Idiopathic necrosis of skeletal muscle in patients who have diabetes. Report of four cases and review of the literature.
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Adult↗
Biomedical subjects
E M Levinsohn
Publications and source records attributed to E M Levinsohn.
Hematomas and limb skeletal malformations in chicken embryos following exposure to 5-fluoro-2-deoxyuridine.
Vascular injury or interruption may play a role in vertebrate limb teratogenesis. Since 5-fluoro-2'-deoxyuridine (FdU) can cause vascular injury in the murine limb and skull prior to the appearance of skeletal malformations in these structures, we studied the effects of this chemical on skeletal development in the chick embryo and noted any vascular injury. The yolk sacs of day three chick embryos (Hamburger and Hamilton states 17-19) were injected with solutions of vary concentrations of FdU in saline. The embryos developed until the 10th day of incubation when they were fixed for study. Uninjected, saline injected, and sham injected control embryos were similarly fixed. Upon gross inspection, frequent diffuse and saccular hematomas, as well as fluid-filled blisters, were noted in the limbs of embryos treated with FdU. After the embryos were fixed and cleared, and the skeletons stained, significant skeletal malformations were observed in these limbs. Bony elements of both the upper and lower limbs were affected in at least some of the embryos. The combination of FdU-induced hematomas and blisters with associated skeletal malformations in the same regions of some embryos suggests a relationship between these phenomena.
Abnormalities, Drug-Induced↗
Magnetic resonance imaging assessment of the rotator cuff: is it really accurate?
Magnetic resonance imaging (MRI) is used increasingly for evaluating the rotator cuff. This study of 39 shoulders (38 patients) compared the accuracy of MRI interpretation of rotator cuff integrity by a group of community hospital radiologists (clinical community scenario, CCS) with that of a musculoskeletal radiologist (experienced specialist scenario, ESS), relative to arthroscopy. For the CCS subgroup, the sensitivity, specificity, positive predictive value (PV), negative PV, and accuracy for partial tears were: 0%, 68%, 0%, 82%, and 59%, respectively; for complete tears: 56%, 73%, 36%, 86%, and 69%, respectively; and for all tears combined: 85%, 52%, 50%, 87%, and 64%, respectively. For the ESS subgroup, the respective values for partial tears were: 20%, 88%, 20%, 88%, and 79%, respectively; for complete tears: 78%, 83%, 58%, 92%, and 82%, respectively; and for all tears: 71%, 71%, 59%, 81%, and 71%, respectively. We concluded that MRI assessment of the rotator cuff was not accurate relative to arthroscopy. MRI was most helpful if the result was negative, and MRI diagnosis of partial tear was of little value. Considering the high cost of shoulder MRI, this study has significant implications for the evaluation of patients with possible rotator cuff pathology.
Adult↗
Embryonic hypertension following exposure to teratogenic doses of 5-fluoro-2'-deoxyuridine.
The teratogenicity of 5-fluoro-2'-deoxyuridine (FdU) is well established. Previously, we have demonstrated that teratogenic doses of FdU produce hematomas and suggested that those hematomas produced skeletal malformations in chicken embryos. In this study, the cardiovascular effects of teratogenic doses of FdU in chicken embryos were studied. A dose of either 0.026 micrograms FdU or 0.030 micrograms FdU was injected into the yolk sacs of fertile chicken eggs containing embryos at Hamburger and Hamilton stages 17-19 of development. The embryos were then returned to the incubator. Aortic systolic and diastolic blood pressure, blood velocity and heart rate were measured at stages 21, 24 or 27 using a servonull system and Doppler ultrasound. In addition, mean arterial blood pressure, blood flow, and stroke volume were calculated from these data. Similar data were also recorded from uninjected and saline injected control embryos. Systolic and mean arterial blood pressures were significantly increased in FdU-treated embryos at stage 27. The other parameters measured or calculated were not significantly different from control embryos. Our study suggests that elevated systolic blood pressure in chicken embryos treated with FdU may lead to hematoma formation and subsequent birth defects.
Animals↗
Pigmented villonodular synovitis of the sequestered suprapatellar bursa.
Two cases of pigmented villonodular synovitis of a sequestered suprapatellar bursa are reported. The embryologic, clinical, arthrographic, and magnetic resonance features of this rare entity are discussed.
Adult↗
The change in ulnar variance with grip.
The effect of grip on ulnar variance was evaluated in 66 symptom-free wrists of 53 volunteers. Zero-rotation posteroanterior x-ray films were taken of each wrist before and after exertion of a grip force measured with a Jamar dynamometer. The volunteers were randomly divided into two groups. Group I subjects (35 wrists) were asked to exert a constant grip force of 11.3 kg. Group II subjects (31 wrists) were asked to exert a maximum grip effort, which resulted in a mean grip force of 30 kg (range, 22.8 kg to 53.6 kg). Group I demonstrated a mean increase in ulnar variance of 1.27 mm and group II showed a mean increase of 1.95 mm. The minimum increase in ulnar variance observed was 0.25 mm. The changes observed were statistically significant. The results confirm that a relative increase in ulnar variance occurs with grip. There may be an etiologic role for daily activities that involve repetitive grip and forearm rotation in development of the ulnar impaction syndrome.
