The management of sprained ankle.
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Ankle Injuries↗
Biomedical subjects
L Klenerman
Publications and source records attributed to L Klenerman.
MRI in the investigation of Morton's neuroma: which sequences?
Morton's 'neuroma' is a painful focus of peri-neural fibrosis, which may affect the interdigital nerves of the feet. Clinical diagnosis and localization may be inaccurate. Computed tomography (CT), ultrasound and magnetic resonance imaging (MRI) have been used to confirm the diagnosis pre-operatively. Recently, MRI using T1-weighted sequences with fat saturation after i.v. Gadolinium DTPA has been suggested as the most effective MR sequence for depiction of Morton's neuroma of the neuroma of the forefoot. Our results show that T1-weighted axial and coronal images with an axial FSE T2-weighted sequence detect neuromata more consistently than an enhanced T1 fat suppressed sequence.
Contrast Media↗
An investigation into the effect of ischaemia and pressure on irritant inflammation.
Reports of chemical burns beneath tourniquets during orthopaedic procedures led us to explore the irritant effects produced by the skin antiseptics used during such procedures. A sphygmomanometer and tourniquet, at a pressure of 200 mmHg for 30 min, was used to created pressure and ischaemia which were then examined separately for their respective effects on irritant inflammation in normal subjects and those with atopic eczema. As no inflammation could be demonstrated with the antiseptics, we subsequently used the known irritant chemical anthralin to examine the effect of ischaemia with and without pressure. Site-related variation in anthralin-induced inflammation was observed but there was no demonstrable effect of either pressure or ischaemia on the inflammatory response. Therefore, as we are unable to show a relationship between ischaemia with or without pressure and irritant inflammation, we conclude that burns under tourniquets are likely to be idiosyncratic reactions and their further investigation requires examination of the individuals affected.
Anthralin↗
Screening for patients at risk of diabetic foot ulceration in a general diabetic outpatient clinic.
An examination of the reproducibility of three tests for identifying patients at risk of diabetic foot complications is reported. One thousand and one patients attending a general diabetic outpatient clinic at the Royal Liverpool University Hospital underwent screening using the Semmes-Weinstein monofilaments, the biothesiometer, and palpation of pedal pulses. Two hundred and fifty-nine patients who were found to have a deficit on at least one of these tests were given a second appointment where the tests were repeated. Two hundred and twenty-nine patients attended for their second appointment. The expected range of variation in readings for the biothesiometer was 5 log hertz, sufficient variation to make the biothesiometer unacceptable as a screening instrument. The range of reproducibility for the four pedal pulses was from 68% to 81%, also an unacceptable level of variation. Over 85% of the results for the Semmes-Weinstein monofilaments were the same on the first and second measurement. Of the three instruments examined in this study, only the Semmes-Weinstein monofilaments have sufficient reproducibility in the clinical setting for them to be recommended for general use as a screening test for risk of diabetic foot complications.
Adolescent↗
Elemental analysis of femoral bone from patients with fractured neck of femur or osteoarthrosis.
The elemental composition of bone has been determined by inductively coupled atomic emission and mass spectrometry to test the hypothesis that changes in major or minor elemental concentrations may contribute to the risk of fracture. Femoral bone was obtained from patients at operation for the treatment of fracture and compared with that of patients with osteoarthrosis and a necropsy control group. The data suggest that there are no major differences in bone elemental composition in patients with fractures compared with the control group. Bone adjacent to joints with osteoarthrosis tends to be less mineralized (per unit trabecular bone volume) than control bone and bone from fracture patients, and has significantly lower concentrations of boron, lead and, zinc. These observations may reflect the more rapid turnover of bone close to the arthritic joint.
Aged↗
Serial changes in serum vitamin K1, triglyceride, cholesterol, osteocalcin and 25-hydroxyvitamin D3 in patients after hip replacement for fractured neck of femur or osteoarthritis.
