Radial nerve palsy associated with humeral shaft fracture. Is the energy of trauma a prognostic factor?

Background

Radial nerve palsy associated with humeral shaft fractures is the most common nerve lesion complicating fractures of long bones. The purpose of the study was to review the outcome of surgical management in patients with low energy and high energy radial nerve palsy after humeral shaft fractures.

Methods

Eighteen patients were treated operatively for a humeral shaft fracture with radial nerve palsy. The mean age was 32.2 years and the mean follow up time was 66.1 months (range: 30-104). The surgical management included fracture fixation with early nerve exploration and repair if needed. The patients were divided in two groups based on the energy of trauma (low vs. high trauma energy). The prevalence of injured and unrecovered nerves and time to nerve recovery were analysed.

Results

Five patients sustained low and 13 high energy trauma. All patients with low energy trauma had an intact (4) or entrapped (1) radial nerve and recovered completely. Full nerve recovery was also achieved in five of 13 patients with high energy trauma where the nerve was found intact or entrapped. Signs of initial recovery were present in a mean of 3.2 weeks (range: 1-8) for the low energy group and 12 weeks (range: 3-23) for the high energy group (p = 0.036). In these patients, the average time to full recovery was 14 and 26 weeks for the low and high energy trauma group respectively. Eight patients with high energy trauma had severely damaged nerves and failed to recover, although microsurgical nerve reconstruction was performed in 4 cases. Patients with high energy trauma had a prolonged fracture healing time (18.7 weeks on average) compared to those with low energy fractures (10.4 weeks), (p = 0.003).

Conclusions

The outcome of the radial nerve palsy following humeral fractures is associated to the initial trauma. Palsies that are part of a low energy fracture uniformly recover and therefore primary surgical exploration seems unnecessary. In high energy fractures, neurotmesis or severe contusion must be expected. In this case nerve recovery is unfavourable and the patients should be informed of the poor prognosis and the need of tendon transfers.     

Tenogenic differentiation of human MSCs induced by the topography of electrochemically aligned collagen threads

Topographical cues from the extracellular microenvironment can influence cellular activity including proliferation and differentiation. Information on the effects of material topography on tenogenic differentiation of human mesenchymal stem cells (human MSCs) is limited. A methodology using the principles of isoelectric focusing has previously been developed in our laboratory to synthesize electrochemically aligned collagen (ELAC) threads that mimics the packing density, alignment and strength of collagen dense connective tissues. In the current study, human MSCs were cultured on ELAC and randomly oriented collagen threads and the effect of collagen orientation on cell morphology, proliferation and tenogenic differentiation was investigated. The results indicate that higher rates of proliferation were observed on randomly oriented collagen threads compared to ELAC threads. On the other hand, tendon specific markers such as scleraxis and tenomodulin, were significantly increased on ELAC threads compared to randomly oriented collagen threads. Additionally, osteocalcin, a specific marker of bone differentiation was suppressed on ELAC threads. Previous studies have reported that BMP-12 is a key growth factor to induce tenogenic differentiation of MSCs. To evaluate the synergistic effect of BMP-12 and collagen orientation, human MSCs were cultured on ELAC threads in culture medium supplemented with and without BMP-12. The results revealed that BMP-12 did not have an additional effect on the tenogenic differentiation of human MSCs on ELAC threads. Together, these results suggest that ELAC induces tenogenic differentiation of human MSCs by presenting an aligned and dense collagen substrate, akin to the tendon itself. In conclusion, ELAC has a significant potential to be used as a tendon replacement and in the development of an osteotendinous construct towards the regeneration of bone-tendon interfaces.     

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.     

经眼《易筋经》传本的避讳与抄刻年考

经眼48种现存《易筋经》传本中的避讳研究,结合各传本中的内容,具有版本价值,可作为《易筋经》早期代表的传本凡15种。包括抄本8种,刻本7种,未见明本。较早的传本均为抄本,道光间方见刻本。沈氏校本不避清代皇帝讳,其序有称“顺治辛丑”,故当抄成于清康熙前期,此为最早。雍正抄本,避“玄”字讳,不避“弘”字讳,并载有雍正年序,抄成于雍正间,当为次早。西谛本避“玄”“弘”两字讳,当为乾隆间或其后抄本。现存刻本中以道光三年之傅金铨校刻本为最早,这也可能是《易筋经》最早的刻本。祝文澜本及来章氏辑本均可能晚于此本。     

