Gunshot wounds of the extremities in children

A ten-year review of gunshot trauma in Manitoba was prompted by an increasing incidence in gunshot trauma in children. Of 54 children treated from 1964 through 1973 60% sustained injury to one or more extremities. Fifteen children sustained long bone fractures, usually complete and often comminuted. All fractures united and there was only one instance of osteomyelitis. The major complication in gunshot wounds to the skeletally immature was limb length inequality secondary to epiphyseal plate injuries. This complication occurred in nine children. In three children there was in epiphyseal growth disturbance, even though the missile did not appear to pass through the plate but only in close proximity to it. Joint contractures secondary to skin loss and resulting subsequent skin contracture were also common. The amount of debridement required following gunshot trauma in children appears to be somewhat less than is recommended for similar injuries sustained by adults in time of war.     

Forearm fractures in children: pitfalls and complications

Five hundred fourty-seven consecutive forearm fractures in children were studied, with special emphasis on complications encountered. The most important apparent conclusion reached from this study is that greenstick and complete fractures are different, and that some of the pitfalls and complications seen following these injuries can be avoided if different methods of reduction are used for each. Greenstick fractures should be reduced by manipulating them into the correct proper plane of rotation; i.e., maximum pronation for distal third fractures, neutral for middle third fractures, and supination for proximal third fractures. Application of this familiar "rule of thirds" to complete fractures, however, may result in ratational deformity at the fracture site. Completer fractures should be reduced by finger trap traction, allowing the fracture to seek its own level of rotation. Several other observations were also noted. Angulation into radial deviation was found to remodel and equally as well as volar angulation, and remodeling may contine for as long as two years after injury. Growth disturbance following fractures through the distal radial epiphyseal plate is uncommon, but premature closure of the epiphysis did occur in one patient with a typical Type II fracture. Six concomitant nerve injuries were seen; all recovered spontaneously within 3 weeks.     

Primary closure of gunshot wounds caused by high-velocity rifles

Sixty gunshot injuries in 48 patients were treated in Mobile Surgical Hospital (30-bed capacity) of the Mountain and Commando Brigade in Hakkari, Türkiye, between May 1990 and May 1991. The David Sisk method was used for the classification of the injuries. Eleven type 1 injuries were treated conservatively, 39 type 2 and 10 type 3 injuries were treated by extensive debridement with suction drainage and primary closure. No infection was seen in type 1 injuries. The infection rate was 2.56% in type 2 and 20% in type 3 injuries. The following results were obtained: type 1 injuries must be treated by conservative measures; type 2 injuries must be treated by primary closure following extensive debridement and suction drainage; type 3 injuries can be treated by extensive debridement with suction drainage and primary closure.     

Maternal vitamin A deficiency and child growth failure during human immunodeficiency virus infection

Salter-Harris type III fractures of the proximal humerus are rare injuries. We report a Salter-Harris type III anterior fracture-dislocation of the proximal humerus in a 10-year-old boy that was open reduced and internally stabilized. A bone scan performed during the initial hospitalization and at 2-year follow-up revealed devascularization and subsequent revascularization of the humeral head. At 2-year follow-up, the patient had full motion of the shoulder, no pain, and arm strength equal to that of the contralateral side. Four cases of Salter-Harris type III fractures of the proximal humerus have been previously reported; good early clinical outcomes were obtained in all. Despite devascularization of the epiphyseal fragment, excellent clinical outcomes may result.     

Laboratory reduction rate and current efficiency studies of batch type electrolytic reduction of U(VI) in a sulfate system

The electrolytic reduction of U(VI) was investigated to improve the batch type electrolytic reduction of uranyl sulfate. For this purpose, theoretical considerations were made on the time variation of reduction rate and of current efficiency. A monitoring device consisting of two titanium electrodes and one platinum electrode was developed to determine the reduction ratio and to detect the end point of the reduction of U(VI). The monitoring device worked well for these purposes. The reduction rate in a batch type electrolytic reduction of U(VI) at constant current was larger than theoretically expected. This phenomenon was attributed to the increase in the mass transfer rate of U(VI) species toward the cathode due to the disturbance of the concentration boundary layer by hydrogen gas evolved from the cathode surface. The deterioration of titanium cathode experienced in an operating plant was investigated, and was found to be caused by platinum plating onto the titanium cathode surface during the operation. The deteriorated cathode could be restored by immersing it in a hot aqua regia or a mixture of hydrofluoric acid and phosphoric acid for a few minutes.     

