The management of severely comminuted fractures of the femoral shaft, using the external fixator

Fractures of the femoral shaft are often treated by an established method of internal fixation, such as a medullary nail or a plate and screws, to obviate the many disadvantages of traction and prolonged rest in bed. Fractures of the femoral shaft which are severely comminuted and open are usually unsuitable for internal fixation. Between July 1981 and March 1983 we treated seven patients with severely comminuted fractures of the femoral shaft (of which three were open), using the ASIF tubular external fixator system or the Wagner apparatus. The technique of application of the external fixator is important and is described. When correctly applied, the knee's movement was not restricted and few complications were experienced. All the fractures united within 8 months in a good position without shortening, and none required an additional operation. The use of the external fixator in these patients reduced their time in the hospital and facilitated their postoperative rehabilitation by allowing uncomplicated healing of a complicated fracture.     

The long-term effect on the tibiofemoral compartment of the knee joint of comminuted fractures of the patella

We have studied the long-term effect of comminuted fractures of the patella with particular reference to the development of degenerative changes in the tibiofemoral joint. Degenerative changes which could convincingly be ascribed to the original injury were found in only one case, but we stress that the numbers are small, and that careful search should be made at operation for damage to the femoral condyles.     

Nerve tumors of the hand and forearm.

Peripheral nerve tumors comprise less than 5% of all tumors of the hand. The most common solitary nerve tumor is the neurilemmoma, which arises from the neural sheath, is well encapsulated, minimally symptomatic, and may be surgically enucleated without producing a neurological deficit. Neurofibromas may be solitary, multiple, or associated with von Recklinghausen's disease. They are usually centrally placed with nerve fibers traversing the tumor mass making it more difficult to remove the tumor without producing permanent neurological damage. Malignant tumors include neurofibrosarcomas which often are very aggressive, requiring wide excision or amputation, and the rare neuroepitheliomas. Reported nerve tumors, intraneural in location but nonneural in origin, include fibrofatty infiltration of the median and digital nerves, intraneural lipoma, hemangioma, and ganglion cysts. These lesions may be treated by decompression or excision, depending on the nature of the tumor. Four unusual cases are described.     

The reduction of supracondylar fractures of the humerus in children treated by traction-in-extension: A review of 18 cases

The records of 182 patients presenting themselves over a fifteen year period with displaced supracondylar fractures of the humerus are reviewed. Eighteen (10%) were complicated by gross swelling, neurovascular damage, instability or delay in reaching hospital, rendering them unsuitable for closed reduction and collar and cuff immobilization. A method is described whereby these fractures are managed with the elbow extended and forearm supinated in traction using a Thomas's splint. Twelve out of fourteen patients thus treated and followed up had satisfactory results without serious loss of movement in any plane and with preservation of the normal carrying angle.     

A survey of fractures of the proximal femur

A series of 1494 fractures of the proximal femur, admitted over a 68-month period to the North East Area Accident Unit, is presented.The mortality for the series was 18 per cent, with operative mortality varying according to the fracture site and the method of treatment, being 18.1 per cent for extracapsular fractures, 14 per cent for Smith-Petersen nailing of intracapsular fractures, and 31 per cent for primary prosthetic replacement.In general terms, morbidity and mortality were proportional to age and to pre-existing general medical conditions. The results are presented in full, and are compared with other published series.     

Reconstruction of the lateral ligament of the ankle

An operation for the treatment of chronic inversion instability of the ankle is described and the results are reported. It is suggested that this operation is considered in all patients with this syndrome, in whom conservative measures have failed.     

Scanning Electron Microscopic Observations on the Epithelium of the Human Prostatic Urethra

The human prostatic urethra has been investigated by means of scanning electron microscopy. On the posterior wall of the urethra, the seminal colliculus with the orifices of the ejaculatory ducts is clearly detectable. The upper portion of the prostatic urethra shows a typical transitional epithelium with large superficial cells of a ruffled appearance. In the lower portion of the organ (underneath the openings of the ejaculatory ducts), the apical pattern of the cells varies considerably. Four main aspects are recognizable: apices provided with microvilli, dome-shaped apices with an almost smooth surface, large apices with labyrinthic microplicae and ciliated apices. Also, apices showing intermediate characteristics can be noted. The functional significance of the morphological patterns as well as the possibility of a transition among the various types of surface structures are discussed.     

Von Frey's method of measuring pressure sensibility in the hand: an engineering analysis of the Weinstein-Semmes pressure aesthesiometer

The development of microsurgical techniques has generated a resurgence of interest in estimating local pressure sensibility as a measure of sensory improvement. Because our experience with Weinstein's modification of Von Frey's probes yielded variable and poorly understood results, we measured two sets of probes and examined them in the light of the engineering principles on which their behavior is based. The mechanical behavior of the nylon monofilaments can be described as buckling with one end built in and the other end pinned. The probes are relatively uniform and consistent. However, no loss in sensitivity would accompany division of the set into two or three equivalent sets. Variations in the buckling stress as high as a factor of eight are difficult to avoid. Gross errors arise from careless application, variations in the elastic modulus due to changes in temperature and humidity, and variations in the attachment of fibers to handles and differences in the ends of the filaments. Interpreting results for this instrument requires an understanding of the factors which can influence those results. The rpobes are simple to use but easy to misinterpret.     

