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We tested the hypothesis that injured ligaments in rabbits treated with ibuprofen would have decreased values of mechanical properties compared with the values of those treated with a placebo. In 24 New Zealand White rabbits, the medial collateral ligament of one hindlimb was ruptured; the contralateral ligament served as an internal control. The rabbits were treated orally, twice daily, with a 14-day course of either 35 mg of ibuprofen per kilogram of body weight or a placebo. The rabbits were sacrificed at 14 or 28 days, and the ligaments were tested in tension to failure at 0.15 mm/sec. There was no statistically significant difference in the values of mechanical properties of ligaments from rabbits treated with ibuprofen versus those treated with placebo at either 14 or 28 days after injury. Our findings suggest that there is no early deleterious effect of a short course of ibuprofen on the mechanical behavior of medial collateral ligaments.

Purpose: Optic neuritis secondary to sinus disease is an infrequent but well-documented association. When a patient presents with signs of optic nerve dysfunction and orbital inflammation the significance of widespread sinus disease on radiology is clear and the management is straightforward. We present a group of patients with isolated optic neuritis and radiological evidence of spheno-ethmoiditis and discuss the clinical relevance of this finding., Methods: We reviewed the notes of 11 patients with optic neuritis who, because of atypical headache, underwent neuroimaging revealing sphenoid sinus opacity. Six patients had endoscopic drainage of the sphenoid sinus; 4 were treated medically., Results: Sinus contents included fungal infection (2), mucopurulent material (5), polyps (1) and necrotic tumour (1). Narrowing of the optic canal due to chronic osteomyelitis was found in 1 patient with irreversible optic atrophy. Visual loss was reversible in 6 patients. Four patients had normal radiological findings after treatment. Two patients had recurrent optic neuritis with sphenoid sinusitis on MRI scan, resolving on treatment, during the 4 year follow-up period., Conclusions: Possible mechanisms of nerve damage in this situation include direct spread of infection, occlusive vasculitis and bony deficiency in the wall of the sinus. Patients presenting with isolated optic neuritis and atypical headache should be scanned; an opaque sphenoid sinus in the context of visual loss should not be dismissed as coincidental but assumed to be pathological and the patient referred for drainage. Sphenoid sinusitis is an uncommon but treatable cause of optic neuritis.

Spinal injuries resulting from falls out of tree stands are often associated with concomitant neurologic deficit, prolonged hospitalization, and long-term disability. The purpose of this study was to review the types of spinal injuries that resulted from falls from hunting tree stands. We retrospectively reviewed 27 patients who came to our institution for treatment of spine injuries related to tree-stand accidents between 1981 and 1997. Eleven percent of the falls were alcohol related. Mean height of the fall was 19.6 feet (range, 10 to 35 feet). There were 17 burst fractures, 8 wedge compression fractures, 4 fractures involving the posterior elements, and 1 coronal fracture of the sacral body. Significant neurologic injury occurred in 12 patients (44%). Sixteen patients (59%) had associated injuries. Nine patients (33%) had open reduction, internal fixation, and fusion of their spine fractures. One patient was treated with a halo jacket. The remaining patients were treated in rigid, molded, polypropylene thoracolumbar orthoses or lumbosacral corsets. Accidental falls from tree stands may result in significant spinal fractures often associated with concomitant neurologic injury, extended hospitalization, and permanent disability. Many of these injuries may be prevented through aggressive hunter safety education.

Two patients, members of the same family, were found to have entrapment of the suprascapular nerve from a calcified superior transverse scapular ligament. The chief complaint in both cases was pain and weakness and atrophy of the supraspinatus and infraspinatus muscles. The nerve entrapment was confirmed by electromyographic studies and required surgical decompression to relieve the symptoms in both patients. Release of the entrapped nerve resulted in complete pain relief and full return of strength at 1-year followup.

Internal rotation of the shoulder is frequently measured by noting the maximal vertebral level reached by the patient's thumb, but it is not at all certain that this maneuver is strictly measuring internal rotation. We analyzed this maneuver with computed tomographic scans of the shoulder in differing positions. We also analyzed extension of the glenohumeral joint and scapulothoracic articulation with scapular lateral radiographs. Finally, we used posteroanterior radiographs to analyze elbow flexion at the limits of internal rotation behind the back. We found that maximal internal rotation behind the back occurs in approximately a 2 : 1 ratio between the glenohumeral joint and the scapulothoracic articulation. However, the scapulothoracic articulation was more significant in placing the arm behind the back, whereas the glenohumeral joint performed most of the internal rotation in front of the body. The scapulothoracic articulation assists in this motion by both extension and internal rotation of the scapula on the thorax. The limits of internal rotation behind the back are reached with a significant contribution from elbow flexion. We conclude that measuring shoulder internal rotation by the maximal vertebral level reached by the patient's thumb greatly oversimplifies the concept of internal rotation and that limitations in this motion may not be strictly due to a loss of internal rotation at the glenohumeral joint.

