Surgical management of distal humerus gunshot fractures: descriptive case series

PURPOSE

The purpose of this study was to report our 5 years surgical experience and the rate of neurovascular injury following gunshot fractures of the distal humerus in a in level-1 Trauma Centre in South Africa.

METHODS

A retrospective case series of 25 consecutive adult gunshot injuries to the distal humerus. Demographic and injury data were extracted from clinical case notes and electronic operative records. Imaging archives were used to classify fractures according to the AO/OTA classification.

RESULTS

Twenty-five male patients, with mean age of 32-years-old, sustained gunshot injuries to the distal humerus. Eleven patients had multiple gunshots. Forty-four percent of patients underwent Computed Tomography Angiography (CTA), 20% had confirmed brachial artery injury. Limbs with vascular injury were salvaged with arterial repair and external fixation. Fractures were extra-articular in 20 cases (80%). Nineteen fractures were classified as highly comminuted. Nerve injuries occurred in 52% and were all managed expectantly. Only 32% of patients attended follow-up beyond 3 months.

CONCLUSIONS

These are rare challenging injuries with high rates of neurovascular damage. This demographic of patients is poorly compliant with follow up highlighting the need for high-quality early care. Brachial artery injury should be excluded with CTA and can be managed with arterial repair and external fixation. All fractures in this series were surgically managed with conventional anatomical plate and screw fixation techniques. For nerve injury, we advocate expectant management.

LEVEL OF EVIDENCE

IV.

Current Concepts: Corrective Osteotomy for Extra-Articular Deformity Following a Distal Radius Fracture

Fracture malunion alters wrist and distal radioulnar joint (DRUJ) biomechanics, resulting in incongruence and instability of the DRUJ. Selected patients with painful functional limitation and significant deformity of the radius, but without advanced degenerative joint disease, may benefit from corrective distal radial osteotomy. Non-union and complications arising from metalwork are the most common reasons for reoperation. Surgeons should have a good understanding of risks and complications in order to fully inform their patients and manage expectations. This article reviews the biomechanical effects of radial malunion and the current concepts for treatment. Distal radial osteotomy is suitable for symptomatic patients with angular radial deformity and shortening. Evidence supports a volar approach without bone grafts for modest corrections. Bone grafts or synthetic bone substitutes are appropriate for larger corrections. Functional improvements are reported regardless of technique. Despite a high complication rate, patient satisfaction with the corrective radial osteotomy is high.

Long-term patient reported sexual and urological dysfunction in males after operatively treated pelvic ring injuries Do generic outcome measures identify genitourinary health problems?

BACKGROUND

A consecutive series of 177 male patients, with high energy pelvic ring injuries, were treated operatively in our institution. The purpose of this study was to evaluate long-term sexual and urological dysfunction in these patients using validated disease specific patient reported outcome measures (PROMs), and identify if sexual and urological dysfunction is detectable from generic outcome scores used in the assessment of pelvic ring injury at a minimum of 10 years follow-up (range 10-22).

METHODS

Surviving patients were contacted to complete validated PROMs to examine genitourinary and global functional outcome. Fifty-two male participants, had a mean age of 44-years-old (range,16-69) and ISS of 17 at time of injury. Mean duration follow-up of 15 years. The primary outcome measures were the Sexual Health Inventory for Men (SHIM) and the Modular Questionnaire for Male Lower Urinary Tract Symptoms (MLUTS). Secondary outcomes were the EQ-5D and Short Form 36. Responses were tested for correlation between generic and disease-specific PROMs and analyzed for association with genitourinary injury and age as risk factors of poor outcome.

RESULTS

Genitourinary injuries occurred in 7 patients (13%), and ten patients (19%) had documented neurological dysfunction following injury. Satisfactory general functional outcome was reported with EQ-5D-3L VAS score of 71. However, 80% report some level of sexual dysfunction with 37% reporting it as severe. MLUTS mean symptom score was 9 (range, 0 - 26) and bothersomeness score was 21 (range, 0-90). There was poor correlation between urological and sexual dysfunction scores and between the disease specific and generic scores.

CONCLUSION

In operatively treated pelvic ring injuries, validated disease specific PROMs, (SHIM and MLUTs) identified a significant impact to both sexual and urological patient health, with 37% reporting severe sexual dysfunction. Longstanding sexual and/or urological dysfunction can be a source of significant psychological impact that this study has shown is not identifiable using generic PROMs; EQ-5D-3L and SF-36. To gain a holistic understanding of the functional outcome of patients following a pelvic injury, urological and sexual dysfunction must not be overlooked.

