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PubMed1981

Disuse atrophy with resistance to pancuronium.

To determine whether disuse atrophy of skeletal muscle results in resistance to pancuronium, the dose response to pancuronium was determined simultaneously in both gastrocnemius muscles of six dogs that had one hind limb immobilized in a plaster cast for one month. Muscle responses were evoked during pentobarbital-nitrous oxide anesthesia by stimulation of the exposed sciatic nerves, using the train-of-four pattern. Muscle subject to disuse atrophy was resistant to pancuronium. The ED50 (dose of pancuronium which causes a 50 per cent depression of twitch tension) was 0.051 mg/kg for casted and 0.027 mg/kg for uncasted limbs for a potency ratio of 1.89. On the basis of these data the author predicts that bedridden or immobilized patients are likely to require greater doses of nondepolarizing relaxants for paralysis.

Animals↗
PubMed1996

Prolonged d-tubocurarine infusion and/or immobilization cause upregulation of acetylcholine receptors and hyperkalemia to succinylcholine in rats.

BACKGROUND: Hyperkalemic cardiac arrest after the administration of succinylcholine (SCh) to critically ill intensive care patients has been attributed to changes in the acetylcholine receptors (AChRs) at the muscle membrane. The current study attempts to characterize the contributory roles of chronic administration of nondepolarizing muscle relaxants typified by d-tubocurarine (dTC) and/or of immobilization on AChR upregulation and the relationship of these AChR changes to SCh-induced hyperkalemia. METHODS: Rats received chronic subparalytic infusion of saline or dTC for 28 days via subcutaneous osmotic pumps inserted while they were under anesthesia. Approximately half of the saline- or dTC-treated rats underwent bilateral hind-limb immobilization with plaster casts for the same duration as the infusion. After 4 weeks, the osmotic pumps were removed, and 24-48 h later, the blood potassium concentrations were measured at baseline and at 1, 3, 5, 7, and 10 min after SCh (3 mg/kg). At the end of this period, the gastrocnemius muscle was excised for quantitation of AChR number using (125)I-alpha-bungarotoxin. RESULTS: At 28 days, the weight gain in mobile animals receiving saline or dTC infusion did not differ, nor did that in immobilized animals receiving saline or dTC infusion, confirming that infusion of dTC did not unduly affect the ability of the animals to feed. The maximal potassium change after SCh occurred at 5 min. Potassium responses to SCh changed (mean +/- SE): (1) from 3.9 +/- 0.04 to 4.5 +/- 0.1 mEq/1 in the mobile saline- treated control group, where the AChR concentration was 18.4 +/- 2 fmol/mg protein; (2) from 3.9 +/- 0.03 to 5.1 +/- 0.1 in the mobile dTC-infused group (AChRs = 48.6 +/- 7); (3) from 3.8 +/- 0.1 to 5.5 +/- 0.3 in the immobilized saline- treated group (AChRs = 107.4 +/- 14); and (4) from 3.8 +/- 0.1 to 6.3 +/- 0.2 in the immobilized-dTC-treated group (AChRs = 183.5 +/- 23). There was a significant positive correlation between maximal change in blood potassium concentration and the respective AChR concentration in the gastrocnemius of the same animal (r = 0.81, P<0.01). CONCLUSIONS: Subtherapeutic (subparalytic) doses of chronic infusion of dTC (with no immobilization) or immobilization alone (with no dTC) independently increased number of AChRs. The infusion of dTC with immobilization caused the greatest upregulation of AChRs. The magnitude of the increase in blood potassium to SCh was directly dependent on AChR number. This study shows direct evidence and confirms previous speculation that AChR number plays an important role in the magnitude of the hyperkalemic response to SCh. Presuming this represents an appropriate model for patients who are immobilized and/or receiving nondepolarizing muscle relaxants for prolonged periods, exaggerated blood potassium responses to SCh are possible when either or both of these perturbations are present in patients.

Animals↗
PubMed1979

Influence of cleft palate closure by osteotomy technique on growth of the dentomaxillary complex in human beings.

