References

Skokan, E.G., Olson, L.M., Cook, L.J. and Cornell, H.M. (2001), Snowmobile injuries in Utah. Academic Emergency Medicine, 8 (12), 1173-1177.

Abstract: mObjective: To describe the epidemiology of snowmobile injuries in Utah. Methods: Analysis of probabilistically linked statewide emergency department (ED), hospital admission, and death certificate data for 1996 and 1997. Results: There were 625 cases of snowmobile-related injuries. The majority (83%) were evaluated in the ED only. Median ED patient age was 29 years (range 3-74 years), and 66% were male. The leading diagnoses were open wounds to the head (7.8%), back strains (5.4%), and contusions of the trunk and lower extremities 5.2% and 5.0%, respectively). An Injury Severity Score (ISS) of greater than or equal to4 (range 1-75) was found in 37% of the ED patients. The median charge was $373 per patient, with two- year cumulative charges of $266,283. One hundred seven patients required inpatient hospital care, Median inpatient age was 32 years (range 4-92 years), and 60% were male. Leading inpatient diagnoses were fracture of the vertebral column (9.3%), lower extremity fracture (9.3%), upper extremity fracture (6.5%), and pelvis fracture (3.7%). An ISS of greater than or equal to4 (range 1-38) was found in 70% of the hospitalized patients. Average length of stay was 3 days, with a range of 1 to 68 days. Median inpatient charge was $6,003 per patient, with two- year cumulative charges of $1,333,218. Ten inpatients required transfer for rehabilitation or skilled nursing care. There were a total of six fatalities, three of which occurred in the ED, one in the inpatient population, and two identified from the death certificate database. Conclusions: By combining ED, inpatient, and death certificate data sets, probabilistic linkage provides a comprehensive description of snowmobile- related injuries and a baseline evaluation of morbidity, mortality, and financial burden

Keywords: extremity/injury control/probabilistic linkage/rehabilitation/snowmobile/sports and recreational injuries/trauma

Devarebeke, B.J. and Vanosselaer, G. (1993), Migration of Kirschners Pin from the Right Sternoclavicular Joint Resulting in Perforation of the Pulmonary-Artery Main Trunk. Acta Chirurgica Belgica, (6), 287-291.

Abstract: The spontaneous migration, in a 62-year-old patient, of a broken Kirschner's pin from the right sternoclavicular joint to the anterior mediastinum, with perforation of the pericardium and puncture of the main trunk of the pulmonary artery resulting in cardiac tamponade, is described. A review of the literature stresses the high risk of migration when pins or wires are used for internal fixation of the shoulder girdle, resulting sometimes in life-threatening situations and the need for major thoracic interventions. It seems mandatory to remove all foreign material after consolidation, certainly when pins or wires are broken or when there is evidence of local bone resorption, as the broken parts may migrate. The legal implications, when adequate and regular follow-up has been neglected, are described

Keywords: ACROMIOCLAVICULAR JOINT/AORTIC RUPTURE/CARDIAC TAMPONADE/CLAVICLE/DISLOCATION/FRACTURE FIXATION/FRACTURES/PROSTHESIS/PULMONARY ARTERY/STERNOCLAVICULAR JOINT

Kotani, Y. and Tokuhiro, A. (2002), Kinesiological study of the push-up motion in spinal cord injury patients: Involving measurement of hand pressure applied to a force plate. Acta Medica Okayama, 56 (2), 75-82.

Abstract: We studied the pressure exerted by hands during push-ups in 21 paraplegic and 2 tetraplegic patients employing 4 different hand positions. In the fingers-spread

position, the initial force exerted was a vertical force (Fz), followed by a medio- lateral force (Fy) and then an antero-posterior force (Fx). In the other 3 positions, the order of force type exertion was Fz, Fx, and then Fy. All subjects with neurological injury levels above T4 and subjects between T5 and T10 without spinal instrumentation could not push themselves up in the fingers- spread position. The fact that Fy is initiated before Fx in the fingers-spread position indicates that lateral balancing of the trunk is critical in this position, thus explaining why subjects without spinal instrumentation with neurological injury at a level higher than T10 could not control their spinal columns while performing push-ups. In contrast, antero- posterior balancing takes priority in the other hand positions. We believe that spinal instrumentation helps balance the trunk in the lateral direction, converting the thoracic spine into a rigid body in subjects with neurological injury at levels above T10

Keywords: floor reaction force/FRACTURE-DISLOCATIONS/INSTRUMENTATION/kinesiology/LUMBAR SPINE/push-up/rehabilitation/spinal-cord-injury

Parkkari, J., Natri, A., Kannus, P., Manttari, A., Laukkanen, R., Haapasalo, H., Nenonen, A., Pasanen, M., Oja, P. and Vuori, I. (2000), A controlled trial of the health benefits of regular walking on a golf course. American Journal of Medicine, 109 (2), 102-108.

Abstract: PURPOSE: To study the effects of regular walking during a golf game on various health and fitness indicators in middle aged men. METHODS: Study subjects were 55 healthy male golfers aged 48 to 64 years who had been sedentary during the 7 months before the study, and 55 age-matched, similarly sedentary controls. During the 20-week study, those in the intervention group were encouraged to play golf two to three times a week; the controls were not. Measurements of body composition, cardiorespiratory performance, motor and musculoskeletal fitness, blood pressure, and serum lipid, glucose, and insulin levels were obtained at baseline and after the 20-week study. RESULTS: Walking during a golf game was a practical and safe form of physical activity with high adherence. It significantly increased aerobic performance and trunk muscle endurance, with a net difference (pretraining to posttraining change between the golfers and controls) of 36 seconds (95% confidence interval [CI]: 19 to 53 seconds, P < 0.001) for treadmill walking time and 13 seconds (95% CI: 2 to 24 seconds, P = 0.02) for static back extension. In addition, regular walking favorably affected body composition, including reductions in weight of 1.4 kg (95% CI: 0.6 to 2.1 kg, P < 0.001), in waist circumference of 2.2 cm (95% CI: 1.0 to 3.3 cm, P < 0.001), and in abdominal skin fold thickness of 2.2 cm (95% CI: 0.9 to 3.4 cm, P = 0.001). Golfers also had significantly greater increases in serum high-density lipoprotein (HDL) cholesterol levels and ill the ratio of HDL cholesterol to total cholesterol. CONCLUSIONS: Regular walking had many positive effects on the health and fitness of sedentary middle-aged men. Walking during a golf game is characterized by high adherence and low risk of injury and is therefore a good form of health- enhancing physical activity. Am J Med. 2000;109:102-108. (C) 2000 by Excerpta Medica, Inc

Keywords: ADULTS/COLLEGE ALUMNI/CORONARY HEART-DISEASE/EXERCISE/FITNESS TEST BATTERY/HIP FRACTURE/MEN/MORTALITY/PHYSICAL- ACTIVITY/RISK-FACTORS

O'Neill, D.F. and McGlone, M.R. (1999), Injury risk in first-time snowboarders versus first-time skiers. American Journal of Sports Medicine, 27 (1), 94-97.

Abstract: Between 1994 and 1996 we studied injury patterns in more than 22,000 first-

time snowboarders and first-time skiers to determine the comparative injury risk of these two popular sports coexisting in winter resort areas. The first-time participants included in this study had no previous experience in their activity of choice and enrolled in Learn to Snowboard and Learn to Ski programs in two major northeastern ski resorts. Data were gathered from physician evaluations at the medical clinics at each mountain. Two hundred seventy-three (4%) of the first-time snowboarders (N = 6585), and 641 (4%) of the first-time skiers (N = 15,795) sustained an injury. Injuries were further evaluated by location (upper extremity, lower extremity, head, and trunk area) and severity (emergent versus nonemergent). Snowboarders had a higher percentage of upper extremity injuries (53%), while skiers had a higher percentage of lower extremity injuries (63%). Snowboarders, however, sustained a significantly higher incidence of emergent injuries (such as fracture, concussion, dislocation, lost teeth) necessitating immediate intervention. While there have been other reports describing injuries in these activities, no previous study attempted to look at the first-time participants with similar age, experience, and equipment to determine comparative risk. We conclude that for the first-time participant, snowboarding does show a higher incidence of emergent injuries

Keywords: extremity/fracture/headTremollieres, F.A., Pouilles, J.M. and Ribot, C.A. (1996), Relative influence of age and

menopause on total and regional body composition changes in postmenopausal women. American Journal of Obstetrics and Gynecology, 175 (6), 1594-1600.

Abstract: OBJECTIVE: We measured total and regional body composition to evaluate the differences in body composition associated with menopause and to determine whether the changes in fat distribution were more related to age or to menopause. STUDY DESIGN: Two hundred five healthy white women who had never received estrogen replacement therapy were studied according to menopausal status and age. Bone mass and body composition were measured by dual x-ray absorptiometry. The proportions of android and gynoid fat were calculated in all women and differences were sought by statistical analysis. RESULTS: Compared with premenopausal women, postmenopausal women were characterized by a significant increase in the proportion of android fat and the ratio trunk fat/leg fat, whereas the absolute amount of body fat mass did not significantly change. The different variables of android fat distribution tended to correlate better with years since menopause than with age. In multiple linear regression, years since menopause was a predictor of body fat mass and fat trunk, whereas age was not a predictor of any of the fat distribution variables. CONCLUSIONS: This study underlines the early changes in body fat distribution with a shift of body fat toward a more central location in postmenopausal women. This change in fat distribution appears to be more related to menopause than to age and might, together with other factors, contribute to explain the increased cardiovascular risk reported in postmenopausal women

Keywords: ADIPOSE-TISSUE/body composition/body fat distribution/BONE LOSS/CARDIOVASCULAR-DISEASE/CORONARY HEART-DISEASE/dual X-ray absorptiometry/FAT/FRACTURE/MASS/menopause/PARTICIPANTS/postmenopausal women/RISK/SKELETAL

Lyles, K.W., Gold, D.T., Shipp, K.M., Pieper, C.F., Martinez, S. and Mulhausen, P.L. (1993), Association of Osteoporotic Vertebral Compression Fractures with Impaired Functional Status. American Journal of Medicine, 94 (6), 595-601.

Abstract: PURPOSE: To determine if vertebral compression fractures in elderly women were associated with impairments in physical, functional, and psychosocial

performance. SUBJECTS AND METHODS: Ten white women with confirmed vertebral compression fractures were age- and race-matched with 10 control subjects without fractures in a case-control design. All subjects invited to participate in this study were patients of the Geriatrics Division of the Department of Medicine at Duke University Medical Center. All study participants lived either in the community or in the independent-living sections of local retirement communities in and around Durham, NC. Subjects with fractures (mean age = 81.9 years, SD = .5 years) had two or more vertebral compression fractures in their medical records, whereas control subjects (mean age = 79.6 years, SD = 6.5 years) had no history of vertebral fractures Spinal radiographs of all women confirmed group assignment. Physical, functional, and psychosocial performances were evaluated. Physical performance was assessed by measurements of maximal trunk extension torque and thoracic and lumbar spinal motion in the sagittal plane, functional reach, mobility skills, 10-ft timed walk, and 6-minute walk test. Thoracic and lumbar spinal configurations were also determined. Functional performance was assessed using the Functional Status Index. Psychosocial performance was assessed with the following scales: Hopkins Symptom Checklist 90 Revised, Rosenberg Self-Esteem Scale, West Haven-Yale Pain Inventory, Beck Depression Inventory, and single-item health-belief questions. RESULTS: Control subjects were not significantly different from patients with fractures in age, weight, number of current illnesses, number of prescribed medications, number of pain medications, ratings of lumbar spine degenerative disc disease, or lumbar spine facet joint arthritis. Activity levels and exercise participation were similar in both groups. Control subjects had no vertebral fractures, whereas fracture subjects had 4.2 +/- 2.6 fractures (range: 2 to 10). Thoracic kyphosis was increased and lumbar lordosis was reduced in fracture subjects. Fracture subjects had reduced maximal trunk extension torque, thoracic and lumbar spine sagittal plane motion, functional reach, mobility skills, and 6-minute walk test. The Functional Status Index showed reduced levels of functional performance in fracture subjects compared with controls with increased levels of assistance, pain with activity, and difficulty in activities. Psychosocial performance was limited in fracture subjects with increased psychiatric symptoms, increased pain, and greater perception of problems caused by health. CONCLUSION: Vertebral compression fractures are associated with significant performance impairments in physical, functional, and psychosocial domains in older women

Keywords: BONE-MINERAL DENSITY/DISCHARGE/elderly/EPIDEMIOLOGY/fracture/HIP-FRACTURES/INSTRUMENT/kyphosis/MASS/MORTALITY/POSTMENOPAUSAL OSTEOPOROSIS/spine/THERAPY/WOMEN

Dawsonhughes, B. and Harris, S. (1992), Regional Changes in Body-Composition by Time of Year in Healthy Postmenopausal Women. American Journal of Clinical Nutrition, 56 (2), 307-313.

Abstract: We examined regional changes in fat, lean, and bone tissue for > 1 y in 125 postmenopausal women. Duplicate whole-body scans were performed at 6-mo intervals. Period 1 was June or July to December or January and period 2 was December or January to the following June or July. Lean and bone tissue mass in the arms, legs, trunk, and whole body increased in period 1 and decreased in period 2 [eg, lean tissue in legs increased 1.84 +/- 0.41% (xBAR +/- SE) in period 1 and decreased 2.84 +/- 0.39% in period 2, P < 0.001]. In each region except the arms, fat tissue decreased in period 1 and increased in period 2. Quadriceps muscle strength was correlated with lean tissue mass of the legs [r(p) (controlled for height) = 0.24, P

= 0.02] and physical activity was correlated with quadriceps strength. Overall, body weight did not change significantly (0. 17 +/- 0.41% increase, P > 0.20); however, there was a net loss of 1.08 +/- 0.39% (P < 0.0 1) in lean tissue in the legs and a net increase of 3.43 +/- 1.12% (P < 0.01) in fat tissue in the trunk

Keywords: BODY COMPOSITION/BONE/BONE-MINERAL CONTENT/DUAL-PHOTON ABSORPTIOMETRY/ELDERLY SUBJECTS/FAT/HIP FRACTURE/LEAN/MUSCLE STRENGTH/NEUTRON-ACTIVATION/PHYSICAL-ACTIVITY/POSTMENOPAUSAL WOMEN/RISK-FACTORS/SEASON/SEASONAL-VARIATIONS/strength/X-RAY ABSORPTIOMETRY

Shimada, H., Obuchi, S., Kamide, N., Shiba, Y., Okamoto, M. and Kakurai, S. (2003), Relationship with dynamic balance function during standing and walking. American Journal of Physical Medicine & Rehabilitation, 82 (7), 511-516.

Abstract: Objective: To investigate the relationship between dynamic balance functions in young adults and elderly adults while standing and walking. Design: In standing balance tests, the Sensory Organization Test (SOT) of six combinations of three visual and two support-surface conditions was used to measure standing balance, and the Motor Coordination Test (MCT) was used to provoke automatic postural reactions through a series of sudden translations of support surface. The gait test measured maximum anterior acceleration (MAA) and maximum posterior acceleration (MPA) of the trunk during perturbed walking using a bilaterally separated treadmill, and calculated latency until MAA and latency until MPA. Results: The elderly adults showed more significant functional decline than young adults in SOT1, SOT4, SOT6, medium intensity MCT, large intensity MCT, and MPA. In the correlation analysis of the outcome from the standing examinations, close correlations among SOT4, SOT5, and SOT6 conditions were observed in both groups of young adults and elderly adults. In the MCT, there was very close correlation between varied translation intensity in two groups. On the other hand, the only weak correlation between SOT and MCT findings was between SOT4 and large intensity MCT in elderly adults (r = -0.471, P = 0.049). In the gait test, although correlation was not significant in young adults, the significant correlations between MAA and latency until MAA (r = 0.705, P = 0.001) and latency until MAA and latency until MPA (r = 0.497, P = 0.036) were recognized in elderly adults. In the balance function findings of the standing examinations and the gait examinations, there was significant correlation between medium intensity MCT and latency until MAA (r = -0.552, P = 0.018) in young adults, and SOT6 and latency until MPA (r = -0.473, P = 0.047) in elderly adults. However, no relationship was observed in most of other factors. Conclusions: Most falls experienced by elderly people are caused by tripping or slipping during walking. The fact that walking balance function did not correlate with standing balance function indicates that multifaceted evaluation is important to comprehend dynamic balance function while standing and walking

Keywords: ADJUSTMENTS/balance/COORDINATION/dynamic balance/elderly/elderly persons/FALLS/falls/gait/HIP FRACTURE/HUMANS/MUSCLE-ACTIVITY/OLDER ADULTS/POSTURAL RESPONSES/POSTUROGRAPHY/RECOVERY/Sensory Organization Test/standing balance

Hurter, H., Post-Stanke, A. and Tolksdorf, W. (2000), Lethal vascular arrosion after percutaneous dilatational tracheostomy. Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie, 35 (10), 658-660.

Abstract: We report on a patient who underwent dilatational tracheostomy (Ciaglia technique) because of ARDS. 29 days after the procedure she died of hemorrhage from an arrosion of the bracheocephalic trunk, caused by the cuff of the tracheal cannula. This complication has, so far, been reported only after surgical tracheostomy. The fracture of tracheal cartilages is considered to be the specific cause of this fatal complication. The consequent loss of circular stability of the trachea demands increased cuff insufflation and pressure to tighten the airway. Prevention and therapy consist in control of the cuff pressure and caudal placement of the tracheal cannula

Keywords: cuff pressure/fracture/fracture of tracheal cartilage/MANAGEMENT/percutaneous dilatational tracheostomy/tracheoarterial fistula

Fujitsuka, N., Fujitsuka, C., Shimomura, Y., Murakami, T., Yoshimura, A., Kawakami, K., Ritchie, W.F., Kaneko, N. and Sokabe, M. (1998), Intramembrane structure of the sensory axon terminals in bullfrog muscle spindles. Anatomical Record, 252 (3), 340-354.

Abstract: Much physiologic and morphologic research has been done into the sensory mechanism of the frog muscle spindle. However, no freeze-fracture study has described in detail the shape and intramembrane structure of the nonmyelinated sensory axon terminals of the frog muscle spindle. In this study, muscle spindles were isolated from the red part of bullfrog semitendinous muscles. Chemically fixed spindles were subjected to freeze fracturing. The sensory axon endings were reconstructed, and the size and density of intramembrane particles (IMPs) were measured along the sensory nerve endings. The axon terminals had four distinctive parts: parent trunks (>0.5 Fun in diameter), primary branches (0.15-0.5 mu m), terminal branches (<0.1 mu m), and varicosities (0.02-0.5 mu m) IMPs ranged from 5 nm to 21 nm in diameter and were present in the intramembrane space of the plasma membrane all throughout the nonmyelinated sensory nerve endings. Mean IMP sizes in the protoplasmic face (PF) and the external face (EF), respectively were 8.1 nm and 8.4 nm in the parent trunks, 8.8 nm and 8.8 nm in the primary branches, 9.4 nm and 9.0 nm in the varicosities, and 8.7 nm and 8.7 nm in the terminal branches. Mean IMP size in the PF was smallest in the parent trunk and largest in the varicosity. Mean IMP densities (numbers of IMPs per mu m(2)) in the PF and the EF, respectively, were 2,500 and 700 in the parent trunks, 2,200 and 500 in the primary branches, 1,700 and 400 in the varicosities, and 1,000 and 300 in the terminal branches. Density decreased with the tapering of the axon terminal, with IMPs distributed evenly in the PF and the EF. The characteristic intramembrane structure of sensory nerve endings is discussed. Anat. Rec. 252:340-354, 1998. (C) 1998 Wiley-Liss, Inc

Keywords: complex muscle spindle/density and size of intramembrane particles/freeze-fracture/PARTICLES

Beckers, V., Milet, J. and Legros, J.J. (2001), Prolonged treatment with recombined growth hormone improves bone measures: study of body composition in 21 deficient adults on treatment. Annales D Endocrinologie, 62 (6), 507-515.

