Chance fracture in a child: a case report with nonoperative treatment

The Chance fracture is an unusual lesion of the lumbar spine. Although 33 cases have been reported, only eight have occurred in adolescents and none in young children. We report here a case in a 6-year-old child.     

髋臼骨折经手术或非手术治疗失败后的晚期全髋关节置换术

目的探讨髋臼骨折经手术或非手术治疗失败后采用晚期全髋关节置换术（LTHA）治疗的方法与疗效。方法共16例16髋，其中男9例，女7例。年龄26～71岁（平均45岁）。首次骨折治疗：非手术6例（非手术组），切开复位内固定10例（手术组）。LTHA术前诊断：创伤性关节炎（PA）6例，股骨头无菌性坏死（NFH）5例，PA合并股骨头脱位5例。伤后至LTHA的时间为4个月～20年。假体选择与固定：采用陶瓷-陶瓷假体9例（陶瓷组），金属-聚乙烯臼假体7例（金属-聚乙烯组）。全部假体均采用生物学固定。结果无感染、脱位以及神经、血管损伤等并发症。术后X线片示臼杯覆盖固定以及股骨柄假体初始固定均优良。随访2～10年（平均6年）后，优12例，良2例，尚可2例（因原合并坐骨神经伤未恢复），至今无1例假体翻修或需要翻修治疗。结论①LTHA是髋臼骨折经手术或非手术治疗失败后的有效治疗方法；②髋臼骨折经手术治疗失败后的LTHA，由于广泛瘢痕、异位骨化、以及内固定阻挡等原因，手术难度显著大于经非手术治疗失败者；③采用非骨水泥固定以及采用界面耐磨损材料假体是改善LTHA远期疗效的关键。     

Carotid endarterectomy after a completed stroke: reduction in long-term neurologic deterioration

The merit of carotid endarterectomy for patients who previously have sustained a completed stroke remains controversial. Between January 1976 and December 1983, 118 stroke patients with mild to severe permanent neurologic deficits were evaluated. Fifty-nine patients were managed nonoperatively and 59 operatively. Both cohorts were similar in age and sex distribution, incidence of hypertension (69%), diabetes mellitus (25%), and cardiac disease (39%). In the long-term follow-up (medical cohort average was 44.1 +/- 5.0 months; surgical cohort average, 41.8 +/- 3.7 months) the overall survival rate was comparable, that is, there were nine medical deaths and eight surgical deaths. However, there was a significant difference in the development of new neurologic deficits. Twelve of the 59 unoperated patients had new neurologic deficits and three patients died at 12, 36, and 48 months as a result of a recurrent stroke. New neurologic deficits developed in only two of the 59 surgical patients and there were no stroke-related deaths. When the cumulative probability of remaining free from recurrent deficits was examined in the surviving patients at 6 years, all of the patients in the operated group remained free from recurrent deficits, whereas only 58% of the patients in the unoperated group were free of new neurologic deficits (p = 0.02). These data suggest that stroke patients with fixed mild to moderate neurologic deficits and with carotid lesions may be protected from recurrent neurologic complications by carotid endarterectomy.     

Septic arthritis of the hip after nonoperative treatment of a pelvic fracture associated with bladder rupture

A case is presented describing a patient who developed septic arthritis of the hip after nonoperative treatment for a closed pelvic fracture associated with an extraperitoneal bladder rupture.     

Late deterioration of neurologic function in patients surgically treated for spinal dural arteriovenous fistulas

BackgroundA limited number of reports on the long-term neurologic outcome of patients with SDAVFs treated by surgery and/or embolization are available in the literature. The aim of our study is to neurologically evaluate these patients at 2 different follow-up stages, after surgery, to demonstrate a possible late neurologic deterioration after an initial improvement.MethodsBetween January 1987 and May 2002, 29 patients with SDAVFs were operated on at the Verona Department of Neurosurgery. In this group we retrospectively identified 16 patients who had 2 different clinical follow-ups, at a mean of 4.5 and 9.2 years, respectively. We compared their neurologic status using the ALS. All these data were obtained from clinical charts and phone interviews.ResultsThe epidemiologic, clinical, and radiologic features of our group of patients are very similar to those previously described in the literature. Comparing the global clinical status between the 2 different follow-up stages, we observed a late deterioration in 8 cases (50%). A worsening of the mean G and M values of the ALS was also noted. Spinal angiography and contrast-enhanced MRI did not show any signs of recurrence of the fistula.ConclusionsOur study confirms the possible occurrence of a late clinical deterioration in as many as 50% of patients surgically treated for a SDAVF. We deem that the main pathophsyologic mechanism underlining this phenomenon is a gradual and irreversible decline in spinal function related to those hemodynamic modifications induced by the fistula and to the persistence of a state of anatomofunctional deficiency of the spinal venous drainage.     

