A new clinical test in diagnosing quadriceps tendon rupture

INTRODUCTION

Extensor mechanism ruptures might be easily overlooked and misdiagnosed, and delayed diagnosis of quadriceps tendon rupture is frequent. However, the literature recommends early surgical repair within 72 h.

PATIENTS AND METHODS

This paper describes a new simple clinical diagnostic test that directly evaluates the integrity of the distal 5 cm of the quadriceps tendon itself. It consists of inserting a needle in the tendon, proximal to the suspected rupture and mobilising the knee joint.

RESULTS

The suspected ruptured quadriceps tendons with a positive 'needle' diagnostic test were confirmed intra-operatively.

CONCLUSIONS

This minimally invasive and easily available technique should be considered in the diagnostic work-up and treatment planning of patients with suspected tears of the quadriceps tendon.

Spontaneous reduction of a traumatic L2-L3 subluxation without fracture in a 14-year-old boy

OBJECTIVE

To report a rare case of lumbar vertebral subluxation associated with spontaneous reduction in an adolescent treated conservatively.

CLINICAL PRESENTATION AND INTERVENTION

A 14-year-old male victim of a snowboard accident, which caused a lumbar spinal injury, was referred to the emergency room with significant lumbar pain. Neurologic examination was normal. Radiographic assessment at admission showed a unilateral left lateral subluxation of the L2-L3 vertebrae without associated fractures. These findings were confirmed by CT scan and a surgical management was decided. The preoperative MRI performed 24 h after the accident, however, revealed the spontaneous reduction of the subluxation, and an associated tear of the quadratus lumborum and the psoas muscles on the right side at the level of L2, L3 and L4. Following these findings conservative treatment with a plaster brace for 2 months was carried out. The brace was removed after 2 months. The patient had no pain and the range of motion of his lumbar spine was normal. Three months after injury, sports activities were resumed. At follow-up of 24 months, the patient was free of pain and radiographs showed a right positional bending without rotational or translation anomaly.

CONCLUSION

To date, this is the first case of subluxation without fracture in a child, presenting without neurological deficit and where spontaneous reduction occurred. In this case, conservative treatment was effective and the outcome at 2-year follow-up was excellent.

Transolecranon anterior fracture dislocation

Between January 1996 and July 2003, 93 consecutive patients operated on with a diagnosis of olecranon fractures were identified from our trauma unit files. Fourteen transolecranon fracture-dislocations were found after a retrospective X-radiographic evaluation. Eight patients were women and six were men, with a mean age of 54 years. There were 4 noncomminuted olecranon fractures, treated with K-wires and single tension-band wiring. The remaining 10 fractures were complex fractures, treated in 3 cases with multiple K-wires and single tension-band wiring, in 2 by use of one-third tubular plates, in 1 with a 3.5-mm dynamic compression plate, and in the remaining 4 with 3.5-mm reconstruction plates. Ligament repair was not performed in any case. Three patients needed reoperation because of early failure of primary fixation. Patients were reviewed at a mean follow-up of 3.6 years. Two reported difficulties in daily activities, none with any symptoms of elbow instability. According to the Broberg and Morrey score, 4 patients had excellent results, 6 had good results, 2 had fair results, and 2 had poor results. Four patients showed signs of degenerative arthritis on the radiographs obtained at follow-up. We conclude that transolecranon fracture-dislocation is an underreported and misdiagnosed injury. Various fixation techniques can restore the anatomic relationships and contour of the trochlear notch; the imperative goal is to obtain a good stable primary fixation and allow early active mobilization.

Arthroscopic biceps tendon tenodesis: the anchorage technical note

Treatment of long head biceps (LHB) tendon pathology has become an area of renewed interest and debate among orthopaedic surgeons in recent years. The background of this manuscript is a description of biceps tenodesis which ensure continual dynamic action of the tendon which depresses the head and impedes lateral translation. A new technique has been developed in order to treat LHB tendon irreversible structural abnormalities associated with cuff rotator lesions. This technique entails the construction of a biological anchor between the LHB and supraspinatus and/or infraspinatus tendons according to arthroscopic findings. The rationale, although not supported by biomechanical studies is to obtain a triple, biomechanical effect. The first of these biomechanical effects which we try to promote through the procedure of transposition is the elimination of the deviation and oblique angle which occurs as the LHB completes its intra-articular course prior to reaching the bicipital groove. Furthermore, we have found this technique extremely useful in the presence of large ruptures of the rotator cuff with muscle retraction. The most common complication associated to this particular method, observed in less than 3%, is failed biological fixation which manifests as subsidence of the tenodesis and consequent descent of the tendon with evident aesthetic deformity.

Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg

Chronic exertional compartment syndrome (CECS) of the leg is a pathological condition often related to overuse in subject who engage repetitive physical activities. Fascial release is the mainstay of surgical management. The purpose of this study was to evaluate the results obtained with a double incision decompressive fasciotomy. Eighteen consecutive athletes with a diagnosis of anterior and/or lateral CECS of the leg were operated on with a minimal double incision fascial release after a mean period of 4 months after onset of symptoms. In 11 cases (61%) CECS was bilateral. Surgery was performed without tourniquet and active mobilization was starting immediately. Sports activities were resumed gradually at a mean period of 25 days. The athletes were followed until 2 years. All resumed pre-injury level sports activity. Two patients (18%) of the 11 who underwent to bilateral fasciotomy referred a sensation of leg weakness for an average period of 3 months. The surgical technique presented in this paper seems to be a good mean to treat anterior and lateral leg CECS. The use of tourniquet is deconselled to obtain an accurate intraoperative haemostasis so reducing the risk of post-operative haematoma.

Tuberculosis of the greater trochanter. Report of four cases

OBJECTIVE

To present four cases of tuberculosis of the greater trochanter.

CASE PRESENTATION AND INTERVENTION

The four cases (3 females and 1 male), aged 45-70 years, presented with mechanical pain in the trochanteric area associated with progressive swelling in the 3 female patients in whom mobility was also restricted. X-ray revealed a mass in 2 females; CT scan and MRI exhibited an abscess in the 3 females. Histological and bacteriological examinations showed Mycobacterium bovis in the 3 females and M. tuberculosis in the male. In the females, tritherapy and surgery were performed, while in the male quadritherapy and surgery. All the patients recovered and were followed up for 4-9 years.

CONCLUSION

These cases show that both chemotherapy and surgery must be synergic if tuberculosis is diagnosed and an abscess is confirmed by imaging.

Percutaneous retrograde screwing for stabilisation of acetabular fractures

OBJECTIVES

To evaluate the results of retrograde percutaneous screw fixation (PSF) in minimally or undisplaced acetabular fractures in a geriatric population.

PATIENTS AND METHODS

Between July 1998 and July 2001, 21 consecutive patients with an acetabular fracture underwent fluoroscopic guided percutaneous fixation. The mean age was 81 years (range 67--90 years). In all cases, the fracture was minimally or undisplaced (<2mm). Two cannulated cancellous 7.3mm screws were inserted in a retrograde fashion to stabilise the posterior and the anterior column. Bed to chair transfer began after 24h. Weight bearing as tolerated was allowed at 4 weeks.

RESULTS

Eighteen patients were reviewed at a mean of 3.5 years (range 2--5 years). Soft tissue dissection was minimal. There were no intraoperative or postoperative complications. At the latest follow-up there was no radiographical evidence of secondary displacement of fragments, degenerative changes, or screw failure. Fractures healed at a mean time of 12 weeks (range 8--15 weeks). Clinical results were satisfactory in 17 patients.

CONCLUSION

Our results show that percutaneous screw fixation under fluoroscopic control is a safe technique to treat some pattern of acetabular fracture.

Minimal invasive surgery for coronoid fracture: technical note

Operative treatment of coronoid fracture often requires a large dissection of soft tissue, resulting in elbow stiffness and functional limitation. The authors present a minimal invasive, safe technique, useful in the case of isolated coronoid fracture associated with elbow dislocation. This technique does not require soft tissue dissection and allows an early unlimited resumption of sports activities.

Modified triangular posterior osteosynthesis of unstable sacrum fracture

We report preliminary results for unstable sacral fractures treated with a modified posterior triangular osteosynthesis. Seven patients were admitted to our trauma center with an unstable sacral fracture. The average age was 31 years (22-41). There were four vertical shear lesions of the pelvis and three transverse fracture of the upper sacrum. The vertical shear injuries were initially treated with an anterior external fixator inserted at the time of admission. Definitive surgery was performed at a mean time of 9 days after trauma. The operation consisted in a posterior fixation combining a vertebropelvic distraction osteosynthesis with pedicle screws and a rod system, whereby the transverse fixation was obtained using a 6 mm rod as a cross-link between the two main rods. Late displacement of the posterior pelvis or fracture was measured on X-ray films according to the criteria of Henderson. The patients were followed-up for a minimum time of 12 months. Four patients who presented with a pre-operative perineal neurological impairment made a complete recovery. No iatrogenic nerve injury was reported. One case of deep infection was managed successfully with surgical debridement and local antibiotics. All patients complained of symptoms related to the prominence of the iliac screws. The metalwork was removed in all cases after healing of the fracture, at a mean time of 4.3 months after surgery. No loss of reduction of fracture was seen at final radiological follow-up. The preliminary results are promising. The fixation is sufficiently stable to allow an immediate progressive weight-bearing, and safe nursing care in polytrauma cases. The only problem seems to be related to prominent heads of the distal screws.