Abstract: Adult growth hormone deficiency is characterized by changes in body composition :increase in total fat, decrease in lean mass and osteopenia, with a fall in Bone Mineral Content (BMC) and in Bone Mineral density (BMD) leading to a rise in risk of fracture. We have analyzed the changes in body composition in 21 adults treated from 9 to 78 months, by dual X-RAY absorptiometry (DEXA). We've demonstrated a gain in bone mass and density, particulary of axial skeleton; a latence

of minimum 12 months has been necessary to objective these changes. The balance of fat and lean mass has been poorly modified by treatment except for the lean mass of the trunk, which is significantly increased. We think that the usual doses of rGH, based on IGF-1 level, are perhaps underestimated

Keywords: adult growth hormone deficiency/body composition/bone mineral content/bone mineral density/fracture/MEN/MINERAL DENSITY/ONSET GH DEFICIENCY/osteopenia/REPLACEMENT THERAPY

Robinovitch, S.N., Hayes, W.C. and McMahon, T.A. (1997), Distribution of contact force during impact to the hip. Annals of Biomedical Engineering, 25 (3), 499-508.

Abstract: Hip fracture is a common, costly, and debilitating injury occurring primarily in the elderly. Commonly viewed as a consequence of osteoporosis, it is less often appreciated that > 90% of hip fractures are caused by falls, and that fracture risk is governed not only by bone fragility, but also by the mechanics of the fall. Our goal is to develop experimental and mathematical models that describe the dynamics of impact to the hip during a fall, and explain the factors that influence hip contact force and fracture risk during a fall. In the current study, we used ''pelvis release experiments'' to test the hypothesis that, during a fall on the hip, two pathways exist for energy absorption and force generation at contact: a compressive load path directly in line with the hip, and a flexural load path due to deformation of muscles and Ligaments peripheral to the hip. We also explored whether trunk position or muscle contraction influence the body's impact response and the magnitude of force applied to the hip during a fall. Our results suggest that only 15% of total impact force is distributed to structures peripheral to the hip and that peak forces directly applied to the hip are well within the fracture range of the elderly femur. We also found that impacting with the trunk upright significantly increases peak force applied to the hip, whereas muscle contraction has little effect. These results should have application in the development of fracture risk indices that incorporate both fall severity and bone fragility, and the design of interventions such as hip pads and energy-absorbing floors that attempt to reduce fracture risk by decreasing in-line stiffness and hip contact force during a fall

Keywords: damping/elderly/falls/FALLS/FRACTURE/hip fracture/impact force/osteoporosis/RISK-FACTORS/stiffness

Alektiar, K.M., Leung, D., Zelefsky, M.J., Healey, J.H. and Brennan, M.F. (2002), Adjuvant brachytherapy for primary high-grade soft tissue sarcoma of the extremity. Annals of Surgical Oncology, 9 (1), 48-56.

Abstract: Background: We reviewed single-institution experience using brachytherapy alone for primary high-grade soft tissue sarcoma of the extremity. Methods: Between July 1982 and September 1997, 202 adult patients with primary high-grade soft tissue sarcoma of the extremity were treated with limb-sparing surgery and adjuvant brachytherapy. All patients underwent complete gross resection, but the margin of resection was microscopically positive in 18% of patients. The median dose of brachytherapy was 45 Gy delivered over 5 days. Tumors located in the shoulder or groin were defined as central location. Complications were assessed in terms of wound complications, bone fracture, and peripheral nerve damage. Results: With a median follow-up of 61 months, the 5-year local control, distant relapse-free survival, and overall survival rates were 84%, 63%, and 70%, respectively. On multivariate analysis, poor local control correlated with shoulder location, positive microscopic margins of resection, and nonshoulder upper extremity site. The 5-year actuarial rates of wound complications requiring reoperation, bone fracture, and grade greater than or equal to3 nerve damage were 12%, 3%, and 5%, respectively.

Conclusions: Adjuvant brachytherapy provides adequate local control and acceptable morbidity that compares favorably with data reported for external beam radiation. Shoulder tumor location was identified as an independent prognostic factor for poor local control. mandating further improvement in the local management of these tumors

Keywords: brachytherapy/EXTERNAL-BEAM IRRADIATION/extremity/fracture/high grade/LOCAL-CONTROL/POSTOPERATIVE RADIOTHERAPY/PREOPERATIVE RADIATION/PROSPECTIVE RANDOMIZED TRIAL/RADIATION-THERAPY/soft tissue sarcoma/SUPERFICIAL TRUNK/SURGERY/SURGICAL MARGINS/WOUND COMPLICATIONS

Smith, G.A. and Shields, B.J. (1998), Trampoline-related injuries to children. Archives of Pediatrics & Adolescent Medicine, 152 (7), 694-699.

Abstract: Objective: To describe the epidemiological features of trampoline-related injuries among children treated in an urban pediatric emergency department. Design: A descriptive study of a consecutive series of patients. Setting: The emergency department of a large, urban, academic children's hospital. Participants: Children treated for trampoline-related injuries from May 1, 1995, through April 30, 1997. Results: Two hundred fourteen children were treated for trampoline-related injuries during the study period, representing, on average, 1 child treated approximately every 3 days. Children ranged in age from 1 to 16 years (mean [SD], 9.4 [3.6] years). The area of the body most commonly injured was a lower extremity (36.0%), followed by an upper extremity (31.8%), the head (14.5%), the trunk (9.8%), and the neck (7.9%). The most common type of injury was a soft tissue injury (51.9%), followed by fracture (34.6%) and laceration (11.7%). Several patterns of trampoline- related injury were identified. Extremity fractures were more common in the upper extremities (P = .006; relative risk [RR] = 1.64; 95% confidence interval [CI], 1.16-2.31); however, soft tissue injuries were more common in the lower extremities (P = .006; RR = 1.66; 95% CI, 1.16-2.38). Lacerations were associated with injury to the head region (P < .001; RR = 67.9; 95% CI, 16.8-273.6) and were more common among children younger than 6 years (P = .02; RR = 2.58; 95% CI, 1.24-5.34). Soft tissue injuries were more common among children 6 years of age and older (P = .01; RR = 1.66; 95% CI, 1.08-2.55). Four patients (1.9%) with fractures were admitted to the hospital. The trampoline was located in the backyard in 96% (119/124) of cases. Adult supervision was present at the time of injury for 55.6% (65/117) of children, including 73.3% (22/30) of children younger than 6 years. Parents reported that they had been aware of the potential dangers of trampolines before the injury event (73% [81/111]), that their child had previously attempted a flip on a trampoline (56.9% [66/116]), that this was not the child's first injury on a trampoline (10% [12/120]), and that their child continued to use a trampoline after the current injury event (54.8% [63/115]). Conclusions: Trampoline-related injuries to children treated in the emergency department are almost exclusively associated with the use of backyard trampolines. The prevention strategies of warning labels, public education, and adult supervision are inadequate to prevent these injuries. Children should not use backyard trampolines, and the sale of trampolines for private recreational use should be halted

Keywords: extremity/fracture/head/QUADRIPLEGIA/SPINERing, D., Vaccaro, A.R., Scuderi, G., Klein, G., Green, D. and Garfin, S.R. (1997), An

association between the flat back and postpolio syndromes: A report of three cases.

Archives of Physical Medicine and Rehabilitation, 78 (3), 324-326.Abstract: The cases of three patients with a history of paralytic poliomyelitis in

childhood who developed the flat back syndrome before or after spinal fusion for degenerative disease as adults were reviewed. The flat back syndrome, a combination of an inability to stand erect because of forward flexion of the trunk and pain in the low back and/or legs, typically occurs in the setting of decreased lumbar lordosis as a result of distraction instrumentation of the spine for scoliosis, vertebral fracture, or degenerative disease. Focus was placed on determining the factors responsible for the development and/or persistence of the flat back syndrome in these patients despite maintenance of, or partial operative restoration of, lumbar lordosis. Considering the essential role that the trunk extensor musculature plays in maintaining upright posture, it may be that a new onset of weakness (postpolio syndrome) in this musculature represents a major contributing factor to the flat back syndrome in these patients. Spine surgeons considering operative procedures in patients with a remote history of paralytic poliomyelitis should be aware of the possible increased risk of the flat back syndrome in this population of patients. (C) 1997 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Keywords: fracture/fusion/LUMBAR LORDOSIS/SCOLIOSIS/spineEdwards, M. (1996), Anthropometric measurements and ejection injuries. Aviation

Space and Environmental Medicine, 67 (12), 1144-1147.Abstract: Background: A previous study examined anthropometric variables to

determine possible ejection seat risk factors. It concluded that individuals who weighed below the average body weight or who met the criteria of having a tall, thin physique as measured by body mass index (BMI = kg . m(-2)) were significantly more at risk for acceleration induced back injuries. Hypothesis: Because of the increased number of female pilots and the potential need to modify ejection seats for lighter aviators, this retrospective analysis of Naval Safety Center data attempted to reproduce and confirm the same results with more current data, covering a 5-yr period from lan 1989- Dec 1993. Methods: In this study, the same criteria were used to define back injury, including thoracic or lumbar vertebral fractures and soft tissue injuries, and the same anthropometric variables were used, including weight, height, BMI, and below average weight. Additional categories of injury were examined, including all spinal fractures alone without soft tissue back injuries, all injuries combined, and severity of injury. Sitting height and trunk height were added to the variables. Results: Out of 810 aircrew involved in mishaps, 199 ejected. Of all the ejections, 111 (56%) had some type of injury as a result of the ejection. Severe injuries occurred in 8 (4%) including 4 (2%) fatalities. Back injuries occurred in 44 (22%), and 8 (4%) involved spinal fractures. Although there were no significant risk factors for ejection back injury, weight and height were statistically significant risk factors for severe injury and spinal fracture, respectively. Conclusions: Aircrew with severe injury were heavier (average weight 88 kg. vs. 79 kg.). In addition, taller aircrew (185 vs. 180 cm.) were at increased risk for any spinal fracture

Keywords: AIR-FORCE/back injuries/fracture/spinal fracturesKronberg, B.I., Fralick, P.W. and Benchimol, R.E. (1998), Late Quaternary

sedimentation and palaeohydrology in the Acre foreland basin, SW Amazonia. Basin Research, 10 (3), 311-323.

Abstract: Our study explores the geohydraulic history of the Acre retroarc foreland basin by gathering both spatial and temporal information from the upper 400 m of sediments. We also inquire into controls on sediment accommodation space as well

as on stream vs. lacustrine domination. The Acre basin is located in south-west Amazonia, proximal to the Sen a do Divisor which demarcates the eastern edge of the Andean fold-thrust belt. Radiocarbon ages from a range of materials indicate that the upper 50-250 m of the Solimoes Formation accumulated during the past 50 000 years. Both surficial and drill-core sediment records show lacustrine-fluvial transitions throughout the Late Quaternary. These shifts in depositional environments are in response to episodic changes in hydrological conditions as well as to geodynamic activity, such as subsidence. Juxtaposition of lacustrine and fluvial systems in the vertical Acre basin record mimics the regional-scale trends in the modern, upper and middle Solimoes-Amazon floodplains. In the Acre basin record lacustrine successions are characterized by increasing calcium contents up-section. This is also manifested, in the upper portions of lacustrine sequences outcropping at the surface, as alternating elastic and calcareous layers. The up- section increase in carbonate content is related to increasing salinities brought about by drier hydrodynamic conditions. Desiccation cracks are typically infilled with gypsum as are cavities of fossils in bone-beds. The latter represent isolated ponds in which the original fauna died as aridity intensified and waters became increasingly saline. Modern trunk river systems in the Acre basin flow from south-west to north-east with tributaries entering from the south-west, suggesting the influence of a domino-style, basement, fault regime. Fault or, at least, fracture control on stream channels is also suggested throughout the greater Amazon basin in the orthogonal dispositions and asymmetric terrace systems of trunk rivers as well as of major tributaries

Keywords: AMERICA/ANDES/BRAZIL/CHEMISTRY/CHRONOLOGY/DEPOSITS/fracture/RIVER/TECTONICS

Pearce, G., Ryan, P.F.J., Delmas, P.D., Tabensky, D.A. and Seeman, E. (1998), The deleterious effects of low-dose corticosteroids on bone density in patients with polymyalgia rheumatica. British Journal of Rheumatology, 37 (3), 292-299.

Abstract: The beneficial effects of corticosteroid therapy in the treatment of rheumatic diseases may be offset by the occurrence of corticosteroid-related osteoporosis. This problem may be overcome by using low-dose corticosteroids; however, the dose of corticosteroids that is both efficacious and skeletal sparing is uncertain. Therefore, the aim of this study was to determine whether low-dose prednisolone treatment results in bone loss and modifies bone turnover. Nineteen patients (12 female, seven male) suffering from polymyalgia rheumatica received 10 mg or less daily, given in reducing dosage, with a range of 2.5-10 mg and an average of 6.0 +/- 0.2 mg daily (+/- S.E.M.). Prior to the commencement of therapy and at regular intervals during treatment, bone mineral density (BMD) using dual X-ray absorptiometry and circulating biochemical and hormonal determinants of bone turnover were measured. The patients were followed for 14.4 +/- 1.6 months (range 6-27). They were compared to 19 age-matched controls. Despite a mean exposure dose of 6 mg/day and disease remission, BMD decreased in the patients at the lumbar spine (2.6 +/- 0.8%, P < 0.01), femoral neck (2.9 +/- 1.5%, P = 0.06), Ward's triangle (5.5 +/- 2.9%, P = 0.06) and the trochanter (4.3 +/- 1.9%, P < 0.05). Total body bone mass decreased by 50 +/- 19 g in the first 6 months (P < 0.02), and by 39 +/- 30 g in the remaining 8 months of follow-up [not significant (NS)]. In the first 6 months, BMD decreased at the lumbar spine (1.7 +/- 0.9%, P = 0.06). From 6 months to the end of follow-up, BMD decreased by 8.5 +/- 3.5% at Ward's triangle (P < 0.05) and by 4.8 +/- 2.5% at the femoral neck (P = 0.08). The fall in BMD correlated with the cumulative prednisolone dose at trabecular-rich regions (trunk r = -0.72, P < 0.001;

ribs r = -0.53, P < 0.05). Bone resorption, assessed by urinary cross-laps, was 54.7% higher than controls before treatment was started (P < 0.05) and decreased by 23.5 +/- 7.1% in the first month of treatment when the mean prednisolone dose was 9.1 mg/day, range 5-10 (P < 0.0001). Serum osteocalcin was not suppressed by disease before treatment, decreased by 27.4 +/- 5.1% during the first month of treatment (P < 0.001), remained suppressed while the daily dose of prednisolone was >5 mg/day, but returned to baseline below this dose. Serum parathyroid hormone was 19.3% lower in the patients than controls at baseline (NS), and increased by 46.1% (P < 0.05) but was no higher than controls at any time. Muscle strength increased by 20-60% (P < 0.05 to < 0.01). Prophylaxis should be considered in patients receiving greater than or equal to 5 mg/day prednisolone daily as bone loss is 2- to 3- fold expected rates. Earlier trabecular bone loss may predispose to spine and rib fracture; later cortical bone loss may predispose to hip fractures. Doses of prednisolone of <5 mg daily may be skeletal sparing, but may not be efficacious

Keywords: ALKALINE-PHOSPHATASE/bone mineral density/bone turnover/corticosteroid-related bone loss/dual X-ray absorptiometry/fracture/GLUCOCORTICOID THERAPY/IMMUNORADIOMETRIC ASSAY/INDUCED OSTEOPOROSIS/MINERAL DENSITY/osteoporosis/POSTMENOPAUSAL WOMEN/PREDNISONE TREATMENT/PROXIMAL FEMUR/SHORT-TERM/spine/strength/TRABECULAR BONE

Williams, R.L., Sweetnam, D.I.S. and Stanislas, M. (1995), Skiing injuries: The increasing workload. British Journal of Sports Medicine, 29 (4), 252-254.

Abstract: All skiing injuries presenting to a fracture clinic during the period December 1992 to April 1993 were studied. Fifty five patients with 59 injuries were treated during this period. Thirty (54.5%) were male and 25 (45.5%) female. The mean age was 34 years (range 9-61). The anatomical distribution of injuries seen corresponded very closely with those seen in much larger studies abroad. There were 35 upper limb injuries (59.3%), 22 lower limb injuries (37.3%), with only two spine and trunk injuries (3.4%). While only two patients underwent surgery abroad, a further 12 needed surgical intervention on return, requiring a total stay of 61 'inpatient days'. The bulk of the workload was, however, on an outpatient basis, with a total of 172 appointments. Many advances have been made towards improving the safety of skiing. However with skiing becoming increasingly popular we can expect an increasing workload and cost associated with such injuries

Keywords: fracture/orthopaedic department/skiing injury/spine/workloadRico, H., Revilla, M., Hernandez, E.R., Villa, L.F. and Debuergo, M.A. (1995), Total

and Regional Bone-Mineral Content and Fracture Rate in Postmenopausal Osteoporosis Treated with Salmon-Calcitonin - A Prospective-Study. Calcified Tissue International, 56 (3), 181-185.

Abstract: Seventy-two postmenopausal osteoporotic women having more than one nontraumatic vertebral crush fracture were studied. Thirty- six of them, aged 68.8 +/- 1.2 years (18 +/- 4 YSM-years since menopause), were treated with 100 IU/day of salmon calcitonin i.m. plus 500 mg of elemental calcium for 10 days each month. The remaining 36 patients, aged 69.6 +/- 1.4 years (19 +/- 3 YSM), were given only 500 mg of elemental calcium for 10 days each month. All patients underwent clinical and analytical evaluation every 3 months. Radiological evaluation, assessment of vertebral deformities, and metacarpal radiogrammetry were done every 6 months. Densitometric measurements of total and regional bane mass were made every 12 months. At 24 months, the calcitonin group showed a 60% reduction in the number

of new fractures and the group receiving only calcium had a 45% increase (P < 0.001). The incidence of vertebral fractures was 0.07 per patient-year in the group treated with calcitonin and 0.45 per patient-year in the group treated with calcium (P < 0.001). At 2 years, the calcitonin group showed a 12% increase in cortical bone mass on metacarpal radiogrammetry, a 16% increase in the axial skeleton on trunk densitometry, a 3.5% increase in total body bone mineral content, a 30.7% increase in pelvic bone mineral content, and a 6.2% increase in arm bone mineral content (all P < 0.001). In the group treated with calcium alone there was a loss of bone mass in every region. These findings suggest that salmon calcitonin is effective in the treatment of osteoporosis and show that it acts on cortical and trabecular bone

Keywords: bone mineral content/BONE RADIOGRAMMETRY/CARCITONIN THERAPY/DENSITY/DUAL-PHOTON-ABSORPTIOMETRY/ESTABLISHED OSTEOPOROSIS/ETIDRONATE/fracture/FRACTURE RATE/LONG-TERM TREATMENT/MASS/menopause/NASAL SPRAY/osteoporosis/POSTMENOPAUSAL OSTEOPOROSIS/THERAPY/TOTAL AND REGIONAL BONE MASS/WOMEN/X-RAY ABSORPTIOMETRY

Chuter, T.A.M. (2002), Stent-graft design: the good, the bad and the ugly. Cardiovascular Surgery, 10 (1), 7-13.

