Gartland type III extension supracondylar humerus fracture in a 10-year-old child. A surgical case report of an infrequent technique of medial and lateral column stabilization

INTRODUCTION AND IMPORTANCE

Supracondylar humeral fractures in children are the most common fractures of the elbow accounting for 16 % of all pediatric fractures. The treatment depends on age, the degree of displacement, and the presence of additional injuries.

PRESENTATION OF CASE

A case reports a 10-year-old girl with a Gartland type III supracondylar humeral fracture accompanied by anterior interosseous nerve neurapraxia preoperatively. The patient was treated operatively with medial and lateral column cross-pinning using four K-wires due to unsatisfactory closed reduction and lateral pinning only. Follow-up examinations performed in 1 and 6 months postoperatively revealed a 10° flexion contracture of the elbow with good functional and radiological results otherwise.

CLINICAL DISCUSSION

The main intervention was not focused on the AIN neuropraxia itself but on unsatisfactory closed reduction followed by cross-fixation with lateral pinning only. A standard anterior approach to visualize the fracture line, free interposing tissues, and perform stabilization was utilized. The unusual use of an additional medial pin formed a cross-frame to adequately support the medial cortex.

CONCLUSION

Closed reduction and percutaneous pinning are the preferred treatment options for most displaced supracondylar fractures. The open reduction via anterior approach and pinning for Gartland type III fracture gives good outcomes. Medial pinning is mandatory in particular fracture patterns and in case of unsatisfactory closed reduction. In the presented case medial and lateral column cross-pinning technique using four K-wires guaranteed no subsequent displacement on follow-up assessment and good results.

Optimizing pain relief in a specialized outpatient palliative radiotherapy clinic: contributions of a clinical pharmacist

PURPOSE

Bone metastases are the most common cause of cancer pain, with palliative radiotherapy (RT) the mainstay of treatment. However, relief from RT may be delayed, incomplete, or short-lived and therefore optimized pharmacologic therapy is essential. Our objective was to describe the contribution of the clinical pharmacist (CP) to an outpatient palliative RT clinic.

METHODS

The Edmonton Symptom Assessment System, an 11-point scale for measuring nine symptoms, and other validated screening tools were administered, and a medication history performed by the CP. Baseline CP assessment also included opioid toxicity, need for supportive medications, and drug interactions. Anonymized clinical information was collected prospectively and descriptive statistics were compiled including themes of counselling performed by the CP.

RESULTS

The CP reviewed 114 patients over 140 clinic visits (01/2007-12/2008). Median age was 68.3 years, 68.4% were male and 36.8% had prostate cancer. All symptoms improved or stabilized in ≥ 80% by 4 weeks. Median pain score was 6/10 (SD 2.6) at baseline, and 2.1/10 (SD 2.4) by week 4. Average morphine equivalent daily dose was 76.8 mg at baseline and 44.5 mg at week 4. CP assessment included screening for opioid toxicity (87.9%), recommending a change in analgesic (28.9%), and liaison with the community pharmacy (17.1%). Medication counselling took place in 84.3% of visits, on bowel routine (85.6% of the time), opioids (82.2%), and hydration (40.7%).

CONCLUSIONS

The CP plays a key role in holistic patient assessment and optimization of pharmacologic therapy, contributing to improved symptom control of patients receiving palliative RT.