Purpose: The Sixth International Society of Pediatric Oncology study (SIOP6) concerned Wilms' tumor with favorable histology, preoperatively treated to obtain a high rate of stage I patients, and sought to reduce treatment for patients with stage I and stage II negative nodes (IIN0) tumors and to find better therapy to prevent relapses in stage II positive nodes (IIN1) and stage III patients., Patients and Methods: Eligible patients (N = 509) had received four weekly doses of vincristine (VCR) and two courses of dactinomycin (AMD) preoperatively and were assigned after surgery, according to stage and lymph node involvement, to three different prognostic groups, which were to be randomized. Stage I patients (n = 303) received VCR and AMD either for 17 weeks (S) or 38 weeks (L). Stage IIN0 patients (n = 123) received either 20 Gy irradiation (R+) or no irradiation (R-) and received VCR and AMD for 38 weeks. Stage IIN1 and III patients (n = 83) received intensified VCR and AMD (INTVCR) versus VCR, AMD, and Adriamycin (ADRIA; Doxorubicin Farmitalia Carbo Erba, Rueil, Malmaison, France; doxorubicin). Assessment criteria were 2-year disease-free survival (DFS) and 5-year survival (SURV) percentages. A stopping rule was added that took into account abdominal recurrences for the stage IIN0 trial., Result: A 52% rate of stage I tumors was obtained, with a low rate of ruptures (7%). The 2-year DFS and 5-year SURV rates according to the different therapeutic groups were stage I, 92% versus 88% (equivalent) and 95% versus 92% for S and L, respectively; stage IIN0, 72% versus 78% (stage equivalent) and 88% versus 85% for R+ and R-, respectively; and stage IIN1 and stage III, 49% versus 74% (P < .029) and 77% versus 80% for INTVCR and ADRIA, respectively, which results in an 82% DFS and 89% SURV rate for the entire trial population. However, six abdominal metastases observed during the first year of follow-up (FU) in the R- group versus none in the R+ group resulted in discontinuation of the stage IIN0 trial., Conclusion: Risk-adapted therapy to limit risk of sequelae is possible. More intensive chemotherapy is necessary to prevent abdominal recurrences in nonirradiated stage IIN0 patients treated preoperatively. A three-drug protocol is necessary in stage IIN1 and stage III patients.

Colonization of the vaginal introitus by gram-negative bacilli is a critical event in the pathogenesis of bacteriuria and is promoted by an abnormal pH elevation. To determine whether a pH reduction might inhibit colonization we conducted a placebo controlled, crossover study of a site release vaginal pH buffer cream. A total of 12 premenopausal women with a history of urinary tract infection participated in the 12-week investigation. The mean introital pH during application of the placebo and buffer was 4.87 and 4.61, respectively (p less than 0.01). However, the percentage of positive introital cultures during application of the placebo and buffer (40.3 and 35.3, respectively) and the mean density of colonization (23,600 and 22,700 bacteria per ml., respectively) were not significantly different. The percentage of positive introital cultures and the mean colonization density were also not different during application of the placebo and buffer when the patients were retrospectively stratified as light and heavy colonizers. These data suggest that alteration of the introital pH within a range of 4.5 to 5.0 does not influence the growth of uropathogens on the vaginal mucosa.

Snakebite is relatively common in North Carolina. The Copperhead is the most common offender, though we have representatives of all three genera of the Pit Viper family in addition to the Coral Snake. Pit Vipers are identified by the characteristic triangular head, elliptical eyes, well-developed fangs, and with the Rattlesnakes, a tail rattle. The Coral Snake is identified by its characteristic color pattern with red bands adjacent to yellow bands. Treatment is initiated by the safe identification of the snake, taking care to avoid a second bite. A lymphatic constriction band is applied above the bite and an Extractor, if available, is applied within three minutes. The extremity is splinted and the victim evacuated to the nearest trauma center as soon as possible.

Rupture of the posterior tibial tendon has rarely been associated with closed ankle fractures. All previous cases have been in association with pronation-external rotation type fractures in which the medial malleolus has been fractured. This case represents the first such report of a severed posterior tibial tendon in the absence of a medial malleolar fracture and reemphasizes the importance of critically evaluating intraoperative radiographs following the open reduction and internal fixation of closed ankle fractures to assess the possibility of soft tissue interposition. In the event of an acute rupture of the posterior tibial tendon, the authors recommend primary tendon repair.

To examine changes in indications for cataract surgery which have contributed to the increasing rate of cataract extractions, we compared preoperative characteristics of 265 patients who had undergone surgery in 1988 with a similar number who had undergone surgery by the same four ophthalmologists in 1974 and 1982. Between 1974 and 1988 the number of extractions performed annually by two high-referral hospital-based surgeons rose by 68%. Over 90% of these procedures in 1974 were intracapsular extractions; in 1988, 90% were extracapsular extractions with intraocular lenses. In 1988, preoperative visual acuity was better in both the study eyes and the fellow eyes, the proportion of those with acuities better than 20/60 having risen from 10% to 21%, and from 49% to 67%, respectively. The proportion of patients waiting more than 2 years for surgery on the second eye doubled between 1974 and 1988. These changes, already evident by 1982 for the hospital-based surgeons, became characteristic of the community-based surgeons' practices as well between 1982 and 1988.

In a prospective seven-year study, we treated 32 patients with partial ruptures of the anterior cruciate ligament (ACL) verified by arthroscopy. Twelve knees (38%) progressed to complete ACL deficiency with positive pivot shift tests and increased anteroposterior translation on tests with the KT-1000 arthrometer. Patients with partial ACL tears frequently had limitation for strenuous sports, while those developing ACL deficiency had additional functional limitations involving recreational activities. Three factors were statistically significant in predicting which partial tears would develop complete ACL deficiency: the amount of ligament tearing--one-fourth tears infrequently progressed, one-half tears progressed in 50% and three-fourth tears in 86%; a subtle increase in initial anterior translation; and the occurrence of a subsequent re-injury with giving-way.