Abstract: 10 years of experience with endovascular AAA repair has yielded important information regarding the relationship between stent- graft design and stent-graft performance. Commercially available systems differ in important ways. General conclusions regarding endovascular AAA repair need to be qualified by reference to a specific system, or systems. Nevertheless, one can draw conclusions regarding the observed effects of certain design features, some of which are common to several devices. For example: tapered, trackable delivery systems (less than or equal to20 French in diameter) rarely fail to traverse tortuous iliac arteries: transmural barbs provide the most secure means of proximal attachment, column strength is of little value; proximal stent migration is becoming the primary late failure mode; modular stent-grafts are more versatile than unibody stent-grafts; fully-stented graft limbs are less prone to thrombosis than unstented graft limbs, iliac implantation and low porosity are associated with lower rates of aneurysm dilatation in the absence of endoleak (endotension); any movement between the angle of a stent and the overlying fabric will lead to grafts erosion; unpolished (black) Nitinol is prone to fracture; and a long trunk/short limb combination is more stable than a short trunk/long limb combination. (C) 2002 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved

Keywords: ABDOMINAL AORTIC-ANEURYSMS/aneurysm/aorta/ENDOVASCULAR REPAIR/endovascular repair/FIXATION/fracture/stent-graft/strength

Frediani, B., Allegri, A., Bisogno, S. and Marcolongo, R. (1998), Effects of combined treatment with calcitriol plus alendronate on bone mass and bone turnover in postmenopausal osteoporosis two years of continuous treatment. Clinical Drug Investigation, 15 (3), 235-244.

Abstract: One hundred and twenty postmenopausal women with osteoporosis were enrolled into an open, controlled study of 24 months' duration, with the aim of evaluating the metabolic action and the effect on bone mineral density (BMD) of calcitriol (0.5 mu g/day), alendronate (10 mg/day) and combined treatment with alendronate (10 mg/day) + calcitriol (0.5 mu g/day). We also studied 30 patients treated with placebo (calcium 500 mg/day). BMD was measured by total body dual-energy x-ray absorptiometry (DPX-Lunar) as total body BMD and at different sites

of interest including the spine, trunk, arms, legs and pelvis. BMD appeared to be significantly higher in the group of patients receiving combined therapy compared with the group treated with alendronate or calcitriol alone. In the placebo group, BMD decreased significantly. Depending on the skeletal regions in which BMD was measured (total body or selected areas), 15 to 23% of patients treated with calcitriol, 37 to 48% of patients treated with alendronate, and 69 to 78% of patients treated with alendronate + calcitriol, respectively, had a BMD increase greater than the lowest significant densitometric difference. In patients treated with alendronate, 24-hour urinary calcium and hydroxyproline levels fell significantly after 3 months, and alkaline phosphatase levels fell significantly after 6 months; these parameters remained unchanged in all patients on combined treatment. We concluded that combined treatment with calcitriol + alendronate was more effective than therapy with alendronate alone

Keywords: 1/25- DIHYDROXYVITAMIN-D3/BIOCHEMICAL MARKERS/bone mineral density/bone turnover/CALCIUM-ABSORPTION/DIETARY CALCIUM/FRACTURE/LONG-TERM TREATMENT/ORAL ALENDRONATE/osteoporosis/POST-MENOPAUSAL OSTEOPOROSIS/postmenopausal osteoporosis/postmenopausal women/spine/VITAMIN-D METABOLITES/WOMEN

Frangolias, D.D., Taunton, J.E., Rhodes, E.C., McConkey, J.P. and Moon, M. (1997), Maintenance of aerobic capacity during recovery from right foot Jones fracture: A case report. Clinical Journal of Sport Medicine, 7 (1), 54-57.

Abstract: Purpose: We sought to evaluate the effectiveness of continued training with deep water running (DWR) on the healing process from a lower leg fracture in maintaining aerobic fitness. Case summary: An elite male middle distance runner presented with a Jones fracture of the right foot. The patient opted for nonsurgical treatment. Non-weight-bearing immobilization in a cast proceeded for 14 weeks. The patient continued training by simulating land running and team land workouts with DWR. DWR was the principal mode of exercise through week 24. Physiological and race performance assessments noted a progressive and complete return to preinjury fitness and performance levels. Discussion: DWR can be used by competitive runners during a rehabilitative period to maintain fitness and does not impede the healing process. In developing a DWR regimen, it should be noted that the exercise heart rate when working above the ventilatory threshold will be similar to 12 bpm lower in water. Relevance: DWR may be feasible for maintenance of competitive edge during lower trunk injury rehabilitation

Keywords: deep water running/elite distance runner/fracture/immobilization/Jones fracture/rehabilitation/RESPONSES/TREADMILL/WATER

Ersoy, A., Yavuz, M., Usta, M., Ercan, I., Aslanhan, I., Gullulu, M., Kurt, E., Emir, G., Dilek, K. and Yurtkuran, M. (2003), Survival analysis of the factors affecting in mortality in injured patients requiring dialysis due to acute renal failure during the Marmara earthquake: Survivors vs non-survivors. Clinical Nephrology, 59 (5), 334-340.

Abstract: Background: We reviewed medical records of dialyzed patients admitted to our hospital after the Marmara earthquake and evaluated the factors affecting mortality in survivors and non- survivors according to the survival times. Patients and methods: Crush syndrome ( CS) was diagnosed in 110 patients. Dialysis treatment was initiated in 60 patients; 21 of all died. The patients were divided into 2 groups which consisted of 39 survivors ( Group A, 25 male, 14 female, mean age: 31 +/- 2.2 years) and 21 nonsurvivors ( Group B, 9 male, 12 female, mean age: 27 +/-

3.0 years). Victims treated by any form of renal replacement therapy, including daily or intermittant hemodialysis and/or continuous venovenous hemodiafiltration. Clinical and laboratory findings were recorded regularly. Statistical analysis was performed with Kaplan-Meier method, log rank test and Cox regression analysis for the survival functions. Results: APACHE II scores were 13.5 +/- 0.5 for Group A and 13 +/- 0.9 for Group B. Dialysis support was started to patients in Group A in a mean period of 2.8 +/- 0.2 days and in Group B in a mean period of 3.7 +/- 0.6 days after the earthquake ( p > 0.05). The most frequent site of trauma was lower extremity (61.5%) and upper + lower extremities (23%) in Group A, and lower extremity (38.1%) and trunk + lower extremity (23.8%) in Group B. The frequencies of abdominal trauma, pelvic fracture and thoracic trauma in Group B were 23.8%, 19% and 14.2%, respectively. Multiple trauma was more frequent in Group B than in Group A (42.8% vs 2.5%). The rates of fasciotomy, amputation and surgery were similar in both groups. The frequency of sepsis was higher in nonsurvivors. In our center, the overall mortality rate was 8%, mortality rate in CS was 21% and in dialyzed patients it was 35%. Mortality was mainly associated with sepsis. Survival periods (52.3 +/- 4.0 days) in Group A were longer than in Group B (17.3 +/- 2.5 days). With Cox regression analysis, the parameters such as systolic hypotension on admission, female gender, high serum peak creatine kinase (> 20,000 U/l) and multiple trauma including thoracic and abdominal regions, were factors increasing risk of mortality. Conclusion: As a result, sepsis, multiple trauma and severe crush injury were the main factors increasing mortality risk in dialyzed injuries after the earthquake

Keywords: acute renal failure/ARMENIAN EARTHQUAKE/CRITICALLY-ILL PATIENTS/crush syndrome/CRUSH- SYNDROME/dialysis/earthquake/extremity/fracture/HANSHIN-AWAJI EARTHQUAKE/MANAGEMENT/MORBIDITY/mortality/pelvic fracture/rhabdomyolysis/RHABDOMYOLYSIS/survival time/trauma/VICTIMS

Coene, L.N.J.E. (1993), Mechanisms of Brachial-Plexus Lesions. Clinical Neurology and Neurosurgery, 95 S24-S29.

Abstract: The main causes of brachial plexus palsies are traction, due to extreme movements, and heavy impact. In downward traction of the arm and forcible widening of the shoulder-neck angle the lesion will occur in the upper roots and trunk. Forcible upward traction will cause avulsion of T1 and C8. The most violent trauma will result in a lesion at all levels. Rupture of the cords and/or individual infraclavicular nerves will be produced by traction and/or forcible widening of the scapulohumeral angle. Vascular structures are subjected to the same mechanism and injuries of these structures give information about the site and severity of nerve lesions; fractures of the skull, cervical spine, clavicle, first rib or arm yield further data on the mechanism of trauma that has produced the brachial plexus palsy. Heavy impact or crush lesions are caused by direct trauma to the (supra)clavicular region and are nearly always associated with fracture of the clavicle

Keywords: BRACHIAL PLEXUS LESIONS/clavicle/fracture/spine/trauma/TRAUMA MECHANISMS

Harris, M.L., Polkey, M.I., Bath, P.M.W. and Moxham, J. (2001), Quadriceps muscle weakness following acute hemiplegic stroke. Clinical Rehabilitation, 15 (3), 274-281.

Abstract: Objective: To determine whether quadriceps muscle weakness develops on the side ipsilateral to the brain lesion in the first week following acute ischaemic hemiplegic stroke. Design: A prospective study of muscle strength. Setting: Acute

stroke unit (ASU) in a teaching hospital. Subjects: Ten patients admitted within 48 hours of stroke onset, and 10 healthy age- matched controls. Interventions: Repeat nonvolitional measurements of quadriceps muscle strength of the unaffected limb in patients and the right leg in normal subjects using magnetic femoral nerve stimulation (MS), prospectively one week apart. In addition the level of voluntary activation was assessed during a maximum voluntary contraction (MVC) manoeuvre. The Trunk Control Test (TCT) was measured in the patients. Results: The median (95% confidence interval, (CI)) baseline quadriceps twitch tension (Tw Q) and MVC in the control group were 9.4 kg (6.1-12.5 kg) and 37.2 kg (23.8-54.6 kg), and in the stroke group were 7.6 kg (4.4-9.9 kg) and 12.15 kg (7.9-30.8 kg). The median (95% CI) change in Tw Q and MVC respectively between baseline and one week later were 1.75% (- 9.8 to 8%) and 5.45% (-15.1 to 22.7%) (NS) in the control group and -16.2% (-6 to -25.9%) and -30.45% (0 to -78.6%) (p < 0.01) in the stroke patients. There was a significant correlation between the percentage fall in Tw Q and both change in TCT (r(s) = 0.83, p < 0.01) and percentage change in body weight (r(s) = 0.83, p < 0.01). Conclusion: In the first week after acute hemiplegic stroke, weakness develops in the unaffected leg

Keywords: ACUTE ISCHEMIC STROKE/brain/CERVICAL MAGNETIC STIMULATION/FRACTURE/HUMAN SKELETAL-MUSCLE/IMMOBILIZATION/muscle strength/PHRENIC NERVES/POWER/prospective study/RELIABILITY/STRENGTH/TWITCH

Clubley, S.K. and Winter, S.N. (2003), On the fatigue and fracture of site splice welds at the River Mardle Viaduct. Engineering Failure Analysis, 10 (5), 593-604.

Abstract: The River Mardle Viaduct is a curved, twin box girder bridge, spanning a total length of 177 m. Four continuous spans carry the A38 trunk road over the River Mardle and Old Totnes Road. The bridge forms an important part of the heavy load network in and out of the tourist areas of Devon and Cornwall. In September 2001, an initial inspection of the site splice welds joining the box girders detected a series of large imperfections. These weld defects were confirmed by a further independent inspection 6 months later and the results subsequently analysed using detailed fracture mechanics. The results of the fatigue analysis and the implications to the structural integrity of the bridge are discussed in this paper. (C) 2003 Elsevier Ltd. All rights reserved

Keywords: box girder/bridge failures/fatigue strength/fracture/site splice/weld defectsKatsamouris, A.N., Steriopoulos, K., Katonis, P., Christou, K., Drositis, J., Lefaki, T.,

Vassilakis, S. and Dretakis, E. (1995), Limb Arterial Injuries Associated with Limb Fractures - Clinical Presentation, Assessment and Management. European Journal of Vascular and Endovascular Surgery, 9 (1), 64-70.

Abstract: Objectives: Review of limb arterial injuries associated with limb fractures. Design: Retrospective study. Setting: University Hospital. Materials and Methods: The clinical presentation, assessment and management of 25 patients with upper (seven) and lower (18) limb arterial injuries associated with limb bone fractures has been retrospectively reviewed. Main Results: Five patients presented with life threatening injuries and classic signs of acute limb ischaemia, 15 patients had an obvious limb arterial injury, and 5 presented with a suspected limb arterial injury. The site of arterial damage was: superficial femoral (4); popliteal (11); tibioperoneal trunk (3); anterior tibial (4); posterior tibial (3); peroneal (2); axillary (1); brachial (5); radial (4); and ulnar artery (4). The types of arterial repair were: autogenous vein interposition or bypass grafting (17); P.T.F.E. (2); end-to-end anastomosis (14); and ligation (8). The popliteal vein was injured in six cases, repaired in four and ligated

in two; the superficial femoral vein was injured in four cases, repaired in three and ligated in one; and the axillary vein was injured in one case and was ligated. Primary nerve repair was employed in six out of seven injured nerves. Skeletal fixation preceded vascular repair in 21 patients with lower limb ischaemia. Completion arteriography revealed residual thrombi in the distal foot of four patients, in whom intraarterial thrombolysis was effective. During the follow-up period of 1.5 to 2 years, the upper and lower limb preservation rate was 100 and 89%, respectively. The upper limb function was judged excellent in five patients, good in one and fair in one. In the lower limbs it was excellent in 11 patients, good in three, fair in one and poor in one. Conclusions: To ensure life and functional limb salvage of patients with devastating vascular injuries, a well organised multidisciplinary approach is necessary

Keywords: ACUTE ISCHEMIA/ARTERIAL INJURY/ARTERIOGRAPHY/LIMB BONE FRACTURE/THROMBOLYSIS/VENOUS INJURY

Leferink, V.J.M., Keizer, H.J.E., Oosterhuis, J.K., van der Sluis, C.K. and ten Duis, H.J. (2003), Functional outcome in patients with thoracolumbar burst fractures treated with dorsal instrumentation and transpedicular cancellous bone grafting. European Spine Journal, 12 (3), 261-267.

Abstract: The aim of the study was to develop an insight into the impairments in spinal fracture patients, operatively treated with an internal fixator, and also into their ability to participate in daily living, return to work and quality of life as defined by the World Health Organization. Nineteen patients operated for a type A fracture of the thoracolumbar spine (T9- L4) between 1993 and 1998 in the University Hospital Groningen, the Netherlands, aged between 18 and 60 years, without neurological deficit were included in the study. Operative treatment consisted of fracture reduction and internal fixation using the Universal Spine System, combined with transpedicular cancellous bone grafting and dorsal spondylodesis. No ventral fusion operations, laminectomies or discectomies were done. Restrictions in body function and structure were measured on radiographs and in functional capacity tests, such as lifting tests and ergometry. Restrictions in activities were studied with the Visual Analogue Scale (VAS) Spine Score and the Roland Morris Disability Questionnaire (RMDQ). Restrictions in participation/quality of life were analysed with the Short Form 36 (SF36) and described in the return to work status. The radiological results are comparable to the literature. The reduction of the anterior wedge angle was followed by a gradual partial loss of intervertebral angle and regional angle. The maximum oxygen uptake (VO2-max) was reduced in only 8.3% of the patients. Arm and trunk lift was within the normal range in 87% and 80% of the patients respectively, but only 53% of the patients were able to perform a leg lift within the normal range. A mean RMDQ score of 4.0 positive items (SD 6.0) was found, and the mean VAS Spinal Score was 79.4 (SD 25.0), both better than in other series. No significant differences compared to the values of a comparable (healthy) age group could be identified in any variable of the SF36. A high correlation was seen between RMDQ, VAS Spine Score and the SF36 categories. No correlation was found between the anterior wedge angle and the regional angle on the one hand, and functional capacity tests or questionnaire scores on the other. Of the patients in paid employment before the trauma, 87% had returned to work at follow-up. About 50% of the patients had been obliged to change the intensity of their work or the kind of work they performed after the injury and treatment. In this matter, leg (muscle) performance seems a more important factor than overall condition (VO2- max). The results of the study indicate that patients with thoracolumbar spinal fractures without

neurological deficit, treated with dorsal instrumentation, perform like healthy people 3-8 years after injury, according to the RMDQ, VAS Spine Score and SF36 results. Physical capacity tests reveal that leg (muscle) performance seems a more important factor in impairment than arm lift or overall condition

Keywords: DISABILITY SCALE/exercise test/fracture/fusion/HEALTH SURVEY QUESTIONNAIRE/internal fixator/ISOINERTIAL LIFTING EVALUATION/LOW-BACK-PAIN/NATURAL-HISTORY/operative treatment/outcome assessment/questionnaires/SENSITIVITY/SEVERITY/spinal fracture/spinal fractures/SPINE/SPINE SURGERY/SURVEY SF-36/trauma/VALIDATION

Pfeifer, M., Begerow, B., Minne, H.W., Schlotthauer, T., Pospeschill, M., Scholz, M., Lazarescu, A.D. and Pollahne, W. (2001), Vitamin D status, trunk muscle strength, body sway, falls, and fractures among 237 postmenopausal women with osteoporosis. Experimental and Clinical Endocrinology & Diabetes, 109 (2), 87-92.

Abstract: aim of this study was to identify factors associated with fractures in patients with postmenopausal osteoporosis. The overall hypothesis was that trunk muscle strength, body sway and hypovitaminosis D would influence daily activities and the likelihood of falls and fractures. - In 237 women (mean age 62.9 +/- 7.4 years) osteoporosis was defined by a T-score at the femoral neck below -2.5 SD. Trunk muscle strength was determined using isokinetic dynamometry and body sway was measured according to Lord et al. Limitations in everyday life were assessed and the history of falls was documented. A fracture was defined as a vertebral height reduction of more than 20% or at least 4 mm. The assessment was carried out using the Spine Deformity Index (SDI) and was confirmed by an experienced radiologist. Pearson coefficients of correlation were calculated. - After correction for age, significant associations were found for body sway and 25-hydroxyvitamin D (p<0.001), body sway and falls (p<0.001), body sway and rib fractures (p<0.01), trunk muscle strength and limitations in everyday life (p<0.001), trunk muscle strength and SDI (p<0.001), trunk muscle strength and bone density (p<0.001), and bone density and 25-hydroxyvitamin D (p<0.001). No significant correlation was found for trunk muscle strength and 25-hydroxyvitamin D (p=0.712). - Findings suggest that hypovitaminosis D is associated with increased body sway and an elevated risk for falls and falls-related fractures. Musculoskeletal rehabilitation should include strengthening exercises for the trunk muscles and training of neuromuscular co-ordination and balance

Keywords: 1/25-DIHYDROXYVITAMIN-D3/body sway/BONE-MINERAL DENSITY/CALCIUM/D SUPPLEMENTATION/DEFORMITY INDEX SDI/ELDERLY WOMEN/falls/fracture/IDENTIFICATION/muscle strength/osteoporosis/PHYSICAL-ACTIVITY/postmenopausal osteoporosis/postmenopausal women/rehabilitation/SPINE/strength/trunk muscle strength/VERTEBRAL FRACTURE/vitamin D

Bauer, M. and Patzelt, D. (2002), Intracranial stab injuries: case report and case study. Forensic Science International, 129 (2), 122-127.

