Accidental Fracture Research Articles

An ethnobotanical study of traditional anti-inflammatory plants used by the Lohit community of Arunachal Pradesh, India

Aim of the study Most people especially in rural areas depend on herbal medicines to treat many diseases including inflammation-related ailments such as rheumatism, muscle swelling, cut wound, accidental bone fracture, insect bites, pains and burn by fire and hot water. The objectives of this study were: to catalog ethno-medicinal plants of Lohit community, ecological status, indigenous folk medicinal uses, morphological parts used and to determine their reported pharmacological studies. Materials and methods The ethnobotanical information on traditional medicinal plants exclusively used for management of inflammation-related ailments by the Khampti community of Arunachal Pradesh, India was based on first-hand field survey work through semi-structured interviews. Results and conclusion A total of 34 species in 32 genera and 22 families were encountered during the field survey. Botanical families such as Asteraceae, Euphorbiaceae, Zingiberaceae and Lamiaceae were represented by the highest numbers of species reported in this study. Thirteen plant species, namely: Bombax ceiba, Canarium strictum, Chloranthus erectus, Xanthium indicum, Lycopodium clavatum, Coleus blumei, Batrachospermum atrum, Chlorella vulgaris, Marchantia palmata, Marchantia polymorpha, Eria pannea, Sterculia villosa and Alpinia galanga are reported for the first time for the treatment of inflammation-related diseases.

Fractures of the fifth metacarpal

The literature is limited concerning the epidemiological issues of fracture in the fifth metacarpal bone. To explore the incidence and types of this fracture, and how the fracture is related to age, gender, trauma mechanism, and at what day of the week the causing trauma occurred. All hand fractures registered at the Department of Radiology, Buskerud Hospital, Norway, in the period between 2004 and 2006 were reviewed. Of 1475 hand fractures, 271 (18.4%) were located in the fifth metacarpal bone. In 130 of these cases (121 male, nine female), the trauma had occurred through aggression, such as a fistfight or from punching a hard object. The majority of fractures were located in the neck of the metacarpal bone (boxer's fracture). The median age of this group was 22 (7-51) years. Concerning the time of trauma, there was a significant peak during weekends (95 patients). One hundred forty-one of the fifth metacarpal fractures were caused by accidental trauma (99 males, 42 females). In this group, the fractures were located approximately equally in the subcapital, diaphyseal, and basal part of the metacarpal. The median age was 34 (2-90) years. The accidental traumas occurred about as often during the weekdays as during the weekend. Of all hand fractures, fractures of the fifth metacarpal bone are the most common. There are as many aggression-related fractures as accidental fractures in the fifth metacarpal bone. When the fracture is caused by aggression, the typical patient is a young male sustaining fracture during the weekend.

The pedicled vascularised scapular bone flap for proximal humerus reconstruction and short humeral stump lengthening

The vascularised scapular bone free flap is popular in mandible reconstruction, but it is less commonly used as a pedicled flap to reconstruct the upper humerus. We analysed our experience with pedicled scapular crest flaps in humerus reconstruction and compared our results with cases reported in the literature. We considered the age at surgery, the time elapsed before reconstruction, the time required to obtain solid bony union, the operative indication, the osteosynthesis procedure used and whether circumflex scapular vessels or angular vessels were used. There were eight patients (seven men and one woman, mean age=33): four humerus stump lengthenings, two upper-third humerus bone and soft tissue defects and two multioperated established humerus non-unions. Flaps were pedicled either on circumflex scapular vessels (three) or angular vessels (five). The mean size of the scapular bone used was 9.4 cm (range 7-11 cm). We associated a covering flap for seven patients. All the flaps survived and bone healed in a 3.75 month mean delay (range three to six months), and there was one accidental secondary fracture one year after reconstruction. For a vascularised reconstruction of the upper humerus, the pedicled scapular bone flap is a valuable option especially if a composite reconstruction is needed. For short humerus stump lengthening, this flap seems to provide a very satisfactory solution.

