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Summary 1. The temporomandibular joint is a ginglymo-diarthrodial joint whose anatomy and actions are still not completely known or understood. 2. Degenerative joint disease of the temporomandibular joint is widespread in its occurrence, although it is often symptomless. 3. The etiology of this disease is complex. Microtrauma, overclosure of the mandible, mandibular muscle spasms, age, and possibly heredity all play their part. 4. Local and referred pain and clicking and snapping sounds are the outstanding symptoms. Loss of hearing, tinnitus aurium, vertigo, and neuralgias are accepted as connected with these joint disturbances, but only by some investigators. 5. Roentgenography of the temporomandibular joint has little to offer at this time, and it is of uncertain value in diagnosis. Cinefluorography with image intensification may be part of the answer, but this technique is too new to evaluate. 6. Treatment is aimed to remove the sources of trauma by correcting the occlusion and restoring the vertical dimension, where necessary, to its correct physiologic level. 7. The prognosis is good, and we can usually look forward to a good functional result.

The glenoid labrum is the fibrocartilage of the shoulder joint, anchoring the joint capsule and shoulder ligaments. Morphology varies regionally, especially in the superior and anterior region; these variants can sometimes be confused with pathological aspects. The labrum is often involved in shoulder pathology, by single trauma or, more often, repeated microtrauma. It seems logical to classify and to describe tears according to two criteria: the sector involved, and associated pain or instability. In the superior labrum, SLAP lesions are the most frequent. These combine labral lesion and lesion of the proximal insertion of the long head of the biceps brachii tendon. The most frequent form is SLAP II. They may be associated with instability or not. In the antero-inferior and postero-inferior labrum, lesions are mainly due to instability, particularly Bankart lesions (capsulolabral avulsion) anteriorly and Kim's lesion posteriorly. Circumferential labral lesions may be found in unstable shoulder. Finally, postero-superior lesions involve Walch's internal impingement: repeated contact between the deep surface of the cuff and the labrum, which takes on a degenerative aspect, with a kissing lesion of the cuff. There is no general rule for management: some labral lesions are resected and others fixed. The cause (which is usually shoulder instability), however, needs to be assessed and treated.

Osteoarthritis is the most common joint disease and a major cause of disability. The knee is the large joint most affected. While chronological age is the single most important risk factor of osteoarthritis, the pathogenesis of knee osteoarthritis in the young patient is predominantly related to an unfavorable biomechanical environment at the joint. This results in mechanical demand that exceeds the ability of a joint to repair and maintain itself, predisposing the articular cartilage to premature degeneration. This review examines the available basic science, preclinical and clinical evidence regarding several such unfavorable biomechanical conditions about the knee: malalignment, loss of meniscal tissue, cartilage defects and joint instability or laxity. Level of evidence IV., info:eu-repo/semantics/publishedVersion

Age is the strongest independent risk factor for the development of osteoarthritis (OA) and for many years this was assumed to be due to repetitive microtrauma of the joint surface over time, the so-called ‘wear and tear’ arthritis. As our understanding of OA pathogenesis has become more refined, it has changed our appreciation of the role of ageing on disease. Cartilage breakdown in disease is not a passive process but one involving induction and activation of specific matrix-degrading enzymes; chondrocytes are exquisitely sensitive to changes in the mechanical, inflammatory and metabolic environment of the joint; cartilage is continuously adapting to these changes by altering its matrix. Ageing influences all of these processes. In this review, we will discuss how ageing affects tissue structure, joint use and the cellular metabolism. We describe what is known about pathways implicated in ageing in other model systems and discuss the potential value of targeting these pathways in OA.

Athletes are at increased risk of developing soft-tissue lesions of the lower limbs. Although the majority of these will be benign, the differential diagnosis is broad and increasingly, doctors are turning to magnetic resonance imaging (MRI) as a first-line investigation when presented with these sorts of lesions, both to narrow the differential diagnosis and exclude malignancy. We report the case of a 28-year-old Caucasian man who presented with 2 soft-tissue lesions of the right foot. History and examination of the nodules fitted with a diagnosis of surfers' knots, an unusual form of acquired, benign, connective tissue nodule that may appear over the tibial tuberosities, dorsum of the feet, and occasionally on the chest of surfers in association with repetitive microtrauma during surfing. MRI findings were consistent with this diagnosis with both lesions exhibiting T1 hypointensity and speckled T2 hypointensity with no significant blooming artifact on gradient echo imaging. When imaged with gadolinium, they demonstrated only mild contrast enhancement. MRI is a valuable tool when investigating athletes with soft-tissue lesions over the lower limbs where the possibility of malignancy must be addressed. In selected cases, MRI may be sufficient to permit a conservative approach to the management of these patients.

