Closed subtalar dislocation with non-displaced fractures of talus and navicular: a case report and review of the literature

Closed subtalar dislocations associated with talus and navicular fractures are rare injuries. We report on a case of a 43-year-old builder man with medial subtalar dislocation that was further complicated by minimally displaced talar and navicular fractures. Successful closed reduction under general anesthesia was followed by non-weight bearing and ankle immobilization with a below-knee cast for 6 ;weeks. At 3 years post-injury, the subtalar joint was stable, the foot and ankle mobility was in normal limits and the patient could still work as a builder. However, he complained for occasionally mild pain due to the development of post-traumatic arthritis in subtalar and ankle joints. Our search in literature revealed that conservative treatment of all the successfully reduced and minimally displaced subtalar fracture-dislocations has given superior results compared to surgical management. However, even in cases with no or slight fracture displacement, avascular necrosis of the talus or arthritis of the surrounding joints can compromise the final functional outcome

Foramen magnum, occipital condyles and hypoglossal canals morphometry: anatomical study with clinical implications

Background: Current study examines morphometric alterations of the foramen magnum (FM), occipital condyles (OCs) and hypoglossal canals (HCs) and highlights all the morphometric parameters of the FM area that present side asymmetry, gender dimorphism and are affected by the ageing. Materials and methods: One hundred and forty-one (73 male and 68 female) Greek adult dry skulls were examined. Results: Short and long OCs were detected in 27.7% and 26.2%. A combination of short OCs and long HCs was presented in 27.5%. A complete septum was found in 23.6% of the HCs and osseous spurs in 12.9%. Side asymmetry was detected regarding the HCs length (p = 0.046), the maximum extracranial (p = 0.001) and minimum intracranial (p = 0.001) diameters. Mean FM anteroposterior and transverse diameters, FM perimeter and FM surface area were significantly larger in male than in female skulls (p = 0.001 for each parameter). Similarly, the OCs length (right, p = 0.004 and left, p = 0.024) and width (right, p = 0.008 and left, p = 0.006) the left distance HC-OC posterior border (p = 0.048), the anterior (p = 0.011) and posterior (p = 0.001) intercondylar distances and the HCs right length (p = 0.046) were significantly greater in males. A significant decrease was observed with ageing in FM anteroposterior diameter (p = 0.038), FM surface area (p = 0.05), anterior intercondylar distance (p = 0.014) and HC-OC posterior border (p = 0.013). Conclusions: The study confirmed that only specific HC dimensions showed side asymmetry (HCs maximum extracranial and minimum intracranial diameters and HCs length), gender dimorphism (HCs right length and left distance HC-OC posterior border) and age influence (HC-OC posterior border and HC left extracranial minimum diameter) among young, adults and elderly individuals. FM and OCs dimensions presented gender dimorphism and the age influenced only FM anteroposterior diameter and surface area and the anterior intercondylar distance. The safe zone of OCs drilling in Greeks, calculated by the distance HC-OC posterior border represents the maximum HC depth and is among the lowest values reported in the literature. The significant decrease of this distance with ageing confirms the existence of a drilling safe zone for young, adults and elder individuals. Regarding OCs length, the same probability exists dealing with a short or a long OC during condylectomy. Before planning a transcondylar approach, the coexistence of short OCs and long HCs should be taken into account. These outcomes will be useful for a safe surgery in the craniocervical region in Greeks

Assessment of available online educational resources for patients with atrial fibrillation

Background: A diagnosis of atrial fibrillation (AF) often leads patients to search online for information, which can expose them to information of varied quality. Objective: We conducted a qualitative systematic review of websites that contain useful information regarding AF. Methods: The following terms were searched on 3 search engines (Google/Yahoo/Bing): (Atrial fibrillation for patients), (What is atrial fibrillation), (Atrial fibrillation patient information), (Atrial fibrillation educational resources). Inclusion criteria included websites with comprehensive AF information and information about treatment options. The Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) and PEMAT for Audiovisual Materials assessed understandability and actionability (score range 0–100). Those with a mean PEMAT-P score of .70, meaning acceptable understandability and actionability, underwent DISCERN score assessment of information content quality and reliability (score range 16–80). Results: The search yielded 720 websites that underwent full review. After exclusions, 49 underwent full scoring. The mean overall PEMAT-P score was 69.3 6 17.2. The mean PEMAT-AV score was 63.4 6 13.6. Of the websites that scored .70% on the PEMAT-P, 23 (46%) underwent DISCERN scoring. The mean DISCERN score was 54.7 6 4.6. Conclusions: There is a wide variation in the understandably, actionability, and quality of websites, many not providing patientlevel materials. Knowledge of quality websites could provide an important adjunct for improving patients understanding of AF.Melissa E. Middeldorp, Ellen Lyrtzis, Kyle Heath, Tanya Hall, Kadhim Kadhim, Prashanthan Sander