Correlation of IL-1alpha and IL-4 gene polymorphisms and clinical parameters in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a serious disease characterized with progressive scarring of the lungs in which a genetic background is supposed. We have tested correlation of promotor regions of IL-1alpha and IL-4 gene polymorphisms with clinical parameters in IPF. We investigated the group of 30 patients with IPF. The correlations of vital capacity (VC) and diffusing capacity for carbon monoxide (DL(CO)), bronchoalveolar lavage (BAL) fluid cell counts and high resolution computed tomography (HRCT) alveolar and interstitial scores with different genotypes of IL-4 at (-1098), (-590) and (-33) positions and IL-1 alpha at (-889) position were tested. The PCR method was used for genotyping. The carriers of CT genotype at IL-1 alpha (-889) position had higher VC at the time of diagnosis. The CC genotype at this position was more frequent in patients with higher counts of HLADR+ T lymphocytes in BAL. The GT genotype at IL-4 (-1098) position correlated with higher counts of CD4(+) T lymphocytes, and inversely the TT genotype with higher counts of CD8(+) T lymphocytes in BAL fluid. According to dynamic changes of HRCT score the CT genotype at IL-4 (-33) was more frequent in patients with progressive disease compared to that with stable disease. We assume from our data that the gene polymorphisms of the promotor region of IL-4 at position (-1098) and (-33) and IL-1 alpha at position (-889) are likely to play a pathogenic role in IPF and in modification of its clinical presentation and severity.

Extrinsic allergic alveolitis: comparative study of the bronchoalveolar lavage profiles and radiological presentation

INTRODUCTION

Extrinsic allergic alveolitis (EAA) is an immunologically mediated interstitial lung disease. The abnormalities in the bronchoalveolar lavage (BAL) fluid cell counts are almost always seen in patients with EAA according to the stage of the disease. The aim of this retrospective study was to find out how the BAL lymphocyte count, percentage of lymphocytes expressing HLA-DR, CD4/CD8 T cell ratio in BAL fluid, and the concentration of immunoglobulin G in serum correspond to the inflammatory activity of the disease.

METHODS

The study included 14 patients with EAA. BAL fluid samples were obtained and processed for cytological and cytometric analysis. Immunoglobulin G serum concentrations were measured. High resolution computed tomography (HRCT) scoring system modified by Gay was used for establishing the alveolar and interstitial score in each patient.

CONCLUSIONS

It was found that subjects with normal value of CD4/CD8 ratio in BAL fluid had higher interstitial HRCT score. Clinical presentation, continuous exposure to the causative antigens, and BAL lymphocyte count positively correlated with the alveolar HRCT score. It is proposed that the increased BAL lymphocyte count could be the predictor of the inflammatory activity of the disease, especially in people with lasting exposure to the offending antigen.

Avulsion fracture of the pelvis: separation of the secondary ossification center in the superior margin of the acetabulum

A 13-year-old female sustained a rare avulsion fracture of the secondary ossification center in the superior margin of the acetabulum as the result of contraction of the reflected head of the rectus femoris muscle. Diagnosis was made from plain films and CT scans with 3D image reconstruction. The patient was treated non-operatively by bed rest with semiflexion of the hip and knee, and appropriate analgesia.

[Kramer's distal I metatarsal osteotomy in the treatment of halluces valgi]

The paper presents the surgical technique for Kramer's distal I metatarsal osteotomy and the results of halluces valgi treatment in 23 patients. The mean age of the patients was 48.6 years and mean follow-up time was 4 years and 5 months. Final clinical and radiological evaluation was performed according to Kramer's scale. Excellent and good results were found in 54% of the cases, fair in 32% and bad in 14%. This simple extraarticular osteotomy, without use of any external immobilization yielding three-dimensional correction is a useful method for treatment of hallux valgus.

[Efficacy of operative treatment for pathological fractures in bone metastases in relation to length and comfort of survival]

The paper presents a retrospective evaluation of 47 patients with bone metastases treated surgically during the last 10 years at our ward. The mean age of the patients was 62.5 years. There were 31 females (mean age: 62.8 years) and 16 males (mean age: 62.3 years). In 37 cases (78.8%) it as possible to establish the primary localization of the tumour: breast carcinoma--16 cases, ovary cancer 5 cases, lung cancer--5 cases, prostate cancer--5 cases, kidney cancer--2 cases, stomach cancer--1 case, vagina cancer--1 case, hepatocarcinoma--1 cases and plasmocytoma--1 cases. In 10 cases (21.1%) we were unable to establish the primary focus of the tumour. The localization of the metastases was as follows: femur--32 cases, humerus--6 cases, tibia--3 cases, lumbar spine--1 case. Patients treated very briefly after qualification for surgery, in some cases during emergency service. In 2 cases of metastases to the tibia amputations at the femur were performed. The remaining patients were treated by local excisions of the metastatic tumours, followed by: in 33 cases internal osteosynthesis and bone cement application; in 7 cases osteosynthesis, in 4 cases hip arthroplasties and posterior spine instrumentation in 1 case. In 6.4% we had poor results because of the death of 3 patients. The mean follow-up was three months. In 93.6% we had good and very good results--no pain, good function and independence during daily activities. Mean survival time was 13.5 month (range 5-28 months).