Car surfing: an uncommon cause of traumatic injury

Car surfing is an infrequent cause of traumatic injuries treated by emergency physicians. This very dangerous activity can result in serious injury or death. We report 5 cases of injuries caused by car surfing seen at our hospital during 1996 and 1997. All involved head injuries after a fall from a moving motor vehicle. There were 3 male and 2 female patients, and 3 cases were fatal. Health care providers should be aware of this type of injury and support efforts to prevent it.     

Binaural response patterns in subdivisions of the medial geniculate body

Auditory evoked potentials (AEPs) to binaural click stimulation were examined in the ventral (MGv) and caudomedial (MGcm) subdivisions of the medial geniculate body (MG) in guinea pigs. Binaural stimulation caused a decrease in amplitude for the response component recorded from the MGv, but an increase in amplitude for the AEP component recorded from the MGcm. Findings suggest that the evoked responses recorded from MGv and MGcm are functionally distinct. The inhibitory binaural response (BR) pattern seen in MGv was similar to that of the middle latency response (MLR) component recorded over the temporal cortex, while the additive BR pattern typical of the MGcm was similar to that of the surface midline MLR component. Furthermore, these data imply that the binaural response patterns seen in the primary and non-primary auditory cortex may be processed and encoded at the thalamic level. It is concluded that the distinct BR patterns noted for the two MG subdivisions reflect the predominant type of binaurally responsive neurons within the respective pathways.     

Differential effects on Xenopus development of interference with type IIA and type IIB activin receptors

One candidate for a mesoderm-inducing factor in early amphibian development is activin, a member of the TGF beta family. Overexpression of a truncated form of an activin receptor Type IIB abolishes activin responsiveness and mesoderm formation in vivo. The Xenopus Type IIA activin receptor XSTK9 differs from the Type IIB receptor by 43 and 25% in extracellular and intracellular domains respectively, suggesting the possibility of different functions in vivo. In this paper, we compare the Type IIA receptor with the Type IIB to test such a possibility. Simple overexpression of the wild-type receptors reveals minimal differences, but experiments with dominant negative mutants of each receptor show qualitatively distinct effects. We show that while truncated (kinase domain-deleted) Type IIB receptors cause axial defects as previously described, truncated type IIA receptors cause formation of secondary axes, similar to those seen by overexpression of truncated receptors for BMP-4, another TGF beta family member. Furthermore, in animal cap assays, truncated type IIB receptors inhibit induction of all mesodermal markers tested, while truncated type IIA receptors suppress induction only of ventral markers; the anterior/dorsal marker goosecoid is virtually unaffected. The suppression of ventral development by the type IIA truncated receptor suggests either that the truncated Type IIA receptor interferes with ventral BMP pathways, or that activin signaling through the Type IIA receptor is necessary for ventral patterning.     

Ocular findings in the Laurence-Moon-Bardet-Biedl syndrome

The plasticity of masticatory muscles was studied by comparing rats that were wearing a protrusive appliance and were kept on a liquid diet with two control groups: (1) pair-fed rats and (2) rats that had free access to ordinary pelleted food. The animals were 45 days old at the beginning of the experiment and were studied for a period of 20 days. Three jaw muscles with different functions were examined: masseter, temporalis, and digastric. Muscle fiber composition was determined (1) by fiber counting after staining with four monoclonal antibodies, which were able to recognize the four major myosin heavy chain (MHC) isoforms and therefore four fiber types (I, IIA, IIX, IIB) and (2) by electrophoresis on 6% polyacrylamide gels. The comparison between free-diet rats and pair-fed rats showed that the change from a hard pelleted diet to a liquid diet caused a shift in fiber type and MHC distribution, characterized by an increase of IIB MHC in temporalis and digastric muscles but not in the masseter muscle. The comparison between pair-fed rats and rats wearing appliances showed on the contrary a decrease in IIB MHC and an increase in IIA and IIX MHC. The results support the conclusions that (1) rat jaw muscles can quickly adapt to functional demand changing their fiber type composition, (2) the changes appear restricted inside the fast fiber population, and (3) fiber-type changes caused by dietary variation are not less than those caused by orthodontic intervention and must be taken into account to assess the effect of the appliance correctly.     

