Spontaneous rupture of the tibialis anterior tendon: a case report and literature review.

Spontaneous rupture of the tibialis anterior tendon is uncommon. This article presents a case report in which spontaneous rupture of the tibialis anterior tendon occurred secondary to a gouty tophaceous deposit within the tendon. This report adds to the list of pathological conditions that should be considered in closed spontaneous rupture of the tibialis anterior tendon.

Closed reduction of tibial shaft fractures using a sling.

We wish to report a simple technique for closed reduction of tibial shaft fractures. The patient is put in the supine position. Longitudinal traction is applied through a plaster boot on the corresponding foot and ankle. A gauze sling (Fig. 1) placed behind the calf at the fracture site allows suspension of the limb whilst controlling posterior angulation and displacement. This allows control of the limb whilst alignment is checked with the image intensifier in two planes. When satisfactory reduction is obtained, a long leg plaster can be applied to immobilize the fracture. The technique was applied to 21 closed tibial shaft fractures in 21 patients. Satisfactory results were obtained in 20 patients. Analysis of the initial post-manipulation X-rays showed an average of 5.2 mm shortening (range 0-15 mm). The average coronal angulation was 1.9 degrees (range 0-5 degrees), and sagittal angulation was 2.0 degrees (range 0-8 degrees). Average percentage overlap of the fracture fragments was 79% in the coronal plane (range 40-100%) and 82% in the saggital plane (range 50-100%). We found this technique to be simple and reliable. It is particularly useful as the first phase of non-operative treatment of tibial shaft fractures by functional bracing.

Entrapment and transection of the median nerve associated with greenstick fractures of the forearm: case report and review of the literature.

OBJECTIVE: To report an unusual neurologic complication associated with greenstick fractures of the forearm. METHODS: Near-complete transection of the median nerve associated with greenstick fractures of the shaft of the left radius and ulna in a 13-year-old boy is described. The results of treatment are reported in detail. CONCLUSION: Significant median nerve injury may coexist with apparently benign, closed greenstick fractures of the forearm.

Cancellous screw fixation for subcapital femoral neck fractures.

Experience in treating 80 subcapital femoral neck fractures by AO/ASIF cancellous screws is reported. Immediate full-weight bearing was allowed routinely. The mean follow-up was 28 months. Non-union occurred in 2% and late segmental collapse in 12% of patients with undisplaced fractures. Non-union occurred in 16.7% and late segmental collapse in 30% of patients for displaced fractures. Regression of screws occurred in 30% of patients, all of which were detected within the first month after the operation. It was associated with a significantly higher risk of non-union and late segmental collapse for both undisplaced (P < 0.01) and displaced (P < 0.001) fractures.

Partial weight bearing after operations for hip fractures in elderly patients.

Factors affecting a patient's ability to carry out partial weight bearing after operation for hip fracture were studied in 100 patients. Seventy-six were able to do so. Significant factors included the muscle power of the good limbs and the mental state, whereas age, body-weight and type of operation were not significant. Logistical regression analysis showed that it was possible to predict a patient's partial weight bearing potential by simply testing the left hand grip and the 'Set' test score.

Sequential fractures of both hips in elderly patients--a prospective study.

Thirty-five patients with sequential fractures of both hips were studied prospectively. The second hip fractures occurred more commonly if the patients were institutionalized, if they suffered from concomitant neurologic diseases such as previous stroke or Parkinsonism, or if there was biochemical evidence of osteomalacia. Twelve patients sustained the contralateral hip fracture within 12 months of the first one. There was a significant correlation between biochemical evidence of osteomalacia and early occurrence of the second hip fracture. Although rehabilitation was difficult for such patients, it was possible with a longer period of intensive physiotherapy; only three patients were not able to walk upon discharge from the hospital after the second hip fracture.

A prospective study on hip fractures in patients with previous cerebrovascular accidents.

Of 1430 patients with proximal femoral fractures admitted into Queen Mary Hospital, Hong Kong from 1985 to 1990, 146 patients (10.2 per cent) had a history of previous cerebrovascular accidents. The fracture was on the hemiplegic side in 82 percent of patients. Most patients were treated by operation. Intensive physiotherapy was given to these patients for an average of 6 weeks. The prefracture walking ability was regained or even improved upon discharge in 60.9 per cent of patients. After an average follow-up of 21 months, 31 per cent had satisfactory walking and active daily activities. There was significant correlation of the performance upon discharge from the hospital with the walking ability at the final follow-up.