1301 Early MRI in the Diagnosis of Suspected Scaphoid Fractures – An Audit of a Redesigned Diagnostic Pathway

Introduction

MRI is the gold standard for investigation of suspected scaphoid fractures, which can be missed on initial x-rays. This full cycle audit reports the impact of our new patient pathway, which changes repeat x-rays at 2 weeks to urgent limited sequence scaphoid MRI for those with normal initial x-rays, but clinical suspicion of fracture at initial clinic visit.

Method

A second cycle audited MRI requests for suspected scaphoid fractures at Southmead hospital following implementation of the new pathway in October 2020. We collected wait times from request to scan, and radiologist reports. Results were compared to our first cycle, 6-month time period.

Results

he results for 24 limited sequence MRIs via our new pathway were compared to 134 full wrist MRIs of the first cycle. Two scans (9.1%) were positive for scaphoid fracture versus 12% in the first cycle. 19 scans (86%) identified alternate pathology including sprain (6), bone bruise (5), non-scaphoid fractures (4) and degenerative change (3). 1 scan (4.5%) was reported as normal. 73% of MRIs were performed within 14 days, compared to 63% in previous cohort.

Conclusions

Our new pathway using limited sequence MRI identified similar rates of scaphoid fractures. Reduced time to MRI was observed compared to the previous cohort due to shorter scan durations and resulted in earlier diagnosis and fewer outpatient follow-up appointments. Our new pathway has benefits to patient experience and also reduces footfall in hospital, during a time of global Covid-19 pandemic, with no increase in costs.

Three-vessel view debridement of the open tibial fracture: a surgical technique

Adequate debridement of an open fracture is a key component of successful management. Despite having set debridement principles, there is no structured technique available in the literature to guide the surgeon in achieving this. We therefore present a technical note detailing the structured approach to the debridement of any open tibial fracture. Our unit has developed a novel stepwise technique termed locally as the "three-vessel view". Identifying all three primary vessels of the leg facilitates confirmation of inspection of all lower limb compartments thus minimising the risk of missed devitalised tissue or neglected areas of contamination and the potential for consequent disastrous outcomes as a result of inadequate exposure.

Effective rescue treatment with vemurafenib of an infant with high-risk Langerhans cell histiocytosis

INTRODUCTION

The recently identified role of a BRAF somatic mutation in the pathophysiology of Langerhans cell histiocytosis (LCH) offers new therapeutic options. Herein we describe the case of a 10-month-old infant with refractory high-risk LCH successfully treated with vemurafenib.

OBSERVATION

The patient first presented with cutaneous LCH at the age of 2 months. The disease remained undiagnosed until she was 6 months old, when it rapidly evolved to a multisystemic high-risk and life-threatening disease, refractory to 2 lines of chemotherapy. BRAFV600E mutation was found at skin biopsy, and targeted therapy with vemurafenib was started when she was 10 months old. The treatment induced a fast and sustained response, but rapid relapse occurred after treatment discontinuation, leading to resumption of treatment, once more resulting in a sustained response.

CONCLUSION

Our case highlights the first-line role of dermatologists in establishing the diagnosis of LCH, especially in children, in whom the eruption may be difficult to identify, leading to delayed diagnosis. Targeted therapy with vemurafenib has recently been described in children in this indication and our results support its efficacy, highlighting the need for prolonged treatment and raising the question of maintenance therapy, as well as the necessity for large-scale and long-term studies.

Quantifying the effects of a low-ozone event and shallow stratocumulus clouds on ultraviolet erythemal radiation exposure

Meteorological and dosimetric ultraviolet (UV) erythemal radiation (UVER) measurements were performed in Didcot, England, on 6 and 7 April 2017. Both days were characterized by clear-sky conditions in the morning and the afternoon with development of shallow stratocumulus clouds (SSC) around noon. In addition, a low-ozone event occurred on 7 April characterized by a 34 DU (Dobson Unit) drop in total stratospheric ozone content. Compared to 6 April, the ozone mini-hole caused UVER increases of 2.67 standard erythema dose (SED) for diffuse and 4.32 SED for global radiation characterized by radiation amplification factors (RAF) of 1.62 and 1.52, respectively. The total global UVER dose reductions due to SSC coverage amount to 2.33 SED (6 April) and 2.81 SED (7 April). As innovation the RAF is decomposed into two parts, named cloud ozone factor (COF) and radiation amplification factor based on measured data (RAF_m), to quantify the low-ozone event's effect and the SSC influence in independently modifying the UVER doses. Hereby, the weight of each of these two effects acting during the same low-ozone event is expressed by the new COF. In this case, the COF values range between -0.13 and -0.11 for diffuse UVER and -0.03 to -0.07 for the global UV and UV-B parts. A positive COF value (0.18) results for the global UV-A range.