Abstract: Non-missile penetrating brain injuries are rare events in western countries. We report a case with lethal stab injury of the brain and identification of the weapon used in the assault by digital superimposition on CT scans taken at admission of the victim to a hospital. Furthermore, all cases with knife stab wounds of the skull between 1971 and 2000 were analyzed and compared with literature reports. Results of this study show that there is no region preference despite of differences in bone thickness, that stab wounds of the brain are almost invariably associated with

multiple stab wounds to the trunk and that the wound tract may correspond to the dimensions of the blade allowing the identification of the weapon by digital image analysis. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved

Keywords: BRAIN/brain/computed tomography/slot fracture/stab wound/superimposition/WOUNDS

Saito, H. (2002), Evolution of surgery for tetraplegic hands in Japan. Hand Clinics, 18 (3), 535-+.

Abstract: Kenya Tsuge [1] published the first Japanese book on hand surgery in 1965. Only one page was allocated to "cervical cord injury and functional reconstruction of the hand," and it was devoted mostly to the description of Lipscomb's two-stage operation for the cervical cord lesion after fracture dislocation of C6 on C7 [2]. The first stage is reconstruction of the extensors: (1) transfer of the extensor carpi radialis longus (ECRL) to the finger extensors and the rerouted extensor pollicis longus (EPL), (2) occasional transfer of one slip of the extensor carpi radialis brevis (ECRB) to the abductor pollicis longus (APL), and (3) Riordan's intrinsic tenodesis using half a slip of ECRB and the extensor carpi ulnaris (ECU). The second stage is reconstruction of the flexors: (1) transfer of the brachioradialis (BR) to the flexor pollicis longus (FPL), (2) transfer of the pronator teres (PT) to the flexor profundus (FDP), and opponensplasty using the flexor carpi radialis (FCR). At the 10th annual meeting of the Japanese Society for Surgery of the Hand in 1967, Yokoyama et al [3] presented five cases of tetraplegic hands for which functional reconstruction was attempted. An opponensplasty using either FCR or flexor superficialis (FDS) of the ring finger was performed in two of the five cases. Thompson's first-to-second intermetacarpal fusion in palmar abduction associated with transfer of FCR to FDP and of BR to FPL was performed in one case. Results were mainly unsatisfactory because of either insufficient pinch power or spasticity. The patient who underwent intermetacarpal fusion had difficulty supporting the trunk with the operated hand. In the following year, the authors reported three additional cases of intermetacarpal fusion associated with either flexor tenodesis or transfer of ECRB to thumb and finger flexors. Their procedures were not the same as Nickel's "wrist-driven flexor hinge hand," but their work was influenced by his paper published in 1963 [4]

Keywords: fracture/fusion/MULTICHANNEL FES SYSTEM/SPINAL-CORD INJURY

Genoni, M., Jenni, R. and Turina, M. (1997), Traumatic ventricular septal defect. Heart, 78 (3), 316-318.

Abstract: A 26 year old man was admitted to hospital following a traffic accident. He had been sitting in the back of a car without wearing a seatbelt. He suffered crush injuries on the anterior chest wall, trunk, and legs. On admission he was awake and cooperative, but restless, and obviously in severe pain. Radiography of the skull, facial bones, chest, spine, pelvis, and legs revealed a shaft fracture of the left femur and tibia and fracture of the 7th and 8th right ribs. The patient was transferred to the University Hospital of Zurich for further assessment and surgical repair of the lower limb fractures three days later. Because of worsening clinical condition with onset of partial respiratory insufficiency and new loud systolic murmur at the left sternal edge, a transthoracic echocardiography was performed, which showed an apical ventricular septal defect. Surgery was performed immediately. The ventricular septal defect was successfully repaired using a Teflon felt patch and interrupted sutures with pledgets, and sealed with glue. At six months' follow up the patient was doing well. Ventricular septal defects after blunt chest trauma occur either because of heart compression between sternum and the spine or because of myocardial infarction. In

the present case the ventricular septal defect-appeared three days after the accident, probably secondary to a post-traumatic myocardial infarction. Patients with blunt chest trauma and suspicion of cardiac contusion should be monitored carefully

Keywords: acute myocardial infarction/blunt chest trauma/cardiac injuries/fracture/NONPENETRATING CHEST TRAUMA/spine/trauma/ventricular septal defect

Malan, J.W. and Vanwyk, A.E. (1993), Bark Structure and Preferential Bark Utilization by the African Elephant. Iawa Journal, 14 (2), 173-185.

Abstract: Bark fracture properties are thought to influence the debarking of selected trees by the African elephant. This hypothesis was tested for large riverine tree species in the Northern Tuli Game Reserve, Botswana. An index of bark breakage strength and pliability of secondary phloem tissue was compiled for 11 common riverine species, and the bark anatomy of these species was investigated to determine relative fibrosity. The majority of species preferred by elephants have strong and pliable barks, associated with a high proportion of fibres. However, not all preferred species have these characteristics, which indicates that factors other than bark fracture properties affect species preference. Bark structure influences the way pieces of bark are stripped from a tree trunk during debarking. It is hoped that this paper will stimulate further studies on the effects of bark structure on the preferential feeding behaviour of the African elephant

Keywords: AFRICAN ELEPHANT/BARK ANATOMY/DEBARKING/fracture/GELATINOUS FIBERS/MECHANICAL PROPERTIES/SCLEREIDS/strength

Peach, H.G. and Bath, N.E. (1999), Hospital separation rates from osteoporotic and non- osteoporotic fractures in metropolitan and rural Australia. Injury-International Journal of the Care of the Injured, 30 (2), 101-103.

Abstract: Rural populations of the United Kingdom and Scandinavia have lower hospital discharge and incidence rates for hip fractures than urban ones. We compared hospital separations from fractures in rural health regions of Victoria, Australia, with those in metropolitan regions. Fractures were grouped into those commonly (1A), often (1B) or not often (2) associated with osteoporosis. For group 1A fractures, we found rural separation rates were significantly higher among both men and women who were aged either 20-24 or 45-64. The rural separation rates for group 1B fractures were also significantly higher in these age groups but only among men. For group 2 fractures, rural separation rates were significantly higher among young adults. Fractures of the neck, trunk, radius and ulna, but not neck of the femur, contributed to the rural excess of group 1A fractures. If rural adults are not hospitalised more often, risk factors for group 1 and group 2 fractures, which in the middle aged includes osteoporosis, may be more prevalent in rural Victoria. Our findings suggest that international studies of rural-urban differences in fracture rates are needed which include a range of anatomical sites. (C) 1999 Elsevier Science Ltd. All rights reserved

Keywords: CARE/fracture/men/osteoporosis/POPULATION/SWEDEN/URBANAlektiar, K.M., Mckee, A.B., Jacobs, J.M., Mckee, B.J., Healey, J.H. and Brennan,

M.F. (2002), Outcome of primary soft tissue sarcoma of the knee and elbow. International Journal of Radiation Oncology Biology Physics, 54 (1), 163-169.

Abstract: Purpose: Concern is frequently raised regarding the tolerance of irradiation over a joint space. The purpose of this study was to determine the outcome in terms of relapse and potential complications in patients with knee and elbow soft tissue sarcoma treated with limb-sparing surgery with or without adjuvant radiotherapy

(RT). Methods and Materials: A review of our prospective database between June 1982 and December 1999 identified 86 adult patients with primary soft tissue sarcoma arising from the knee (n=65; 76%) or elbow (n=21; 24%) treated with limb-sparing surgery. Tumors had high-grade histologic features in 72% and were >5 cm in 48% of patients. Adjuvant RT was given to 46 (54%) of 86 patients. The type of RT was postoperative external beam RT in 63% and brachytherapy in 37%. Of the 46 patients who received RT, 85% (n=39) had deep, 78% (n=36) high-grade, and 54% (n=25) >5-cm tumors. Complications were assessed in terms of wound complications requiring repeated surgery, bone fracture, nerve damage, and joint stiffness. Results: With a median follow-up of 48 months (range 4-175), the 5-year actuarial rate of local control, distant control, and overall survival was 75% (95% confidence interval [CI] 64-85%),82% (95% CI 73-91%), and 81% (95% CI 71-91%), respectively. The 5-year local control rate for patients who received RT was 80% vs. 71% for those who did not (p=0.3). The type of RT did not significantly influence the local control rate. Patients treated with external beam RT had a 5-year local control rate of 84% compared with 73% for those treated with brachytherapy (p=0.4). On multivariate analysis, tumor size >5 cm retained its significance as an independent predictor of poor local control (p=0.04, relative risk 3; 95% CI 1-6). In addition, high-grade histologic features emerged as an independent predictor of local recurrence (p=0.02; relative risk 4; 95% CI 1-20). No statistically significant difference was found between the RT and no-RT group in terms of the 5-year actuarial rate of wound reoperation (10% vs. 3%, p=0.1), bone fracture (3% vs. 5%, p=0.5), or nerve damage (6 % vs. 3 %, p=0.5). Joint stiffness was significantly higher in the RT group (24% vs. 0%,p=0.001), but this stiffness was severe to moderate in only 2 patients. Conclusion: On the basis of the findings of this retrospective review, adjuvant RT seems to be relatively well tolerated despite the inclusion of part of the joint space in the irradiation portal. Joint stiffness was seen more frequently with adjuvant RT, but it was moderate to severe in only a small number of patients. (C) 2002 Elsevier Science Inc

Keywords: ADJUVANT BRACHYTHERAPY/brachytherapy/elbow/EXTREMITY/fracture/high grade/knee/MANAGEMENT/PROSPECTIVE RANDOMIZED TRIAL/RADIATION/radiotherapy/soft tissue sarcoma/stiffness/SUPERFICIAL TRUNK/THERAPY

Alektiar, K.M., Zelefsky, M.J. and Brennan, M.F. (2000), Morbidity of adjuvant brachytherapy in soft tissue sarcoma of the extremity and superficial trunk. International Journal of Radiation Oncology Biology Physics, 47 (5), 1273-1279.

Abstract: Purpose: We have previously shown that adjuvant brachytherapy (BRT) improves local control in soft tissue sarcoma (STS) of the extremity and superficial trunk. A detailed assessment of the morbidity of this approach has not been examined. The purpose of this study was to evaluate the toxicity associated with adjuvant BRT in terms of wound complications, bone fracture, and peripheral nerve damage. Methods and Materials: Between July 1982 and June 1992, 164 adult patients with STS of the extremity or superficial trunk were randomized intraoperatively to receive or not to receive BRT after complete resection. BRT was delivered with Ir-192 fo a total dose of 42-45 Gy. The BRT and no-BRT arms were balanced with regard to age, sex, presentation (primary vs. recurrent), site, grade, size, and depth. Morbidity was assessed in terms of significant mound complication, bone fracture, and peripheral nerve damage (grade greater than or equal to 3). The significant wound complications were defined as those wound problems requiring

operative revision for coverage or threatened limb loss, persistent seroma requiring repeated aspirations and/or drainage, wound separation > 2 cm, hematoma > 25 ml, and/or purulent wound discharge. The median follow-up was 100 months. Results: The significant mound complication rate was 24% in the BRT group and 14% in the no-BRT group, (p = 0.13). The rate of wound reoperation, however, was significantly higher in the BRT arm (10% vs. 0%; p = 0.006). Examination of other covariables that may have contributed to wound reoperation revealed the width of the excised skin (WES) to be a significant factor [1% (WES less than or equal to 4 cm) vs. 10% (WES > 4 cm),p = 0.02]. Bone fracture only occurred in patients receiving BRT (n = 3, 4%), although this was not statistically significant (p = 0.2). The rate of peripheral nerve damage, however, was similar in both arms (7% vs. 7%). Conclusion: The overall morbidity associated with adjuvant BRT was not significantly higher than that with surgery alone. However, BRT and WES > 4 cm were associated with significantly higher wound reoperation rate. This has significant implications for strategies designed to maximize wound coverage in patients who receive BRT. (C) 2000 Elsevier Science Inc

Keywords: ADULTS/brachytherapy/complications/EXCISION/extremity/fracture/IRRADIATION/LIMB-SPARING SURGERY/MANAGEMENT/POSTOPERATIVE RADIOTHERAPY/PROSPECTIVE RANDOMIZED TRIAL/RADIATION- THERAPY/sarcoma/soft tissue sarcoma/WOUND-HEALING COMPLICATIONS

Kamath, S.S., Parsons, J.T., Marcus, R.B., Zlotecki, R.A. and Scarborough, M.T. (1996), Radiotherapy for local control of aggressive fibromatosis. International Journal of Radiation Oncology Biology Physics, 36 (2), 325-328.

Abstract: Purpose: To evaluate local control rates in patients treated with radiotherapy for aggressive fibromatosis. Methods and Materials: Fifty-three patients with histologically confirmed aggressive fibromatosis were treated with radiotherapy at the University of Florida between March 1975 and June 1992. The minimum length of follow-up was 2 years; 81% of the patients had follow-up for at least 5 years, The lesions arose in an extremity or limb girdle (39 patients), the trunk (10 patients), or the head and neck area (4 patients), Twenty-four patients were treated for gross disease and 29 for presumed microscopic residual disease after one or more operations. Patients were treated with total doses between 35 and 70 Gy; 83% of patients received 50 to 60 Gy. Results: Local control was achieved in 23 of 29 patients (79%) treated postoperatively for microscopic residual disease and in 21 of 24 patients (88%) treated for gross disease; gross disease was controlled in all 8 patients with previously untreated lesions and in 13 of 16 patients treated postoperatively for gross residual or recurrent disease, Overall, aggressive fibromatosis was locally controlled in 83% of treated patients, All nine treatment failures occurred in patients with extremity lesions 4 to 68 months after initiation of treatment, Three recurrences were in the irradiated field, two were out of the field, and four were at the field margin, Eight patients were salvaged with surgery alone or combined with postoperative radiotherapy, A functional limb was maintained in 38 of 39 patients with extremity or Limb girdle lesions, Pathologic fracture occurred in three patients; two patients required rod fixation for treatment. Conclusions: Radiotherapy is a valuable adjunct to surgery in the management of aggressive fibromatosis and can be used alone in patients with unresectable or inoperable disease. Copyright (C) 1996 Elsevier Science Inc

Keywords: aggressive fibromatosis/DESMOID TUMORS/extremity/fracture/head/local neoplasm recurrence/MANAGEMENT/RADIATION-THERAPY/radiotherapy

Nakai, M. (2003), Bone and joint disorders in wild Japanese macaques from Nagano Prefecture, Japan. International Journal of Primatology, 24 (1), 179-195.

Abstract: I studied bone and joint disorders in wild Japanese macaques (Macaca fuscata fuscata) in order to discern some aspects of their life history from the skeletal material. The specimens comprise 107 nearly complete skeletons of subadults and adults that were killed as crop-raiding monkeys between 1997 and 1998 in Nagano Prefecture, Japan. The most frequent disorder is angular deformity due to fractures: 80 healed fractures in 31 of 52 males and 71 healed fractures in 26 of 55 females Secondary osteoarthritis due to fractures is rare. Two males have osteochondritis dissecans bilaterally on the posterior surface of the lateral femoral condyles Degenerative changes are common in the aged individuals Fractures of the trunk- clavicle, scapula, vertebrae, ribs or hip-are frequent in the males Contrarily, the majority of fractures in females are in the hands and feet. While most fractures in males appear to have occurred during adulthood, those in females occurred during childhood and senescence. Interindividual violence should not be regarded as a principal cause for fractures in males and females because there is no bite wound except perhaps for one case of an amputated digit. Fractures of the trunk in males were probably caused by impact forces against their shoulders or hips or both caused by rolling down a steep slope or falling out of trees, perhaps during intertroop transfers

Keywords: AFRICAN APES/AGE/clavicle/EROSIVE ARTHRITIS/fracture/GOMBE CHIMPANZEES/life history/LIFE-HISTORY/Macaca fuscata fuscata/OLD-WORLD PRIMATES/osteochondritis dissecans/pathology/PYROPHOSPHATE DEPOSITION DISEASE/SKELETAL EVIDENCE/SPONDYLOARTHROPATHY/TRAUMA

Sandler, R. and Robinovitch, S. (2001), An analysis of the effect of lower extremity strength on impact severity during a backward fall. Journal of Biomechanical Engineering-Transactions of the Asme, 123 (6), 590-598.

Abstract: At least 280,000 hip fractures occur annually in the U.S., at an estimated cost of $9 billion. While over 90 percent of these are caused by falls, only about 2 percent of all falls result in hip fracture. Evidence suggests that the most important determinants of hip fracture risk during a fall arc the body's impact velocity and configuration. Accordingly, protective responses for reducing impact velocity, and the likelihood for direct impact to the hip, strongly influence fracture risk. One method for reducing the body impact velocity and kinetic energy during a fall is to absorb energy in the lower extremity muscles during descent, as occurs during sitting and squatting. In the present study, we employed a series of inverted pendulum models to determine: (a) the theoretical effect of this mechanism oil impact severity during a backward fall, and (b) the effect oil impact severity of age-related declines (or exercise-induced enhancements) in lower extremity strength. Compared to the case of a fall with zero energy absorption in the lower extremity joints, best-case falls (which involved 81 percent activation of ankle and hip muscles, bill only 23 percent activation of knees muscles) involved 79 percent attenuation (from 352 J to 74 J) in the bod ys vertical kinetic energy at impact (KEv), and 48 percent attenuation (from 3.22 to 1.68 m/s) in the downward velocity of the pelt-is at impact (vv). Among the mechanisms responsible for this were: (1) eccentric contraction of lower extremity muscles during descent, which resulted in lip to 150 J of energy absorption; (2) impact with the trunk in an upright configuration, which reduced the change in potential energy associated with the fall by 100 J; and (3) knee extension during the final stage of descent, which "transferred" up to 90 J of impact energy into horizontal

(as opposed to vertical) kinetic energy. Declines in joint strength reduced the effectiveness of mechanisms (1) and (3), and thereby increased impact severity. However even with reductions of 80 percent in available torques, KEv was attenuated by 50 percent. This indicates the importance of both technique and strength in reducing impact severity. These results provide motivation for attempts to reduce elderly individuals' risk for fall-related injury through the combination of instruction in safe falling techniques and exercises that enhance lower extremity strength

Keywords: biomechanics/COMMUNITY/DISTAL RADIUS/elderly/extremity/falls/FORCES/fracture/HIP FRACTURE/hip fracture/INJURY/knee/mathematical modeling/PREDICTION/RISK-FACTORS/STANDING HEIGHT/strength/WOMEN

Hsiao, E.T. and Robinovitch, S.N. (1998), Common protective movements govern unexpected falls from standing height. Journal of Biomechanics, 31 (1), 1-9.