Serum vitamin K1 concentrations were measured at presentation (just before surgery) and then at weekly intervals for 3 weeks in two groups of elderly patients requiring either hemiarthroplasty for fractured neck of femur (FON, n = 13) or total hip replacement for osteoarthritis of the hip (OA, n = 16). In comparison with healthy elderly volunteers (n = 25), serum vitamin K1 concentrations were significantly lower in both groups at presentation, and fell significantly within 24 h after surgery to concentrations approaching non-detectable, subsequently returning to pre-operative values within 3 weeks. Serum vitamin K1 tended to be lower in the fracture group both before and after operation, although calculation of a vitamin K1-triglyceride ratio reduced the apparent difference as triglyceride concentrations were lower in the fracture group. Osteocalcin concentrations were similar and fell significantly after operation in both groups, returning to pre-operative levels within 7 days. No differences in the two forms of osteocalcin (carboxylated and undercarboxylated) were observed either before or after operation in either group. 25-Hydroxyvitamin D3 concentrations were not significantly different between the two groups at any time. Vitamin K1 status may be lower than desirable in certain groups of the elderly population, and supplementation should be considered as prophylactic therapy.
Aged↗
Plantar foot pressures during treadmill walking with high-heel and low-heel shoes.
The effect of walking with high-heel shoes on plantar foot pressure distribution was investigated. Ten normal women walking in shoes with low heels were compared to women walking in high-heel shoes. It was shown that high-heel shoes increased the load on the forefoot and relieved it on the hindfoot. The load passed toward the medial forefoot and the hallux. The lateral side of the forefoot showed a decrease in contact area, reduced forces, and peak pressures. The medial side of the forefoot had a higher force-time and pressure-time integral. It is suggested that these higher loads on the medial forefoot may aggravate symptoms in patients with hallux valgus deformity.
Adult↗
Ischemia-reperfusion-induced muscle damage. Protective effect of corticosteroids and antioxidants in rabbits.
We examined the potential protective effect of pretreatment with corticosteroids or antioxidants (ascorbic acid or allopurinol) in rabbits with reperfusion-induced damage to skeletal muscle after ischemia. 4 hours of limb ischemia induced by a pneumatic tourniquet, followed by reperfusion for 1 hour, caused a considerable amount of ultrastructural damage to the anterior tibialis muscles accompanied by a rise in circulating creatine kinase activity. Pretreatment of animals with depomedrone by a single 8 mg bolus injection led to a preservation of the anterior tibialis structure on both light and electron microscopy. High-dose continuous intravenous infusion with ascorbic acid (80 mg/hr) throughout the period of ischemia and reperfusion also preserved skeletal muscle structure, although allopurinol in various doses had no protective effect. These data are fully compatible with a mechanism of ischemia/reperfusion-induced injury to skeletal muscle, involving generation of oxygen radicals and neutrophil sequestration and activation. They also indicate that damage to human skeletal muscle caused by prolonged use of a tourniquet is likely to be reduced by simple pharmacological interventions.
Allopurinol↗
The Charcot joint in diabetes.
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Arthropathy, Neurogenic↗
Diagnosis of osteomyelitis in neuropathic foot ulcers.
We reviewed all patients with a clinically infected foot ulcer attending a specialised neuropathic foot clinic. Neuropathy was confirmed by the inability to feel a 5.07 Semmes-Weinstein hair, areflexia and impaired vibration sense, as measured by a biothesiometer. Of 40 patients who attended the clinic over a two-year period, six with ischaemic ulcers were excluded. The remaining 34 had plain radiographs of the foot followed by a 99mTc-MDP bone scan. If the latter was positive, an 111In-labelled WBC scan was performed with planar and/or tomographic dual-isotope studies where appropriate. Bone and WBC scans were performed in 31 patients. In ten, isotope imaging showed infection localised to the soft tissues only and conservative treatment was successful in them all. Eighteen patients were treated surgically with excision of the involved bone, which was sent for culture and histological examination. Dual-isotope scans had a sensitivity of 93% and a specificity of 83%. 99mTc-MDP bone scans with the appropriate In-labelled WBC scans can reliably determine the site and extent of osteomyelitis in the neuropathic diabetic foot.
