Patient-accident-fracture (PAF) classification of acute distal radius fractures in adults.

There is not enough evidence in the literature to support the use of any classification system for distal radius fractures (DRF) in adults. However, there is a need for identification of more homogeneous groups of patients with DRF so that the extent of preoperative workup and sophistication of treatment would best match the needs of the patient. The authors propose an innovative method to analyse and stratify acute DRF in adults. A one-page chart includes criteria related to the patient (P), the energy of the accident (A) and the pathology of the fracture (F). Analysis of the pathology includes not only the distal radius itself but also the associated ulnar and carpal lesions. Radiological suspicion of associated carpal of distal radio-ulnar joint ligamentous injuries is included in the analysis. The preliminary results of the use of this chart in 1610 consecutive adult patients (16-102 years) with unilateral acute DRF are presented. A total of six homogeneous groups of patients are described, and the relevance of this classification regarding the therapeutic options is discussed.

Atypical schwannoma of the median nerve. A case report.

Schwannomas of the hand are very rare tumors and represent less than 3% of all soft tissue tumors in the hand. These tumors share clinical, epidemiological and imaging characteristics with the other soft tissue and peripheral nerve tumors; thus, it can be difficult to make a preoperative diagnosis. Here we report the case of a 48-year-old woman who presented with a schwannoma arising from the palmar branch of the median nerve. The tumor measured 54 × 41 x 52 mm and was located in the thenar eminence. The first hypothesis was a vascular tumor. After surgery and histological analysis, the final diagnosis of an atypical schwannoma was established. The presence of shared immunohistochemical characteristics with cellular histiocytoma and myoepithelial tumors forced us to adopt an aggressive follow-up protocol. As of the last follow-up at 9 years, the patient had good clinical outcomes and no recurrence. This case highlights the difficulties encountered in clinical practice to diagnose such tumors.

Clinical evaluation of two bilateral hand allotransplantations at six and three years follow-up.

We report a six and three years follow-up clinical evaluation of two bilateral hand allotransplantations from brain-dead multi-organs donors performed in two young adult traumatic hand amputees. Lifelong immunosuppressive treatment included tacrolimus, mycophenolate mofetil and prednisolone. In both patients, early complications were observed but were successfully treated. At follow-up, clinical results allow useful hand function in both patients, by far superior to what can be provided by current myoelectric prostheses. Although the long-term risks-benefits ratio of bilateral hand transplantation is still unknown, these two cases demonstrate that this new treatment is feasible. Further experimental and clinical research is needed to better delineate its role in the future of hand surgery.

Treatment of intra-articular fracture of distal radius fractures with fluoroscopic only or combined with arthroscopic control: A prospective tomodensitometric comparative study of 40 patients.

BACKGROUND: Considering articular distal radius fractures treated with volar plate, we hypothesized that articular radio-carpal displacement was better reduced with arthroscopic control than with only fluoroscopic control. METHODS: Forty patients with similar articular radius fracture (type C according to AO classification) and high functional needs were treated with volar plate fixation. They were divided in two comparative groups: 20 patients in Fluoroscopic group and 20 patients in Arthroscopic group. Pre and postoperative radiographs and tomodensitometric images were analysed by an independent observer. We evaluate extra and intra-articular displacements according to "Patient Accident Fracture" classification. RESULTS: We observed a better reduction of the radio-carpal step-off and gap in the arthroscopic group, with a statistically significant difference (p<0.05). The index of postoperative intra-articular reduction was better in the fluoroscopic group (5.5) than in the arthroscopic group (2.2) with a significant difference (p<0.05). CONCLUSIONS: According to these results, arthroscopy is useful to perform a better articular radio-carpal reduction in distal radius fracture. LEVEL OF EVIDENCE: Level 3.

[Testing of pronation and supination strength in the outpatient setting: a preliminary study]. / Evaluation de la force de pronosupination à la consultation: étude préliminaire.

Dynamometric studies of grip strength are widely used in clinics. We present a clinic dynamometer that can be used to measure pronation and supination moments while the subject being tested is holding a cylindrical handle in neutral pronosupination. One hundred volunteers without any previous history of upper extremity injury were tested in pronation and supination in order to provide a database of strength values and to study variations with respect to sex, age, dominance, weight and height.

Hemi-arthroplasty for distal radius fracture in the independent elderly.

