Primary intra-articular non-Hodgkin's lymphoma of the elbow. A case report.
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Adult↗
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Prevalence of osteoarthrosis of the trapeziometacarpal joint.
BACKGROUND: The age and gender-related prevalence of arthrosis of the trapeziometacarpal joint has been incompletely defined. METHODS: The radiographs of 615 consecutive patients who had presented with an isolated fracture of the distal part of the radius over a two-year period were evaluated for evidence of trapeziometacarpal arthrosis. We used a simple three-grade rating system suitable for standard wrist radiographs. Grade I indicated no or nearly no arthrosis; grade II, obvious arthrosis; and grade III, a totally destroyed joint. This rating system was demonstrated to have adequate intraobserver reliability (average kappa of 0.72, p < 0.001) and interobserver reliability (average kappa of 0.56, p < 0.001). The number of patients with each grade of arthrosis was analyzed according to age and gender. RESULTS: The overall radiographic prevalence of trapeziometacarpal arthrosis in patients with a distal radial fracture increased steadily from the age of forty-one years onward and reached a prevalence of 91% in patients older than eighty years of age. The prevalence increased more rapidly in women than in men; it reached 94% in women who were older than eighty years of age compared with 85% in men who were older than eighty years of age. The prevalence of grade-III trapeziometacarpal arthrosis (a totally destroyed joint) was much greater in women than in men at all age levels; it reached a prevalence of 66% in women older than eighty years of age compared with 23% in men older than eighty years of age. CONCLUSIONS: The radiographic prevalence of trapeziometacarpal arthrosis in patients presenting for treatment of a distal radial fracture is age-related, and trapeziometacarpal arthrosis is more likely to lead to complete joint destruction in women than it is in men.
Adolescent↗
Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius.
BACKGROUND: Fractures of the distal part of the radius that are associated with complex comminution of both the articular surface and the metaphysis (subgroup C3.2 according to the Comprehensive Classification of Fractures) are a challenge for surgeons using standard operative techniques. METHODS: Twenty-five patients with subgroup-C3.2 fractures that had been treated with combined dorsal and volar plate fixation were evaluated at an average of twenty-six months after the injury. Subsequent procedures included implant removal in twenty-one patients and reconstruction of a ruptured tendon in two patients. RESULTS: An average of 54 degrees of extension, 51 degrees of flexion, 79 degrees of pronation, and 74 degrees of supination were achieved. The grip strength in the involved limb was an average of 78% of that in the contralateral limb. The average radiographic measurements were 2 degrees of dorsal angulation, 21 degrees of ulnar inclination, 0.8 mm of positive ulnar variance, and 0.7 mm of articular incongruity. Seven patients had radiographic signs of arthrosis during the follow-up period. A good or excellent functional result was achieved for twenty-four patients (96%) according to the rating system of Gartland and Werley and for ten patients (40%) according to the more stringent modified system of Green and O'Brien. CONCLUSIONS: Combined dorsal and volar plate fixation of the distal part of the radius can achieve a stable, mobile wrist in patients with very complex fractures. The results are limited by the severity of the injury and may deteriorate with longer follow-up. A second operation for implant removal is common, and there is a small risk of tendon-related complications.
Bone Plates↗
The influence of three-dimensional computed tomography reconstructions on the characterization and treatment of distal radial fractures.
