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PubMed1978

Lung injury following a 50-metre fall into water.

The pulmonary complications of a 50-metre fall to the water (a form of suicide attempt producing 87% mortality) were studied in 15 survivors. Presenting findings included crackles, haemoptysis, and hypotension. The alveolar-arterial oxygen difference was greater than 150 mmHg (20 kPa) in nine subjects on admission. Ventilatory failure developed in 10 of the patients, including all of those with massive haemoptysis. Radiographic findings included pneumothorax and diffuse pulmonary opacities adjacent to the area of impact. Pneumothorax developed within 12 hours of admission in 10 of 15 subjects but was associated with rib fractures in only four subjects. The clinical course of the condition is consistent with the hypothesis that the traumatic pulmonary tears produced interstitial emphysema, with subsequent development of pneumomediastinum, subcutaneous emphysema, and pneumothorax. Pneumothorax is a common complication of severe lung contusion even in the absence of penetrating pleural injury.

Adult↗
PubMed1988

A diagnostic dilemma in Jordan: two child abuse case studies.

Child abuse was diagnosed in two Jordanian children. The first was a 15-month-old female infant admitted with a history of convulsions and loss of consciousness. The child had previous head and limb injuries resulting in bilateral subdural hematomas and fractures at different stages of healing of femur and pelvis. The second was a 3-year-old male admitted with history of head injury due to an alleged fall. Examination revealed fractured ribs, bruised eye and face, hemothorax, subperiosteal and subdural hematomas. Both children have sustained physical and mental handicaps. This is the first report of child abuse in Jordan. In Jordan, as in the rest of the world, a high index of suspicion is needed to diagnose child abuse early enough to save the affected child its serious sequelae.

Battered Child Syndrome↗
PubMed1997

[Anterior spinal fusion by thoracoscopy. A non-traumatic technique].

PURPOSE OF THE STUDY: Video assisted thoracic surgery (VATS) is a new modality which allows visualization of, and access to the intrathoracic organs without thoracotomy. Recently, this technique has been used for anterior thoracic spine approach to perform surgery which previously required standard postero-lateral thoracotomy. The authors report their initial experience of anterior spinal fusion using thoracoscopy and give a detailed description of their surgical procedure. MATERIAL AND METHODS: This technique, started on June 1993, was performed only in one level 1 in 10 patients who had thoracic spine trauma with fracture or luxation. The procedure was performed in the lateral decubitus position. The patient was prepared in the standard manner for a full thoracotomy. Surgical instruments that are needed for conversion to an open procedure must be in the operative room. Ventilation was stopped to the ipsilateral lung. Lung's collapse of the surgical side was obtained with a double lumen tube. Carbon dioxide (CO2) insufflation was used to further collapse. The first thoracoscopic portal was placed through the sixth or seventh intercostal space in the posterior axillary line, which was the safest place. All subsequent portals were placed under thoracoscopic visualization, in a triangular way as recommended by Landreneau (1992). Only open trocars were used to avoid complication of CO2 insufflation. Once the target level has been defined, a needle was placed into the disc space and roentgenographic confirmation obtained. The parietal pleura was then divided using monopolar electrocautery. Segmental vessels of the operation field lied transversely across the midportion of the vertebral body. They were mobilised and systematically ligated with endoscopic clip to simplify the procedure. Then the intervertebral space was opened and bone and disc were removed, restricted to the anterior and middle third. The graft was placed into the thoracic cavity by using a high density calcium hydroxyapatite ceramic block. Peroperative radiologic control ascertained the good position of the implant. At the end of the procedure a chest tube was placed through the lower trocar site and the lung re-expanded. A post operative CT Scan controlled good position of the graft and complete lung expansion. Contra-indications for VATS are previous surgical procedures or empyema causing extensive pleural adhesions. Procedures not appropriate for VATS approach are some that require anterior instrumentation for stabilisation, burst fracture, or fracture with posterior wall involved. RESULTS: The planned procedure was accomplished in all but one patient who required conversion to an open procedure because of segmental artery bleeding. Mean operative time was 1 h 45 mm, and mean estimated blood loss was 650 cc. There was no complication from CO2 insufflation neither postoperative complication. With an average of 2 years follow up, anterior grafting is as good as an open technique, radiologic evaluation according to Uchida (1990) showed good incorporation of each block without any radiolucent line or displacement. DISCUSSION: According to literature this technique was performed safely in 10 cases, especially without any respiratory complications and chronic pain (impairement of pulmonary function, re-expansion failure, incisional complications, rib fractures, chronic pain and malfunction of the chest wall, limitation of shoulder girdle motion) which are considered to be the main disadvantage of traditional thoracotomy. Many authors previously used VATS for multi level thoracic discectomy for correction of spinal deformities (Mack 1995), spinal reconstructive surgery (Mac Afee 1995) or removal of protrude thoracic disc (Rosenthal 1994). CONCLUSION: This original technique demonstrates that thoracoscopy for anterior thoracic surgery is better for the patients, reducing surgical trauma of the chest wall and to the lung parenchyma (in term of post operative comfort, sh

Adult↗
PubMed2001

Metaphyseal fractures mimicking abuse during treatment for clubfoot.

