Left-side dominance of upper extremity fracture in children

In 148 children who had sustained trauma to the upper extremities from falls, fractures were twice as common on the left as on the right side. This seemed to be due to the childrens' preferential use of the left hand to parry the fall even when both hands were free and because the left arm seemed to be more easily broken than the right arm during trauma.     

A case of intramedullary spinal cavitation after minor trauma

A case of surgically treated intramedullary spinal cavity which appeared 1 year after a minor injury was presented. A 15 year-old boy developed nuchalgia and muscle weakness of his right arm and leg. On admission, he had right hemiparesis and sensory disturbances in the right C6-C8 and left T1-S5 dermatomes. Metrizamide-CT scan and MRI disclosed an intramedullary spinal cavity between C4-C5 vertebral levels. A myelotomy and a biopsy of the cavity wall were carried out in order to communicate the cavity with the subarachnoid space, and to make a definite diagnosis. The microscopic examination of a biopsy specimen revealed no tumor findings but inflammation. Taking into account the location of the cavity, a site corresponding with the site of a previous trauma, the authors finally diagnosed the cavity as intramedullary spinal cavitation after minor trauma. His symptoms improved remarkably after the operation.     

Myocardial contusion in chest trauma

Because myocardial dysfunction may result from severe trauma, the author assessed, prospectively, left and right ventricular function in 25 patients who had sustained severe trauma, including blunt chest injury, by electrocardiographically gated blood pool radionuclide angiography. Focal abnormalities of ventricular wall motion were defined in 17 patients: right ventricular in 12, left ventricular in 2 and biventricular in 3. Traumatic tricuspid insufficiency demonstrated in two patients was subsequently verified by contrast angiography. Other means of detecting myocardial contusion (enzymatic, electrocardiographic and scintigraphic) proved to be insensitive when compared with radionuclide angiography. Two of the five deaths were attributed to refractory arrhythmias. Surgical or autopsy evidence of traumatic myocardial injury was obtained in five instances when radionuclide angiography indicated contusion. Of the 13 patients available for follow-up, 11 showed complete or partial resolution of the ventricular wall abnormality and in 2 there was no change. Comprehensive cardiopulmonary monitoring revealed an inverse relation between the right ventricular ejection fraction and pulmonary vascular resistance as well as between the pulmonary vascular resistance and left ventricular ejection fraction and left ventricular end-diastolic volume. Further, as the right ventricular end-diastolic volume was increased in trauma, left ventricular function and compliance were reduced. In blunt chest trauma, right ventricular contusion occurs more frequently than has been recognized previously and positive radionuclide angiography constitutes prima facie evidence of direct myocardial injury. Moreover, left ventricular function remains preload-dependent, but may be depressed by elevated pulmonary vascular resistance, impeding the blood flow from the right to left ventricle, and decreased left ventricular compliance, or both.     

The branching pattern and communications of the musculocutaneous nerve

Anatomical variations of peripheral nerves are important and can help explain otherwise incomprehensible clinical findings. A study of 26 right and 18 left formalin-preserved upper limbs identified the fact that the musculocutaneous nerve is subject to considerable anatomical variation, including communication with the median nerve. A study of its branching pattern made us aware of why debility after trauma to the lateral aspect of the upper arm may be more than expected, and this study considers the clinical and surgical importance of these variations of the musculocutaneous nerve.     

Variation of carrying angle with age, sex, and special reference to side

We measured the carrying angle using a universal full-circle manual goniometer on the dominant and non-dominant extremity of the elbow in 1275 healthy volunteers (631 males, 644 females) with a mean age of 22.87+/-15.99 years (range: 2-91 years). In the right arm dominant group, right carrying angle was 11.25 degrees +/- 3.73 degrees and left carrying angle was 10.57 degrees +/- 3.63 degrees (P<.001). In left arm dominant group, right carrying angle was 10.65 degrees +/- 3.99 degrees and left carrying angle was 12.93 degrees +/- 4.22 degrees (P<.001). The carrying angle of dominant arm was found to be significantly higher than the non-dominant arm in both sexes. The carrying angle of dominant and non-dominant arms were found to be significantly higher in patients aged >14 years than that of patients aged < or = 14 years; females ranked higher than males.     