Renal salt wasting without cerebral disease: Diagnostic value of urate determinations in hyponatremia

CASE PRESENTATION A 76-year-old woman, who sustained an accidental fracture of the femoral neck, developed hyponatremia after admission. The diagnosis of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) was made by the consulting internist and fluid restriction of 700 cc/day was instituted. Her serum sodium (Na) fluctuated between 122 and 129mmol/l and a renal consultation was requested on the eighth day after undergoing a hemiarthroplasty of the hip when she was ambulating and on no pain medication. Her blood pressure was 100/60 mm Hg, pulse 92 beats/min and there was poor tissue turgor, flat jugular veins, and dry mucous membranes. There was no edema, third spacing, postural hypotension or neurological abnormalities. Her medications included docusate sodium, milk of magnesia, simvastatin, and warfarin. She was not on drugs such as atorvastatin, fenofibrate, or losartan which reduce serum urate by increasing renal urate excretion. 1-3 A low baseline urine Na (UNa) concentration of 6 mmol/l suggested a hypovolemic condition with normal renal function 4 that should result in a prerenal state characterized by low UNa, azotemia, and hyperuricemia. The baseline serum urate of 3.4 mg/dl, however, was inconsistent with prerenal azotemia and its coexistence with hyponatremia was suggestive of SIADH or renal salt wasting. 4-6 The patient was, therefore, included in an IRB-approved protocol to differentiate SIADH from renal salt wasting. After obtaining an informed consent, a blood volume study was performed, using a radioisotope dilution technique.7 With a hematocrit of 31%, the red cell volume was decreased by 28% and the plasma volume increased by 4.7%, resulting in a net blood volume reduction of 7.1%. The pertinent baseline laboratory data are summarized in Table 1. The baseline plasma renin, aldosterone, antidiuretic hormone (ADH), and fractional urate excretion were elevated at 8.63ng/ml/h, 16.5ng/dl, 2.5pg/ml, and 29.6% (normal 5-10%), respectively. Plasma osmolality was decreased at 260 mosm/kgH 2 O, atrial natriuretic peptide was in the low normal range at 35 pg/ml, serum phosphorus and urate were decreased at 2.4 and 3.4 mg/dl, respectively. Renal, adrenal, and thyroid functions were normal. The chest X-ray and urinalysis were normal. Saline was then infused at 125 ml/h for 48 h. Urine osmolality of all spontaneously voided urine was immediately determined and when her urine osmolality decreased to 152 mosM/kgH 2 O at 13.3h, a repeat plasma ADH was undetectable when the serum osmolality was 268 mosm/kgH 2 O. At this time, she had received 1660 ml of saline overnight and excreted 955 ml of urine. The plasma renin and aldosterone decreased to 2.95 ng/ml/h and 7.6ng/dl, respectively, and plasma atrial natriuretic peptide increased to a high normal 65 pg/ml. The serum Na remained unchanged at 129mmol/l but the serum urate decreased from 3.4 to 1.7 mg/dl. It should be noted that the baseline urine osmolality of 321 mosm/kgH 2 O increased to 587 mosm/kgH 2 O and the UNa only increased from a baseline of 6 to 18 mmol/l in the first urine passed 4 h after initiation of saline infusion (Figure 1, Table 2). The serum Na gradually increased from 129 to 138 mmol/l at 45.8 h (Figure 2), as serum urate decreased to 1.0 mg/dl and fractional urate excretion remained elevated (Figure 2). Her UNa increased to a peak of 82 mmol/l at 8.1 h (Table 2).

Was beeinflusst die Rekonvaleszenz nach einer Lungenresektion?