Abstract: Simple energy considerations suggest that any fall from standing height has the potential to cause hip fracture. However, only 1-2% of falls among the elderly actually result in hip fracture, and less than 10% cause serious injury. This suggests that highly effective movement strategies exist for preventing injury during a fall. To determine the nature of these, we measured body segment movements as subjects (aged 22- 35 yr) stood upon a gymnasium mattress and attempted to prevent themselves from falling after the mattress was made to translate abruptly. Subjects were more than twice as likely to fall after anterior translations of the feet, when compared to posterior or lateral translations. In falls which resulted in impact to the pelvis, a complex sequence of upper extremity movements allowed subjects to impact their wrist at nearly the same instant as the pelvis (average time interval between contacts = 38 ms), suggesting a sharing of contact energy between the two body parts. Finally, marked trunk rotation was exhibited in falls due to lateral (but not anterior or posterior) perturbations, resulting in the avoidance of impact to the lateral aspect of the hip. These results suggest that body segment movements during falls, rather than being random and unpredictable, involve a repeatable series of responses which facilitate safe landing. (C) 1998 Elsevier Science Ltd. All rights reserved

Keywords: balance/COMMUNITY/elderly/extremity/falls/fracture/hip fracture/HIP-FRACTURES/IMPACT/protective responses/RISK-FACTORS/wrist fracture

vandenKroonenberg, A.J., Hayes, W.C. and McMahon, T.A. (1996), Hip impact velocities and body configurations for voluntary falls from standing height. Journal of Biomechanics, 29 (6), 807-811.

Abstract: Fall dynamics have largely been ignored in the study of hip fracture etiology and in the development of hip fracture prevention strategies. In this study, we asked the following questions: (1) What are the ranges of hip impact velocities associated with a sideways Fall from standing height? (2) What are the ranges of body configurations at impact? and (3) How do protective reflexes such as muscle activation or using an outstretched hand influence fall kinematics? To answer these questions, we recruited six young healthy athletes who performed voluntary sideways falls on a thick foam mattress. Several categories of falls were investigated: (a) muscle- active vs muscle-relaxed falls; (b) falls From a standing position or from walking; and (c) falls in which an outstretched arm was used to break the fall. Each fall was videotaped at 60 frames s(-1). Fall kinematics parameters were obtained by digitizing markers placed on anatomical points of interest. The mean value for

vertical hip impact velocity was 2.75 ms(-1) (+/-0.42 ms(-1) [S.D.]). The mean value for trunk angle (the angle between the trunk and the vertical) was 17.3 degrees (+/-11.5 degrees [S.D.]). We found a 38% reduction in the trunk angle at impact, and a 7% reduction in hip impact velocity for relaxed vs muscle-active falls. Finally, regarding the falls in which an outstretched arm was used, only two out of the six subjects were able to break the Fall with their arm or hand. For the remaining subjects, hip impact occurred first, followed by contact of the arm or hand. Published by Elsevier Science Ltd

Keywords: aging/falls/fracture/hip fracture/hip fractures/kinematics/RECOVERY/RISKVandenkroonenberg, A.J., Hayes, W.C. and Mcmahon, T.A. (1995), Dynamic-Models

for Sideways Falls from Standing Height. Journal of Biomechanical Engineering-Transactions of the Asme, 117 (3), 309-318.

Abstract: Despite our growing understanding of the importance of fall mechanics in the etiology of hip fracture, previous studies have largely ignored the kinematics and dynamics of falls from standing height. Beginning from basic principles, we estimated peak impact force on the greater trochanter in a sideways fall from standing height. Using a one degree-of-freedom impact model this force is determined by the impact velocity of the hip, the effective mass of that part of the body that is moving prior to impact, and the overall stiffness of the soft tissue overlying the hip. To determine impact velocity and effective mass, three different paradigms of increasing complexity were used: 1) a falling point mass or a rigid bar pivoting at its base; 2) two-link models consisting of a leg segment and a torso; and 3) three-link models including a knee. The total mechanical energy of each model before falling was equated to the total mechanical energy just prior to impact in order to estimate the hip impact velocity. In. addition, the configuration of the model just before impact was used to estimate the effective mass. Our model predictions were compared with the results of an earlier experimental study with young subjects falling on a 10-inch thick mattress. Values from literature were used to estimate the soft tissue stiffness. For the models, predicted values for hip impact velocity and effective mass ranged from 2.47 to 4.34 m/s and from 15.9 to 70.0 kg, respectively. Predicted values for the peak force applied to the greater trochanter ranged from 2.90 k to 9.99 k N. Based on comparisons to the experimental falls, impact velocity and impact force were best predicted by a simple two- link model with the trunk at 45 degrees to the vertical at impact A three-link model with a quadratic spying incorporated in the knee of the model was the best predictor of effective mass. Using our most accurate model, the peak impact force was 2.90 k N for a 5th percentile female and 4.26 k N for a 95th percentile female, thereby confirming the widely held perception that ''the bigger they are, the harder they fall.''

Keywords: falls/fracture/FRACTURE RISK/hip fracture/HIP-FRACTURES/IMPACT/impact force/kinematics/knee/OSTEOPOROSIS/PREDICTION/stiffness

Takata, S., Ikata, T. and Yonezu, H. (2000), Characteristics of regional bone mineral density and soft tissue composition in patients with atraumatic vertebral fractures. Journal of Bone and Mineral Metabolism, 18 (5), 287-290.

Abstract: To clarify the characteristics of total body and regional bone mineral density (BMD) and soft tissue composition in patients with atraumatic vertebral fractures (AVF), we measured total body and regional BMD, lean mass, and fat mass using dual- energy X-ray absorptiometry. Sixty-four women, aged 55-75 years, were divided into two groups: women with AVF (fracture group, n = 30) and women without AVF (nonfracture group, n = 34). Mean BMD of the second to fourth lumbar

vertebrae (L2- 4BMD), regional BMD, and soft tissue mass were measured. Regional BMD was measured in the head, arms, legs, ribs, thoracic vertebrae, lumbar vertebrae, and pelvis. Lean mass and fat mass of head, arms, legs, and trunk were measured. L2-4BMD, total body BMD, and BMD of the lumbar spine, thoracic spine, and pelvis of the fracture group were significantly lower than those of the nonfracture group (P < 0.001). Total lean and fat mass of the fracture group tended to be lower than that of the nonfracture group. The results suggest that BMD of weight bearing bones, except for that of the bones of the legs of the fracture group, is significantly lower than that of the nonfracture group, and that total body lean and fat mass may be a predictor for AVF

Keywords: BONE/bone mineral density/dual-energy X-ray absorptiometry/DUAL-PHOTON ABSORPTIOMETRY/fracture/head/soft tissue composition/spine/TOTAL-BODY

Groh, G.I., Williams, G.R., Jarman, R.N. and Rockwood, C.A. (1997), Treatment of complications of shoulder arthrodesis. Journal of Bone and Joint Surgery-American Volume, 79A (6), 881-887.

Abstract: A reconstructive osteotomy was performed to correct symptomatic malposition after arthrodesis of the shoulder in nine of fourteen patients who had complications related to the arthrodesis. The clinical position of the arm in relation to the trunk was determined,vith the method described by Rowe. Malposition was primarily the result of fusion in more than 15 degrees of either flexion or abduction, or both, coupled with improper rotation, defined as rotation of less than 40 degrees or more than 60 degrees. Reconstructive osteotomy eliminated pain and improved the ability of the patient to perform six activities of daily living. The complications necessitating operative treatment after the arthrodesis in the remaining five patients included failure of the arthrodesis site to unite (three patients), a wound hematoma at the iliac-crest donor site (one patient), and a superficial wound infection (one patient). Two additional complications - a fracture through a screw-hole in the humerus and a fracture distal to the internal fixation device - occurred after the reconstructive osteotomies for malposition. All of the complications resolved with treatment. Arthrodesis of the shoulder is a technically demanding procedure that can lead to serious complications that necessitate operative intervention. Careful attention to operative technique and to the position of the arthrodesis are essential

Keywords: BONE/complications/FIXATION/fracture/fusion/iliac crestLarson, B.J. and Davis, J.W. (1995), Trampoline-Related Injuries. Journal of Bone and

Joint Surgery-American Volume, 77A (8), 1174-1178.Abstract: Two hundred and seventeen patients who had sustained an injury during the

recreational use of a trampoline were managed in the emergency room of Logan Regional Hospital in Logan, Utah, from January 1991 through December 1992. We retrospectively reviewed the charts and radiographs of these patients to categorize the injuries. Additional details regarding the injuries of seventy- two patients (33 per cent) were obtained by means of a telephone interview with use of a questionnaire. The injuries occurred from February through November, with the peak incidence in July The patients were eighteen months to forty- five years old (average, ten years old); ninety-four patients (43 per cent) mere five to nine Sears old. Eighty-four patients (39 per cent) sustained a fracture; fifty-four (25 per cent), a sprain or strain; forty-five (21 per cent), a laceration; and thirty-four (16 per cent), a contusion. Fifty-seven injuries (26 per cent) involved the elbow or forearm; forty-six (21 per cent), the head or neck; forty (18 per cent), the ankle or foot; thirty-three (15 per cent), the knee or leg; nineteen (9 per cent), the trunk or back; thirteen (6 per cent), the

shoulder or arm; and nine (4 per cent), the wrist or hand. Thirteen patients (6 per cent) had a back injury, but none of them had a permanent neurological deficit. One patient who had an ocular injury was transferred to a tertiary care center. One hundred and fifty-six patients (72 per cent) were evaluated radiographically, fifteen (7 per cent) were admitted to the hospital, and thirteen (6 per cent) had an operation. Although severe and Life-threatening injuries were rare, the estimated average cost of the emergency-room visits, radiographs, stays in the hospital, and operations was $673 per patient. On the basis of the patterns of the injuries and the results of the telephone survey, our recommendations for reducing the number of trampoline-related injuries are to place padding on the bars and springs, to limit the number of participants on the trampoline to one at a time, to place the trampoline in a hole so that the jumping surface is at ground level, to avoid somersaults and other high-risk maneuvers, to comply with the manufacturer's instructions, and to allow children to use the trampoline only with parental supervision

Keywords: BONE/elbow/fracture/head/knee/QUADRIPLEGIA/SPINEReichenbach, A., Fromter, C., Engelmann, R., Wolburg, H., Kasper, M. and Schnitzer,

J. (1995), Muller Glial-Cells of the Tree Shrew Retina. Journal of Comparative Neurology, 360 (2), 257-270.

Abstract: The tree shrew is one of the few mammalian species whose retinae are strongly cone dominated, which is usually the case in reptilian and avian retinae. Muller cells of the tree shrew (Tupaia belangeri) retina were studied by transmission electron microscopy of tissue sections and freeze-fracture replicas, by immunolabeling of the intermediate filament protein vimentin in radial paraffin sections and in whole retinae, as well as by intracellular dye injection in slices of retinae. In addition, enzymatically isolated cells were stained by Pappenheim's panoptic staining method. The cells showed an ultrastructure that is similar to other mammalian Muller cells with two exceptions: Due to the extensive lateral fins of cone inner segments, the apical microvilli of Muller cells are arranged in peculiar palisades, and the basket-like Muller cell sheaths around neuronal somata in both nuclear layers consist of unusual multilayered membrane lamellae. Unlike Muller cells in other mammalian species studied thus far, but similar to reptilian and avian Muller cells, those of tree shrews commonly have two or more vitread processes rather than one main trunk. Muller cell densities range between some 13,000 mm(-2) in the periphery and about 20,000 mm(-2) in the retinal center. Neuron: (Muller) glial cell ratios were estimated to be 7.9:1 in the center and 6.2:1 in the periphery. For each Muller cell, about 1.5 (cone) photoreceptor cells, four or five interneurons of the inner nuclear layer, and about one cell of the ganglion cell layer were counted. This is a much lower number of neurons per Muller cell than in most other mammals studied. (C) 1995 Wiley-Liss, Inc

Keywords: CONE/FINE-STRUCTURE/FREEZE-FRACTURE TECHNIQUE/IMMUNOCYTOCHEMISTRY/INDEXING TERMS/LUCIFER YELLOW INJECTION/MORPHOLOGY/MOUSE RETINA/NEUROGLIA/ORTHOGONAL ARRAYS/PHOTORECEPTORS/POSTNATAL-DEVELOPMENT/RABBIT RETINA/RECEPTORS/TUPAIA-BELANGERI/ULTRASTRUCTURE

Guerrissi, J.O. (1997), Facial nerve paralysis after intratemporal and extratemporal blunt trauma. Journal of Craniofacial Surgery, 8 (5), 431-437.

Abstract: Definitive facial nerve paralysis by intratemporal and extratemporal blunt injury is uncommon. Facial palsy as a result of closed temporal trauma is assumed to result if a petrous or temporal fracture is produced. Injury of the extratemporal trunk

is extremely rare, but peripheral branches can be more easily injured. An exhaustive examination is necessary for an assessment if facial nerve damage is inside its bony canal or if it is severed distal to the stylomastoid foramen. Evaluation of facial muscle tone and motion, tear production, taste distribution, and stapedius muscle function must be evaluated. Electroneurography is mandatory because it is an important prognosis factor. Many prognosis factors must also be considered. Computed tomographic scan is also mandatory for providing localization of temporal fractures. Of 30 patients with facial paralysis registered by us between 1991 to 1996, 5 (17%) blunt trauma was the cause. In 2 of these patients with facial paralysis by extratemporal injury, showing selective facial branch injuries (one in the buccal branch and another in the marginal mandibular branch), recovery was complete and spontaneous. Another patient presented with a definitive selective buccal branch palsy after a complete facial paralysis produced by blunt preauricular injury. Of another 2 patients with facial paralysis by intratemporal injury without fracture, 1 recovered and the other did not. In 4 of the just-mentioned 5 patients, prednisolone was prescribed 1 week after trauma; no patients underwent surgical treatment. In conclusion, an extratemporal blunt trauma can produce a temporary facial palsy or paresis by injury of the main trunk or peripheral facial branch; however, recovery is usually complete. Intratemporal closed trauma with or without temporal fractures can produce a definitive facial nerve paralysis; recovery is uncertain

Keywords: blunt trauma/facial nerve paralysis/fracture/PALSY/SURGERY/traumaSeki, H., Saitoh, S., Hata, Y., Murakami, N., Shimizu, T. and Takaoka, K. (2002),

Callus resection for brachial plexus compression following stress-induced first rib fracture. Journal of Hand Surgery-British and European Volume, 27B (3), 293-295.

Abstract: A 27-year-old man presented with a lower trunk brachial plexus injury due to excessive callus formation following a stress- induced first rib fracture. The callus, but not the first rib, was resected through a supraclavicular approach. His symptoms resolved in 2 months, and no recurrence was seen at 2 years follow-up

Keywords: 1ST RIB/fractureMadronero, A., Ariza, E., Verdu, M., Brandl, W. and Barba, C. (1996), Some

microstructural aspects of vapour-grown carbon fibres to disclose their failure mechanisms. Journal of Materials Science, 31 (23), 6189-6193.

Abstract: The microstructure of vapour-grown carbon fibres has been studied by an SEM examination of the transverse section. In this way the duplex structure, of catalytic and pyrolytic carbon, can be differentiated by the fracture of each phase; pyrolytic carbon shows concentric circles, termed free trunk structure, while a glassy appearance characterizes the pyrolytic phase. It was observed that fracture was strongly influenced by the breaking mode of the fibre, because in tensile failure of a thick fibre, fracture similar to the tree trunk appearance can be formed in the outer layer of the pyrolytic phase. Thus it is necessary to study the transverse microstructure of vapour-grown carbon fibres without any failure process. Using a preparation of fibre samples, in slides as thin as necessary for TEM study, the internal structure was disclosed. The pyrolytic phase was constituted of randomly oriented small crystals, while the tree trunk structure was really formed by very elongated crystals with preferential orientation. Electron diffraction of both phases shows a different degree of texture according to the structures. In addition to crystals, TEM examination showed the existence of hollow cavities, that have a clear influence on the failure mechanism. Owing to these faults, the failure process forms parallel grooves, that constitute the tree trunk appearance

Keywords: FIBERS/fracture

Borrelli, J., Goldfarb, C., Ricci, W., Wagner, J.M. and Engsberg, J.R. (2002), Functional outcome after isolated acetabular fractures. Journal of Orthopaedic Trauma, 16 (2), 73-81.

Abstract: Objective: To evaluate objectively the effectiveness of current surgical management of displaced acetabular fractures. To provide insight into how these evaluation methods can be used to identify areas in which improvements in surgery and rehabilitation can be pursued to improve patient outcomes. Design: Consecutive case series. Setting: University medical center. Patients: Fifteen patients were studied, each with an isolated, displaced acetabular fracture treated with a Kocher- Langenbeck approach. Main Outcome Measures: Primary outcome measures included hip muscle strength, including work (Joules/minute) and maximum torque (30degrees/second) for abductors/adductors and flexors/extensors. Gait analysis of patients and able-bodied cohorts, including stride length, speed, and cadence, were also assessed. Motion analysis during gait was also studied for each body segment, including the trunk, pelvis, hip, knee, and ankle, in the sagittal, frontal, and axial planes. Motion data for the affected side was compared with motion data for the unaffected side, and linear gait findings for the study patients were compared to able- bodied cohorts. An assessment of clinical outcome was performed by completion of a validated Musculoskeletal Function Assessment (MFA) questionnaire and the were results correlated with muscle strength and gait analysis. Secondary outcome measures included adequacy of fracture reduction, radiographic grade, the presence and severity of heterotopic ossification at the time of the most recent follow-up, and passive range of motion of the affected and unaffected hips. Results: No statistical differences in muscle strength for each of the major muscle groups were found when the affected limb was compared with the unaffected limb. No statistical differences were found between the study patients and the ablebodied cohorts with regards to stride length, gait speed, and cadence. The only significant difference found in body segment position was trunk inclination. When the study patients were compared with able-bodied cohorts, the patients tended to walk with greater forward inclination of their trunks; this was true for all phases of gait. Total MFA scores averaged 22 (range, 0-57). Patients could be separated into two separate groups based on their total MFA score. One group (n = 6) had an average MFA score of 7 (range, 0-10), while a second group (n = 9) had an average MFA score of 32 (range, 12-57). The scores of study patients as a whole, and those of each individual group of patients, were compared with known MFA scores for nonpatients and patients in the Orthopaedic Trauma Association/Association for the Study of Internal Fixation (OTA/AO) injury group (hip and thigh). When the muscle strengths of these two groups of patients were compared, all hip flexion and extension variables were significantly weaker in the group with an average MFA score of 32, whereas none of the gait variables were different between the two groups. At an average follow-up of 24 months, seven patients had an excellent radiographic grade, four patients had a good grade, two patients had a fair grade, and two patients had a poor grade. These radiographic grades were in contrast to achieving an anatomic reduction in eleven patients, a satisfactory reduction in three patients, and an unsatisfactory reduction in one patient. Heterotopic ossification was found in eight patients, four patients had Grade 1, and four patients, had Grade 2. No statistically significant differences were observed when each MFA group was compared with each of these radiographic variables. Passive hip range of motion was not statistically different when the affected hip was compared with the unaffected hip. Conclusions: Standardized muscle strength determination, gait, and motion analysis, and completion of an MFA

questionnaire provided a thorough and revealing evaluation of patients who have undergone open reduction and internal fixation (ORIF) of a displaced acetabular fracture. Minimal alterations in body posture and affected limb motion were present in patients displaying relatively normal gait parameters, including stride length, speed, and cadence. Despite dissection of the hip musculature during surgery, normal muscle strength recovery was possible after operative repair of these acetabular fractures. However, functional outcome, as determined by MFA scores, was considerably poorer in those patients with significantly weaker hip flexion and extension strength, compared with those of patients with more desirable MFA scores. Based on the current data, it appears that the use of these and similar evaluation instruments can allow determination of factors that negatively affect outcome (hip flexion and extension strength), which otherwise may remain unknown. It is possible that identification and treatment of these factors will improve the quality of life for patients after this type of injury

Keywords: acetabular fractures/fracture/FUNCTION ASSESSMENT INSTRUMENT/gait analysis/knee/MUSCLE/muscle strength/MUSCULOSKELETAL FUNCTION ASSESSMENT/musculoskeletal function assessment (MFA)./OPEN REDUCTION/PATIENT/rehabilitation/strength

Garland, D.E., Stewart, C.A., Adkins, R.H., Hu, S.S., Rosen, C., Liotta, F.J. and Weinstein, D.A. (1992), Osteoporosis After Spinal-Cord Injury. Journal of Orthopaedic Research, 10 (3), 371-378.

