Does timing of surgery matter in fragility hip fractures?

The effect of delay of surgery on the geriatric hip fractures has been a subject of interest in the past two decades. While the elderly patients will not tolerate long periods of immobilization, it is still unclear how soon these surgeries need to be performed. A review of existing literature was performed to examine the effect of timing of surgery on the different outcome parameters of these patients. Although there is conflicting evidence that early surgery would improve mortality, there is widespread evidence in the literature that other outcomes including morbidity, the incidence of pressure sores, and the length of hospital stay could be improved by shortening the waiting time of hip fracture surgery. We concluded that it is beneficial to the elderly patients to receive surgical treatment as an urgent procedure as soon as the body meets the basic anesthetic requirements.

Occupational repetitive strain injuries in Hong Kong.

OBJECTIVE: To review currently available evidence on the epidemiology and management of occupational repetitive strain injuries with particular reference to Hong Kong. DATA SOURCES AND STUDY SELECTION: Medline, PubMed and Cochrane Library searches of local and internationally published English journals from 1990 to 2007 regarding repetitive strain injuries. DATA EXTRACTION: All articles involving occupational repetitive strain injuries in Hong Kong were included in this review. DATA SYNTHESIS: There were 16 articles contributing data on the impact of repetitive strain injuries both in Hong Kong and around the world. There were seven articles dealing with the problem of computer station set-ups and methods for improving the workstation environments. CONCLUSION: Currently there were significant data on the impact of repetitive strain injuries in Hong Kong. The data took the form of compensation claims, days away from work, and cost of medical consultations. Other articles described proper workplace adjustments to help prevent repetitive strain injuries. However, there were no figures in the current literature showing the impact of these adjustments in reducing the incidence of repetitive strain injuries. More research could help to delineate the relationship between different types of interventions and occupational repetitive strain injuries.

Overprotection and the psychological states of cerebral palsy patients and their caretakers in Hong Kong: a preliminary report.

OBJECTIVE: To examine the relation between perceived overprotection and the psychological states of cerebral palsy patients and their primary caretakers in Hong Kong. DESIGN: Cross-sectional survey, in which data of 14 pairs of cerebral palsy patients and their caretakers were analysed. SETTING: Duchess of Kent Children's Hospital, Hong Kong. PARTICIPANTS: Cerebral palsy patients and their primary caretakers in Hong Kong. MAIN OUTCOME MEASURES: Perceived overprotection and psychological states. RESULTS: Nearly two thirds of the 14 patients (mean age of 15 years) and 86% of the 14 primary caretakers (mean age of 47 years) perceived various levels of overprotection. For both patients and caretakers, perceived overprotection was positively associated with anxiety and unhappiness. The patients' and caretakers' psychological states and perception of overprotection were not related to the actual motor ability of the patients. Perceived overprotection of the patients was not related to that of the caretakers. CONCLUSION: Caretakers should be mindful that a well-meaning move may have undesirable consequences. More support and child-rearing education should be considered for caretakers.

Dynamic treatment for proximal phalangeal fracture of the hand.

PURPOSE: To assess a protected mobilisation programme (dynamic treatment) for proximal phalangeal fracture of the hand, irrespective of the geometry. METHODS: Clinical and radiological results of 32 consecutive patients with proximal phalangeal fracture of the hand treated from January 2001 to February 2007 were evaluated. Our supervised rehabilitation programme was strictly followed to gain full range of movement of the proximal interphalangeal joint and to prevent the development of an extension lag contracture. Patients were followed up for a mean period of 15 (range, 13-16) months. Results were evaluated using the Belsky classification. RESULTS: The results were excellent in 72% of the patients, good in 22%, and poor in 6%. Some patients defaulted follow-up, which made long-term assessment difficult. The poor results may have been related to patient non-compliance or default from rehabilitation. Many good results upgraded to excellent following further rehabilitation. CONCLUSION: Skeletal stability, not rigidity, is necessary for functional movements of the hand. Proximal phalangeal fractures can be effectively treated by closed methods, using the stabilising effect of soft tissues (zancolli complex-metacarpophalangeal retention apparatus) and external devices (metacarpophalangeal block splint), thus enabling bone healing and movement recovery at the same time.

Locking compression plate in the treatment of forearm fractures: a prospective study.

