Cultivating leaders for the future.
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Forecasting↗
Biomedical subjects
R R Richards
Publications and source records attributed to R R Richards.
Fat embolism syndrome.
Fat embolism syndrome, an important contributor to the development of acute respiratory distress syndrome, has been associated with both traumatic and nontraumatic disorders. Fat embolization after long bone trauma is probably common as a subclinical event. Fat emboli can deform and pass through the lungs, resulting in systemic embolization, most commonly to the brain and kidneys. The diagnosis of fat embolism syndrome is based on the patient's history, supported by clinical-signs of pulmonary, cerebral and cutaneous dysfunction and confirmed by the demonstration of arterial hypoxemia in the absence of other disorders. Treatment of fat embolism syndrome consists of general supportive measures, including splinting, maintenance of fluid and electrolyte balance and the administration of oxygen. Endotracheal intubation and mechanical ventilatory assistance can be indicated. The role of corticosteroids remains controversial. Early stabilization of long bone fractures has been shown to decrease the incidence of pulmonary complications. Clinical and experimental studies suggest that the exact method of fracture fixation plays a minor role in the development of pulmonary dysfunction. As more is learned about the specifics of the various triggers for the development of fat embolism syndrome, it is hoped that the prospect of more specific therapy for the prevention and treatment of this disorder will become a reality.
Diagnosis, Differential↗
Measuring function of the shoulder. A cross-sectional comparison of five questionnaires.
Measures of both generic and disease-specific health status are being developed and used with increasing frequency for the appraisal of musculoskeletal conditions. The purpose of this study was to compare prospectively the validity of five questionnaires in the assessment of function of the shoulder. Ninety subjects who had various problems related to the shoulder agreed to enter the study. All of the subjects completed a questionnaire package that included the Shoulder Pain and Disability Index, the Simple Shoulder Test, the Subjective Shoulder Rating Scale, the Modified American Shoulder and Elbow Surgeons Shoulder Patient Self-Evaluation Form, and the Shoulder Severity Index as well as a measure of generic health status (the acute version of the Short Form 36 [SF-36]) and two questions that asked the patient to rate the severity of the problem and his or her over-all health. Frequency distributions were created and compared among questionnaires. Spearman rank correlations were calculated to compare the questionnaires with each other and with other assessments. One-way analysis of variance was used to determine the ability of the questionnaires to discriminate between self-rated severity of the problem and over-all health. The frequency distributions were similar among the five shoulder questionnaires, but those of the five shoulder questionnaires differed from that of the SF-36. The correlations were good (0.73 < or = r < or = 0.80) among all of the five shoulder questionnaires except the Subjective Shoulder Rating Scale; they were lower with the Subjective Shoulder Rating Scale and the physical function dimension of the SF-36 (0.12 < or = r < or = 0.60). The shoulder questionnaires discriminated between levels of severity (p < 0.0001) but not between levels of over-all health (0.10 < or = p < or = 0.86). In this concurrent comparison of measures of shoulder-specific outcome in the same subjects, the shoulder questionnaires performed similarly, both in describing function of the shoulder and in discriminating between levels of severity. The shoulder questionnaires performed differently than the SF-36, which confirms the need to use both disease-specific and generic health-status measures to evaluate patients who have a problem related to the shoulder.
Adult↗
Chronic disorders of the forearm.
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Biomechanical Phenomena↗
Dynamic radio-ulnar convergence after the Darrach procedure.
We reviewed 23 patients who had had 25 Darrach procedures for traumatic or post-traumatic disorders of the wrist at a mean follow-up of 75.5 months (36 to 121). The mean age at the time of operation was 61.1 years (34 to 82). All patients were reviewed in person. Assessment included a history, a questionnaire on patient satisfaction and a detailed physical examination. Standardised radiographs of both wrists were taken with the patient's hands in a resting position and during maximal grip. Convergence of the distal ulnar stump towards the distal radius during maximal grip (dynamic radio-ulnar convergence) was seen in 14 wrists including five with actual contact (dynamic radio-ulnar impingement), but this produced symptoms in only two cases. The presence of dynamic radio-ulnar convergence did not correlate with grip strength, pinch strength, range of movement or wrist score, but was associated with increased length of excision of the distal ulna. Nineteen of the 23 patients were satisfied with the procedure. Dynamic radio-ulnar convergence is common after the Darrach procedure, but is rarely symptomatic; resection of the distal ulna remains a reliable procedure in the older patient with pain and loss of movement. Excision of the lower end of the ulna should be restricted to the least required to restore full rotation.