INTRODUCTION: The authors report their experience with hemi-arthroplasty in irreparable fresh distal radius fracture in independent elderly patients as first-line treatment (12 fractures in 11 women; mean age, 74 years) or in second line after clinically disabling primary failure (4 fractures in 4 women; mean age, 78 years). RESULTS: In the 12 primary surgeries, at a mean 32 months' follow-up, there were no complications requiring implant ablation; mean pain score was 1/10, flexion-extension 62°, Lyon Wrist score 75%, and Patient-Related Wrist Evaluation (PRWE) 22 points. In 2 of the 4 secondary surgeries, at a mean 24 months' follow-up, there were no complications requiring implant ablation; mean pain score was 2.5/10, flexion-extension 62°, Lyon Wrist score 58%, and PRWE 50 points: i.e., slightly poorer results than in primary surgery. CONCLUSION: Salvage of complex fracture in independent elderly patients by hemi-arthroplasty, whether primary or secondary to failure, seems to be a considerable progress, to be confirmed in larger series.

[What is the role of primary or secondary hemiarthroplasty for distal radius fractures in independent elderly patients?] / Quelle place pour l'hémiarthroplastie en urgence ou en secondaire pour fracture de l'extrémité distale du radius du sujet âgé autonome ?

The authors report their experience with wrist hemiarthroplasty for acute irreparable distal radius fractures in independent elderly patients (12 women, mean age 76years) and following failed initial treatment in the same population (5 women, mean age 75years). The first 11 cases have a mean follow-up of 30months. No complications requiring implant removal were reported. At follow-up, the mean VAS for pain was 1/10, the mean flexion-extension arc was 60°, the Lyon Wrist score was 73 % and the PRWE (Patient-Related Wrist Evaluation) was 22 points. The five patients who had secondary procedures and were reviewed at mean of 16months' follow-up did not require implant removal but there was one complete forearm rotational ankylosis with ossification. At follow-up, the mean VAS for pain was 3/10, the mean flexion-extension arc was 56°, the Lyon Wrist score was 65 % and the PRWE was 45 points. The authors believe that hemiarthroplasty is a useful salvage procedure for irreparable wrist fractures in the emergency room and after failed initial treatment in active elderly patients.

[Radiological analysis of acute distal radius fractures and clinical outcomes]. / Analyse radiologique des fractures fraîches de l'extrémité distale du radius et évaluation clinique des résultats.

Radiological analysis of acute distal radius fractures (DRF) begins with the initial AP and lateral X-ray views. A CT scan is very often indicated. In addition to the three standard planes, 3D reconstructions are mandatory. We recommend not only AP views of the distal facets of the radius but also a complete 3D view in the surgical position. The distal ulna and carpus should also be analyzed. We describe the radiological sequence and the criteria used. These criteria are recorded in the one-page PAF chart, since they all impact the treatment choice. Clinical outcomes of DRF treatment are rarely addressed in the literature. We review the most commonly used clinical scores and describe the one that we use currently.

[Incidence of distal ulna fractures associated with distal radius fractures: Treatment options]. / Incidence des fractures de l'extrémité distale de l'ulna associées aux fractures de l'extrémité distale du radius (processus styloïde ulnaire). Nos choix thérapeutiques.

Fractures of the neck and/or head of the ulna or distal ulna fracture (DUF) other than ulnar styloid fractures can occur in combination with distal radius fractures (DRF). This combination can have a significant influence on the treatment and prognosis since it causes the entire distal forearm to be unstable. In a series of 1279 consecutive unilateral DRFs, we found an associated ulnar neck fracture in 5.9% of cases, ulnar head and neck fracture in 1.6%, and isolated ulnar head fracture in 1.4%. Overall, 9% of cases in this study had a DUF with a DRF. The frequency of extra-articular "A" (11%) and intra-articular "C" (9%) DRFs according to the AO classification was about the same. There were no cases of DUF combined with partial "B" DRF. There was a correlation between combined DUF with DRF and the patient's group in the PAF classification. DUF are more frequently associated with DRF in elderly patients. Specific distal ulnar locking plates were recently introduced and they may be a useful adjunct to distal radius locking plates when treating patients with combined DUF and DRF.

[Patient-Accident-Fracture (PAF) classification of distal radius fractures]. / Classification Patient-Accident-Fracture (PAF) des fractures fraîches de l'extrémité distale du radius.

Despite the huge amount of literature devoted to acute distal radius fractures, there is currently no consensus as to treatment recommendations. There is no universally accepted anatomical classification other than the three main categories of the AO classification. The authors believe that the only way to improve this field is to stratify the patients according to their general health and functional needs. They propose a new classification system that they have used since 2009 and demonstrate its therapeutic, epidemiological and teaching values.

