Headache after substance abuse: a diagnostic dilemma.

An 18-year-old man inhaled a substance containing synthetic cannabinoids and 1 hour later developed a severe global headache. Imaging revealed a perimesencephalic subarachnoid haemorrhage. An angiogram suggested that a small superior cerebellar artery aneurysm was the culprit. This report discusses the, as yet undefined, relationship between "herbal highs" and intracranial haemorrhage.

Acute compartment syndrome complicating a distal tibial physeal fracture in a neonate.

This case report of a neonate who developed an acute compartment syndrome secondary to a minimally displaced distal tibial physeal injury represents the youngest patient to be reported with such a condition. After undergoing emergency four-compartment decompression fasciotomies, the 4-week-old child had a return of normal neuromuscular function and anatomic remodeling of the fracture. It is difficult to diagnose compartment syndrome in a neonate. The patient can neither give a history, nor follow commands to cooperate with the exam. The physician must rely primarily on the physical examination; however, the quantitative measurement of intracompartmental pressure can corroborate the diagnosis of compartment syndrome. We have found using a monometer to measure intracompartmental pressure to be helpful in conjunction with a physical exam when evaluating a neonate suspected of having a compartment syndrome.

Acute traumatic proximal tibiofibular joint dislocation confirmed by computed tomography.

High-quality AP and lateral radiographs of both knees are essential to confirm the diagnosis. Computed tomography may help resolve diagnostic uncertainty and enable earlier closed reduction to be performed. Moreover, CT scans may be more consistently reproducible than the varied quality of emergency radiographs. In this case, the relative severity of the patient's pain and suggestive radiographs led us to obtain CT scans, which confirmed the diagnosis and enabled early successful closed reduction.

An irreducible distal fibula dislocation while in-line skating.

We present a case report of a variation of a Bosworth fracture, which is a posterior dislocation of the proximal fragment of a distal fibula fracture. Our patient had a distal fibula dislocation without fracture. He was treated with an open reduction and internal fixation using syndesmotic screws. At his most recent follow-up, he was ambulating without pain.

Propagation of a patellar stress fracture in a basketball player.

Cyclic loading of cortical bone with repetitive, low-intensity loading can result in damage at its microstructural level. If this damage accumulates over time without appropriate repair, the strength of bone is reduced. Accumulation of fatigue damage may be manifest as stress fractures. As a link in the extensor mechanism of the leg, the patella is subject to complex loading, which varies with knee flexion and extension. Stress fractures of the patella originate on its anterior cortex and rarely propagate to completion.

Physiologic rationale for abbreviated laparotomy.

Trauma patients who succumb to their injuries do so by one of several mechanisms discussed in this article. The most common include head injury, exsanguination, sepsis, and multiple organ failure. The article also discusses adverse consequences of hypothermia, including a model for calculating total heat loss.

Resection of the right middle lobe and lingula for mycobacterial infection.

BACKGROUND: In a series of 229 patients infected with mycobacterial organisms, we noted a specific female phenotype that involves isolated infections of the middle lobe and lingula. METHODS: Thirteen patients were found to have infections of the middle lobe, lingula, or both. All of them were infected with Mycobacterium other then Mycobacterium tuberculosis, all were women, 12 of the 13 were slender, and most had variable combinations of skeletal abnormalities. All underwent resection of the middle lobe, lingula, or both. RESULTS: There were no operative deaths. Only 2 patients have had reactivation requiring additional antibiotic therapy. All patients have had a decreased number of pulmonary infections in the postoperative period. Anatomic findings at operation included a complete major fissure and at least a partially complete minor fissure with middle lobe resections or an elongated lingula. CONCLUSIONS: Mycobacterial infection of the middle lobe and lingula is primarily a disease of asthenic women and is often associated with skeletal abnormalities and complete fissures or an elongated lingula. We recommend that surgical intervention be performed early once the condition is identified.

Evidence for the polymorphic oxidation of debrisoquine and proguanil in a New Zealand Maori population.

The genetic oxidation polymorphisms of debrisoquine and proguanil were studied in a New Zealand Maori population. A bimodal distribution was observed in the 0-4 h urinary debrisoquine/4-hydroxydebrisoquine metabolic ratio. Of 101 Maori subjects phenotyped, five subjects (5%) were identified as poor metabolizers of debrisoquine, according to criteria established in studies of Caucasian populations. The prevalence of the debrisoquine poor metabolizer phenotype in the Maori appears to be similar to that reported for the Caucasian populations, but higher than that found in Asian (non-Caucasian) populations. The distribution of proguanil:cycloguanil (PG:CG) ratios obtained from 43 Maori subjects was highly skewed. Using a PG:CG ratio of 10 as the cut-off point, three Maori subjects (7%) were classified as poor metabolizers of proguanil. The incidence of the poor metabolizer phenotype of proguanil oxidation of 7% seems to be higher in Maori compared with Caucasian populations, but this is lower than the usual ranges (15-35%) reported in Asian populations.

Open tibial fracture infections in asymptomatic HIV antibody-positive patients.

