Bone scanning in the adductor insertion avulsion syndrome ("thigh splints").

Shin splints is a defined clinical entity resulting from extreme tension on muscles inserting on the tibia, resulting in periosteal elevation which is detectable by bone scanning. The clinical equivalent in the thigh has been described. We found scintigraphic changes in the femurs of seven short, female, basic trainees at the Fort Dix Army base, most of whom were referred for stress fractures elsewhere in the lower extremities. The scan findings were generally noted in the upper or mid femurs, always involved the anteromedial cortex, and were bilateral in five of the seven subjects. The abnormalities were linear and suggested periosteal elevation, and did not have the typical appearance of stress fracture. Since the findings correspond to the insertion of one or more adductor muscle groups, the descriptive term "adductor insertion avulsion syndrome" or "thigh splints" is proposed for this entity.

The semimembranosus-tibial collateral ligament bursa. Anatomical study and magnetic resonance imaging.

A bursa that was deep to the tibial collateral ligament and adjacent to the semimembranosus tendon was studied in fifty cadaveric knees; a vinyl solution was injected into four of the specimens in order to facilitate a study of the relationship between the bursa and its surrounding structures. The bursa had the shape of an inverted U: the superficial arm was an elliptical pocket that was located between the semimembranosus tendon and the tibial collateral ligament, and the deep arm was a triangular pocket that was located between the semimembranosus tendon and the medial tibial condyle. The bursa measured, on the average, twenty-one millimeters in its greatest anteroposterior dimension and ten millimeters in its greatest superoinferior dimension. Magnetic resonance images were made of two patients, and they showed fluid in the bursa.

Testing for isometry during reconstruction of the anterior cruciate ligament. Anatomical and biomechanical considerations.

Instrumented tibiofemoral (bone-to-bone) excursion wires were implanted in the mid-substance of the anteromedial, central, and posterior fiber-regions of the anterior cruciate ligament through limited anterior and posterior arthrotomies in eight fresh knees from cadavera. The change in the distance of linear separation between each pair of osseous fiber-insertion sites was measured and was plotted against the angle of flexion of the knee as the knee was cycled through a 120-degree range of motion. Testing conditions likely to be present during intraoperative testing for isometry were used (anterior cruciate fibers transected, quadriceps relaxed, femur stabilized with the patient in the supine position and the leg freely dependent, and motion of the knee induced in neutral rotation by force applied at the level of the foot). In no instance did the insertion-site centers of any fiber-region exhibit isometric behavior (change in the distance of linear separation of 1.0 millimeter or less). The least deviations from isometry (range, 1.4 to 3.1 millimeters) were observed for the anteromedial sites, under conditions when the gravitational dependency of the lower leg was constrained. When the leg hung in a dependent manner during passive motion, the deviation from isometry of the anteromedial sites of insertion increased significantly (range, 2.8 to 5.6 millimeters). The central sites of insertion were generally less isometric than the anteromedial sites, and the posterior sites were the least isometric, regardless of testing conditions.

Anatomy and kinematics of the lateral collateral ligament of the knee.

The anatomy and kinematics of the lateral collateral ligament were studied in 10 unembalmed limbs and 20 isolated femurs and fibulas. The ligament's average overall length was 66 mm (range, 59 to 74) and the average greatest dimension of its thin middle portion was the anteroposterior dimension of 3.4 mm (range, 3 to 4). The center of the femoral attachment site was 3.7 mm posterior to the ridge of the lateral epicondyle, not at it apex. A potential radiographic technique for operatively locating the femoral attachment site to within 3 mm is described. During knee flexion in neutral rotation the distance between the femoral and fibular attachment sites of the lateral collateral ligament decreased to 88% of its value in full extension. With 6.5 N x m of applied external rotation force, beyond 30 degrees of flexion the attachment sites rapidly approximated. With the same internal rotation force, beyond 15 degrees of flexion the attachment sites separated. From 60 degrees to 105 degrees they were greater than 100% of the value in full extension, suggesting significant distraction between the attachment sites. These changes correlated well with the ligament's change from an 11 degrees posterior slope in extension to a 19 degrees anterior slope in flexion with no applied rotation.