Isolated thumb carpometacarpal joint dislocation: a case report and review of the literature

<p>Abstract</p> <p>Background</p> <p>Isolated thumb carpometacarpal dislocation is a rare injury pattern and the optimal treatment option is still controversial.</p> <p>Case Description</p> <p>We present a 27-year-old basketball player who underwent an isolated dorsal dislocation of the thumb carpometacarpal joint after a fall. The dislocation was successfully reduced by closed means but the joint was found to be grossly unstable. Due to inherent instability, repair of the ruptured dorsoradial ligament and joint capsule was performed.</p> <p>The ligament was detached from its proximal insertion into trapezium and subsequently stabilized via suture anchors. The torn capsule was repaired in an end-to-end fashion and immobilization of the joint was applied for 6 weeks.</p> <p>Results</p> <p>At 3-year follow up evaluation the patient was pain free and returned to his previous level of activity. No restriction of carpometacrpal movements or residual instability was noticed. Radiographic examination showed normal joint alignment and no signs of subluxation or early osteoarthritis.</p> <p>Conclusion</p> <p>Surgical stabilization of the dorsal capsuloligamentous complex may be considered the selected treatment option in isolated carpometacarpal joint dislocations, that remain unstable after closed reduction in young and high demand patients.</p> <p><b>Level of Clinical Evidence: </b>Level IV</p

Bilateral rectus femoris intramuscular haematoma following simultaneous quadriceps strain in an athlete: a case report

<p>Abstract</p> <p>Introduction</p> <p>Bilateral rectus femoris haematoma following a simultaneous strain of the quadriceps muscles is a very rare condition.</p> <p>Case presentation</p> <p>We report the case of a 21-year-old Greek Caucasian female rowing athlete who was injured on both thighs. She complained of pain and inability to walk. Physical examination revealed tenderness over the thighs and restriction of knee movement. The result of a roentgenogram was normal, and there was no evidence of fracture or patella displacement. Magnetic resonance imaging revealed haematoma formation in both the rectus femoris muscles. The diameters of the left and right haematomas within the muscles were 6 cm and 5 cm, respectively. Therapeutic approaches included compression bandages, ice application, rest, elevation, and administration of muscle relaxant drugs. Active stretching and isometric exercises were performed after three days. The patient was able to walk using crutches two days after the initiation of treatment. On the seventh day, she had regained her full ability to walk without crutches. Non-steroidal anti-inflammatory drugs were administered on the fifth day and continued for one week. Six weeks later, she had pain-free function and the result of magnetic resonance imaging was normal. She was able to resume her training programme and two weeks later, she returned to her previous sport activities and competitions.</p> <p>Conclusion</p> <p>There are references in the literature regarding the occurrence of unilateral quadriceps haematomas following strain and bilateral quadriceps tendon rupture in athletes. Simultaneous bilateral rectus femoris haematomas after a muscle strain is a rare condition. It must be diagnosed early. The three phases of treatment are rest, knee mobilization, and restoration of quadriceps function.</p

Rationale and design of the IRON-AF study: a double-blind, randomised, placebo-controlled study to assess the effect of intravenous ferric carboxymaltose in patients with atrial fibrillation and iron deficiency

Introduction: Atrial fibrillation (AF) is associated with significantly impaired quality-of-life. Iron deficiency (ID) is prevalent in patients with AF. Correction of ID in other patient populations with intravenous iron supplementation has been shown to be a safe, convenient and effective way of improving exercise tolerance, fatigue and quality-of-life. The IRON-AF (Effect of Iron Repletion in Atrial Fibrillation) study is designed to assess the effect of iron repletion with intravenous ferric carboxymaltose in patients with AF and ID. Methods and Analysis: The IRON-AF study is a double-blind, randomised controlled trial that will recruit at least 84 patients with AF and ID. Patients will be randomised to receive infusions of either ferric carboxymaltose or placebo, given in repletion and then maintenance doses. The study will have follow-up visits at weeks 4, 8 and 12. The primary endpoint is change in peak oxygen uptake from baseline to week 12, as measured by cardiopulmonary exercise testing (CPET) on a cycle ergometer. Secondary endpoints include changes in quality-of-life and AF disease burden scores, blood parameters, other CPET parameters, transthoracic echocardiogram parameters, 6-minute walk test distance, 7-day Holter/Event monitor burden of AF, health resource utilisation and mortality. Ethics and dissemination: The study protocol has been approved by the Central Adelaide Local Health Network Human Research Ethics Committee, Australia. The results of this study will be disseminated through publications in peer-reviewed journals and conference presentations.Samuel J Tu, Adrian D Elliott, Nicole Hanna-Rivero, Celine Gallagher, Ricardo S Mishima, Ellen Lyrtzis, Danielle Wlochowicz, Nicholas AR Clarke, Kurt C Roberts-Thomson, Michael B Stokes, Mehrdad Emami, Dennis H Lau, Prashanthan Sanders, Christopher X Won