BACKGROUND: Computed tomography identifies important characteristics of distal radial fractures better than plain radiographs do. Our hypothesis was that three-dimensional computed tomography images would further increase the reliability and accuracy of radiographic characterization of distal radial fractures. METHODS: Four independent observers evaluated radiographic images of thirty intra-articular fractures of the distal part of the radius for the presence of a fracture line in the coronal plane, impacted central articular fragments, the presence of comminution (defined as more than three articular fragments), and the number of fracture fragments. A treatment was selected on the basis of the interpretation of the radiographic studies. Three rounds of evaluation were compared: (1) radiographs and two-dimensional computed tomography, (2) radiographs and three-dimensional computed tomography two weeks later, and (3) all three types of images two weeks after that. This cycle was then repeated to assess intraobserver reliability. RESULTS: Three-dimensional computed tomography improved the intraobserver agreement, but not the interobserver agreement, regarding the presence of coronal plane fracture lines and central articular fragment depression. Three-dimensional computed tomography improved both the intraobserver and the interobserver agreement regarding the presence of articular comminution. Interobserver agreement increased when three-dimensional computed tomography was used to determine the exact number of articular fracture fragments. The sensitivity and accuracy of identifying specific fracture characteristics (as compared with intraoperative findings) improved when three-dimensional imaging was used in conjunction with two-dimensional imaging as compared with two-dimensional imaging alone. The addition of three-dimensional computed tomography to two-dimensional computed tomography influenced treatment recommendations, resulting in a significantly greater number of decisions for an open approach (p < 0.05) and combined dorsal and volar exposure (p < 0.001). CONCLUSIONS: Three-dimensional computed tomography improves both the reliability and the accuracy of radiographic characterization of articular fractures of the distal part of the radius and influences treatment decisions. Future studies will be required to determine the impact of these decisions on patient outcome.
Adult↗
Self-reported upper extremity health status correlates with depression.
BACKGROUND: The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is the most widely used upper extremity-specific health-status measure. The DASH score often demonstrates greater variability than would be expected on the basis of objective pathology. This variability may be related to psychosocial factors. The purpose of the present study was to investigate the correlation between the DASH score and psychological factors for specific diagnoses with relatively limited variation in objective pathology. METHODS: Two hundred and thirty-five patients with a single, common, discrete hand problem known to have limited variations in objective pathology completed the DASH questionnaire, the Eysenck Personality Questionnaire-Revised (EPQ-R) to assess neuroticism, the Center for Epidemiologic Studies-Depression (CES-D) scale to quantify depressive symptoms, and the Pain Anxiety Symptoms Scale (PASS). Forty-five patients had carpal tunnel syndrome, forty-four had de Quervain tenosynovitis, forty-eight had lateral elbow pain, and seventy-one had a single trigger finger. In addition, twenty-seven patients were evaluated six weeks after a nonoperatively treated fracture of the distal part of the radius. Relationships between psychosocial factors and the DASH score were determined. RESULTS: A significant positive correlation between the DASH score and depression was noted for all diagnoses (r = 0.38 to 0.52; p < 0.01 for all). The DASH score also correlated with pain anxiety for four of the five diagnoses (carpal tunnel syndrome, r = 0.40; de Quervain tendinitis, r = 0.46; lateral elbow pain, r = 0.42; and trigger finger, r = 0.24) (p < 0.05 for all). The DASH score was not correlated with neuroticism for any diagnosis. There was a highly significant effect of depression (as measured with the CES-D score) on the DASH score for all diagnoses. Both the CES-D score (F = 62.68, p < 0.0001) and gender (F = 11.36, p < 0.001) were independent predictors of the DASH score. CONCLUSIONS: Self-reported upper extremity-specific health status as measured with the DASH score correlates with depression and pain anxiety but not neuroticism. These data support the contention that psychosocial factors have a strong influence on health-status measures.
Adult↗
Corrective osteotomy for intra-articular malunion of the distal part of the radius. Surgical technique.
