Effect of muscular dysfunction on the development of shoulder joint in children with Erb's paralysis

In order to evaluate the disturbances of development of the shoulder joint in children with Erb's paralysis the authors conducted an X-ray examination of the shoulder girdle and the shoulder in the anterior-posterior projection. The assessment of the functional state of the muscles of the shoulder girdle was made with the aid of clinical EMG. It was established that there was a retardation of growth and ossification of the radial head of the humerus on the affected side, a decrease in the longitudinal and cross-sectional sizes of the humerus, a retardation in the development of the joint scopular cavity, disorders in spacial interrelationship in the components of the shoulder joint and internal rotation of the shoulder joint. The structural and anatomical changes in the components of the shoulder joint are associated with disorders of the neurotrophic processes in the bone tissue and the muscular dysbalance.     

Nicotine given intracerebroventricularly does not inhibit the preovulatory surge of LH and PRL secretion in female rats

Twenty-three cases of Little Leaguer's shoulder were reviewed including the history and physical examination findings, as well as bilateral internal and external rotation anteroposterior comparison radiographs of the proximal humerus. The average follow-up was 9.6 months (range, 1.5 to 54), and all patients were observed until they had either returned to baseball or their symptoms had resolved. The average age of the patients in this series was 14 years. The chief complaint in all patients was pain localizing to the proximal humerus during the act of throwing. The average duration of symptoms was 7.7 months. Nineteen patients (83%) were pitchers. Physical examination revealed tenderness to palpation over the proximal humerus in 20 patients (87%), with 16 (70%) demonstrating specific tenderness over the lateral aspect of the proximal humerus. Swelling, weakness, atrophy, and loss of motion were uncommon findings. All 23 patients demonstrated radiographic widening of the proximal humeral physis of the throwing arm on internal and external rotation comparison anteroposterior radiographs of the shoulder. All patients were treated with rest from baseball throwing for an average of 3 months. Twenty-one of the 23 patients (91%) returned to playing baseball and were asymptomatic. The classic radiographic finding of widening of the proximal humeral physis can easily be seen on bilateral anteroposterior internal and external rotation radiographs of the proximal humerus. Rest from throwing for at least 3 months is recommended, followed by a gradual return to throwing in an asymptomatic shoulder.     

Clinical usefulness of measuring prothrombin time as a routine admission test

A questionnaire indicating the presence of a history or physical findings consistent with liver desease or bleeding disorders was completed by house officers on 301 admissions to a Veterans Administration medical service. Each patient had prothrombin time determined on admission. Only two of 107 patients for whom the prothrombin time was measured as a screening test had an abnormal results and one of these was normal when repeated. Of 73 patients with a history of alcoholism but no other pertient case history or physical examination results, only one had an abnormal prothrombin time. Of the remaining 121 patients, who had a pertinent history or physical examination, 41 had an abnormal admission prothrombin time. We conclude that measurement of prothrombin time adds little additional information to that obtained by history and physical examination in screening for liver disease and coagulation defects unless the patient has specific clinical evidence of liver disease, anticoagulation, or other conditions predisposing to bleeding disorders.     

Intestinal lymphangiectasia in a patient with Zellweger cerebrohepatorenal syndrome

OBJECTIVE: To assess the natural history and response to treatment of shoulder disorders in a community elderly population. METHOD: This community study of shoulder pain in the elderly reviewed patients three years after an earlier prevalence study. RESULTS: One hundred and eight of the original 136 patients with an identifiable shoulder disorder were available for reexamination. Eighty (74%) had persisting signs on examination, with persistent symptoms leading to impairment of personal care (21%) and household tasks (27%), and pain on movement (34%). There was no difference between treated and non-treated groups in terms of outcome. CONCLUSIONS: The results of this study serve to confirm and highlight the chronicity of shoulder lesions in this age group and the consequent personal suffering and implications for health care.     