Fourteen patients with 15 open tibial fractures were examined retrospectively to compare postoperative infection rates of asymptomatic patients who tested positive or negative for the human immunodeficiency virus antibody (HIVab). All patients were treated with a standard open-fracture protocol. All of the HIVab-positive patients developed postoperative infections. There were five postoperative infections in 4 patients; 3 of the 4 patients were HIVab-positive and 2 of these patients developed chronic osteomyelitis. The only other infection, in an HIVab-negative patient with insulin-dependent diabetes, resolved without complication. All other HIVab-negative patients had no complications. The infection rate for asymptomatic HIVab-positive patients with open tibial fractures was higher than that for HIVab-negative patients in our study. These data suggest that the HIV status of patients with open tibial fractures is relevant to treatment outcome.

Diagnosis of deep vein thrombosis in elderly hip-fracture patients by using the duplex scanning technique.

To detect the incidence of preoperative and postoperative deep vein thrombosis (DVT) in elderly patients with hip fracture, 100 patients aged 65 years and older with either a subcapital or intertrochanteric hip fracture were evaluated by duplex beta-mode ultrasonography. Treatment was based on each scan result: if evidence for DVT was seen, the patient was therapeutically anticoagulated; lacking signs of DVT, patients were treated prophylactically. Before their operation, 77 patients (77%) had normal results of their scans, while DVT was diagnosed in 12 patients (12%). An additional 11 patients (11%) developed DVT after the operation. The total incidence of DVT in this series was 23%.

Immediate Diagnosis of Ankle Trauma.

In brief Traumatic Injuries to the ankle vary greatly in severity, from minor contusions to displaced intra-articular fractures. A systematic approach to their evaluation can lead to more accurate diagnoses and help simplify treatment options. Primary care physicians can successfully manage most sports-related ankle trauma, but knowing when to obtain orthopedic consultation is equally important.

Normal values of neonatal lower limbs: an evaluation of 1,000 neonates.

The purpose of this study was to establish normal values for neonatal hip range of motion, knee range of motion, tibial torsion, and foot alignment. Normal values for examination of the lower extremity in the neonate are not well-documented in the orthopaedic literature. One-thousand healthy neonates were examined by the orthopaedic residency under the supervision of an attending doctor. A total of 527 girls (53%) and 473 boys (47%) were examined. Results were compared and analyzed for mean, range, and standard deviations. There was a wide normal range for each category measured. For all categories, boys and girls had essentially the same values. There were no differences between right and left values. Normal values for these measurements have not previously been reported from such a large series.

Plasma protein binding of quinine: binding to human serum albumin, alpha 1-acid glycoprotein and plasma from patients with malaria.

The binding of quinine to human serum albumin (HSA), alpha 1-acid glycoprotein (AAG) and plasma obtained from healthy subjects (10 caucasians and 15 Thais) and from Thai patients with falciparum malaria (n = 20) has been investigated. In healthy volunteers, plasma protein binding expressed as the percentage of unbound quinine was 7.9-31.0% (69-92.1% bound). The mean percentage of unbound quinine found with essentially fatty acid-free HSA (40 g L-1) was 65.4 +/- 1.5% (mean +/- s.d.) and was comparable with the value (66.3 +/- 3.8%, mean +/- s.d.) for Fraction V HSA (40 g L-1). This suggests that fatty acids do not influence the plasma protein binding of quinine. Binding of quinine to 0.7 g L-1 AAG was high (mean unbound 61.0 +/- 5.0%), indicating that quinine is bound primarily to AAG and albumin, although other plasma proteins such as lipoproteins may be involved. The mean percentage of unbound quinine was slightly less in caucasians (14.8 +/- 6.7% unbound), compared with healthy Thai subjects (17.0 +/- 6.7% unbound). The higher binding of quinine in caucasian subjects was associated with a higher plasma AAG concentration observed in caucasians. Mean percentage of unbound quinine was significantly lower in Thai patients with malaria (10.9 +/- 4.0%) than in the healthy Thai subjects. The increase in the extent of quinine binding corresponded with the increase in the acute-phase reactant protein, AAG in the patients with malaria. Overall, when the data were combined there was a significant correlation (r = 0.846, P < 0.005) between the binding ratio (bound/unbound) of quinine and the plasma AAG concentration.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of the tibial curved driving piece for AO femoral nail insertion.

The purpose of this article is to demonstrate an improved method of AO femoral nail insertion. The AO/ASIF Universal Femoral Nail (Synthes, Paoli, Pennsylvania) has proven effective in the treatment of femoral shaft fractures. The procedure is sometimes difficult when nailing in the supine position, especially with large or obese patients. The ram device impinges on the flank soft tissue of the patient. By using the curved driving piece (355.16) attached to the femoral set, the ram and the ram rod are brought away from the patient's side, thus allowing a less obstructed nail insertion.

Fractures of the scapula: a retrospective study of 40 fractured scapulae.

Forty fractured scapulae in 39 patients treated by nonoperative means were retrospectively reviewed. The nature of injury, associated injuries, site of fracture, and results were evaluated. The data obtained in this series were compared to data from previous studies. Various associated injuries were found in these patients with scapula fractures. Many of these injuries were life threatening although some could have been easily overlooked on initial presentation. Adequate followup was achieved in 67% of the patients. Seventy-three per cent of the patients had good to excellent results using the criteria of subjective complaints, strength, and range of motion. Three of the 39 patients had poor results. These were multiply injured patients or elderly patients in whom early range of motion was not done.