Properly done, osteotomy cleft palate closure in human beings reproduces a normal dentomaxillary complex in patients with an incomplete cleft palate and in those with a narrow unilateral complete lip and palate cleft. In wider complete clefts, the dentomaxillary complex is influenced by the constrictive action of the lip muscle during closure rather than by the osteotomy procedure. Plaster casts of osteotomy surgical cases late postoperatively demonstrate the normal growth pattern achieved. Variations in cleft palate osteotomy have been worked out for every type of cleft palate.

Child, Preschool↗
PubMed1992

A simple splinting device for skin grafts of the penis.

A simple method to ensure penile skin graft immobilization and easy accessibility is presented. The method uses a hollow cylinder made of plaster-cast material applied to the pubis around the penis, to which the long tails of the skin graft threads are fixed. The method is inexpensive, simple to use, and comfortable both for patients and for the nursing staff.

Bandages↗
PubMed2004

Development of a new three-dimensional cranial imaging system.

The development of a new three-dimensional (3D) imaging system designed to obtain a digital image of an infant's cranium is described. This system is intended to replace the manual plaster-casting technique currently used during the process of fabricating cranial remodeling bands. The system uses 18 triangulated digital cameras and the projection of random infrared patterns to capture a 360 degrees image of an infant's cranium instantaneously, including the face and top of the head. Accuracy was calculated by comparing models digitized with this system with the same models digitized with high-precision inspection equipment. Safety was documented under guidelines established by the American Council of Governmental Industrial Hygienists. Images were acquired in 0.008 seconds and processed for viewing in software within 2.5 minutes. Accuracy was calculated to be +/-0.236 mm. Hazard analysis confirmed the system to be safe for direct continuous exposure. The data acquired may be viewed as a point cloud, wire frame, or surface on which a digital photograph (ie, texture) is automatically overlaid. Physical models are created by exporting the digital data to a multiaxis milling machine or stereolithography machine. Quantitative data (linear and surface measurements, curvature, and volumes) can be obtained directly from the digital data. The cranial imaging system is a safe and accurate method of obtaining digital 3D images of an infant's cranium. Along with the obvious clinical and manufacturing benefits, it also has significant potential as a research tool for documenting the natural history and evaluating the treatment of plagiocephaly.

Cephalometry↗
PubMed1992

Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation.

Odontoid fractures, especially unstable type II fractures have a poor prognosis in respect to healing. Therefore, operative stabilization (posterior fusion C1/2 or anterior screw fixation) has been suggested for the treatment of unstable type II and for some unstable type III fractures. Compared to posterior fusion C1/2, anterior screw fixation has proven to be effective; it has the advantage of leaving the motion segment C1/2 intact, therefore preserving at least some C1/2 rotation. However, in some instances, this method of stabilization is not indicated. In these cases, posterior fusion C1/2 is the treatment of choice. Primary posterior fusion C1/2 is indicated in (a) odontoid fracture associated with comminution of one or both atlanto-axial joints; (b) fracture of the odontoid associated with an unstable Jefferson fracture; (c) unstable type III odontoid fracture, when immobilization in a halo jacket or plaster cast is not suitable, as in elderly people or polytraumatized patients; (d) atypical type II fractures (comminuted or with oblique fracture in the frontal plane); (e) irreducible fracture dislocation C1/2, e.g., several-weeks-old fracture; (f) unstable type II or shallow and unstable type III odontoid fracture, when marked thoracic kyphosis is associated with limited extension of the cervical spine; (g) unstable type II or shallow type III odontoid fracture in elderly people with degenerative narrow spinal canal; (h) pathologic fracture of the odontoid. In all these instances, posterior fusion C1/2 is the treatment of choice. We prefer the transarticular screw fixation technique. Compared to other posterior fusion techniques, it has the advantage of increased stability and allows effective stabilization of C1/2 in a reduced position as well as immediate ambulation with minimal head support. This technique can also be performed when the posterior arch of the atlas is fractured or absent. Our experience of 12 acute odontoid fractures, managed by this technique, is presented. At follow-up, all C1/2 fusions were united in reduced position.