How house officers cope with their mistakes

We examined how house officers coped with serious medical mistakes to gain insight into how medical educators should handle these situations. An anonymous questionnaire was mailed to 254 house officers in internal medicine asking them to describe their most important mistake and their response to it; 45% (N = 114) reported a mistake and completed the questionnaire. House officers experienced considerable emotional distress in response to their mistakes and used a variety of strategies to cope. In multivariate analysis, those who coped by accepting responsibility were more likely to make constructive changes in practice, but to experience more emotional distress. House officers who coped by escape-avoidance were more likely to report defensive changes in practice. For house officers who have made a mistake, we suggest that medical educators provide specific advice about preventing a recurrence of the mistake, provide emotional support, and help them understand that distress is an expected concomitant of learning from the experience.     

Cost effectiveness of magnetic resonance imaging of the knee

When compared to diagnostic arthroscopy in patients with knee complaints consistent with internal derangement, MR imaging emerges as a cost effective diagnostic supplement to clinical examination. This article concludes that the results of MR imaging can be used as a guide for the management of knee pain.     

Choice of first line treatment for arterial hypertension: should one avoid dihydropyridines in diabetic patients?]

The learning experience during a medical school clinical rotation is largely shaped by students' patient encounters. This paper reports on how a log system for recording these encounters can be used for course planning and evaluation. Over the past 5 years, 960 third-year students completed log forms based on their clinical encounters during a required 4-week family medicine clerkship at UT Southwestern. These forms were then optically scanned and the information entered into a computerized database. Log form data revealed that the most common medical problems encountered by students in their ambulatory settings were similar to those reported in the general family practice literature. There was a great deal of consistency in the types of encounters from year to year. The data also showed some differences among clerkship sites in terms of patient demographics and the most frequently reported diagnoses. Information generated from student log forms has been used by the clerkship faculty to determine required readings, prioritize didactic topics and other teaching, adjust curriculum content, prepare support materials and develop examinations. Given the utility of the information obtained and the ease of use of optical mark encounter sheets, we recommend this system for other clerkships.     

The development of clinical practice guidelines for treatment of peptic acid diseases in a VA ambulatory care clinic

The costly treatment of peptic acid diseases at a Veterans Affairs ambulatory care clinic prompted the development of clinical practice guidelines (CPGs) for the disorders. A committee consisting of a clinical pharmacist, the chiefs of ambulatory care and medicine, and a gastroenterologist guided the process. A consensus-style conference format involving medical staff and residents, pharmacists, and other health providers was chosen to develop the CPGs. Before the conference each participant received a list of key issues and literature on practice guidelines, and on peptic acid diseases and their treatment. At the conference the participants were divided into four groups; each group discussed specific key issues using a modified nominal group process. Recommendations from each group were made to the entire conference. Final recommendations were compiled into what was adopted and readily received as the CPGs for the institution.     

Rehabilitation of injuries in competitive swimmers

Competitive swimmers perform highly repetitive motions, therefore characteristic overuse injuries of the shoulder, back, and knee can occur. A thorough history and examination should be performed by both physician and physical therapist. The combination of hypovascularity, fatigue, poor stroke mechanics, and the progressive instability of a hypermobile joint results in shoulder impingement. Medical evaluation should determine the existence of any glenohumeral joint instability or signs of impingement. Back injuries are most commonly due to disc degeneration, hyperextension, or myofascial involvement. Medial knee pain is most common in breaststroke swimmers and may be due to excessive valgus and rotatory stress. Frequently seen diagnosis includes patellofemoral pain, medial collateral ligament stress syndrome, and medial synovitis. Treatment will focus on elimination of inflammation. Rehabilitation should focus on stabilisation exercises for hypermobile joints, postural correction, strengthening and flexibility.     

