[Dyspnea, hypoxia and a confusional state--a post-recovery diagnosis]

We present a case of a 48 year old female, with a medical history significant for paraplegia due to a cervical cord injury and a history of transitional cell carcinoma, which necessitated a urinary bladder ileal reconstruction. The patient was hospitalized due to an acute confusional state, severe respiratory distress and hemolytic anemia. One day prior to hospitalization, she was involved in a minor motor vehicle accident, yet she and her family denied any injuries due to the accident and the patient did not complain of pain. During the course of her hospitalization the patient was febrile, yet we did not find any evidence of an infectious cause for her symptoms. Notably, lumbar puncture and MRI scan were relatively contraindicated, hence a CNS infection was not completely ruled out. We also thoroughly investigated her respiratory symptoms, but could not reach a conclusive diagnosis. Nevertheless, after approximately 14 days of diagnostic efforts, empirical antibiotic treatment and supportive care, all clinical and laboratory abnormalities had resolved. The patient was discharged with a presumed diagnosis of a poorly understood infectious process. However, not long after, she returned to the emergency department complaining of a red, painful, swollen right knee. Imaging studies demonstrated a right supracondylar as well as a tibial plateau fracture. Consequently, a post-recovery diagnosis of fat emboli syndrome was made.

Healing of bone fractures of rat shin and some immunological indices during magnetic laser therapy and osteosynthesis by the ilizarov method

The effect of magnetic and laser therapy on healing of bone fractures and blood levels of T and B lymphocytes was studied in rats during osteosynthesis by the Ilizarov method. Laser therapy induced changes in cells attesting to stimulation of reparative processes and normalization of immunological parameters.

[Surgical management of bone metastases of the lower extremity with AO interlocking nail]

Between January 1991 and June 1995 we have operated on 19 patients (9 male, 10 female) with 22 skeletal metastases of the lower limb (19 femora, 3 tibiae) using a static interlocking nail. Closed intramedullary nailing without resection of the metastasis has been established as our standard procedure. We have stabilized 15 patients with advanced osteolysis and seven pathological fractures. Sixteen patients underwent postoperative local radiation therapy with 40 Gy. As intraoperative complications we have observed one fracture of an osteolysis and one death due to fat embolism. Postoperatively there were observed one seroma, one haematoma and one patient with non fatal pulmonary embolism following DVT. Two patients died within the first 30 postoperative days because of tumor progression. All patients surviving longer than 30 days could be mobilized under full weight-bearing. Morphine like analgetics for metastasis related pain were no longer needed. A secondary instability has not been observed within a mean survival time of 199 days (811 longest follow up). Closed intramedullary nailing in combination with postoperative local radiation therapy seems to be an appropriate and technically non demanding procedure to stabilize skeletal metastases of the lower limb in patients with a short or medium-term expectation of life.

Postfracture irradiation effects on the biomechanical and histologic parameters of fracture healing

The effects of single-dose local irradiation on the biomechanical properties of closed femoral fractures were studied in 75 mature Sprague-Dawley rats. Ten days after fracture, the rats were irradiated with 900 rads at 250 kV to the entire fractured femur. At 2, 3, 4, 8, and 16 weeks after fracture, both fractured and contralateral intact femurs were recovered and evaluated biomechanically by testing to failure in torsion. Results were compared with those from a similar study involving fractures irradiated 3 days after fracture as well as nonirradiated control fractures. Fracture healing progressed faster when irradiation was delayed 10 days than when delayed 3 days, and control fractures healed more rapidly than after either delay. In the 10-day delay group, fractures showed greater strength than did those in the 3-day delay group at 8 weeks, but the strength of irradiated fractures in both groups was similarly depressed at 16 weeks, with a maximum torque well below that of control fractures. These results suggest that delaying radiation exposure of a fracture may mitigate short-term deleterious effects on fracture repair, but that long-term results may be similar to those associated with expeditious irradiation.

Changing concepts in the management of pathological and impending pathological fractures

The benefits in the management of pathological fractures by internal fixation are well recognized. However, failures in bone or metal can occur where there is a large amount of bone destruction. Seven of 69 pathological fractures in our series were treated by internal fixation with adjunctive use of methylmethacrylate without failure. This allowed for secure fixation in fractures with large amounts of bone destruction, thus decreasing the patient's pain and allowing earlier mobilization. Neither the effects of radiotherapy on bone involved with neoplasm nor methylmethacrylate are altered when radiotherapy is used after internal fixation and adjunctive use of methylmethacrylate. We believe that an aggressive program of stabilization of these fractures or fixation before actual fracture provides significant patient benefits including reduction of pain, decreased length of hospital stay, reduction of financial expense, and return to as near normal function as possible.