锁骨钩钢板固定术后肩峰切割2例

正病例1:患者,女,47岁。摔伤致右肩锁关节完全脱位,伤后2 d行肩锁关节切开复位锁骨钩钢板固定术。术后第1天X线片见锁骨远端脱位纠正(见图1A)。术后6周患者诉肩部仍有疼痛,复查X线片及CT,显示锁骨钩切割肩峰,肩锁关节半脱位(见图1B)。与患者沟通后行钢板取出术,症状缓解。病例2:患者,男,70岁。外伤致左锁骨远端骨折,伤后5 d行切开复位锁骨远端锁定钢板内固定术。术后第2天因用力不当导致患肩疼痛,摄X线片见     

特殊类型旋后-内收型踝关节骨折一例

患 女性，18岁，因右踝关节扭伤术后7d来我院就诊。追问受伤史踝关节内翻位损伤。右踝内侧有一长约5cm的手术伤口，踝内外侧轻度肿胀。术前X线片示右内踝斜行骨折，胫骨前结节撕脱骨折；术后X线片示右内踝骨折用1枚踝螺钉和1枚克氏针固定，对位好，下胫腓联合轻度分离（图1）。[第一段]     

肱骨滑车冠状位骨折一例

笔者于2011年10月收治肱骨滑车冠状位骨折1例,报告如下。1病例报告患者,男,36岁。工作时不慎摔倒左手掌着地致左肘关节疼痛、活动障碍1 h就诊。查体:左肘部轻度肿胀,肘关节前内侧肿胀、压痛明显,肘关节轻度活动受限,可触及骨擦音。X线片示肱骨滑车可疑骨折。肘关节CT示左肱骨滑车冠状位骨折,断端移位明显(图1a)。入院后予脱水剂治疗,5 d后行切开复位埋头螺钉内固定术。复查X线片示骨折断端复位良好,内固定     

锁骨骨折合并对侧肩锁关节脱位1例

1临床资料患者,女,47岁,车祸致左食指开放性骨折伴全身多处肿痛功能障碍3h,以“多发性骨折”收住院。X线片示:(1)右锁骨中段骨折,断端移位畸形;(2)左侧肩锁关节脱位、左第2肋骨骨折;(3)左食指中节指骨远端骨折,移位畸形;(4)左外踝骨折,位置可。入院后即由手外科行左食指不全离断伤断指再植术,术后相应处理,1周后转入骨科。锁骨骨折合并对侧肩锁关节脱位行手术治疗,右锁骨骨折予6孔解剖型锁骨接骨钢板内固定、左肩锁关节脱位行切开复位喙锁及肩锁韧带修复加克氏针钢丝张力带固定(图1、2),左外踝骨折行石膏托固定保守治疗。术后相应处理,2周…     

锁骨骨折迟发腋-锁骨下静脉血栓形成1例

1 病例资料 患者,男,53岁,因右肩部外伤14 h,右肩部畸形活动受限,于2010年2月8日入院.查体:右肩部肿胀明显,畸形,可见10.5 cm×6.0 cm皮下淤血斑,右锁骨中段触及骨擦感.右上臂、右前臂及右手无肿胀,右肱二、三头肌无压痛.X线片示:右锁骨中段粉碎性骨折,骨折端重叠错位约3 cm.诊断为右锁骨中段粉碎性骨折(图1).术前血小板计数及凝血项目检查均正常.于2010年2月10日在颈丛麻醉下行切开复位+钢板     

非矩形化Castellvi-ⅢB型腰椎骶化侧位影像序列误判一例

患者 女性,41岁,因"右侧腰腿痛2个月"于2010年2月2日就诊.体检:右髂腰部压痛,右下肢直腿抬高40,右侧小腿后外侧及2～4趾背侧痛觉减退.胸椎正位X线片示T12肋缺如(图1).腰椎正位X线片示L5骶化Castellvi-ⅢB(C-ⅢB)型,L4-5椎间隙在Tuffier线(双侧髂嵴最高点连线)以下(图2).侧位片示腰骶椎间盘略窄,初步判定腰骶椎间盘为L5S1(图3).腰椎矢状位MRI示腰骶椎间盘突出(图4),横断面MRI示腰骶椎间盘右旁侧突出.     

股骨转子下骨折术后不愈合并内固定断裂1例

患者,女,69岁,既往高血压病史,慢性胃溃疡30余年,无糖尿病、冠心病、肝炎等病史。患者于13个月前从约1.5 m高处摔落致右大腿上部疼痛肿胀,伴髋部活动受限,在当地医院行X线检查,诊断为右股骨转子下骨折,AO分型32-A2型(见图1A)。于当地医院行切开复位动力髋螺钉内固定术治疗,术后X线片显示对位对线良好(见图1B)。术后患者能缓慢行走,定期当地门诊复查,见折端骨痂生长,但愈合迟缓,右侧股骨有逐渐内翻趋势。3 d前晨起时突发右侧大腿疼痛肿胀,中段可扪及异物感,行走困难,遂于2017年1月20日至我院门诊就诊。行X线检查提示:右股骨转子下骨折,内固定术后改变,折端部分愈合,股骨上段内固定钢板外移,螺钉断裂(见图1C)。     

肩胛骨喙突骨折并肩锁关节脱位漏诊1例

<正>患者,女,35岁,骑自行车不慎跌倒后右肩部疼痛剧烈,肩关节活动受限,于2011年3月18日急诊入院。X线片示:右锁骨骨折(图1)。查体:右侧肩关节饱满,右肩部压痛,肩锁关节无明显台坡,琴键征可疑阳性,右侧锁骨中段可及骨擦感骨擦音,肩关节活动障碍。入院诊断:右锁骨中段骨折。于次日在颈丛麻醉下行右锁骨骨折切开复位内固定术。术中见右锁骨中段短斜形骨折,采用锁骨重建钛钢板固定,术后右上肢三     

外伤后突然气促、面色苍白并休克的病例分析

病历摘要患者男,59岁。自述从拖拉机上摔下,右侧胸腹及肩部着地,当时即觉右胸、右肩部疼痛。伤后19小时来院。查体:痛苦病容,神志清楚,被动体位。头部及五官未见异常,两侧瞳孔等大正圆,光反应良好。颈软,右锁骨外侧畸形肿胀,局部压痛明显。右前胸第4、5肋骨畸形、压痛明显,右胸呼吸运动减弱,肺肝界位于右锁骨中线第5肋间,两肺呼吸音正常,心音纯、律整,心率84次/分。腹平软,右上腹轻度压痛,无移动浊音,肠鸣音存在,双下肢活动自如。X线检查:腹部未见液平面,右锁骨外1/3骨折,右胸第4、5肋骨骨折。     

上肢离断伤短缩再植一例

患者女,33岁.右上肢不慎被绞入搅拌机,30分钟后入院.检查:锁骨外1/3处压痛及骨擦感;右上臂有异常活动及骨擦感;右前臂自中上1/3交界处完全离断,肢体远端完整,无皮下青紫瘀血斑,右前臂近端皮肤广泛撕脱,右胸壁皮肤擦伤,右侧第3肋处压痛明显.X线片示右锁骨外1/3处粉碎性骨折,右肱骨中段骨折,右侧第3肋骨骨折.手术在臂丛麻醉下进行.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.