Reduction of displaced supracondylar fracture of the humerus in children by manipulation in flexion

Sixty-one children with posteriourly displaced supracondylar fractures of the humerus were treated by minipulation with the elbow flexed 40 degrees-60 degrees. This method proved to be safe, easy to apply and was followed by a high rate of success. The elbow was immobilized using a collar-and-cuff or a broad sling and binding of the arm to the forearm with zinc oxide adhesive plaster. In difficult children, the limb was put under the child's clothing to avoid its being used. Redisplacement occurred in only 8.2 per cent of the patients and in none of these was it severe enough to justify remanipulation.     

Reduction of Displaced Supracondylar Fracture of the Humerus in Children by Manipulation in Flexion

Sixty-one children with posteriorly displaced supracondylar fractures of the humerus were treated by manipulation with the elbow flexed 40°-60°. This method proved to be safe, easy to apply and was followed by a high rate of success. The elbow was immobilized using a collar-and-cuff or a broad sling and binding of the arm to the forearm with zinc oxide adhesive plaster. In difficult children, the limb was put under the child's clothing to avoid its being used. Redisplacement occurred in only 8.2 per cent of the patients and in none of these was it severe enough to justify remanipulation.     

Correlation of fetal posture and congenital dislocation of the hip

A statistical study was carried out on the incidence of CDH associated with mechanical factors in the uterus, including congenital genu recurvatum. There were 72 cases of CDH among 6559 infants (1.1 per cent). The incidence of CDH was 0.7 per cent in cephalic presentation, 2 per cent in footling presentation and 20 per cent in single-breech presentation. In another series, CDH was found in six of seven infants with congenital genu recurvatum. These findings suggest that a fetal posture with the hip flexed and the knee extended predisposes to the development of CDH.     

Regulation of Proprioceptive Memory by Subarachnoid Regional Anesthesia

Background: Patient perception of limb position during regional anesthesia is frequently incorrect. The existing model ascribes this misperception, or phantom sensation, as a reversion to a fixed, slightly flexed, body schema. A model was developed to evaluate the influence of limb position changes on the incidence of incorrect or phantom sensations during regional anesthesia.

Methods: Forty American Society of Anesthesiologists physical status I-III adult patients undergoing genitourinary procedures under subarachnoid anesthesia were assigned to a lidocaine or bupivacaine treatment group and randomly assigned to one of four time groups (1, 4, 7, and 10 min). After blockade, patients were placed supine and blinded to limb positioning manipulations. One leg was flexed and the contralateral leg extended, with leg positions subsequently reversed at the assigned time point. At 10 min, patients were asked to identify the position of each leg. Percentage of incorrect response was analyzed using a logistic regression model with two independent variables: treatment and time. A supplemental study was undertaken to evaluate the observed difference in incorrect perceptions relative to flexed first versus extended limb first sequencing.

Results: The inability to perceive a change in limb position under regional anesthesia is dependent on the time after the block that the position change is initiated in relation to the onset characteristics of the local anesthetic. A phantom sensation of an extended leg position clearly exists. The flexed-first limb has a significantly higher incidence of incorrect or phantom perceptions.     

The assessment of the ulnar nerve at the elbow by ultrasonography in children

We evaluated the morphological changes to the ulnar nerve of both elbows in the cubital tunnel by sonography in a total of 237 children, of whom 117 were aged between six and seven years, 66 between eight and nine years, and 54 between ten and 11 years. We first scanned longitudinally in the extended elbow and then transversely at the medial epicondyle with the elbow extended to 0 degrees . We repeated the scans with the elbow flexed at 45 degrees , 90 degrees , and 120 degrees . There were no significant differences in the area of the ulnar nerve, but the diameter increased as the elbow moved from extension to flexion in all groups. More importantly, the ulnar nerve was subluxated anteriorly on to the medial epicondyle by 1.5% to 1.9% in extended elbows, by 5.9% to 7.9% in those flexed to 45 degrees , by 40.0% to 44% in those flexed to 90 degrees , and by 57.4% to 58.1% in those flexed to 120 degrees , depending on the age group. Sonography clearly and accurately showed the ulnar nerve and was useful for localising the nerve before placing a medial pin. Because the ulnar nerve may translate anteriorly onto the medial epicondyle when the elbow is flexed to 90 degrees or more, it should never be overlooked during percutaneous medial pinning.     