BACKGROUND: Corrective osteotomy is an appealing treatment for malunited articular fractures of the distal part of the radius since articular incongruity may be the factor most strongly associated with arthrosis and diminished function after such fractures. Enthusiasm for osteotomy has been limited by concerns regarding the difficulty of the technique and the potential for additional injury, osteonecrosis, and nonunion. METHODS: Twenty-three skeletally mature patients were evaluated at an average of thirty-eight months after corrective osteotomy for an intra-articular malunion of the distal part of the radius. The indication for the osteotomy included dorsal or volar subluxation of the radiocarpal joint in fourteen patients and articular incongruity of >/=2 mm as measured on a posteroanterior radiograph in seventeen patients. Six patients had combined intra-articular and extra-articular malunion. The average interval from the injury to the osteotomy was six months. The average maximum step-off or gap of the articular surface prior to the operation was 4 mm. RESULTS: One patient had a subsequent partial wrist arthrodesis because of radiocarpal arthrosis, and three patients had additional surgery because of dysfunction of the distal radioulnar joint. One patient had a rupture of the extensor pollicis longus, which was treated with a tendon transfer. The final articular incongruity averaged 0.4 mm, and the final grip strength averaged 85% of that on the contralateral side. The rate of excellent or good results was 83% according to the rating systems of Fernandez and of Gartland and Werley, and 43% according to a modification of the rating system of Green and O'Brien. CONCLUSIONS: The results of corrective osteotomy for the treatment of intraarticular malunion are comparable with those of osteotomy for the treatment of extra-articular malunion. Intra-articular osteotomy can be performed with acceptable safety and efficacy, it improves wrist function, and it may help to limit the need for salvage procedures such as partial or total wrist arthrodesis.
Adolescent↗
Dive Europa: a search-for-life initiative.
Liquid water, underwater volcanoes and possibly life forms have been suggested to be present beneath the estimated 10 km-thick ice shell of Europa the Jovian satellite J2. Europa's possible ocean is estimated to be 100-200km deep. Despite the great depth of the Europa's ocean, hydrostatic pressure at the seafloor would be 130-260 MPa, corresponding to 13-26 km depth of a theoretical Earth's ocean. The hydrostatic pressure is not beyond the edge of existing deep-sea technology. Here we propose exploration of Europa's deep-sea by the use of current technologies, taking a symbolic example of a deep submergence vehicle Shinkai 6500 which dives to a depth of 6.5 km deep (50 km depth of Europa's ocean). Shinkai 6500 is embarkable in the payload bay of the Space Shuttles in terms of size and weight for the transportation to a Low Earth Orbit (LEO). Secondary boost is needed for interplanetary flight from the LEO. On-orbit assembly of the secondary booster is a technological challenge. The International Space Station (ISS) and ISS-related technologies will facilitate the secondary boost. Also, ice shell drilling is a challenge and is needed before the dive into Europa's ocean. These challenges should be overcome during a certain leading time for matured experience in the ISS operation.
Diving↗
[Microbes on the edge of global biosphere].
The search for life on the edge of global biosphere is a frontier to bridge conventional bio/ecology and exo/astrobiology. This communication reviews the foci of microbiological studies on the inhabitants of the selected "edges", i.e., deep-sea, deep subsurface and Antarctic habitats. The deep-sea is characterized as the no-light (non-photosynthetic) habitat, and the primary production is mostly due to the chemosynthetic autotrophy at the hydrothermal vents and methane-rich seeps. Formation of the chemosynthesis-dependent animal communities in the deep leads to the idea that such communities may be found in "ocean" of the Jovian satellite, Europa. The oxygen minimal layer (OML) in mid-water provides another field of deep-sea research. Modern OML is a relatively thin layer, found between the water depth of 200 and 1000 m, but was much thicker during the periods of oceanic anoxia events (OAEs) in the past. The history of oceanic biosphere is regarded as the cycle of OAE and non-OAE periods, and the remnants of the past OAEs may be seen in the modem OML. Anoxic (no-O2) condition is also characteristic of deep subsurface biosphere. Microorganisms in deep subsurface biosphere exploit every available oxidant, or terminal electron acceptor (TEA), for anaerobic respiration. Sulfate, nitrate, iron (III) and CO2 are the representative TEAs in the deep subsurface. Subsurface of hydrothermal vents, or sub-vent biosphere, may house brine (high salt) habitats and halophilic microorganisms. Some sub-vent halophiles were phylogenetically closely similar to the ones found in the Antarctic habitats which are extremely dry by the liophilizing climate. Below the 3000-4000 m-thick glacier on Antarctica, there have been >70 lakes with liquid water located. One of such sub-glacial lakes, Lake Vostok, has been a target of "life in extreme environments" and is about to be drill-penetrated for microbiological studies. These 'microbiological platforms' will provide new knowledge about the diversity and potential of the Earth's life and facilitate the capability of astrobiologial exploration.