Adolescent↗
Most human lower limb malformations appear to result from postspecification insults.
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Congenital Abnormalities↗
Extent of duplication in lower-limb malformations suggests the time of the teratogenic insult.
Investigations of vertebrate limb development have suggested that a process called "specification" instructs the cells of the future limb as to which tissues they should form. This process proceeds in a wave-like manner, starting at the most proximal levels of the future limb and ending at its distal tip. Human limb specification probably occurs during the fourth and fifth weeks of development. It is proposed that human limb duplications result from errors of specification and, furthermore, that the more distal the duplication, the later the occurrence of the teratogenic event during the specification process. Therefore, among human lower limbs with duplications, one may be able to estimate the relative time of the teratogenic event by comparing the levels at which the duplications occur.
Cell Polarity↗
Subperiosteal osteoid osteoma of the hamate: a case report.
Osteoid osteoma is uncommon in the hand. The lesion can arise from either cortical or cancellous bone or subperiosteally. The latter localization is extremely rare in the hand, with only 4 reported cases in the English-language literature. Furthermore, characteristic radiographic findings of a central lucency surrounded by reactive sclerosis often emerge only late in the process, or not at all. Consequently, the diagnosis of osteoid osteoma of the hand can be delayed. We report a case of a subperiosteal osteoid osteoma of the hamate in which the diagnosis was delayed 2 years.
Adult↗
Bicipital groove dysplasia and medial dislocation of the biceps brachii tendon.
The purpose of this study was to investigate the plain film finding of dysplasia of the lesser tubercle of the humerus and its relationship to medial dislocation of the tendon of the long head of the biceps brachii muscle as diagnosed by shoulder arthrography. Of 55 patients referred for arthrography of the shoulder because of undiagnosed shoulder pain, 12 demonstrated flattening of the medial wall of the bicipital tendon groove. Of these, 58% had medial dislocation of the biceps tendon, and 43% of patients with dislocation of the biceps tendon were also shown to have a tear of the rotator cuff. Since biceps tendon pathology has long been implicated in shoulder pain and weakness, assessment of the bicipital groove may provide important information in evaluating patients with potential abnormality of the biceps tendon.
Female↗
The wrinkled patellar tendon: an indication of abnormality in the extensor mechanism of the knee.
Rupture of the quadriceps tendon is an uncommon condition which requires early diagnosis and treatment to avert prolonged disability. In four patients who had surgically confirmed quadriceps tendon rupture, lateral radiographs of the knee and/or sagittal magnetic resonance (MR) images demonstrated a corrugated appearance to the patellar tendon. Sagittal MR images of the knee following patellectomy in one patient and radiographs of a transverse fracture of the patella in another also demonstrated this appearance. MRI has superb contrast resolution which provides optimal visualization of the contour of the patellar tendon on sagittal images. A retrospective review of 50 consecutive knee MRI examinations was carried out to evaluate the appearance of the normal patellar tendon. In 49 of 50 patients, the sagittal images demonstrated a straight or nearly straight patellar tendon. A corrugated appearance of the patellar tendon on sagittal images indicates a reduction in the normal tensile force applied to it and indicates the need for careful evaluation of the patella and quadriceps tendon mechanism.
Adult↗
Consistent arterial abnormalities associated with a variety of congenital malformations of the human lower limb.
A number of seemingly unrelated congenital deformities of the lower limb have been presented which include clubfoot, fibular deficiency, tibial aplasia, and diplopodia. Although the bony morphology in these limbs is quite different, they all share a strikingly similar arterial pattern, that being deficiency or absence of the anterior tibial artery, and of its derivative, the dorsal pedis artery. Since all of these diverse conditions share a similar aberrant arterial pattern, we suspect that the arterial changes are important in the pathogenesis of those conditions. Study of the soft tissue anatomy of these specimens suggests that the etiologic teratogenic event occurred early in embryonic development. In those limbs that contain the remnant of a missing structure, it is concluded that injury occurred after the mesenchyme was instructed to form that structure. These are termed "post-specification" defects. In those circumstances where limb duplication occurs, the injury affected the signal before instruction of mesenchyme to develop into a specific structure was completed and these abnormalities are termed "pre-specification" malformations. The musculotendenous and neurologic abnormalities seem to be reactive to the pre-existing bony pattern.
Angiography↗
Wrist arthrography: value of the three-compartment injection method.
