Cervical spinal cord injury: the correlations of initial clinical features and blood gas analyses with early prognosis.

The predictive values of some early post-traumatic clinical symptoms and signs and laboratory tests on the problems, complications and prognosis of the initial treatment of tetraplegic patients were studied. The study was carried out by scrutinizing the files of 54 patients with a cervical spinal cord injury (40 of them complete and 14 incomplete). Most of the patients (n = 43) needed ventilatory support, the duration of which depended on the level and completeness of the spinal cord injury. Bradycardia, hypotonia and tachypnoea at admission occurred most frequently in those patients who later developed complications or died. In addition, the frequency of complications correlated with a patient's age, previous diseases and with the height and degree of the spinal cord injury. Tachypnoea on admission forecast the later development of respiratory complications. All 8 patients who died, 5 of them from pneumonia and 3 from pulmonary embolism, had their spinal cord injury at the level C4 to C5 and they were significantly older than those who survived.

Blunt injury patients benefiting from intensive care.

The files of 2,002 trauma patients admitted to our intensive care unit between 1966 and 1984 were analyzed. 74% of the patients were admitted because of the trauma after primary care and 26% later. The main reasons for later admissions were respiratory distress in 11% and postoperative follow-up in 8% of the cases. The series consists of blunt injury patients with a mean age of 39 years for those who survived and 52 years for those who died. 65% of the patients were injured in road traffic accidents. Injuries to the lower extremity were the most frequent (60%) and injuries to the cervical spine the least frequent (11%). The injury Sum (= sum of injuries) ranged from 1 to 18 with an average of 5.6 in the whole series. Two thirds of the patients were multiply injured. A statistical analysis showed that the most important determinants between the dead and those who survived were resuscitation, need for respirator treatment, age of the patient, amount of primary blood transfusions, brain and renal complications. The ICU mortality was 9.0% and the total hospital mortality was 11.9%.

Characteristics of patients with multiple injuries treated in an intensive care unit with favorable results.

A series of 1,169 consecutive patients with multiple injuries was analyzed. A strict criterion for multiple injury was used, the average Injury Sum (sum of the severities of regional injuries) was 7.6, the average time of treatment in the intensive care unit was 11 days and the mean duration of hospital treatment was 51 days. Road traffic accidents were the most common cause of injury (75%) and the regions most commonly injured were the lower extremity (68%), brain (62%) and chest (58%). 46% required ventilation. Mortality was 11.3% during intensive care and the total hospital mortality was 13.1%. The factors most relevant to patients who were able to return home from the hospital were: no need for respirator treatment, no renal complications, no previous mental disturbance or alcoholism, young age, less severe brain or thoracolumbar spine injuries, few initial blood transfusions, few complications during treatment and prompt operative intervention if required.

Cefamandole and isoxazolyl penicillins in antibiotic prophylaxis of patients undergoing total hip or knee-joint arthroplasty.

In a prospective comparative clinical efficacy and safety study, 58 patients undergoing total hip or knee arthroplasty were randomly allocated to two groups; one received 29 cefamandole intravenously before operation and then 1 g every 6 h parenterally for 3 days and the other received 29 cloxacillin i.v. every 8 h for 1 day and 29 dicloxacillin perorally every 8 h for 2 days. Concentrations of cefamandole and cloxacillin were measured in the serum of all patients and in the synovial fluid of 28 patients. The serum C-reactive protein (CRP) level was measured in 16 randomly allocated patients preoperatively and daily for 8 days. In serum the concentrations of cefamandole and cloxacillin were high. The great variation in cloxacillin concentration can be due in part to its strong affinity for blood proteins. Cefamandole entered the synovial fluid of the knee joint at high concentrations in 5-15 min; similar concentrations of cloxacillin were measured after 16-30 min. Thus, cefamandole seems to be more recommendable as antibiotic prophylaxis in total hip and knee replacements. The CRP level decreased to below 60 mg/l in all 16 patients on the 6th postoperative day.

Radial palsy in shaft fracture of the humerus.

Fifty-nine patients with immediate and 16 with secondary radial nerve palsy complicating a fracture of the shaft of the humerus were reviewed. According to the preferences of the surgeon in charge, the palsy was treated either with early exploration of the radial nerve and internal fixation of the fracture or with initial expectance. Of the latter, 12 were later explored. No useful recovery of motor function could be seen in 13/59 patients with immediate and in 2/16 patients with secondary palsy. In patients with immediate palsy treated by early exploration, there were 8/27 nonrecoveries. Among those treated with initial expectance, there were 5/32 nonrecoveries. For secondary palsy, these figures were 2/10 and 0/6, respectively. No support emerged for routine early exploration.

