Biomedical subjects
Publications and source records attributed to M J Bell.
We report a case of fracture of the ulnar sesamoid of the metacarpophalangeal joint of the thumb. The role of arthrography and stress X-rays in delineating the pathological anatomy of this injury is discussed.
Linscheid and Dobyns (1972), in a classical article on post-traumatic instability of the wrist described two major types of instability, dorsal and volar. The dorsal intercalated segment instability (D.I.S.I.) was the more common and occurred with scapholunate dissociation and displaced scaphoid fractures. The instability occurred in these conditions as a result of the scaphoid losing its ability to support the carpus. They presented five cases of volar intercalated segment instability (V.I.S.I.) of which four were related to congenital ligament laxity and not to traumatic ligament disruption. In the one case of traumatic origin they felt that the capitolunate ligament was ruptured. However, more recent publications by Taleisnik, Prietto (1982) and Reagan, (1984) have proposed that for V.I.S.I. to occur the lunate triquetral interosseous ligament must be disrupted. We report this case as it demonstrates which ligamentous structures are torn for V.I.S.I. to occur. In addition, these ligament disruptions were pathological and occurred spontaneously as a result of longterm systemic steroid medication.
We report the ulnar impingement syndrome, which is caused by a shortened ulna impinging on the distal radius and causing a painful, disabling pseudarthrosis. Of the 11 cases reported, 10 were due to excision of the distal ulna after injury to the wrist; the other was a result of a growth arrest after a fracture of the distal ulna in a child. The symptoms are a painful, clicking wrist and a weak grip; clinical examination reveals a narrow wrist with pain on compression of the radius and ulna and on forced supination. Radiographs in the majority of cases show scalloping of the distal radius corresponding to the site of impingement. The mechanism by which ulnar impingement occurs after radio-ulnar convergence is illustrated. The plan of management for the young patient with traumatic dysfunction of the distal radio-ulnar joint is discussed; excision of the lower end of the ulna is not advised in such patients.
Excellent results can be achieved by plating fractures of the shaft of the humerus in patients with multiple injuries. This helps in nursing care and in the management of other injuries. In 38 patients admitted to a regional trauma centre, 39 humeral shaft fractures were plated. There were 27 men and 11 women, with an average age of 31.5 years. Fourteen of the humeral fractures were compound and 20 had significant comminution; 23 were fixed by a plate on the day of admission and all 39 by the twentieth day. Follow-up of 34 fractures showed that all had united, 33 primarily. All patients but one had a fully functional shoulder and no patient with a fractured humerus alone had lost any elbow movement. Complications were rare--one case each of non-union, fixation failure and infection. No permanent nerve injuries were produced at operation. The plating of fractures of the humerus in these circumstances has been shown to produce excellent results and has a place in the management of the patient with multiple injuries.
Seven pectoralis major transfers in children suffering from bilateral paralysis of elbow flexion due to arthrogryposis or to trauma are reported. A technique is described in which the muscle is mobilised from the clavicle to allow the tendon of insertion to be attached to the biceps tendon at the elbow. The biceps tendon was found to be present and could be mobilised forwards in all the arthrogrypotic elbows. Subjectively, the results were considered by patients or parents to be very good in six cases and fair in one. Elbow flexion power against gravity and against some resistance was achieved in all patients except one. The overall function was very good in one elbow, good in two, fair in three and poor in only one. The merits of the various procedures described for the restoration of elbow flexion in arthrogryposis are discussed. It is concluded that total pectoralis major transfer by the method described here has given the best results.
A review of 60 neonates with perforation of the gastrointestinal tract and peritonitis was undertaken to evaluate efficacy of current treatment. Perforation was most frequently associated with necrotizing enterocolitis, spontaneous gastric perforation, intestinal obstruction and feeding tube perforation of the duodenum. Primary closure of proximal gastrointestinal tract perforations and resections with diversion for distal perforations were the commonly used operative procedures. Mortality was 33 per cent, with most deaths (80 per cent) a result of sepsis or its complications. Increased risk of mortality was associated with lower birth weight and lower weight for gestational age, males, initial serum pH less than 7.30, delay in surgical treatment and feeding tube perforation. Peritoneal cultures were dominated by aerobic and facultative organisms with only 21 per cent yielding mixed aerobic-anaerobic cultures. No anaerobes were retrieved from post-operative wound infections or abscesses, and only one of 22 positive blood cultures yielded an anaerobe. Antibiotic therapy included combinations of aminoglycoside beta-lactam antibiotics and clindamycin. Improving survival in this population, particularly in infants less than 1 kilogram birth weight, was demonstrated.
