Orthopaedic surgeons in Yorkshire--are we ATLS positive?

INTRODUCTION: In 1993, the Major Trauma Working Group of Yorkshire proposed that hospitals should be accredited as Trauma Reception Hospitals with a policy for the response to the arrival of a trauma patient. These requirements include specific criteria for orthopaedics. METHODS: To evaluate if these criteria are being fulfilled, we carried out an audit comparing the response in the hospitals within the Yorkshire deanery to the arrival of major trauma. All consultant and middle-grade orthopaedic surgeons on call for trauma were contacted and questioned as to their ATLS provider status and involvement in the "trauma call". RESULTS: 16 hospitals were included of which 13 have a "trauma team". 191 surgeons (96% response) were included. 175 have completed an ATLS course. Of these, 72 (41%) had out-of-date qualifications. Only 9 (13%) were waiting to revalidate. Variation was seen in the frequency of accident and emergency department attendance by different grades of surgeon for major trauma. DISCUSSION: All hospitals have a response for major trauma although variations occur. The vast majority of orthopaedic surgeons in Yorkshire have been adequately trained in ATLS management (more so than any study has previously shown), particularly the middle grades, who are usually first to attend. The level of revalidation is low and reasons for this are discussed with recommendations for revalidation in the future.

An easy and accurate preoperative method for determining tibial nail lengths.

Estimating the correct nail length for solid tibial nails can be problematic. Most techniques reported in the literature for determining tibial nail length are not accurate. In a retrospective study of 16 patients in our unit, only three had ideal nail sizes. In these patients, as part of phase I of our study, we measured their normal leg's length from knee joint line to ankle joint line. An ideal nail length for each of these patients was estimated from a whole length radiograph of the nailed tibia. Comparing these two data, we found that deducting 20 mm from the leg measurement gave appropriate nail lengths. We also compared this with three other anthropometric measurements; tibial tuberosity to medial malleolus, joint line to medial malleolus and olecranon to head of V metacarpal head distance. The joint line to joint line measurement was the most reliable and showed the best correlation with ideal nail lengths (0.982). In phase II, a prospective study on 15 patients, we used the joint line to joint line measurement to determine nail sizes. A postoperative review of the radiographs showed all the nails to be of adequate length. This strengthened the fact that the joint line to joint line measurement is the most accurate and easy method to determine tibial nail lengths.

The crossing of the spinothalamic tract.

The question whether the spinothalamic and spinoreticular fibres cross the cord transversely or diagonally was investigated in cases of anterolateral cordotomy and in a case of thrombosis of the anterior spinal artery. The pattern of sensory loss following transection of the anterolateral quadrant of the cord consists of a narrow area of decreased nociception and thermanalgesia at the level of the incision; it extends for 1-2 segments cranial and cordal to the incision. This area is immediately cranial to the area of total loss of these modalities. This pattern of sensory loss is explained as follows. The cordotomy incision transects two groups of fibres: those that are already within the anterior and anterolateral funiculi and those that are crossing the cord. The area of total thermanaesthesia and analgesia is due to transection of fibres that are already within this region. The area of partial sensory loss is due to transection of the fibres that are crossing the cord at that level. Owing to the craniocaudal extent of the branches of the dorsal roots, there is an overlap of their collaterals that results in every spinothalamic neurone receiving an input from several dorsal roots. The narrow cordotomy incision thus divides the few fibres crossing at that level, causing diminished noxious and thermal sensibility over a few segments above and below the incision. These facts can be accounted for only on the assumption that these spinothalamic fibres are crossing the cord transversely. This evidence of transverse crossing was found in the cervical, thoracic and lumbar segments. There were three of 63 cordotomies for which this explanation of the partial sensory loss could not be maintained. Although no explanation has been suggested, this is unlikely to be due to the fibres crossing the cord diagonally.

Using metadata to create navigation paths in the HealthInsite Internet gateway.