[Percutaneous lumbar sympathectomy--presentation of a new trans-diskal approach]

The authors present the technique of chemical lumbar sympathectomy by an anatomically new medial transdiscal approach. On a group of 80 operations they analyze the indication criteria, complications and results of this method. They compare the percutaneous technique of severing of the sympathetic nerve with the classical surgical approach. In 41 patients where a modified transdiscal approach was used the authors did not encounter any serious complications. Using thin needles (minimum 23-G) they recommend this method as an alternative of the classical approach of Kappis.

[The analysis of causes of divergence between clinical and radiological results of conservative treatment for distal radius fracture in patients over 50 years of age]

A series of 231 distal radius fractures treated with closed manipulation and cast immobilization has been retrospectively evaluated. Excellent and good results were reported in 69.7% (according to patient's evaluation), in 67.1% according to Gartland-Werley clinical criteria and in 52.4% according to Sarmiento radiologic scale. Fair and poor results constitute circa 30% of results; their share increases as the Frykman fracture type increases and so increases the divergence between clinical and radiologic results.

[Influence of patient's age and fracture morphology on the final result of conservative treatment]

Three hundred and thirty-three cases of the distal radius fractures have been retrospectively analyzed. The patients were divided into 4 age groups (15-29, 30-49, 50-69 and above 70 years of age) and into 8 groups according to Frykman's classification of fracture morphology. Excellent and good results in the first and second age group were found in 84.3% (patients evaluation), in 85.3% (clinical evaluation according to Gartland-Werley criteria) and in 87.2% (radiologic Sarmiento scale). The scores in age groups III and IV were 69.7%, 67.1% and 52.4% respectively. Extraarticular fractures (Frykman I and II) were found in 69.7% in age groups II and I and in 37.3% in group III and IV. Excellent and good results in the extraarticular fractures group were found in 88% subjectively, 84.2% clinically and in 85.1% radiologically whilst in the intraarticular fractures group in 57.6%, 59.3% and 37.4% respectively. Clinical and radiologic results worsen as the fracture morphology gets more complicated and this occurs with increasing age of the patient.

[A comparison of kinesitherapy with and without continuous passive motion (CPM) after the entire allograft surgery of the knee]

A prospective randomized single blind investigation after total knee arthroplasty was performed to evaluate two rehabilitation protocols (one with CPM and the other without CPM). A series of 87 consecutive total knee arthroplasties in 76 patients (72 women and 4 men) was analyzed. The average age of the patients was 64.7 years. Kinesitherapy with CPM was performed in 30 (34.5%) cases, where as in 57 (65.5%) cases kinesitherapy without CPM was performed. Early functional results according to the HSS scale were assessed on the 14th day after surgery. In the group treated with CPM there were 26.7% excellent results, 70.0% good results and 3.3 satisfactory results. The group treated without CPM there were 26.3% excellent results, 70.2% good results and 3.5% satisfactory results. No statistically significant differences were noted between the results yielded by these two rehabilitation protocols.

[Own experience with the use of Charnley hip arthroplasty and preliminary results of treatment in the materials of the Department]

Early clinical and radiological results of Charnley hip arthroplasties performed in 1995-1998 in Department of Orthopaedics and Traumatology of Zeromski's City Hospital in Cracow are presented. Control evaluation was made in 86 hips (76 patients) among 155 hips (170 patients) which were done in this Department. 97 per cent good results in clinical and 100 per cent good results in radiological evaluation were found in controlled group. In group of 170 alloplasties were 4.1 per cent local and none system complications. Results in this series confirm Charnley prosthesis as a most effective device in treatment of many hip pathologies.