关于普通骑行者膝关节耐受性的MRI研究

目的:根据90例普通骑行者在不同的骑行速度负荷下的膝关节的MRI表现,总结适合普通骑行者骑行速度。方法:随机选择本市某骑行大队90名骑行爱好者分3组,每组30人,分次分组测试,每次目标人数为3人,测试标准采用21速山地车,常规使用18～21速骑行,骑行速度分别为A组20km/小时、B组25km/小时、C组30km/小时骑行,骑行里程为往返100km,返程后第2天行膝关节MRI检查,观察受试者膝关节MRI表现。结果:A组:除1例因山地车故障未完成全程测试外,其余均随行领骑安全返程,MRI显示2例半月板及相应肌群信号增高;B组:1例因出现相应膝关节不适症状未完成全程测试,其余均完成全程测试,全组测试后MRI显示3例膝关节半月板、韧带及其附着点,相应肌群压脂像出现信号增高,1例出现骨质挫伤,2例出现关节腔内积液;C组:3例出现膝关节症状未完成测试,全组核磁检查显示3例骨质挫伤,5例关节面损伤及关节积液,8例半月板、肌腱附着点及相应肌群出现信号改变,9例出现韧带肿胀、信号增高,1例出现复合型损伤,关节腔内出现脂血症。结论:针对普通骑行者,骑行速度在一定程度上受膝关节耐受性的限制,为了达到锻炼目的,并且不损伤膝关节,较为适合的骑行速度为15～20km/h;体质较好且膝关节耐受能力较大的普通骑行者时速也不能大于25km/h。     

Rupture complète fermée du tendon du long fléchisseur de l’hallux

Purpose

A closed rupture of the longus flexor hallucis tendon is rarely observed and has few publications. A direct suture is the more often the case. The clinical result at long term depend on the integrity of the brevis fexor hallucis tendon. On the other hand, an old rupture is more uncommon.

Results

A case report of a old closed rupture of the longus flexor hallucis tendon on young women, the authors performed an arthrodesis of the hallux articulation with an excellent result.     

Tensile strength of a weave tendon suture using tendons of different sizes

Background

This study compared the maximum load, stress, elongation at failure and the mode of failure of three kinds of tendons most frequently used for tendon grafting and tendon transfers, using the Pulvertaft weave suture.

Methods

Sixty tendons were used from fresh human cadaver upper and lower extremities. The performed repairs included: 9 specimens of flexor digitorum superficialis or profundus tendon with flexor digitorum superficialis or profundus tendon (thick–thick suture), 10 specimens of flexor digitorum superficialis or profundus tendon with palmaris longus tendon (thick–medium thin suture), and 10 specimens of flexor digitorum superficialis or profundus tendon with plantaris tendon (thick–thin suture).Material testing machine was used to test repairs to failure.

Findings

The mean maximum load at failure increased with the thickness of donor tendon. For the thick–thick specimen, the maximum load at failure was 125 newtons (N), for the thick–medium thin specimen it was 86,8 N, and for the thick–thin it was 65,2 N. These differences were all statistically significant.

Interpretation

The active rehabilitation protocol is possible only with thick–thick connections used, the strength of the thick–medium thin connection is on the border of indications for the active rehabilitation protocol, and the thick–thin connection strength is sufficient only for the passive rehabilitation protocol.     

腱鞘修复材料的研究进展

肌腱与周围组织粘连是临床中难以解决的问题之一,严重影响患者术后功能恢复。肌腱粘连的发生主要是在修复过程中,肌腱周围组织通过腱鞘向损伤处增生和侵入,形成异常的纤维化瘢痕愈合。因此,保持肌腱腱鞘的完整性,抑制肌腱外源性愈合,对防止肌腱粘连具有重要作用。但腱鞘的损伤或缺失很难原位修复,所以选择一种良好的腱鞘替代品尤为重要。     

The Effect of Mobilization on Repaired Extensor Tendon Injuries of the Hand: A Systematic Review

Talsma E, de Haart M, Beelen A, Nollet F. The effect of mobilization on repaired extensor tendon injuries of the hand: a systematic review.

Objective

To systematically review the available evidence comparing the effectiveness of different rehabilitation regimes in repaired extensor tendon injuries of the hand.

Data Sources

A systematic literature search of the Cochrane Library, MEDLINE (1950–January 2008), PEDro (up to January 2008), EMBASE (1980–January 2008) and CINAHL (1982–January 2008) databases was conducted, and reference lists were scanned for relevant studies.

Study Selection

Studies on the rehabilitation of surgically repaired extensor tendon injuries of the hand in which patients received one of the following interventions: immobilization, early controlled mobilization, or early active mobilization.

Data Extraction

The methodologic quality of the selected studies was assessed by 2 reviewers. All randomized controlled trials, high quality controlled clinical trials, and other design studies with sufficient quality were included in the best evidence synthesis.

Data Synthesis

Four randomized controlled trials and 1 other design study were included. Short-term outcomes after immobilization were significantly inferior to outcomes after early controlled mobilization. Inconclusive findings suggested that early controlled mobilization might lead to better short-term effects (4wk postoperatively) than early active mobilization. In time, differences in effects disappeared and 3 months postoperatively no significant differences were found between early controlled mobilization and early active mobilization.

Conclusions

Although strong evidence was found for the short-term superiority of early controlled mobilization over immobilization for extensor tendons, no conclusive evidence was found regarding the long-term effectiveness of the different rehabilitation regimes. High quality prospective studies should be performed to further explore the outcomes of rehabilitation of extensor tendon injuries and to substantiate the available evidence.