Reverse HAGL: a possible complication of a tight anterior gleno-humeral stabilization

Recently the posterior humeral avulsion of the glenohumeral capsule (Reverse HAGL or RHAGL) has been reported in the orthopaedic literature as another possible cause of posterior traumatic shoulder instability. In the present paper we describe three patients in whom a RHAGL was probably a consequence of a tight open anterior shoulder stabilisation. The main complaint of these patients was a stiff shoulder after an open anterior stabilisation. A progressive and worsening discomfort was reported by patients in spite of an accurate rehabilitation program. At persistence of symptoms arthroscopy was performed with evidence of RHAGL that was repaired in association with an anterior release. Clinical and functional improvement was observed but the final outcome seems to be related to range of motion recovery and not only to the posterior repair.

Die Behandlung von Acetabulumfrakturen bei geriatrischen Patienten mittels modifizierter Kabelcerclage und prim�rer H�fttotalprothese

This prospective study addresses early results of the treatment of acute acetabular fractures in elderly patients by total hip arthroplasty and cerclage wiring. Fifteen patients with an average age of 81 years were treated at our institution between February 1998 and December 2000. There were two transverse fractures, eight T-shaped fractures, two transverse fractures with associated posterior wall fracture, two posterior column fractures with associated posterior wall fracture, and one fracture of both columns. Treatment consisted of cerclage wiring of the fracture and primary non-cemented total hip replacement. All of the patients were followed for a mean of 36 months. Although there was one patient with three hip dislocations during the first 10 months after the operation, we found an excellent or good result for the entire group. During this relatively short follow-up period, we have not found a radiological loss of fracture reduction of more than 1 mm or a cup migration of more than 3.2 mm. All of the fractures healed and no loosening of the implant was evident. Primary total hip arthroplasty combined with internal fixation is a valid treatment option for acetabular fractures in the elderly. Preliminary results are convincing, but a bigger patient population and a longer follow-up time are necessary before we are able to draw final conclusions.

Post-traumatic overload or acute syndrome of the os trigonum: a possible cause of posterior ankle impingement

The purpose of this paper is to discuss the post-traumatic overload syndrome of the os trigonum as a possible cause of posterior ankle impingement and hindfoot pain. We have reviewed 19 athletes who were referred to our foot unit between 1995 and 2001 because of posterior ankle pain, and in whom a post-traumatic overload syndrome of os trigonum was diagnosed. All these patients were followed up over a period of 2 years. In 11 cases a chronic repetitive movements in forced plantar flexion was found. In the other eight cases the pain appeared to persist after a standard treatment of an ankle sprain in inversion plantar flexion. The diagnosis was based on clinical history, physical examination and X-rays that revealed a non-fused os trigonum. The confirmation of diagnosis was carried-out injecting local anaesthetic under fluoroscopic control. In all cases a corticosteroid injection as first line treatment was performed. In 6 cases a second injection was necessary to alleviate pain because incomplete recovery with the first injection. Three cases (16%) were recalcitrant to this treatment and in these three cases a surgical excision of the os trigonum was carried out. Our conclusion is that after some chronic athletic activity or an acute ankle sprain the os trigonum, if present, may undergo mechanical overload, remain undisrupted and become painful. Treatment by corticosteroid injection often resolves the problem.

Fracture of the non fused os trigonum, a rare cause of hindfoot pain. A case report and review of the literature

A case of "astrigonum" fracture is described. The Authors described the history, clinical signs, radiographic picture of this lesion. Conservative treatment lead to healing with good result, when the diagnosis is promptly made.

