Chapter 16: history of the development of the neurological examination

Extensor digitorum brevis muscle flap for lower extremity coverage in a context of posttraumatic sepsis

INTRODUCTION

Traumatic injuries to the distal quarter of the leg present a significant risk of skin necrosis and exposure of the underlying fracture site or the osteosynthesis material that often result in bone and joint infection. In the case of small or medium-sized bone exposure, local muscles may be one of the best options for lower extremity coverage. We describe our experience using the extensor digitorum brevis muscle flap in a context of posttraumatic bone and joint infection in fourteen patients. Our main objective was to assess the outcomes and the donor-site morbidity of the extensor digitorum brevis muscle flap.

MATERIALS AND METHODS

A single-center retrospective study in a French reference center for bone and joint infection from 2014 to 2018 reviewed cases of traumatic injuries with skin complications and bone and joint infection that required an extensor digitorum brevis muscle flap coverage. Fourteen patients were evaluated for early and late complications, 11 men and three women with a mean age of 51.4±17.72 (19-71) years. Seven of these were open fractures and nine cases were pilon fractures. Donor-site morbidity was assessed in nine patients.

RESULTS

Early flap complications included two cases (14.2%) of hematoma, one case (7.1%) of partial necrosis and four cases (28.5%) of donor-site dehiscence. Late complications caused by persistent infection were found in two patients (14.2%), with one case (7.1%) of chronic osteoarthritis and one case (7.1%) of septic pseudarthrosis. From a functional and cosmetic point of view, eight patients (89%) were satisfied, to very satisfied.

CONCLUSION

Experience and a multidisciplinary approach are keys in providing an optimal treatment strategy for complex cases of bone and joint infection. The extensor digitorum brevis muscle is a reliable flap for small defects with underlying infection. Being made up of muscle tissue, this flap offers good resistance to infection and enables satisfactory distribution of antibiotics.

LEVEL OF EVIDENCE

IV.

[Otfrid Foerster (1873-1941) and his ambivalent attitude towards National Socialism]

When Adolf Hitler was appointed Chancellor of the Reich Otfrid Foerster was almost 60 years old and an internationally renowned neurologist, neurosurgeon and a pioneer of localization research. Since 1922 he held the chair of neurology in Breslau (Wroclaw) and from 1925 to 1932 he was president (later honorary president) of the first Society of German Neurologists. In 1934 "his" Neurological Research Institute in Breslau was inaugurated. Biographical studies have unanimously established that he has never been a member of the party, that he found himself promptly marginalized after 1933 within his own ranks, and that he never participated in eugenic measures or "euthanasia" activities. A re-reading and analysis of his relevant papers and publications on neurology reveal however reverences paid to the Nazi state, which are surprising in this clarity. A possible explanation for Foerster's overall ambivalent attitude, he was married to a non-Aryan woman (in Nazi jargon), is the threat posed to his relatives by Nazi racial hygiene laws. On the other hand, there are clear indications of his conservative German national patriotism encouraging and supporting a restrengthened state and the National Socialist vision of the German Reich as a "great power". Further investigations will have to show how the numerous influential factors that had a bearing on his biographical characteristics, political attitude, medical research interests and private motivation should be weighted.

History of neurologic examination books

The objective of this study was to create an annotated list of textbooks dedicated to teaching the neurologic examination. Monographs focused primarily on the complete neurologic examination published prior to 1960 were reviewed. This analysis was limited to books with the word "examination" in the title, with exceptions for the texts of Robert Wartenberg and Gordon Holmes. Ten manuals met the criteria. Works dedicated primarily to the neurologic examination without a major emphasis on disease description or treatment first appeared in the early 1900s. Georg Monrad-Krohn's "Blue Book of Neurology" ("Blue Bible") was the earliest success. These treatises served the important purpose of educating trainees on proper neurologic examination technique. They could make a reputation and be profitable for the author (Monrad-Krohn), highlight how neurology was practiced at individual institutions (McKendree, Denny-Brown, Holmes, DeJong, Mayo Clinic authors), and honor retiring mentors (Mayo Clinic authors).

The history of examination of reflexes

In the late 1800s, Wilhelm Erb, Joseph Babinski, William Gowers, and others helped develop the neurologic examination as we know it today. Erb was one of the first to emphasize a detailed and systematic neurologic exam and was co-discoverer of the muscle stretch reflex, Gowers began studying the knee jerk shortly after it was described, and Babinski focused on finding reliable signs that could differentiate organic from hysterical paralysis. These physicians and others emphasized the bedside examination of reflexes, which have been an important part of the neurologic examination ever since. This review will focus on the history of the examination of the following muscle stretch and superficial/cutaneous reflexes: knee jerk, jaw jerk, deep abdominal reflexes, superficial abdominal reflexes, plantar reflex/Babinski sign, and palmomental reflex. The history of reflex grading will also be discussed.