Adult↗
PubMed1975

Minimal internal fixation of tibial fractures.

Flexible wire and small pins cause minimal disturbance of osseous blood supply, and introduce minimal foreign material into the wound. Supplemental support by a plaster cast or by traction is required, but the external support can generally be discontinued early for joint mobilization. Several simple auxillary fixation devices extend the usefulness of wire fixation. Removal of metal is not required. Many common fractures of the tibia are amenable to this method of minimal internal fixation. In the diaphysis, long oblique fractures are the most suitable for this application; the firmness of their fixation by cerclage is augmented by muscle pull. Rotation is effectively controlled by a plate which is L-shaped in cross section, and is held in position by cerclage. In the metaphysis, articular fractures of the knee and ankle are securely fixed by a flattened loop of wire and two washers (wire-washer set), supplemented sometimes by pins or hand-made staples. Two pins alone provide excellent fixation of the medial malleolus. A single pin, or a single wire loop through drill holes, may be sufficient to impart stability to an unstable tibial fracture. A key-type graft of iliac bone, maintained by crossed wire loops through cortical drill holes, is effective in the tibial diaphysis. Autogenous iliac cancellous chips provide minimal and effective internal fixation for an infected ununited fracture of the tibia. The surgical instrument most important for making wire fixation highly successful is a tightener-twister which protects wire loops from excessive strain during application, and permits twisting at a predetermined and therefore reproducible tension. Other special and ordinary instruments are valuable assets.

Adult↗
PubMedDate not supplied

Clinical and radiographic appearance of congenital talipes equinovarus after successful nonoperative treatment.

Thirty-one children with 49 feet after successful nonoperative treatment for congenital talipes equinovarus (CTEV) by redressements, hypoallergic adhesive bands, and plaster casts underwent follow-up. At the follow-up, the patients ranged in age from 4.2 years to 12.3 years (average, 8.3 years). The initial type of the deformity was as follows: type I (mild), 18 feet; type II (intermediate), 29 feet; type III (severe), two feet. Mild supination of the forefoot in five feet, isolated excavation in three, and adduction greater than physiological in two feet were the only persistent elements of the deformity. The lack or restriction of the dorsal flexion in the ankle were noted in 22 feet. In only three feet was the Beatson-Pearson index was < 40 degrees. In 17 feet, the radiographs revealed full talonavicular reduction in sagittal and horizontal planes. The average value of the talometatarsal first and tibiocalcaneal angles as in accordance with the standard. The most characteristic osseous disturbances concerned the tarsal navicular (22 feet) and consisted of the decrease of the ossification center, its flattening, fragmentation, cystic-like changes, and wedging.

Casts, Surgical↗
PubMedDate not supplied

Bleeding complications following percutaneous tendoachilles tenotomy in the treatment of clubfoot deformity.

Ponseti demonstrated correction of most clubfeet in infants using proper manipulative techniques followed by application of well-molded long-leg plaster casts and a percutaneous tendoachilles tenotomy to correct residual equinus contracture. Medical complications occurring as a result of this technique have not to our knowledge been reported. The authors retrospectively reviewed 134 consecutive infants with 219 idiopathic clubfeet treated with the Ponseti method. A percutaneous tendoachilles tenotomy was performed on 200 clubfeet (91%) at a mean age of 16 weeks (range, 6-77 weeks) when less than 10 degress of ankle dorsiflexion was present after casting. A total of 4 patients had serious bleeding complications following the percutaneous tendoachillis tenotomy--3 due to presumed injury to the peroneal artery and 1 due to injury to the lesser saphenous vein. The authors detail the technique of performing a percutaneous tendoachilles tenotomy and offer guidelines that may help others avoid this same complication.

Achilles Tendon↗
PubMed1989

Occult scaphoid fracture: a diagnostic enigma.