A study of function and residual joint stiffness after functional bracing of tibial shaft fractures.

Ninety-eight diaphyseal tibial fractures were treated with custom made functional braces in 97 patients older than 14 years of age. The average follow-up period was 1.86 years, and 53 patients had more than two years' evaluation (average, 2.83 years). The majority of the patients did not have full range of movement in the ankle and subtalar joints when the brace was removed after fracture healing. Although the stiffness decreased with time, a significant number of patients were left with residual joint stiffness. At an average follow-up period of 1.86 years, 68.4% of the patients had normal ankle motion and 60% had normal inversion and eversion of the hindfoot. In patients with more than two years' evaluation, 75.5% had normal ankle movement and 71.1% had normal inversion and eversion of the foot. In the knee joint, the incidence of residual joint stiffness was small and the amount of stiffness was clinically insignificant. Patients with an abnormal walking pattern after fracture healing had a high incidence of ankle and subtalar joint stiffness.

A prospective study of 245 open digital fractures of the hand.

We report a prospective study of 245 open digital fractures of the hand in 201 patients. Management followed clear guidelines set out in protocol. The incidence of infection (2.04%) and non-union (2.45%) was low. Proximal phalangeal fractures and comminuted fractures did worst and associated significant soft tissue injuries had a particularly deleterious effect on the outcome. A classification based on the different soft-tissue components involved is proposed. In fractures associated with simple lacerations or isolated digital nerve injury only, one can expect about 40% good results and about 25% poor results. Where extensor tendon injury or extensive skin loss are also present, there will be approximately 18% good results and 50% poor results. If there is also injury to the flexor tendon or more than one component of significant soft-tissue damage, about 80% will be poor and good results are rare.

Unstable phalangeal fractures: treatment by A.O. screw and plate fixation.

A prospective study of fifty-two fresh traumatic unstable fractures of the proximal or middle phalanges of the hand in forty-seven patients was reviewed. All the fractures were fixed with A.O. miniature screws and plates. The overall results were not satisfactory and complications were frequent. Only 26.9% of the fractures had good results. Fractures associated with significant soft tissue injuries had very poor results. When the present series was compared with a comparable group of fractures fixed with Kirschner wires, there was no significant improvement in the results. The unsatisfactory outcome of this group of unstable fractures may be largely due to the frequent association with poor prognostic factors.

A splint for controlled active motion after flexor tendon repair. Design, mechanical testing, and preliminary clinical results.

A splint for controlled active motion after flexor tendon repair is described. It incorporates a single core-coated elastic band passing around a palmar pulley and attached proximally to a spring wire. Its mechanical properties were tested against six other systems. The tension in various systems all rose near full extension. However, the palmar pulley, the spring wire, and the elastic band each could lower the tension significantly. When the bending moments at the interphalangeal joints were measured, all systems produced a peak during the latter part of extension. With the palmar pulley, spring wire, and elastic band, the rise was minimal and in fact, the bending moments diminished near full extension. Initial results in 28 flexor tendon repairs using this splint showed less flexion contracture when compared with 78 flexor tendon repairs using a standard rubber band anchored at the wrist.

Tuberculosis of the lumbosacral junction. Long-term follow-up of 26 cases.

Of 37 consecutive patients suffering from tuberculosis of the lumbosacral spine, 26 were reviewed after an average follow-up of 20 years. Those presenting at under 10 years of age usually had a discharging sinus or a pointing abscess and a visible kyphosis. In older patients, low back pain was the predominant presenting symptom. Neurological involvement was uncommon. Both operative and conservative treatment had resulted in fusion but all patients treated conservatively ended up with a kyphosis associated with trunk shortening. They had a higher incidence of back pain and more complications in pregnancy. Anterior debridement and fusion with a strut graft can reduce the incidence and size of kyphosis, but is technically demanding. Treatment remains difficult and requires individual consideration.

Evaluation of results in flexor tendon repair: a critical analysis of five methods in ninety-five digits.

The development of an internationally accepted system of assessment of results after flexor tendon repair is important. In a prospective study of ninety-five digits, gross discrepancies were demonstrated between five popular methods of assessment: Buck-Gramcko, linear measurement, Grossman, American Society for Surgery of the Hand, and Strickland. The relative merits of each systems were studied and modifications for the Buck-Gramcko system are suggested.