Preparation and electrochemical behavior of gramicidin-bipolar lipid monolayer membranes supported on gold electrodes

Gramicidin-containing synthetic bolalipid membranes comprised of 2,2'-di-O-decyl-3,3'-O-1,20-eicosanyl-bis-rac-glycero-1,1'-diphosphocholine (C20BAS) have been synthesized and supported on gold electrodes. Supported membranes were prepared by first depositing a partial bolalipid layer on the electrode using a thioctic acid-modified bolalipid (1'-O-omega-thioctamidetetraethylene glycol-2,2'-di-O-decyl-3,3'-di-O-1,20-eicosanyl-bis-rac-glycero-1-phosphate, SSC20BAS) as an anchoring group, followed by a vesicle fusion step using either pure C20BAS or gramicidin-containing C20BAS (C20BAS-GA) vesicles. The latter configuration was designed to immobilize single, continuously-on channels of gramicidin in the C20BAS membrane. Vesicle deposition to form supported bolalipid monolayer membranes was monitored by impedance spectroscopy and cyclic voltammetry. Impedances were observed to increase with vesicle deposition time. Pretreatment of the impedance electrode with SSC20BAS accelerated the supported monolayer membrane deposition rate. Impedances decreased in a gramicidin concentration-dependent manner when gramicidin was incorporated into the C20BAS membrane. These supported bolalipid membranes are also surprisingly inert to organic solvent exposure (CH(3)CH(2)OH;CH(2)Cl(2)), suggesting that they may serve as robust host matrices for integral membrane protein-based sensors.

Routine analysis of 101 polychlorinated biphenyl congeners in human serum by parallel dual-column gas chromatography with electron capture detection

Polychlorinated biphenyl (PCB) exposure has been linked to a variety of toxic effects in animal experiments and in certain human case reports and epidemiologic studies. A total of 209 individual PCB congeners are possible, based on chlorination level and ring substitution pattern. Commercial PCBs are a complex mixture of congeners, and over 75 of these have been reported to be present in human tissues at widely varying levels. Because the biologic activity of individual PCBs is a function of extent and pattern of chlorine substitution, "congener-specific" PCB analysis of human tissue has gained increasing importance in assessing possible links between PCB exposure and toxic effects. A high-sensitivity analytical method using dual-column gas chromatography (GC) with electron capture detection (ECD) for determining 101 PCB congeners (83 individual, 18 as pairs/triplets) plus 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (p,p'-DDE), hexachlorobenzene (HCB), and mirex, in human serum is described. Separation is performed concurrently on parallel-configured DB-5 and Apiezon-L capillary columns. The current method is a modification of previously reported dual-column GC-ECD systems with improvements to the extraction and analytical protocols and the implementation of a comprehensive QA/QC program. The method employs two surrogate standards (PCBs IUPAC 125 and 192) and internal standard (IUPAC 104)-based quantitation, in addition to per-batch check standards and method blanks. Although optimized for serum, the method is applicable to all human, experimental animal, and environmental biota samples. The accuracy, precision, and reliability of the method were assessed using a variety of QA/QC endpoints. Finally, the use of the method in determining level and prevalence of PCB congeners in a cohort of adult Native-American individuals with historical environmental PCB exposure is reported.

[Atropine poisoning. Importance of the clinical diagnosis]

A case of suspected high dose atropine poisoning is described. In a veterinarian good healthy young man the appearance of light coma with psychomotor agitation and the contemporary presence of evident symptoms of muscarinic peripheral block, suggesting an anticholinergic syndrome, an atropine-like intoxication in absence of toxicological analysis. The safely clinical course of the poisoning during observation in intensive care unit permitted the discharge of the patient without sequelae and without treatment with physostigmine as antidote.