High-level gymnastic training may cause clinical and radiographic changes in the wrist. A case is reported demonstrating bilateral closure of the ulnar side of the distal radius epiphyseal plate in a patient with a history of high-level gymnastic training. Cumulative microtrauma to the ulnar side of the distal radius epiphyseal plate may cause premature closure leading to a Madelung-like deformity.

A case of ulnar artery occlusion following repeated micro-trauma to one hand is reported. Following resection of the diseased portion of the artery and reconstruction with an interposition vein graft. The patient recovered normal use of the hand. Pathologic examination of the artery confirmed the operative findings. This case is typical of the vascular problems of the hand associated with certain occupations.

Often in the practice of medicine the exact order in which a patient relates his symptoms promptly suggests to his physician a specific line of clinical investigation. Approximately three years ago a patient was examined whose complaints were only those of pain in the jaw joint and hearing loss on the same side. As observed by a younger otolaryngologist, interest in symptoms related to dysfunction of the temporomandibular joint has waxed and waned. Initial enthusiasm was tempered by older confreres and teachers who were pressed to take a stand pro or con. Attempts to explain pinched nerves as producing pain when an intact meniscus was demonstrable by x-ray examination led to further doubts. The more recent concept of disturbed neuromuscular physiology with dental malocclusion caused by missing teeth and prolonged dental microtrauma as etiological factors producing muscle spasm and pain is now widely accepted. An excellent historical review of this

Material fractures in the femoral part of total hip replacements, a late complication, are usually observed in the shaft. In our case, a fatigue fracture of the ball-neck weld occurred 8 1/2 years after implantation of the prosthesis because of insufficient weld depth. Additional negative factors proved to be varus implantation and overloading of the prosthesis due to obesity. The weld represented a point of low resistance. Even if major traumatic events are responsible for the fracture or loosening of an endoprosthesis, overloading (i.e., multiple "microtrauma") is also an important contributing factor.

1. The time course and regional distribution of ‘spontaneous’ cutaneous lesions in rats desensitized to capsaicin as newborns was correlated to behavioural observations and regional distribution of substance P-like immunoreactivity (SP-LI) and tachykinin-like immunoreactivity (TK-LI) in various skin areas. 2. ‘Spontaneous’ skin lesions in the form of wounds, scabs and areas of alopecia were observed in 80–90% of rats desensitized to capsaicin. No major sex-related differences were observed with regard to incidence and distribution of the lesions with the possible exception of a lesser tendency to bilateral lesions in female rats. 3. ‘Spontaneous’ skin lesions were almost restricted to the head: the areas most frequently affected were snouts, periocular and retroauricular regions and ventral area of the neck. 4. No major differences were observed between capsaicin- or vehicle-treated animals in spontaneous or novelty-induced grooming as well as in open-field gross behaviour. Likewise, no differences were observed in the mouse-killing behaviour. 5. Both SP-LI and TK-LI in various skin areas were significantly reduced by systemic capsaicin pretreatment. The rank order of various skin areas for SP-LI or TK-LI levels was: snouts > thigh > neck > abdomen ≃ retroauricular region. 6. Intradermal injection of Arg-neurokinin B, a potent and water soluble derivative of neurokinin B, produced a similar plasma extravasation (Evans blue leakage technique) in the skin of vehicle- or capsaicin-pretreated rats. 7. In capsaicin-desensitized rats fur regrowth (measured at abdominal level, 28 days after shaving) was significantly less than in vehicle-treated animals. 8. The s. c. injection of 1 N HCl in the dorsal thoracic region (an area devoid of ‘spontaneous’ lesions in capsaicin-desensitized animals) produced cutaneous ulcers whose area and depth were greater in capsaicin- than vehicle-treated rats. 9. These findings are consistent with the hypothesis that capsaicin-sensitive nerves play a trophic role in the rat skin and contribute to its ability to react and repair injuries. The most consistent explanation for the restricted localization of ‘spontaneous’ skin lesions to the head seems to be that ‘normal’ injurious factors (such as grooming) operate on a distrophic skin to induce lesions by repeated microtrauma.

A consecutive series of 43 pyogenic granulomata in the oral cavity is presented. Most were located to the marginal vestibular gingivae and only a minority (12%) of these had a history of trauma whereas 70% in extragingival locations had a previous history of injury. On the basis of an evaluation of oral conditions the aetiology and the pathogenesis of the pyogenic granuloma are discussed. Trauma, microtrauma due to toothbrushing and gingival inflammation seem to be pathogenetic elements. It is suggested that the granuloma is a localised tissue response to a non-specific irritant.