International Olympic Committee consensus statement on pain management in elite athletes

Pain is a common problem among elite athletes and is frequently associated with sport injury. Both pain and injury interfere with the performance of elite athletes. There are currently no evidence-based or consensus-based guidelines for the management of pain in elite athletes. Typically, pain management consists of the provision of analgesics, rest and physical therapy. More appropriately, a treatment strategy should address all contributors to pain including underlying pathophysiology, biomechanical abnormalities and psychosocial issues, and should employ therapies providing optimal benefit and minimal harm. To advance the development of a more standardised, evidence-informed approach to pain management in elite athletes, an IOC Consensus Group critically evaluated the current state of the science and practice of pain management in sport and prepared recommendations for a more unified approach to this important topic

Morphometric analysis and anatomical variations of craniocervical junction bones

ABSTRACT Aim: The aim of the current doctoral thesis is the morphometric study of the osseous structures of the craniocervical junction and the recording of their anatomical variants. Material: One hundred and forty-one (73 male and 68 female) adult dry skulls of a North-Greek population were investigated. The sample was part of the bone’s collection of the Department of Anatomy and Surgical Anatomy of the Medical School of the Aristotle University of Thessaloniki. A part of the sample derived from the ossuaries of the cemeteries of Thessaloniki and Serres. Method: Measurements were mainly performed with a digital caliper and rarely with metric tape. Photographs of all osseous structures were taken from a fixed distance, vertically on the horizontal plane. Digital photos were taken and the angles were measured with the program MB-Ruler 5.3. Surface area, perimeter and circularity of the foramen magnum were measured with Photoshop CS5 tutorial. Dimensions and angles of the osseous structures were measured and the shape of their surfaces was evaluated. Correlations, existence of asymmetry, the impact of the gender and the age on the variables were investigated. Results: The majority of the skulls had an ellipsoid foramen magnum, while the square and exagonal shapes were rare. No shape was representative of the gender in the Greek population. The predominant shape of the occipital condyle was the ellipsoid, followed by the octoid and asymmetry was detected. Τhe anteroposterior diameter of the foramen magnum was higher than laterolateral diameter. The occipital condyle was symmetrical regarding to their length, width and height, while the hypoglossal canals were asymmetrical concerning their length. They were closer to the posterior than the anterior border of the occipital condyle. Male skulls had a wider foramen magnum and wider occipital condyles bilaterally. The right hypoglossal canals were elongated in males, as well as the intercondylar distances. Τhe minimum thickness of the bone on vertebral artery groove was prevalent in right side. The external dimensions of the atlas vertebra, the vertebral foramen, the length of the anterior and posterior arch, the height of the posterior arch, the distance of the vertebral artery groove from the posterior tubercle, the posterior distance of the glenoid articular facets and the dimensions of the transverse foramen were higher in males. A strong correlation was found between the lengths of the anterior and posterior arch, as well as between the height and width of the fossa of the dens. The dimensions of the vertebral foramen of the axis and the anteroposterior diameter of the vertebral body were higher in males.Conclusions: The dissertation highlights the differences among populations, comparing the findings in Greek population with those of other populations. It also underlines the morphometric differences between the genders and the existence of asymmetry in Greeks. The surgeon who intervenes in the area should always evaluate the ethnic, gender and age differences and possible anatomical variants in order to select the appropriate surgical approach and anatomical landmarks.