Reconvalescence after lung resections underlies several influences. The aim of this study was to outline the effect of patient and operative factors. Between 1/97 and 6/98 a cross sectional prospective study was undertaken at the University of Ulm. 125 patients with lung resections for various reasons via anterolateral thoracotomy were included. Variants thought to affect postoperative recovery were statistically analysed using uni- and multivariate analysis. A "good postoperative recovery" (GPR) was seen as at least two of the following criteria were fulfilled on the second postoperative day: Spitzer Index >/=6, FEV1 >40% of preoperative measurement, pain on LASA scale </=3. Chi-Square testing revealed a more frequent GPR for patients with benign diseases (61 vs 40%, p=0,0436), an atypical compared to anatomical resection (63 vs 40%, p=0,0157) and an opening of the retractor of not more than 13 cm (61 vs 34%, p=0,0033). Multivariate analysis demonstrated only the opening of the retractor as being of independent influence (p=0,0148). Age, sex, BMI, incision length, transsection of M. latissimus dorsi, number of accidental rib fractures, time of operation and routine of the surgeon were of no statistical relevance to GPR. Malignant disease requiring anatomical lung resection is accompanied by delayed postoperative recovery when compared to lung resections for other reason. In contrast the width of opening of the retractor is of independent negative influence for reconvalescence. Once more the significance of a non-aggressive access procedure for lung resections is underlined.

Audit of nasal fracture management in accident and emergency in a district general hospital

Nasal fractures are a common occurrence in accident and emergency and dealt with by inexperienced senior house officers. This can lead to inappropriate X-rays being performed, no proper documentation of septal haematomas and often no follow-up with a specialist team leading to in some cases complex cosmetic surgery whereas simple manipulation may have sufficed. We report an ambispective audit carried out on nasal fracture management in a busy district general hospital over a 6-month period. 46 patients were seen 24 in the first 3 months and 22 the next three. 10 had nasal X-ray performed initially on audit. Nine had no documentation of septal haematoma and seven had no follow-up arranged. After appropriate education and the setting up of a department protocol based on best practice, the next cycle was repeated. Two nasal X-rays were performed looking for foreign bodies, all patients had appropriate documentation of septal haematoma and appropriate follow-up. Appropriate education and implementation of departmental guidelines can result in more effective and efficient use of resources when dealing with nasal fractures in accident and emergency.

Scleredema Adultorum Of Buschke: A Case With Multiple Causes

Background: Scleredema adultorum of Buschke is an uncommon skin condition that may accompany following diabetes mellitus, proceeding of infection or may be associated with monoclonal gammopathy,. Our case had it with multiple other underlying causes. Observation: This is report of a case with scleredema of Buschke with history of eight months. The patient had no history of a definite diabetes mellitus, but only an impaired glucose tolerance test. Hyper IgG gammopathy with increasing of ASO titer in association with a history of preceding chronic infection of both legs following accidental fractures since of two years ago were seen also. Histological findings of a biopsy specimen from involved neck skin showed marked thickening of the reticular dermis and collagen fibers has been broaden and separated by clear spaces which showed positive reaction with alcian blue. Anti streptolysin O titer in his serum level was more than 1000 UI/ml (international union / per milliliter). Glucose tolerance test (2 hours after oral eating 70 gram anhydrous glucose powder) showed impaired (>200mg/dL) in three times doing exam, but glycosylated hemoglobin A-1c was as 4.5 as in goal limitation (action suggested >6.4). Results: Therapeutic plan included oral penicillin and cyclosporine and azathioprin that were not significantly effective during the last 7 months, but the patient feels mild improvement in the last month. Conclusion: This is an uncommon case of progressive scleredema adultorum of Buschke in a man with multiple underlying causes with mild impaired glucose tolerance test, increased G type of immunoglobulin (IgG) of 1942 mg/dl (normal range =700-1600mg/dl), and increased serum level of ASO titer, as well as history of chronic over imposing infections on both leg fractures and after operations.