Because knowledge of overuse syndromes is limited, the diagnosis and treatment of these conditions are a challenge to sports medicine physicians. Trial and error methods of treatment and too little attention to basic research have resulted in less than optimum solutions. We do know that these maladies most frequently result from overload or repetitive microtrauma stemming from extrinsic factors such as training errors, poor performance, poor techniques and inappropriate surfaces or intrinsic factors including malalignment and muscle imbalance. Overuse injuries involving the muscles include compartment syndromes and muscle soreness; while those involving the tendons result from a variety of degenerative and inflammatory processes. Overstress of bone results in stress fractures, apophysitis and periostitis. Bursitis and joint overstress problems are also discussed briefly. General guidelines for establishing the appropriate diagnosis are: the initial stages of therapy require rest, often a modification or scaled down exposure to the athlete's usual performance rather than complete abstinence; in acutely symptomatic cases pain medications and various measures to control inflammation may be necessary; an exercise programme should start early with range of motion exercises and isometric muscle contractions; when pain allows, dynamic muscle and flexibility exercises can resume together with a conditioning programme; if possible, eccentric exercises should be performed. The treatment may also include other conservative treatment modalities and surgery in special cases. Overuse injuries constitute a great diagnostic and therapeutic problem because the symptoms are often diffuse and uncharacteristic. An appropriate diagnosis followed by adequate treatment can improve or eliminate most of these conditions, but perhaps even more importantly a proper understanding of overuse syndromes should allow physicians to assist athletes, trainers, and coaches in preventing them.

A moderate degree of friction is unavoidable in everyday contact between man's skin and his environment. However, excessive friction and other forms of microtrauma can cause various dermatoses as well as lesions of hair and nails. This paper illustrates that microtraumata significantly influence many skin disorders, including those of occupational origin.

Osteolysis in the distal clavicle--manifested radiographically by erosions, resorption of the subchondral cortical bone, and an increased space between the acromion and clavicle--may occur in patients who experience repeated stress or microtrauma to the shoulder. This entity has a radiographic appearance similar to posttraumatic osteolysis of the clavicle. One patient with painful shoulders and typical osteolytic changes of the clavicles on radiographs is described, with three other cases reported.

It is often difficult to define the boundary between idiopathic arthrosis and trauma. Thus, hallux rigidus and Freiberg-Kohler osteochondritis may be related to microtrauma, and considering the strenuous use to which the foot is put, it is perhaps surprising that osteoarthrosis is not more common. The wearing of poorly adapted shoes and the performing of unsuitable surgical procedures are examples of the abuse to which the evidently robust structures can be subjected. Arthroses are frequent in occurrence, and the failure of one particular component reverberates throughout the organ. Every plan for surgical management of arthrosis must embody a clear appreciation of any overall disturbance.

The increasing participation in organized sports has been paralleled by an increasing number of sports injuries. An exact diagnosis of the injury and an understanding of the mechanisms of injury are essential for proper management, relief of pain, and restoration of function. The two mechanisms of injury are single-impact macrotrauma and repetitive microtrauma. Overuse injuries, which result from repetitive microtrauma, are caused by the interaction of a number of risk factors. Determining the etiological factors present in a given injury is essential for proper management and prevention of overuse injuries. The roles of non-narcotic analgesics, muscle relaxants, and nonsteroidal anti-inflammatory drugs (NSAIDs) in aiding recovery and restoration of function in sports injuries have been extensively studied. NSAIDs, in particular, have been demonstrated in clinical and laboratory studies to speed recovery from overuse sports injury. Their place in acute sports injuries due to single-impact macrotrauma, however, is more controversial.

Charcot's neuroarthropathy may be associated with several conditions, including diabetes mellitus,~ syphilis, = syringomyelia, 3 nutritional deficiencies, 4 congenital indifference to pain, 5,~ and others. 7'8 In recent years, diabetes mellitus has challenged syphilis as the major recognized cause of Charcot joints, 9(pp3-9) although only a small minority of diabetics develop neuroarthropathy. In one large hospital, 90 Charcot joints were observed in an unstated number of diabetics over a 12-yr period, i° The etiology of diabetic neuroarthropathy is unclear, although loss of pain and proprioceptive sensations are probably of major importance2 (ppT-8) Ischemia may play a significant role, 11 despite preservation of the peripheral pulses, 1= and small blood vessel disease may act synergistically with neuropathy, trauma, and infection to produce bone resorption in the distal portion of the foot. Blunting of pain perception or a proprioceptive defect, possible common denominators, deprives the joint of its protection from repeated microtrauma. The arthropathy is characterized by joint swelling, instability, hypermobility, and disproportionately mild pain, and evolves through three pathologic phases.~(vP3-~) Initially, repeated trauma produces fragmentation of cartilage and subchondral bone; pathologic findings are dead bone and dead or living cartilage embedded in synovium. Bone and cartilage fragments coalesce later, producing the characteristic juxta-articular sclerosis. In the presence of joint destruction and disorga

Low-humidity dermatoses arise in the work place as a result of low water content of the air. At a relative humidity of 10% or less, the horny layer becomes rigid and brittle. The combination of low humidity, high temperature, and, frequently, rapid air movement dehydrates the outer stratum corneum. This leads to pruritus and, finally, to low-grade eczema. A roughened, scaly stratum corneum becomes more susceptible to mechanical trauma. Microtrauma from small particles can aggravate the dry scaly dermatosis. Low-humidity lesions resolve quickly with the simple expedients of routine use of moisturizers and/or raising the relative humidity.