[Carpal instability after fractures of the distal end of the radius]

Evaluation of the scapho-lunate angle (SLA) was made on the lateral X-rays of 335 cases after Colles' fracture. Value of SLA over 65 degrees was accepted as the sign of the dorsal intercaleted segmental instability of the wrist (DISI). In the material was stated 84 cases (25%) of the DISI. Frequency of the incidence of the DISI was analysed according to fracture type and the age of the patient. More frequent incidence of the DISI was discovered in the intraarticular fractures (44%) than in the extraarticular (20%). The difference between fractures with or without dislocation was not so great (27% tp 21%). Increasing percent of the DISI was stated in the older age-groups (the greatest--49%--in the group after 70-years old).

[Intrathoracic occurrence of post-transplantation lymphoproliferation]

In the submitted case-history the authors wished to draw attention to serious complications after transplantation. Posttransplantation lymphoproliferation (PTLP) is a rare complication of organ transplantation, its incidence amounts to some 2% of organ recipients, in combined heart-lung transplantations the incidence is as high as 10%. The prerequisite of lymphproliferations is infection with the Epstein-Barr virus. The virus causes transformation of B lymphocytes and subsequent lymphoproliferation. Immunosuppressive preparations, due to their effect on Tlymphocytes promote this transformation. The decisive imaging method in tumoriform occurrence is high resolution computed tomography. Based on CT examination surgical biopsy is performed with subsequent in situ hybridization which confirms unequivocally the diagnosis of posttransplantation lymphoproliferation. Only on the basis of results of in situ hybridization treatment may be started which involves restriction or discontinuation of immunosuppressive treatment and administration of antiviral preparations. Frequently this treatment fails and must be discontinued on account of a rejection reaction of the organism. The prognosis in untreated forms is adverse.

[Fractures in osteoporosis as a social, economic and therapeutic problem]

The most serious consequence of osteoporosis are fractures of the bones. The fractures mainly affect: the vertebral bodies, the hip, the distal radius, the proximal humerus and the pelvis. The fractures occur more commonly in women than men and affect the population after 45 years of age. Increasing, in the recent years, frequency of the osteoporotic fractures and high cost of their treatment made from this question the serious public health problem. In the procedure of the orthopaedic treatment of osteoporotic fractures (particularly in the most serious of them--the hip fracture) are used most commonly the operative methods of internal fixation. This procedure gives a possibility to quick mobilisation of the patient and prevents many of complications connected with non-operative treatment and long-term immobilisation.

Glottal airflow characteristics of women's voice production along an aging continuum

Anatomical and physiological changes of the speech production mechanism that occur with aging may result in phonatory distinctions between older and younger speakers. This investigation examined amplitude-based glottal airflow characteristics from sustained vowel production in healthy adult women. Sixty women participated in this study, 10 each in six age groups of 20-, 30-, 40-, 50-, 60-, and 70-year-olds. Measures included peak, alternating, and minimum glottal airflow. Additionally, a ratio of minimum to peak glottal airflow was calculated. Results from an analysis of variance indicated no significant group mean difference for any of the dependent measures. A greater variability in peak glottal airflow for the 70-year-old age group as compared to the 20-year-old age group was found. None of the dependent variables were significantly related to age and therefore were not good predictors of age. The results imply that laryngeal senescence in healthy women may not be significant enough to affect the magnitude of phonatory function parameters. Either the assumed anatomical changes produce less significant phonatory change in the healthy individual or the healthy individual is more capable of using strategies to counteract degenerative laryngeal changes.

[3-D CT imaging of skeletal trauma]

The authors draw attention to another method for diagnostic visualization, i.e. three-dimensional reconstruction CT. They demonstrate some typical cases of possible application of this method. Despite the great asset of the method they draw attention to the fact that it is a selective and limited method.

