Unreported "de novo" rearrangement of chromosomes 4 and 7: Unbalanced rearrangements of the chromosomes are extremely rare and associated with an abnormal phenotype and usually result in an abortion in early pregnancy. The current literature includes reports on the conditions related with rearrangements of chromosome 4 and 7. Herein, we describe a rearrangement between these two chromosomes, which is the first presentation of a specific translocation t(4;7)(q31;p15) and its consequent phenotype following de novo rearrangement of the chromosomes. It brought into light phenotypic similarities with other aberrations following breakage from adjacent band loci. We hope these features will help further genetic investigations on these chromosome regions.

EEM syndrome is a rare condition characterised by ectodermal dysplasia, ectrodactyly and macular dystrophy. Additional abnormalities such as alopecia, cataract, absent eyebrows, and oligodontia may occur. We report two brothers and a sister born to consanguineous parents with EEM syndrome. EEM syndrome differs from other ectrodactly syndromes by the characteristic findings in the ocular fundus showing extensive retinochoroidal atrophy with diffuse retinal pigmentation and mild arteriolar attenuation at the posterior pole. In contrast to other ectrodactyly syndromes autosomal recessive inheritance is most likely.

Traumatic rupture of the deep flexor tendon is a well-recognized entity known as “jersey finger”. However, simultaneous traumatic rupture or avulsion of both flexor tendons in a finger without pre-existing disease is extremely rare. Such an injury is presented and discussed here, with regards to the mechanism, location, and treatment in comparison with similar reports in the literature.

OBJECTIVE:In the present study, the effects of magnesium sulfate (MgSO4) on tissue lactate and malondialdehyde (MDA) levels after spinal cord trauma (SCT) in rabbits were studied.SUBJECTS:Thirty New Zeland rabbits. Interventions. The rabbits were divided equally into three groups: group I was the sham- operated group, group II suffered from SCT but received no treatment, group III was given a dose of 100 mg/kg of magnesium sulfate intravenously at 5th minute after SCT. MEASUREMENTS. The lactate and MDA levels were measured in contused spinal cord tissue at 60 minutes after SCT. There was a significant increase of lactate and MDA levels in group II (p < 0.05) when compared with groups I and III, and a significant increase in the level of MDA in group III compared with group I, and also a significant decrease compared with group II, which was the trauma group without treatment (p < 0.05).CONCLUSION:The findings of this study showed that magnesium sulfate can attenuate the increase of tissue MDA and supply a normalization of lactate levels following SCT which may be related to the neuroprotective effects of (MgSO4).

Study Design. Prospective, randomized, double blind, placebo-controlled, crossover clinical trial.Objectives. To determine the efficacy of gabapentin in the treatment of neuropathic pain related to spinal cord injury.Summary of Background Data. Neuropathic pain is initiated or caused by a primary lesion or dysfunction in the nervous system. Neuropathic pain associated with spinal cord injury is quite refractory, and current treatments are not effective. Gabapentin, an anticonvulsant, has become the first choice in the treatment of neuropathic pain. The place of gabapentin in the treatment of spinal cord injury-related neuropathic pain was questioned in only a few recent reports; however, they are retrospectively designed, nonstandardized, and uncontrolled studies, or involve a very small series of patients using less than optimum doses.Methods. A total of 18-week study period included a 4-week medication/ placebo titration period. This was followed by a 4-week stable dosing period when the patients continued to receive maximum tolerated doses, a 2-week washout period, then a crossover of 4 weeks of medication/ placebo titration, and another 4 weeks of stable dosing period. Twenty paraplegic patients (female/male: 7/13) with complete spinal cord injury at the thoracic and lumbar level, aged between 20 and 65 years, with neuropathic pain for more than 6 months were recruited for the study.Results. All patients completed the study. Gabapentin reduced the intensity as well as the frequency of pain, relieved all neuropathic pain descriptors except the itchy, sensitive, dull, and cold types, and improved the quality of life ( P < 0.05).Conclusions. Gabapentin can be added to the list of first-line medications for the treatment of chronic neuropathic pain in spinal cord injury patients. It is a promising new agent and offers advantages over currently available treatments.

BACKGROUND:Developmental dysplasia of the hip (DDH) continues to be missed by routine physical examination in up to 50% of cases. Ultrasound (US) supplementation is the best method of screening for DDH, but the resources required should not be underestimated. Limited abduction of the hip (LHA) in an infant triggers suspicion, and often an urge to treat, in most orthopaedic surgeons and pediatricians alike. This study aimed to document the value of unilateral LHA in the diagnosis and decision making of DDH, and the correlation between LHA and US.METHODS:In total, 464 infants referred from the pediatrics clinic with LHA, aged between 30 and 120 days, were included in the study.RESULTS:Physical examination revealed LHA in 186 (41%) infants, 26 of which were unilateral and 160 were bilateral. US examination showed that 13 (8.1%) patients in the bilateral LHA group and 18 (69.2) patients in the unilateral LHA group, had DDH (total number 31, 7%).CONCLUSION:Unilateral limitation of hip abduction was found to be a sensitive sign for developmental hip dysplasia, but US could be defined once again as the best golden standard before initiating treatment.