Abstract: Dual-photon absorptiometry characterized bone loss in males aged < 40 years after complete traumatic paraplegic and quadriplegic spinal cord injury. Total bone mass of various regions and bone mineral density (BMD) of the knee were measured in 55 subjects. Three different populations were partitioned into four groups: 10 controls (healthy, age matched); 25 acutely injured (114 days after injury), with 12 reexamined 16 months after injury; and 20 chronic (> 5 years after injury). Significant differences (p < 0.0001) in bone mass mineral between groups at the arms, pelvis, legs, distal femur, and proximal tibia were found, with no differences for the head or trunk. Post hoc analyses indicated no differences between the acutely injured at 16 months and the chronically injured. Paraplegic and quadriplegic subjects were significantly different only at the arms and trunk, but were highly similar at the pelvis and below. In the acutely injured, a slight but statistically insignificant rebound was noted above the pelvis. Regression techniques demonstrated early, rapid, linear (p < 0.0001) decline of bone below the pelvis. Bone mineral loss occurs throughout the entire skeleton, except the skull. Most bone loss occurs rapidly and below the pelvis. Homeostasis is reached by 16 months at two thirds of original bone mass, near fracture threshold

Keywords: bone mineral density/BONE-MINERAL DENSITY/DISODIUM/ENDOCRINE CHANGES/ETIDRONATE/fracture/head/HYPERCALCEMIA/IMMOBILIZATION/knee/OSTEOPOROSIS/PARALYSIS/PARAPLEGIC PATIENTS/SKELETON/SPACE-FLIGHT/SPINAL CORD INJURY/spinal-cord-injury

Clugston, P.A., Courtemanche, D.J., Lawson, I., Christensen, L.B. and Tredwell, S. (1995), Revascularization of A 7-Week-Old Infant Lower-Extremity - Case-Report. Journal of Reconstructive Microsurgery, 11 (2), 107-111.

Abstract: A seven-week-old infant suffered a closed segmental fracture of the left tibia and fibula complicated by vascular disruption and a secondary compartment syndrome. Initial orthopedic assessment revealed a clinically mottled, cool, pulseless

extremity 4 hr post-injury. Radiologic investigations showed multiple displaced fractures of both the tibia and fibula. The infant underwent four compartment fasciotomies and intramedullary nailing of the tibial fractures. The vascularity of the limb failed to improve significantly Angiograms done 22 hr post-injury revealed disruption of arterial inflow just distal to the bifurcation of the tibial peroneal trunk and posterior tibial artery. Urgent revascularization utilizing a contralateral greater saphenous vein graft was undertaken with a successful outcome. Despite delay in transport from the community hospital and lack of definitive management of the vascular injury, the infant has had a good-to-excellent functional outcome

Keywords: extremity/fracture/transportHakkinen, A., Sokka, T., Kotaniemi, A., Kautiainen, H., Jappinen, I., Laitinen, L. and

Hannonen, P. (1999), Dynamic strength training in patients with early rheumatoid arthritis increases muscle strength but not bone mineral density. Journal of Rheumatology, 26 (6), 1257-1263.

Abstract: Objective. To assess the effects of 12 months' dynamic strength training on muscle strength and bone mineral density (BMD) at the lumbar spine and femoral neck in patients with early rheumatoid arthritis (RA). Methods. Thirty-two subjects in the training group (EG) and 33 in the control group (CG) completed the study. EG carried out strength training 2 times a week with moderate loads of 50-70% of repetition maximum. They were also encouraged to do recreational physical activities. CG performed recreational physical activities and range of motion exercises. Maximal strength of the knee extensors, trunk extensors and flexors, and grip strength were recorded with dynamometers. BMD was measured using dual x-ray absorptiometry. Modified Disease Activity Score, erythrocyte sedimentation rate, and pain were used for the estimation of disease activity, and Stanford Health Assessment Questionnaire to measure functional disability Results, The 12 month resistance training in EG led to statistically significant mean increases of 22-35% in all muscle groups examined. CG patients were also able to increase their strength to some degree (3-24%), but at the end of the study strengths in CG were significantly lower than in EG. By the end of the study lumbar spine BMD had changed by +0.19% (4.24) in EG and by -1.14% (4.36) in CG, The corresponding changes of femoral BMD were +1.10% (3.71) and -0.03% (3.58). The changes in BMD were minor and statistically not significant in both groups. However, femoral BMD was found to be decreased among those patients treated periodically with oral glucocorticoids (n = 15, 3 subjects from EG and 12 from CG) compared with changes in BMD among those not treated with systemic glucocorticoids (n = 50). Conclusion, Minimally supervised strength training resulted in significant improvements in muscle strength without detrimental effects on disease activity. The detected annual changes in central BMD were minor and statistically insignificant in both groups. Special attention should be focused on those patients with RA with high disease activity and concomitant glucocorticoid treatment

Keywords: bone mineral density/DETERMINANTS/disease activity/DISEASE-ACTIVITY/FUNCTIONAL-CAPACITY/HOME EXERCISE/knee/LOW-DOSE CORTICOSTEROIDS/MASS/METABOLISM/muscle strength/OSTEOPOROSIS/POSTMENOPAUSAL WOMEN/rheumatoid arthritis/spine/strength/VERTEBRAL FRACTURE

Zelle, B., Zeichen, J., Pape, H.C., Weissenborn, K. and Krettek, C. (2002), Upper sympathetic trunk lesion after video-assisted fracture stabilization of the thoracic spine: A case report. Journal of Spinal Disorders & Techniques, 15 (6), 502-506.

Abstract: This case report draws attention to the upper sympathetic trunk lesion as a

complication of video-assisted thoracic spine surgery. A 39-year-old man developed an upper sympathetic trunk lesion after right-sided thoracoscopic fracture stabilization of T5 and T6. Dizziness and reduced perspiration persisted at the most recent follow-up 8 months after surgery. This rare complication can be overlooked and remain undiagnosed. Diagnosis is based on clinical symptoms and neurologic examination. There are no treatment options. Symptoms can be bothersome for the patient and may persist. In the upper thoracic spine, the course of the sympathetic trunk lies in close proximity of the vertebral bodies; thus, care must be taken to avoid it when resecting the posterior parts of the vertebral body

Keywords: DISEASE/fracture/INJURIES/LUMBAR SPINE/OPERATIVE TREATMENT/POSTOPERATIVE PAIN/spinal fracture stabilization/spine/SURGERY/THORACOLUMBAR FRACTURES/thoracoscopy/THORACOSCOPY/THORACOTOMY/upper sympathetic trunk lesion

Nicholas, J.J., Reidy, M. and Oleske, D.M. (1998), An epidemiologic survey of injury in golfers. Journal of Sport Rehabilitation, 7 (2), 112-121.

Abstract: In order to supplement the literature that describes individual injuries of the shoulder, carpal tunnel, and back in golfers, we administered a sun ey to demonstrate the incidence of golfers' injuries and describe the most frequent types. A questionnaire was administered to 1,790 members of the New York State Golf Association (amateur) under age 21. Three hundred sixty-eight players responded. Half of those responding had been struck by a golf ball at least on one occasion (47.6%), and 23% of the injuries were to the head or neck. Male golfers were 2.66 times more likely to be struck by a golf ball than females. Women and golfers with a higher handicap were at an increased risk for upper extremity problems, whereas younger and overweight golfers were more likely to have golf-related back problems. We concluded that golf is associated with a significant morbidity. Repetitious trunk and upper limb motions probably contribute to musculoskeletal disorders. However, an unexpectedly high incidence of trauma from projectile golf bails leads to the conclusion that no amount of stretching or muscular exercise is as important as increased alertness by golfers to decrease this hazard

Keywords: CHILDREN/extremity/FRACTURE/head/HEAD-INJURIES/traumaFernandez-Seara, M.A., Song, H.K. and Wehrli, F.W. (2001), Trabecular bone volume

fraction mapping by low-resolution MRI. Magnetic Resonance in Medicine, 46 (1), 103-113.

Abstract: Trabecular bone volume fraction (TBVF) is highly associated with the mechanical competence of trabecular bone. TBVF is ordinarily measured by histomorphometry from bone biopsies or, noninvasively, by means of high-resolution microcomputed tomography and, more recently, by micro-MRI. The latter methods require spatial resolution sufficient to resolve trabeculae, along with segmentation techniques that allow unambiguous assignment of the signal to bone or bone marrow. In this article it is shown that TBVF can be measured under low- resolution conditions by exploiting the attenuation of the MR signal resulting from fractional occupancy of the imaging voxel by bone and bone marrow, provided that a reference signal is available from a marrow volume devoid of trabeculation. The method requires accurate measurement of apparent proton density, which entails correction for various sources of error. Key among these are the spatial nonuniformity in the RF field amplitude and effects of the slice profile, which are determined by B, field mapping and numerical integration of the Bloch equations, respectively. By contrast, errors from variations in bone marrow composition (hematopoietic vs. fatty) between

trabecular and reference site are predicted to be small and usually negligible. The method was evaluated in phantoms and in vivo in the distal radius and found to be accurate to 1% in marrow volume fraction. Finally, in a group of 12 patients of varying skeletal status, TBVF in the calcaneus was found to strongly correlate with integral bone mineral density of the lumbar vertebrae (r(2) = 0.83, p < 0.0001). The method may fail in large imaging objects such as the human trunk at high magnetic field where standing wave and RF penetration effects cause intensity variations that cannot be corrected. (C) 2001 Wiley-Liss, Inc

Keywords: B-1 correction/bone mineral density/bone volume measurement/CALCANEUS/calcaneus/DENSITY/fast spin echo/FRACTURE/IMAGES/IN-VIVO/MARROW/OSTEOPOROSIS/PENETRATION/STRENGTH/X-RAY ABSORPTIOMETRY

Trunk, B. and Wittmann, F.H. (2001), Influence of size on fracture energy of concrete. Materials and Structures, 34 (239), 260-265.

Abstract: Concrete structures frequently exhibit cracks. In order to investigate the influence of cracks on durability and the remaining load bearing capacity of buildings, fracture mechanics models can be used. For materials like concrete non- linear models for example the fictitious crack model introduced by Hillerborg, Modeer and Petersson [1] or the crack band model proposed by Bazant and Oh [2] are able to describe crack formation and propagation in a realistic way. But it has been observed, that the parameters of these models depend both, on structural size and geometry. In this paper a simple model to explain the nature of size and geometry dependence of the specific fracture energy is presented. The model is evaluated with experimental data from Trunk and Wittmann [2, 4, 5]

Keywords: fractureBotvina, L.R., Oparina, I.B. and Novikova, O.V. (1997), Analysis of the process of

damage cumulation on various scale levels. Metal Science and Heat Treatment, 39 (3-4), 151-155.

Abstract: It is known that the structure of the material plays a decisive role in the stage of initiation of fracture that is connected with formation of multiple pores and cracks. This stage has been studied less than the stage of development of a localized microcrack, which is described in terms of fracture mechanics. However, in order to optimize the structure of metals and alloys we should understand the laws governing the cumulation of discontinuities in the stage of the appearance of a trunk crack at various structural levels. This will allow us to relate the parameters of the structure with the characteristics of the process of cumulation of pores and microcracks and thus provide a basis for developing new materials with a high fracture resistance in the initial stage of fracture and for damage diagnostics by methods of nondestructive testing. It should be noted that analysis of damage cumulation is also of interest from the standpoint of the general laws of the fracture process in various materials, including metals, nonmetals, and rocks, because much experimental data show that these laws are similar and independent of the nature of the material and the scale level considered

Keywords: EARTHQUAKES/fracture/STEELRico, H., Revilla, M., Villa, L.F., Arribas, I. and Debuergo, M.A. (1993), A

Longitudinal-Study of Total and Regional Bone-Mineral Content and Biochemical Markers of Bone-Resorption in Patients with Idiopathic Hypercalciuria on Thiazide Treatment. Mineral and Electrolyte Metabolism, 19 (6), 337-342.

Abstract: The effect of thiazides on total body bone mineral content and axial (trunk) and peripheral (arms) bone mass was evaluated. First, dual-energy X-ray

absorptiometry was used to study bone mass in 24 patients with idiopathic hypercalciuria and in 22 healthy subjects. Next, the patients were randomized into a group of 14 patients treated with chlorthalidone (50 mg/day) and a group of 10 untreated patients who served as controls; in these two groups biochemical and bone mass studies were repeated 1 year later. Compared with healthy controls, patients with idiopathic hypercalciuria had less bone mass in total body(p < 0.02), arms (p < 0.001), and trunk (p < 0.05). After 1 year, the group of patients treated with thiazides manifested an increase of bone mass in total body (p < 0.0045), arms, and trunk (p < 0.0001) and a decrease in 24-hour calciuria, urinary calcium/creatinine ratio, and serum tartrate resistant acid phosphatase concentration; the untreated group of patients lost bone mass in all three sites. Under baseline conditions, the groups of treated and untreated patients exhibited a negative linear regression between total body bone mass and both urinary calcium/creatinine (r(2) = 0.234; p < 0.001) and serum tartrate resistant acid phosphatase concentration (r(2) = 0.399; p < 0.0001). Our results confirm the favorable effect of thiazides on bone mass and provide evidence of enhanced bone remodeling in idiopathic hypercalciuria

Keywords: ACID-PHOSPHATASE/BIOLOGICAL MARKERS/BONE MASS/bone mineral content/BONE REMODELING/DENSITY/DISEASE/DIURETICS/DUAL PHOTON-ABSORPTIOMETRY/dual-energy X-ray absorptiometry/HIP FRACTURE/IDIOPATHIC HYPERCALCIURIA/PATHOGENESIS/RISK/WOMEN/X-RAY ABSORPTIOMETRY

Reid, I.R., Ames, R.W., Evans, M.C., Gamble, G.D. and Sharpe, S.J. (1993), Effect of Calcium Supplementation on Bone Loss in Postmenopausal Women. New England Journal of Medicine, 328 (7), 460-464.

Abstract: Background. The use of calcium supplements slows bone loss in the forearm and has a beneficial effect on the axial bone density of women in late menopause whose calcium intake is less than 400 mg per day. However, the effect of a calcium supplement of 1000 mg per day on the axial bone density of postmenopausal women with higher calcium intakes is not known. Methods. We studied 122 normal women at least three years after they had reached menopause who had a mean dietary calcium intake of 750 mg per day. The women were randomly assigned to treatment with either calcium (1000 mg per day) or placebo for two years. The bone mineral density of the total body, lumbar spine, and proximal femur was measured every six months by dual-energy x-ray absorptiometry. Serum and urine indexes of calcium metabolism were measured at base line and after 3, 12, and 24 months. Results. The mean (+/-SE) rate of loss of total- body bone mineral density was reduced by 43 percent in the calcium group (-0.0055+/-0.0010 g per square centimeter per year) as compared with the placebo group (-0.0097+/-0.0010 g per square centimeter per year, P = 0.005). The rate of loss of bone mineral density was reduced by 35 percent in the legs (P = 0.02), and loss was eliminated in the trunk (P = 0.04). Calcium use was of significant benefit in the lumbar spine (P = 0.04), and in Ward's triangle the rate of loss was reduced by 67 percent (P = 0.04). Calcium supplementation had a similar effect whether dietary calcium intake was above or below the mean value for the group. Serum parathyroid hormone concentrations tended to be lower in the calcium group, as were urinary hydroxyproline excretion and serum alkaline phosphatase concentrations. Conclusions. Calcium supplementation significantly slowed axial and appendicular bone loss in normal post-menopausal women

Keywords: BALANCE/bone mineral density/DENSITY/DIETARY CALCIUM/ESTROGEN/HIP FRACTURE/menopause/MIDDLE-AGED

WOMEN/OSTEOPOROSIS/PHYSICAL-ACTIVITY/POPULATION/postmenopausal women/spine/TRIAL

Hofmann, S., Huemer, G., Kratochwill, C., Kollerstrametz, J., Hopf, R., Schlag, G. and Salzer, M. (1995), Pathophysiology of Fat-Embolism in Orthopedic and Traumatic Surgery. Orthopade, 24 (2), 84-93.

Abstract: It is well known that fat embolisms can occur after long bone fractures, and this has been feared for more than 100 years. Since 1970 fat embolisms have also been recognized in endoprosthetic surgery. The clinical manifestation was described as the fat embolism syndrome (FES) by Gurd in 1974. Based on reports in the literature and our own data, a concise pathophysiological model of the FES is presented in this paper. The increase in intramedullary pressure (IMP) in the long bones is the most decisive pathogenic factor for the development of an FES. Any long bone fracture, stabilization of fractures, or implantation of knee or hip endoprostheses can generate IMP peaks leading to bone marrow release into the circulation. Bone marrow itself is a tremendous stimulus for activation of the clotting system. As a result, hypercoagulation and venous stasis in the draining veins generate mixed macro-emboli from the initial bone-marrow microemboli. Bone-marrow embolization of the lung in phase I leads to mechanical obstruction of pulmonary arteries. In phase II, release of local mediators, triggered by a systemic inflammatory response (SIR) of the lungs, causes damage to the pulmonary membranes. Disturbed gas exchange and respiratory insufficiency with possible cardiac and cerebral decompensation are the result. In most cases an FES may not be detected clinically, and any mild cardiorespiratory changes are treated easily with oxygen insufflation and usually disappear within 48 h. Of paramount importance for clinical manifestation of an FES are the quantity and duration of bone-marrow release and co-factors (cardiorespiratory compliance and perioperative stability of the patient). Patients with preexisting cardiorespiratory disease in combination with massive intraoperative bone-marrow release may even face a deadly FES event. Increased IMP causes local obstruction of cortical vessels with bone marrow. In combination with the damaged endosteal blood supply, avascular necrosis of the cortical bone occurs. During endoprosthetic procedures, mechanical - and mediator - triggered damage of the intima of big veins, in combination with venous stasis and hypercoagulation may be responsible for the high incidence of proximal thrombosis of femoral veins. As a delayed result of the disseminated intravascular coagulopathy, petechial bleeding in the trunk and subconjunctiva can be seen. A better understanding and recognition of the FES's pathophysiology may help to use prophylactic, diagnostic and therapeutical measures more effectively

Keywords: ENDOPROSTHETIC SURGERY/FAT EMBOLISM/fracture/knee/PATHOPHYSIOLOGY/TRAUMATOLOGY

Tsauo, J.Y., Chien, M.Y. and Yang, R.S. (2002), Spinal performance and functional impairment in postmenopausal women with osteoporosis and osteopenia without vertebral fracture. Osteoporosis International , 13 (6), 456-460.

