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Twenty-two cases of paraplegia complicating injury of the cervical column have been reviewed. The vertebral injury may be due to flexion or hyperextension violence.
1) A case is reported of paraplegia with normal radiographic appearances in which cervical cord damage was shown at autopsy to have been due to hyperextension injury.
2) The mechanism of such injuries is discussed, together with the differential diagnosis from acute prolapse of an intervertebral disc.
3) The grave dangers of using the fully extended position of the cervical spine in the management of these cases is noted.
1. The causes of pressure on the neuro-vascular bundle of the upper limb are many and varied. No one cause such as clavicular pressure can explain all cases.
2. Costo-clavicular pressure is not possible when there is a normal first rib and a normal thoracic outlet, but it is certainly a factor when the costo-clavicular interval is narrowed by the presence of a large cervical rib or an abnormal first thoracic rib. Clavicular pressure can act only during retraction and abduction, not in depression of the shoulder.
3. Temporary alterations in the radial pulse on movements of the shoulder in normal individuals are due to causes distal to the clavicle and have no relation to costo-clavicular pressure.
4. While irritation of sympathetic nerve fibres may explain the majority of cases of thrombosis, there are others in which clotting occurs in an aneurismal dilatation produced by pressure between the clavicle and the abnormal costal element. It is likely that the thrombosis occurs in an aneurism which has been present for some length of time. The cause of the aneurismal dilatation may be vaso-motor paralysis of a segment of the artery, ending distally at a point where a fresh intact leash of nerves is relayed to the vessel.
5. The importance of the scalenus anterior syndrome has been over-emphasised. If operative treatment is limited in all cases to anterior scalenotomy the results will be disappointing.
6. If operation is advised it should be performed without rigid and preconceived ideas, through an adequate incision, and with exploration wide enough to allow thorough investigation of the cause of pressure.
1. A hope expressed in 1940, that further cases of spontaneous fracture of the lowest third of the apparently normal fibula would be described, has been fulfilled. The literature is here reviewed. Five further personal cases are added.
2. The clinical and radiographic features, diagnosis, treatment and results are considered in the light of the information so far available. Special note is made of misleading freedom of ankle and tarsal movements and the occasional absence of tenderness.
3. It is established that fractures of the lowest third occur particularly in two groups of subjects: 1) young male runners and skaters; 2) active and hard-pressed women of middle age and over.
4. In male runners and skaters the fracture usually occurs through slender, mainly cortical bone, two inches or more above the tip of the lateral malleolus; in middle-aged women the fracture is usually distal to the interosseous ligament through thicker, mainly cancellous bone, one and a half inches from the tip of the lateral malleolus.
5. The most convenient name for both groups of fractures in the lowest third is low
6. A review of the literature of fatigue fracture of the uppermost third of the fibula shows that it is very often precipitated by jumping. The most convenient name for it is
7. Like all clinical classifications this distinction between low and high fractures has exceptions (a low fracture of one fibula in a runner was followed later by a high fracture of the other; most military fractures were high, but a few may have occurred at other levels).
8. Fatigue fracture of the fibula, high or low, may be bilateral.
9. A fracture similarly situated to the high fatigue fracture of the fibula has been frequent in parachute schools. It is a speculative possibility that military and parachutist fractures of the upper third of the fibula indicate the link between true fatigue fractures (as exemplified by march fractures with minimal trauma often repeated) and purely traumatic fractures (with adequate trauma applied once only).
Ischaemia threatening an injured limb gives rise to the syndrome of pain, pallor, paralysis, and pulselessness. It is due to arterial injury by laceration, compression, intra-mural rupture or contusion, or to arterial spasm with or without demonstrable local arterial damage. The differentiation of spasm without local injury from organic obstruction is not possible by clinical methods.
The suggested plan of treatment and of management is:
1. General systemic investigation (blood-pressure, blood-count, coagulation time, etc.).
2. Removal of all external pressure.
3. Resuscitation.
4. Direct attempt to relieve the obstruction by operation.
5. Post-operative care.
The operative procedure recommended is:
1. Manipulative reduction of the fracture if possible.
2. Proximal control of the artery.
3. Arteriography.
4. Exposure of the occluded artery (unless contra-indicated by time factors and by the anatomy of the collateral circulation), liberation and mobilisation of the vessel, repair by suture where such is necessary and possible, and arterectomy only forirreparable local damage.