不同上肢体位对正常人和青少年特发性脊柱侧凸患者站立位脊柱矢状面形态的影响

目的 探讨不同上肢体位时,脊柱侧位片上脊柱区域和整体的形态变化,并确定上肢何种体位能更正确地反映脊柱的矢状位形态.方法 研究对象包括特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)胸弯患者21例和正常青少年志愿者13名.均摄站立位脊柱全长正位X线片及上肢平举及上肢抱胸两种体位的侧位X线片.侧位X线片上测量的参数指标包括:(1)线性距离指标.T1与C-铅垂线(C7 plumb line,C7PL)的距离、胸椎后凸顶点与C7PL的距离、L1与C7PL的距离、腰椎前凸顶点与C7PL的距离、骶骨后上缘与C7PL的距离(SVA);(2)区域前凸及后凸角度的指标.T2～5、T5～12、T10～L2、T1～12、L1～S1、上胸椎后凸(T1上缘与水平线的夹角)、下胸椎后凸(T12下缘与水平线的夹角)、上腰椎前凸(L1上缘与水平线的夹角)、下腰椎前凸(S1上缘与水平线的夹角);(3)骨盆的形态参数:骨盆倾斜角(pelvic tilt,PT)、骶骨倾斜角(sacral slope,SS)、骨盆投射角(pelvic incidence,PI).分别对AIS组及正常组就不同上肢体位时参数的测量结果进行配对t检验.结果 当上肢平举时,AIS组及正常组的腰椎前凸顶点与C7PL的距离、SVA及上胸椎后凸角度均小于上肢抱胸时的测量结果,下胸椎后凸角度及上腰椎前凸角度大于上肢抱胸时的测量结果;另外当上肢平举时,AIS组的腰椎前凸(L1-S1)较上肢抱胸时增大,胸椎后凸顶点与C7PL的距离、L1与C7PL的距离较上肢抱胸减小.结论 双上肢抱胸体位可以更好地反映生理状况下脊柱的矢状面形态.     

Haemodynamic effects of the position chosen for the insertion of an epidural catheter

An epidural catheter may be inserted with the patient either in the flexed left lateral or the sitting position. We have studied, non-invasively, the haemodynamic changes associated with these positions, using the thoracic bio-impedance method (BOMED NCCOM3 Monitor). Maternal arterial pressure and fetal heart rate were monitored simultaneously. Twenty healthy pregnant patients at term and 20 non-pregnant healthy controls, matched for age and height, were studied. The pregnant patients were scheduled for elective caesarean section and had singleton healthy fetuses. A significant reduction in stroke index (SI) occurred when the pregnant patients were repositioned from supine 15degrees wedged position to either flexed left lateral (P < 0.01) or sitting positions (P < 0.05). Similar reductions in SI with positioning were observed in the non-pregnant patients: flexed left lateral (P < 0.01); and sitting (P < 0.01). These changes in SI produced significant reductions in cardiac index (CI) in both groups. In the pregnant patients the CI was significantly lower in the flexed left lateral than in the sitting position (P < 0.01). Consequently maternal systolic blood pressure was lower in the flexed left lateral position (P < 0.01).     

The effect of increasing degrees of spinal flexion on cerebrospinal fluid pressure

The effects of increasing degrees of flexion on cerebrospinal fluid pressure were investigated in 12 neurosurgical patients requiring lumbar subarachnoid drains. Cerebrospinal fluid pressure and central venous pressure were measured in three positions: fully flexed ('chin on chest'), flexed at ninety degrees and straight. There was a significant increase in cerebrospinal fluid pressure on moving from the fully flexed to the flexed position (p < 0.0001), but not from the flexed to the straight position. These results were mirrored by smaller changes in central venous pressure. In patients without intracranial pathology these increases in cerebrospinal fluid pressure are probably unimportant. However, intracranial pathology may result in low cerebral perfusion pressures and any increase in cerebrospinal fluid pressure in this group may be harmful. The fully flexed position should be avoided when inserting lumbar drains in at risk patients.     