The following hypothesis is offered for the etiology of neonatal necrotizing enterocolitis (NEC): that NEC is caused by the acquisition of a potentially pathogenic organism by a susceptible host infant. To test this hypothesis, serum IgM, IgG, IgA, C3, and C4, were measured in 11 neonates with NEC and 11 control infants matched for age and birth weight. Mean initial serum IgA was found to be significantly greater (p less than 0.05) in patients with NEC (8.4 mg/dl) than in control subjects (0.6 mg/dl). This difference persisted during a subsequent period of observation. There were no significant differences in initial concentrations of the other immunoglobulins or complement components. Serum IgM was noted to increase and serum IgG to decrease in both study groups during the period of observation. C3 rose minimally and C4 fell in patients with NEC. An explanation for this alteration in serum IgA concentration in infants with NEC is, at this time, speculative. However, this association, suggests that further evaluation of host susceptibility in this patient group may lead to a better understanding of this disorder.
Seventeen patients with early rheumatoid synovitis underwent synovial biopsy to assess the interrelationship between both ferritin (the intracellular iron storage protein) and Perls' positive iron (ferric iron in loose combination with protein), on the activity and course of rheumatoid disease. The amount of ferritin was associated to a significant degree with the activity of the disease at the time of biopsy, but showed no relation to the way the disease progressed over the following year. In contrast, the amount of Perls' iron bore no relation to the activity of the disease at biopsy, but its presence was associated with persistent disease. It is argued that this association is direct, that ferritin production may fail in a population of synovial macrophages, and that Perls' ferric iron may either be reduced to the ferrous form and promote the formation of toxic free radical species, or stimulate collagenase and prostaglandin release from synovial macrophages.
The fecal and gastric microflora of 178 critically ill neonates was compared with that of 30 normal full-term infants. Significant findings included increased frequency of single species retrieval and decreased frequency of mixed aerobic-anaerobic fecal cultures in the ill infants. Also noted were increased retrieval of pathogenic organisms, ie, staphylococcus aureus from gastric and fecal cultures of the ill infants, and decreased retrieval rates of Escherichia coli enterococcus, B fragilis, and other anaerobes in the feces of this group. Yeast retrieval was increased in the feces of the ill neonates. Statistical analysis showed that delivery route, birth weight, and antibiotic therapy were significantly related to the retrieval rates of certain organisms in the gastric and fecal flora of the ill neonate. Given the breast-fed and formula-fed infants have different normal floral patterns, this study suggests that the flora of the ill neonate conforms to a different pattern. Implications in the prevention and treatment of various neonatal septic processes may be drawn from this data.
The pharmacokinetics of intravenously administered clindamycin phosphate was studied in 40 children less than 1 year of age. Mean peak serum concentrations were 10.92 micrograms/ml in premature infants less than 4 weeks of age, 10.45 micrograms/ml in term infants greater than 4 weeks, and 12.69 micrograms/ml in term infants less than 4 weeks of age. Mean trough concentrations were 5.52, 2.8, and 3.03 micrograms/ml, respectively, in the same groups. Serum half-life was significantly longer (8.68 vs 3.60 hours) in premature compared with term infants less than 4 weeks of age. Both premature and term infants less than 4 weeks had significantly decreased clearance when compared with infants greater than 4 weeks (0.294 and 0.678, respectively, vs 1.58 L/hr). Clearance was significantly greater (1.919 vs 0.310 L/hr) and serum half-life less (1.75 vs 7.57 hours) in infants with body weight greater than 3.5 kg. On the basis of these data it is recommended that in infants greater than 4 weeks or greater than 3.5 kg, intravenous clindamycin dosage be 20 mg/kg/day in four divided doses. In premature neonates less than 4 weeks, the dose should be reduced to 15 mg/kg/day in three divided doses. Term infants greater than 1 week of age may also receive 20 mg/kg/day in four doses.
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Twenty extremely premature infants (birth weight, less than 1,100 g) underwent 49 surgical procedures for acquired conditions, including necrotizing enterocolitis, other forms of gastrointestinal perforation, gastroesophageal reflux, patent ductus arteriosus, and hydrocephalus. Few congenital anomalies requiring operation were encountered in this group. The overall survival rate was 58%. Using a computerized data base to compare surgical patients with a weight-matched group of nonsurgical patients, it was shown that survival was similar and that adverse prenatal and perinatal influences were equally distributed between both groups. Surgery per se did not adversely influence survival in extreme low-birth-weight infants, and surgical patients are not a preselected group of stronger infants.