Abstract: Previous studies have paid much attention to the impact on functional impairment or quality of life from vertebral fractures secondary to osteoporosis, but little research has addressed the function of osteoporotic women without fractures. The purposes of this study were: (1) to describe spinal performance and functional impairment in postmenopausal women with osteoporosis and osteopenia without vertebral fracture, and (2) to investigate the relationship between them. Thirty postmenopausal women diagnosed as having osteoporosis or osteopenia were recruited who fulfilled the following criteria: (1) menopause for at least 6 months; (2)

no vertebral fracture; (3) no medication that would interfere with calcium intake. Measurements included assessment of functional impairment and spinal performance including trunk extension/flexion isokinetic strength, spinal range of motion (ROM) and movement velocity in three planes (sagittal, frontal and transverse). The results showed that spinal ROM and velocity were significantly reduced in the osteoporosis group compared with the osteopenia group (p < 0.05), but no significant difference in trunk strength was shown. Functional impairment level showed a slight difference between the two groups (p = 0.042). There was a significant correlation between spinal ROM and motion velocity with bone mineral density; however, functional impairment correlated with motion velocity only in the transverse plane (trunk rotation) (p < 0.05). Spinal strength did not show any correlation with other parameters. It was concluded that spinal motion performance declined and functional impairment increased in relation to the severity of bone mineral loss in postmenopausal women without vertebral fracture, but their physical performance was not correlated with functional impairments

Keywords: ASSOCIATION/bone mineral density/DEFORMITIES/EUROPEAN-FOUNDATION/fracture/functional impairment/LOW-BACK-PAIN/MEN/menopause/osteopenia/osteoporosis/postmenopausal women/QUALITY-OF-LIFE/QUESTIONNAIRE/RELIABILITY/spinal performance/strength

McGrother, C.W., Donaldson, M.M.K., Clayton, D., Abrams, K.R. and Clarke, M. (2002), Evaluation of a hip fracture risk score for assessing elderly women: The Melton Osteoporotic Fracture (MOF) study. Osteoporosis International, 13 (1), 89-96.

Abstract: Risk assessment for osteoporotic fracture within a primary care context, in old age, has received little attention. We aimed to develop such a risk score and assess its feasibility and validity. This was a 100% population-based, prospective cohort study, with a minimum 5 1/2 year follow-up among women aged 70 years and over, set in a large single general practice in Melton Mowbray, Leicestershire, UK. The main outcome measures were hip fracture, death and migration. Baseline measures included calcaneal broadband ultrasound attenuation (BUA), reported falls, balance, previous fracture history, medical problems, visual acuity, foot problems, body size, lifestyle factors and cognitive impairment. Seventy percent of the sample (1289) participated, including those in residential accommodation. Independent predictors of hip fracture over 3 years were low weight, kyphosis, poor circulation in the foot, epilepsy, short-term use of steroids and poor trunk maneuver. Using the highest tertile, a risk score based on these variables identified 84% (95% CI: 70% to 98%) of the hip fractures with a specificity of 68% (95% CI: 65% to 71 %). BUA did not independently predict hip fracture in women of this age group. This study shows that a combination of readily obtained risk factors can identify elderly women who will sustain a hip fracture in the next 3 years more accurately than bone measurements alone in younger women. It also suggests that a risk score approach to universal assessment in the elderly is a feasible proposition in the primary care setting

Keywords: balance/BONE-MINERAL DENSITY/COST/elderly/EPIDOS/falls/fracture/hip fracture/hip fractures/kyphosis/OSTEOPOROSIS/POPULATION/PREDICTION/primary care/prospective study/risk score/SIZE/ULTRASOUND ATTENUATION

Shipp, K.M., Purser, J.L., Gold, D.T., Pieper, C.F., Sloane, R., Schenkman, M. and Lyles, K.W. (2000), Time loaded standing: A measure of combined trunk and arm endurance suitable for people with vertebral osteoporosis. Osteoporosis

International, 11 (11), 914-922.Abstract: Chronic back tiredness or fatigue is a common complaint of people who have

a history of osteoporotic vertebral fracture. Trunk muscle endurance has not been studied in people with vertebral osteoporosis, partly due to the lack of assessment tools. We developed a measure of combined trunk and arm endurance suitable for people with vertebral osteoporosis, timed loaded standing (TLS). TLS measures the time a person can stand while holding a two-pound dumbbell in each hand with the arms at 90 degrees of shoulder flexion and the elbows extended. Intraclass correlation coefficients (ICCs) for same day inter- trial and six to ten day test-retest reliability were 0.89 (lower bound 95% confidence interval [LB 95% CI] 0.79) and 0.84 (LB 95% CI 0.68), respectively, in a sample of 21 older women with no known osteoporosis. In 127 women with vertebral fractures, the ICC for same day inter-trial reliability was 0.81 (LB 95% CI 0.75). In a sub-sample of 30 of these women with vertebral fractures, the six to ten day test-retest reliability was 0.85 (LB 95% CI 0.75). Moderately: strong and statistically significant (p less than or equal to 0.05) correlations were found between TLS and sixteen of eighteen measures of physical impairment and function. Functional reach distance, gait velocity, MOS-36 Physical Function Subscale, shoulder flexion strength, and six minute walk distance were most strongly associated with TLS time. Women with vertebral fractures who endorsed having back tiredness when standing and working with the arms in front of the body, sitting to rest because of back tiredness or pain, and planning rest periods because of back tiredness or pain had significantly lower TLS times. TLS is a simple, safe physical performance measure of combined trunk and arm endurance that demonstrates acceptable reliability (inter-trial and test- retest) and concurrent validity

Keywords: ASSOCIATION/back injuries/BACK MUSCLE ENDURANCE/EXERCISES/fracture/FRACTURES/FUNCTIONAL STATUS/muscle weakness/osteoporosis/PAIN/physical endurance/QUALITY-OF-LIFE/RELIABILITY/spinal fractures/spine/STRENGTH/WOMEN

Fatayerji, D., Cooper, A.M. and Eastell, R. (1999), Total body and regional bone mineral density in men: Effect of age. Osteoporosis International, 10 (1), 59-65.

Abstract: Bone density is related to the risk of fracture, with a decrease in bone density resulting in an increased risk of fracture. The aims of this study were to characterize the relationship between bone mineral density (BMD) and age at different skeletal sites in men, and to determine whether the BMD pattern with age reflects the pattern of fracture in men. We studied 178 healthy Caucasian men, ages 20-79 years (approximately 30 per decade) from a general practitioner register. Spinal radiographs were obtained from men over 50 years of age and graded by a radiologist for spinal osteoarthritis by the method of Kellgren. BMD was measured by dual-energy X-ray absorptiometry at the anteroposterior (AP) lumbar spine, femoral neck, Ward's triangle, trochanter, ultradistal forearm and total body (providing estimates for the pelvis, head, arms, legs, trunk, ribs and spine). Severe osteoarthritis (grades 3 and 4) was associated with increased spine BMD, and therefore individuals with severe osteoarthritis were excluded from analysis of the spine. There was a decrease in height of Vertebrae L2-4 in men between 20 and 79 years of age (4%), resulting in a decrease in projected area. The change in BMD in standard deviation units (T-score) between 20 and 79 years was calculated: there were significant decreases at the femoral neck (-1.6), Ward's triangle (-2.4), total body (-0.6), and its subregions the pelvis (-1.4), trunk (-0.8), ribs (-0.7) and legs (-0.7). There was no change in BMD with age at the AP lumbar spine, ultradistal forearm, or the total body subregion of the head. Similar results were found after

adjusting for height and weight. Thus, there was only a small decrease in total body BMD across Life, but a substantial decrease in BMD of the pelvis and proximal femur, sites rich in trabecular bone. These are the same sites associated with substantial increases in fracture incidence in men with aging

Keywords: ABSORPTIOMETRY/aging/ASSOCIATION/bone mineral density/dual-energy X-ray absorptiometry/FEMUR/fracture/FRACTURES/head/MASS/men/OSTEOPOROSIS/SPINE/WHITE/WOMEN

Nuti, R. and Martini, G. (1993), Effects of Age and Menopause on Bone-Density of Entire Skeleton in Healthy and Osteoporotic Women. Osteoporosis International, 3 (2), 59-65.

Abstract: We studied 885 women to evaluate the effects of age and menopause on bone mineral density (BMD) in both healthy and postmenopausal osteoporotic subjects. The study cohort consisted of 161 healthy premenopausal women (age range 25-54 years), 357 healthy postmenopausal women (35-85 years) and 367 osteoporotic women (41-87 years). Total body and regional (spine, trunk, pelvis, arms, legs) BMD were measured with a dual-energy X-ray (DXA) device (Lunar DPX). Premenopausal BMD values remained essentially unchanged until the first half of the fourth decade, when they decreased. BMD values in both healthy postmenopausal and osteoporotic women were significantly lower than premenopausal values, and continued to decrease statistically after the onset of menopause. The highest Z-score (0.96 +/- 0.92) was found for total body BMD. Higher T-score values were found in osteoporotic than in normal postmenopausal women. In both healthy and osteoporotic postmenopausal women the best fits for BMD changes in total body, spine, trunk, arms and legs were obtained with the natural logarithm of years since menopause; only the pelvis BMD decreased linearly. Multiple regression analysis indicated that postmenopausal BMD changes in both normal and osteoporotic women were linked chiefly to body weight and years since the onset of menopause

Keywords: AGE/BONE DENSITY/bone mineral density/DUAL-PHOTON-ABSORPTIOMETRY/FEMUR/HIP FRACTURE/LUMBAR SPINE/MASS/MENOPAUSE/MINERAL CONTENT/NECK/OSTEOPOROSIS/POSTMENOPAUSAL OSTEOPOROSIS/postmenopausal women/PREMENOPAUSE/RISK/spine/TOTAL BODY ABSORPTIOMETRY

Bianchi, M.L., Mazzanti, A., Galbiati, E., Saraifoger, S., Dubini, A., Cornelio, F. and Morandi, L. (2003), Bone mineral density and bone metabolism in Duchenne muscular dystrophy. Osteoporosis International, 14 (9), 761-767.

Abstract: Very few studies on bone mineral density and bone metabolism in Duchenne muscular dystrophy (DMD) have been reported. DMD is a severe, progressive muscular disease resulting in death at a young age. No specific therapies are available, but corticosteroids induce improvement and slower progression of the disease. However, long-term steroid therapy is a serious risk factor for osteoporosis. This study was aimed at evaluating bone mineral density and calciotropic hormones in a group of children affected by DMD, with or without steroid therapy. Bone mineral density was measured by DXA scan on lumbar spine and total body. Evaluation of calcium, phosphorus, bone turnover markers and calciotropic hormones was performed. Thirty-two children affected by DMD were studied: twenty-two on long-term prednisone therapy, ten not taking corticosteroids. Bone mineral density was lower than normal for age in all patients, and even lower in the group of steroid-treated children. Trunk and lower limb bone mineral densities were

more reduced than upper limb mineral density, especially in the steroid-treated subjects. A marked reduction in spine bone mineral density, hypocalciuria, low 25-hydroxyvitamin D levels, and increased bone turnover markers were observed, and even these especially in the steroid-treated group. In conclusion, decreased bone mineral density and derangement of calcium metabolism were present in DMD patients, and were worsening during corticosteroid therapy. It is thus recommended that bone and mineral metabolism be carefully evaluated in patients with DMD, so that appropriate measures could be taken, especially now that chronic corticosteroid therapy is frequently given

Keywords: bone mineral density/bone turnover/bone turnover markers/CALCIUM INTAKE/CHILDREN/CORTICOSTEROID-THERAPY/corticosteroids/DEFLAZACORT/DOUBLE-BLIND/Duchenne muscular dystrophy/FRACTURE RISK/INDUCED OSTEOPOROSIS/MASS/OSTEOPOROSIS/PHYSICAL-ACTIVITY/PREDNISONE/PTH/spine/vitamin D metabolites

Chiaviello, C.T., Christoph, R.A. and Bond, G.R. (1994), Infant Walker-Related Injuries - A Prospective-Study of Severity and Incidence. Pediatrics, 93 (6), 974-976.

Abstract: Objective. To determine the incidence and significance of walker-related injuries in infants. Methods. During a 3-year, 8-month period, all infants who were brought to the University of Virginia Pediatric Emergency Department with a walker- related injury were prospectively studied. During the emergency department visit, demographic and epidemiologic information were recorded. The annual incidence of walker-related injuries occurring in infants <1 year of age that resulted in a hospital emergency department visit was calculated from the home zip codes of the injured patients and from the population of infants <1 year of age living in Charlottesville and in Albemarle County. Results. Sixty-five patients were enrolled in the study. The age distribution ranged from 3 months to 17 months, with 95% younger <1 year old. Mechanisms associated with walker-related injuries included stairway falls in 46 infants (71%), tip-overs in 14 infants (21%), falls from a porch in 2 infants (3%), and burns in 3 infants (5%). These injuries predominantly involved the head and neck region (97%), with few injuries to the extremities (6%) and trunk (3%). Although the majority of injuries were minor, significant injuries occurred in 19 infants (29%). These injuries included skull fracture, concussion, intracranial hemorrhage, full- thickness burns, c-spine fracture, and death. After excluding the burned patients, all the serious injuries resulted from falls down stairs. The annual incidence of injuries occurring in infants <1 year of age, related to the use of walkers, and resulting in an emergency department visit was 8.9/1000, and for serious injuries was 1.7/1000. Conclusions. The incidence and significance of infant walker-related injuries in infants are unacceptably high

Keywords: BABY WALKERS/CONTINUING PROBLEM/falls/fracture/head/HEAD INJURIES/INFANT WALKERS/INJURY CONTROL

Gaulrapp, H., Eckstein, S. and Auracher, M. (2000), Bilateral fracture of the calcaneus in a paraglider: Rehabilitation through climbing therapy. Physikalische Medizin Rehabilitationsmedizin Kurortmedizin, 10 (2), 65-70.

Abstract: This report deals with the postoperative rehabilitation of a paraglider having sustained fractures of both calcaneus. Primarily he was treated by ice, lymphatic drainage, hydrotherapy and continuous passive motion. Physiotherapy concentrated on rear foot mobilisation, muscle chain stabilisation and coordination. Isokinetic training was performed to the legs. After full weight bearing was allowed elements of sport climbing were applied as therapeutic means aiming at activation of

functional muscle chains and movement patterns. Moreover motivation and cooperation were influenced positively. Further implications were the enforcement of ventral as well as dorsal trunk muscle groups enabling an active oblique stabilisation under modification of training parameters. Muscle rebalancing and active rear foot mobilisation were additional goals. Finally the motion of upper and lower ankle joints could markedly be improved, activities of daily living could be carried out without pain to a great extent. These rehabilitation purposes could be achieved although, due to the severeness of the injuries, specific scoring systems only showed fair results

Keywords: calcaneus/calcaneus fractures/fracture/INJURIES/paragliding accidents/rehabilitation/therapeutical climbing

Black, J.A. and Waxman, S.G. (1988), Freeze-Fracture Studies on Unmyelinated Axolemma of Rat Cervical Sympathetic Trunk - Correlation with Saxitoxin Binding. Proceedings of the Royal Society of London Series B-Biological Sciences, 233 (1270), 45-&

de Salazar, A.O., Gonzalez, J.A., Zuazo, J., Gomez, J.J. and Vallejo, J.A. (1998), Occult rupture of aortic arch after a motor vehicle accident. Revista Espanola de Cardiologia, 51 (1), 72-74.

Abstract: A patient presented to our emergency department from another hospital diagnosed with pelvic fracture after a motor vehicle accident. In the ensuing 12 hours, chest pain developed, and a widened mediastinum on chest radiography was found. Posterior aortography showed aortic arch rupture. During surgery, we found a complete circumferential disruption of the arch between the brachiocephalic trunk and the carotid artery. Even though thoracic aortic injuries rarely ocurr in motor vehicle accidents, thoracic arch ruptures are extremely uncommon. This injury should be suspected after high-speed motor vehicle accidents, when accompained with chest pain or widened mediastinum

Keywords: aortic arch/automobile accident/fracture/pelvic fracture/traumatic ruptureMartin, S.S., Perez, R., Sepulveda, M., Rodriguez, M., Duran, B., Trujillo, C. and

Arraztoa, J. (1993), Soft-Tissue Sarcomas - Results of Treatment with the Combination of Chemotherapy, Radiotherapy and Conservative Surgery. Revista Medica de Chile, 121 (2), 144-147.

Abstract: The preliminary results of a prospective and cooperative protocol for the treatment of soft tissue sarcomas of trunk and extremities, stages IB-IIIB are presented. Thirty one patients (17 males, 22 with a tumor larger than 5 cm) aged 16 to 68 years, were treated with one dose of epirrubicine 70 mg/m2 ev and radiotherapy (3000 rads in 10 fractions) Two or three weeks later an ample surgical complications occurred in 6 patients and were all of infectious origin, The median follow up period has been of 26 months. During this period 5 patients presented late surgical complications (edema in 4 and a pathological fracture in 1), 2 patients had a local tumor recurrence and distant metastases appeared in 7. Actuarial survival was 60% at 48 months. Ninety six percent of surviving patients conserved their extremity. It is concluded that with this treatment modality local recurrence is acceptable, morbidity is low and that the majority of patients do not require amputations or crippling resection

Keywords: complications/DRUG THERAPY/EXTREMITIES/extremity/fracture/LIMB-SPARING SURGERY/OPERATIVE/RADIATION-THERAPY/RADIOTHERAPY/SARCOMA/SOFT TISSUE NEOPLASM/SURGERY

Cadilhac, C., Fenoll, B., Peretti, A., Padovani, J.P., Pouliquen, J.C. and Rigault, P.

(2000), Congenital pseudarthrosis of the clavicle: 25 childhood cases. Revue de Chirurgie Orthopedique et Reparatrice de l Appareil Moteur, 86 (6), 575-580.

Abstract: Purpose of the study Congenital pseudarthrosis of the clavicle is rare, only 200 cases having been reported. Based on 25 personal cases and an overview of the literature, we try to explain the etiology of this condition and the different kinds of treatment. Material and methods A retrospective analysis was performed on twenty-five children (16 females, 9 males, mean age at the end of the follow up - 11.5 yrs) from three different centers. We assessed the outcome of surgical and nonsurgical procedures, based on pain, functional ability, cosmetic results, and x-ray examination. Results A family background was noted in three children. The lesion always involved the right side. Twenty patients presented a bump over the middle third of the clavicle, thirteen a foreshortened shoulder girdle, three complained of discomfort. In two cases, palpation of the clavicular area was painful. No neurovascular compressive syndrome was reported. None of the patients complained of a decrease in the range of motion or in the strength of the upper limb. X-rays showed a middle third defect. In five cases we found abnormal first ribs. Seventeen patients underwent surgery, at a mean age of 6 years and 4 months. The procedure always included excision of the pseudarthrosis at both ends and internal fixation with a wire or a plate. in only eight cases a bone graft was used. Healing was achieved in fourteen patients. Three patients needed a second surgical procedure. In these 3 cases we had not used bone grafting. All patients had a normal range of shoulder motion, except a twelve year old girl who complained of discomfort of the right upper limb. The cosmetic result was good in eleven cases, one surgical wound was noted as hypertrophic, and one developed a keloid. An asymmetry of the trunk was still noted in seven cases. The X-rays showed symmetric clavicles in ten cases. Eight patients were treated conservatively All of them had a normal range of motion of the shoulder, six had a good cosmetic result and two cases a poor one. Discussion According to Alldred, the anomaly results from the failed coalescence of the two primary ossification centers of the clavicle. The overview of the literature and our findings (in one case) confirm that the cartilage which covers both ends of the bone is made of growth cartilage. However, the true mechanism of the nonunion is still unknown. The three familial cases of our work suggest a possible genetic transmission of the disease. The diagnosis is based on the following criteria: right side lesion, found in infancy, without previous fracture, increasing size with growth, without major functional consequences, without neurofibromatosis or cleidocranial dysostosis symptom. X-rays or histologic examination will confirm the diagnosis showing the usual findings described above. Complications of the pseudarthrosis of the clavicle are rare and late. Conservative management appears to give good results as seen with our eight patients. However surgical treatment ensures symmetrical shoulder girdles and good function with few complications. Therefore, we recommend performing an excision of the cartilaginous caps, followed by an iliac bone graft and an internal fixation with wire. Surgical management will be preferred in symptomatic patients, in the case of major or increasing deformity, or on parental request

Keywords: clavicle/complications/congenital pseudarthrosis/fracture/strengthTonetti, J., Cloppet, O., Clerc, M., Pittet, L., Troccaz, J., Merloz, P. and Chirossel, J.P.

