Biomedical subjects
Publications and source records attributed to B R Johnstone.
Duplicate thumb is a common congenital difference with complex management. Surgical treatment includes reconstruction of the collateral ligaments to optimise future function and cosmesis. We present the use of the "U-ligament" to further refine collateral ligament reconstruction. We have found it to be a simple and reliable technique.
Primary shortening of the flexor digitorum profundus tendon to the pollicized index finger was routinely performed during all congenital pollicizations over a 3-year period. Interphalangeal joint flexion of the pollicized digit was observed to begin within weeks after pollicization. The rebalancing of the pollicized long flexor musculotendinous unit has the potential for greater long-term strength.
Necrotising fasciitis is a severe soft tissue infection which spreads rapidly through fascial planes, is characterised by soft tissue necrosis and is potentially life-threatening. It is a rare entity in the head and neck region. The management of this condition is difficult and early diagnosis and aggressive surgical and medical management are essential. This paper reports two cases of necrotising fasciitis as a result of ascending odontogenic infection involving the temporalis muscle.
A consecutive series of 20 joints in 13 patients underwent arthroplasty with the RMS PIP joint surface replacement implant. Twelve joints were treated for painful osteoarthritis (all females). Two joints were implanted for rheumatoid arthritis, two for post-traumatic pain and stiffness, two for post-traumatic stiffness and one each for post-traumatic pain and pain-free post-traumatic instability. Excellent, often total long-term pain relief was obtained in 18 joints. The other two patients with (compensible work-related) post-traumatic pain and stiffness reported "50-70% pain reduction". No patients lost movement and 14 out of 20 joints were pain-free with a 73.1 degrees average arc of motion. Six joints from the first half of the series had poor motion (average arc of 19.6 degrees ), even after open extensor tenolysis or manipulation under anaesthesia. As experience was gained, reliably better results were achieved with a more intensive regimen of hand therapy, particularly within the first post-operative week.
Rural residents with brain injury have difficulty in accessing care from qualified psychologists for consequent cognitive, emotional and behavioural symptoms. We examined high-quality videoconferencing to enhance care for persons with brain injury in three areas: cognitive assessment, psychotherapy and rural mental health training. The assessment study evaluated 52 outpatients seen for diagnostic visits over videoconferencing, and compared their experiences with those of 52 age- and diagnosis-matched controls seen in person. Persons seen via telemedicine were more likely than controls to want to repeat their experience and more satisfied than were the neuropsychologists who examined them. In the psychotherapy study, neurorehabilitation patients were seen via videoconferencing for therapy related to brain injury or stroke. Persons receiving psychotherapy were less likely than persons receiving assessment services to want to repeat their experience. In the training study, 39 rural mental health providers were trained via videoconferencing, and trainees demonstrated significant improvement on tests of knowledge about brain injury. Trainees formed a network of mental health provider referrals for persons with brain injury in a wide geographic area. Given adequate training and ongoing support, rural clinicians can treat many brain-injury adjustment issues locally, reserving specialist consultation for emergency or complex problems.
We report the use of an innervated posterior thigh flap to reconstruct the sole of a 6-year-old boy. This modification of the posterior thigh flap produced an aesthetically and functionally normal foot, capable of withstanding the stresses of youth and allowing the wearing of normal footwear, with a minimal donor defect.
Lawn mowers cause severe injuries, particularly to the lower limbs in children. The study of 52 inpatient cases treated over 12 years shows that ride-on lawn mowers cause the most severe trauma, resulting in longer hospitalization. These children more often require further admissions for reconstructive surgery including free tissue transfer. These accidents can be avoided if young children are prevented from playing near or using power lawn mowers.
Plastic surgeons have contributed to the understanding of pressure sore pathophysiology and prophylaxis. Increasingly sophisticated surgical techniques such as myocutaneous or innervated flaps add to the reliability and durability of repairs. The majority of quadriplegics may benefit from surgical restoration of active elbow extension, lateral pinch and grasp. Prolonged postoperative care in bed or immobilisation of the upper limb demands that patients should understand fully all that the reconstructive procedure involves. The nature and importance of subsequent rehabilitation must be appreciated by the patient so that he will be motivated to achieve the best possible result. Functional electrical stimulation may find an increasing role in the years to come.
The options for surgical reconstruction of the quadriplegic upper limb are clarified by a new international classification of each limb independently, based upon the lowest functioning key muscle and residual sensation. Surgical restoration of active elbow extension, of pinch, and of grasp is now an accepted part of rehabilitation. This additional function may be achieved by transfer of a non-essential muscle, by tenodesis, or occasionally by arthrodesis. The techniques available for each group of the new international classification are described.
Fifteen quadriplegic (tetraplegic) patients from the Spinal Injuries Unit of the Austin Hospital have had surgery to improve function in 17 of their upper limbs. Changes in strength, function, subjective ratings and the influence on 198 activities of daily living are reviewed. The posterior third of the deltoid muscle was transferred into 8 triceps tendons to provide active elbow extension in seven patients. Six patients had transfers of forearm muscles to provide grasp and lateral pinch or active extension of wrist and fingers. Other operations included transfer of the latissimus dorsi to the forearm producing elbow flexion, medial advancement of the anterior deltoid origin improving shoulder control (an operation which has not been described previously), and tenodesis for stabilizing the wrist. The objective results were satisfactory in 12 patients. Eleven patients had either good or excellent subjective results. The maximum force of active elbow extension achieved was 6.8 kg and the peak grip strength reached was 10.5 kg. Six patients achieved subjective results higher than would have been expected from objective assessment. All patients benefited in some way, 13 patients felt that surgery was worthwhile and no patient lost appreciable function. The results of this series indicate that upper limb surgery has a definite place in rehabilitation of the quadriplegic patient. Improved surgical technique may reduce the time required for postoperative rehabilitation and thus make these procedures feasible for a larger number of patients.
A pattern of injuries has been observed in five (5) female front seat passengers wearing seat belts. All were involved in high speed frontal impact motor vehicle accidents on country roads. Varying degrees of abdominal wall disruption involving fat, fascia or muscle, were universally associated with hollow viscus injury and right-sided rib fractures. Most patients had mesenteric or omental tears, flail chests and left clavicular injuries. Intimal tears of the distal aorta, right breast injuries and spinal injuries were also observed. The hollow viscus and mesenteric injuries may result from direct crushing, sudden rises of intraluminal pressure, or shearing forces acting at points of mesenteric attachments. At laparotomy it is recommended that necrotic or contused fascia and muscle be excised with primary abdominal closure and contused fat be excised or curetted and suction drainage applied to the subcutaneous tract. Abdominal wall disruption from seat belt trauma reflects the forces involved on impact and should alert the surgeon to the observed pattern of internal injuries.
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The case of a man who was injured by a stroke of lightning while using the telephone is reported. The patient sustained paralysis, sensory symptoms, otological disturbance and pathognomonic dendriform cutaneous marks (Lichtenberg figures). The relevant literature is reviewed, and the epidemiology and preventive measures are discussed.