Management of suspected scaphoid fractures in accident and emergency departments – time for new guidelines

The objectives of this work were to assess the clinical knowledge of clinicians in the accident and emergency (A&E) departments in England & Wales and evaluate the current trend for the acute management of radiologically normal, but clinically suspected, fractures of the scaphoid. We conducted a telephone survey on 146 A&E senior house officers (SHOs) in 50 different hospitals. This survey assessed the clinicians' experience, their clinical and radiological diagnostic methods, and their initial treatment of suspected scaphoid fractures. The majority (55.8%) of SHOs performed only one clinical test to diagnose suspected scaphoid fractures. Overall, 41% were unable to cite the number of the radiographic views taken and only 10% of departments have direct access to further radiological investigation. There is wide variation in the early treatment of this injury, with the scaphoid cast used most commonly (46%). The majority of SHOs (89%) were unable to describe the features of immobilisation. The mean follow-up period was 10 days, and 53% of cases were followed-up by the senior staff in A&E. Of SHOs, 54% were not aware of any local guidelines for the management of suspected scaphoid fractures in their departments, and 92% were not aware of the existence of the 1992 British Association for Accident and Emergency Medicine (BAEM) guidelines. The clinical knowledge and the management of suspected scaphoid fractures in A&E are unsatisfactory. We, therefore, suggest that the dissemination of up-to-date guidelines could help to educate clinicians to provide better care to the patients.

A Custom-Made Distraction Device for Experimental Mandibular Distraction Osteogenesis

Distraction osteogenesis has recently become popular in craniofacial reconstruction, after it was first described for long bones. Despite the widespread clinical use of this technique, currently, lack of an ideal experimental model for small animals hampers investigations focused on its molecular basis, which warrants further elucidation. The authors developed a new device for distraction of the rat mandible and, to asses its effectiveness, practiced on 30 animals assigned to either an acute 3-mm distraction group (n = 7) or a gradual distraction group (0.25 mm twice a day for 6 days; n = 23). The authors applied the devices to a localization that allowed them to perform the ostomies posterior to the molar teeth. Because of a U-shaped plate that the authors used for posterior pin fixation, their device maintained its stability until the end of the study, despite the delicate anatomy of the bone at the posterior part of the mandible. Additionally, the authors described a practical and easy method of transient mandibular stabilization method that facilitates the manipulations while the mouth is open for safer airway control during surgery. This new nutrition technique with enteral feeding solution solved the problem of progressive weight loss after surgery. Application of the device was easy and practical, without demanding complex manipulations. The authors did not observe any device dislodgement or a high rate of accidental fractures during the manipulations. They demonstrated that the device works properly and is able to create ossified regenerate bones that fill the entire distraction gap, which can be used for various investigations during distraction osteogenesis.

Clinical Outcome of Salmon Calcitonin Nasal Spray Treatment in Postmenopausal Women after Total Hip Arthroplasty

Objective: The increasing rate of hip fractures is giving rise to a number of socio-economic problems for the aging community. In addition to being unable to resume their previous living habits, many patients fail to achieve full functional recovery after the fractures. Total hip arthroplasty (THA) is a successful operation for the majority of patients with all forms of hip fractures, being performed increasingly often throughout the world. Revision rates for THA range up to 20% per year. Aseptic loosening is the reason for 75% of the revisions. An additional problem post-THA is the rate of heterotopic soft tissue calcification after THA, resulting in severely impaired function, pain, and a reduced range of hip movement. Subjects: In an open study, 37 women who had undergone cementless THA after accidental hip fractures were treated twice daily with 200 IU of salmon calcitonin nasal spray for 12 months. Simultaneously the patients received one bag of 1,000 mg calcium plus 880 IU vitamin D daily throughout the treatment period of 1 year. A parallel group of 38 women with a similar clinical status in terms of hip fractures and cementless THA were treated with only one bag of 1,000 mg calcium plus 880 IU vitamin D daily through the treatment period. Results: The results of this 12-month clinical trial show that 200 IU of salmon calcitonin nasal spray per day significantly improves the clinical outcome of postmenopausal elderly women following THA. Treatment with a salmon calcitonin nasal spray significantly reduces bone turnover, loss of bone density, and pain. The functional status of the patients was improved and the risk of falling reduced by rehabilitation during the observation period of 12 months. Additionally, calcitonin promoted the repair of hip fractures and was associated with a significantly lesser rate of refractures as well as periprosthetic ossifications. Conclusion: The increasing revision rate for THA during the first year and the patient’s problem of resuming their previous living habits are the main foci of our study. Calcitonin nasal spray seems to cause few side effects. The additive treatment appears to improve the clinical outcome of THA in elderly postmenopausal women.