Antarctic Regions↗
[Psycrophilic organisms in snow and ice].
Psychrophilic and psycrotrophic organisms are important in global ecology as a large proportion of our planet is cold. Two-third of sea-water covering more than 70% of Earth is cold deep sea water with temperature around 2 degrees C, and more than 90% of freshwater is in polar ice-sheets and mountain glaciers. Though biological activity in snow and ice had been believed to be extremely limited, various specialized biotic communities were recently discovered at glaciers of various part of the world. The glacier is relatively simple and closed ecosystem with special biotic community containing various psychrophilic and psycrotrophic organisms. Since psychrophilic organisms was discovered in the deep ice-core recovered from the antarctic ice-sheet and a lake beneath it, snow and ice environments in Mars and Europa are attracting a great deal of scientific attention as possible extraterrestrial habitats of life. This paper briefly reviews the results of the studies on ecology of psychrophilic organisms living in snow and ice environments and their physiological and biochemical adaptation to low temperature.
Antarctic Regions↗
Fracture of the radius with instability of the wrist.
Review of 190 consecutive fractures of the distal radius revealed 14 instances of ligamentous carpal instability (7.4%). Instability was more likely to occur in older patients but was not related to the degree of fracture displacement. There was an association between instability and radial styloid fracture, and in five of nine Colles fractures a separate radial styloid fragment was present, suggesting a component of avulsive force. The relatively common coexistence of fracture and instability is not generally appreciated, and the findings of instability often are overlooked.
Humans↗
Free vascularized fibular grafts: radiographic evidence of remodeling and hypertrophy.
OBJECTIVE: A study was undertaken to determine the growth potential and radiographic appearance of a free vascularized fibular graft as it responds to the mechanical and physiologic features of its new environment. MATERIALS AND METHODS: In a 10-year period, 30 patients underwent reconstruction of a large skeletal defect with a vascularized fibular graft. Radiographic studies were adequate for assessing sequential changes in 21 patients. Hypertrophy was evaluated by serial measurements of the periosteal and endosteal dimensions and was assessed with respect to age, sex, duration and location of the graft, the indication for reconstruction, and fixation apparatus. RESULTS: Hypertrophy of vascularized bone grafts is not rare. Among 21 vascularized fibular grafts, a measurable degree of hypertrophy was found in eight. Hypertrophy was caused by periosteal formation of new bone. The amount of hypertrophy could be considerable; in some cases it reached 2 cm of new cortical bone, resulting in an unusual radiographic appearance of marked cortical thickening. The amount of hypertrophy was greatest in young males, but was independent of diagnosis and site, and could be seen even in grafts bridged by metallic plates. CONCLUSION: Hypertrophy of vascularized bone grafts is a relatively frequent finding and has distinctive radiographic features. It is unclear why hypertrophy occurs to a much greater extent in some grafts than in others.
Adolescent↗
Unrecognized dislocation of the medial portion of the triceps: another cause of failed ulnar nerve transposition.
OBJECT: Failed surgical treatment for ulnar neuropathy or neuritis due to dislocation of the ulnar nerve presents diagnostic and therapeutic challenges. The authors of this paper will establish unrecognized dislocation (snapping) of the medial portion of the triceps as a preventable cause of failed ulnar nerve transposition. METHODS: Fifteen patients had persistent, painful snapping at the medial elbow after ulnar nerve transposition, which had been performed for documented ulnar nerve dislocation with or without ulnar neuropathy. The snapping was caused by a previously unrecognized dislocation of the medial portion of triceps over the medial epicondyle. Seven of the 15 patients also had persistent ulnar nerve symptoms. The correct diagnosis of snapping triceps was delayed for an average of 22 months after the initial ulnar nerve transposition. An additional surgical procedure was performed in nine of the 15 cases and, in part, consisted of lateral transposition or excision of the offending snapping medial portion of the triceps. Of the four patients in this group who had persistent neurological symptoms, submuscular transposition was performed in the two with more severe symptoms and treatment of the triceps alone was performed in the two with milder neurological symptoms. Excellent results were achieved in all surgically treated patients. Six patients declined additional surgery and experienced persistent snapping and/or ulnar nerve symptoms. CONCLUSIONS: Failure to recognize that dislocation of both the medial portion of the triceps and the ulnar nerve can exist concurrently may result in persistent snapping, elbow pain, and even ulnar nerve symptoms after a technically successful ulnar nerve transposition.