The effect of posture on the fluid content of lumbar intervertebral discs

Cadaveric lumbar motion segments were creep loaded for 4 hours, and the fluid content of the intervertebral discs was measured and compared with that of unloaded discs. Half of the specimens were wedged to simulate sitting with the lumbar spine flexed, and the other half were wedged to simulate sitting or standing erect. The results showed that "flexed" discs lost more fluid, especially from the nucleus pulposus, than did the "erect" discs. It is concluded that fluid flow in flexed postures can aid the nutrition of the lumbar discs.     

Quantitative studies of the flexion-relaxation phenomenon in the back muscles

In quiet standing positions involving substantial trunk flexion, myoelectric activity in the back muscles diminishes to low levels. Aspects of that "flexion-relaxation" phenomenon were explored through measurements of myoelectric activities in 11 young men during performance of 19 isometric tasks in flexed positions. Biomechanical model analyses were used to predict the internal loads imposed on the lumbar trunk structures during those performances. Flexion-relaxation consistently occurred in quiet flexed standing, but marked increases in myoelectric activity were found on imposition of external loads in flexed positions. Increases in myoelectric activity per unit increase in back muscle contraction force increase were nearly the same as those found in upright postures. Whether or not flexion-relaxation occurs, large trunk flexions load the spine heavily.     

Evaluation of Sun-Protective Practices of Organ Transplant Recipients

The incidence, morbidity and mortality of skin cancer are markedly increased in organ transplant recipients. Efforts aimed at reducing sun exposure through sun avoidance, sunscreens and sun-protective clothing are the most effective means to reduce the risk of skin cancer. We evaluated the sun-protective behaviors of 205 transplant recipients. Twenty-three percent of transplant patients continued to seek a tan. Thirty percent of patients did not use sunscreens, and of those patients who did, less than 5% were committed to using them daily. Thirty-seven percent of patients frequently wore hats and 39% of patients frequently wore additional clothing to block the sun. When data were stratified according to patient age, gender or skin phototype, we identified preferences for specific sun-protective methods. These data strongly suggest that many transplant recipients do not use adequate sun protection. Further study of strategies to encourage the use of sun protection among transplant patients is needed to reduce the incidence of skin cancer.     

Radiologic evaluation of the ulnar styloid.

The ulnar styloid (US) architecture was examined radiologically and directly by dissection in 13 cadaver wrists to examine a potential relationship between US shape and US abutment syndrome and to determine an optimal radiographic view that could be used to detect US fractures. A higher incidence of US abutment syndrome in the radially deviated US type was observed by dissection. Radiographs taken at varying shoulder abduction angles suggested that the base of the US and ulnar head are not round. To best evaluate the fovea and the US for possible US fractures, radiographs should be taken with the glenohumeral joint abducted 45 degrees, the elbow flexed 90 degrees, the forearm in neutral rotation, and the x-ray beam directed through the wrist perpendicular to the floor.     

Lumbar interspinous pressure pain threshold values for healthy young men and women and the effect of prolonged fully flexed lumbar sitting posture:An observational study

BACKGROUND Low back pain(LBP) is a common condition with large burden worldwide.Exposure to prolonged sitting with a flexed lumbar posture has been suggested in the literature to be a potential risk factor for self-reported LBP.No study has previously investigated whether exposure to prolonged flexed sitting posture provokes discomfort/pain and decreased interspinous pressure pain thresholds for healthy young men and women without back pain,despite this being a suggested risk factor for LBP.AIM To investigate whether sitting in a prolonged flexed lumbar posture provokes discomfort and lowers interspinous pressure pain thresholds in the lumbar spine for healthy young men and women without previous LBP.METHODS This is a an observational before and after study of 26 participants(13 men,13 women) between 20-35 years old.Algometry was used to examine the pain threshold for pressure applied between spinous processes of the lumbar spine L1-L5.Pressure algometer measures were performed in prone before and after participants were instructed to sit in a fully flexed posture for a maximum of 15 min or until discomfort was experienced in the low back(Borg CR10 = 7/10).Wilcoxon signed-rank test was used for analyze values from the before and after test conditions.Mann-Whitney U test was used to investigate potential gender difference.RESULTS Fully flexed lumbar spine sitting posture up to 15 min provoked temporary discomfort but the proportion of participants experiencing discomfort 7/10 in the low back was 62%.For all pain pressure threshold locations tested,there was a significant difference for the study population with moderate-large decreased(r =-0.56) pressure pain threshold after exposure to prolonged flexed sitting posture(P 0.01).Comparisons between gender did not show any significant difference.CONCLUSION The result showed that exposure to fully flexed lumbar sitting posture for up to15 min produced temporary discomfort in the low back in young healthy adults with no previous history of LBP and significantly reduced lumbar interspinous pressure pain thresholds.No gender-based differences were observed.     