[The nutritive effect of Bacillus cereus as a probiotic in the raising of piglets. 2. Effect and microbial count, composition and resistance determination of gastrointestinal and fecal microflora]

After a feeding trial of 42 days with 4 x 12 piglets 4 x 6 piglets were slaughtered and the influence of spores of the Bacillus cereus strain FH 1457 S added to the feed on the microorganism counts of Lactobacillus/Bifidobacterium, Eubacteria, Bacteroidaceae, E. coli, Enterococcus and passants (Bacillus cereus) in duodenum, jejunum, ileum, caecum and colon was investigated. Beside a negative control the feed was supplemented with 10(7), 10(8) and 10(9) CFU Bacillus cereus/kg. The feeding trial included two periods each of 21 days. In each period faeces was collected from all animals and the influence on the microorganism counts and also the frequency of resistance of the E. coli and Enterococcus germs against selected antibiotics and chemotherapeutics investigated. The addition of 10(8) CFU Bacillus cereus decreased E. coli counts in duodenum and jejunum, however increased them in ileum, caecum and colon. In the highest dosage the counts of Bacillus cereus in duodenum, caecum, colon and faeces were significantly higher. The addition of Bacillus cereus reduced the counts of E. coli and Enterococcus in faeces in the first period. In the second period the dosage 10(8) CFU showed significant increased counts of E. coli and the sums of microorganisms of the main and satellite flora. The additions had no influence on the frequency of resistance of E. coli and enterococci against the tested antibiotics and synthetic chemotherapeutics. From the addition of Bacillus cereus in this case a selection of factors influencing resistance is not to be expected.

External ATP antagonizes the effect of potassium channel openers in guinea-pig ventricular papillary muscle

Right ventricular papillary muscles of the guinea-pig heart were electrically stimulated. Cromakalim 10-100 microM and Ro 31-6930 3 microM depressed the contractile force and shortened the duration of action potentials. Glibenclamide 0.3-3 microM, ATP 100 microM and alpha, beta-methylene ATP (alpha, beta-meATP) 30 microM antagonized these effects. Suramin 300 microM failed to reverse the alpha, beta-meATP-evoked antagonism of the action of cromakalim. It is concluded that both intra- and extracellular ATP may interfere with potassium channel openers and that extracellular ATP does not act via the known P2-purinoceptor subtypes.

Dysmorphophobia: body dysmorphic disorder or delusional disorder, somatic subtype?

The DSM-III-R proposes to divide dysmorphophobia into two separate disorders: delusional disorder, somatic subtype and dysmorphic disorder. We believe that this distinction of delusional and nondelusional is impossible from a phenomenological point of view, and that dysmorphophobic beliefs are better classified as overvalued ideas. The concept of dysmorphophobia and its relationship to monosymptomatic hypochondriacal psychoses and DSM-III-R categories is reviewed. A case report is described to support these arguments.

Isolation of a mycotoxin (gliotoxin) from a bovine udder infected with Aspergillus fumigatus

A bovine udder infected with Aspergillus fumigatus was analysed by physico-chemical methods (thin layer chromatography, high performance liquid chromatography and direct exposure probe-mass spectrometry) for the presence of mycotoxins. Gliotoxin, a fungal metabolite with cytotoxic and immunosuppressive properties was isolated for the first time from naturally infected tissue. The gliotoxin concentration analysed (9.2 mg kg-1 udder) was approximately 100 times higher than the concentration known to produce morphological changes of cells. Gliotoxin may play an important role in the establishment and development of an infection with A fumigatus.

Influence of two non-steroidal anti-inflammatory drugs on lipolysis and on plasma post-heparin lipoprotein lipase activity in normal man

Indomethacin 50 mg i.v. or p.o. and diclofenac sodium 50 mg p.o. produced a prompt and significant increase in plasma free fatty acid concentration. In 10 subjects who took indomethacin 150 mg/d p.o. for 3 days, plasma post-heparin lipoprotein lipase activity was also significantly increased. The same effect occurred in 9 subjects treated for 3 days with diclofenac sodium 50 mg t.d.s. Since both indomethacin and diclofenac sodium are potent inhibitors of prostaglandin synthetase, these findings are consistent with the hypothesis tht prostaglandins are involved in the feed-back regulation of lipolysis, and mediate the inhibitory effect of lipolysis on lipoprotein lipase activity.