The effect of short-term dependency and immobility on skin temperature and colour in the hand

The effects of short-term dependency and immobility on skin temperature were assessed in two experiments. In the first study, ten volunteers hung their left arm dependent and motionless while using their right hand for light office work. After 30 minutes, the dependent left hands were cooler (mean=0.9 degrees C: 95% CI=0.7-1.1) than the active right hands and exhibited a deeper colour with significantly increased green intensity (P=0.03) as assessed on digital images. In the second study, seven volunteers submerged both their hands in water at 15 degrees C for 15 minutes. The left arm was then left dependent and motionless while the right hand was placed on the table and its fingers were flexed and extended every 10 seconds. The left hands remained cooler than the right and were a median of 3.6 (range 2.9-4.5) degrees C cooler after 60 minutes. These studies demonstrate that skin temperature and colour differences between the hands, which are sometimes used to support the diagnosis of CRPS-1, can be produced and maintained by short-term immobility and dependency of the hand.     

Brachial plexus neuropathy (stinger syndrome) occurring in a patient with shoulder laxity

The stinger syndrome is a common neuropathy caused by traction or compression of the brachial plexus. In general, it is seen in young adults involved in sport activities and a major contact trauma is the rule. An 11-year-old boy with bilateral glenohumeral joint laxity had pain in the left shoulder, numbness and decreased strength in the left arm that developed after striking against a wall while running, with the left shoulder in extension and the neck in minimal lateral flexion to the contralateral side. Physical examination showed extreme anteroinferior passive translocation of the humeral head in neutral rotation and a positive sulcus sign in the left shoulder. The diagnosis was made as brachial plexus neuropathy (stinger syndrome) resulting from traction trauma and shoulder joint laxity and a shoulder-arm brace was applied. After two weeks, atrophy was detected in the right deltoid, supraspinatus, and infraspinatus muscles, and active and passive motion exercises of the shoulder were initiated. At the end of three months, he achieved normal range of motion of the shoulder and muscle strength.     

Left atrial myxoma with cerebral oncotic aneurysms with special reference to the importance of serial angiography

A case of atrial myxoma with cerebral oncotic aneurysms was presented. A 37 year-old woman was admitted complaining of right hemiparesis, and episodes of syncope. Neurological examination on admission revealed a right arm monoparesis, a right hemisensory disturbance, and a motor aphasia. Computed tomography (CT) demonstrated low density areas in the left fronto-parietal region, and multiple discrete enhancing high density spots scattered bilaterally in the parietal lobes. Cerebral angiography showed multiple fusiform peripheral aneurysms especially in the distribution of the bilateral middle cerebral arteries. Cerebral emboli from the cardiac source were suspected, and an echocardiography was performed, which disclosed a huge villous mass in the left atrium. The cardiac mass was resected uneventfully under cardiopulmonary bypass. It proved to be a left atrial myxoma. Postoperatively, her neurological deficit persisted. After the resection of the cardiac tumor, follow-up angiographies were undertaken twice. The second angiography performed 6 months later revealed spontaneous resolution or stabilization of most of the aneurysms detected before. On the other hand, newly-developed aneurysms were seen at the sites which had seemed normal previously on the first angiography. No remarkable changes were seen on the third one except the slight enlargement of one of the aneurysms in the middle cerebral territory. At 3 years she was neurologically stable. Because of the paucity of knowledge concerning the natural history of cerebral oncotic aneurysms and lack of definite treatment for them, long-term follow-up including serial angiography is mandatory after the resection of left atrial myxoma.     

