Biomedical subjects
Publications and source records attributed to A A Halpern.
A fracture of the scapula is frequently associated with other significant injuries. In the case described, a motorcycle accident victim sustained multiple injuries, including a scapular fracture associated with a tear of the subclavian artery, demonstrated by angiography and confirmed at operation. A literature review revealed no similar case.
A compartment syndrome of the forearm can be a devastating injury if not relieved promptly by early fasciotomy. Of five patients who developed compartment syndromes, compartment pressures were measured in four and found to average 69 mm Hg. Tissue pressure measurements provided early objective evidence of the presence of the compartment syndrome and contributed significantly to the ultimate functional recovery. We would advise repeating the measurement for pressures in excess of 30 mm Hg in the upper extremity, and fasciotomy for pressures in excess of 40 mm Hg when accompanied by any neurovascular compromise.
A compartment syndrome of the interosseous muscles can be a challenging diagnosis as there is generally no neurovascular compromise to the digits involved. The most sensitive clinical sign is pain with passive motion at the metacarpal phalangeal joint of the involved digit. In this report, a 31-year-old man developed a compartment syndrome of the first, second, and third dorsal interosseous muscles following an injection of heroin in the "snuffbox" area. Compartmental tissue pressure measurements were 80, 75, and 55 mmHg respectively, and were a significant aid in the early diagnosis as well as management.
Vertebral osteomyelitis is a frequent consequence of disseminated coccidioidomycosis. In a 25-year-old man, the sequela was a single level unilateral osseous bridge between the second and third lumbar vertebra. A review of previous cases has disclosed one case with a similar roentgenographic picture. The occurrence of a single level unilateral reactive process should arouse suspicion of a localized chronic bone infection.
A recent survey of congenital hand anomalies has revealed that symphalangism of the distal interphalangeal joint is more frequent than had previously been reported. To date, however, only 3 familial pedigrees have been documented in the literature. The family reported in this article had 9 individuals spanning 4 generations affected with symphalangism of the distal interphalangeal joint. In all cases, this was associated with ankylosis of the distal interphalangeal joint of the second through fifth toes. One child in the family also had brachyphalangism bilaterally as well as a bifid distal phalanx of the thumb. The world's literature does not seem to include a similar case. As with previous cases of fusion of the distal interphalangeal joint, there was little functional disability resulting from this anomaly and we do not recommend operative procedures to restore motion.
A 47-year-old paraplegic patient is described who developed a massive synovial cyst of the upper extremity. The cyst developed in combination with a tear of the rotator cuff and the long head of the biceps tendon and involved the fasica surrounding the long head of the biceps. The increased pressure in the cyst resulted in a compartment syndrome of a portion of the long head of the biceps muscle. A review of the literature revealed no similar case.
Arthrography of the knee is most frequently used for diagnosis of conditions affecting the cartilage and menisci. In a 40-year-old man with pigmented villonodular synovitis, arthrography demonstrated a characteristic pattern of multiple filling defects. Arthrography may prove to be as useful for diagnosis of synovial lesions as for other intraarticular lesions.
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Two outbreaks of postoperative wound infections by organisms of the Mycobacterium fortuitum complex have focused attention on this notoriously drug resistant organism. In this report 2 cases are presented which developed infections with this organism, one of which responded to systemic antimicrobials despite discouraging in vitro sensitivities. Surgical debridement must remain the choice of treatment; however, systemic antibiotics may prove effective in some cases.
A case is presented in which selective embolization of gelfoam was used to control late postoperative bleeding, developing in a patient following hip arthroplasty. Although primarily used in gastrointestinal bleeding, diagnostic and therapeutic angiography, selective embolization is clearly applicable to postoperative bleeding encountered in orthopedics.
A patient being treated with androgens developed an acute bilateral compartment syndrome. Androgens are known to cause hypertrophy of muscle, which in a closed fascial compartment may predispose to a compartment syndrome. While an acute syndrome has not been reported previously, patients on androgen therapy frequently complain of cramps and leg pain, which may be manifestations of chronic compartment syndrome. The above case report does not establish a positive cause and effect relationship, but because this occurrence has not been documented before we believe the relationship should be considered. Patients on androgens should be examined for the possibility of compartment syndromes, either acute or chronic. The actual compartment pressures can be measured in suspected cases.
In five patients, tendon ruptures occurred in association with corticosteroid therapy, either systemic or local infiltration. The chronic nature of the pain in all of these patients suggests that what we often call tendinitis may in fact be early or partial ruptures of tendons. Patients who receive local infiltration of corticosteroids should perhaps be advised of the risk of a ruptured tendon. In addition, particularly when the Achilles tendon is involved, immobilization should be utilized initially for a presumed tendinitis or early rupture, to protect the tendon from further injury.
The effect of 5 different sit-up regimens on the abdominal muscle activity were investigated by electromyography as well as the degree of lumbar flexion required with each type of sit-up. In the long-lying position the rectus abdominus muscles were only active an average of 34% of the sit-up cycle. The greatest duration of activity (90%) was found in the shoulder lift hook-lying (knees flexed) sit-up in which the subject elevates the trunk to the point where the scapula is lifted from the mat. In addition, this sit-up requires minimal flexion of the lumbar spine (3 degrees versus 38 degrees) and is less likely to result in increased forces across the lumbar disk. The evidence is that this sit-up is the most effective in terms of abdominal muscle activity and the safest in terms of causing lumbar spinal flexion.
Osteonecrosis of the femoral head following cardiac transplantation has led to bilateral total hip arthroplasties in 2 patients. The clinical course and rejections of these patients are outlined. The pathological changes in the femoral heads suggested that the process leading to osteonecrosis in the cardiac transplant patient is the same as that following renal transplantation, both being due to immunosuppression probably related to steroid dosage. Successful joint replacement can be carried out in the cardiac transplant with careful monitoring of anesthesia. Both patients have done well, being followed for 14 and 6 months respectively.
Contrast studies of draining sinus tracts can be of great assistance in defining the extent of an infection. Complications of this procedure must be quite rare. A 35-year-old paraplegic patient developed septicemia following a sinogram. An intraosseous venogram of the entire femoral shaft was visualized in addition to the sinus tract itself. The moderate pressure used to inject the dye may have contributed to the systemic spread of the infection and may be a hazard of sinography.
Persistence of femoral anteversion into adulthood is a developmental abnormality which Somerville has postulated may predispose to the later development of osteoarthritis of the hip. To test this hypothesis, the femoral anteversion was measured in 20 adult patients with idiopathic osteoarthritis of the hip. The average anteversion in painful hips was found to be 24 degrees compared with 12.11 degrees in the uninvolved hip. None of the pain-free hips had an anteversion of greater than 22 degrees while 54% of those with pain had anteversion greater than this value. While these results are preliminary, they suggest that increased femoral anteversion may definitely contribute to the later development of osteoarthritis of hip.