Differential splintage for flexor tendon rehabilitation: an experimental study of its effect on finger flexion strength

We conducted laboratory tests to investigate the possibility of partly de-powering flexor digitorum profundus with a view of reducing flexion force during active flexor tendon rehabilitation. We constructed a splint and applied tapes to the proximal segments of fingers to test the hypothesis that holding three fingers more extended than the other finger would reduce the flexion strength of the more flexed finger. The splint allowed the metacarpophalangeal joint of the more flexed finger to be held in three positions of increasing flexion (15 degrees , 30 degrees , and 45 degrees ) compared to the remaining three fingers. We have called this 'differential splintage'. Healthy volunteers were tested for maximum active flexion strength at the different flexion angles. 'Differential splintage' of up to 45 degrees resulted in mean decreased flexion strength of 28% in the index finger and 35% to 38% in the middle, ring and little fingers. The results suggest that "differential splintage" of a finger after flexor tendon repair may be useful in reducing tension across the repair during a program of active tendon rehabilitation and we feel that it has potential to reduce the incidence of repair rupture before healing is complete.     

Assessment of Attention to Clothing and Impact of Its Restrictive Factors in Iranian Patients with Traumatic Spinal Cord Injury (ACIRF-SCI): Introduction of a New Questionnaire

Background:

Patients with spinal cord injury (SCI) deal with various restrictive factors regarding their clothing, such as disability and difficulty with access to shopping centers.

Objectives:

We designed a questionnaire to assess attention to clothing and impact of its restrictive factors among Iranian patients with SCI (ACIRF-SCI).

Methods:

The ACIRF-SCI has 5 domains: functional, medical, attitude, aesthetic, and emotional. The first 3 domains reflect the impact of restrictive factors (factors that restrict attention to clothing), and the last 2 domains reflect attention to clothing and fashion. Functional restrictive factors include disability and dependence. Medical restrictive factors include existence of specific medical conditions that interfere with clothing choice. Construct validity was assessed by factorial analysis, and reliability was expressed by Cronbach’s alpha.

Results:

A total of 100 patients (75 men and 25 women) entered this study. Patients with a lower injury level had a higher total score (P < .0001), and similarly, patients with paraplegia had higher scores than those with tetraplegia (P < .0001), which illustrates an admissible discriminant validity. Postinjury duration was positively associated with total scores (r = 0.21, P = .04). Construct validity was 0.97, and Cronbach’s alpha was 0.61.

Conclusion:

Iranian patients with SCI who have greater ability and independence experience a lower impact of restrictive factors related to clothing. The ACIRF-SCI reveals that this assumption is statistically significant, which shows its admissible discriminant validity. The measured construct validity (0.97) and reliability (internal consistency expressed by alpha = 0.61) are acceptable.Key words: clothing, Iran, spinal cord injuryThe incidence of traumatic spinal cord injury (SCI) varies among different nations. The estimated incidence was 87.7 per million in the United States by the end of 2009.¹ Iran is one country with a high rate of road accidents² and SCI. SCI influences many aspects of life, including choice of clothing. Clothing is an important issue for wheelchair users, because it plays an important part in social appearance.Inattention to fashion can originate from many sources including disability, difficulty in accessing shopping centers, depression, and existence of specific medical conditions such as pressure sores. Until now, no validated questionnaire was available to provide a scale for determining the level of attention to clothing among people with SCI. The score of such a questionnaire can be used for psychological evaluation. We tried to determine the most important factors that may restrict attention to clothing.Choice of clothing is known to be linked with personality.³ Disability may limit choice of clothing because of restricted ability to don clothing independently as a result of immobility and reduced hand function. Although disability caused by SCI may limit the ability to dress independently, it has been strongly recommended that people with SCI be encouraged to choose their own clothing.⁴SCI causes a significant alteration in a person’s self-image because it results in changes in physical abilities, skills, and appearance.⁵ Before attempts are made to alter and modify clothing for this population, it is essential to have some information about attention to clothing before and after injury. Until now, no standard assessment method to measure level of attention to clothing has been proposed. Howe⁶ tried an online survey and evaluated some aspects of attention to clothing among people with SCI. The report emphasized the necessity of more consistency between people’s requirements and what is available in the market. We designed a new questionnaire to assess attention to clothing and impact of its restrictive factors among Iranian patients with SCI (ACIRF-SCI). The ACIRF-SCI includes the following 5 domains: functional, medical, attitude, aesthetic, and emotional. The first 3 domains reflect mainly restrictive factors, and the last 2 domains reflect attention to clothing and fashion. Our purpose was to develop a tool to evaluate the level of attention to clothing along with the impact of its restrictive factors (factors that prevent an individual from caring about clothing). In Islamic countries, such as Iran, a significant difference exists among men and women regarding clothing; therefore, in this study, data for men and women are reported separately.Along with assessment of validity and reliability of this questionnaire, we present preliminary data related to clothing choice and management in Iranian individuals with SCI.     