Bone and Bones↗
The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting.
STUDY DESIGN: Three hundred patients, attending their general practitioners with attacks of acute low back pain, formed the subject population for a study of fear avoidance and other variables in the prediction of chronicity. Follow-up was at 2 and 12 months. OBJECTIVE: The hypothesis to be tested was that evidence of psychological morbidity, particularly fear-avoidance behavior, would be manifest from the outset of the presenting attack in susceptible subjects. SUMMARY OF BACKGROUND DATA: While back pain is an almost universal human experience, only about 5% of sufferers seek medical advice. Most of these respond to conservative treatment. However, approximately 10% of those who experience an acute attack of low back pain go on to become chronic sufferers. METHODS: Psychosocial and physiological data (including fear-avoidance measures) were collected from a sample of 300 acute low back pain patients within 1 week of presentation and at 2 months, to try to predict 12 month outcome. RESULTS: Data analysis showed that subjects who had not recovered by 2 months were those who went on to become chronic low back pain patients (7.3%). Using multiple regression analyses, fear-avoidance variables were the most successful in predicting outcome. Using multiple discriminant function analyses, the results suggest that the outcome in terms of the future course of low back pain can be correctly classified in 66% from fear-avoidance variables alone and in 88% of patients from all variables. CONCLUSIONS: The results suggest that, at the earliest stage of low back pain, fear of pain should be identified by clinicians and, where this is severe, pain confrontation should arguably form part of the approach to treatment.
Acute Disease↗
Evolution of spinal bone loss and biochemical markers of bone remodeling after menopause in normal women.
The main objective of this study was to describe longitudinal patterns of spinal bone loss in normal women who undergo a natural menopause. The second objective was to determine if a proportion of women suffer excessively rapid postmenopausal bone loss from the spine. If this was the case it was the aim to devise a means of predicting the woman at excess risk; but if all women lost bone at similar rates, the aim was to document changing loss rates over the first 5-8 postmenopausal years. Responding women in six suburban general practices recalled for cervical smears who had their last menstrual period 9- 36 months previously were invited to participate in a longitudinal study of bone loss and the biochemical markers plasma osteocalcin and urinary hydroxyproline. Sixty-four subjects agreed to participate, a response rate of 80%. In the ensuing 5 years, six received hormone replacement therapy and are not reported on. The main outcome measures were rates of spinal bone loss over 5 years, measured by dual photon absorptiometry, and radial bone loss over the first 2 years measured to quantitative computed tomography. Spinal bone loss was similar between individuals, with 94% of the variability in the data being accounted for by a statistical model that assumed parallel rates of bone loss. A less restrictive model allowing women to have different rates of spinal bone loss accounted for 12% more of the remaining variance in the data than the previous model. However, rates of radial bone loss were more dissimilar between women than rates of spinal loss. The results of the biochemical data collected serially showed that the plasma osteocalcin rose slowly to a plateau at 5 years postmenopause; in contrast, the hydroxyproline fell progressively with time over the whole period of study. These results were interpreted as being consistent with diminishing rates of bone destruction which gradually reequilibrated with bone formation as time passed after menopause.
Absorptiometry, Photon↗
The pathology of the lower leg muscles in pure forefoot pes cavus.
Enlargement of the peroneus longus muscle is a common occurrence in patients with forefoot pes cavus, and may contribute to the cavus deformity. The present study compares the morphology of up to five lower leg muscles from 17 patients with forefoot pes cavus with those of normal muscles. Eight cases had an identifiable neurogenic cause for the cavus. In four cases of hereditary motor-sensory neuropathy, the tibialis anterior showed more severe damage than the peroneus longus. In two cases of cerebral palsy, fibre atrophy and increased oxidative enzyme activity were observed. In nine clinically idiopathic cases, the histological appearances ranged from normal to generalised fibre atrophy or hypertrophy in individual muscles. There was a trend for the mean fibre area to be greater in peroneus longus than in tibialis anterior in six of the idiopathic group of patients. The muscle cross-sectional area on magnetic resonance imaging was correlated closely with the mean fibre area measured on tissue sections. In idiopathic forefoot pes cavus, fibre hypertrophy in peroneus longus (relative to tibialis anterior) may contribute to the cavus deformity. Muscle fibre hyperplasia may contribute to the peroneal muscle enlargement in Friedreich's ataxia. In none of the cases was peroneus longus enlargement due to fat or fibrous tissue replacement.