The author raises questions about the reliability of Parewijck et als finding of a statistically significant association between IUD users and nonusers in terms of the prevalence of vaginal colonization by Candidiasis. Before any conclusions on the causative role of the IUD can be drawn comparisons should be made between women of the same age and sexual behavior. Parewijck et al do not analyze the characteristics of cases and controls in their study. However 1 important difference between the 2 groups is evident: control women were neither wearing an IUD nor using hormonal contraception. Thus it can be assumed that at least some of these women were using barrier methods of contraception (associated with less frequent sexual intercourse than other methods) or had no sexual partner at the time of the study. This is an important factor to assess in that the contribution of sexual transmission to candidiasis has been appreciated. It seems likely that sexual intercourse facilitates vaginal candidiasis by the transfer of flora from the female external genitalia into the vagina and by microtrauma.

Hindfoot function involves eccentric loading of the subtalar joint and repetitive strain of the calcaneal soft tissues. Both are induced by the serial pattern of foot support. The subtalar joint experiences rapid eversion following heel strike and subsequent inversion during terminal stance. Although these actions reduce the rotatory strain on the ankle joint, they also challenge the local soft tissues and controlling muscles. Compression and traction of the soft tissues about the heel are normal events during each walking cycle. Loading the limb at the onset of stance causes heel pad compression. Conversely, the plantar fascia and tendo Achillis are subjected to significant traction as body weight is transferred onto the forefoot during the latter half of the single limb support period. The intensity of hindfoot stress increases with the vigor of activity. Running creates symptoms that do not arise with ordinary walking. Microtrauma is cumulative. Also, the aging process reduces the ability of tissue to accommodate repetitive force.

Most reports regarding synovial cysts of the spinal canal have been presentations identifying an unusual pathological entity that is to be included in the differential diagnosis of cauda equina compression syndromes. Most of the 26 cases reported represent isolated examples of this pathological process. We present five cases of lumbar synovial cysts encountered in our practice in the past 8 years. Patients with lumbar synovial cysts do not demonstrate any predictable clinical picture. They may present with a unilateral sciatica or neurogenic claudication. Lumbar extension is usually restricted, whereas flexion is full. Mechanical signs of nerve root entrapment or lumbosacral plexus irritation are unimpressive. Neurological deficits are usually mild, if present. Radiological findings include degenerative spondylosis, spondylolisthesis, and a rounded posterolateral extradural mass of low attenuation value adjacent to a facet shown on computed tomographic scan. The etiology of lumbar synovial cysts is not known. Histological findings of myxoid degeneration, microcystic change, calcification, and hemosiderin deposits suggest that chronic microtrauma with occasional focal hemorrhage may play a major role in the etiology of the cysts. With resection of the cyst, the postoperative course is usually uneventful. Recurrences have not yet been encountered in our patients.

In 1910, Kienbock, an Austrian radiologist, described the disease of the lunate that bears his name. It is thought to be caused most often by continuing microtrauma which interrupts the circulation and causes avascular necrosis. In most instances, the lunate receives sufficient blood supply both dorsally and volarly so that if one of these sources of blood supply is interrupted, the other will still provide adequate circulation. In some patients, however, either one or the other of the sources of blood supply is predominant, and if that one is interrupted, avascular necrosis of the lunate results.

Cross-country skiing exercises most of the joints, muscles and tendons in the body giving the skier an all around workout. This, in combination with a low incidence of injury, makes cross-country skiing an ideal recreational and competitive sport. The new skating techniques developed during the last decade have resulted in greater velocity. The maximum speed during the diagonal stride technique is 6 m/sec compared to 8 to 9 m/sec when skating and double poling. Top-level skiers today use strong and ultra light skis of fiberglass and graphite. The ski weight is less than 500g. Today's skating technique does not require any waxing and only the cambered portion of the ski is waxed when performing the diagonal stride. The preparation of the ski course has improved with the development of special track machines. This allows top-level skiers to reach 60 to 80 km/h on downhill slopes, which has resulted in an increased risk of injury. Because cross-country skiing takes place wherever snow is available, it is difficult to establish accurate injury rates in comparison to alpine skiing which is performed on very specialised terrain at ski areas. Studies estimate the cross-country ski injury rate in Sweden to be around 0.2 to 0.5 per thousand skier days. A prospective study of cross-country ski injuries conducted in Vermont revealed an injury rate of 0.72 per thousand skier days. 75% of the injuries sustained by members of the Swedish national cross-country ski team during 1983 and 1984 were overuse injuries while 25% resulted from trauma. The most common overuse injuries included medial-tibial stress syndrome, Achilles tendon problems and lower back pain. Most common among traumatic injuries were ankle ligament sprains and fractures, muscle ruptures, and knee ligament sprains. Shoulder dislocation, acromioclavicular separation and rotator cuff tears are not infrequent in cross-country skiing. Injuries to the ulnar collateral ligament of the metacarpal phalangeal joint of the thumb (Stener's lesion) is the most common ski injury involving the upper extremity. Cross-country skiers 16 to 21 years of age complained more frequently of mild lower back pain than similarly aged non-skiers. This may result from repetitive hyperextension motions during the kick phase and the recurring spinal flexion and extension during the double poling phase. Repeated slipping on hard and icy tracks infrequently produce partial tears or microtrauma in the muscle tendinous units of the groin.(ABSTRACT TRUNCATED AT 400 WORDS)

