Health care the tie that binds.
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Canada↗
Biomedical subjects
R Y McMurtry
Publications and source records attributed to R Y McMurtry.
Acting in medical practice.
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Attitude of Health Personnel↗
An alternative method for determination of the carpal height ratio.
Radiographs of the wrist often do not include the entire third metacarpal, so the standard method for measurement of the carpal height ratio (the carpal height divided by the length of the third metacarpal) cannot be used. In this study, the ratio of the carpal height relative to the length of the capitate was evaluated for its suitability as a reproducible alternative. The revised carpal height ratio (the carpal height divided by the capitate length) was evaluated for reproducibility and clinical utility in both in vitro and in vivo studies: it was determined from the radiographs of ten cadaveric wrists; those of 100 wrists (fifty pairs) of normal volunteers, made with controlled positioning; those of 100 wrists, drawn at random from radiographs that had been previously interpreted as showing normal findings; and those of fifty wrists of twenty-nine patients who had documented rheumatoid arthritis. The new ratio was found to be constant in the normal population, consistent bilaterally, decreased in patients who had carpal collapse, and reproducible.
Adult↗
The professional perspective--why get involved?
Four myths threaten Canadian medical education and the health care system. These myths are: (1) that health care costs are out of control; (2) that physicians can stimulate demand for health services; (3) that health research is a nicety; and (4) that health is an externality to considerations of economic policy. These myths tend to focus current concerns on sustainability, rather than on the ideal of continuous improvement. Comparative examinations reveal that Canadian health care spending is not out of line with that in other developed countries and suggest relative efficiency in the Canadian health care system. A broad and introspective approach to medicine is required that can critically address diverse issues such as variance in clinical practice patterns and the impact of poverty and unemployment. If health care educators can enshrine this approach in medical schools, professional medicine will be able to respond to the changing needs of Canadian society.
Canada↗
Multidirectional radiocarpal dislocation without fracture: a case report.
The first reported case of posttraumatic multidirectional instability of the radiocarpal joint is described with a review of the relevant literature. A 31-year-old man sustained a palmar radiocarpal dislocation that also dislocated dorsally with gentle provocation and showed ulnar translation and a dorsal intercalated segmental instability pattern after closed reduction. Treatment consisted of open reduction and internal fixation with 11 weeks of immobilization. Follow-up at 32 months showed excellent clinical and radiographic results. Multidirectional instabilities of the radiocarpal joint can occur with radiocarpal dislocation, and one must look for them when planning treatment. Anatomic realignment of the bones and joints is recommended to allow soft tissue healing and prevention of secondary ligamentous laxity.
Adult↗
A critical analysis of Swanson ulnar head replacement arthroplasty: rheumatoid versus nonrheumatoid.
Clinical and radiographic assessment of the results of 40 Swanson silicone ulnar head prosthesis implants in three different patient groups is presented. Twenty-eight were done for treatment of rheumatoid arthritis, eight for ulnoradial impingement after the Darrach procedure, and four for ulnocarpal impingement resulting from malunited Colles' fractures. Patients were reviewed 12 to 48 months after operation (mean, 29 months). Seventy-eight percent of patients reported relief of pain and improved function. Radiologic examination showed that all patients exhibited resorption of the distal ulna (mean 4.4 mm) and that resorption was worst in the group with rheumatoid arthritis. Bone resorption about the implant predisposed the cap to both side-to-side tilt and pistoning of the prosthesis on supination and pronation. There was a 10% revision rate because of silicone synovitis. Although clinical results remain satisfactory for patients with rheumatoid arthritis and ulnocarpal impingement, the radiologic results suggest that Swanson ulnar head replacement should be restricted to elderly patients with rheumatoid arthritis.
Age Factors↗
Open reduction and internal fixation of comminuted, intraarticular fractures of the distal radius.
Comminuted intraarticular fractures of the distal radius present a difficult problem in management. It is well established that unreduced significant articular incongruency will result in early degenerative osteoarthritis. The technical demands of, and the results to be expected from, formal open reduction and internal fixation of these comminuted articular fractures have not been addressed in the current literature. From 1981 to 1986, 20 patients were treated by open reduction after failure of closed means. Seventeen patients were personally reviewed at an average follow-up of 3.25 years. The results indicate that the procedures are technically demanding and have high early (15%) and late (35%) complication rates. This gives an overall complication rate of 50%, including the need for further operative procedures. However, patient satisfaction is very high, most patients (89%) returning to previous occupations. Function and radiographic results are excellent. Articular congruency was restored in 88%.
Adult↗
Blood alcohol testing of motor vehicle crash admissions at a regional trauma unit.