Recruitment of women by GPs for pap tests: a meta-analysis

General practitioners (GPs) have a pivotal role to play in recruiting women for Pap tests. In recent times, considerable attention has been paid to the role of reminder systems in encouraging women to have regular Pap tests. Although a number of studies have investigated the effectiveness of reminder systems, there has been no comprehensive review. This paper aims to determine the effectiveness of patient and GP reminders in increasing the proportion of women screened for cervical cancer. Two electronic databases were searched for English-language randomized controlled trials conducted in a general practice or family medicine setting, and examining the effectiveness of GP and patient reminders in increasing the proportion of women screened for cervical cancer. Ten trials were identified, and meta-analytic techniques were employed to analyse the data from these trials. The women whose GPs had been prompted to remind them to have a Pap test were significantly more likely to do so than were control women (typical risk difference (TRD) = 6.6%, 95% CI = 5.2%-8.0%). The typical risk difference for the patient reminder studies was 4.9% (95% CI = 2.6%-7.2%). In both cases, sensitivity analysis revealed that one study stood out as an exceptional result. The omission of this study induced homogeneity among the remaining studies. Once this study was removed, the TRDs for the GP reminder and patient reminder studies were 7.9% (95% CI = 6.5%-9.4%) and 10.8% (95% CI = 8.1%-13.6%), respectively. The results strongly suggest that GPs should make use of GP and patient reminder systems.     

Giant congenital nevocellular nevus overlying an encephalocele

OBJECTIVE: To compare patients with knee osteoarthritis (OA) who have and do not have back pain, and evaluate the prevalence, characteristics, and consequences of back pain among knee OA patients. METHODS: During a 3-year period, consecutive patients attending an outpatient rheumatology clinic were evaluated for the presence of back pain, and 368 were found to have OA of the knee. Clinical status was evaluated by the Clinical Health Assessment Questionnaire, radiographs, and joint examinations. RESULTS: Back pain was present in 54.6% of patients with OA of the knee. Almost every clinical status measure was worse among those reporting back pain, including Health Assessment Questionnaire (HAQ) disability, pain, global severity, fatigue, and psychological status. Back pain was more common in women and the obese, but was not associated with age, marital status, formal education, smoking history, or knee radiographic scores. In multivariate analyses the strongest correlates of back pain in knee OA patients were anxiety, night pain, HAQ disability, and global severity. CONCLUSION: Back pain is prevalent among OA clinic patients, more common than in rheumatoid arthritis or population studies, is linked to body mass index, and is associated with clinically significant increases in pain and other measures of clinical distress.     

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.     

Epidemiology, physical examination, and neurodiagnostics

The overall frequency of troublesome neck pain is estimated to be approximately 34%, and it was observed that the frequency of complaints lasting 1 month or longer was higher in women than in men. The prevalence increased with age with regard to both pain duration and chronic pain. A total of approximately 14% of a randomly selected population meets the criteria for chronic neck pain, with complaints lasting for more than 6 months. It could be that the structural transformation of the intervertebral disc, the uncovertebral processes, and the zygapophyseal joints is a process accompanied by disturbed function, ultimately inducing pain. For diagnosis of radicular and myelopathic syndromes, the physical and neurologic examination is enhanced by neurophysiologic assessment. Electromyography, performed with needle electrodes, is the oldest method to diagnose nerve root compression syndromes and is claimed to have no false positive results. Electromyography for radiculopathy is justified if clinical symptoms, such as muscular weakness, don't correlate with clinical findings (diminished or absent reflex), or for documentation of muscle activity if difficult decompressive surgery is expected. For diagnosis of cervical myelopathy by routine examination, the sensory evoked potentials by stimulation of tibial nerve as well as motor evoked potentials from upper and lower extremities are recommended because clinically "silent" myelopathy can be verified by abnormalities in evoked potentials. During history taking, the symptoms possibly attributed to radiculopathy or myelopathy should be differentiated from primary systemic neurologic disorders such as shoulder angiotrophy ("plexus neuritis"), multiple sclerosis, amyotrophic laterals sclerosis, and peripheral neuropathy. The assessment of range of motion, the functional status of shoulder and neck muscles, and palpatory examination of soft tissue is widely used to determine non-operative therapeutic procedures. However, scientifically, the validity of the different testing procedures has not been evaluated satisfactorily.     