Adolescent↗
Fractures of the distal humerus.
We present a rational approach to the classification and surgical management of intraarticular fractures of the distal humerus. The fractures are classified on the basis of the surgical anatomy of the distal humerus, which is divided into two skeletal columns held together by the trochlea. The basic surgical aim is to restore all three elements with sufficient stability to permit functional movement. The surgical tactics are presented in detail.
Fracture Fixation, Internal↗
Enchondroma versus chondrosarcoma of the phalanx.
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Aged↗
EURO-EUS 2003: pancreatic tumor: impact of endoscopic ultrasonography on diagnosis, staging and treatment.
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Endosonography↗
Clavicular Nonunion and Malunion: Evaluation and Surgical Management.
Nonunions and malunions of the clavicle are uncommon but can be disabling. Pain, limitation of shoulder mobility, or local compression of the brachial plexus can produce profound functional impairment. Nonunions usually are associated with more severe fractures, open injuries, or failures of operative treatment. Reconstructive procedures are focused on gaining union and restoring clavicular anatomy-most often achieved with plates and screws and autogenous bone graft. Salvage procedures include excision of a bony prominence, partial or total clavicular resection, and resection of the first rib. While most patients with a malunited clavicular fracture are asymptomatic, osteotomy and correction of the deformity should be considered when there is associated functional or neurovascular impairment.
Journal Article↗
Complex Articular Fractures of the Distal Radius: Classification and Management.
Articular fractures of the distal radius require an anatomic reduction, as even minimal step-offs are associated with the development of osteoarthritis. Such fractures are classified on the basis of both the mechanism and the pattern of injury. The comprehensive classification of fractures established by Muller et al defines those occurring from a shearing mechanism and involving part of the articular surface as type B fractures. These are in turn subdivided into group B1 fractures, which involve the radial styloid (chauffeur's fracture); group B2, which involve the dorsal margin of the radius; and group B3, which involve the volar margin of the distal radius (Barton's fracture). Type B fractures are unstable and often require operative intervention. Articular fractures resulting from a compression force on the end of the radius are classified as type C. A group C1 fracture is a two-part fracture without metaphyseal comminution; group C2, a two-part fracture with metaphyseal comminution; group C3, a fracture with more than two pieces, with or without comminution. The operative tactic for compression fractures involves restoration of the four common fragments in sequence. This can often be accomplished by manipulative means alone or with limited exposure of the fracture fragments and stabilization with percutaneous Kirschner wires. Neutralization with an external fixator and use of an autogenous bone graft are often required.
Journal Article↗
Monteggia fractures in children and adults.
The eponymous term "Monteggia fracture" is most precisely used to refer to dislocation of the proximal radioulnar joint in association with a forearm fracture. It is the character of the ulnar fracture, rather than the direction of radial head dislocation, that is useful in determining the optimal treatment of Monteggia fractures in both children and adults. Stable anatomic reduction of the ulnar fracture results in anatomic reduction of the radial head. The notoriously poor results of treatment of Monteggia fractures in adults improved dramatically after the development of modern techniques of plate-and-screw fixation, which facilitate early mobilization by ensuring anatomic reduction. The relatively good results associated with nonoperative treatment of pediatric Monteggia injuries reflect the prevalence of stable (incomplete) fractures in children. Unstable (complete) ulnar fractures are prone to residual or recurrent displacement and may require operative fixation. Late reconstruction of chronic Monteggia lesions in children can be complicated and unpredictable. The key to a good outcome after a Monteggia-type fracture-dislocation of the forearm remains early recognition of proximal radioulnar dissociation.
Adult↗