Motor vehicle crashes remain a leading cause of death and injury in the industrialized world. Alcohol consumption is implicated as a major factor in fatal motor vehicle crashes (MVCs), but only poor estimates of blood alcohol concentrations among nonfatally injured crash victims are available. A 3-year study was undertaken at a Regional Trauma Unit to determine the demographics, injury severity, and alcohol positivity of motor vehicle crash victims. Between August 1, 1986 and July 31, 1989, 825 motor vehicle crash victims were available for study; 368 drivers were admitted to the unit within a period of 4 hours. Of 715 patients tested for alcohol, 31.0% were positive. A total of 333 drivers were tested for blood alcohol; 128 (38.4%) were positive. The mean blood alcohol concentration (BAC) at admission for the drivers was 145.6 mg/100 ml; the estimated mean BAC at crash was 180.9 mg/100 ml. The mean age of BAC positive drivers was 31.4 years, compared to a mean age in the BAC negative drivers of 35.2 years (p less than 0.02). Male patients represented 76.6% of the drivers, yet represented 83.6% of the BAC positive drivers (p less than 0.05). There was a marked seasonal variation in BAC positivity, with 46.1% of drivers positive during the summer months. Alcohol appears to be a significant factor in nonfatal MVCs.
Accidents, Traffic↗
Current concepts in trauma: 1. Principles and directions for development.
Despite considerable advances in treatment in the last 20 years, trauma continues to be the main cause of disability and death for people under the age of 40 years. The outcome after injury has been improved by the introduction of advanced prehospital life support, early transfer and the establishment of specialized programs. Trauma care is governed by two underlying principles: early definitive management and a continuum of treatment from the time of injury to the return to the activities of daily life. Most important, a team approach is necessary in the treatment of the trauma patient. This requires the cooperation and participation of prehospital emergency personnel and referring hospitals as well as multidisciplinary collaboration within each trauma centre. There continue to be areas of neglect that prevent optimal trauma care and must be addressed.
Adolescent↗
Current concepts in trauma: 2. The Sunnybrook Medical Centre trauma program: the first 11 years.
Sunnybrook Medical Centre is a tertiary care teaching hospital situated in metropolitan Toronto. Its trauma unit, opened in June 1976, serves the inhabitants of metropolitan Toronto and the surrounding area (approximately 5 million). More than 3200 patients were admitted to the unit between 1976 and 1987. The criteria for admission were age at least 14 years and an Injury Severity Score (ISS) of 16 or greater, two or more significant injuries at anatomically discrete sites when the score on the Abbreviated Injury Scale was 3 or greater, or grade IV shock (systolic blood pressure of 80 mm Hg or less). The number of patients admitted annually to the unit increased over the study period. The survival rate also increased, from 76% in 1976 to 88% in 1987, although the average age and ISS of the patients remained unchanged. Less than 2% of the patients required long-term rehabilitative or chronic care. The patient profile is similar to that seen in other trauma centres in North America. The success of this program is largely the result of expeditious stabilization and transfer from referring hospitals coupled with early definitive surgical intervention.
Academic Medical Centers↗
Radiographic definition of the dorsal and palmar edges of the distal radius.
The dorsal and palmar edges of the distal radius, as well as the concavity of the articular surface were labeled with wire and radiographs taken from neutral to 30 degrees of added dorsal tilt. The dorsal edge was identified as the structure that protrudes distally in neutral. The palmar edge was found to overlap with the sclerotic subchondral bone of the radius in neutral. With increasing dorsal tilt the profile of the palmar edge appeared as it protruded distal to the sclerotic subchondral line of the radius. The profile of the palmar edge could be distinguished from that of the dorsal edge on the anteroposterior view. The wire, which was placed midway between the dorsal and palmar edges and the concavity of the articular surface corresponded to the prominent sclerotic subchondral bone line of the distal radius. This did not change in position with increasing dorsal tilt. This clarification of the radiologic anatomy is helpful in extending the use of the anteroposterior radiograph for the interpretation of fractures and malunions of the distal radius.
Humans↗
Gamekeepers thumb: a prospective study of functional bracing.
Patients with acute thumb metacarpophalangeal joint injuries were assessed by stress radiography, arthrography, and clinical examination. Arthrograms served to assess tissue injury by the extent and location of dye leaks including the differentiation of displaced (Stener lesion) from undisplaced tears of the ulnar collateral ligament. Patients were treated for a minimum of 6 weeks by use of a removable custom-fit splint and daily range of motion exercises, and followed at a minimum of 1 year. In the 32 patients available for follow-up, mean relative instability improved from 17 degrees (after injury) to 2.3 degrees (follow-up) (p = 0.0001). Functional and subjective outcomes were good or satisfactory in more than 90% of patients; outcomes for all patients with Stener lesions were satisfactory, although joint stabilization was less than in the whole group. The three failures involved persistent symptoms, that defied subsequent surgery. These cases could not be predicted from the initial clinical tests. The treatment regimen was an economical, noninvasive, and effective method for a range of acute thumb metacarpophalangeal joint injuries.