5. The provision of sympathetic block by injection or by sympathectomy.
The important elements of post-operative care are:
1. To maintain the blood-pressure while cooling the limb and heating the patient.
1. Fat embolism occurs in a high percentage of all cases of injury and it is a relatively frequent complication of fractures of the long bones in civilian accidents as well as battle casualties.
2. The diagnosis can usually be established by the clinical features together with certain physical signs which must however be sought deliberately.
3. Important clinical features are the mental disturbance, alternation of coma with full consciousness, petechial haemorrhages in the conjunctiva and skin, and typical changes in the retina.
4. Evidence is still conflicting as to whether the fat arises by embolism from an injured bone, or by general metabolic disturbance.
5. The fat is harmful not so much by reason of mechanical obstruction of vessels as by erosion and rupture of the vessel wall clue to the liberation of fatty acids.
6. Preventive treatment appears to be of some value but no satisfactory specific treatment is yet available for the established case.
7. Ligation of the profunda vein has been tried in two patients, one of whom recovered and the other died.
The advantages of plastics are well known, but there are still some who maintain that these materials are costly and difficult to manipulate. It is not usually remembered, however, that plastics already have their place in orthopaedic splint manufacture, for example in celluloid appliances of many kinds which are in everyday use. They are much lighter than plaster of Paris; they are unaffected by water and body secretions; and some are radiolucent. With the rapid development of modern plastics now taking place there is a wide field for research into their application in orthopaedic surgery. In describing a range of plastic splints and appliances, and outlining the details of their construction, we have tried to show that such research is worth while.
Traumatic uraemia is of particular significance to orthopaedic surgeons in so far as this complication is responsible for high mortality in cases of severe injury, crushing injury, traumatic shock, gun-shot wounds, incompatible blood transfusions, and the misuse of tourniquets. In this contribution the association between muscle injury and renal failure is reviewed.
The syndrome of the "crush kidney," which at first was thought to be the result of deposition of myohaemoglobin in the renal tubules, is almost certainly due to the association of many factors, all of which lead to alteration of the renal circulation and renal ischaemia.
Certainly the combination of ischaemia of the kidney with deposition of pigment and haemolysis of blood causes a high mortality in animals, and it is believed that this may account for the serious prognosis in human cases where there is both shock and haemolysis.
Disturbance of water balance, allergic phenomena, and chemical nephrotoxic action are also discussed. The pathology is considered together with significant changes in the blood chemistry.
A plea is made for early recognition of this clinical syndrome with its characteristic features. Important aspects of treatment are discussed. The dangers of excessive intravenous infusion are emphasised.
Closer investigation and further research promise to throw light on the more accurate localisation of function in the nephron, to add to our knowledge of traumatic arterial spasm, and to explain many orthopaedic problems which hitherto appeared insoluble.
1. Two successive movements at a joint, if not in one and the same plane, constitute a diadochal movement.
2. Diadochal movements impose conjunct rotation upon the bone which has been moved. This may be countered by a rotation of opposite sense.
3. All muscles of a given joint are, therefore, rotators in some degree.
4. Upon the basis of these principles diagnostic and therapeutic suggestions are made.
1. Two cases of an unrecognised congenital defect of the humeral head are described and the cause is discussed.
2. Only six cases with similar radiographic appearances could be collected from the literature. In most of these cases other skeletal deformities were present, whereas in those now reported only the shoulder was affected.
3. Examination of radiographs suggests that the main deformity consists of lack of development of the capital epiphysis of the humerus.
4. Consideration of the cases, together with experimental data from the studies of Fell and Canti, suggests that the time in development at which the fault occurred was the presumptive joint stage, just when the articular rudiments had separated.
5. A "nociferous agent," acting only for a limited period, and only on certain tissues, is postulated.
6. It is suggested that the defects recorded should be recognised as a group of congenital deformities of the shoulder joint.