Twenty dogs with a hematoma of the thymus are described. In four dogs the cause of the hematoma was a ruptured dissecting aneurysm of the aorta and in three cases the dogs had been hit by cars. In seven dogs the necks were overstretched by different factors. One dog was hit by a stone. In two dogs no anamnestic data were available, and in the last three cases, according to owner's statements, no trauma had occurred before the first signs. Thymic hemorrhages in the dog should not be considered to be a circumscribed pathogenetic entity. Indications are offered that trauma, or even commonly occurring microtrauma, can be involved in the pathogenesis of the hematomas in the thymus.

One hundred nine runners were treated conservatively without immobilization for overuse injury to the Achilles tendon. Treatment strategies were directed toward re habilitation of the gastrocnemius/soleus muscle-tendon unit, control of inflammation and pain, and control of biomechanical parameters. One fair, 12 good, and 73 excellent results were reported, with a mean recovery time of 5 week.Followup was incomplete in 23 cases. The three most prevalent etiological factors were overtraining (82 cases), functional overpronation (61 cases), and gastrocnemius/soleus insufficiency (41 cases). The authors speculate that runners are susceptible to Achilles tendinitis with peritendinitis due to micro- trauma produced by the eccentric loading of fatigued muscle, excess pronation producing whipping action of the Achilles tendon, and/or vascular blanching of the Achilles tendon produced by conflicting internal and external rotatory forces imparted to the tibia by simul taneous pronation and knee extension. Virtually all cases of Achilles tendon injury appear to result from structural or dynamic disturbances in normal lower leg mechanics and require active treatment regimens which attempt to establish normal function to prevent recur rence.

In most sports the extensor mechanism of the knee is repeatedly stressed. Some athletes will develop an inflammatory response from the accumulation of microtrauma, which can be concentrated at either the superior or inferior pole of the patella. This symptom complex has been well classified by Blazina and co-workers into several phases of jumper’s knee.1 Several studies have demonstrated the histological findings of tendon degeneration from the repeated microtrauma.1–3 This process can remain localized to the attachments at either pole of the patella, as described by Phases 1 through 3 in Blazina’s classification, or it can proceed to tendon failure in one catastrophic event.

Mechanisms of knee injury are very complex and depend on multiple factors. The purpose of this article was to describe mechanisms of knee injury. Causes of knee injury include microtrauma and macrotrauma. For microtrauma, mention was made of the accumulation of inflammatory reactions that eventually produces clinical signs and symptoms. For macrotrauma, particular emphasis was placed upon immediate injuries resulting in straight one-plane instabilities and transverse plane rotatory instabilities.

Sequelae of single impact and recurrent microtrauma may not be separated either in all cases of knee joint lesion, mainly concerning those of menisci and hyaline cartilage. The missed early treatment of cartilage and ligamentous lesion leads to a degenerative damage of the joint.

We present the case of an 11-month-old baby with a burn that healed normally over a month, but subsequently developed successive crops of blisters over the scar. There were no changes in his general condition. Clinical, immunological, histological and ultrastructural studies provided a diagnosis of mechanical dermatitis produced by microtrauma. Electron microscopy studies revealed the sub-epidermal nature of the blisters and the presence of underlying fibrin deposits.

The interaction between natural aging and exercise in the knee joints of 38 female Wistar rats, 14 of which performed treadmill exercise for 6 or 12 months was assessed. Qualitative morphological changes observed with age in joint tissues other than cartilage of sedentary and exercised animals were similar. Chondrocyte counts were only significantly different between groups of young and older control animals in the lateral tibia1 condyle with older animals having a higher median than younger control animals. Defects in the articular cartilage were observed in animals of all ages and in both groups; however, exercised animals showed a significantly higher frequency and greater severity of defects than age-matched sedentary animals. The interaction between exercise intensity and age-related changes in the rat warrants further investigation since these observations suggest exercise may increase microtrauma to the articular cartilage. J Orthop Sports Phys Ther 1986;8(6):310-319.