Sequential forearm intravenous regional and infiltration anaesthesia: value for haemostasis.

Intravenous regional anaesthesia using 0.5% lignocaine with a forearm tourniquet is a satisfactory technique for operations on the distal forearm, wrist and hand. Since recovery of pain sensation is rapid, haemostasis after release of tourniquet becomes difficult and sometimes impossible. Local wound infiltration or metacarpal block with 1% lignocaine just before release of the tourniquet can allow subsequent haemostasis and wound closure to be carried out without causing pain. 55 patients received this sequential forearm intravenous regional and infiltrative anaesthesia. Subsequent haemostasis and wound closure could be carried out without pain in 51 patients (92.7%); three patients (5.5%) noticed mild discomfort but the operations could be finished without any additional anaesthetic agent. No complications were encountered with this modified technique.

25-Hydroxycholecalciferol and insulin-like growth factor I are determinants of serum concentration of osteocalcin in elderly subjects with and without spinal fractures.

Osteocalcin is one of the major proteins in the osseous matrix. To evaluate the determinants and thus the physiological control of osteocalcin production in normal and osteoporotic subjects, the serum levels of osteocalcin, 25-hydroxycholecalciferol (25-OH-D3), and insulin-like growth factor I (IGFI) were measured by radioimmunoassay in 44 subjects over 60 years old. Circulating osteocalcin, 25-OH-D3, and IGFI were 0.28 +/- 0.10 nmol/L (1.65 +/- 0.96 ng/mL), 70.5 +/- 25.1 nmol/L (28.3 +/- 10.1 ng/mL), and 23.8 +/- 12.0 nmol/L in 27 healthy controls respectively, as compared with 0.09 +/- 0.09 nmol/L (0.52 +/- 0.52 ng/mL), 48.2 +/- 19.9 nmol/L (19.35 +/- 7.91 ng/mL), and 16.56 +/- 6.96 nmol/L in 17 patients with spinal fractures. Significant correlation was found between osteocalcin and 25-OH-D3 level, as well as between osteocalcin and IGFI. The results show that IGFI and 25-OH-D3 are important determinants for serum concentration of osteocalcin in elderly subjects with and without spinal fractures.

Vitamin D status among patients with fractured neck of femur in Hong Kong.

Vitamin D deficiency leads to secondary hyperparathyroidism initially and then to mild osteomalacia, both of which conditions may be aymptomatic and may predispose to bone fracture. To assess the importance of vitamin D deficiency in predisposing to fractured neck of femur, we studied the vitamin D status, dietary intake and socio-economic characteristics in 69 patients with fractured neck of femur (group A), 28 normal subjects with age above 60 (group B), and 101 normal volunteers (group C). Patients with fractured neck of femor had significantly lower levels of serum 25-hydroxy-cholecalciferol compared with subjects of groups B and C. There is no statistically significant difference in other biochemical parameters, including calcium, phosphate, and alkaline phosphatase. Patients with fractured neck of femur and with 25-hydroxycholecalciferol below 20 ng/mL were characterized by a home-bound and/or institutionalized life-style, smaller living place, and limited access to open space. To conclude, hypovitaminosis D is a common problem among elderly patients with fractured neck of femur in Hong Kong. The fact that such vitamin D deficiency is associated with muscle weakness may contribute to falls, and thus indirectly account for an increased rate of hip fractures over the normal control.

Prognostic factors and progress for ambulation in elderly patients after hip fracture.

A longitudinal study of the ambulation progress was done on 102 patients in the first 9 wk after an operation for repair of hip fractures. The time taken to achieve a stable walking pattern from frame to a cane was recorded for every patient. Results showed that 82.2% of the patients were able to walk with a cane at 4 wk postoperatively. Of the remaining 17.8% of the patients, 7.7% were able to walk with a cane at 6 wk whereas 10.1% were not able to walk with a cane at 6 wk. Several factors including the age, sex, mental state, the type of operation and the preoperative ambulation level of the patients were studied to predict the ambulation progress of the patients. The most important factors affecting the ambulation progress were the age and the preoperative ambulation level of the patient. Because of the general trend in the aging of the population, an increase in the number of hip fractures is expected. The result of this study may help in predicting the prognosis and provide guidance for restoring the function of the patients.