PURPOSE: To evaluate the use of locking compression plates (LCPs) in diaphyseal forearm fractures. METHODS: 9 women and 23 men (mean age, 35; range, 12-70 years) with 45 forearm fractures were treated by open reduction and internal fixation with 3.5-mm stainless steel LCPs. All patients were followed up monthly until union; the mean duration being 20 months. Radiographic assessment was performed at 3, 6, 12, and 18 months. Clinical assessments regarding pain and function were undertaken at the final follow-up. RESULTS: Two patients had delayed union but none had nonunion. There was no deep infection and only one superficial infection. Two refractures occurred after implant removal, both were of simple transverse type and at the sites of the original fractures. 33% of the fractures were reduced anatomically. 56% of the fractures healed with no or minimal callus formation and 44% with moderate callus formation. In total, 13% of the anatomically reduced fractures had moderate or abundant callus formation. 22 patients opted for removal of the implants (29 LCPs), after a mean of 16 (range, 9-21) months. CONCLUSION: The LCP is an effective bridging device used for treating comminuted fractures, but for treating simple fractures its superiority over conventional plating is yet to be proven.

Nicolau syndrome following intramuscular diclofenac administration: a case report.

Nicolau syndrome (livedoid dermatitis) is a rare adverse reaction of a still largely unidentified pathogenesis at the site of intramuscular drug injection. The typical presentation is pain around the injection site soon after injection, followed by erythema, livedoid patch, haemorrhagic patch, and finally necrosis of skin, subcutaneous fat, and muscle tissue. The phenomenon has been related to the administration of a variety of drugs, including non-steroidal anti-inflammatory drugs, corticosteroids, and penicillin. We report a case of Nicolau syndrome following an intramuscular injection of diclofenac. The large ulceration over the right buttock was positive for Pseudomonas aeruginosa, and histology revealed subcutaneous fat necrosis and non-specific inflammation with no evidence of malignancy or vasculitis. The lesion required multiple debridements and a partial-thickness skin graft. Subcutaneous injection, rather than intramuscular injection, was found to be a determining factor in this case. Clinicians must be cautious in the use of proper injection procedures, including appropriate needle length, in order to minimise complications.

Treating deep-seated mycobacterium marinum infection in the hand: a report of three cases.

We report three cases of an unusual aggressive type of Mycobacterium marinum infection of the hand which had been a nightmare both for us and the patient. These were the patients in which even after repeated thorough surgical debridement and appropriate (drug sensitive) medical treatment over a period had resulted in amputation or devastation of the soft tissues so extensively that almost only the neurovascular bundle, bone and the skin were the only structures left (cosmetic fingers - no function) at the last debridement after which the infection has not recurred. By presenting this article we want to stress on certain points pertaining to diagnosis, management, varied presentation and of course the dreadful complications of deep-seated M. marinum infection.

A novel artificial prosthetic replacement for the proximal interphalangeal joint of the hand--from concept to prototype.

This article describes the development of a proximal interphalangeal (PIP) joint prosthesis based on the principles of replicating anatomical surface components, the use of macrolocking intramedullary stem and the use of a cobalt-chrome alloy material. The design features are intended to obtain an optimal range of motion while retaining stability and longevity. The final prototype, for which a patent has been filed, is described.

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.

Synovial involvement by Mycobacterium marinum. A histopathological study of 25 culture-proven cases.

The present culture-proven cases are contrary to the generally held view that infection with Mycobacterium marinum is habitually a superficial infection without potentially serious consequence. A wide spectrum of pathological lesions may be seen in the synovium and adjacent tissues in patients infected by M. marinum. Variations in the morphology of the inflammatory reaction occurs both between cases and, to a lesser extent, in different areas of individual cases. The inflammation ranges from the common non-specific diffuse form, to lesser areas of focal non-caseating lesions, to rarer focal caseating types of granulomatous reaction, and can include an acute inflammatory cell component. Fibrinous exudate on the synovial surface is a recurrent feature and is often the site harbouring most acid-fast bacilli. The variation of inflammatory reaction with time and the possible effects of local steroid injection are discussed.

Treatment of displaced intra-articular fractures of the distal end of the radius with plates.

