25-Hydroxycholecalciferol and insulin-like growth factor I are determinants of serum concentration of osteocalcin in elderly subjects with and without spinal fractures.

Osteocalcin is one of the major proteins in the osseous matrix. To evaluate the determinants and thus the physiological control of osteocalcin production in normal and osteoporotic subjects, the serum levels of osteocalcin, 25-hydroxycholecalciferol (25-OH-D3), and insulin-like growth factor I (IGFI) were measured by radioimmunoassay in 44 subjects over 60 years old. Circulating osteocalcin, 25-OH-D3, and IGFI were 0.28 +/- 0.10 nmol/L (1.65 +/- 0.96 ng/mL), 70.5 +/- 25.1 nmol/L (28.3 +/- 10.1 ng/mL), and 23.8 +/- 12.0 nmol/L in 27 healthy controls respectively, as compared with 0.09 +/- 0.09 nmol/L (0.52 +/- 0.52 ng/mL), 48.2 +/- 19.9 nmol/L (19.35 +/- 7.91 ng/mL), and 16.56 +/- 6.96 nmol/L in 17 patients with spinal fractures. Significant correlation was found between osteocalcin and 25-OH-D3 level, as well as between osteocalcin and IGFI. The results show that IGFI and 25-OH-D3 are important determinants for serum concentration of osteocalcin in elderly subjects with and without spinal fractures.

Vitamin D status among patients with fractured neck of femur in Hong Kong.

Vitamin D deficiency leads to secondary hyperparathyroidism initially and then to mild osteomalacia, both of which conditions may be aymptomatic and may predispose to bone fracture. To assess the importance of vitamin D deficiency in predisposing to fractured neck of femur, we studied the vitamin D status, dietary intake and socio-economic characteristics in 69 patients with fractured neck of femur (group A), 28 normal subjects with age above 60 (group B), and 101 normal volunteers (group C). Patients with fractured neck of femor had significantly lower levels of serum 25-hydroxy-cholecalciferol compared with subjects of groups B and C. There is no statistically significant difference in other biochemical parameters, including calcium, phosphate, and alkaline phosphatase. Patients with fractured neck of femur and with 25-hydroxycholecalciferol below 20 ng/mL were characterized by a home-bound and/or institutionalized life-style, smaller living place, and limited access to open space. To conclude, hypovitaminosis D is a common problem among elderly patients with fractured neck of femur in Hong Kong. The fact that such vitamin D deficiency is associated with muscle weakness may contribute to falls, and thus indirectly account for an increased rate of hip fractures over the normal control.

Desmoplastic fibroma of bone.

A 5-year-old Chinese boy had dull pain in his right knee for about one year. An intraosseous osteolytic lesion in the metaphysis of the right lower femur was curetted. The diagnosis of desmoplastic fibroma, possibly the first in a Hong Kong Chinese, was based on the clinical, radiological and histological findings. About one year later the only abnormality was a small rounded radiological lucency, static for 4 months. The fibroblastic nature of the lesion and its tendency to local recurrence support a fibromatosis of intraosseous origin.

Effusions in the knee in elderly patients who were operated on for fracture of the hip.

The incidence of an effusion in the knee in 155 consecutive elderly patients who had been operated on for a proximal femoral fracture was studied. The preoperative incidence had been 7.7 per cent in the ipsilateral knee and 1.3 per cent in the contralateral knee. Postoperatively, fifty patients (32.3 per cent) had an effusion on the ipsilateral side. In seven of them, the effusion had been present before the operation. All of the effusions subsided completely within three weeks after the operation. Results of the laboratory analysis of a specimen of the effused material from eight patients who were chosen at random showed non-inflammatory fluid. Probably the effusions were traumatic in origin, and it is likely that they were a response to stresses that had been incurred during the operation or at the time of fracture.

Mycobacterium marinum infection of the hand and wrist. Results of conservative treatment in twenty-four cases.

Inadequate débridement, extensive scarring, and breakdown of the wound have been commonly encountered after surgical débridement has been employed as the initial treatment of infection with Mycobacterium marinum involving the deep structures of the hand. Because of our disappointment with the results of this form of treatment, from 1982 to 1986 we treated twenty-four patients who had such an infection with rifampicin and ethambutol after a diagnostic biopsy was done. Surgical treatment was deferred until it was determined that the infection had not been controlled by the chemotherapy. The clinical outcome for these patients could be divided into three patterns: eleven patients (Group I) had a good result with no complications, three patients (Group II) had delayed healing of the wound, and ten patients (Group III) did not have a good response to conservative treatment and required one or more surgical débridements. Complications were sometimes associated with use of the drugs, and loss of visual acuity was a concern in three patients. In twenty-one (87 per cent) of the patients, at follow-up the function of the treated hand was equal to that of the other hand. Persistent pain, a discharging sinus, and previous local injection of steroids were unfavorable prognostic factors. If these factors are present, surgical débridement is advised.