Unusual mechanism of Chance fracture in an adult

Flexion-distraction injuries of the upper lumbar spine typically occur in case of a head-on motor vehicle collision, while wearing a lap seat belt without shoulder strap. According to Smith and Kaufer the axis of flexion is situated at the point of contact of the belt with the abdominal wall. This results in a horizontal separation of the anterior, middle and posterior columns. The lesion is called a Chance fracture when it involves primarily bone, rather than ligaments. However, a Chance fracture can happen in unbelted persons: the present case concerns a 30-year-old man who fell from a height.     

Brain dehydration and neurologic deterioration after rapid correction of hyponatremia

We made rats severely hyponatremic, varying the rate of onset and duration of the disturbance, and then compared rapid correction to slow correction. An acute fall in the plasma Na to 106 mEq/liter within seven hours caused seizures and coma, but these findings resolved and survival was 100% after either rapid or slow correction. A more gradual fall in plasma Na to 95 mEq/liter in three days caused neither seizures nor coma. Measurements of brain water and electrolytes showed that adaptive losses of brain Na and K (maximally depleted within seven hours) and slower losses of non-electrolyte solutes progressively reduced brain edema. After three days of hyponatremia, rapid correction to 119 mEq/liter with 1 M NaCl or to 129 mEq/liter by withdrawing DDAVP caused brain dehydration because lost brain K and non-electrolyte solutes were recovered slowly. This treatment was followed by a delayed onset of severe neurologic findings, demyelinating brain lesions and a mortality rate of over 40%. Slow correction (0.3 mEq/liter/hr) avoided these complications and permitted 100% survival. We conclude that the rat adapts quickly to hyponatremia and can survive with extremely low plasma sodium concentrations for prolonged periods. Although rapid correction is well tolerated when hyponatremia is of brief duration, it may cause brain damage in animals that have had time to more fully adapt to the disturbance.     

Causes of neurologic deterioration following surgical treatment of cervical myelopathy

Neurologic deterioration was analyzed in 110 patients with surgically treated cervical myelopathy secondary to soft disc hernia or spondylosis. Follow-up periods ranged from 2 to 14 years, with an average of 6 years. Of 110 patients, 29 suffered neurologic deterioration. In most of the patients, deterioration occurred within the first year after surgery. Causes of deterioration were divided into three categories: direct trauma to neural tissue during surgery (a preventable complication); instability of the spine, progression of spondylotic changes above or below the level of fusion, and non-union (apparently unpreventable but treatable); and nonsurgery-related accidental trauma (unavoidable and often irreversible). Countermeasures for the deterioration are discussed.     

Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture

BACKGROUND: Nonunion is a rare complication of a fracture of the clavicle, but its occurrence can compromise shoulder function. The aim of this study was to evaluate the prevalence of and risk factors for nonunion in a cohort of patients who were treated nonoperatively after a clavicular fracture. METHODS: Over a fifty-one-month period, we performed a prospective, observational cohort study of a consecutive series of 868 patients (638 men and 230 women with a median age of 29.5 years; interquartile range, 19.25 to 46.75 years) with a radiographically confirmed fracture of the clavicle, which was treated nonoperatively. Eight patients were excluded from the study, as they received immediate surgery. Patients were evaluated clinically and radiographically at six, twelve, and twenty-four weeks after the injury. There were 581 fractures in the diaphysis, 263 fractures in the lateral fifth of the clavicle, and twenty-four fractures in the medial fifth. RESULTS: On survivorship analysis, the overall prevalence of nonunion at twenty-four weeks after the fracture was 6.2%, with 8.3% of the medial end fractures, 4.5% of the diaphyseal fractures, and 11.5% of the lateral end fractures remaining ununited. Following a diaphyseal fracture, the risk of nonunion was significantly increased by advancing age, female gender, displacement of the fracture, and the presence of comminution (p < 0.05 for all). On multivariate analysis, all of these factors remained independently predictive of nonunion, and, in the final model, the risk of nonunion was increased by lack of cortical apposition (relative risk = 0.43; 95% confidence interval = 0.34 to 0.54), female gender (relative risk = 0.70; 95% confidence interval = 0.55 to 0.89), the presence of comminution (relative risk = 0.69; 95% confidence interval = 0.52 to 0.91), and advancing age (relative risk = 0.99; 95% confidence interval = 0.99 to 1.00). Following a lateral end fracture, the risk of nonunion was significantly increased only by advancing age and displacement of the fracture (p < 0.05 for both). On multivariate analysis, both of these factors remained independently predictive of nonunion (p < 0.05), and, in the final model, the risk of nonunion was increased by a lack of cortical apposition (relative risk = 0.38; 95% confidence interval = 0.25 to 0.57) and advancing age (relative risk = 0.98; 95% confidence interval = 0.97 to 0.99). CONCLUSIONS: Nonunion at twenty-four weeks after a clavicular fracture is an uncommon occurrence, although the prevalence is higher than previously reported. There are subgroups of individuals who appear to be predisposed to the development of this complication, either from intrinsic factors, such as age or gender, or from the type of injury sustained. The predictive models that we developed may be used clinically to counsel patients about the risk for the development of this complication immediately after the injury.     