Carotid artery disease development after traumatic injury inflicted by a Ram's Horn

A 36-year-old man presented for treatment of headache, paresthesis, and weakness of his right arm and leg. Examination revealed an atherosclerotic plaque in the left common carotid artery, lying to the left internal carotid artery and resulting in 99% stenosis. The plaque was removed successfully by carotid endarterectomy. Pathological examination of the tissue confirmed the diagnosis of an atherosclerotic plaque. Detailed investigation of risk factors led to the conclusion that the stenosis of the carotid artery was due to blunt trauma caused by an injury that had occurred 30 years previously when the patient was gored by a ram's horn.     

Right- and left-arm blood pressure discrepancies in vascular surgery patients

To identify a relationship between atherosclerotic vascular disease and differences in blood pressure between the right and left arms, blood pressure differences between arms were measured in patients with peripheral vascular disease (PVD, n = 58), in patients with coronary artery disease (CAD, n = 38), and in patients with no evidence of atherosclerotic disease, who served as a control group (n = 38). The incidence and magnitude of right and left arm pressure difference determined by the oscillometric technique were compared between the patient groups. The incidence of systolic pressure difference greater than or equal to 20 mmHg between arms in patients with PVD (21%) was greater than that in either those with CAD (3%) (P less than or equal to 0.05) or control subjects (0%) (P less than 0.01). The incidence of systolic pressure difference greater than or equal to 45 mmHg between arms in patients with PVD (10%) was greater than that in either those with CAD (0%) (P less than 0.05) or control subjects (0%) (P less than 0.05). Patients with PVD also had a greater incidence of right and left arm difference than did those with CAD or controls for mean and diastolic blood pressures. Of all patients with a systolic difference greater than 10 mmHg, neither the right nor the left arm blood pressure was consistently higher: 21 of 35 (60%) had a higher pressure in the right arm, and 14 of 35 (40%) had a higher pressure in the left arm (P = 0.33). Gender, diabetes, hypertension, smoking, and age were not associated with a difference in blood pressure between the right and left arms.(ABSTRACT TRUNCATED AT 250 WORDS)     

Repeated upper limb salvage in a case of severe traumatic soft-tissue and brachial artery defect

We present the case of a 9-year-old male patient who suffered a gunshot injury to the right arm. The patient arrived in shock, his right arm severely traumatized, with soft-tissue loss involving the anterior surface and both sides of the right arm. The humerus was exposed. There was brachial artery defect and damage to the lateral fibers of the median nerve. The mangled extremity severity score (MESS) was 8 points. The patient was treated with general resuscitation, blood transfusion, and debridement. A venous graft, 12 cm in length, to bridge the brachial artery defect, and tendon transfer, triceps to the biceps, was performed in one step. Postoperatively, there was a normal radial pulse, normal skin color, normal temperature, and normal movement of the fingers without pain. Unfortunately, the patient then sustained a second trauma to the right arm 3 weeks later, rupturing the graft. This time he lost 1,500 cc of blood. After another blood transfusion, we performed a second reverse saphenous vein graft. The patient stayed at the hospital for 3 weeks. At follow-up 12 months later, the limb has good function and, except for the presence of a scar and skin graft, is equal in appearance to the left side.     

应用端侧吻合修复高位尺神经损伤的研究

目的 探讨高位尺神经损伤后尽早恢复手内在肌功能的一种修复方法。方法 纯种大耳白兔18只，采用同体自身对照方法。左侧高位尺神经切断后直接吻合，同时在低位（前肢远端）切断尺神经，将其远侧断端与正中神经外膜开窗处作端侧吻合为实验侧，右侧尺神经高位切断后直接吻合为对照侧。按手术先后分为A、B、C三个时间组，分别于术后4、8、12周时做电生理检测和组织学检查。结果 A、B、C三组实验侧均测出诱发电位，而对照侧均未测出诱发电位。组织学观察结果显示术后4、8、12周时实验侧神经纤维数量、密度随时间延长而逐渐增加．而对照侧未检测到再生神经纤维。结论 高位尺神经损伤后在高位端端吻合恢复手外在肌功能的同时加低位端侧吻合可作为尽早恢复手内在肌的功能的一种新方法。     