BACKGROUND: Metaphyseal injuries resembling the classic metaphyseal lesion (CML) of abuse may occur as the result of serial casting during treatment of clubfoot deformity. Mentioned in the orthopedic literature in 1972, this iatrogenic fracture has not been described in the radiologic literature nor has the similarity to injuries occurring with abuse been previously recognized. OBJECTIVE: To describe the mechanism and radiographic appearance of metaphyseal injury observed during serial casting of clubfoot. Note similarities to the CML of abuse. MATERIALS AND METHODS: Eight children ranging in age from 1 to 4 months underwent casting for clubfoot. Five orthopedic surgeons from three different institutions performed the casting. Two patients had spina bifida and one, arthrogryposis. A complete skeletal survey was performed on one child who was abused; there was no suspicion of abuse in the remaining seven. RESULTS: All children manifest injury with periosteal new bone. One child had clear evidence of abuse with 24 rib fractures. X-rays of lower extremities in short leg casts revealed bilateral tibial metaphyseal fractures. Four other children had metaphyseal fractures resembling the CML of abuse, and three developed an area of sclerosis within the metaphysis. CONCLUSION: In the setting of serial casting for equinovarus deformity, metaphyseal injury even the CML of abuse may be noted. Since inflicted injuries are almost always unobserved and explanations rarely offered, the fact that the CML occurs as a result of orthopedic maniuplation may offer some further insight concerning the pathogenesis of this well-described abuse injury.

Casts, Surgical↗
PubMed2003

Development of Side Impact Thoracic Injury Criteria and Their Application to the Modified ES-2 Dummy with Rib Extensions (ES-2re).

Forty-two side impact cadaver sled tests were conducted at 24 and 32 km/h impact speeds into rigid and padded walls. The post-mortem human subjects were instrumented with accelerometers on the ribs and spine and chest bands around the thorax and abdomen to characterize their mechanical response during the impact. Load cells at the wall measured the impact force at the level of the thorax, abdomen, pelvis, and lower extremities. The resulting injuries were determined through detailed autopsy and radiography. Rib fractures with or without associated hemo/pneumo thorax or flail chest were the most common injury with severity ranging from AIS=0 to 5. Full and half thorax deflections were computed from the chest band data. The cadaver test data was analyzed using ANOVA and logistic regression. The age of the subject at the time of death had influence on injury outcome while gender and mass of the subject had little or no influence on injury outcome. Existing side impact injury criteria were evaluated such as Thoracic Trauma Index (TTI), Average Spinal Acceleration (ASA), full and half thorax deflections, chest velocity and viscous criterion, and contact force. The analysis results indicate that maximum normalized average half thorax deflection was the best predictor of AIS>/=3 and AIS>/=4 thoracic injury. TTI and upper spine accelerations were also good predictors of thoracic injury. Sixteen side impact sled tests were also conducted with the modified ES-2 dummy with rib extensions (ES-2re) under similar impact conditions as the cadaver tests. The rib extensions were added to the original ES-2 dummy ribs to prevent the "seat grabbing" action of the back plate that was noticed in some side impact vehicle crash tests with the ES-2 dummy. A separate analysis was conducted using the injury response and subject characteristics from the cadaver tests and the physical parameters derived from measurements on the ES-2re dummy in sled tests under similar conditions as the cadaver tests. This analysis provided thoracic injury criteria that could be directly applied to the ES-2re dummy. This analysis indicated subject age to have significant influence on injury outcome. Maximum rib deflection and ASA of the ES-2re were the best predictors of thoracic injury. A 50% risk of AIS>/=3 thoracic injury for a 45 year old corresponds to 44 mm (standard error range: 32 to 54 mm) of ES-2re maximum rib deflection and ASA of 46 gs (standard error range: 34 -58 gs).

Journal Article↗
PubMed1997

Early histologic and ultrastructural changes in microvessels of periosteal callus.