We reviewed 13 patients with end stage jumper's knee, 10 with patellar tendon ruptures, and 3 with ruptures of the quadriceps tendon to evaluate our long-term results in treating these tendon ruptures in an athletic population. The focus was on the natural history, the time until return, and the level of return, to athletic activity. Jumper's knee affected all patients to a varying degree prior to rupture. Basketball was the most com mon sport involved. At followup, averaging 4½ years, patients underwent functional and clinical, as well as Cybex and roentgen ographic, evaluations. Results indicated patellar tendon ruptures, where the ruptures are complete, have a more favorable prognosis than those of the quadriceps ten don which are incomplete. All of the latter patients continued to have quadriceps tendinitis following repair. In both groups, the poor results were obtained in patients with chondromalacia and/or patella alta. Cybex testing yielded results of greater than 100% strength in three patients with patellar tendon ruptures, but no patient with quadriceps rupture had comparable test results. There was no apparent relationship between ruptures and cortisone injections. Patellar and quadriceps tendon ruptures from indirect injury in athletes represent the end stage of jumper's knee and result from repetitive microtrauma. Excellent function usually follows repair of patellar tendon rup tures when surgery is performed early and care is taken to restore normal patellar tendon length. Results of quadriceps ruptures are less satisfactory since these ruptures are usually incomplete and all degenerative tissue may not be involved in the healing response.

Cumulative Trauma Disorders, CTD, are the summary results of many microtrauma. Though known since the early 1800s, they have become a matter of urgent ergonomics concern in the 1980s. They are usually caused by repeated and/or forceful exertions, often in the hand-arm-shoulder region. They predominantly occur to soft tissues, such as tendons and ligaments, and to nerves and blood vessels. They are commonly associated with certain occupational and leisure activities. Many CTD can be avoided by a set of fairly simple and straightforward ergonomics procedures.

This short clinical case report illustrates a case of traumatic alopecia appearing during orthodontic therapy. A girl, aged 9 years, presented with a localized alopecia on the vertex. There were obvious signs of microtrauma on the skin surface with moderate erythema and crusting over the area. The alopecia and the irritation developed, while the patient applied a device every night to maintain a constant traction during resting time at the level of the maxillae. The goal of the application of the orthopedic forces was restoration of malocclusion.

Introduction : The adventitious bursas are structures that appear in the adulthood, as a mechanism of protection against physical forces on the tissue. The reaction to stress by an axial load on the sesamoids will produce repetitive microtrauma, being the main cause an excessive plantar flexion of M1.Clinically we observed signs of inflammation and a fluctuating mass with pain on palpation. Clinical case: We present a 47-year-old woman presented with pain and swelling in the plantar region of the 1st metatarsophalangeal joint of the right foot, of 4 weeks of evolution. In the exploration an increase in the volume of the 1st plantar MTF was observed, with signs of heat, flushing, erythema with pain on direct palpation and joint mobility, which in running and standing caused it to limp. It is confirmed sonographically and radiographically “Active inflammatory bowel bursitis of biomechanical etiology”. Discussion: The treatment was conservative as described by various authors, with excellent results, using foot supports and shoe modifications. No oral anti-inflammatory drugs or local infiltrations were administered. Conclusions: With the ultrasound, it has been possible to provide an accurate diagnosis with low cost, innocuous, in the chiropody consultation, being able to implement the treatment early.

This study reviews 11 years' experience with carcinoma of the lung in relation to anthracosilicosis at the Veterans Administration Hospital, Wilkes-Barre. Carcinoma of the lung was diagnosed in 7 percent of 2,360 anthracosilliotics compared to 1.08 percent in 31,187 nonanthracosilicotics. Epidermoid carcinoma was the predominant cell type encountered in the anthracosilicotics, but anaplastic carcinoma and adenocarcinoma were not The possible role of immunologic factors, chronic microtrauma by the silica particles and uranium radioactivity in the pathogenesis of bronchogenic carcinoma in these cases is discussed. The difficulties in diagnosis are mentioned and in particular, the lower operability and resectability rates of carcinoma in this group is emphasized.

Many cases of work related compression neuropathy of the ulnar and median nerves at the wrist have been described. This report presents a case of bilateral distal neuropathy of the median and ulnar nerves in a parquet floorer, who laid wooden block flooring by hand and used the palms and volar surface of both hands to hit the blocks into place. He also used an electric sander and polisher. Bilateral numbness and paraesthesias in all fingers had been present for about one year. Clinical examination was normal; the neurological assessment indicated slight impairment in response to tactile, heat, and pain stimuli in all 10 fingers. Electroneurography showed increased distal motor latencies of median and ulnar nerves at both wrists, although the lower limbs were normal. The results of blood, urine, and instrumental tests excluded systemic disease or local factors that could cause compression neuropathy. After stopping work for three months, the clinical picture and electroneurographic results improved. These data support the hypothesis that the damage to the median and ulnar nerves had been caused by the patient's way of working, which provoked repeated bilateral microtrauma to his wrists. To diagnose work related multiple neuropathy can be difficult and an accurate work history is necessary. Preventive measures and diligent health care are required for this category of worker.