Activities of Daily Living↗
Development and multi-institutional implementation of coding and transmission standards for health outcomes data.
Health care delivery institutions and providers, employers, and government agencies throughout the U.S. are sharing information and pooling resources in an attempt to produce reliable measurements of health outcomes. The rapid rate of growth in the collection and pooling of health outcomes data has prompted the need for standardization. The work of health care organizations and consortiums pooling data would be greatly facilitated by widely accepted standards for the coding and transmitting of outcomes data. Moreover, standards allow for the inter-operation of data capture products, data analysis tools, and data pooling services developed by a variety of different vendors. The Health Outcomes Institute (HOI) and Henry Ford Health System (HFHS) have developed and maintain a database of health outcomes questions which provides a mechanism for uniquely coding data elements. HFHS and the American Medical Group Association (AMGA) have created a software tool to facilitate the conversion and transmission of health outcomes data elements in an American Society for Testing and Materials (ASTM)/Health Level Seven (HL7) format, which incorporates HOI question standards.
Health Services Research↗
Grip strength testing using the BTE work simulator and the Jamar dynamometer: a comparative study. Baltimore Therapeutic Equipment.
This study compared the results obtained from testing grip strength using the hydraulic Jamar dynamometer and the BTE Work Simulator. The grip strength of 14 adults was assessed with the Jamar at 90 degrees elbow flexion, Jamar at 45 degrees elbow flexion, and the BTE using the manufacturers recommended position. Greater strength measurements were generated with the elbow at 90 degrees rather than 45 degrees on the Jamar. The Jamar measurements at 90 degrees of elbow flexion were not significantly different from the BTE work simulator values. Intraclass correlation coefficients between the Jamar at 90 degrees and the BTE work simulator values were excellent. This study demonstrated that the results obtained from the BTE work simulator and the Jamar dynamometer are comparable. These findings validate the use of the BTE work simulator for grip strength testing.
Adult↗
Steindler and pectoralis major flexorplasty: a comparative analysis.
Previously published studies on transfers to restore elbow flexion have rarely compared the outcomes among different techniques. We found no comparison between the Steindler procedure and pectoralis major tendon transfer. This study compared functional outcomes after these two types of elbow flexorplasty performed in conjunction with shoulder arthrodesis for patients with brachial plexus injuries. The same examiner assessed 14 patients who underwent shoulder fusion and elbow flexorplasty. Five had a pectoralis major tendon transfer, and nine underwent a modified Steindler procedure. All patients had brachial plexus lesions that were irreparable or had not responded to neurolysis, repair, or grafting. Average follow-up time was 60 months (range, 12 months-10 years). All patients completed a questionnaire (pain, function) and underwent an objective assessment of range of motion, isometric strength, isotonic power, grip, and pinch strength. The BTE Work Simulator (Baltimore Therapeutic Equipment, Hanover, MD) was used for muscle strength testing. Improvement was noted in daily activities including dressing and bilateral activities and was reflected in a significant improvement over preoperative function. No differences (at p = .05 level of significance) were found in objective tests between the pectoralis major transfer and the Steindler groups. In the patient requiring stabilization of the shoulder and flexorplasty, the pectoralis major tendon transfer was at least equivalent to the modified Steindler flexorplasty in terms of range of motion, strength, and subjective measures.
Activities of Daily Living↗
A Madreporic-surfaced femoral component in a canine total hip arthroplasty model: bone remodelling response at 6 and 24 months.