Salmon calcitonin nasal spray treatment for postmenopausal women after hip fracture with total hip arthroplasty

The increasing rate of hip fractures is giving rise to a number of socioeconomic problems for the aging community. In addition to being unable to resume their previous living habits, many patients fail to achieve full functional recovery after the fractures. Total hip arthroplasty (THA) is a successful operation for the majority of patients with all forms of hip fractures. Dislocation and aseptic loosening are the major reasons for revisions. An additional problem post-THA is the rate of heterotopic soft tissue calcification after total hip arthroplasty, resulting in severely impaired function, pain, and a reduced range of hip motion. In an open study, 37 women who had undergone cementless total hip arthroplasty after accidental hip fractures were treated twice daily with 200 IU salmon calcitonin nasal spray for 12 months. Simultaneously, the patients received one bag of 1000 mg calcium plus 880 IU vitamin D daily throughout the treatment period of 1 year. A parallel group of 38 women with a similar clinical status in terms of hip fractures and cementless total hip arthroplasty were treated with only one bag of 1000 mg calcium plus 880 IU vitamin D daily through the treatment period. The results of this 12-month clinical trial show that 200 IU salmon calcitonin nasal spray per day promotes general independence from foreign assistance, mobility, and fear of further falls in postmenopausal elderly women following THA. Treatment with a salmon calcitonin nasal spray reduces bone turnover serum markers, loss of further bone density, and pain. Additionally, calcitonin promoted the repair of hip fractures and, as a coincidence finding, was associated with a significantly reduced rate of refractures as well as periprosthetic ossifications.

Lung Cancer Risk in Shoe Manufacturing

Workers in shoe manufacturing have been reported to be at a greater relative risk for bronchogenic carcinoma. Given the implications for our practice setting, we carried out a study to a) clarify whether working in shoe manufacturing is a risk factor for lung cancer and b) detect histological differences between lung cancers in shoe manufacturers and in other lung cancer patients. This case-control study compared all lung cancer patients diagnosed in Hospital Elda, Alicante, Spain, between January 1994 and December 1999, with a control group composed of patients admitted to the same hospital for accidental fractures. Information on occupational history and tobacco dependency was collected from all patients by telephone questionnaire. One hundred and ninety-one case patients and 192 control patients were included in the study; 52 of the cases (27.2%) and 48 controls (25%) worked in shoe manufacturing. No statistically significant differences were found between the 2 groups, not even when we limited the cases and controls to only those who had worked more than 30 years in shoe manufacturing or when we analyzed only subjects who had had especially high risk occupations. No differences in tumor histology were found between cancer patients who worked in shoe manufacture and those who did not. Working in shoe manufacturing has not proven to be a risk factor for bronchogenic carcinoma.

Fracture du col fémoral compliquant la réduction orthopédique d’une luxation de hanche: À propos de 4 observations