Σκοπός της παρούσας διατριβής είναι η μορφομετρική μελέτη των οστών της κρανιοαυχενικής συμβολής και η καταγραφή των ανατομικών τους παραλλαγών. Υλικό: Εξετάσθηκαν 141 αποξηραμένα οστά ενηλίκων Ελλήνων από τη Βόρεια Ελλάδα (73 ανδρών και 68 γυναικών). Το υλικό που χρησιμοποιήθηκε ανήκε σε σκελετούς που φυλάσσονται στο Εργαστήριο της Ανατομίας και Χειρουργικής Ανατομίας της Ιατρικής Σχολής του Α.Π.Θ. και σε οστεοφυλάκια των νομών Θεσσαλονίκης και Σερρών. Μέθοδος: Οι μετρήσεις πραγματοποιήθηκαν κυρίως με ηλεκτρονικό παχύμετρο ακριβείας και σπανιότερα με μετρική ταινία. Ελήφθησαν φωτογραφίες όλων των οστών από σταθερή απόσταση, κάθετα στο οριζόντιο επίπεδο. Ακολούθησε ψηφιακή ανάλυση των φωτογραφιών και μέτρηση γωνιών με τη χρήση του προγράμματος ΜΒ-Ruler 5.3. Το εμβαδόν, η περίμετρος και η κυκλικότητα του μεγάλου τρήματος μετρήθηκαν με το πρόγραμμα Photoshop cs5 tutorial. Μετρήθηκαν οι διαστάσεις και οι γωνίες όλων των οστών και αξιολογήθηκε το σχήμα των επιφανειών τους. Αναζητήθηκαν συσχετίσεις, ύπαρξη ασυμμετρίας, επίδραση του φύλου και της ηλικίας στις μεταβλητές της περιοχής. Αποτελέσματα: Η πλειονότητα των κρανίων παρουσίαζε ελλειψοειδές σχήμα μεγάλου τρήματος, ενώ το τετράγωνο και εξάγωνο σχήμα ήταν σπάνια. Κανένα σχήμα δεν ήταν αντιπροσωπευτικό του φύλου στον Ελληνικό πληθυσμό. Το επικρατέστερο σχήμα ινιακού κονδύλου ήταν το ελλειψοειδές, ακολουθούμενο από το οκτωειδές και υπήρχε ασυμμετρία. Η προσθιοπίσθια διάμετρος του μεγάλου τρήματος ήταν μεγαλύτερη από την πλαγιοπλάγια. Οι ινιακοί κόνδυλοι ήταν συμμετρικοί ως προς το μήκος, πλάτος και ύψος τους, ενώ οι υπογλώσσιοι πόροι ήταν ασύμμετροι ως προς το μήκος τους. Ο υπογλώσσιος πόρος βρισκόταν πιο κοντά στο οπίσθιο, από ότι στο πρόσθιο άκρο του ινιακού κονδύλου. Τα ανδρικά κρανία παρουσίαζαν ινιακό τρήμα μεγαλύτερων διαστάσεων και ινιακούς κονδύλους πλατύτερους αμφοτερόπλευρα. Οι δεξιοί υπογλώσσιοι πόροι ήταν επιμηκέστεροι στους άνδρες, όπως μεγαλύτερες ήταν και οι διακονδυλικές αποστάσεις. Το ελάχιστο πάχος τόξου στην αύλακα της σπονδυλικής αρτηρίας ήταν μεγαλύτερο δεξιά. Οι εξωτερικές διαστάσεις του άτλαντα, του σπονδυλικού τρήματος, το μήκος του προσθίου και οπισθίου τόξου, το ύψος του οπισθίου τόξου, η απόσταση της αύλακας της σπονδυλικής αρτηρίας από το οπίσθιο φύμα, η οπίσθια απόσταση των γληνοειδών αποφύσεων, οι διαστάσεις των εγκαρσίων τρημάτων παρουσίαζαν στατιστικά μεγαλύτερες τιμές στους άνδρες. Βρέθηκε ισχυρή συσχέτιση του μήκους του προσθίου με το μήκος του οπισθίου τόξου καθώς του ύψους με το πλάτος του βοθρίου του οδόντα. Οι διαστάσεις του σπονδυλικού τρήματος του άξονα και η προσθιοπίσθια διάμετρος του σπονδυλικού σώματος παρουσίαζαν στατιστικά μεγαλύτερες τιμές στους άνδρες. Συμπεράσματα: Η διατριβή αναδεικνύει την ύπαρξη πληθυσμιακών διαφορών συγκρίνοντας τα ευρήματα στον Ελληνικό πληθυσμό με τα αντίστοιχα άλλων πληθυσμών. Επιπλέον επισημαίνει τις μορφομετρικές διαφορές μεταξύ των δύο φύλων και την ύπαρξη ασυμμετρίας στον Ελληνικό πληθυσμό. Ο χειρουργός που επεμβαίνει στην περιοχή πρέπει πάντα να αξιολογεί τις πληθυσμιακές, φυλετικές και ηλικιακές διαφοροποιήσεις και τις τυχόν υπάρχουσες ανατομικές παραλλαγές προκειμένου να επιλέξει την κατάλληλη προσπέλαση και τα οδηγά σημεία

Revision of Carpal Tunnel Release due to Palmaris Longus Profundus

Purpose. The palmaris longus profundus has been documented throughout the literature as a cause of carpal tunnel syndrome. We present a case of palmaris profundus tendon removal during the revision of carpal tunnel release. Method. During a carpal tunnel release in a 66-year-old woman, palmaris profundus tendon was found inside the tunnel under the transverse carpal ligament, just above the median nerve, but it was left intact. The patient complained of pain in the hand at night and weakness of her hand one month after surgery. We decided on a revision of the carpal tunnel release. The palmaris profundus tendon was found and was removed. Results. The patient had a normal postoperative course. Two months later she returned to her normal activities and was asymptomatic. Conclusions. When a palmaris profundus muscle is located in carpal tunnel, we recommend its excision during carpal tunnel release. This excision will eliminate the possibility of recurrent compression over the median nerve