OBJECTIVE: To evaluate the bone-remodelling response at 6 and 24 months after total hip arthroplasty around a two-thirds Madreporic-surfaced femoral component in a canine model. DESIGN: A research study in dogs. Statistical analysis was by multivariate analysis of variance. SETTING: A musculoskeletal research laboratory in a university teaching hospital. MATERIAL: Ten mature mixed-breed dogs. INTERVENTION: Unilateral implantation of total hip arthroplasty in the right femur with a Madreporic-surfaced prosthesis. Studies were conducted at 6 months in five dogs and at 24 months in five dogs. In each case, the nonoperated femur was the study control. MAIN OUTCOME MEASURES: Fluorescence microscopy analysis on comparable sections at four levels of the femora, percent porosity computed by image analysis, cortical atrophy. RESULTS: Cancellous hypertrophy was most prominent at the junction of the beaded and smooth portions of the femoral stem. At 6 months the cortex demonstrated atrophy predominant in the anteromedial quadrant. Active bone turnover was present within the interstices of the prosthesis at 6 and 24 months. No significant cortical bone loss occurred between 6 and 24 months. Stress transfer to the bone-prosthesis interface and endosteal cortical "cancellization" appear to be linked phenomena.
Animals↗
A study of micromotion and appositional bone growth to a canine madreporic-surfaced femoral component.
A canine total hip arthroplasty model was used to examine micromotion and bone apposition to a proximally two-thirds madreporic-surfaced femoral prosthesis. Micromotion was also measured following initial press-fit implantation into canine cadaveric femora. After initial press-fit fixation and either 6 or 24 months of biologic fixation, micromotion was less than 23 microns in the proximal and midstem regions, a magnitude consistent with bone apposition. Bone apposition was greatest near the junction of the madreporic and smooth surfaces and was not significantly different between 6 and 24 months (51% at 6 months and 47% at 24 months). The quality of the interface tissue appears to be conductive to long-term fixation.
Animals↗
The floating radius in bipolar fracture-dislocation of the forearm.
Ten cases of bipolar forearm fracture-dislocation are presented. Recognition of the full extent of the skeletal, articular, and soft-tissue injuries is essential. Treatment consists of an anatomical reduction and proximal and distal stabilization of the skeleton to achieve control as well as maintain the position of the floating radius segment. The forearm bones can then be maintained in an optimal position to avoid interosseous soft-tissue contracture that will compromise the supination-pronation function of the forearm.
Adult↗
A special plate for arthrodesis of the wrist: design considerations and biomechanical testing.
The purpose of this investigation was to determine the strength and mode of failure of a plate specifically designed for wrist arthrodesis. An eight-hole plate was constructed with a solid central portion and a distal taper. Four 2.7 mm screws were used in the distal (metacarpal) portion of the plate. Four 3.5 mm screws were used in the proximal (radius) portion. The strength of the wrist arthrodesis plate was compared with that of a conventional 10-hole 3.5 dynamic compression plate by gap testing and a paired cadaver wrist arthrodesis construct. The strength of the wrist arthrodesis plate was similar to the strength of the conventional dynamic compression plate when applied to cadaver wrist arthrodesis constructs. Failure of the wrist arthrodesis constructs occurred through bone without deformation of either plate.
Arthrodesis↗
Measurement of wrist, metacarpophalangeal joint, and thumb extension strength in a normal population.
An objective method of measuring isometric wrist, finger (metacarpophalangeal joints) and thumb extension strength was developed, and values for a normal population were defined. Disability due to extensor dysfunction was not assessed in this study. The testing technique involved the use of a load cell myometer held in a specially constructed jig. A total of 2232 measurements in 372 persons were made. Mean values for the strength of extension were as follows: men--wrist, 13 kg; metacarpophalangeal joint, 6 kg; thumb, 3 kg; women--wrist, 7 kg; metacarpophalangeal joint, 4 kg; thumb, 2 kg. Strength was greatest in the third decade and decreased in each subsequent age group. Wrist extension strength was 10% greater in the dominant hand. Interrater and test-retest reliability were assessed and found to be satisfactory. The method is proposed primarily as a clinical research tool, providing the clinician with an objective means of assessing wrist, metacarpophalangeal joint, and thumb extensor function. Potential applications include measurements of recovery after radial nerve injury or grafting and after other reconstructive procedures to restore extensor function.
Adult↗
Intraarticular capacity and compliance of stiff and normal elbows.