OBJECTIVE: To document early histological and ultrastructural changes in periosteal fracture callus blood vessels. DESIGN: Rabbit control and fractured ribs, after healing for three, six, and twelve hours and daily for seven days, were evaluated by light and electron microscopy. RESULTS: Control periosteal microvessels were formed mainly by endothelial cells and occasionally by pericytes. Only these cells displayed basal lamina within the periosteum. Three to twelve hours postfracture, periosteal microvessels were little changed. By two days postfracture, dramatic increases in size and population of microvessel cells resulted in a smaller lumen and thicker wall. Microvessel cells, while retaining their basal lamina, had transformed to mesenchymal cells. Transformed pericytes, as evidenced by their basal lamina, had extravasated. Three to four days postfracture, additional transformed pericytes had extravasated. Within the distal periosteal callus, a close spatial relationship among transformed microvessels, extravascular mesenchymal cells (some with basal lamina), and osteoblasts was present. Four to five days postfracture, within the proximal periosteal callus, a close spatial relationship among transformed microvessels (rapidly disappearing because of continued extravasation), extravascular mesenchymal cells (some with basal lamina), and chondroblasts (some with basal lamina) was present. CONCLUSIONS: New evidence showed that after fracture, periosteal microvessel endothelial cells and pericytes increased in population and transformed to mesenchymal cells. These changes, their subsequent extravasation as mesenchymal cells, and their development into chondroblasts were verified by basal lamina evidence. New evidence also suggested that continued extravasation of transformed microvessel cells rendered the fracture callus cartilage avascular.

Animals↗
PubMed1993

Radiotherapy alone in breast cancer. Analysis of tumor and lymph node radiation doses and treatment-related complications. The experience of the Gustave-Roussy Institute and the Princess Margaret Hospital.

This retrospective analysis was conducted on breast cancer patients treated by radiotherapy alone at The Princess Margaret Hospital and at the Institut Gustave-Roussy. These patients had either operable tumors, but were unfit for general anesthesia, or had inoperable tumors due to local contraindications to surgery. Previous results showed that a radiation dose increase of 15 Gy can decrease the relative risk of tumor or lymph node recurrence twofold. In this third report, the same data were analyzed to determine the treatment-related complication rates and to correlate these to the radiation dose levels. Overall results were analyzed on 453 patients, but detailed analyses on complications were conducted on 372 patients not developing local recurrence in the first 6 months of follow-up. Each complication was graded on a 3-level previously defined scale. Most frequent complications were skin changes of different degrees, which were usually asymptomatic. More disabling complications were arm edema, impaired shoulder mobility, rib fractures and brachial plexopathy. The incidence of disabling complications was low. The only factor significantly increasing the risk of complications was the radiation dose level to the tumor and axilla. Technical factors such as overlapping fields should also be taken into account. As the more effective control of tumor and lymph nodes obtained in patients treated with higher radiation doses is counterbalanced by an increase in the complication rate, the dose to be delivered for each patient should be carefully chosen according to individual risk factors.

Arm↗
PubMed2006

Percutaneous cement injection into a created cavity for the treatment of vertebral body fracture: preliminary results of a new vertebroplasty technique.

OBJECTIVES: Vertebral body fractures (VBFs) are the most common complication of osteoporosis. Minimally invasive placement of cement to stabilize VBFs results in significant pain reduction and improved performance of daily activities. The authors describe a modified percutaneous vertebroplasty (PV) procedure during which a cavity is created manually in the VBF, allowing the cement to be injected with less resistance. METHODS: Data were gathered from a retrospective chart review from 15 consecutive patients with acute compression VBFs who underwent 33 PV procedures with the Cavity Creation System. Mean follow-up was 30 weeks. Oral opiate intake, quality of life improvement, and visual analog pain scores (VAS) were measured before and 1 month after the procedure. RESULTS: All 15 patients exhibited a reduction in pain VAS (mean reduction 5.9 +/- 2.5). Improvement in quality of life was demonstrated by lower (improved) FACIT scores in the General Activity, Enjoyment of Life, Mood, Normal Work Routine, and Sleep subscales. In addition, opioid use decreased in 10 of the 12 (83%) patients who were taking opioids before surgery. In eight (67%) patients, opioid use decreased by over 50%. Complications included extrusion of cement in two patients (an incidence of 5.7% of the levels operated) and two patients with intraoperative rib fractures. No postoperative neurologic deficits were noted. CONCLUSIONS: The Cavity Creation System is a safe, cost-effective treatment of VBF resulting in good/excellent pain relief and an improved quality of life.