In order to discern the frequency of preventable traumatic deaths in children, the medical examiners' records of 118 consecutive traumatic deaths (except burns and drownings) in children up to 15 years of age in metropolitan St. Louis were reviewed between 1977 and 1981. Thirty-eight different hospitals were involved in the case of these patients. Where possible, victims were assigned a Modified Injury Severity Score (MISS). Twenty-five percent of the deaths unassociated with neurological damage were deemed preventable. The frequency of preventable deaths and the excessive number of hospitals involved suggests that pediatric surgeons should become involved in the development of regionalized trauma care, lending their expertise to the development of triage and treatment protocols for injured children.
We studied gastrointestinal tract excretion of sodium and water in seven infants with an abdominal ileostomy (group 1) and three children with a Soave ileoendorectal pull-through (group 2). When the daily sodium intake of the patients was 5 to 7 mEq/kg (twice usual maintenance), average daily ileal sodium losses were 2.4 mEq/kg body weight in group 1 and 3.3 mEq/kg in group 2. Ten days after ileostomy closure in group 1, when the infants' daily sodium intake averaged 2 to 3 mEq/kg/day, gastrointestinal tract sodium losses were reduced to 0.3 mEq/kg body weight/day. The mean daily fecal weight and water also decreased after closure. Mean serum aldosterone concentration before closure was 84 ng/ml, and declined to 58 ng/100 ml after closure; and mean plasma renin values fell from 8.8 to 2.9 ng/ml/hr. In the children with an ileoendorectal pull-through, daily sodium intake was restricted to 0.3 to 0.5 mEq/kg/day, an amount that would maintain balance in a child of similar age with normal sodium conservation. Mean serum aldosterone concentration increased to 501 ng/ml (normal 1 to 22.7). Although renal conservation of sodium occurred promptly, gastrointestinal losses of sodium and water continued and the patients' sodium balance became negative. The diet of a patient with an ileostomy should include increased amounts of sodium until bowel continuity is restored.
A case report demonstrating that carpal dislocations can occur with fractures of the distal radius. The mechanism of injury is discussed and the results of treatment described.
Laparotomy with a preoperative diagnosis of acute appendicitis disclosed a normal appendix in 105 children (22.1 percent). In less than half of these, another condition was found or later identified, which explained the symptoms leading to operation. Ovarian lesions, acute ileocolitis, and serositis were the most frequently identified abnormalities. Twelve patients (11 percent) underwent definitive procedures in addition to appendectomy. Among patients in whom no abnormality was identified at laparotomy, peritoneal cultures yielded a broad range of organisms in 42 percent of those who had cultures. This may represent a mild form of acute primary peritonitis and may explain the symptoms which were confused with acute appendicitis.
Nine children with nesidioblastosis underwent pancreatic resection at St. Louis Children's Hospital. Four of these underwent 99 percent of near-total resection. Only one child required permanent insulin therapy postoperatively. Pathologic examination of the resected pancreases revealed a diffuse disturbance of the pancreatic architecture. Prolonged hypoglycemia can have devastating neurologic sequelae. Based on clinical experience and the pathologic demonstration of a diffuse process in the affected pancreas, it is advocated that near-total (99 percent) pancreatectomy is the primary procedure of choice for this disease.
Active pulmonary vasoconstriction and subsequent right-to-left atrial and/or ductal shunting of venous blood may influence the course of many neonatal cardiorespiratory disorders. The term "persistent fetal circulation" has been applied to these infants. This report concerns the late occurrence of fetal circulation after major intraabdominal operative procedures in two neonates. The first patient was a full-term, 3.6-kg infant with a covered, large liver-containing omphalocele. Cyanosis, hypoxia, and a right-to-left shunt were present at birth, but were improved by 24 hr of life. Primary repair was delayed for 6 days, in the belief that fetal circulation was unlikely to recur. On day 7, primary fascial closure of the omphalocele was followed by severe hypoxia secondary to right-to-left shunt, documented to be due to postoperative fetal circulation (POFC). The second was a 1600-g premature infant who was well until noted to be lethargic on the fourth day of life. Radiologic findings of pneumoperitoneum led to laparotomy and closure of a spontaneous gastric perforation. Twenty-four hours later the patient developed severe hypoxia and a right-to-left shunt at the atrial level was documented with contrast echocardiogram, again supporting the diagnosis of POFC. Each patient survived and has a normal heart. Both patients responded to hyperventilation and/or tolazoline therapy. Contrast echocardiography was a helpful, noninvasive means of establishing the diagnosis. This diagnosis should be considered in postoperative neonates after more common cardiac and pulmonary causes of hypoxia are excluded.