The objective of this study was to evaluate the HealthInsite topic query technique, which uses a dynamic database search to assign resources to a topic. It is an alternative to the explicit classification technique, which relies on the classification of each resource using a predefined classification scheme. We performed a recall-precision analysis on all topics within the broad topic area of Child Health. Recall and precision errors were checked to determine which part of the information retrieval process was at fault. We then compared the topic query technique with the explicit classification technique. The results show errors or problems at every stage of the information retrieval process. This has initiated a review of all the tools used in the process, from indexing guidelines to the search engine. While many errors could be corrected, there were still features of the explicit classification technique that could not be achieved by the topic query technique. In conclusion, the topic query technique has the advantage of flexibility, but close co-operation between the different information retrieval specialists is needed to get the best results. The HealthInsite topic navigation structure should be regarded as an organized set of predefined searches rather than a full classified listing.

Vestibulospinal, reticulospinal and descending propriospinal nerve fibres in man.

The course and location of vestibulospinal, reticulospinal and descending propriospinal fibres in man are reported. The investigation was carried out on three patients with supraspinal lesions, four with transection of the spinal cord and 33 with anterolateral cordotomies. The lateral vestibulospinal tract at the medullospinal junction and in the first three cervical segments lies on the periphery of the spinal cord lateral to the anterior roots. It moves to the sulcomarginal angle in the remaining cervical segments. In the thoracic cord, it moves laterally, being traversed by the most lateral of the anterior roots. Reticulospinal fibres descend bilaterally in the spinal cord with a preponderance of ipsilateral fibres. Reticulospinal fibres in general do not form well-defined tracts, but are scattered throughout the anterior and lateral columns. They are intermingled with propriospinal fibres and with ascending and descending fibres of other systems. Most reticulospinal fibres move posterolaterally as they descend. It follows that fibres from the brainstem that enter the cord in the anterior column may be in the lateral column anterior to the lateral corticospinal tract at lower levels. Reticulospinal fibres within the lateral column lie anterior to the lateral corticospinal tract. They consist of scattered fibres between the lateral horn and the periphery, most of them in the medial two-thirds of the column. In addition, they are present in a more compact group, forming a triangle on transverse section on the periphery of the lateral column, immediately anterior to the lateral corticospinal tract. On the periphery of the anterior and anterolateral columns reticulospinal fibres descend as small groups or as a continuous band of fibres. The most medial of these reaches the sacral segments and is included in the sulcomarginal fasciculus. A compact group of fibres, shown previously to be central sympathetic fibres ending in the intermediolateral and intermediomedial cell columns, surrounds the lateral horn. They do not extend throughout the thoracic cord in all cases. Anterior to this group is another group of fibres lying on the anterolateral surface of the anterior horn. As these fibres were degenerating following a pontine lesion, they must be reticulospinal fibres. The fibres were not seen in all cases and they did not always reach the lowest thoracic segments. Reticulospinal fibres enter the grey matter in the zona intermedia and along the anterolateral and anterior surfaces of the anterior horns. Caudal to the cervical enlargement, the number of reticulospinal fibres decreases, and their place is taken by propriospinal fibres. But they are not totally replaced by the propriospinal fibres, for reticulospinal fibres continue down into the lowest sacral segments. Of the propriospinal fibres, the majority are short: descending fibres within the juxtagriseal layer are one to two segments long or less.

Clinical and pathological study of two patients with progressive supranuclear palsy and Alzheimer's changes. Antigenic determinants that distinguish cortical and subcortical neurofibrillary tangles.