Adolescent↗
Distal radial osteotomy.
Malunions of distal radius fractures are commonplace. Patients are decreasingly willing to accept the disability that may be associated with them. While the first line of treatment is initial good fracture care, corrective osteotomies offer later opportunity for pain relief and improved function.
Adult↗
Limited open reduction of the lunate facet in comminuted intra-articular fractures of the distal radius.
Intra-articular incongruity of the distal radius at the radiocarpal joint is a bad prognostic feature; reduction by closed or open operative techniques is important. However, both techniques have limitations. We describe a new technique of reduction of the lunate facet under radiographic control, with very limited operative exposure and tissue trauma. In two cases anatomic restoration of the radiocarpal joint was obtained by this technique and maintained with external and limited internal fixation. Follow-up results are very encouraging. Currently we suggest use of this simple technique when faced with an incongruous radiocarpal joint after unsatisfactory attempts at closed reduction.
Adult↗
Dorsal dislocation of the ulnar styloid and extensor carpi ulnaris tendon into the distal radioulnar joint: the empty sulcus sign.
Two cases of distal radioulnar joint (DRUJ) disruption and diastasis secondary to distal radial fractures were associated with displacement of the ulnar styloid and extensor carpi ulnaris (ECU) into the DRUJ. Both cases had a palpable empty ECU tendon sulcus. In one case surgical exploration revealed that the ulnar styloid, triangular fibrocartilage, and extensor carpi ulnaris tendon had dislocated into the DRUJ as a unit. The end result was good. In the second case lack of recognition and reduction of the ECU tendon and ulnar styloid led to persistent subluxation and diastasis. The end result was poor. Early recognition of the dislocation of the ulnar and ECU into the DRUJ and their significance may avoid poor results.
Aged↗
Pathologic conditions of the pisiform and pisotriquetral joint.
In eight of sixteen patients with symptomatic pisotriquetral joints the pisiform was excised. A detailed study allowed correlation of the etiologic factors with the pathologic diagnosis. In a similar fashion pathologic-etiologic data were retrieved from 216 cases identified from the world literature and organized into the following four pathologic groups: primary OA (2.3%), secondary OA (48.4%), other arthritides (4.7%), and flexor carpi ulnaris enthesopathy (44.6%). The most common causes were acute and chronic trauma and instability. On the basis of these data, we hypothesized that loss of integrity to the surrounding retinacular structures of the pisiform may lead to instability and thus dysfunction of the joint.
Adult↗
The unstable pelvic fracture. Operative treatment.
While the pendulum has swung to the operative side, open reduction and internal fixation will surely not prove to be the panacea for all unstable pelvic fractures. The lasting effects, however, of attempts at aggressive fixation of the pelvic fracture will be the principles of management that are being established. This begins with the recognition of pelvic instability. It is in these unstable injuries that obtaining and maintaining an anatomic reduction is the best way to alter the natural history of the untreated pelvic fracture and to maximize the probability of obtaining a good long-term result. While the actual methods of internal and external fixation will continue to change, this principle is unlikely to alter. Therefore, if effective treatment can be achieved by closed means alone, that is an acceptable method. Similarly, external, internal, and combined operative and traction treatment methods that achieve this goal would also be acceptable. The question remains: Which method achieves the goal of obtaining and maintaining an anatomic reduction yet minimizes the early and late morbidity? This question is best answered by appropriate preoperative evaluation, subsequent planning, and precise, technically skillful surgery done by an experienced surgeon.
Bone Plates↗
Median nerve compression by volarly displaced fragments of the distal radius.
Median nerve compression may occur acutely, subacutely, or late following fractures of the distal radius. Hematoma and swelling at the mouth of the carpal tunnel are the likely cause in acute cases. A contributing factor generally not recognized initially is a volarly displaced fragment of distal radius compressing the median nerve against the proximal edge of the flexor retinaculum. In nine such fractures, median nerve compression occurred in eight. Lack of recognition led to the delay in diagnosis and treatment of two patients. The volar fragment could always be seen on the first postreduction roentgenogram. Carpal tunnel release and removal or reduction of the displaced volar fragment should be carried out as early as possible to avoid the complications of reflex sympathetic dystrophy. Removal of the bony fragment alone, without carpal tunnel decompression, may be insufficient.
Carpal Tunnel Syndrome↗