The capacity, compliance, and position of minimum intraarticular pressure were measured in eight stiff and 10 normal elbows of 11 patients before corrective surgery for posttraumatic elbow joint contracture. Capsular compliance was determined from the slope of the pressure/volume relationships. The capacity of the normal elbow joint capsule was 14 +/- 2, whereas that of the stiff elbow was 6 +/- 3 ml. The capsular compliance of the stiff elbow was only 15% of normal, confirming that the capsule is structurally altered and not just contracted. Adequate capsular distension of the stiff elbow might therefore not be possible, increasing the potential for neurovascular injury with use of the anterior portals in elbow arthroscopy. The position of minimum intraarticular pressure and maximum compliance ("resting position"), of the normal elbow was 70 degrees. If the elbow is left immobilized in this position for an extended period of time, the risk of posttraumatic elbow joint capsule contracture might increase. This agrees with our finding that the stiff elbows had a preoperative arc of motion of 70-120 degrees and a significantly diminished capsular capacity relative to normal.
Adolescent↗
Acromioclavicular joint injuries.
The effective treatment of injury to the acromioclavicular joint requires knowledge of the relevant anatomy and the pathoanatomy of a variety of injury patterns. The six-part classification system facilitates the understanding of the underlying pathoanatomy. Insight into the natural history of acromioclavicular joint injury is crucial to the success of any treatment program. Surgical reconstruction should be reserved for patients with grade IV, V, and VI lesions or those with lower grade lesions that have become chronically symptomatic. If the decision is made to proceed with surgical reconstruction, I prefer coracoclavicular fixation, over-drilling the clavicle, and use of an AO 6.5-mm cancellous lag screw to maintain reduction of the clavicle, followed by careful repair of the overlying soft tissues.
Acromioclavicular Joint↗
The relationship between wrist position, grasp size, and grip strength.
In the first part of this study, the position assumed by a normal wrist during unconstrained maximal grip and the relationship between wrist position and grip strength were investigated in 20 healthy subjects. Grip strength and wrist position were recorded in the self-selected position and then again while the subjects voluntarily deviated the wrist randomly into flexion, extension, or radial or ulnar deviation of 10 to 15 degrees. The self-selected position was 35 degrees of extension and 7 degrees of ulnar deviation. Grip strength was significantly less in any position of deviation from this self-selected position, even after accounting for fatigue. With the wrist in only 15 degrees of extension or in neutral radio-ulnar deviation, grip strength was reduced to two thirds to three fourths of normal. Sex did not affect wrist position. The dominant wrists were within 5 degrees of the nondominant ones but were relatively less extended and in more ulnar deviation. Grip strength is significantly reduced when wrist position deviates from this self-selected optimum position. In the second part of the study, the effect of grasp size on this self-selected position was studied in 21 subjects. The degree of wrist extension was inversely and linearly related to how large a setting on the Jamar dynamometer was used. This was true regardless of hand size, although the effect was more significant for smaller hands. Radial and ulnar deviations were not affected by handle position. A minimum of 25 degrees of wrist extension was required for optimum grip strength.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Ipsilateral fractures of the distal radius and scaphoid treated by Herbert screw and external skeletal fixation. A report of two cases.
Two patients with comminuted, displaced fractures of the distal radius associated with ipsilateral, undisplaced scaphoid fractures were treated by internal fixation of the scaphoid fracture with a Herbert screw in association with external fixation of the distal radial fracture. One of the patients had a limited open reduction of the distal radius combined with bone grafting. Both patients had satisfactory results. Internal fixation of the scaphoid is indicated if distraction is applied to the carpus to treat an associated fracture of the distal radius, even if the scaphoid fracture is undisplaced.
Accidental Falls↗
The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults.
Fifty-five adults who had a fracture of both bones of the forearm were managed with plating and were followed for a mean of six years (range, one year to sixteen years and two months) with functional and radiographic assessment. Malunion was quantified by measurement of the amount and location of the maximum radial bow in relation to the contralateral, normal forearm. Fifty-four of the radial and fifty-four of the ulnar fractures united. Eighty-four per cent of the patients had an excellent, good, or acceptable functional result, according to the criteria of Grace and Eversmann. Bone-grafting did not affect the rate of union. Restoration of the normal radial bow was related to the functional outcome. A good functional result (more than 80 per cent of normal rotation of the forearm) was associated with restoration of the normal amount and location of the radial bow (p less than 0.05 and p less than 0.005). Similarly, the recovery of grip strength was associated with restoration of the location of the radial bow toward normal (p less than 0.005).
Adolescent↗