Activities of Daily Living↗
PubMed1996

Extensive extramedullary disease in myeloma. An uncommon variant with features of poor prognosis and dedifferentiation.

BACKGROUND: The development of extramedullary plasmacytomas and elevated serum lactic dehydrogenase (LDH) in myeloma indicates poor prognosis. A 75-year-old man was diagnosed with immunoglobulin (Ig) A, lambda myeloma when he developed pathologic rib fractures, hypercalcemia, and anemia. After 6 months of treatment with melphalan and prednisone, he was in complete remission as evidenced by the disappearance of the monoclonal protein in the serum and free light chain in the urine. Eight months after diagnosis, his disease took an unusual course with the simultaneous development of plasmacytomas in the skin, breast, stomach, and pancreatic head, complicated by severe upper gastrointestinal bleeding and obstructive jaundice. METHODS: Immunohistochemical staining of the marrow and breast mass was done using monoclonal antibodies against B-cell and T-cell antigens as well as kappa and lambda light chains. In situ hybridization was performed to detect ras oncogene overexpression in the breast mass. RESULTS: Immunohistochemical staining of the original marrow and breast mass was positive for IgA and lambda, confirming the identical clonal origin of the plasma cells. The disorder expressed elevated serum LDH, both at diagnosis and relapses. Features of dedifferentiation were expressed by the disappearance of myeloma protein in the serum at relapse, absence of marrow plasma cell infiltration, and development of multiple extramedullary plasmacytomas. There was no overexpression of H-ras or N-ras oncogenes by in situ hybridization of the plasmacytoma from the breast. The patient died shortly after the development of the extramedullary plasmacytomas. CONCLUSIONS: The simultaneous appearance of plasmacytomas in multiple extramedullary sites heralds a change of clinical behavior in myeloma. When accompanied by the disappearance of serum myeloma protein, and marrow plasma cell infiltration, and serum LDH elevation, the disorder may follow a fulminant course.

Aged↗
PubMed1986

Somatosympathetic reflex unilateral sweating and pupillary dilatation in a paraplegic man.

Sympathetic spinal reflex responses to painful stimuli have been studied in experimental animals, but have rarely been demonstrated in human beings. We report the case of a paraplegic man with a high thoracic sensory level to pain, who developed unilateral pupillodilatation and sweating from the head to the midthoracic region as a response to rib fractures below the sensory level. This regional sympathetic reflex response was similar in many ways to that seen in spinally transected animals. Regional sympathetic reflex responses may provide a clinically useful sign of a painful and perhaps dangerous condition which is located below the analgesic level in spinal cord-injured patients.

Adult↗
PubMed2003

Radiation-therapy effects on bone density.

Only limited data are available on the effects of radiation-therapy on the mineral content of the bone of children treated for malignancy. The incidence of osteopenia varies between 8 and 23%, but confounding factors were the use of chemotherapy and the effects of prophylactic cranial irradiation. The factors influencing bone atrophy are no more clearly defined in adults treated for cancer by high dose local radiation-therapy. Pathological observed in patient tissues, indicates a clear role for vascular changes in the development of osteopenia, although there remains some uncertainty as to the effects of osteoblast cell loss. Reduced blood flow in bone is clearly dose-related in experimental animal studies and after single doses of >20 Gy changes in bone mineral content have been found. However, this was only at late times (>/=30 weeks) after irradiation. The relationship between these changes and bone strength remains unproven because of the limited nature of many of the animal studies. Radiation dose fractionation data for rib-fracture in breast cancer patients suggests an alpha/beta ratio is in the range 1.8-2.8 Gy, comparable to values obtained for other late responding normal human tissues.

Bone Density↗
PubMedDate not supplied

Traumatic bronchial injuries in children.

Between 1975 and 1981 five children (three girls and two boys) from 3 to 11 years were treated for blunt chest trauma with major tears in two areas of the right main bronchus. All were hit or run over by motor vehicles and were in acute respiratory distress. All suffered right pneumothoraces; three did not respond to a chest tube with suction. Four of five children had subcutaneous emphysema, and two had fractured ribs on the ipsilateral side; three children also had contralateral chest injuries. Four had major extrathoracic injuries. Three children required early repair, while two needed late treatment. All five patients recovered well and have remained healthy from 5 to 10 years after injury. These cases serve as illustrations for a review of a survey of the literature.

Bronchi↗
PubMed1987

[Differential diagnosis of accident and resuscitation traumas].