Carpal tunnel syndrome. MR imaging diagnosis.

Carpal tunnel syndrome is a common condition that is often diagnosed by careful history and physical examination. Symptoms from cervical disc disease, thoracic outlet syndrome, and more proximal entrapment syndromes of the median nerve may be confused clinically with carpal tunnel syndrome. Incision of the flexor retinaculum in these patients will not relieve the symptoms, because the locus of the entrapment is not in the carpal tunnel. Electrophysiologic studies are invasive, painful, and may be equivocal on occasion. Furthermore, they provide little information into the cause of carpal tunnel syndrome. MR imaging is the best modality to image the carpal tunnel. It can define the locus of entrapment to the carpal tunnel. Findings includes swelling of the median nerve just proximal to the carpal tunnel, flattening of the nerve within the carpal tunnel, bowing of the flexor retinaculum, and increased signal intensity of the median nerve. Etiologic findings can differentiate space occupying lesions from diffuse inflammatory causes, and this may aid in management. Also, the signal characteristics of soft-tissue masses may be diagnostic. Knowledge of the course of the median nerve may be helpful when planning corticosteroid injection or surgery, especially with the endoscopic technique. MR imaging also may serve a role in postoperative evaluation of patients with recurrent symptoms by demonstrating an incomplete release of the flexor retinaculum or healing of an incised retinaculum. These unique abilities of MR imaging makes it a useful diagnostic tool not only for the initial evaluation and management but also in the postoperative evaluation of patients with carpal tunnel syndrome.

Magnetic resonance imaging of ankle ligaments. Emphasis on anatomy and injuries to lateral collateral ligaments.

Ankle ligament sprains are the most frequent sports injury, and radiographic evaluation of the ankle accounts for 10% or all radiographic examinations requested from an emergency department. This article reviews the diagnosis of the ankle sprain and the anatomy and injuries of the ankle ligaments.

Anterior protrusion of retroperitoneal processes. A mimic of lesser sac or gastrohepatic masses.

The space between the left lobe of the liver and the lesser curvature of the stomach normally contains intraperitoneal structures. These include the gastrohepatic recess of the greater peritoneal cavity, the medial recess of the lesser sac and the interposed gastrohepatic ligament. An anterior protrusion of retroperitoneum can project into this space, dorsal to the posterior reflection of the medial compartment of the lesser sac. Tumors that extend into this fossa are anterior and medial to the fundic and upper body region of the stomach. These tumors may cause confusion regarding their origin if the radiologist is not aware of the existence of this retroperitoneal protrusion. Between 1982, and 1986, 183 patients with pancreatic cancer were hospitalized at our institution, 63 of whom had computed tomography (CT) scans of the abdomen. Four of these patients (6.3%) demonstrated direct tumor extension anterior to the stomach. During this same period, four large benign retroperitoneal tumors also exhibited this finding. Masses in the gastrohepatic interval between the liver and stomach can be extensions of retroperitoneal processes and should not be assumed to represent intraperitoneal involvement.

Comparison of pencil-grip patterns in first graders with good and poor writing skills.

The purpose of this study was to compare nondysfunctional children with and without handwriting difficulties for an examination of grip and hand preference. Additionally, in the group of children with handwriting difficulties, the children with decreased proprioceptive-kinesthetic finger awareness were compared with the children without such a decrease. The results suggest that children with handwriting difficulties may demonstrate a lower grip score than children without handwriting problems. In addition, among children with poor handwriting, those with decreased proprioceptive-kinesthetic finger awareness may demonstrate a lower grip score than those with good proprioceptive-kinesthetic awareness. Children with poor hand-writing also show less hand preference than those with good handwriting.

The efficacy of upper extremity inhibitive casting: a single-subject pilot study.