After a few reports on end-to-side nerve repair at the beginning of the last century, the technique was put aside until its recent reintroduction. The authors present their results in three patients with median nerve defects that were between 15 and 22 cm long and treated using end-to-side median-to-ulnar neurorrhaphy through an epineurial window. The follow-up times were between 32 and 38 months. Sensory evaluation involved superficial touch, pinprick, and two-point discrimination tests. Motor evaluation was completed by assessing the presence of opposition and by palpating the abductor pollicis brevis muscle. Sensory recovery was observed in all patients in the median nerve dermatome, and motor recovery was absent, except in Case 1. End-to-side nerve repair can be a viable alternative to nerve grafting in patients with long gaps between the ends of the injured nerve.

STUDY DESIGN:Patients with cervicobrachial pain were examined in detail with special attention to vertebral artery loop formation.OBJECTIVES:To determine the incidence, short-time natural course and response to a conservative approach to vertebral artery loop formation in a group of patients with cervicobrachial pain.SUMMARY OF THE BACKGROUND DATA:Vertebral artery loop formation is reported to be a rare cause of cervicobrachial neuralgia, discovered incidentally during the search for its cause. It can be congenital or acquired, occurring equally in both sexes. Surgical decompression has been the preferred method in the majority of reported cases, with favorable results.METHODS:One hundred seventy-three patients with cervicobrachial pain were examined in a period of 7 months using physical examination, radiography, and magnetic resonance imaging with or without angiography.RESULTS:Thirteen patients with a mean age of 43.9 +/- 13.5 years were diagnosed with vertebral artery loop formation. The most common level was C6-C7. Four patients presented with loop formation at two levels. None of the patients had symptoms attributable to intervertebral disc pathology. The complaints were in accordance with the level of the vascular pathology. Complete relief or decrease in pain was observed in all patients with the conservative approach.CONCLUSIONS:In patients with cervicobrachialgic symptoms and without established discopathy, during the examination of sagittal magnetic resonance images, vertebral artery loop formation should be kept in mind, and in suspected cases, the vertebral artery should be visualized using three-dimensional time of flight magnetic resonance angiography. Vertebral artery-nerve root relation should also be demonstrated using the multiplanar reformatting method from time of flight images. A conservative course of treatment has a favorable outcome.

Our aim was to determine the clinical effectiveness and safety of Ilizarov external fixation for the acute treatment of severely comminuted extra-articular and intercondylar fractures of the distal femur. A total of 14 consecutive patients with complex fractures was treated. There were three type-A3, two type-C2 and nine type-C3 fractures according to the AO/ASIF system. The mean follow-up was 14 months. Most fractures (13) united primarily at a mean of 16 weeks. One patient with a type-IIIA open fracture had infection and nonunion. The mean range of flexion of the knee at the final follow-up was 105 degrees (35 to 130). We conclude that, in the treatment of comminuted fractures of the distal femur, the Ilizarov fixator is safe and effective in providing stability and allowing early rehabilitation.

OBJECT:In cases of irreparable injuries to the radial nerve or in cases in which nerves are repaired with little anticipation of restoration of function, tendon transfers are widely used. In this study, the authors searched for a more natural alternative for selectively restoring function, with the aid of a motor nerve transfer.METHODS:Ten arms from five cadavers were used in the study. The posterior interosseous nerve and the median nerve together with their motor branches were exposed in the proximal forearm. The possibility of posterior interosseous nerve neurotization via the median nerve through its motor branches leading to the pronator teres, flexor pollicis longus, flexor digitorum profundus, and pronator quadratus muscles was investigated. The lengths of the nerves from points of divergence and their widths were measured using calipers, and the means with standard deviations of all nerves were calculated. Motor branches to the pronator teres, flexor pollicis longus, and pronator quadratus muscles were found to be suitable for neurotization of the posterior interosseous nerve at different levels and in various combinations. The motor nerve extending to the flexor digitorum profundus muscle was too short to use for transfer.CONCLUSIONS:These results offer a suitable alternative to tendon transfer for restoring finger and wrist extension in cases of irreversible radial palsy. The second step would be clinical verification in appropriate cases.