Adolescent↗
The results of surgical management of displaced tibial plateau fractures in the elderly.
We retrospectively reviewed 32 elderly patients (mean age 71.7 years, range 66-83 years) with displaced tibial plateau fractures after a mean of 3.7 years (range 1-7 years) after operative treatment. Schatzker type 2 fracture was the commonest pattern of fracture (60.3 per cent). According to the modified Rasmussen clinical and radiographic criteria, there were nine excellent, 14 good, five fair and four poor results clinically, and 11 excellent, 12 good, six fair and three poor results radiographically. There was no significant correlation between the final radiographic appearance and clinical outcome. Fourteen patients mobilized postoperatively on a continuous passive motion machine followed by a cast brace had a better result than those mobilized in a cast brace alone, but the difference was not statistically significant (P = 0.29). Postoperative complications included deep vein thrombosis in two patients.
Aged↗
Fractures of the distal radius and ulna.
Associated fractures of the distal ulnar metaphysis were present in 19 of 320 distal radial fractures requiring either closed manipulation or surgical treatment over a 2-year period. Four morphological patterns of ulnar fracture were encountered, the commonest being the type 1 simple extra-articular fracture of the distal end of ulna with minimal comminution (eight out of 19). 15 patients were treated conservatively and two each were treated by internal and external fixation. 15 patients were reviewed after a mean follow-up of 23.8 months and there were four excellent, five good, five fair clinical results and one poor result. Radiographically the distal radio-ulnar joint (DRUJ) was normal in eight wrists, but longitudinal or horizontal disruption of the DRUJ was present in seven wrists. Fracture callus encroached on the DRUJ in three patients, who also had limitation of forearm rotation. Two comminuted ulnar fractures (type 4) developed non-union, but both patients had full forearm rotation, in contrast to restriction of forearm rotation in four out of five patients with type 1 fractures.
Aged↗
The foot and ankle in rheumatoid arthritis.
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Ankle Joint↗
A biomechanical comparison of the SACH, Seattle and Jaipur feet using ground reaction forces.
The Jaipur prosthetic foot was developed in India in response to specific socio-cultural needs of Indian amputees. It is being used extensively in India and several other developing countries. Its claim of being a cheaper and satisfactory alternative to other prosthetic feet has not been investigated biomechanically. The present study was undertaken to compare its biomechanical properties with the SACH and Seattle feet, using ground reaction forces. Three trans-tibial amputees participated in the experiment which measured the ground reaction force data using a Kistler force plate. Subject's normal foot was used as a reference. Six variables from the vertical and anteroposterior components of ground reaction forces were quantified, their statistical analysis showed that the normal foot generates significantly larger ground reaction forces than the prosthetic foot. The shock absorption capacity of the SACH foot was found to be better when compared with the other two feet, while the Jaipur foot allowed a more natural gait and was closer in performance to the normal foot. None of the prostheses significantly influenced the locomotor style of the amputees.
Adult↗
Effect of the shoe on plantar foot pressures.
The bare foot plantar pressures were compared to in-shoe pressure measurements in 11 normal male volunteers using the EMED system. Shoes diminished pressures and forces in most areas under the foot except the medial forefoot. The hallux showed less force, a smaller contact area and a reduced contact time. Therefore a shoe can interfere with the toe-off mechanism. There was no difference between various types of shoes with rubber and leather soles. Heavier subjects tended to put less weight on the medial forefoot.
Adult↗