A three-dimensional analysis of the sigmoid notch.

Fractures of the distal radius are among the most common injuries of the upper extremity, though treatment has traditionally focused on restoration of the radiocarpal joint and late sequelae may persist. X-ray imaging underestimates sigmoid notch involvement following distal radius fractures. No classification system exists for disruption patterns of the sigmoid notch of the radius associated with distal radius fractures. This study quantifies the anatomy of the sigmoid notch and identifies the landmarks of the articular surface and proximal boundaries of the distal radioulnar joint (DRUJ) capsule. Computed tomography scans of freshly frozen cadaveric hands were used - followed by dissection, and three-dimensional reconstruction of the distal radius and sigmoid notch. The sigmoid notch surface was divided into two surfaces and measured. The Anterior Posterior (AP) and Proximal Distal (PD) widths of the articulating surface were reviewed, along with the radius of curvature, version angle and depth. The study showed that the sigmoid notch is flatter than previously believed - and only the distal 69% of its surface is covered by cartilage. On average, it has about nine degrees of retroversion, and its average inclination is almost parallel to the anatomical axis of the radius. Clinical implications exist for evaluation of the DRUJ involvement in distal radius fractures or degenerative diseases and for future development and evaluation of hemiarthroplasty replacement of the distal radius.

A novel technique for the surgical treatment of achalasia in children: evaluated with postoperative esophageal manometry.

INTRODUCTION: The current surgical treatment for achalasia in the pediatric population is the laparoscopic Heller myotomy with or without a fundoplication. Although medical management with serial dilations and botulism toxin injections may offer short-term benefits, surgical therapy offers definitive treatment. In this article, we propose a modified surgical technique that avoids pitfalls associated with the standard procedure and evaluated our results with postoperative manometry. METHODS: Charts were reviewed for all patients having undergone the proposed surgical procedure. Seven patients underwent postoperative manometry, while 12 answered a short questionnaire. RESULTS: While manometry showed a statistically significant reduction of lower esophageal sphincter tone, from a mean preoperative lower esophageal sphincter (LES) of 56.1 mm Hg (SD = 8.88, 95% CI = 50.36-61.93) to mean postoperative LES tone of 11.69 mm Hg (SD = 11.69, 95% CI = 3.287-20.08; P < 0.0001), peristalsis was not consistently affected, although a trend toward improvement was noted. Symptoms related to dysphagia were noted in 42% of patients postoperatively but were mild, while all patients showed improved feeding tolerance and weight gain. Interestingly, patients with a postoperative LES pressure <12 mm Hg were more likely to have no symptoms, although this LES pressure was arbitrarily chosen and the study was not powered to detect this outcome (chi-square = 3.73, df = 1; P < 0.053). CONCLUSIONS: The proposed surgical technique for the treatment of achalasia in children was successful at improving feeding and weight gain and attaining normal postoperative LES tone; however, underlying esophageal dysmotility persisted.

Hand injuries as an indicator of other associated severe injuries.

The purpose of this study was to investigate the incidence of disabling or life-threatening injuries in patients with hand injuries. Retrospective data were collected from a level 1 trauma center registry. A total of 472 patients with hand injuries were admitted to the trauma unit between January 2000 and March 2004. Forty-four per cent of patients with hand injuries had life-threatening injuries. Fifty-one per cent of them had motor vehicle crash-related injuries. Motorcycle crashes were the next most common cause followed by explosions, falls, gunshots, machinery, stabs, bites, crushes, and so on. Frequency of associated injuries was as follows: head injuries, 31 per cent, including skull fractures, 22 per cent; spine injuries, 18 per cent, including spine fractures 18 per cent; chest injuries, 36 per cent, including rib fractures, 15 per cent; and abdominal injuries, 13 per cent. The authors focused on the incidence of disabling or life-threatening injuries in patients with hand injuries. Motor vehicle crashes were most common cause of hand injuries. The most common organs to be injured were chest and head. The most common head injury was skull fracture. Other injuries in decreasing order were spine and rib fractures. These data may be helpful in assessing ambulatory patients in the emergency room, in those hand injuries maybe indicative of other simultaneous life-threatening or disabling injuries.

Dose-dependent impairment of collagen deposition by topical granulocyte-macrophage colony-stimulating factor in human experimental wounds.

OBJECTIVE: The authors studied the dose-dependent effect of topically administered granulocyte-macrophage colony-stimulating factor (GM-CSF) on the connective tissue response using an experimental repair model in surgical patients. SUMMARY BACKGROUND DATA: GM-CSF is primarily indicated in the treatment of immunosuppressed states. The effect of GM-CSF on the tissue repair response in humans is unclear. METHODS: Expanded polytetrafluoroethylene tubes were implanted subcutaneously and GM-CSF was applied locally at concentrations of 0.1 micro g/mL (total dose 0.4 micro g), 1.0 micro g/mL (4.0 micro g), 10 micro g/mL (40 micro g), or 75 micro g/mL (300 micro g) in one arm and saline alone (control) in the contralateral arm of 56 surgical patients. The content of collagen and total protein in the tubes was quantified as hydroxyproline and proline by high-performance liquid chromatography 10 days after implantation. Cellularity and the number of procollagen I-positive fibroblasts were determined by histology and immunohistochemistry. The direct effects of GM-CSF on collagen production by and proliferation of wound fibroblasts cultured from granulation tissue were also measured. RESULTS: Local application of GM-CSF stimulated the inflammatory cell infiltration but reduced the number of fibroblasts in the granulation tissue. GM-CSF treatment suppressed specifically and dose-dependently collagen deposition by up to 81%. A reduced collagen accumulation was also found in the control-treated arm at GM-CSF doses of 4 micro g or more, indicating a systemic depressive effect of GM-CSF on tissue repair. The selective downregulation of collagen production by GM-CSF was also found in wound fibroblasts in vitro. CONCLUSIONS: Inhibition of fibrogenesis with GM-CSF intervention may impair tissue repair processes during surgery.