Clinical and sonographic meniscus diagnosis

Clinical examination still plays an important role in diagnosing meniscal tears. The types of sensitive nerves in the knee joint are responsible for nonspecific pain, which is often correlated with too little specificity in meniscal tests. Ultrasound examination of meniscal structures of the knee joint has been debated extensively in recent years. Criticism of this noninvasive technique was due to small patient groups, improper technical and inaccurate manual standards. Since 1988 ultrasound of the tibial meniscus has become a standard technique in our Department of Orthopaedic Surgery with defined criteria of the intersecting plane and evaluation of ultrasound images. A prospective follow-up study during 6/1988 and 5/1993 including 1186 ultrasound examinations before arthroscopy, was performed. The sensitivity for ultrasound of the lateral meniscus was 58% and for the medial meniscus 83%. Specificity with 98% for the lateral and 90% for the medial meniscus was good. Sonographic detection of meniscal tears depends on the shape and location of meniscal tears. This has been shown by experimental studies in cadavers. A follow-up study including 113 knee joints was performed to prove the value of clinical and ultrasound examination in relation to arthroscopy. The sensitivity of sonography for medial meniscus was 81% and 40% for the lateral meniscus. Although the sensitivity of the clinical examination was 81% (medial) and 47% (lateral), the low specificity of 70% for meniscus tears indicated that it was because of false-positive clinical evaluation of meniscal disorders. In young patients with reflectory muscle spasm and those with acute trauma of the knee joint, clinical examination of the meniscal structures showed poor results. In these cases, too, ultrasound examination showed advantages. Ultrasound of the knee joint meniscus is noninvasive, reproducible and low cost. In cases of uncertain clinical results, ultrasound offers a good opportunity to visualize meniscal disorders.     

Clear cell tumors of the alimentary tract and abdominal cavity

In a population of male workers in two ship maintenance companies (n = 32), a workplace survey was conducted in order to quantify their physical load. Postural load was measured by using the Ovako Working posture Analyzing System. During 7480 observations, working postures, exertion of force and working activities were recorded. Awkward postures of the back occurred in 38% of the worktime, stress on the neck/shoulder region due to one or both arms above shoulder level was present in 25% of the worktime. Forceful exertions during lifting, pushing and pulling activities sometimes exceeded published guidelines for manual material handling. Determinants of physical load could be identified and a hazard evaluation procedure was designed by applying rating schemes to weight various patterns of physical load. Ship maintenance work compared well with other strenuous occupations. Considering the high prevalence of back pain (80%) and neck/shoulder pain (60%), as well as the results of the observation method ergonomic improvements are warranted. Physical load can be reduced by several technical adaptations and applications, and by enlarging task rotation.     

The value of screening for psychiatric disorders in rheumatology referrals

BACKGROUND: Musculoskeletal complaints are common and often unexplained and often lead to rheumatology referrals. The prevalence of psychiatric disease in patients with musculoskeletal complaints is unknown. OBJECTIVES: To determine the prevalence of common psychiatric disorders among patients referred to a rheumatology clinic and the likelihood of establishing a rheumatic diagnosis if a psychiatric disorder is present. DESIGN: Prospective diagnostic survey. SETTING: Two hospital-based rheumatology clinics and a general medicine clinic. PARTICIPANTS: A consecutive sample of newly referred patients (n = 185) and their rheumatologists (n = 9). INTERVENTION: Before their visit, all patients filled out a self-administered version of PRIME-MD (Primary Care Evaluation of Mental Disorders), a questionnaire that makes Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: Primary Care Version, diagnoses of depressive, anxiety, and somatoform disorders. After the visit, the study rheumatologists, who were unaware of the PRIME-MD results, completed a questionnaire regarding their diagnostic assessment. These patients were compared with 210 patients with musculoskeletal complaints who were cared for in a general medicine clinic. MAIN OUTCOME MEASURES: Psychiatric and rheumatic disorders. RESULTS: Compared with patients with musculoskeletal complaints in a general medicine clinic, patients referred to a rheumatology clinic had a higher prevalence of psychiatric disease (40% vs 29%; P = .008), had an almost 2-fold higher prevalence of anxiety disorders, and were more likely to have multiple psychiatric disorders (odds ratio = 2.70, 95% confidence interval = 1.50-5.00). The likelihood of a psychiatric disorder differed among patients with connective tissue disease, nonsystemic articular or periarticular disorders, and nonarticular disorders (27%, 38%, 55%, respectively; P = .006). In a best-fitting logistic regression model, psychiatric disorders markedly decreased the likelihood of a connective tissue disease (odds ratio = 0.24, 95% confidence interval = 0.09-0.62). CONCLUSIONS: Forty percent of patients referred to a rheumatology clinic in this study had a psychiatric disorder, and its presence predicted a lower likelihood of a connective tissue disease. Prospective studies are needed to determine if screening for psychiatric disease before referring patients with unexplained musculoskeletal complaints would reduce costs or improve recognition of potentially treatable psychiatric disorders.     