Posterior dislocation of the femoral head with fracture is an exceptional hip injury. Emergency reduction is required. Reposition into the acetabular cavity of the dislocated femoral head may not be feasible. Irreducibility, instability, and more rarely accidental fracture of the femoral neck may also occur. We encountered this latter complication in four patients and report here its frequency and mechanism and propose preventive therapeutic measures. Seventy dislocations and fracture-dislocations of the hip were treated in our unit from March 1997 to February 2003. Among these cases, fourteen hip dislocations were complicated by femoral head fractures. Fracture of the femoral neck occurred during reduction in four. All four cases occurred in men, mean age 49.7 years, who were traffic accident victims (drivers or passengers). There were two Pipkin IV fracture-dislocations and two Pipkin II. The first reduction, achieved under general anesthesia in an emergency setting, was performed by an orthopedic surgeon in one patient and a general surgeon in three patients. Arthroplasty was used to treat the femoral neck fracture in three patients and pinning in one. We reviewed retrospectively the clinical and imaging data before and after reduction. Sub-capital fracture situated 4.0 cm (mean, range 3.5-4.5 cm) from the lesser trochanter occurred in all four cases. The head remained attached above and posteriorly to the acetabulum and was rotated less than 90̊. The fragment remaining in the acetabulum was displaced in two cases. In one patient, the fracture-dislocation of the head was associated with a fracture of the posterior rim of the acetabulum. This complication appears to result from an abrupt inappropriate reduction movement. The neck fracture would occur when capsulomuscular retention of the femoral head is associated with a head defect which catches on the rim of the acetabulum during the reduction movement. Neck fracture during reduction of traumatic hip dislocation is a serious complication. Prevention of this iatrogenic event requires a slow, progressive reduction limiting the trauma to a minimum; first intention open surgery may be required in selected cases.

Scanning electron microscopic examination of third metacarpal/third metatarsal bone failure surfaces in thoroughbred racehorses with condylar fracture.

To examine the fracture failure surfaces from Thoroughbred horses that had sustained a catastrophic condylar fracture. Bone specimens from the failure surface were obtained from 12 Thoroughbred racehorses with catastrophic injury and 2 non-racing horses with accidental long bone fracture. Bone specimens from the failure surface of each fracture were incubated with gold microspheres to label microcracks before examination at x50 to x60,000 using scanning electron microscopy. Microcracking at the failure surface was assessed using a visual analog scale. Branching arrays or clusters of microcracks were seen over a range of magnifications in adapted subchondral bone in the distal end of the MC3/MT3 bone from racing Thoroughbreds with a catastrophic displaced condylar fracture. In the palmar/plantar region, microcracking was associated with the formation of an array of macroscopic cracks in the condylar groove. A different pattern of microcracking was seen in specimens of bone from distal metaphyseal and diaphyseal MC3/MT3 failure surfaces from Thoroughbred racehorses with catastrophic fracture and non-racing horses with an accidental diaphyseal long bone fracture. Few microcracks were seen and typically did not form branching arrays. These data suggest that propagation of condylar fracture in Thoroughbred racehorses is initiated by the formation of nanoscale microcracks in adapted subchondral bone that form during exercise-induced bone adaptation. Accumulation and coalescence of branching microcracks into arrays or clusters appears to eventually lead to the development of macroscopic subchondral cracks in the condylar groove and initiation of a condylar fracture.

Fractures in infants: one in four is non‐accidental

AbstractThe study examines the cause of fractures in infants under a year of age presenting to an Accident and Emergency (A&amp;E) department in order to ascertain the proportion of non‐accidental (NA) to accidental fractures. It also considers whether there were any child protection concerns in either group in the 4–5 years following the fracture. The study involved a retrospective review of notes of infants presenting with fractures over a 2‐year period. Health visitors (HV) completed a questionnaire regarding the well‐being of these children 4–5 years after the fracture occurred. The study identified 28 infants with fractures, seven NA and 21 accidental. Of the seven NA cases, five were diagnosed on presentation but two only on subsequent referral (2 days and 5 weeks later). On second presentation, one of these had more severe injuries. Six of the seven with NA fractures were male, five were less than 4 months of age and in four a skeletal survey revealed other fractures. Information from the HV questionnaire revealed that one of those considered to have had an accidental fracture in infancy was later put on the Social Services child protection register. It was concluded that fractures in infants under a year of age have a high risk of being NA and distinguishing these cases from accidental fractures can be difficult. The younger the infant, the greater the risk of a fracture being NA. A missed diagnosis may result in a child sustaining more severe injuries. A&amp;E departments should have clear guidelines on the assessment of infants with fractures. Liaison with HVs and general practitioners is important to ensure primary care advice on accident prevention and to allow for surveillance regarding possible neglectful care. Copyright © 2003 John Wiley &amp; Sons, Ltd.