Bone bruise of the calcaneus. A case report

A bone bruise to both calcanei after axial overloading is reported. Because radiographs were normal and weightbearing was not possible, magnetic resonance imaging was performed and showed characteristic findings for a bone bruise of the calcaneus more extended on the left side than the right side. Resolution of pain was within the first 2 weeks after trauma on the right side, whereas partial weightbearing was necessary for 4 months on the left side. Six months after trauma, complete resolution of magnetic resonance signal changes was evident. Bone bruises should be considered when radiographs are normal. Because bone bruises pose a potential risk for chondrolysis and stress fracture, mobilization and weightbearing should be increased gradually.     

Subclavian steal syndrome associated with the right aortic arch in a patient with Peutz-Jeghers syndrome: case report

We report an adult case who presented vertigo attacks due to subclavian steal syndrome associated with the right aortic arch in a patient with Peutz-Jeghers syndrome. A 29-year-old male diagnosed as having Peutz-Jeghers syndrome developed frequent vertigo attacks and was admitted to our hospital. Blood pressure of the left arm was 20 mmHg lower than that of the right arm. Aortagraphy showed that he had a right aortic arch and isolation of the left subclavian artery. Right vertebral angiography opacified the left vertebral artery and the subclavian artery in retrograde fashion, suggesting subclavian steal phenomenon. Blood flow studies disclosed impaired reactivity to acetazolamide in the bilateral cerebellar hemispheres. We successfully carried out left common carotid artery-transverse cervical artery bypass. Postoperative angiography confirmed the patency of the graft and the disappearance of subclavian steal phenomenon. Vasoreactivity to acetazolamide normalized in the cerebellum. Vertigo attacks were not noted during the one-year follow-up period.     

The deeply burned upper extremity: functional graft distribution concept with selective use of a synthetic dermal substitute (Integra) and split-thickness skin grafts

A 15-year-old boy sustained a severe inhalation injury and second/third degree burns following a flame burn involving the face, neck, upper thoracic regions, and upper extremities measuring 25% of his total body surface area. The right arm had a full-thickness burn, the left arm deep partial-thickness burns. Tangential excision and split-thickness skin grafting (STSG) were performed. Because of the full-thickness burns on the right arm, an epifascial excision was necessary on the left arm, sparing the venous tributaries. To reconstruct the epifascially excised extremity, a new concept was used. Split-thickness skin graftings were selectively distributed over the digits, and the remaining zones were covered with a synthetic dermal substitute (Integra). Unfortunately, the dressing changes and the definitive grafting of the synthetic dermal substitute had to be delayed until day 62 because of severe lung failure, acute respiratory distress syndrome (ARDS), the necessity for extracorporeal membrane oxygenation, multiple organ failure, and prolonged intensive care stay. Despite circulatory and ischemic complications, all grafts taken on both extremities after incorporation of the dermal substitute, both immediate and delayed, were complete. There was no infection or other complication. The functional range of motion of all involved joints and the skin surface quality and contour were remarkably good. It is emphasized that the considerations in this report should be considered as preliminary and that further investigations are required.     

Bilateral multiple pulmonary arteriovenous fistulas treated by surgery and embolization

A 46-year-old man, with an abnormal shadow in left lower area in chest X-ray was admitted to our hospital. Three dimensional computed tomography (3 D-CT) and pulmonary arteriogram revealed bilateral multiple pulmonary arteriovenous fistulas (PAVF). PAVF was simple in the right S8, and were multiple in the right lower lobe. PAVF in left side was treated with percutaneous transcatheter coil embolization. PVAFs in right side were treated by lower lobectomy. This combination therapy seemed to be useful for bilateral multiple PAVFs.     