Objectives In patients with systemic sclerosis (SSc), fingertip digital ulcers (DUs) are believed to be ischaemic, and extensor surface DUs a result of mechanical factors/microtrauma. Our aim was to assess blood flow response to topical glyceryl trinitrate (GTN) compared to placebo in SSc DUs, looking for differences in pathophysiology between fingertip and extensor lesions. Method This was a double-blind, randomised, crossover, placebo-controlled study. Sixteen (6 fingertip, 10 extensor) DUs were each studied twice (one day apart): once with GTN and once with placebo ointment. Perfusion at the DU centre (‘DUCore’) and periphery (‘DUPeriphery’), as measured by laser Doppler imaging was performed before and immediately after ointment application, then every 10 min, up to 90 min post-application. We calculated the area under the response curve (AUC) and the ratio of peak perfusion to baseline, then compared these between GTN and placebo. Results Perfusion was lower in the DUCore compared to the DUPeriphery (ratio of 0.52). The microvessels of the DUCore were responsive to GTN, with an increase in perfusion, with a similar effect in both fingertip and extensor DUs. The AUC and peak/baseline perfusion difference in means (ratio, 95% confidence interval) between GTN and placebo at the DUCore were 1.2 (1.0–1.6) and 1.2 (1.0–1.5) respectively, and at the DUPeriphery were 1.1 (0.8–1.6) and 1.0 (0.9–1.2) respectively. Conclusion DUs (both fingertip and extensor) were responsive to topical GTN, with an increase in perfusion to the ischaemic DU centre. If both fingertip and extensor DUs have a (potentially reversible) ischaemic aetiology, this has important treatment implications.

Articular cartilage predominantly serves a biomechanical function, which begins in utero and further develops during growth and locomotion. With regard to its 2-tissue structure (chondrocytes and matrix), the regenerative potential of hyaline cartilage defects is limited. Children and adolescents are increasingly suffering from articular cartilage and osteochondral deficiencies. Traumatic incidents often result in damage to the joint surfaces, while repetitive microtrauma may cause osteochondritis dissecans. When compared with their adult counterparts, children and adolescents have a greater capacity to regenerate articular cartilage defects. Even so, articular cartilage injuries in this age group may predispose them to premature osteoarthritis. Consequently, surgery is indicated in young patients when conservative measures fail. The operative techniques for articular cartilage injuries traditionally performed in adults may be performed in children, although an individualized approach must be tailored according to patient and defect characteristics. Clear guidelines for defect dimension–associated techniques have not been reported. Knee joint dimensions must be considered and correlated with respect to the cartilage defect size. Particular attention must be given to the subchondral bone, which is frequently affected in children and adolescents. Articular cartilage repair techniques appear to be safe in this cohort of patients, and no differences in complication rates have been reported when compared with adult patients. Particularly, autologous chondrocyte implantation has good biological potential, especially for large-diameter joint surface defects.

BACKGROUND: Tumours of the nail bed are rare. Squamous cell carcinoma is the most frequent among them. Chronic infection, chemical or physical trauma/microtrauma, genetic disorders such as congenital ectodermal dysplasia, radiation, tar, arsenic or exposure to minerals, sun exposure, immunosuppression, and previous HPV infection have all been discussed as etiologic factors. The diagnosis is often delayed because of the variety of clinical manifestations, often resembling benign or common infectious processes. Rapidly growing ulcerative lesions should also be considered as potential malignancy. Furthermore, a lack of antifungal or antibacterial treatment response is the most indicative symptom, always requiring subungual biopsy. Early diagnosis is of great importance for therapeutic effectiveness.CASE PRESENTATION: We present a case of subungual squamous cell carcinoma, associated with long-lasting onychomycosis in a 76-year-old female patient, treated with amputation of the distal phalanx and the distal part of the proximal phalanx.CONCLUSION: Although there are no available data in the literature to confirm or reject the contribution of the chronic nail infection to the malignant process, we emphasise the importance of this co-existence regarding the possible disguising of the malignant process. An early biopsy of a chronic persistent nail lesion may be preventive and beneficial regarding avoiding more aggressive treatments and achieving a favourable prognosis.