A simple method to estimate the rib hump in scoliosis.

A simple device to measure the rib hump deformity in scoliosis is described. The importance of defining the plane of measurement rigidly was stressed. The visible rib humps from 30 scoliotic patients were measured in the form of plotted curves by a group of paramedical and medical staffs. Highly reproducible results were obtained. The expected difference between two curves measured on a random patient by a single investigator was .116 cm, and the expected difference between the curves made by two random investigators on the same patient was .167 cm. This instrument is useful in charting the progress of the rib hump deformity in daily clinical practice.

Unrecognised compartment syndrome in a patient with tourniquet palsy.

We report a case in which compartment syndrome and tourniquet paralysis occurred simultaneously. This is a previously unreported combination which presents a diagnostic problem. We recommend that electrophysiological studies and continuous monitoring of compartment pressures should be used to minimise morbidity in high-risk cases.

Thenar crush injuries.

Crushing of the radial side of the hand results in a wide spectrum of injuries varying from contusion of muscles to total loss. The main problem concerns the function of the thumb. The results of such injuries in 161 hands were reviewed. Those with mild injuries treated conservatively or by debridement alone had good results. When skin flaps were required for wound coverage, the results were still satisfactory. However, when bones and joints were injured, the results were poor. In certain patients opponensplasty through scarred tissue proved to be a good procedure to improve the function of the thumb.

Tuberculosis of the lumbosacral junction. Long-term follow-up of 26 cases.

Of 37 consecutive patients suffering from tuberculosis of the lumbosacral spine, 26 were reviewed after an average follow-up of 20 years. Those presenting at under 10 years of age usually had a discharging sinus or a pointing abscess and a visible kyphosis. In older patients, low back pain was the predominant presenting symptom. Neurological involvement was uncommon. Both operative and conservative treatment had resulted in fusion but all patients treated conservatively ended up with a kyphosis associated with trunk shortening. They had a higher incidence of back pain and more complications in pregnancy. Anterior debridement and fusion with a strut graft can reduce the incidence and size of kyphosis, but is technically demanding. Treatment remains difficult and requires individual consideration.

A prospective study of 245 open digital fractures of the hand.

We report a prospective study of 245 open digital fractures of the hand in 201 patients. Management followed clear guidelines set out in protocol. The incidence of infection (2.04%) and non-union (2.45%) was low. Proximal phalangeal fractures and comminuted fractures did worst and associated significant soft tissue injuries had a particularly deleterious effect on the outcome. A classification based on the different soft-tissue components involved is proposed. In fractures associated with simple lacerations or isolated digital nerve injury only, one can expect about 40% good results and about 25% poor results. Where extensor tendon injury or extensive skin loss are also present, there will be approximately 18% good results and 50% poor results. If there is also injury to the flexor tendon or more than one component of significant soft-tissue damage, about 80% will be poor and good results are rare.

Sequential forearm intravenous regional and infiltration anaesthesia: value for haemostasis.

Intravenous regional anaesthesia using 0.5% lignocaine with a forearm tourniquet is a satisfactory technique for operations on the distal forearm, wrist and hand. Since recovery of pain sensation is rapid, haemostasis after release of tourniquet becomes difficult and sometimes impossible. Local wound infiltration or metacarpal block with 1% lignocaine just before release of the tourniquet can allow subsequent haemostasis and wound closure to be carried out without causing pain. 55 patients received this sequential forearm intravenous regional and infiltrative anaesthesia. Subsequent haemostasis and wound closure could be carried out without pain in 51 patients (92.7%); three patients (5.5%) noticed mild discomfort but the operations could be finished without any additional anaesthetic agent. No complications were encountered with this modified technique.

Spontaneous rupture of the tibialis anterior tendon: a case report and literature review.

Spontaneous rupture of the tibialis anterior tendon is uncommon. This article presents a case report in which spontaneous rupture of the tibialis anterior tendon occurred secondary to a gouty tophaceous deposit within the tendon. This report adds to the list of pathological conditions that should be considered in closed spontaneous rupture of the tibialis anterior tendon.

Influence of the erect posture on the development of the lumbosacral region. A comparative study on the lumbosacral junction of the monkey, dog, rabbit and rat.

An animal study was carried out to gain better understanding on the effect of erect posture in the development of the lumbosacral junction. Rhesus monkeys which are able to sit in an upright position were compared with quadrupeds, including rats, rabbits and dogs, whose lumbosacral spines are normally more or less horizontal. The important finding was the presence of the iliolumbar ligament in the rhesus monkey which attached to the last, occasionally the second last, lumbar transverse process and the adjacent iliac wing. A similar ligament was absent in the quadrupeds. We postulate that the stresses created across the lumbosacral junction as a result of the erect posture in the rhesus monkey have played an important role in stimulating the formation of this ligament.