(2000), Optimal placement of iliosacral screws: 3D computed tomography simulation. Revue de Chirurgie Orthopedique et Reparatrice de l Appareil Moteur, 86 (4), 360-369.

Abstract: Purpose of the study Percutaneous iliosacral screws are used advantageously

to fix unstable pelvic girdle avoiding the morbidity of open access for conventional screw fixation. The insertion technique must be precise due to the risk of injury to the lumbosacral nerve trunk, the cauda equina roots, and the first sacral nerve. We undertook a study of the implantation site of iliosacral screws looking for a means of standardizing the drilling procedure on the basis of 3D computed tomography (CT) data. Material and methods A CT series with 3D reconstruction was performed on 11 pelvis bones. We retained pelvis parameters and characterized the axis and narrow zone of the sacral wing. The insertion routes of 6.5 mm cancelous bone screws were simulated: two iliosacral routes fixing S1, and two iliosacroiliac routes fixing S1 and S2. The values of the pelvic parameters and the positions of the screws were compared with the Spearman correlation test and graphic regression. Results The pelvic incidence was a mean 47 degrees. The length of the sacral wing was a mean 73 mm. The narrow zone of the wing was 47 mm from the lateral iliac fossa. In the narrow zone, the wing section showed an oval shape: 22 mm largest diameter, 11 mm smallest diameter. The wing was oriented 84 degrees in the paracoronal plane perpendicular to the plane of the sacral plate, 67 degrees in the para-axial plane parallel to the sacral plate, and 37 degrees in the sagittal plane of the subject. The length of the upper S1 screw was a mean 80 mm. This upper screw was inclined 89 degrees in the para-coronal plant, 61 degrees in the para-axial plane and 28 degrees in the sagittal plane. The length of the lower S1 screw as a mean 80 mm. This lower screw was inclined 74 degrees in the para- coronal plane, 91 degrees in the para-axial plane and 110 degrees in the sagittal plane. The fixation screws could be inserted in 12 out of 22 cases. Correlations were found with height of the subject, length of the wing and the screw, and screw inclination. The inclination of the upper S1 screw in the para-coronal plane was correlated with the larger diameter of the sacral wing. Discussion The pelvis parameters measured were comparable with data in the literature. The very small dimensions of the narrow zone dictate a very precise drilling for the narrow zone. This narrow zone determines the inclination of the screw insertion. In the sagittal plane the standard deviation was very large making it impossible to interpret the data. The route of the upper screw runs obliquely forward in the plane parallel to the sacral plate. The lower screw runs upwardly in the plane perpendicular to the sacral plate. It does not appear possible to insert fixation screws in a routine procedure. Preoperative assessment would be necessary before percutaneous insertion. Conclusion The 3D CT reconstructions of the sacral wing can be used to determine the precise optimal position of the two iliosacral screws. The principle orientations can be deducted from the plane of the sacral plate. Approximate indications can help reduce operative time and exposure to irradiation (patient and surgeon). Percutaneous iliosacroiliac screw fixation cannot be proposed for all patients

Keywords: computed tomography/CT scan simulation/FIXATION/iliosacral fixation/LAG SCREWS/pelvic fracture/percutaneous screwing

Valdes, M., Molins, J. and Acebes, O. (2000), Avulsion fracture of the iliac crest in a football player. Scandinavian Journal of Medicine & Science in Sports, 10 (3), 178-180.

Abstract: We describe an unusual injury of the iliac crest in an adolescent football player, The injury occurred as a result of a sudden twist of the trunk while kicking, Plain radiographs showed avulsion fracture of the anterior part of the iliac crest apophysis, Five months later the injury was partially ossificated but the patient felt minor pain and,vas not confident of returning to playing football

Keywords: APOPHYSIS/avulsion fracture/European football/fracture/iliac

crest/PELVISWieslander, J.B. (1991), Tissue Expansion in Functional and Aesthetic Reconstruction

of the Trunk and Extremities - Case-Report. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery , 25 (3), 285-289.

Abstract: To illustrate how the technique of tissue expansion may be adapted for different types of reconstruction, the following cases are described: a 10-year-old girl with a circumferential naevus from shoulder (at the back) and umbilicus (at the front) to the knees; a 3-year-old boy with a severe injury to the left arm; a 36-year-old man with an amputation injury of the left hip; and an 18-year-old girl with scars from a complicated fracture of the left lower leg. In all cases function and/or appearance were considerably improved

Keywords: fractureMaruo, S. and Matumoto, M. (1996), Spinal fractures resulting from the 1995 Great

Hanshin Earthquake of the Kobe-Osaka area of Japan. Spinal Cord, 34 (7), 382-386.Abstract: One of the worst earthquakes hit the Hanshin area between Kobe and Osaka,

in the early morning at 5:46 AM on January 17th 1995. The destructive force with MG 7.2 severely damaged buildings, houses, roads and railways, leaving 6500 dead, and 34 900 injured. Hyogo College of Medicine located in this area was also severely damaged, thus there was a major challenge to provide post-quake medical support. A post-quake investigation in this area was done by 50 affiliated hospitals. More than 15 000 victim-patients were treated at these hospitals during the first 3 days after the quake. Major injuries were spinal fractures, and other trunk fractures, including rib or pelvis fractures, but fractures of long bones were uncommon, because the quake hit this area in the early morning when most people were asleep. In this study, the mechanisms of these major injuries were analysed by direct interview soon after the quake, with 230 victim-patients who had 140 spinal fractures, and 100 with rib or pelvis fractures. Most of those who had a spinal fracture had either sat up or stood up on their 'Futon' mattresses without bed frames and were struck on their backs by falling furniture or ceilings. On the other hand, patients who had fractures of the ribs or the pelvis had been lying in the supine or lateral position and were hit on their chest or pelvis. This characteristic lifestyle pattern of the Japanese people to lie down on the floor directly beside furniture, resulted in these injuries. From these results, we will emphasize the following precautions:- If an earthquake occurs during sleeping hours at home, do not stand up or sit up. The best position is to crouch on the 'Futon' mattress

Keywords: disaster/earthquake/fracture/Kobe Japan/pelvis fracture/rib fracture/spinal fracture/spinal fractures

Perry, S.D., McLellan, B., McIlroy, W.E., Maki, B.E., Schwartz, M. and Fernie, G.R. (1999), The efficacy of head immobilization techniques during simulated vehicle motion. Spine, 24 (17), 1839-1844.

Abstract: Study Design. Laboratory experiment. Objective. To compare the efficacy of different head immobilization techniques during motion simulating ambulance transport. Background. A significant number of neurologic injuries associated with cervical spine fractures arise or are aggravated during emergency extrication or patient transport. Previous studies have not addressed the effect of head immobilization on the passive motion that could occur across the neck during transport. Methods. Three different head-immobilization methods were compared in six healthy young adults by using a computer- controlled moving platform to simulate the swaying and jarring movements that can occur during ambulance transport. In all tests, the trunk was secured by means of a commonly used "criss-

cross" strapping technique. Efficacy of head immobilization was evaluated using measures of head motion and neck rotation. Results. None of the three immobilization techniques was successful in eliminating head motion or neck relation. Movement of the trunk contributed substantially to the lateral bending that occurred across the neck. A new product involving the placement of wedges underneath the head provided some small, but statistically significant improvements in fixation of the head to the fracture board; however, there was no improvement in terms of the relative motion occurring across the neck. Conclusions. Somewhat improved fixation of the head to the fracture board can be achieved by placing wedges under the head; however, the benefits of any fixation method, in terms of cervical spine immobilization, are likely to be limited unless the motion of the trunk is also controlled effectively. Future research and development should address techniques to better control head and trunk motion

Keywords: ambulance/CERVICAL-SPINE IMMOBILIZATION/fracture/head/immobilization/spine/transport

Nagai, H., Shimizu, K., Shikata, J., Iida, H., Matsushita, M., Ido, K. and Nakamura, T. (1997), Chylous leakage after circumferential thoracolumbar fusion for correction of kyphosis resulting from fracture - Report of three cases. Spine, 22 (23), 2766-2769.

Abstract: Study Design. A description of the clinical picture of chylous leakage after spinal surgery. Objectives. To present the clinical course of three cases of chylous leakage after spinal surgery and to discuss the pathogenesis of the disease. Summary of Background Data. Chylous leakage is a rare complication after spinal surgery. It has been attributed to direct injury of a lymphatic trunk or one of its major tributaries by surgical maneuver. Methods. Three cases of chylous leakage after circumferential thoracolumbar fusion for correction of kyphosis resulting from fracture were reported. Results. All of the three cases were managed successfully; two cases of chyloretroperitoneum detected within 4 days after surgery were healed conservatively, but one case of chylothorax, of which the onset was noticed 5 weeks after spinal surgery, required surgical ligation of the thoracic duct and pleurodesis. Conclusion. Early detection of this disease is important for a good prognosis. Retroperitoneal drainage is necessary for the detection and management of chyloretroperitoneum. The pathogenesis and management of the chylous leakage are discussed in this report

Keywords: chyle/chylothorax/chylous leakage/fracture/fusion/kyphosis/lymphatic injury/spine

Webster, B.S. and Snook, S.H. (1994), The Cost of 1989 Workers Compensation Low-Back-Pain Claims. Spine, 19 (10), 1111-1116.

Abstract: Study Design. Cost data were gathered from computerized records of the Liberty Mutual Insurance Company for low back pain workers' compensation claims (N = 119,107) and for all claims (N = 731,087) initiated from 45 jurisdictions (states) during 1989. Objective. This study provided more current, accurate, and additional information to estimate the costs and incidence associated with compensable low back pain compared with all compensation claims Methods. The first group of data included all compensable low back claims selected by specific codes: body part codes consisted of low back area, sacrum and coccyx, disc, and multiple trunk; injury codes consisted of strain, sprain, inflammation, rupture hernia, fracture, and contusion. The second sample included all compensable claims, including both occupational injuries and illnesses. Results. Low back pain cases represented 16% of all claims but 33% of all claims costs; 55.4% of the low back pain cases received medical payments only (i.e., did not receive indemnity payments for lost time). The

mean cost per case for low back pain was $8321; median cost per case was $396. Medical costs represented 32.4% of the total costs; indemnity costs (i.e payment for lost time) represented 65.8%. Conclusions. Since indemnity costs represent the greatest percentage of workers' compensation expenditure, the primary goal of low back pain management should be the prevention or reduction of prolonged disability

Keywords: COMPENSATION/COST/fracture/INDEMNITY COST/LOW BACK PAIN/MEDICAL COST/SPINE

Okada, K., Miyakoshi, N., Takahashi, S., Ishigaki, S., Nishida, J. and Itoi, E. (2003), Congenital pseudoarthrosis of the tibia treated with low- intensity pulsed ultrasound stimulation (LIPUS). Ultrasound in Medicine and Biology, 29 (7), 1061-1064.

Abstract: A 16-year-old Japanese boy was admitted to our institution in September 2000 because no apparent callus had appeared around a fracture after 6 weeks of cast fixation. Physical examination revealed a tenderness of the right lower leg, and multiple small subcutaneous tumors and cafe-au-lait spots in extremities and trunk. Radiographs showed the fracture of the right lower tibia with bony sclerosis and a localized fusiform osteolytic lesion at the fracture site. The affected tibia bowed anteriorly and the medullary space in the lower tibia was narrow. A diagnosis of Boyd type IV congenital pseudoarthrosis of the tibia was made. Treatment with low-intensity pulsed ultrasound (US) stimulation (LIPUS) was administered for 20 min/day, and a nonweight-bearing gait was continued with a cast or brace fixation. At 6 months after the treatment, a small amount of bridging callus was seen. We continued the treatment for 1 year until the solid fusion was observed on radiographs and the patient started full-weight-bearing. (E-mail: cshokada@med.akita-u.ac.jp) (C) 2003 World Federation for Ultrasound in Medicine Biology

Keywords: ACCELERATION/CHILDREN/congenital pseudoarthrosis of the tibia/fracture/fusion/GRAFT/low intensity/PSEUDOARTHROSIS/PULSING ELECTROMAGNETIC-FIELDS/ultrasound

Biewener, A., Holch, M., Muller, U., Veitinger, A., Erfurt, E. and Zwipp, H. (2000), Impact of preclinical effort and logistics on letality after severe trauma. Unfallchirurg, 103 (2), 137-143.

Abstract: 122 cases of patients who died in sequel of an accident (recruitment period 1993/94, mean ISS 40+/-19) in reach of air rescue base Dresden, Germany, were examined. Data were assessed from autopsy protocol and the protocol of the physician who treated on scene. We analyzed the time course of the emergency, the sheduled emergency medical service and the quality of prehospital diagnosis and therapy by the emergency team. The mean response time was 8.1+/-5,9 min, the mean distance between EMS bases und incident location 5,9+/-5,7 km. In 94,4% of all cases a mobile intensive care unit- with an emergency physician as crew member- was on scene, in 5,6% a paramedic car. Air rescue by helicopter, including an emergency physician,was performed only in 8,7% of all cases although a helicopter was available in 54% of all accidents. Mechanisms of injury were traffic: accident (71,4%), fall (14,3), 5,9% accident on building site, shot and stab injuries (5,9%) and burns (1,7%).82 patients reached the emergency room alive (67,2%, mean ISS 37+/-18). Only 26% of all patients were transported directly to a level I trauma center. Mean survival time of all 122 patients was 146+/-30,4 h. Severe head injury described by autopsy protocol was diagnosed on scene in 82%. Preclinical treatment was: intubation and ventilation (63%), O-2 insufflation (17,4%), no specific treatment (19,6%). Severe thoracic trauma was diagnosed in 54%. Preclinical treatment was: intubation and ventilation (64,8%), O-2 application (18,8%), no specific treatment (16,2%). Severe thoracic trauma with haemato-pneumothorax

(n=26) was recognized by the emergency physician in 65,6%, specific therapy (application of chest drain) was performed in 7,1%. Preclinical diagnosis rates concerning abdominal trauma were 29% and 27,8% in case of unstable pelvis fracture. Hemorrfiagic shock related to these injuries was found in 44,2%, mean resuscitation volume applicated in these cases was 950+/-610 ml. Typical faults in diagnosis and treatment were underestimating of severe trunk trauma and non-consistent use of invasive treatment procedures. Primary transport of the severely injured patient to a level 1 trauma center by helicopter was performed only rarely

Keywords: air rescue/CARE/fracture/head/INJURY/MULTIPLE TRAUMA/ORGAN FAILURE/PATIENT/pelvis fracture/polytrauma/quality of preclinical medical care/transport/trauma

Kach, K. and Trentz, O. (1994), Distraction Spondylodesis of the Sacrum in Vertical Shear Lesions of the Pelvis. Unfallchirurg, 97 (1), 28-38.

Abstract: The sacroiliac region is the link through which the weight of the trunk is transmitted to the legs and a region frequently indicated by patients as the site of back pain. Sacral fractures often remain undiagnosed and untreated and frequently result in neurologic symptoms and deficits. Since a systematic approach is used to analyse the pelvic ring fractures with CT scans, the surgical management of sacral fractures had become a focus of interest. Stabilization is important for survival of the patient and may improve the long-term functional results of treatment of such injuries. Specific treatments aimed at neurologic problems are available and may allow the patient functional recovery. Previous attempts to achieve internal fixation for sacral stabilization have used lag screws, sacral bars and plates in a compression mode. We present a new type of stabilization for vertically unstable sacral fractures in zones II and III (Denis). The aim of our suggested stabilization is a stable fixation without compression on the fracture side to protect the neural structures. We perform a transfixation from L5 to the pelvic rim with an internal fixator. Our instrumentation allows decompression (fracture reposition, sacral laminectomy, sacral foraminotomy) of the neural structures and stable fixation without compression. Five multiply traumatized patients with sacral fractures as a component of vertical shear injury of the pelvis had the sacroiliac region stabilized with the internal fixator. The preliminary results are presented

Keywords: fractureHersche, O., Isler, B. and Aebi, M. (1993), Prognosis and Follow-Up of Neurological

Lesions in Pelvic Ring Injuries. Unfallchirurg, 96 (6), 311-318.Abstract: The extent of neurological lesions following an injury of the pelvic ring is

often not initially recognized, as interest is then focused on the treatment of the pelvic ring fracture. Once the fracture has healed, the patient suffers from the sequelae of the neurological injury. Our series of 323 pelvic ring injuries includes 161 sacral fractures and 12 complete disruptions of the sacroiliac joint. Twenty-three patients sustained an injury of the lumbosacral plexus, and 20 patients were examined retrospectively. The different parts of the lumbosacral plexus showed variable recovery potential. An important or complete recovery was noted in 8 of 9 patients suffering from a motor deficit of the lumbar plexus, the obturator nerve, the superior gluteal nerve or the inferior gluteal nerve. Four out of 8 patients with a motor deficit of the sacral plexus had an important or complete improvement. In contrast to these results was the poor recovery of lesions of the lumbosacral trunk. Eight out of 11 patients showed no or only minor recovery, although the pelvic ring was stabilized by operative means in 9 patients. In 2 patients the lumbosacral trunk was directly decompressed by a dorsal approach. In both cases the recovery was

complete. In 6 patients the sphincter function was damaged. Recovery was dependent on the localization of the sacral fracture. If the fracture traversed the sacral canal, no neurological improvement was noted

Keywords: fractureMeguro, S. and Miyawaki, A. (1994), A Study of the Relationship Between Mechanical

Characteristics and the Coastal Vegetation Among Several Broad-Leaf Trees in Miura Peninsula in Japan. Vegetatio, 112 (2), 101-111.

Abstract: The mechanical properties of broad-leaf tree species in a maritime-wind exposed habitat in central Japan were examined. The broad-leaf trees studied were Celtis sinensis var. japonica, Ilex integra, Eurya japonica, Pittosporum tobira, Euonymus japonicus and Cinnamomum japonicum. The results obtained can be summarized briefly as follows: 1. At places with weaker wind, the number of species increased and the height of the canopy increased. 2. The fracture strength sigma(m) showed no dependence on tree part or branch thickness, but was constant. 3. The order of strength was Celtis sinensis var. japonica>Ilex integra>Eurya japonica>Pittosporum tobira>Euonymus japonicus>Cinnamomum japonicum, and these six species could best adapt to the wind pressure in the Study area. 4. Within species, fracture strength varied directly with wind strength. 5. The strain epsilon(m) decreased as the trunk became thicker. 6. Within species, strain energy U-m varied directly with wind strength

Keywords: BENDING STRENGTH/fracture/STRAIN/STRAIN ENERGY/strength/WIND/WIND SPEED