Physical performance characteristics of women with fibromyalgia

OBJECTIVE: The aim of this study was to examine physical performance in women with fibromyalgia (FM) using methods that are easy to use in clinical settings and to compare our findings with published norms or a healthy comparison group. METHODS: Measures of shoulder pain and range-of-motion, isometric shoulder endurance, neck rotation, leg strength, hand grip strength, back flexibility, 6-minute walk distance, and symptom duration were completed on 97 subjects with FM. The comparison group was 30 age-matched healthy women. RESULTS: The FM group had significantly lower physical functioning scores on all variables when compared to the healthy group or published norms. When pain at rest was controlled, pain on motion was the most significant predictor of variance in shoulder range of motion, whereas range of motion was the most significant predictor of right shoulder endurance and grip strength of both hands. CONCLUSIONS: Women with FM are markedly below average in physical performance abilities when measured by clinical tests.     

The treatment of symptomatic os acromiale

During a four-year period, fourteen individuals (fifteen shoulders) who had been seen at the shoulder service of our institution because of pain in the shoulder had a radiographic finding of an os acromiale. On clinical examination, the pain appeared to be due to an unstable os acromiale because the patients had point tenderness over the acromion and pain on forward elevation of the shoulder. The diagnosis of an os acromiale was confirmed on radiographs, magnetic resonance images, or a bone scan. Eight patients had an associated tear of the rotator cuff. The os acromiale was located in the pre-acromion in one shoulder, the meso-acromion in eleven shoulders, and the meta-acromion in three shoulders. At the operation, the anterior aspect of the acromion was found to be unstable in all shoulders. Eleven patients (twelve shoulders) had open reduction of the os acromiale and insertion of an autogenous iliac-crest bone graft. Of those patients, four (five shoulders) had open reduction and internal fixation with a tension-band procedure with use of pins and wires. Only one of those shoulders had a solid osseous union, and the other four shoulders had a non-union that was due to a disruption of the fixation. The remaining seven patients (seven shoulders) had open reduction and internal fixation with use of cannulated screws and a tension-band construct; a solid osseous union was achieved in all but one of them. One patient had excision of the pre-acromion, which relieved the pain. Two patients who had had failed open reduction and internal fixation had excision of a grossly unstable os acromiale in the meso-acromion; both patients had pain and weakness after this procedure. Of the twelve shoulders that had open reduction and bone-grafting, seven had union of the os acromiale; the average time to radiographic and clinical union was nine weeks (range, seven to twenty weeks). We concluded that, although it is rare, symptomatic unstable os acromiale does occur and can be effectively treated with use of autogenous bone-grafting and internal fixation with a rigid tension-band construct and cannulated screws.     

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.     

The anterior cruciate ligament in controlling axial rotation. An evaluation of its effect

Changes in axial tibial rotation after anterior cruciate ligament sectioning were evaluated in 14 fresh human knee joints. Simulation of vertical stance in a quadriceps-stabilized knee was performed. Internal and external rotational torques were applied before and after anterior cruciate ligament sectioning. Pivot shift tests were done in the intact and anterior cruciate ligament sectioned knee. Results of pivot shift tests were all negative before sectioning and positive after isolated sectioning. No significant change in axial rotation occurred between the intact and sectioned knee for external rotation (P = 0.24) or internal rotation (P = 0.12). Presence of a load at the femoral housing in both the intact and ligament-sectioned knees caused a significant change in external rotation (P < 0.0001). No significant change was noted in internal rotation between loaded and unloaded states (P = 0.70). Total tibial rotation in the intact knee was noted to vary between 31 degrees at 0 degree of flexion and 42 degrees at 60 degrees of flexion. These results suggest that the anterior cruciate ligament does not play a significant role in limiting axial rotation and that rotational instability is not a major factor after isolated anterior cruciate ligament rupture.