Manipulative therapy in the treatment of benign cervicobrachialgia of mechanical origin

The authors compared two methods of rehabilitation, traditional physical therapy and manual therapy, in the treatment of benign cervicobrachialgia of mechanical origin, typical of young subjects, generally consequent to mild and moderate trauma, occasional strain or incorrect posture repeated in time. A MID (minor intervertebral deficit) is at its origin, characterized by the absence of objective instrumental signs (X-ray, CT scan, MRI) and it is only diagnosed based on clinical history and accurate physical examination of the spine segment involved. A sample of 80 patients was divided at random into two groups: the first group was submitted to traditional physiotherapy, the second to manipulative therapy carried out according to the French method of R. Meigne. The results obtained, which were evaluated by univaried ANOVA and Student's "t" test statistical analysis, showed the greater effectiveness of manipulative treatment, in the short term and in the long term.

The surgical treatment of hallux valgus using distal metatarsal osteotomy and stabilization with a hallux splint. Preliminary results

The preliminary results of the surgical treatment of hallux valgus using subcapitate chevron-type osteotomy of the 1st metatarsal modified using a dynamic interfragmentary device are reported. The method satisfies the need to restore angular metatarsophalangeal and intermetatarsal values and improves metatarsal pain caused by hallux valgus correction, which influences the cosmetic results.

Sub- or intertrochanteric fracture following screw fixation of an intracapsular proximal femoral fracture: true complication or technical error?

PURPOSE

To review, retrospectively, the possible causes of sub- or intertrochanteric fractures after screw fixation of intracapsular fractures of the proximal femur.

METHODS

Eighty-four patients with an intracapsular fracture of proximal femur were operated between 1995 and 1998 by using three cannulated 6.25 mm screws. The screws were inserted in a triangular configuration, one screw in the upper part of the femoral neck and two screws in the inferior part. Between 1999 and 2001, we use two screws proximally and one screw distally.

RESULTS

In the first series, two patients died within one week after operation. Sixty-four fractures healed without problems. Four patients developed an atrophic non-union; avascular necrosis of the femoral head was found in 11 patients. Three patients (3.6%) suffered a sub- and/or intertrochanteric fracture after a mean postoperative time of 30 days, in one case without obvious trauma. In all three cases surgical revision was necessary. Between 1999 and 2001 we did not observe any fracture after screwing.

CONCLUSION

Two screws in the inferior part of the femoral neck create a stress riser in the subtrochanteric region, potentially inducing a fracture in the weakened bone. For internal fixation for proximal intracapsular femoral fracture only one screw must be inserted in the inferior part of neck.

[Hemilithotomy position for intramedullary nailing of the femur and compartment syndrome of the healthy leg]

The well leg compartment Syndrome following long procedures in the dorsal lithotomy or hemi-lithotomy position is a rare complication. Its diagnosis is usually late and the neurological deficit are often permanent. We report two cases of femoral nailing complicated by Compartment Syndrome of the contralateral leg. We review the published literature on 40 cases which suggests a clear relationship between these positions, the duration of the intervention and the degree of leg elevation. Given the potentially severe sequel, prevention is a must and a high degree of suspicion is the key to an early diagnosis. A modified hemi-lithotomy position is proposed. That avoids extreme elevation of the leg and diminishes the hip and knee flexion required while allowing adequate fluoroscopy.

Lumbar disc herniation and cauda equina syndrome. Considerations on a pathology with different clinical manifestations

The authors describe six cases of cauda equina syndrome (CES) with different clinical manifestations, etiopathogenetic causes, and degrees of disc prolapse. In three of the cases, the clinical onset was dramatic and acute, in the others it was a hemisyndrome (with acute onset in only 1 case). The site of the disc prolapse was L4-L5 in 3 patients, L3-L4 in 2 patients, and L5-S1 in 1 patient. The authors emphasize the need for the early recognition of the syndrome with a careful clinical examination and history of the patient, as well as timely treatment within 24 hours. For the sake of prevention, and particularly when the hernia is large, the authors suggest monitoring of the stability of the residual disc during surgery and postoperatively the use of a brace for at least one month.

Health care issues of gay and lesbian youth

Gay and lesbian youth are adolescents who, in many ways, are no different from their peers. What distinguishes homosexual youth from other adolescent populations is the emotional, psychological and physical trauma resulting from the homophobia they experience in their daily lives. Although suicide, HIV infection, substance use, and violence appear to disproportionately affect this population, most homosexual youth grow up healthy and happy. Frequently lost in discussions of risk and risk behaviors is an appreciation of the strengths very much present in these young people. Health care providers must remain aware of the unique issues and health risks of homosexual youth but must also remember to address each patient as an individual within the context of general adolescent development. By doing so, pediatricians can play a vital role in preserving and enhancing the health of this "at-risk" population.