[Complications of volar locking plates used to treat distal radius fractures]. / Complications des plaques antérieures verrouillées pour fractures fraîches de l'extrémité distale du radius.

About 10 years after volar locking plates were introduced to treat acute distal radius fractures, several papers have reported short-term complications. The aim of this paper was to report our complication rate over a 2-year period and to compare it to the literature. We found similar complication rates despite different classification systems. Because of the prospective nature of our study, we were able to demonstrate that extra-articular and/or intra-articular scores exceeding 8 points on a 12-points scale were statistically associated with more complications, irrespective of the patient's overall health and age.

Evidence that the cytosolic activity of 3-hydroxybutyrate dehydrogenase in chicken liver is L-3-hydroxyacid dehydrogenase.

Classical fractionation studies showed that chicken liver contains two enzymes which can oxidize DL-3-hydroxybutyrate. The cytosolic enzyme is specific for the L-(+) isomer and accounts for 60% of the total activity. The mitochondrial activity is specific for the D-(-) isomer and accounts for 40% of the total activity. Kinetic studies showed that L-gulonic acid is a competitive inhibitor of the enzyme. We conclude that the cytosolic enzyme is the previously described L-3-hydroxyacid dehydrogenase.

Intestinal absorption of fish oil in rats previously adapted to diets containing fish oil or corn oil.

A study was conducted to evaluate whether the composition of previous dietary fat affects the absorption and composition of lymph obtained after a meal of fish oil. Adult male Sprague-Dawley rats were fed diets containing either corn oil or fish oil (MaxEPA) for 2 weeks. They were then given intraduodenally a bolus of an emulsion of 0.5 ml of fish oil plus 0.5 ml of 20 mM sodium taurocholate. Intestinal lymph was collected from a cannula in the main intestinal lymph trunk for various times after oil administration. Rats proportion of the test dose fo fish oil than those fed corn oil. There was an effect of previous diet on the fatty acid composition of the lymph. Rats fed fish oil had a higher percentage of eicosapentaenoic and docosahexaenoic acids in the lymph lipids than those fed corn oil while those fed corn oil had a higher percentage of linoleic acid. These results rule out decreased intestinal absorption as a mechanism for the hypotriacylglycerolemic effect of dietary fish oils. They also indicate a significant contribution of endogenous lipids to the fatty acids in lymph.

Intestinal absorption and lymphatic transport of fish oil (MaxEPA) in the rat.

Adult male, chow-fed Sprague-Dawley rats were given intraduodenally a bolus of emulsion of 0.5 ml of fish oil (MaxEPA) or olive oil plus 0.5 ml of 20 mM sodium taurocholate. Intestinal lymph was collected from a cannula in the main intestinal lymph trunk for various times after oil administration. There was no difference in the absorption of either type of oil over 6 and 24 h, over which times about 40 and 70% of the administered dose was taken up. For MaxEPA, the flux of triacylglycerols remained at a basal level of 0.07 mumol/min for 30 min, after which it rose rapidly to a maximum of 0.87 mumol/min between 90 and 120 min. The flux was 0.4 mumol/min for the subsequent 4 h. After 30 min, the composition of the lymph triacylglycerols began to change to show the presence of large proportions of fatty acyl chains that were characteristic of fish oil, especially eicosapentaenoate (20:5(n-3] and docosahexaenoate (22:6(n-3]. The composition of the lymph remained fairly similar to that of the fish oil for up to 6 h, the last time point at which detailed analysis was done. The docosahexaenoate in the triacylglycerols of the fish oil was primarily in the sn-2 position of glycerol, whereas a more random distribution of eicosapentaenoate over all glycerol positions was found. The positional distribution of the acids in the lymph triacylglycerols was similar to that in the fish oil. There was no evidence of substantial chain elongation or shortening during absorption. The results indicate that fish oil is effectively absorbed from the rat intestine without substantial alteration in the acyl chains of the triacylglycerols.

Childhood urolithiasis: experiences and advances.

Between June 1979 and June 1989, 54 children with urolithiasis were evaluated and treated at the Johns Hopkins Children's Center. The most common symptoms were flank or abdominal pain (58%) and gross hematuria (28%). In 46 children (86%), stones were secondary to a preexisting condition and in only 8 (14%) no apparent cause of stone formation could be found. Thirty-six patients (66%) had a solitary stone, most commonly found in the kidney. Urinary tract infections were present in 25 (47%) of the patients who had stones. Stones composed either of calcium oxalate or struvite were the most frequently recovered in these patients with infections. Twenty-one patients (39%) spontaneously passed their stones whereas 23 (43%) required either surgery or extracorporeal shock-wave lithotripsy to resolve stones. Ten (20%) showed recurrence of their urolithiasis, with follow-up examination periods ranging from 1 month to 10 years. Recent advances in the management of urolithiasis and their applicability to the pediatric population are discussed.