Arthrography of the wrist was performed on 300 consecutive patients by injecting contrast material separately into the radiocarpal (RCJ), midcarpal (MCJ), and distal radioulnar (DRUJ) joints. The addition of MCJ and DRUJ injections to the standard RCJ injection significantly improved diagnostic yield. In 78 (26%) of the 300 cases, the abnormality was found after MCJ or DRUJ injections alone. Of the 103 triangular fibrocartilage complex (TFCC) abnormalities identified, 27 (26%) could be demonstrated after DRUJ injection alone. Of the 145 abnormal RCJ and MCJ communications, 42 (29%) could be seen after MCJ injection alone. Similarly, 22 (15%) of the 145 abnormal RCJ and MCJ communications were seen after RCJ injection alone and would have been missed if only MCJ injection had been performed. Thus, three separate injections into the RCJ, MCJ, and DRUJ are necessary for complete arthrographic evaluation.
Adolescent↗
Device for facilitating lesion localization in breast biopsies.
To allow easier radiographic localization and pathologic correlation of occult lesions in breast biopsies, a specimen holder composed of two Plexiglas plates was devised. The specimen is compressed between the plates and radiographed. The lesion can be localized by inserting a 22-gauge needle through the appropriate hole in the bottom plate. Holes are centered within alpha numerically labeled squares on a grid created by grooves on the plates. The grooves allow the pathologist to excise only the tissue with the lesion.
Biopsy↗
The anatomy of a human foot with missing toes and reduplication of the hallux.
Detailed dissection of a malformed human foot was performed so that the skeletal and soft tissue anomalies in the foot could be compared and contrasted with those found in three previous specimens that we have dissected. The specimen described here consisted of a foot with a reduplicated hallux and two missing toes. Study of the bones revealed a wide medial metatarsal that articulated with a reduplicated hallux. There were two complete lateral toes with normal bones. Two toes and their metatarsals were missing with no remnants. The arterial pattern was similar to those seen previously by us. The dorsalis pedis artery was absent and the plantar arch was abnormal in that it did not terminate with a dorsal anastomosis. There was an extra lateral branch of the medial plantar artery. The digital arteries to the missing toes were also missing. The nerves of the foot were normal with the exception of an extra lateral branch from the medial plantar nerve. As with the arteries, the nerves to the missing toes were also missing. The muscles and tendons on the dorsal surface of the foot were all present but several of the tendons were inserted in abnormal locations in apparent response to the abnormal bone pattern. Most of the muscles and tendons of the plantar surface were present with the exception of the flexor hallucis longus and brevis muscles. Several of the remaining tendons apparently were influenced by the abnormal skeletal pattern and the missing muscles to become inserted on or near the replicated phalanges of the hallux. The anatomy of this specimen suggests that the teratogenic event occurred when specification of the limb bud mesoderm cells had progressed to the level of the distal tarsus and was located in the region that normally would have formed the metatarsals and phalanges of Toes 2 and 3. Further, we propose that the association between skeletal anomalies and arterial deficiencies has aetiological significance. We hypothesise that the abnormal arterial pattern put the limb at risk of teratogenic damage by reducing the number of collateral blood supply routes and that some event, such as extravasation of blood or embolisation, compromised the blood flow in the remaining blood vessels. These events could have resulted in both general shortening of the limb and the specific defects observed in this foot.
Arteries↗
Magnetic resonance imaging of the triangular fibrocartilage complex.
Magnetic resonance imaging of seven fresh human cadaveric specimens was used to evaluate the integrity of the triangular fibrocartilage complex of the wrist. A variety of imaging parameters were systematically investigated, including T1-weighted images with and without contrast, long repetition times, short echo time images, and T2-weighted sequences. A variety of imaging planes were also evaluated. Wrist arthrography, dissection, and frozen coronal sections were done to substantiate our interpretations of the magnetic resonance images. T2-weighted images in the coronal plane proved to be of the greatest diagnostic value because the synovial fluid of the joint spaces serves as an excellent endogenous contrast agent. Long repetition time, short echo time sequences could be simultaneously obtained with T2-weighted sequences with the use of a multi-echo pulse sequence to provide an excellent diagnostic package in the future. On the basis of our investigation, the triangular fibrocartilage complex can be consistently and accurately evaluated with magnetic resonance imaging. As magnetic resonance imaging technology improves, wrist probes and suitable magnets should become available that will make the evaluation of triangular fibrocartilage complex abnormalities with magnetic resonance imaging clinically useful.
Cartilage, Articular↗
Necrosis leading to amputation following clubfoot surgery.
Amputation after clubfoot surgery is a rare and catastrophic complication. This case report involves an amputation necessitated by postoperative necrosis on the medial side of the foot. To our knowledge, only one brief published report of necrosis following clubfoot surgery exists in the literature, and that report contains little clinical information. Although we know of several additional cases of necrosis following clubfoot surgery, the details of these cases remain unavailable to us for publication. The clubfoot deformity is almost always associated with vascular deficiencies involving the anterior tibial and dorsalis pedis arteries, as well as their derivatives. Since the area of necrosis in this case report coincided with the anatomic distribution of the derivatives of the congenitally reduced or absent dorsalis pedis artery, we suggest that insufficient blood flow to the dorsal and medial sides of the foot, and to the hallux contributed to the necrosis. In our opinion, the surgeon should assume that an abnormal vascular pattern, as described here, is present unless proven otherwise.
Amputation, Surgical↗