Management of the asymptomatic HIV-infected patient: an update

Guidelines for initiating antiretroviral therapy in asymptomatic patients continue to be debated. Physicians and patients should decide whether drug treatment is advisable after jointly considering psychosocial issues as well as measurements of immune function and HIV burden. Other components of care include appropriate immunizations, screening for other sexually transmitted infections, safer-sex counseling, and referral for substance abuse treatment, if indicated.

[The usefulness of the association of clinical probability, rapid plasma measurement of D-dimer, compression echography of the lower limbs and echocardiography in the diagnosis of acute pulmonary embolism]

BACKGROUND

The aim of this study was to investigate the diagnostic utility of clinical probability, rapid plasma D-dimer assay, compression ultrasonography (CUS) and transthoracic echocardiography (TTE) in patients with suspected pulmonary embolism.

METHODS

One hundred forty consecutive outpatients with suspected pulmonary embolism were enrolled in a prospective trial. We evaluated sensitivity, specificity, positive and negative predictive value of a combination of clinical probability, D-dimer, CUS and TTE using perfusion lung scan and pulmonary angiography as a combined gold standard for determining the presence or absence of pulmonary embolism. Clinical probability was assessed in accordance with the PIOPED criteria. The D-dimer (Nycocard) level was considered as abnormal > 0.3 mg/l, the CUS if incompressibility of the leg veins was showed, and the TTE if right ventricular dilation was present, in the absence of chronic pulmonary disease. The combination of these tests was considered consistent with the presence of pulmonary embolism if D-dimer plus CUS and/or TTE showed abnormal results. A pulmonary embolism was excluded if D-dimer and CUS showed normal findings or a low clinical probability was associated with normal findings of CUS and TTE.

RESULTS

One hundred eleven patients were evaluated. Pulmonary embolism was present in 45/111 (40%) patients. The combination of tests showed positive findings in 39/39 patients with pulmonary embolism, negative findings in 47/50 without pulmonary embolism and non-diagnostic results in 22/111 (20%) patients (95% confidence interval--CI 12-28%). There were three false positive and no false negative results. Sensitivity and specificity were 100 and 94% respectively (95% CI 92-100% and 87-100%); positive and negative predictive values were 93 and 100% (95% CI 85-100% and 93-100%). None of these tests, separately, showed enough sensitivity and specificity.

CONCLUSIONS

The combination of clinical probability, D-dimer, CUS and TTE was highly accurate to confirm or rule out pulmonary embolism.

Sexual orientation and risk of suicide attempts among a representative sample of youth

OBJECTIVE

To examine whether sexual orientation is an independent risk factor for reported suicide attempts.

DESIGN

Data were from the Massachusetts 1995 Centers for Disease Control and Prevention Youth Risk Behavior Survey, which included a question on sexual orientation. Ten drug use, 5 sexual behavior, and 5 violence/ victimization variables chosen a priori were assessed as possible mediating variables. Hierarchical logistic regression models determined independent predictors of suicide attempts.

SETTING

Public high schools in Massachusetts.

PARTICIPANTS

Representative, population-based sample of high school students. Three thousand three hundred sixty-five (81%) of 4167 responded to both the suicide attempt and sexual orientation questions.

MAIN OUTCOME MEASURE

Self-reported suicide attempt in the past year.

RESULTS

One hundred twenty-nine students (3.8%) self-identified as gay, lesbian, bisexual, or not sure of their sexual orientation (GLBN). Gender, age, race/ethnicity, sexual orientation, and all 20 health-risk behaviors were associated with suicide attempt (P<.001). Gay, lesbian, bisexual, or not sure youth were 3.41 times more likely to report a suicide attempt. Based on hierarchical logistic regression, female gender (odds ratio [OR], 4.43; 95% confidence interval [CI], 3.30-5.93), GLBN orientation (OR, 2.28; 95% CI, 1.39-3.37), Hispanic ethnicity (OR, 2.21; 95% CI, 1.44-3.99), higher levels of violence/ victimization (OR, 2.06; 95% CI, 1.80-2.36), and more drug use (OR, 1.31; 95% CI, 1.22-1.41) were independent predictors of suicide attempt (P<.001). Gender-specific analyses for predicting suicide attempts revealed that among males the OR for GLBN orientation increased (OR, 3.74; 95% CI, 1.92-7.28), while among females GLBN orientation was not a significant predictor of suicide.

CONCLUSIONS

Gay, lesbian, bisexual, or not sure youth report a significantly increased frequency of suicide attempts. Sexual orientation has an independent association with suicide attempts for males, while for females the association of sexual orientation with suicidality may be mediated by drug use and violence/victimization behaviors.