Thirty-four displaced intra-articular fractures of the distal aspect of the radius in thirty-four patients were treated with open reduction and internal fixation with plates and screws. Although there was a high rate of complications (nine [26 per cent] of thirty-four fractures), twenty-eight patients (82 per cent) had a good or excellent result according to the system of Gartland and Werley and twenty patients (59 per cent) had a good or excellent result according to the modified system of Green and O'Brien at the most recent evaluation. Immediately postoperatively, the articular surface of the distal aspect of the radius was restored to a mean of 2 degrees of volar tilt and 20 degrees of radial angulation and radial length was improved by a mean of ten millimeters compared with the preoperative length. The articular surface was restored to congruity or to at most one millimeter of step-off in twenty-six patients (76 per cent). By the time of the most recent evaluation, the initial postoperative alignment had changed markedly in three patients (9 per cent) and degenerative osteoarthrosis (grade II or III) had developed in six patients (18 per cent). We considered that the initial postoperative alignment had changed markedly when the articular surface was displaced by two millimeters or more, when the extra-articular alignment had changed by more than 10 degrees of radial tilt, or when there was more than five millimeters of radial shortening. The potential for restoration of normal alignment and the stability of the fixation are the main advantages of internal fixation with plates. Restoration of congruity to the joint was the major difficulty in this group of patients.

Fat embolism in Hong Kong Chinese.

A prospective study on fact embolism showed that of ninety-five patients with a fractured shaft of the femur, seven (7 percent) demonstrated both pulmonary and cerebral disturbances, while there were profound disturbances in arterial PO2, hemoglobin level, pulse rate, and temperature in about 40 per cent of the patients. Using a modified Gurd test, a significant amount of fat was demonstrated in 5.7 per cent of the samples of venous blood and in 18.5 per cent of the samples of arterial blood.

Surgical treatment of scoliosis following poliomyelitis. A review of one hundred and ten cases.

We reviewed the cases of 110 patients with paralytic scoliosis due to poliomyelitis who were operated on. In the lumbar region, anterior Dwyer instrumentation with posterior fusion gave excellent correction of scoliosis and pelvic obliquity. In the more rigid thoracic curves, combined anterior Dwyer instrumentation and posterior fusion gave better results than posterior fusion alone, but had more morbidity. Long c-shaped curves benefited more from a combined anterior Dwyer procedure at the apex of the curve and long posterior Harrington instrumentation. Traction was found to be of use only in rigid curves and in those larger than 80 degrees. With combined anterior and posterior fusion, there was a pseudarthrosis rate of 7 per cent in lumbar curves, none in thoracic curves, and 12.5 per cent in long c-shaped curves. The pseudarthrosis rate rose to more than 25 per cent in patients who had a posterior fusion alone.

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.

Anterior spinal fusion or deranged lumbar intervertebral disc.

Ninety-seven patients who underwent anterior interbody fusion for lumbar disc derangement were examined two to 15 years after the operation. Complete relief of back pain was obtained in 60% and of sciatica in 85%; marked improvement of back pain was obtained in 29% and of sciatica in 10%. The fusion rate was 63% and was only slightly correlated with symptomatic improvement. Many complications were encountered, most of which were transient.

Psychosocial factors influencing outcome in patients with low-back pain.

A psychosocial analysis of 58 patients with low-back pain was conducted. Three groups of patients with different outcomes were delineated with distinctly different psychosocial profiles. Patients who recovered uneventfully had a better income, reported more satisfaction with hospitalization or medical personnel, and had prolonged pain-free periods. Patients with the worst outcomes in terms of poor work role adjustment and severe pain complaints were more likely to be immigrants from mainland China, to be engaged in heavy manual labor, to be involved in compensation claims for work-related injuries, manifested a high degree of anxiety and depressive symptoms, and were hostile toward medical personnel. An intermediate group of patients with adequate work role adjustment but severe to moderate levels of pain were characterized by being females with varying combinations of anxiety and depressive symptoms. A preliminary clinical interview guide for screening potential problematic patients was developed.

Fracture of the tibial tubercle in the adolescent.

We have reviewed 16 patients with avulsion fractures of the tibial tubercle, mostly boys who sustained left-sided injuries during sport. Two-thirds had type I or II injuries and were treated conservatively. Fractures involving the knee joint (type III) had internal fixation. The final results were good except for minor complications such as a prominent and uncomfortable tibial tubercle.

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.