Two cases with classical clinical manifestations of progressive supranuclear palsy (PSP) showed severe progressive dementia as an additional clinical feature. Neuropathological study demonstrated typical features of PSP in the brainstem. Additionally, histological criteria of Alzheimer's disease (AD) were observed. A topographic and immunohistological study (with neurofilament subunit and Tau and Ubiquitin antibodies) of the distribution of neurofibrillary tangles (NFTs) was performed in order to compare the characteristics of NFTs from cortex and brainstem. NFTs from cortex were positive with all antibodies used and were predominantly distributed in cortical layers III and V and affected medium size neurons. Brainstem NFTs were positive only for neurofilament subunits and Tau. Cortical and brainstem NFTs showed immunohistological differences. Cortical NFTs in our two cases had a similar distribution as in control AD cases. On the basis of our observations we believe (1) that cortical tangles in our PSP cases are related to Alzheimer's disease and (2) that the cortical NFTs of PSP and AD are morphologically and immunohistologically distinct. Mechanisms concerned with the production of cortical and brainstem NFTs in PSP and AD are discussed.

The corticospinal tracts in man. Course and location of fibres at different segmental levels.

The course, location and relations of the corticospinal tracts within the spinal cord of man are demonstrated on the basis of cases with lesions above the spinal cord restricted to the corticospinal tracts, of motor neuron disease, and of anterolateral cordotomies; control cases were of normal spinal cords. The following features of the lateral corticospinal tract are emphasized in the cervical cord: (1) the large extent of the white matter of the cord covered by the tract, and the anterior extent of the tract, the border being anterior to the central canal; (2) in the lower cervical cord, the separation of fibres from the main mass of the tract, which reach the periphery of the cord in the anterolateral sector; (3) the presence in many cords of the ventral crossed bundle; and (4) the relationship of the denticulate ligament to the tracts in the cervical segments. The following features of the anterior corticospinal tracts are emphasized: (1) their location, caudal extent and asymmetry; and (2) the changes in location in relation to the median fissure as the tract descends and its relationship to other tracts of the anterior column. Three-quarters of spinal cords are asymmetric and in three-quarters of asymmetric cords the right side is the larger. The asymmetry is due to a greater number of corticospinal fibres crossing to the right side. As more fibres have crossed in the decussation, the anterior tract opposite the large lateral tract is smaller than the ipsilateral anterior tract: that accounts for the asymmetry of the two halves of the cord. The greater number of corticospinal fibres in the right side of the cord is unrelated to handedness, but correlates with the fact that in three-quarters of corticospinal decussations, the crossing from left to right occurs at a more cranial level than the opposite crossing. A group of short peripheral ascending fibres is described running along the sides of the median fissure in the thoracic cord.

The anatomy of spinal deformity: a biomechanical analysis.

The essential lesion in idiopathic scoliosis is a lordosis at the curve apex. For the rotational instability provided by a lordosis to progress, asymmetry must be present in another plane. A biomechanical analysis of spinal shape demonstrates a delicate balance between the median, transverse, and coronal planes. The normal cervical and lumbar lordosis which are inherently rotationally unstable are protected by: a) prismatic shaped vertebral bodies with their bases anterior, b) considerable available intersegmental flexion, and c) powerful posterior soft tissue support. In contrast, the thoracic vertebral bodies are shaped as prisms with their apices anterior. This rotationally unstable configuration is protected by a kyphosis with the axis of spinal rotation situated anteriorly. The thoracic vertebral prisms are asymmetric, their apices lying to the right of the median plane. In the presence of a lordosis the apices of the prisms will be directed toward the right producing a right-sided scoliosis. Any significant degree of left-sided coronal asymmetry can override the influence of the transverse plane and therefore left-sided curves are not uncommon. Thoracic idiopathic scoliosis is located at T8/T9 and the lordosis here is often an upward continuation of the normal lumbar lordosis such that the asymmetric thoracic prisms are no longer protected.

Combined idiopathic kyphosis and scoliosis. An analysis of the lateral spinal curvatures associated with Scheuermann's disease.