Carbamoylation of glutathione reductase by N,N-bis(2-chloroethyl)-N- nitrosourea associated with inhibition of multidrug resistance protein (MRP) function

The physiopathology of radiation-induced bone damage is no completely elucidated. Ionizing radiation may induce an inhibition or an impairment of growing bone. This fact is of particular importance in children, and represents one of the most important dose-limiting factors in the radiotherapeutic management of children with malignant diseases. Scoliosis, epiphyseal slippage, avascular necrosis, abnormalities of craniofacial growth may be observed after radiation. Child's age at the time of treatment, location of irradiated bone and irradiation characteristics may influence the radiation-related observed effects. In adults, pathological analysis of mature bone after ionizing radiation exposure are rare, suggesting that it is difficult to draw a clear feature of the action of radiation on the bone. Osteoporosis, medullary fibrosis and cytotoxicity on bone cells lead to fracture or necrosis. Various factors can influence bone tolerance to radiation such as bone involvement by tumor cells or infection, which is frequent is mandibulary osteoradionecrosis. Technical improvements in radiation techniques have also decreased radio-induced bone complications: the volume, fractionation and total dose are essential to consider. The absence of a consistent radiation-induced late effects evaluation scale has hampered efforts to analyze the influence of various therapeutic maneuvers and the comparison of results from different reported series. The currently proposed evaluation scale may help harmonizing the classification of radiation-induced bone late effects.     

Blast injuries of the lungs

Up until 1968 Northern Ireland was a relatively peaceful community. The outbreak of civil disturbance has resulted in many patients being admitted to hospital with severe injuries from bullets and bomb explosions. Initial resuscitation must not be unduly delayed to be effective and should be carried out by experienced personnel. Respiratory failure from bomb explosions is rare and invariably fatal. The mechanism is discussed and is thought to be due to direct compression.     

Axial osteomalacia: report of a new case with selective increase in axial bone mineral density

We report a case of a rare congenital nasal malformation. A young male patient was seen with a unilateral duplication of the left nostril. According to the morphogenetic classification, described by van der Meulen, this nasal malformation could be classified as a type IV nasal dysplasia. The other observed abnormalities that were seen were part of the CHARGE association, which is defined as coloboma of the iris, heart deformities, choanal atresia, retarded growth, genital and ear deformities. The patient underwent a surgical correction of the nose using an L-approach, yielding a satisfactory result 1 year postoperatively. Details of the case and a review of the scarce literature are presented.     

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.     

Ipsilateral oculomotor nerve palsy and contralateral downbeat nystagmus due to unilateral paramedian thalamopenduncular infarction--a case report

A case of midbrain and thalamic infarction which showed complete oculomotor nerve palsy of the ipsilateral eye and monocular downbeat nystagmus, ptosis, upward movement disturbance and adduction disturbance of the contralateral eye was reported. The patient is a 53-year-old woman who was admitted to our hospital because of sudden onset of double vision. Head magnetic resonance imaging showed unilateral midbrain and thalamic infarction. The midbrain lesion was located in the paramedian area and the bilateral ptosis, bilateral upward gaze palsy and adduction disturbance of the contralateral eye were considered to be caused by the lesion involving the unilateral oculomotor nucleus. This case is considered to be important because the association of contralateral monocular downbeat nystagmus is very rare.     

Fractures of the pelvis in children

Pelvic bony injuries are uncommon in children except for avulsion fractures. Medical records and radiographs of 54 children, in whom pelvic fractures were diagnosed from 1974 to 1993, were reviewed. Children 16 years of age and younger who were treated as inpatients were included in this study. Thirty-two patients were boys (59.3%) and 22 were girls (40.7%). In 47 (87.0%) patients, trauma was caused by motor vehicle accidents. The fractures were classified according to the Torode and Zieg classification and the Tile AO/Association for the Study of Internal Fixation classification. Forty-seven (87.0%) children had associated pelvic or extrapelvic injuries. The mean Injury Severity Score was 30.5 (range, 4-66). The AO classification correlated well with the severity of the injury. Eight children (14.8%) died. In most (38 patients = 70.4%) patients, the pelvic bony injury was treated by conservative means. External or internal fixation of the fracture was performed in 16 (29.6%) patients. A followup examination was conducted in 35 of 44 survivors (79.5%; 2 other patients died of unknown causes) with a mean followup of 135 months (range, 18-235 months); 1 additional patient was interviewed by telephone. In this series, long term morbidity was rare and was attributed to severe pelvic ring disruptions, acetabular fractures, or concomitant injuries. It is concluded that in unstable pelvic ring disruptions and acetabular fractures, the principles of management in children should not differ greatly from those in adults. Serious associated pelvic or extrapelvic injuries may pose more management problems than does the pelvic fracture.     