[An unusual case of extensive false aneurysm of the superior gluteal artery]

The authors describe an uncommon case of a false aneurysm of the superior gluteal artery, most probably of post-traumatic aetiology. The condition was resolved by exclusion of the aneurysm from the circulation. In the available literature no reference to a similar clinical finding and its treatment was found.

[Hyperparathyroidism and parathyroidectomy in dialyzed patients]

The authors present older and more recent views regarding the pathogenesis of hypocalcaemia and secondary hyperparathyroidism in patients with chronic renal failure with emphasis on the impact of inorganic phosphate retention and lack of 1,25-dihydroxyvitamin D3 in body fluids. As regards therapeutic procedures the initial problem is to control hyperphosphataemia and to suppress the increased parathormone secretion in particular in dialyzed patients. When treating hyperphosphataemia it is necessary with regard to the severity of the finding to use concurrently several procedures and avoid aluminium phosphate binders. Aimed reduction of high parathormone levels in the blood stream can be achieved by medicamentous--pharmacological means, using 1,25 (OH)2 D3 or surgery of the hypertrophic parathyroid glands. The term parathyroidectomy can comprise also percutaneous infiltration of the parathyroid glands with ethanol. From this aspect under certain circumstances a combination of different therapeutic procedures may prove useful. In the conclusion the authors mention basic data on para-thyroidectomies performed in their department: the favourable long-term results of operations amounted to 80.4%.

[Alcohol block of the celiac plexus in severe visceral pain]

The authors present their own experience with percutaneous alcohol block of the coeliac plexus. Between April 1988 and December 1991 they used it in 22 patients. Except one patient the others suffered from severe pain of abdominal organs associated with carcinoma of the pancreas. The first four operations were made using angiography, the remainder under CT control. During evaluation of results two weeks after the intervention complete regression of pain was recorded in six patients. A partial effect was achieved in 11 patients, and the intervention failed in five patients. The intervention was repeated in four patients. The authors emphasize that the procedure is relatively simple and safe, and if successful, makes it possible to reduce or even eliminate opiates. It improves the quality of the remaining life of the patient.

[Fracture of the acetabular cup as an early complication of total hip replacement]

The authors have presented 12 patients with non traumatic fracture of the acetabular cup of the Weller hip prosthesis. All the fractures have occurred 10 to 40 months following hip arthroplasty 9 of the broken sockets have been removed at the time of revision arthroplasty. They showed marked destruction with multiple fragmentation of the polethylen. The area of the destruction was surrounded by active tissue reaction described as resorbtion granulation. The remowed fragments of the polethylen have been examined physicochemically and showed marked increase in the degree of crystalisation. The authors have come to the conclusion that the main reason for the failure of the presented series of the polietylene cups was defect of the material used in their production.

[Pseudotumor of the left epigastrium]

The authors describe the case of a patient with an accessory spleen located between the spleen and upper pole of the left kidney. A repeated sonographic examination suggested a suspicion for a kidney tumour, shape anomaly of the spleen, accessory spleen or kidney, but did not exclude even benign tumour in retroperitoneum. Computer tomography proved a formation between the upper pole of the kidney and the spleen, whose density characteristic after a rapid intravenous injection of 60% Verografin at the amount of 1 ml per kg body weight was the same as that of the spleen. Only angiographic examination revealed that the case is an accessory spleen and not a tumour.

[Comprehensive diagnosis of tumors of the statoacoustic nerve]

The authors describe first the diagnosis procedure in tumours of the statoacoustic nerve, and analyze the reasons of their late detection. In the submitted paper they analyze in detail the applied examination methods. Consistent with data in the literature, they state that the greatest contribution to diagnosis is that of objective audiometry computed tomography has the final word in diagnosis; the authors proved by CT in a group of 37 examined patients in 21 a neurinoma of the statoacoustic nerve or another expansive lesion of the posterior cranial fossa.