A radiological study of 50 patients with thoracic Scheuermann's disease revealed two types of lateral spinal curvature. A total of 43 lateral curves was present in 35 of the patients. Thirteen were apical at the same level as the Scheuermann's kyphosis and were due to vertebral-body wedging in the coronal plane; these curves had a mean Cobb angle of 15 degrees, occurred with equal prevalence in boys and girls and were directed equally to right and left. Thirty curves occurred in regions of compensatory lordosis (mean 5.6 degrees) situated above or, more commonly, below the Scheuermann's kyphosis. These scolioses had a mean Cobb angle of 16 degrees, were more often convex to the right than to the left and were significantly more prevalent in girls than in boys. The presence of these kyphoses and scolioses in the same spine, separated by only a few vertebrae, emphasises the importance of the sagittal plane in idiopathic spinal deformities and strongly suggests that idiopathic scoliosis and Scheuermann's disease share a common pathological process.

Comparison of the thrombogenicity of four types of knitted Dacron arterial graft in an artificial circulation.

The thrombogenicity of four types of knitted Dacron arterial graft was compared by measuring the effect of each prosthetic graft on human platelet function in an artificial circulation. The grafts examined were plain knitted (Meadox 'Cooley'), knitted double velour (Meadox 'Microvel'), filamentous external velour (U.S.C.I. 'Sauvage Filamentous') and a plain knitted graft with a pyrolytic carbon coating (Meadox 'Carboknit'). Platelet count, adhesion and percentage aggregation were all decreased during perfusion. The greatest changes in these parameters were produced by the filamentous velour graft and the least by the carbon coated graft. Electron microscopy demonstrated significantly more platelets adherent to the filamentous graft (rho less than 0.01) with changes in platelet morphology indicating activation. These results suggest that the filamentous graft is more thrombogenic than the other grafts.

Topographical anatomy of the posterior columns of the spinal cord in man. The long ascending fibres.

Nine cases are presented which illustrate the segmental anatomy of the posterior columns with respect to the long ascending fibres. It is concluded that the fasciculus gracilis (FG) and the fasciculus cuneatus (FC) should be considered as separate anatomical entities. It is shown that the shape of each fasciculus is different in, and characteristic of, each of the upper thoracic and cervical segments. A certain degree of segmental lamination is present in the FG, but with extensive overlapping of fibres from different segments. The orientation of the laminae is not the same in all segments, being very approximately parallel to the medial border of the posterior horn in most caudal segments, approximately parallel to the median septum in intermediate segments, and oblique in an anteromedial posterolateral direction in cranial sections. The pattern of lamination in the FC and the degree of overlapping of fibres resembles that in the caudal FG. There is no, or minimal, overlapping of fibres of the FC with those of the FG. The most medial fibres of the FC, lying along the lateral border of the FG, are in proximity with fibres, in that fasciculus, from many different segments.

Idiopathic scoliosis in three dimensions. A radiographic and morphometric analysis.

Eleven articulated scoliotic spines were examined radiographically and morphometrically. Measurement of the curve on anteroposterior radiographs of the specimens gave a mean Cobb angle of 70 degrees, though true anteroposterior radiographs of the deformity revealed a mean Cobb angle of 99 degrees (41% greater). Lateral radiographs gave the erroneous impression that there was a mean kyphosis of 41 degrees while true lateral projections revealed a mean apical lordosis of 14 degrees. Morphometric measurements confirmed the presence of a lordosis at bony level, the apical vertebral bodies being significantly taller anteriorly (P less than 0.02). There were significant correlations (P less than 0.01) between the true size of the lateral scoliosis, the amount of axial rotation and the size of the apical lordosis. This study illustrates the three-dimensional nature of the deformity in scoliosis and its property of changing in character and magnitude according to the plane of radiographic projection.

Results of vascular reconstruction with double velour Dacron in patients with critical lower limb ischaemia.

The results of 65 arterial reconstructions with double velour Dacron carried out for limb salvage have been reviewed. Successful revascularization was achieved initially in 86%, and the peri-operative mortality was 9.0%. Cumulative salvage was greater in patients with aorto-iliac disease (65% at 5 years) than in those with femoropopliteal disease (36% at 5 years). Results were poorest in patients with gangrene or marked trophic changes at presentation, in those with distal disease and in those who required revisional surgery.