In a prospective study, 38 patients with so-called "wrist sprains" and a clinical nonradiological diagnosis of scaphoid fracture were immobilized in a plaster cast for 2 weeks. At 2 weeks, six patients were found to have a complete fracture of the scaphoid through the waist. In view of this high incidence (15.8%) of occult scaphoid fracture, it is once again suggested that all cases of wrist sprains where scaphoid fracture is suspected be immobilized for a 2-week period.

Adult↗
PubMed1992

Self-reinforced absorbable screws in the fixation of displaced ankle fractures: a prospective clinical study of 152 patients.

The series consisted of 152 patients with ankle fractures treated between May 1987 and August 1989 using absorbable screws of self-reinforced polyglycolide 3.4 mm in inner diameter and 25-70 mm in length. The mean follow-up time was 2 years, 5 months (range, 1 year, 7 months-3 years, 10 months). After open reduction, a channel was drilled through the fracture surfaces and the fragments were fixed with one absorbable screw or screws. A plaster cast was used postoperatively. At 1-year follow-up observation, the radiographical result was anatomical in 93.3% of 104 patients with unimalleolar and bimalleolar ankle fractures (Weber A or B) and in 80.5% of 41 severe ankle fractures. Seven patients were unavailable for follow-up observation. Two reoperations were performed because of primary or secondary failure of fixation. In all unimalleolar and bimalleolar fractures and in 95.1% of severe ankle fractures the functional recovery score was at least satisfactory. Sinus formation as a sign of tissue reaction was observed in 10 patients 2-6 months postoperatively, but this did not influence the healing of the fracture or the functional recovery. This report is the first extensive publication on the clinical use of absorbable screws.

Activities of Daily Living↗
PubMedDate not supplied

Effects of limb elevation on abnormally increased intramuscular pressure, blood perfusion pressure, and foot sensation: an experimental study in humans.

OBJECTIVES: To study the effects of limb elevation on abnormally increased intramuscular pressure (IMP) and blood perfusion pressure in the anterior compartment of the leg. DESIGN: An experimental cross-over design. The test leg was elevated and the control leg was kept at heart level. PARTICIPANTS: Eight healthy subjects with a mean age of twenty-nine years. INTERVENTION: IMP was measured in the anterior compartment of the leg, and blood pressures were taken in the left arm and both legs. Four variables were recorded (with or without venous stasis, with or without plaster cast). All measurements were made simultaneously in both legs. RESULTS: When the leg was obstructed by venous stasis and elevated to between thirty-three and thirty-five centimeters, IMP decreased from 16.5 to 9.8 millimeters of mercury. When venous stasis was simulated in a level casted leg, the IMP was thirty-eight (SD = 6.4) millimeters of mercury but showed only a slight decline to thirty-five (SD = 7.8) millimeters of mercury after the leg was elevated. Blood perfusion pressure fell significantly once the leg was elevated, decreasing 53 percent from forty-seven (SD = 7.8) to twenty-five (SD = 8.0) millimeters of mercury (p < 0.001). All subjects experienced loss of foot sensation in the elevated limb. CONCLUSION: In those cases in which venous stasis increased IMP levels in the anterior compartment of the leg, elevating the limb produced a 40 percent reduction in IMP. However, limb elevation did not significantly reduce increased IMP levels when the venous stasis occurred in a casted leg. Therefore, we believe casted legs in which abnormally increased IMP is attributable to venous stasis should not be elevated above heart level because elevation induces low perfusion pressure and sensory dysfunction.

Adult↗
PubMedDate not supplied

Capacitively coupled electrical stimulation treatment: results from patients with failed long bone fracture unions.