The purpose of this paper is to define the criteria for the differential diagnosis of trauma following resuscitation and road accidents. To this end, 311 cases of thoracic and epigastric trauma were selected from the 2893 medico-legal autopsies carried out between 1979 and 1982 at the Institute of Forensic Medicine of the University of Heidelberg. Cardiopulmonary resuscitation had to be considered as the cause of trauma in 140 of these, but 45 of this group were excluded from further evaluation as they had been the victims of blunt trauma and no clear-cut distinction was possible between trauma resulting from an accident and trauma resulting from resuscitation. Thus, we were left with 95 cases of internal injury that presented as emergencies and in whom death followed resuscitation, as a group for comparison with 171 road accident victims who had not received cardiopulmonary resuscitation. Rib fractures, predominantly on the left side, were established in half the cases resuscitated, sternal fractures also being found in one-third of these victims. Bleeding at various sites, including hemato-thorax, was rare, with an incidence of 15%, thus making it highly unlikely that serious traumas caused by resuscitation were a major factor in the cause of death. This paper encompasses an extensive discussion on serious injuries, such as aortic and gastric ruptures, in this connection.

Abdominal Injuries↗
PubMed1984

Combined use of HFPPV with low-rate ventilation in traumatic respiratory insufficiency.

Two patients with chest injuries, flail chest and respiratory failure were mechanically ventilated by a system composed of 2 Bennett respirators and an independent source of gas. This system provides high-frequency positive pressure ventilation (HFPPV), low-frequency conventional mechanical ventilation (LFCMV) and high inspiratory flow of fresh gas (HIF), through the independent source. This system made use of the advantages of HFPPV and also solved the problem of possible CO2 retention. Using this system we could ventilate the patients while they were fully conscious and cooperative, thus eliminating the need for sedatives and muscle relaxants. Time of mechanical ventilation was shortened since the internal pneumatic fixation was very good and made it possible for the fractured ribs to unite rapidly. Restoration of spontaneous breathing was immediate after disconnection from the ventilator. We suggest this method as another mode of ventilation for patients with flail chest and respiratory failure.

Aged↗
PubMed1983

The diagnostic value of bone scintigraphy in patients with low back pain.

Bone scintigraphy has been studied in two groups of patients presenting with low back pain. In one group of 38 patients suffering "nonspecific" back pain, bone scintigraphy and laboratory findings were negative in 24. There were abnormal laboratory findings in all of the remaining 14 and 7 had positive bone scans indicative of clinically significant disease. Selection of patients for bone scintigraphy in this group should therefore be influenced by abnormal laboratory findings and elevation of the erythrocyte sedimentation rate in particular. By comparison, the bone scans were reviewed from another group of patients suffering previously known malignancy. Out of 138 patients, nearly 40% showed a positive bone scan due to subsequently proven metastasis. Bone scintigraphy was positive in a further 14% as a result of osteoporotic rib fracture and vertebral body collapse. In half of these, it was not possible to exclude malignancy by scintigraphy. The present findings indicate that bone scintigraphy is not a useful procedure in patients with long-standing low back pain who have normal radiographs and normal laboratory findings.

Adult↗
PubMed1976

Hypophosphatasia. Review of 24 cases.

Radiographic analysis of 24 cases of hypophosphatasia (H) from 9 Paediatric Centres was performed. 3 cases were of neonatal (lethal), 18 cases of infantile (severe) and 3 cases of late (benign) type. Some of the patients were in reality borderline cases between these groups. In the authors' material all the patients showed radiographic signs of the disease. These were divided into diagnostic, characteristic and suggestive features. All of the patients had in common generalised (usually irregular) osteoporosis, generalised (usually irregular) metaphyseal changes, craniostenosis (13 of 18 infantile cases) or widened cranial sutures and ofter bowing of the long bones. Besides the well know radiographic features of hypophosphatasia some less well known, rare or 'new' ones such as, 1. spurs of the long bones (Bowdler sign), 2. distal femoral central metaphyseal defects and epiphyseal defects, 3. S-like deformities of the tibiae, 4. abnormal shape of the distal phalanges of the fingers, 5. multiple rib fractures and slender bones, 6. wedging of the lower thoracic and upper lumbar vertebrae, 7. partial premature fusion of the epiphyses, 8. nephrocalcinosis, 9. loss of lamina dura around the teeth, 10. variation in radiographic appearances of a pair of siblings with lethal form, and, 11. rapid changes in roentgen appearances. are discussed. In two of our patients (siblings) phosphoethanolamine was undetectable in the urine. The authors doubt if a normal skeletal survey may be present at any stage in any of the three major types of hypophosphatasia.

Adolescent↗