Pseudosarcoma of the Esophagus

Polypoid lesions of the esophagus occur infrequently and may be benign or malignant. One malignant polypoid tumor, pseudosarcoma, appears to be a distinct pathological entity; the polypoid portion is composed of sarcomatous spindle cells and the base of the polyp shows in situ or invasive squamous cell carcinoma. A patient with this lesion is described and the 16 previously reported patients are reviewed. The results indicate that local resection is inadequate; radical esophagectomy is required for cure.     

Intra-articular fractures of the calcaneum.

A method of reducing deformity of displaced, intra-articular fractures of the calcaneum is described, together with a programme of management aimed at restoring a painless and mobile foot. The clinical and radiographic results are presented in 41 patients treated over a 10-year-period, with a minimum follow-up of 2 years. The complications, none of which were serious, are described. The results are compared with a group of 52 patients whose fractures were treated over the same period by early movements without any attempt at reduction. Although disabling pain was not a notable feature in either group, more patients in the reduced group had resumed work of a heavy nature entailing climbing or walking on rough ground. Analysis of the figures suggests that this is related to the better function regained in the subtalar joint by this group.     

Congenital anomalies of the upper limb among the Chinese population in Hong Kong

Three hundred twenty-six patients with 396 congenital upper limb anomalies are classified according to the system adopted by the International Federation of Societies for Surgery of the Hands. The relative incidence of each separate anomaly is listed and compared with that of other series. Two hundred cases are also analyzed with respect to the family history, pregnancy history, neonatal history, and associated anomalies and the results are discussed. Significant racial differences were found in the incidence of polydactyly, syndactyly, anomalies associated with syndromes, and transverse arrests. The incidence of polydactyly is higher in this series than in comparable western series.     

Management of post-traumatic instability of the wrist secondary to ligament rupture

A retrospective review of 55 patients with post-traumatic radioscapholunate ligament disruption suggests that rupture of this ligament can be treated successfully if certain guidelines are followed. If the rupture is seen within 4 weeks, an anatomic reduction maintained in plaster for 8 weeks leads to good results. Ligament ruptures that cannot be held in reduction or that are diagnosed after 4 weeks do poorly with immobilization only. Results after ligament reconstruction have ranged from good to fair but appear to have been sufficiently successful to warrant continued trial rather than resort to arthrodesis, proximal row carpectomy, or similar reconstructive procedures. Patients with degenerative joint disease associated with radioscapholunate rupture are not candidates for ligament reconstruction. Radial styloidectomy or some variety of wrist arthrodesis or wrist arthoplasty should be considered in these instances.     

Fractures of the calcaneum: a study of the long-term prognosis

Two hundred and three consecutive fractures of the calcaneum occurring in 185 patients between 1961 and 1968 have been reviewed. These patients were treated by essentially non-operative methods. The study revealed that fracture of the calcaneum is a relatively common injury, after which persisting symptoms are frequent. Symptoms present two years after injury showed little tendency to improve. The duration of absence from work was often lengthy. The prognosis after this fracture is better if the fracture does not involve the posterior talocalcaneal joint. The usual radiographs taken to investigate a suspected calcaneal fracture seldom provide adequate information about the congruity of that joint, and oblique views are recommended.The results of non-operative treatment, though no worse than reported results of operative intervention, are not good enough and demand further studies on this subject.     

Primary chemotherapy in the treatment of children with bladder--prostate tumors in the Intergroup Rhabdomyosarcoma Study (IRS-II)

Twenty-nine children (24, male; 5, female) with non-disseminated rhabdomyosarcomas of the bladder or prostate were treated (1978-1980) by a primary chemotherapy regimen consisting of vincristine, actinomycin D, and cyclophosphamide ("Pulse" VAC), with or without local radiotherapy. During the initial 20 wk of chemotherapy, nine children achieved a Clinical Complete Response (CCR). Three of these are without evidence of disease (NED) and have functional bladders, two following partial cystectomy. Four who achieved a CCR subsequently relapsed or remained biopsy positive, but are at present NED following radiotherapy and anterior exenteration. Two patients who achieved CCR status relapsed and have died of disease. Twelve patients had a Clinical Partial Response (CPR) in less than 20 wk and two others in less than 40 wk. Seven of these are NED with intact bladders following chemotherapy-radiotherapy; and an additional patient is NED following partial cystectomy. Four patients in the CPR group have been treated by exenteration following failure to achieve complete response, and are NED. One patient has died, and one has progressive disease. Six patients had an inadequate response to chemotherapy (NR). Anterior exenteration was carried out in three, and two of these have survived. The overall results in these 29 patients are: (A) alive and disease-free with functional bladders, 11; (B) alive and disease-free following anterior exenteration, 10; and (C) dead or death from tumor anticipated, 8. The function of retained bladders (11) has been satisfactory.     