OBJECTIVE: To determine the extent to which capacitively coupled electrical stimulation (CCEST) at a long bone fracture site can promote healing of nonunited fractures. DESIGN: Sixteen patients with nonunited fractures of nine to seventy-six months were treated with CCEST. Thirteen patients had previously undergone one or more surgical procedures, and the other three had been given plaster casts. A sixty-three-kilohertz, six-volt peak-to-peak sine wave signal was applied across two forty-millimeter-diameter stainless steel plates placed on the skin at opposite sides of the fracture site. The device was used for up to thirty weeks until either healing occurred or it was removed after this period and considered to have failed. RESULTS: Eleven of the nonunions achieved union at an average of fifteen weeks of stimulation. The only significant factor determining the success of healing was the distance between the plates; a distance of eighty millimeters or less resulted in healing in all cases. Healing was not affected significantly by any of the following factors: whether or not the nonunion had been treated surgically prior to stimulation, whether or not it had been infected, whether or not the patient bore weight after treatment, or by the presence or absence of metal at the fracture site from previous surgery. CONCLUSIONS: These findings confirm those of previous studies that CCEST promotes bone healing of fracture nonunions. The dependence of healing on the interplate distance suggests that maintaining sufficient current across the plates is necessary to allow healing, which for larger bones may be achieved by increasing the area of the plates, the applied voltage, or the excitation frequency of the stimulation signal.

Adolescent↗
PubMed2003

Combined Monteggia and Galeazzi fractures in a child: a case report and review of the literature.

We present an unusual case in which a combination of Monteggia and Galeazzi fractures occurred in the same forearm. The patient was a 10-year-old male who climbed up the pole of a basketball net, caught hold of the net, then lost his grip, and fell onto his right hand. On physical examination, a complete paralysis of the radial ulnar and median nerves was recognized. X-rays showed an olecranon fracture and lateral dislocation of the radial head in the elbow joint, a dorsal dislocation of the distal bone fragments due to a fracture of the distal third of the radius, and a palmar dislocation of the distal end of the ulna at the wrist joint. The injuries were diagnosed as a combination of a Bado type III Monteggia fracture and a palmar-type Galeazzi fracture of the same arm. Manual reduction and immobilization in a plaster cast were performed. Three years after the injury, both the distal and proximal radioulnar joints were maintained in the reduction position. Range of motion was reduced minimally in extension at the patient's elbow, and there was complete recovery of all three nerves. A combination of Monteggia and Galeazzi fractures in the same arm has been reported in only two pediatric patients worldwide and in eight cases total when adult patients are included, indicating that this is an extremely rare trauma.

Child↗
PubMed2003

Physeal fractures of the distal radius and ulna: long-term prognosis.

OBJECTIVES: The long-term prognosis of injuries to the distal physis of forearm bones, including complications such as radioulnar length discrepancy and styloid nonunion, has not been extensively studied. Reliable radiographic prognostic criteria to predict physeal disturbance at trauma are also lacking. The aim of this study is to investigate both issues. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS/PARTICIPANTS: One hundred sixty-three lesions to the distal physis of the forearm bones in 157 patients were available for a long-term follow-up. Seventy-seven injuries of the distal radial physis were radiographically isolated, 54 were associated with a fracture of the ulnar styloid, and 26 with a fracture of the distal ulnar metaphysis. Of the six injuries of the distal ulnar physis, five were associated with a fracture of the distal radial metaphysis, and one was an isolated injury of the distal ulnar physis. INTERVENTION: Treatment consisted of wrist immobilization in a long-arm plaster cast for 6 weeks. Dorsal or volar displacement was reduced using general anesthesia. MAIN OUTCOME MEASUREMENTS: All patients had both clinical and radiographic evaluation, with an average follow-up of 25.5 years (range 14-46 years). The average age of the patients at injury was 11.6 years (range 5-17 years), whereas their average age at follow-up was 35.5 years (range 22-56 years). Both the Salter and Harris and the Ogden classifications were used to classify physeal injuries. RESULTS: According to Salter and Harris, of the 157 radial lesions, 18 were type 1 and 139 type 2. According to Ogden, 14 were type 1A, 4 type 1C, 84 type 2A, 13 type 2B, 17 type 2C, and 25 type 2D. Of the 6 ulnar lesions, 2 were Salter and Harris type 1 (Ogden type 1A), 3 type 2 (Ogden type 2A), and 1 type 4 (Ogden type 4A). Fifty-four radiographically evident fractures of the ulnar styloid associated with injuries of the distal radial physis were classified as Ogden type 7A. At follow-up, all of our patients were fully asymptomatic, except for those who had forearm bone growth failure of more than 1 cm. Shortening of the previously injured forearm bones ranging from 1 to 6.5 cm was observed in 2 open and subsequently infected lesions as well as in 5 uncomplicated lesions of the 157 distal radial physeal injuries (4.4%), and in 3 of the 6 distal ulnar physeal injuries (50%). Shortening of 1 cm or more was observed in the uncomplicated lesions of radial physeal injury with Ogden type 1C, 2B, and 2D lesions, and in ulnar physeal injuries Ogden type 1A, 2A, and 4A. Thirty-eight additional patients had radioulnar length discrepancy that ranged from 2 to 9 mm, and 53 patients had styloid nonunion, but all of them were asymptomatic. CONCLUSIONS: None of the patients reviewed at follow-up, including those with radioulnar length discrepancy of less than 1 cm and those with styloid nonunion, complained of any symptom related to their previous injury, not even those engaged in heavy manual labor. Of the 10 patients with either radial or ulnar shortening of more than 1 cm, only 2 with radial growth arrest and marked radioulnar length discrepancy had severe functional problems. Growth disturbances of more than 1 cm following distal radial physeal injury occurred only in Ogden type 1C, 2B, and 2D lesions, whereas in distal ulnar physeal injuries, growth disturbances occurred regardless of the Ogden classification type.

