sixteen of 19 patients (84%) acquired good or excellent results according to Neer's classification. No further collapse or avascular necrosis was found. CONCLUSION: The method of closed reduction and percutaneous fixation, although technically demanding, yields satisfactory results in displaced proximal humerus fracture. Cannulated screws provided rigid fixation that was the underlying tenet for early functional retrieval.     

Jones' fractures and related fractures of the proximal fifth metatarsal

At least three fracture types occur in the proximal fifth metatarsal: the Jones' fracture, the proximal diaphysial stress fracture, and the tuberosity avulsion fracture. Each has distinct characteristics. The diaphysial stress fracture is commonly confused with the Jones' fracture, thereby obscuring vital differences in prognosis and treatment. Anatomical and biomechanical characteristics, as well as vascular studies of the proximal portion of the fifth metatarsal, are discussed in an attempt to better understand their diverse healing potentials. Guidelines for treatment are controversial, and must frequently be individualized. Although surgical intervention for certain proximal fifth metatarsal fracture types may speed recovery time, most fractures heal with immobilization. Treatment of displaced, intra-articular fractures, delayed unions, and nonunions usually requires operative methods.     

Operative treatment of displaced proximal humeral fractures: two-year results in 99 cases

The operative treatment of comminuted and displaced fractures of the proximal humerus has been evolving in recent years. Classical open reduction and internal fixation techniques have an increased risk of avascular necrosis. Minimal osteosynthesis procedures often result in a suboptimal fracture reduction and require postoperative immobilization of the arm in some cases. This study reviewed ninety-nine out of 142 patients (70%), an average of 30 months (range 12 to 72 months) after indirect reduction and internal fixation of two-, three- or four-part fractures of the proximal humerus. The surgical procedure includes indirect fracture reduction with no manipulation of the different fracture fragments and subsequent buttress-plate fixation, using a limited deltopectoral approach. Mean age of patients was 63 years (range 17 to 85 years). Twenty percent of patients had associated lesions. Five patients presented with fracture-dislocations. Results were, according to the UCLA- and the Constant-rating system good to excellent in 76 and 69% of cases. Twelve patients had a poor functional outcome. The indirect reduction technique reduces the opening of the fracture site to minimum and thereby limits the risk of iatrogenic damage to local vascularity and the rotator cuff. Complete and partial humeral head necrosis developed in 3% and 1% of cases respectively. Non-union occurred in one case. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus. The incidence of avascular necrosis and non-union are low, when fracture reduction is performed indirectly. Plate fixation enables an early functional treatment, with no need for postoperative immobilization.     

Comparative analysis of breast cancer contamination in mobilized and nonmobilized hematopoietic grafts

We report a case of an 18-month-old female who presented with three supernumerary upper limbs of varying lengths on the right side. Each limb had a proximal, middle, and distal segment, and an intercalated elbow and wrist joint. A single digit was present in the superior limb, three digits in the middle limb, and two digits in the caudal-most limb. Right plagiocephaly, congenital torticollis, scoliosis involving the upper and mid thoracic region, and a hypoplastic right pectoralis major were the other abnormal features noted. Radiography showed two scapulae, humerus, a single forearm bone in each limb, and rudimentary metacarpals and phalanges. Limb duplication may rarely be encountered in parasitic conjoined twins. The role of mutagens, drugs, cellular contributions, and morphogens in the growth and differentiation of limbs has been studied in animals. It is rather difficult to deduce the time of action of the factors responsible for such a malformation.