Facial palsy that occurs immediately after middle ear surgery (stapedectomy, stapedotomy, and tympanoplasty) can be a consequence of the local anesthetics and it regresses completely within a few hours. In the case of delayed facial palsy, the alarming symptom occurs several days or even weeks after uneventful surgery. The mechanism of the neural dysfunction is not readily defined. Surgical stress, intraoperative trauma, or laceration of the chorda tympani nerve with a resultant retrograde facial nerve edema can all be provoking etiological factors. A dehiscent bony facial canal or a multiple microporotic fallopian canal (microtrauma or laser effect) can also contribute to the development of this rare phenomenon. The most popular theory related to the explanation of delayed facial palsy at present is the reactivation of dormant viruses. Both the thermal effect of the laser and the elevation of the tympanomeatal flap can reactivate viruses resting inside the ganglion geniculi, facial nerve, or facial nuclei. The authors report the case histories of a 55-year-old female, and a 45-year-old male who presented with a delayed facial palsy following laser stapedotomy. The clinical characteristics, the therapeutic options, and the possibility of prevention are discussed.

The authors describe a rare case of congenital afibrinogenemia with concom itant K-dependent protein C deficit that was brought to our observation for ischemic lesions of the foot in association with fibrinogen concentrate infusions. These lesions can be attributed to the association of various factors: fibrino gen infusion without heparin coverage, microtrauma, and protein C (PC) defi cit. In fact, thromboembolic complications during afibrinogenemia were previously reported usually in association with substitutive therapy, and it is also known that PC deficit predisposes to thrombotic complications. To the authors' knowledge, the case described by them is the first in which PC deficit is associated with afibrinogenemia. This association cannot be ex plained by a common genetic mechanism because the genes for fibrinogen and for protein C are located on different chromosomes (chromosomes 4 and 2 re spectively) .

To the Editor.— Dr Rogers, in a recent reply to a query regarding burning mouth and tongue (1981;246:2377), discussed the problems associated with the etiology and treatment of burning mouth syndrome (BMS), which is a disorder primarily of postmenopausal women who experience a constant intraoral burning sensation. Although uncertainty exists as to its etiology, some cases have been linked to deficiencies in vitamin B 12 , iron, and folate, hypoestrogenism postmenopausally, diabetes, microtrauma to the oral mucosa from dentures or other local irritants, and psychological disturbances. 1 In many patients, however, these features are not displayed, and the disorder is diagnosed as idiopathic. 2 During the last two years, I have been undertaking an intensive clinical, neurological, and hematologic investigation of patients with BMS. In view of the suggestion 3 that intraoral symptoms may be related to rheumatoid arthritis, I have also carried out immunologic tests for rheumatoid factor (RF), antinuclear

Femoral neck abnormalities in spina bifida can be of two types: Type A, consisting of widening of the physis and often associated with varus deformity, and Type B, characterized by marked narrowing of the femoral neck, resulting in a typical mushroom appearance. The Type A deformity is usually associated with an abduction contracture of the hip. This physeal lysis seems to be secondary to microtrauma sustained during persistent exercise done by the parents and therapist to overcome the abduction contracture. No treatment is required, even when varus deformity is present. These patients require an orthosis with a pelvic band for ambulation, and their mobility will not be affected by the deformity.

The two main objectives of medical or nonsurgical therapy for osteoarthritis are symptomatic relief and protection of affected joints from misuse. The patient is most likely to consult a physician because of the first objective, to obtain relief of pain. But effective therapy also needs to be primarily directed toward prevention or deceleration of degenerative changes of cartilage (fig. 1). In its early stages at least this degenerative process is generally asymptomatic. In advanced stages degenerative articular disease is a potential cause of symptoms, since cartilaginous degeneration is more nearly complete, the joint space is significantly narrowed and irregular, osseous eburnation and sclerosis develop in the subchondral bone, and osteophytes may form (fig. 2). The uncomplicated development of degenerative articular disease as a result of ordinary use is known as primary osteoarthritis. Secondary osteoarthritis may occur when joints are injured either by moderate to severe acute trauma or chronic microtrauma

THE CARPAL tunnel syndrome is a pathological entity manifested by motor and sensory abnormalities distal to the wrist because of compression of the MEDian nerve within the carpal tunnel. This syndrome was probably first described by Paget 1 in the midnineteenth century. Slowly over the years isolated reports of this syndrome, particularly by Marie and Foix, 2 in 1913, and Moersch 3 in 1938, were published in the literature. However, the entity was firmly established and commonly recognized only within the last two decades, due to the contributions of Brain et al, 4 Phalen et al, 5 Love, 6 and Kendall. 7 Among the causes of carpal tunnel syndrome are included major trauma, postimmobilization neuropathy, osteoarthritis, occupational microtrauma, nonspecific thickening of the anterior carpal ligament, rheumatoid arthritis, amyloid, multiple myeloma, 8 Leri's pleonosteosis, 9 acromegaly, 10 myxedema, pregnancy, congestive heart failure, carpal ganglion, 11 shoulder-hand syndrome, and nonspecific tenosynovitis. 12