Pseudorotation of the little finger metacarpal

Fractures of the little finger metacarpal are common, and are often associated with significant soft-tissue swelling and the appearance of rotational malalignment when the fingers are flexed. Our hypothesis is that soft-tissue swelling causes this apparent rotational deformity of the flexed little finger. The fourth intermetacarpal spaces of three of the authors' non-dominant hands were injected with saline. Following injection, all the hands exhibited the appearance of internal rotation of the little finger. The mean change in rotation was 16 degrees and the maximum was 25 degrees. There was no change in the plane of the nail plate in extension in any hand. We conclude that soft-tissue swelling can cause the appearance of internal rotation of the flexed little finger in the absence of fracture.     

Tracheal intubation through the intubating laryngeal mask in a patient with a fixed flexed neck and deviated larynx

Insertion of the conventional laryngeal mask is more difficult or impossible when the patient's head and neck are in either the neutral or flexed position. The intubating laryngeal mask is best inserted when the patient's head is supported by a pillow, without placing the head and neck into the Magill position; therefore, insertion of this modified mask may be less difficult than the conventional mask in the patient with a flexed neck. We report a case of successful insertion of the intubating laryngeal mask and subsequent tracheal intubation through the mask using a fibre-optic bronchoscope, in a patient with a flexed neck in whom tracheal intubation using several methods had been difficult previously.     

Effect of elbow position on grip and key pinch strength

Twenty-nine college women participated in a study to investigate the effect of elbow position on grip and key pinch strength evaluations. Standardized instructions and positioning were followed with the exception of the two elbow positions. The elbow was flexed to 90 degrees in one test condition and it was fully extended in the other. The results showed a significantly stronger grip strength measurement in the 90 degree elbow flexed position than in the fully extended position. For evaluation of key pinch strength, both hands were stronger in the elbow flexed position, but only the right hand was significantly stronger. This study supports the use of the elbow flexed position in standardized grip and key pinch evaluations.     

Primary total knee arthroplasty for a complex distal femur fracture in the elderly: a case report

Fractures of the distal femur in the elderly account for 4–5% of fractures in the geriatric population and are usually due to low energy ground level fall onto a flexed knee. A high incidence of postoperative complications and poor results are secondary to associated co-morbidities and osteopenia in this age group resulting in high levels of comminution and articular damage at the time of injury. Preservation of knee function and early weight bearing should be the objectives of management in the geriatric population. We present in this case report of an elderly patient with comminuted distal femoral fracture who had Primary total knee arthroplasty as an alternative to internal fixation.     

The mechanical cause of congenital dislocation of the hip joint: Dynamic ultrasound study of 5 cases

5 hip joints with untreated congenital dislocation of the hip were examined for hip movement by ultrasound. With the hip joint flexed, the direction of the dislocated femoral head was posterior to the acetabulum. The dislocated femoral head displaced more posteriorly when the knee joint was extended, with the hip joint held in flexed position. As the dislocated hip was extended, on the other hand, the direction of the dislocated femoral head was anterior to the acetabulum. The dislocated femoral head displaced more anteriorly when the baby tried to bend the hip with the joint held in extended position.

These findings indicate that a fetal posture with the hip flexed and the knee extended predisposes to the development of CDH by the action of hamstrings, and that an infant posture with the hip extended is likely to provoke femoral head dislocation by the action of the iliopsoas.