Anesthesia for patients with congenital insensitivity to pain and anhidrosis: a questionnaire study in Japan.

We investigated the anesthetic management of patients with congenital insensitivity to pain and anhidrosis (CIPA) in Japan. CIPA is a rare inherited disease characterized by a lack of pain sensation and thermoregulation. Although lacking pain sensation, some patients do have tactile hyperesthesia. Thus, anesthetics are a necessity during operations. We also determined that because patients with CIPA have problems with thermoregulation, temperature management is a concern during the perioperative period and sufficient sedation is necessary to avoid accidental fractures. Additionally, it was found that the use of muscle relaxants does not present a problem, malignant hyperthermia is not associated with CIPA, and that the possibility of abnormalities in the autonomic nervous system must be taken into consideration. Therefore, patients with CIPA can be safely managed with anesthesia. We investigated the anesthetic management of patients with congenital insensitivity to pain and anhidrosis. We clarified the following three important points: anesthesia is necessary, temperature management must be maintained, and there must be sufficient perioperative sedation in the anesthetic management of patients with congenital insensitivity to pain and anhidrosis.

Probabilistic fracture analysis of a straight pipe with through-wall circumferential crack using R6 method

Deterministic fracture analysis of cracked structures has been successful in demonstrating the behavior of structures under observed or postulated flaws. The key ingredients in a deterministic fracture mechanics analysis are the initial crack size, crack-driving force, applied stress and material properties. However, crack size, postulated accidental loading, mechanical and fracture parameters are often subjected to considerable scatter or uncertainty. Hence, the result of fracture mechanics analysis must be viewed with some skepticism. Quite often, conservative bounds on inputs are employed on these by providing a conservative estimate to fracture. However, it may lead to predict the overly conservative and unrealistic results. These uncertainties encourage us to adopt a statistical or probabilistic approach to the structural integrity. R6 is a well-known engineering assessment procedure for the evaluation of the structural integrity of the flawed structure. This paper presents the determination of failure probabilities of a straight pipe with a through-wall crack in the circumferential direction, using the R6 method. The pipe is subjected to an in-plane bending moment. The scatter in the crack size, mechanical and fracture properties are considered. The probability of failure is studied for variation in applied loads. Monte Carlo simulation is used to find the failure probability. The study is performed by constructing failure assessment diagram (FAD) using all the three options of R6. The results are compared with the approximate analytical formulations and with those available in the literature.

Hand Fractures: A Study of Their Site and Type in Childhood

AIM: The purpose of the study was to document the site and type of fractures of the hand in children up to 16 years of age. MATERIALS AND METHODS: The radiographs of 280 children who were found to have a fracture in Accident and Emergency over a one-year period were reviewed. A total of 293 fractures of the hand and 3 distal interphalangeal joint dislocations without fracture were identified. There were 293 fractures as some children had more than one fracture. RESULTS: Distal tuft fractures were commonest in the 0 to 4-year age-group; fractures of distal phalanx (both transverse and tuft) in the 5 to 8-year age-group; transverse fractures of the proximal phalanx of little finger in the 9 to 12-year age-group and transverse fractures of neck of the fifth metacarpal in the 13 to 16-year age-groups. CONCLUSION: Hand fractures are more common in older children, with a male preponderance in most groups except in the 0–4 age-group. The site of injury is different in the various corresponding age-groups, reflecting the differing mechanisms of injury. The management of hand fractures rely on a correct diagnosis and a knowledge of their common site in each age-group should aid diagnosis. Rajesh, A.et al. (2001)Clinical Radiology56, 667–669.