This pilot study was designed to examine the effects of short-term (48-hr) upper extremity inhibitive casting, with an encased thermoplastic splint, on problems related to upper motor neuron damage. The subject was an 8 1/2-year-old girl with left upper extremity spasticity. Three different measures were used: (a) rating of videotaped active movements of the child; (b) the Modified Ashworth Scale, a clinical measure of spasticity; and (c) The Biodex System, a measure of torque during passive elbow flexion and extension. After cast removal, subjective improvements were noted in the quality of active movement (through videotapes) and increased awareness and use of the casted hand by the child (through parents' reports). A trend toward decreased spasticity was demonstrated by the Modified Ashworth Scale and a statistically significant decrease in resistance to passive movement was shown by the Biodex recordings. However, this reduction in symptoms was temporary, lasting less than 3 days. The results of this study suggest that short-term inhibitory casting may prove efficacious in the treatment of the child with cerebral palsy, although further research is needed.

Descriptive analysis of the developmental progression of grip position for pencil and crayon control in nondysfunctional children.

This study was designed to investigate the developmental progression in pencil and crayon grip. The subjects were 320 nondysfunctional children aged 3.0 to 6.11 years, with 20 boys and 20 girls at each 6-month age interval. On the basis of a review of the literature, developmental pencil and crayon grips were defined for the study, and the type of grips each child used to perform a drawing task and a coloring task were recorded. Many children at each age level used mature pencil grips. A developmental progression, however, was shown by the percentage change of children at each age level who used mature grips. Forty-eight percent of the youngest group used mature grips, compared with 90% of the oldest children. Two pencil grips-dynamic and lateral tripod-appear to be common in older children. Differences in the developmental progression of pencil grip were noted between boys and girls and between a drawing task and a coloring task.

Developmental differences in praxis in learning-disabled and normal children and adults.

Gestures made on tasks in response to verbal command or to imitation and on tasks involving axial and distal movements were compared for groups of learning-disabled and normal children and adults. The 15 learning-disabled children and 15 adults scored lower than the 15 normal children and 15 adults on all tasks. All groups scored higher on imitation than on verbal command and scored similarly on the axial and distal tasks. The findings from this study suggest that it would be worthwhile to test the hypothesis that dyspraxic behaviors may persist into adulthood.

[Teaching development and professional identity in nursing: the system of concepts as a mediator in learning]. / Desenvolvimento discente e identidade profissional de enfermagem: os sistemas de conceitos como mediadores do aprendizado.

The focus of this study is characterisation of the representations socially constituted about the concepts "Nursing" and "Nursing and context". The interpretative mental schemes were sequentially configured during the Graduation course starting from the written answers supplied by students to the following questions: "How do you judge Nursing?" and "What is the relation between the profession and social context? "We have used interpretation schemes based on the contain analysis. As a result, we have identified a peculiar development of schemes formed by means of structures that were involved with forming system and used system of human resources as reference which promote distinct perspectives of professional performance. The components nucleuses of each stage of conception expressed the logical structure which were incorporated to subsequent construction, that configures a evolution determined by selective adhesion of students to the graduation or to the practice field. There has been a movement alongside to those systems resulting from discrepancy between the experience and personal schemes.

The anatomy of lumbar spondylosis.

To identify the major osseous, ligamentous, and neural relations of the lumbar spine pertinent to understanding the pathogenesis, diagnostic imaging, and therapy of lumbar spondylosis, 25 bony lumbar spines and 25 intact cadaver spines were studied both qualitatively and quantitatively. Pedicle anteroposterior dimension and obliquity and the relative interarticular process-interpedicle dimensions were found to be important osteologic determinants of the presence and size of lateral recesses at different vertebral levels and of the increasing size of each lateral recess as it descends. The varying length and relations of the osteoligamentous nerve root canals at different lumbar levels are a function of a progressively earlier exit from the dural sac by the lower lumbar nerve roots. Both the osteoligamentous nerve root canals and their terminal intervertebral canals showed significant normal narrowing at the level of the opposed intervertebral discs and facet joint capsules. This caused the normal nerve root canals to have a beaded appearance and the osteoligamentous intervertebral canals to have the appearance of long-necked gourds. These normally narrow areas correlate well with the spondylotic neural entrapment points. Narrowing of the disc interval is an important cause of many of the interdependent degenerative changes in the lumbar spine. Hence, its reconstitution should be a major goal of spondylotic surgery.