Sarcoidosis of the upper extremity: case presentation and literature review

Sarcoidosis of the skeletal system is not rare but problems related to it are unusual. Two cases of sarcoidosis, with involvement of the upper extremity, are presented to point out problems that may occur in its treatment. Osteolytic sarcoid involvement of the phalanges leads to resorption and collapse, with a poor response to bone grafting or splinting. The phalangeal collapse could be treated with intramedullary cement or Kirschner wire fixation. Sarcoid involvement of fractures can lead to a nonunion and they should be treated with excision when appropriate, rather than attempting osteosynthesis. Arteriograms of sarcoid lesions show them to have a very poor blood supply. A bone scan can be used to demonstrate areas of sarcoid involvement before the characteristic lesion becomes evident on a radiography.     

Nonoperative management of subcapsular hematomas of the liver

The liver is the second most common organ injured in blunt abdominal trauma, and with the use of diagnostic techniques such as hepatic scanning, an increasing number of patients with intrahepatic lesions are being identified. Five patients with this type of lesion are presented. A plan of management, including observation in an intensive care unit, repeated physical examinations, frequent reevaluation of laboratory values, bed rest, gastrointestinal tract decompression and broad spectrum antibiotics, is suggested as the treatment of choice for this type of injury. All patients in the series have done well with no abscess formation, delayed rupture or hemobilia, and all show resolution of the defect on follow-up hepatic scanning.     

Reconstructive surgery of roller injuries of the hand.

Eleven patients with roller injuries to the upper extremity are described. Nine were treated initially; two were referred for treatment within 3 weeks after injury. Six patients were injured by kneading machines in bakeries, two by hot dry-cleaning mangles, two by industrial rolling machines, and one by a transmission belt which acted as a roller. The tissue damage depends on (1) the space between the rollers, (2) the speed of the rollers, (3) the hardness of the rollers, (4) the temperature of the rollers, and (5) how violently the patient attempts to withdraw the entrapped part. Lesions may be closed, consisting of a compression of the soft tissues, which may result in skin necrosis, or a tearing and separation of the skin and soft tissues away from the deep fascia (more common on the dorsal surface of the hand), or destruction of skin and deep tissue because of burns. Closed injuries usually respond to conservative care, although decompression sometimes is necessary. Experience gained from treating these 11 patients indicates that the inexperienced surgeon often tries to replace distally based flaps. Such flaps usually die and predispose to deep infection. If the condition of the wound permits, primary skin grafts should be applied; but if the bed is of poor quality, skin grafting can be delayed for several days. If it is necessary to protect exposed deep structures, they should be covered with immediate pedicle flaps. It is better to use skin from an uninjured area for a free skin graft than to use the avulsed skin as a graft. Distant flaps should be used if secondary reconstruction is anticipated. In circumferential skin loss, a combination of pedicle skin and free skin grafts is better than encircling the part with a pedicle flap. The thumb and radial fingers should be preserved, but the ulnar fingers are expendible in severe injuries. By amputating parts of fingers, reconstruction often is simplified.     

Medical and surgical importance of the arterial blood supply of the thumb

The arterial supply of the thumb was studied in 50 cadaver hands. In 80% the princeps pollicis artery was the first palmar metacarpal artery, a major branch of the deep radial arch. In 50% of the specimens the princeps pollicis artery also supplied the proper radial digital artery to the index finger. Variations of the thumb arterial patterns were present in 25%. In 75% there was a single end-arterial blood supply to the thumb. The anatomic findings are correlated with problems of radial artery injections, thrombosis, and surgical injury to illustrate the clinical importance of the princeps pollicis artery.     

Non-operative treatment in the management of traumatic lesions of the spleen —A new kind of therapy?—

The onset of severe episodes of sepsis in splenectomized patients has induced surgeons to perform conservative operations in order to save at least partial functioning of the spleen. Recently, great interest has been focused on the non-operative treatment of traumatic lesions of the spleen, which involves careful and continual observation of patients with splenic trauma to monitor their course towards recovery. This method of treatment was recently adopted by our department for two patients whose case histories are presented herein. Non-operative treatment is suitable only in strictly selected subjects, who must be carefully monitored in an intensive care unit where constant examination and sophisticated diagnostic procedures are readily available. Although the non-operative treatment of splenic trauma is not new, it is only recently that its management, programming and role have been updated.     

Congenital hypoplastic thumb in the Silver syndrome--a case report and review of upper extremity anomalies in the world literature

A case of classical Silver syndrome presented with a congenital hypoplastic thumb, absent thenar musculature, and partial index ankylosis. No previous association of congenital hypoplastic thumb and the Silver syndrome has been noted by Dr. Silver or described in the world literature. Restoration of thumb function was achieved in this particular case by the abductor digiti minimi transfer described by Huber. The upper extremity anomalies thus far reported with Silver syndrome in the world literature are summarized.