Immediate radial nerve palsy complicating fracture of the shaft of the humerus: when is early exploration justified?

A series of 59 patients with immediate complete radial nerve palsy complicating a fracture of the shaft of the humerus was analysed. In 27 patients the radial nerve was explored and the fracture was fixed within 3 weeks of the accident. In 12 other patients exploration was performed after an average of 17 weeks. The remaining 20 patients showed signs of spontaneous recovery within 4 months and were managed conservatively. The mean follow-up time was 3 years. At exploration, laceration, interposition between the fragments or entrapment of the radial nerve in callus was found significantly (P less than 0.01) more often with longitudinal fractures of the distal third (46 per cent) than with transverse fractures of the middle third, in which 85 per cent of the explored cases showed the nerve to be no more than slightly bruised. Useful recovery was seen in 46 patients (78 per cent of the whole series).

Late results in supracondylar humeral fractures in children.

The end results of supracondylar humeral fractures in 151 children after an average follow-up period of 15 years are presented. The relationship between the carrying angle and the functional result was analyzed. A deformity of the carrying angle was not felt by the patients to be a cosmetic handicap, and the functional results were not problematic. However, the least satisfactory subjective results in the series were associated with a decrease of the carrying angle by at least 10 degrees and with a significant proportion of the limitations of movement of the elbow joint.

Flail chest--pathophysiology, treatment and prognosis.

Multiple injury is often associated with an unstable serial rib fracture and a pulmonary contusion under the contact area which both lead to respiratory insufficiency. This has to be treated at an ICU by respirator with IMV and PEEP from the beginning. With this method the time of respirator treatment has been lowered to nearly one half and tracheostomy is seldom needed. Also, the required oxygen concentration is less (35%) which decreases the risk of toxic pulmonary injury. The prognosis is poorer with head injury or other concomitant injury, especially severe trauma causing bleeding in parenchymatous organs of the abdomen.

Fractures of the patella treated by operation.

A retrospective analysis of 93 operatively treated fractures of the patella is presented. Tension band fixation was used in 14, circumferential wire in 15 and screw fixation in 19 patients. Partial patellectomy was performed in 35 cases and total patellectomy in 10 cases. The result was considered excellent in 27% of the patients, good in 49%, fair in 16% and poor in 8%. Patients under 30 years of age had better results than the older ones (p less than 0.01). Tension band fixation gave results superior to screw fixation (p less than 0.05) and partial patellectomy superior to total patellectomy (p less than 0.02). The length of the immobilization time in plaster showed no statistical significance. As a result of this investigation tension band fixation and partial patellectomy seem to be the methods of choice in the management of those fractures of the patella which need operative treatment.

Spinal nerve block. A diagnostic test in sciatica.

The cause of sciatica has been studied by blocking spinal nerves of the lumbosacral plexus in intervertebral foramina. The nerve, which is singled out with the aid of an image intensifier, is injected with 1 ml of 1 per cent Xylocain. If the Xylocain injection eliminates the sciatic pain, the surgeon may be confident that a true nerve-root compression is involved, and he can then explore as far as he finds necessary. The correlation between the site of compression and the level indicated by the test was confirmed by operation in 19 patients.

Why a meniscectomy fails.

The clinical and roentgenological data on 30 patients with unsatisfactory recovery or recurrent symptoms after meniscectomy were analysed. The meniscectomy was regarded as having been the wrong choice of therapy in four patients and as ineffective therapy in 11. In 10 patients other knee lesions dominated postoperatively, in three the recovery was delayed for no obvious reason but the symptoms slowly disappeared, and in the remaining two patients a degenerative osteoarthritis developing some time after the meniscectomy was regarded as the cause of the recurring symptoms. We conclude that with an optimal clinical and arthrographic analysis and with careful operative tecnique as many as 17 arthrotomies (out of 30 primary and 13 reoperations) in the material presented could have been avoided.

Surgical or conservative treatment of total dislocation of the acromioclavicular joint.

A follow-up investigation on 41 patients with complete dislocation of the acromioclavicular joint was performed. Nineteen patients had been treated surgically, 22 conservatively. The surgery performed had consisted of repair of the coracoclavicular ligament and fixation of the acromioclavicular joint by means of a Kirschner wire. In the conservatively treated patients, a strapping was applied to maintain reduction of the acromioclavicular joint. A good functional end-result is correlated with a good anatomical result. A good anatomical result was more frequent in the surgically treated group. Better functional results were achieved by operation than by conservative treatment. In general, post-traumatic arthrosis of the acromioclavicular joint was slight and was not correlated with the functional results.