The three-dimensional kinematics and flexibility characteristics of the human ankle and subtalar joints--Part I: Kinematics.

The in-vitro, three dimensional kinematic characteristics of the human ankle and subtalar joint were investigated in this study. The main goals of this investigation were: 1) To determine the range of motion of the foot-shank complex and the associated range of motion of the ankle and subtalar joints; 2) To determine the kinematic coupling characteristics of the foot-shank complex, and 3) To identify the relationship between movements at the ankle and subtalar joints and the resulting motion produced between the foot and the shank. The tests were conducted on fifteen fresh amputated lower limbs and consisted of incrementally displacing the foot with respect to the shank while the motion of the articulating bones was measured through a three dimensional position data acquisition system. The kinematic analysis was based on the helical axis parameters describing the incremental displacements between any two of the three articulating bones and on a joint coordinate system used to describe the relative position between the bones. From the results of this investigation it was concluded that: 1) The range of motion of the foot-shank complex in any direction (dorsiflexion/plantarflexion, inversion/eversion and internal rotation/external rotation) is larger than that of either the ankle joint or the subtalar joint.; 2) Large kinematic coupling values are present at the foot-shank complex in inversion/eversion and in internal rotation/external rotation. However, only a slight amount of coupling was observed to occur in dorsiflexion/plantarflexion.; 3) Neither the ankle joint nor the subtalar joint are acting as ideal hinge joints with a fixed axis of rotation.; 4) Motion of the foot-shank complex in any direction is the result of rotations at both the ankle and the subtalar joints. However, the contribution of the ankle joint to dorsiflexion/plantarflexion of the foot-shank complex is larger than that of the subtalar joint and the contribution of the subtalar joint to inversion/eversion is larger than that of the ankle joint.; 5) The ankle and the subtalar joints have an approximately equal contribution to internal rotation/external rotation movements of the foot-shank complex.

The three-dimensional kinematics and flexibility characteristics of the human ankle and subtalar joint--Part II: Flexibility characteristics.

The objective of the present study was to investigate the in-vitro, coupled, three-dimensional load-displacement and flexibility characteristics of the human ankle joint complex consisting of the talocrural and the talocalcaneal joints and to determine the effects that sectioning of the anterior talofibular ligament has on these characteristics. Similar to other anatomical joints such as the knee and the intervertebral joint, the ankle joint complex was found to exhibit highly nonlinear load-displacement characteristics with the angular displacement approaching asymptotic values as the external load was increased. Therefore, a procedure of incremental linearization was used to derive the flexibility characteristics of this structure. According to this procedure, external loads were applied to the calcaneus in small increments and its resulting three dimensional displacements were recorded. The incremental flexibility coefficients were then derived by assuming linear load-displacement relationship for each increment. From the results obtained from fifteen human ankle specimens, it was evident that the ankle joint complex exhibit highly coupled flexibility and load-displacement characteristics. It was further concluded that the ankle joint complex is the most flexible in the neighborhood of the unloaded, neutral position and that all the flexibility coefficients of the structure decrease rapidly toward the extremes of the range of motion. Rupture of the anterior talofibular ligament was found to have a significant effect on the load-displacement and flexibility characteristics of the ankle joint complex. This effect was manifested as a change in the load-displacement characteristics and a large increase in the flexibility coefficients primarily in those corresponding to rotations in the transverse and the coronal plane. The results of the present study can provide the necessary data base for the development of quantitative diagnostic technique for identifying the site and the extent of injury to the collateral ligaments of the ankle.

Magnetic resonance imaging of the knee and correlation with normal anatomy.

Orthogonal sections usually suffice to demonstrate the soft tissues of the knees, but oblique MR sections may provide better images of the cruciate ligaments. The authors cite indications for oblique sections and discuss their production.