Effect of type IIB von Willebrand disease mutation Arg(545)Cys on platelet glycoprotein Ib binding--studies with recombinant von Willebrand factor

Type IIB von Willebrand disease (vWD) is characterized by a selective loss of high molecular weight von Willebrand factor (vWF) multimers in plasma due to their abnormally enhanced reactivity with platelets. Several missense mutations in the platelet glycoprotein Ib (GPIb) binding domain of vWF were recently characterized that cause type IIB vWD. The effect of type IIB mutation Arg(545)Cys on vWF binding to platelet GPIb was studied using recombinant wild type (rvWFWT) and mutant rvWFR545C expressed in COS-7 cells. In the absence of ristocetin, 50% of rvWFR545C bound spontaneously to platelet GPIb and the binding increased to 70% in the presence of 0.2 mg/ml ristocetin; rvWFWT did not bind significantly under either condition. Botrocetin-induced binding of rvWFR545C was only slightly increased compared to rvWFWT. These data demonstrate that the Arg(545)Cys mutation increases the affinity of vWF for GPIb, resulting in the characteristics gain-of-function type IIB vWD phenotype.     

Management of infant laryngeal disorders in relation to wound healing processes of the rabbit larynx

Laryngotracheal injury caused by prolonged intubation is mostly treated by reintubation or surgical intervention. To understand the histopathological processes involved in wound healing of laryngeal trauma and to assess the value of reintubation as treatment for post-intubation injury, the findings of a study in preterm infants were placed next to the results of experimental studies on laryngeal disorders in young, growing rabbits. Observations at laryngobronchoscopy in the child are compared to histopathological investigations in the animal. In both series various, evidently similar categories of injury could be distinguished viz. edema, ulcerations and granulations. The results of treatment like reintubation would vary with the diagnosed category of the injury; the more granulation tissue, the less successful conservative treatment will be. It is concluded that histopathologic classification is essential for good management of intubation injuries and that therapeutic re-intubation in case of superficial lesions should precede the decision for surgery.     

Injury and recovery process of intestine caused by okadaic acid and related compounds

The injuries and repair processes in the intestines of mice induced by dinophysistoxin 3 (DTX 3) were compared morphologically to those induced by okadaic acid (OA) and dinophysistoxin 1 (DTX 1). DTX 3 impaired intestinal villi by the oral route only, whereas OA and DTX 1 caused intestinal injury with both oral and intraperitoneal exposures. The character of the lesions caused by the 3 toxins and the recovery processes were highly similar. Within 5 min of dosing, the basal portion of the covering epithelium became homogeneous and peeled from the lamina propria, while the upper portion containing microvilli remained intact. There were two types of villous injury and recovery: 1) When the injuries were limited to the villi, new cells from the crypts moved upward and differentiated into columnar cells. 2) When injuries progressed into the glands of Lieberkuhn, clusters of crypt cells were exposed to the intestinal lumen, and in the most severe case they were completely separated. Villous fusion was often seen in the recovery process of the type 2 cases. Recovery from the injuries was almost completed within 2 days. When mice were pretreated with fusarenon-X, a mycotoxin which injuries undifferentiated crypt cells preferentially, the injury induced by OA to the intestinal crypts was exacerbated and the recovery was delayed.     

A system for classifying mechanical injuries of the eye (globe). The Ocular Trauma Classification Group

PURPOSE: To develop a classification system for mechanical injuries of the eye. METHODS: The Ocular Trauma Classification Group, a committee of 13 ophthalmologists from seven separate institutions, was organized to discuss the standardization of ocular trauma classification. To develop the classification system, the group reviewed trauma classification systems in ophthalmology and general medicine and, in detail, reports on the characteristics and outcomes of eye trauma, then established a classification system based on standard terminology and features of eye injuries at initial examination that have demonstrated prognostic significance. RESULTS: This system classifies both open-globe and closed-globe injuries according to four separate variables: type of injury, based on the mechanism of injury; grade of injury, defined by visual acuity in the injured eye at initial examination; pupil, defined as the presence or absence of a relative afferent pupillary defect in the injured eye; and zone of injury, based on the anteroposterior extent of the injury. This system is designed to be used by ophthalmologists and nonophthalmologists who care for patients or conduct research on ocular injuries. An ocular injury is classified during the initial examination or at the time of the primary surgical intervention and does not require extraordinary testing. CONCLUSIONS: This classification system will categorize ocular injuries at the time of initial examination. It is designed to promote the use of standard terminology and assessment, with applications to clinical management and research stud ies regarding eye injuries.