Usefulness of tacrolimus versus cyclosporine after pediatric heart transplantation.

This study compared the early clinical course of 9 pediatric heart transplantation recipients treated with cyclosporine A-based immunosuppression with 10 similarly aged recipients treated with tacrolimus-based therapy. One-year follow-up after transplantation revealed that tacrolimus-treated children had similar left ventricular function, experienced fewer episodes of severe rejection, were more rapidly weaned from corticosteroids, and had relatively few side effects from immunosuppression compared with cyclosporine A-treated children.

The effects of HLA mismatching and immunosuppressive therapy on early rejection outcome in pediatric heart transplant recipients.

BACKGROUND: Although HLA-DR antigen mismatching between heart transplant recipients and donors has been associated with increased early allograft rejection in adult patients treated with cyclosporine, little information exists in the pediatric age group. In this study we examined retrospectively the effects of HLA mismatching and immunosuppression choice, cyclosporine versus tacrolimus on early rejection outcome in pediatric heart transplant recipients. METHODS: Between 1992 and 1997, 38 patients (ages 10 days to 18 years) underwent 40 heart transplantations. All recipients were typed prospectively and donors retrospectively by use of serologic microcytotoxicity testing for HLA-A and HLA-B antigens and by a polymerase chain reaction technique for HLA-DR antigens. All heart transplant recipients received induction immunosuppression with methylprednisolone and maintenance prednisone, and 38 received OKT3. The first 25 heart transplant recipients received cyclosporine and azathioprine, and the last 15 were given tacrolimus. Clinical courses, HLA mismatching, and biopsy results for the first year after heart transplantation were reviewed and compared between treatment groups. RESULTS: Mean age, donor/recipient weight ratios, and biopsies/patient were similar between treatment groups. Five deaths occurred among cyclosporine-treated patients and none among tacrolimus-treated patients during the study period. HLA mismatching was similar between groups, with 94% of patients having 1 or 2 HLA-A mismatches and 96% having 1 or 2 HLA-B and -DR mismatches. Both International Society for Heart and Lung Transplantation grade 2 and grade 3 or 4 rejections were significantly increased in biopsies from cyclosporine-treated patients (P < .05). Significantly increased grade 3 or 4 rejection was present in patients treated with cyclosporine who had two DR mismatches versus those with one DR mismatch (3.0+/-1.6 vs 1.4+/-0.8; P < .05); no statistical significance between patients treated with tacrolimus with 1 vs 2 DR mismatches was noted. Patients treated with tacrolimus who had 2 DR mismatches had fewer grade 3 or 4 rejection episodes/patient than either patients treated with cyclosporine who had one DR mismatch (0.6+/-0.4 vs 1.4+/-0.8, P = .03) or those treated with cyclosporine who had two DR mismatches (0.6+/-0.4 vs 3.0+/-1.6, P = .01). Grade 3 or 4 rejection episodes/patient were not affected by HLA-A or B mismatching, and grade 2 rejection was not affected by mismatching at any of the loci. CONCLUSION: Although mismatching of HLA-A and -B antigens did not affect frequency of early cellular rejection, the presence of 2 HLA-DR loci mismatches increased the risk of high-grade rejection in pediatric heart transplant recipients treated with cyclosporine. The potent effects of tacrolimus-based immunosuppression mitigated the impact of HLA-DR mismatching, because patients treated with tacrolimus who had 2 DR mismatches had less rejection than even patients treated with cyclosporine who had one DR mismatch and seemed to be at no greater risk for rejection than patients treated with tacrolimus who had 1 DR mismatch.

Release of lactate by the liver in metabolic acidosis in vivo.

Chronic metabolic acidosis was induced in dogs by HCl. Pyruvate and lactate production and extractions were studied by arteriovenous sampling and electromagnetic flow probe measurements of gut and hepatic blood flows. The following results were obtained: (1) In control, overnight-fasted dogs, no net lactate or pyruvate was extracted by the liver. (2) In chronic acidosis, large amounts of lactate were produced. (3) Reduced tissue pyruvate levels and reduced activity of pyruvate dehydrogenase were found in the liver of these dogs compared with normal. These results demonstrate an unexpected effect of acidosis on hepatic lactate metabolism.