Tuboovarian abscess mimicking intraligamentar uterine myoma and a intrauterine device: A case report

A case study is presented of tubo-ovarian abscess (pathohystological-verified actinomycosis) in a 41-year-old woman with an intrauterine device (IUD), which on US was found to be imposed upon an intraligamentary degenerated myoma (pyomyoma). The patient was afebrile, with normal vital functions (diuresis, blood pressure and pulse). Exposure of the abdominal cavity by lower transverse laparotomy performed under general endotracheal anaesthesia revealed slight uterus enlargement with normal left adnexa, whereas right adnexa were not exposed due to the soft tumour in the region of the right ligamentum latum, which displaced the urinary bladder and uterus leftward. The peritoneum fold was incised and deprepared, revealing a tumorous formation imposed onto the myoma or onto the 'cold' tubo-ovarian abscess. Total hysterectomy was then performed. Left adnexa showed a normal finding. Hemalaun-eosin staining of the preparation of the tumour capsule and tumour content showed colonies of threads extending radially to the surrounding tissues (drusen), surrounded by pus corpuscles, polymorphonuclears and macrophages containing lipids (sulfur granules). The patient was free from disease relapse at 2 years after the procedure. Thus, total abdominal hysterectomy and salpingoophorectomy, along with antibiotic therapy, were the definite mode of treatment for pelvic actinomycosis.

Transcranial doppler ultrasonography as an early outcome forecaster following severe brain injury

Knowledge of post-traumatic cerebral haemodynamic disturbances might be beneficial for predicting the management outcome when measuring the basal cerebral arteries blood flow velocity by ultrasonic transcranial Doppler device immediately after severe head injury. Thirty patients who sustained severe brain injury underwent an early blood velocity measuring by transcranial Doppler ultrasonography during a 1-year period of study. The standard technique of measuring the mean blood flow velocity in the middle cerebral artery was applied. The outcome was assessed at 6-month follow-up by the Glasgow Outcome Score. The middle cerebral artery low blood flow velocity, and the increased values of the pulsatility index significantly correlated to an unfavourable outcome. Transcranial Doppler ultrasonography for measuring the middle cerebral artery blood flow velocity has been proved worthy as a possible predictor of severe head injury management outcome. This non-invasive and simple procedure could be engaged in the daily management of severely brain-injured patients.

Minimal fixation in the treatment of open hand and foot bone fractures caused by explosive devices: case series

AIM

To evaluate minimal fixation method with Kirschner's wires in the treatment of open fractures of the hand and foot short bones, caused by explosive devices.

METHOD

There were 270 wounded persons with open fractures of hand and foot short bones, who were surgically treated at the Department of Surgery at the Osijek University Hospital. The stabilization of an unstable open fracture was performed with intramedullary positioned Kirschner's wires. In a few cases, satisfactory stabilization was achieved with Kirschner's wires positioned percutaneously alongside the wound and perpendicularly through the fracture. In the rest of the wounded, plaster immobilization was sufficient after surgical treatment and fracture reposition.

RESULTS

Among 270 persons with 412 open hand and foot bone fractures, 49% had fracture only in the feet, 27% only in the hands, and 24% in both hands and feet. Unstable short bone fractures were found in 56 patients (21%). Such fractures were stabilized with Kirschner's wires (n=71). In 58 patients (21%) partial hand and foot amputations had to be performed. Reconstructive operations to improve pseudarthrosis after minimal osteosynthesis were performed on 5 short bones (7%). Osteitis was found on four short bones (6%) after minimal osteosynthesis.

CONCLUSION

Minimal osteosynthesis with Kirschner's wires is a reliable and adequate method of the treatment of open unstable short bone fractures caused by explosive devices.

Quadricepsplasty after war fractures

Knee movements after fractures caused by explosive devices, as well as after intra-articular fractures of the knee, are often inadequate. This paper presents the results of quadriceps-plasty performed in 10 patients with the purpose of improving knee function. All of the patients were treated by the external fixation method, either after femoral fractures caused by explosive devices or for intra-articular knee fractures. All of them manifested markedly decreased knee flexion (15-70 degrees, with an average of 32 degrees). After quadricepsplasty and physical therapy, the achieved knee flexion was enough for normal walking (80-130 degrees, average 97.5 degrees). Mean knee mobility was increased 65.5 degrees. Our paper presents indications, methods, results, and complications for quadricepsplasty performed after war injuries.

[Analysis of results of treatment of open and unstable grade II and III fractures in the calf]

Unstable lower limb fractures are undoubtedly indications for operative treatment by external or internal stabilization method. In this paper we discuss our experience in healing of 413 patients with unstable calf fractures, operatively treated in the period from 1990-1994. Internal stabilization method was applied, strictly respecting indications, in 375 patients (90.8%), while 38 of them (9.2%) were treated by external fixation method (external fixator Zagreb 1 or set 63305-00). Lower limb osteitis was diagnosed in 36 patients (9.6%), when internal fixation method was used, while osteitis on the fracture site, after external fixator application, was found in 2 patients (5.3%). According to their experience, the authors suggest the employment of external fixators for the healing of open and unstable calf fractures of the second and the third degree.