Features of Femoral Fractures in Nonaccidental Injury

Femoral fracture is one of the most common long bone fractures owing to nonaccidental injury, but there is little evidence in the literature about their characteristics. It is important medicolegally to establish a diagnosis of child abuse. Fourteen femoral fractures from definite nonaccidental injury were analysed and compared with 33 femoral fractures caused by definite accident. The age, site, and fracture patterns were carefully studied. Of inflicted femoral fractures, 92.8% (13 of 14) occurred in children younger than 1 year old. On studying the fracture morphology, we conclude that there is no specific roentgenographic site or fracture pattern that allows differentiation between accidental and nonaccidental femoral fractures.

Candesartan Cilexetil is not Associated with Cough in Patients with Enalapril-induced Cough

Treatment with angiotensin-converting enzyme (ACE) inhibitors is frequently associated with persistent dry cough. This side effect is thought to be due to the non-specific action of ACE inhibitors, which, in addition to suppressing the renin-angiotensin system (RAS), leads to the accumulation of kinins, encephalins and other biologically active peptides. Candesartan cilexetil is a new, long-acting angiotensin II type 1 (AT 1 ) receptor blocker, which offers a more specific means of suppressing the RAS than can be achieved with ACE inhibitors. In this study, we compared the incidence and severity of cough during treatment with candesartan cilexetil, enalapril and placebo in patients with hypertension and enalapril-induced cough. Men and women, aged 20-80 years, with a history of medically treated primary hypertension and ACE-inhibitor-related cough were enrolled. The presence of cough was confirmed during a 4-week challenge period with enalapril, 10 mg, which abated during a subsequent 4-week washout period with placebo. Patients with confirmed ACE-inhibitor-related cough were then randomized to double-blind treatment with candesartan cilexetil, 8 mg once daily ( n = 62), enalapril, 10 mg once daily ( n = 66), or placebo ( n = 26). Baseline blood pressure was similar in all groups. Although blood pressure was recorded during the study, this was for safety monitoring, and the measurements were not standardized in relation to study drug intake or time of day. The frequency of dry cough was recorded on a visual analogue scale (VAS). For each assessment, patients marked a cross on a straight horizontal 100 mm line, rating cough frequency from 'none of the time( at one end of the line to 'all of the time( at the other end. The impact of treatment on quality of life was also studied, using the Symptom Assessment (SA) questionnaire and the Minor Symptom Evaluation (MSE) profile. The SA questionnaire assessed the severity of nine symptoms, including dry cough, by means of a five-graded Likert scale (not at all, a little, moderately, quite a bit, extremely). Changes in the three dimensions of the MSE profile - contentment, vitality and sleep - were recorded using a VAS. Candesartan cilexetil was superior to enalapril regarding the change in frequency ( p = 0.001) and severity ( p < 0.001) of dry cough. After 8 weeks of treatment, the proportions of patients with cough were 26.9% for placebo, 35.5% for candesartan cilexetil and 68.2% for enalapril ( p < 0.001, candesartan cilexetil versus enalapril; p > 0.20, candesartan cilexetil versus placebo). Treatment with candesartan cilexetil did not compromise patients' well-being. Compared with placebo, candesartan cilexetil was superior in terms of its effect on contentment; similar trends were noted for vitality and sleep, although the differences were not significant. When all adverse events were considered, candesartan cilexetil was very well tolerated. No serious adverse events occurred in the candesartan cilexetil or placebo groups, while three patients in the enalapril group reported serious adverse events (chest pain, agranulocytosis, accidental fracture). No treatment-related changes of clinical relevance could be found with regard to laboratory variables, ECG or vital signs/physical findings, except the anticipated blood pressure reduction in the active treatment groups. In conclusion, candesartan cilexetil is not associated with cough in hypertensive patients with previous ACE-inhibitor-induced cough. The incidence of dry cough in patients treated with candesartan cilexetil was similar to that of placebo and lower than that of enalapril.