The cause of neurologic deterioration after acute cervical spinal cord injury

STUDY DESIGN: A retrospective review was performed to identify patients at risk for secondary neurologic deterioration after complete cervical spinal cord injury. OBJECTIVE: To examine the causes of early neurologic deterioration in patients with complete spinal cord injury at a regional spinal cord injury center. SUMMARY OF BACKGROUND DATA: After complete spinal cord injury, neurologic deterioration occurs in a subgroup of patients. Despite anecdotal reports, no study has clearly identified the subgroups at highest risks. METHODS: One hundred eighty-two patients with complete spinal cord injury were identified among 1904 consecutive patients with acute spinal trauma evaluated from March 1993 through September 1999. Parameters analyzed included demographics, mechanism of injury, American Spinal Cord Injury Association (ASIA) level on admission and during hospital stay, onset of ascension, blood pressure, hemoglobin, febrile episode, heparin administration, and the timing of operation and traction. Radiographs of patients with ascending complete spinal cord injury were reviewed with attention to fracture type and neurologic and vascular injuries. RESULTS: Twelve of 186 patients with ASIA Grade A (6.0%) complete spinal cord injury had neurologic deterioration during the first 30 days after injury. No patients with penetrating injuries had deterioration. A significant association between death and ascension was observed. The onset of ascension of the injury could be categorized into three discrete temporal subsets. Early deterioration (less than 24 hours) was typically related to traction and immobilization. Delayed deterioration (between 24 hours and 7 days) was associated with sustained hypotension in patients with fracture dislocations. Late deterioration (more than 7 days) was observed in a patient with vertebral artery injuries. CONCLUSION: Delayed neurologic deterioration in complete spinal cord injury (ASIA A) is not rare. Specific causes were identified among discrete temporal subgroups. Management of complete spinal cord injury can be improved with recognition of these temporal patterns and earlier intervention.     

Acute thoracolumbar burst fractures in the absence of neurologic deficit. A comparison between operative and nonoperative treatment

The treatment of thoracolumbar burst fractures in the absence of neurologic deficit remains controversial. The present study is a retrospective analysis of 52 of these acute burst fractures among 104 cases of thoracolumbar burst fractures treated either operatively or nonoperatively. Results are expressed in terms of neurologic function, pain, work status, and complications. All patients who had surgical treatment and no unrelated disability returned to full-time work. Twenty-five percent of the patients treated nonoperatively were unable to return to work full time. Of the patients in the nonoperative group, 17% developed neurologic problems. Prophylactic stabilization and fusion of acute burst fractures without neurologic deficit have significant advantages over conservative management.     

Acute neurologic deterioration following lumbar puncture in an epidural abscess occurring 14 months after epidural catheter placement

We report the case of a 19-year-old girl admitted to the hospital with a 2-month history of back pain and a 1-week history of severe weakness, who underwent a diagnostic lumbar puncture which was swiftly followed by acute neurologic deterioration requiring ventilation. She was subsequently shown to have an epidural abscess extending from the second cervical to the fifth lumbar vertebrae. She had received uneventful epidural analgesia for childbirth 14 months previously. The case is unusual in both the acute deterioration following lumbar puncture, and also in the length of time from epidural siting to abscess formation, if this were indeed the source of the infection.     

Isolated talar fracture in an adolescent

Isolated talar fractures are rare. Their true incidence is unknown and may be overlooked following ankle and hindfoot injuries. We present an isolated talar fracture in an adolescent girl following a trivial injury and suggest a rationale for the investigation of persistent ankle and hindfoot pain in this situation.     

Lumbar Chance fracture in an child associated with an intra-abdominal lesion

We report the case of a teenager who was involved in a road traffic accident. She presented a flexion-distraction type of vertebral injury, (Chance fracture). This fracture was associated with an intra-abdominal injury. The child was a passenger in a rear seat using a shoulder seatbelt restraint.     

Late fiber deterioration in Dacron arterial grafts.

The occurrence of late fiber deterioration was examined in 493 Dacron arterial prostheses. Grafts implanted were of four types: 137 Meadox Wesolowski Weavenit (WN), 71 Golaski Microknit (MK), 70 USCI Sauvage(Tm) external velour non-crimped (EVNC), and 215 USCI Sauvage external velour random-crimped (EVRC). Prostheses had been implanted for three to 15.3 years; no defects were detected prior to three years. Deterioration occurred in 15 of 493 grafts (mean incidence: 3%). Between 4.9% and 5.8% of patients had graft deterioration-nearly the same incidence in all four types of grafts. Deterioration consisted of thinning and breakage of yarn filaments, causing development of holes and, in some cases, graft dilatation. Dilatation did not always precede filament breakage. Broken filament ends were either tapered or square-ended, suggesting that modes of breakage. Tensile strength tests howed that fibers sometimes weakened nonuniformly within a specimen. Fiber breakage was associated with crimp ridges. The findings suggest that manufacturing variations probably reduce fiber resistance to mechanical fatigue. Other contributing factors may include storage conditions, sterilization methods, handling, and the degradative effects of tissue fluids and enzymes.