External fixation as a primary and definitive treatment of open limb fractures

This paper analyses the medical records of 5024 injured persons treated and operated on at the Surgical Clinic of the Clinical Hospital in Osijek, during the war against Croatia (1991 and 1992). There were 1653 (33.0 per cent) admitted, while the rest were treated as out-patients. Of the admitted patients 82.7 per cent (1372) had limb injuries. In 760 (15.0 per cent) of the wounded, 1320 limb fractures caused by explosives were diagnosed, out of which 856 were of the lower and 464 of the upper limbs. One hundred and ninety-two (3.9 per cent) were treated by external fixation. External fixators were applied to 147 lower and 68 upper open long bones, respectively. Adequate reconstructive operations were performed on 106 (2.1 per cent) patients with associated injuries to important blood vessels. The stabilization of the open and unstable external fractures was achieved by external fixation, mostly at one level, regardless of the wound size. The importance of good wound cleaning has been particularly stressed as well as bone fragment reposition. Special attention has been given to the preoperative and intra-operative assessment of the limbs. In 20 patients (9.3 per cent) treated with external fixation, osteitis occurred. Twenty-one more patients (9.7 per cent), because of bad fracture healing after external fixation, were submitted to secondary internal bone fixation combined with bone grafts. Out of these, nine (42.8 per cent) developed osteitis as a consequence of the additional treatment.

[Personal experience in the care of open fractures using external fixation during the hostilities in Osijek and surrounding region]

In the period of aggression of the Federal Army and Serbian paramilitary forces on the City of Osijek and its surrounding, beginning in the summer of 1991, 4036 wounded were treated at the Department of Surgery, Osijek General Hospital. Extremity injuries were documented in 3889 patients, including 959 bone fractures. The majority of patients had wounds caused by highly destructive explosives filled with metal fragments of different shapes and dimensions, and having sharp and uneven edges. One hundred and forty wounded were treated by external fixators. In 102 patients this mode of fixation was applied for gun- and explosive-related long bone fractures of the lower extremities. External fixator for the upper and forearm fractures was used in 38 cases. During this period, different types of external fixators were used and experience in this work has been gained. Stability of both open and unstable bone fractures of the extremities, caused by explosive devices, has been obtained by the external fixation mostly in one plane, regardless of the type of external fixator used. The advantages of use of external fixators of the types Instrumentarija Zagreb 1 and 2 for the treatment of long bone fractures has been emphasized as well as the possibility of the subsequent corrections owing to the technical construction of the bone spike. The usefulness of the longitudinal bar of the AO/ASIF fixator for the healing of fractures of the upper leg with subsequent callus formation is also stressed. The same stability has been achieved by the CMC fixator. The external fixators of a type Zagreb 2 have been a satisfactory treatment for forearm fractures as well.(ABSTRACT TRUNCATED AT 250 WORDS)

[Relation between the incidence of fractures of the upper part of the femur and the season of the year]

A number of patients hospitalized at the Osijek General Hospital Surgical Ward with hip fractures determined for a ten-year period (1976-1985) indicates that the number of these injuries during a period of year with less sunny hours (November to February, i.e. during winter) exceeds by 66.6% (p less than 0.0005) the number of injuries during summer, i.e. the period of year with larger number of sunny hours (May to September). There are mathematical proofs that occurrence of these injuries is partially periodical and that there is a statistically significant negative correlation between the number of sunny hours (quantity of ultraviolet rays) and the number of hip fractures (r = 0.487, p less than 0.0005). Based on numerous data available in literature on presently known physiological functions and oscillations of vitamin D, some basic postulates on hip biomechanics, earlier analyses done by the authors regarding frequency of this type of injury depending on age, sex, laterality and fracture site, and supported by the results presented in this paper, it has been concluded that reduced frequency of hip fractures in affected population during periods with more of ultraviolet radiation could be partially explained by a more potent muscle contraction, smaller instability and consequently reduced frequency of falls during this period of year.

Effects of coincubation of the pituitary and hypothalamus of intact and castrate male rats and the influence of LH-RH on pituitary 5 alpha-reductase activity1,2

Pituitary 5 alpha-reductase activity in intact male rats increases after the pituitary is incubated with the hypothalamus. Incubating the pituitary of castrate rats with the hypothalamus of intact rats relatively inhibits pituitary 5alpha-reductase activity. Coincubation of the pituitary and hypothalamus of castrate rats, or the pituitary of intact with the hypothalamus of castrate males, does not elicit changes in pituitary 5alpha-reductase activity. Different amounts of LH-RH in the incubation medium can modify 5alpha-reductase activity, i.e., activate it in the intact pituitary and inhibit it in the castrate pituitary. Hypothalamus from intact rats, which according to SHIN et al. [1974] is 'rich' in LH-RH, induces changes in pituitary 5alpha-reductase activity. The LH-RH-'poor' hypothalamus of castrate rats does not cause changes in this enzyme activity. The results suggest that there is a very close relationship between LH-RH and 5alpha-reductase activity in the pituitary.