Massive arm necrosis as a result of a subclavian artery occlusion after mastectomy and radiotherapy

A 60-year-old woman with a severe necrosis caused by a blunt trauma of her right upper arm is described. She had a history of ablation and radiotherapy of her right breast followed by a diagnosis of breast cancer 34 years previously. An angiogram revealed a complete occlusion of the right subclavian artery. After the reperfusion of the right arm, the necrosis at the upper arm was resected. After further operations, the wound could finally be closed with a skin graft. Today, the patient is able to complete all her activities of daily living. Despite a restriction in her range of motion, she complains about intermittent pain. Arterial occlusion of the ipsilateral limb is a rare event decades after mastectomy and radiation. A related necrosis in these dimensions and successful limb-saving treatment has not been previously described.     

Cerebral artery occlusion due to blunt cervical trauma

Three cases are reported in which cerebral infarction developed due to blunt cervical trauma. All of these patients had external signs of cervical trauma and presented focal cerebral ischemic symptoms. Cerebral angiography demonstrated characteristic findings in each case. The first case: A 27 year-old man developed left hemiparesis four days after hitting his neck against a bed rail. Cerebral angiography showed complete occlusion of the right extracranial internal carotid artery 1.5 cm distal to its origin and emboli in distal branches of the right middle cerebral artery. He was treated conservatively. The second case: A 32 year-old man developed disturbance of consciousness with motor aphasia and right hemiparesis a few hours after hitting his chest and neck against baggage hanging from a crane. Cerebral angiography showed complete occlusion of the left middle cerebral artery and no abnormalities of the left internal carotid artery. He was treated with STA-MCA anastomosis two weeks after the accident. The third case: An 84 year-old man, who failed in a suicidal hanging, was semicomatose on admission and had right hemiparesis. Computed tomography demonstrated massive cerebral infarction of the territory of both anterior and left middle cerebral arteries. Cerebral angiography showed linear shadow defect of the left extracranial internal carotid artery corresponding with the site of the ligature. He was treated conservatively. From these angiographic findings, it was thought that intimal tear, intramural hematoma, vasospasm of the internal carotid artery and emboli given might bring about cerebral infarction. In such cases of blunt cervical trauma, cerebral angiography should be undertaken as soon as possible if focal cerebral ischemic symptoms can be seen.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bilateral internal thoracic artery harvesting under robotic video-assistance

Background: Following upon the recent development of minimally invasive coronary robotic surgery, we set out to evaluate the feasibility of bilateral internal mammary artery (IMA) harvesting using the voice-controlled AESOP 2000 video assisted robot. Methods: The robot is placed on the right side of the patient. The left IMA is first totally video-harvested, with the arm of the robot crossing over the patient to reach the left chest. The voice-controlled movement of the arm allows the surgeon to obtain the best video image of the artery. After completion of the dissection, the arm is positioned on the right part of the chest. The right IMA is then harvested using the same technique. Results: Two patients underwent harvest of a bilateral IMA using this technique. The time of dissection was 52 min and 86 min, respectively. Conclusion: This technique allows a more precise, faster, tremor-free dissection, as compared to a conventional thoracoscopic harvesting. apd: 6 February 2001     

A cause and cure of some cases of "writer's cramp"

Writer's cramp is a very disabling condition characterized by difficulty in fine movements of the hand such as writing, shaving, or performing surgery. It is associated with pain in the forearm and upper arm. Women with writer's cramp experience comparable difficulty. An analysis of 100 cases of ruptured C6 disk, proved at operation and taken at random from the files of Semmes-Murphey Clinic, was carried out, and showed that 60 of these had pain in the right arm and 40 had pain in the left arm. Twenty of those with right arm pain had writer's cramp. There was one questionable case of writer's cramp in the left arm. Of the 20 who had writer's cramp, 13 had complete relief of writer's cramp and pain, 1 had no relief (Dr. Butts), and there were 6 lost to follow-up. At least one cause of writer's cramp is suggested, but no claim is made that this is the only cause.