Adolescent↗
PubMed1975

The tibial shaft fracture.

Two large series of civilian-incurred (212) and combat-incurred (228) tibial shaft fractures are compared. Closed tibial fractures were treated by closed manipulation and weight bearing ambulation in a long leg plaster cast. Open injuries following wound exploration and debridement were treated similarly with wound closure. Combat-incurred tibial shaft fractures responded similarly to civilian-incurred injuries. Allowing an open fracture to heal with exposed bone at the fracture site resulted in an average time to removal of external immobilization only two weeks greater than for the uncomplicated tibial fracture. Whether weight bearing ambulation was instituted immediately (24-48 hr) or early (3-4 wk) did not shorten the time to removal of external immobilization. The infection rate in 289 open tibial fractures (228 combat-incurred and 61 civilian-incurred) was 3.8%, and all infections occurred in the open penetrating injuries.

Amputation, Surgical↗
PubMed1977

Fractures of the femoral neck in childhood. Results of conservative treatment.

Experience with nine patients with fracture of the femoral neck in childhood, eight of whom were treated conservatively by closed reduction and fixation with a plaster cast, and one in whom Steinmann pins and open reposition had to be employed to accomplish fixation, is presented in brief. In six children the results were evaluated as good and in three (including the one case of open reduction) as fair. No serious complications were observed. The problem of nonsurgical versus surgical approach is discussed in the light of the relevant literature. It is suggested that while there can be no set rule as to which treatment should be used, conservative management yields results which are comparable with those attained with a more aggressive approach.

Adolescent↗
PubMed1981

Percutaneous pinning of distal radius fractures.

Reduction of distal radius fractures is often difficult to maintain with plaster casting alone. Achieving this goal with an easily executed technique which carries a low morbidity is desirable, especially in multiply injured patients. Between July 1977 and September 1980, 24 high-energy fractures of the distal radius in 22 patients were treated by percutaneous pinning of the radial styloid fragment to the opposite radial cortex. Roentgenograms at the time of pinning and 8 weeks or more in followup demonstrating healing were available in 20 patients (22 fractures). Using a previously described method of roentgenographic grading, these cases were evaluated. At followup five fractures were felt to anatomically excellent, 16 good, and one poor. Five fractures in review were felt to be not ideally pinned and these represented three of the five fractures that lost a grade of evaluation rating during healing. One superficial pin tract infection developed and two patients complained of local pin discomfort. These complications resolved with pin removal. If guidelines for pinning are followed properly, percutaneous pinning provides a simple and useful method for maintaining reduction in unstable distal radius fractures in multiply injured patients.

Adolescent↗