Entrapment and transection of the median nerve associated with greenstick fractures of the forearm: case report and review of the literature.

OBJECTIVE: To report an unusual neurologic complication associated with greenstick fractures of the forearm. METHODS: Near-complete transection of the median nerve associated with greenstick fractures of the shaft of the left radius and ulna in a 13-year-old boy is described. The results of treatment are reported in detail. CONCLUSION: Significant median nerve injury may coexist with apparently benign, closed greenstick fractures of the forearm.

Closed reduction of tibial shaft fractures using a sling.

We wish to report a simple technique for closed reduction of tibial shaft fractures. The patient is put in the supine position. Longitudinal traction is applied through a plaster boot on the corresponding foot and ankle. A gauze sling (Fig. 1) placed behind the calf at the fracture site allows suspension of the limb whilst controlling posterior angulation and displacement. This allows control of the limb whilst alignment is checked with the image intensifier in two planes. When satisfactory reduction is obtained, a long leg plaster can be applied to immobilize the fracture. The technique was applied to 21 closed tibial shaft fractures in 21 patients. Satisfactory results were obtained in 20 patients. Analysis of the initial post-manipulation X-rays showed an average of 5.2 mm shortening (range 0-15 mm). The average coronal angulation was 1.9 degrees (range 0-5 degrees), and sagittal angulation was 2.0 degrees (range 0-8 degrees). Average percentage overlap of the fracture fragments was 79% in the coronal plane (range 40-100%) and 82% in the saggital plane (range 50-100%). We found this technique to be simple and reliable. It is particularly useful as the first phase of non-operative treatment of tibial shaft fractures by functional bracing.

Intravenous regional analgesia with a forearm tourniquet.

Lidocaine 0.5 per cent in a dose of 2 mg X kg-1 was used for intravenous regional analgesia with the tourniquet cuff placed over the forearm. The level of tourniquet cuff pressure employed was the arterial "occlusion pressure" plus 50 mmHg. In 48 normotensive patients successful analgesia was achieved; in seven hypertensive patients, four were pain-free, but the other three required more lidocaine to achieve adequate analgesia. No toxic symptoms and signs were observed. Measurement of serum lidocaine concentrations in 12 patients confirmed the safety of the technique, although small leakage of lidocaine past the inflated forearm tourniquet was detected in some patients.

Long-term results and complications of cement augmentation in the treatment of unstable trochanteric fractures.

Thirty-eight patients with unstable trochanteric fractures of the femur were treated with Dimon-Hughston displacement osteotomy and cement augmentation at the fracture site. Of these patients 76 per cent had excellent and good results after an average follow-up of 3.7 years (range 2-5 years). Late complications occurred in six hips. These included non-union at the trochanteric fracture, protruding pin, partial destruction of the femoral head, subcapital fracture of the femoral neck, and avascular necrosis of the femoral head. All complications occurred late (1 year after surgery) and were related to inappropriate placement and excessive amount of cement, together with inadequate new bone formation. The augmentation of cement provided early stability for early mobilization in these elderly patients. However, when improperly used, late complications can occur.

A prospective study on hip fractures in patients with previous cerebrovascular accidents.

Of 1430 patients with proximal femoral fractures admitted into Queen Mary Hospital, Hong Kong from 1985 to 1990, 146 patients (10.2 per cent) had a history of previous cerebrovascular accidents. The fracture was on the hemiplegic side in 82 percent of patients. Most patients were treated by operation. Intensive physiotherapy was given to these patients for an average of 6 weeks. The prefracture walking ability was regained or even improved upon discharge in 60.9 per cent of patients. After an average follow-up of 21 months, 31 per cent had satisfactory walking and active daily activities. There was significant correlation of the performance upon discharge from the hospital with the walking ability at the final follow-up.

Sequential fractures of both hips in elderly patients--a prospective study.

Thirty-five patients with sequential fractures of both hips were studied prospectively. The second hip fractures occurred more commonly if the patients were institutionalized, if they suffered from concomitant neurologic diseases such as previous stroke or Parkinsonism, or if there was biochemical evidence of osteomalacia. Twelve patients sustained the contralateral hip fracture within 12 months of the first one. There was a significant correlation between biochemical evidence of osteomalacia and early occurrence of the second hip fracture. Although rehabilitation was difficult for such patients, it was possible with a longer period of intensive physiotherapy; only three patients were not able to walk upon discharge from the hospital after the second hip fracture.