BACKGROUNDThe aim of this study was to investigate whether enhanced stimulation voltage could be a predictor of the extent of injury in acute compressive peripheral nerve trauma.METHODSThe femoral nerves were exposed on both sides, in 11 anesthetized rabbits. Supramaximal stimulation voltage was used to produce a maximal-amplitude compound muscle action potential (CMAP) from the quadriceps femoris muscle. Afterward, the left femoral nerve was clipped for 1 minute, and the right femoral nerve for 5 minutes to produce an acute compressive injury. Immediately after removal of the clip, the proximal and distal sides of the clippage site were stimulated by gradually increased voltage until CMAPs were obtained. The same procedure was repeated at the 30th and 60th minutes. The ratio of the CMAP amplitudes obtained from proximal and distal stimulation was measured to establish a classification.RESULTSThe stimulation voltages and amplitudes of the CMAPs before clippage were similar with the after-clippage values obtained from distal stimulation (p > 0.05), but the after-clippage values obtained from proximal stimulation were different in both sides (p < 0.05). Doubled stimulation voltage was enough to obtain CMAPs on the left side, but eightfold the initial level was required on the right side. The amplitude ratios recovered to preinjury levels in all of the subjects on the left side, but only two showed recovery on the right side (p < 0.001). Histopathologically, there was axonal compression without discontinuity on the left side, whereas the fibers were dispersed on the right side.CONCLUSIONStimulation voltage was found to discriminate the severity of the lesion in experimental peripheral nerve injury. Proximal to distal amplitude ratio seems to be a prognostic factor when the injury is less severe.

Background The distally based superficial sural artery flap, first described as a distally based neuroskin flap by Masquelet et al., is a skin island flap supplied by the vascular axis of the sural nerve. In the difficult area of defects in the lower leg and the ankle and heel region, it has a wide variety of indications, even in the vascularly compromised patients. It has the largest arc of rotation of all flaps that have been described in this region. The most important advantage is that it does not compromise a major artery. It is simple to dissect and has a low donor morbidity. Methods We reported our experience with this new flap in 15 cases and also described a new indication for the patients with neglected ruptures of the Achilles tendon. Results In 13 patients, the flap was successfully transferred. In two cases, partial necrosis of the flap ensued, which healed with secondary intention. Conclusion This flap deserves a high degree of interest in the reconstructive armamentarium of the trauma surgeon.

Opposition, one of the most important functions of the hand, is lost or impaired after median nerve injury. Complete recovery does not always occur after treatment, and various techniques of opponensplasty are used for restoring opposition. This study was performed in order to develop an alternative method for selective restoration of thenar muscle function. Ten arms from 5 cadavers were used. The median nerve with its thenar motor branch (Tb) and the anterior interosseous nerve with its motor branch to pronator quadratus (PQb) were prepared in the distal forearm. The mean widths and the number of myelinated fibres of these nerves were: PQb 1.3±0.10 mm, Tb 1.4±0.12 mm and PQb 912±88 mm, Tb 1020±93 mm. The minimum necessary distance from the distal flexor crease of the wrist for neurotisation of the Tb by the PQb was 60±5.41 mm. It was concluded that PQb‐Tb neurotisation would be possible anatomically. The advantages are that motor function is reestablished with a motor nerve, the diameters and the number of myelinated fibres of both nerves are similar, the loss of function after denervation of the pronator quadratus is slight and opponensplasty still remains as a final option.

Background: Proximal ulnar-nerve lesions have an unfavorable prognosis. The goal of the present study was to evaluate the feasibility of selective restoration of motor function of the ulnar nerve by the transfer of the anterior interosseous nerve or one of its branches to the motor branch of the ulnar nerve. Methods: Ten cadaveric arms were used in the present study. The ulnar nerve and its motor and sensory branches as well as the anterior interosseous nerve and its branches were dissected. The widths of the motor branch of the ulnar nerve and the anterior interosseous nerve and its motor branches as well as the relevant distances from the points of divergence were measured. The axons were counted, and the distances from the end of the main anterior interosseous nerve, its motor branches, and the motor branch of the ulnar nerve to the level of the dorsal sensory branch of the ulnar nerve were measured. Results: Our results indicate that the length, width, and number of axons of the branch of the anterior interosseous nerve to the pronator quadratus make it suitable for transfer to the motor branch of the ulnar nerve. The use of the main anterior interosseous nerve or its motor branches to the flexor pollicis longus and the flexor digitorum profundus is less feasible because of the need to graft a long segment and the longer distance from the level of transfer to the motor end points. Conclusions: The findings of the present study confirm the feasibility of motor-nerve transfer for reconstruction after an injury of the ulnar nerve. Nerve-grafting would be needed for injuries distal to the level of the dorsal sensory branch of the ulnar nerve.

In evaluation of genu varum-genu valgum, tibiofemoral (TF) angle and intercondylar (IC) or intermalleolar (IM) distance are commonly measured. In this study, we determined mean values and normal limits for TF angle and IC/IM distance in 590 normal Turkish children (287 girls and 303 boys) aged from 3 to 17 years using clinical methods. We noted a significantly higher degree of valgus angle than that in previous reports. The maximal mean valgus angle was 9.6 degrees at 7 years for boys and 9.8 degrees at 6 years for girls. These differences were considered racial differences between Turkish children and those of other races. Turkish children, aged between 3 and 17 years, exhibited < or =11 degrees physiologic valgus. A measurable varus angle or a valgus higher than 11 degrees during this period should be considered abnormal.

Open fractures in children have a high level of morbidity and require early treatment. This case describes the successful treatment of a child who sustained an open tibial fracture with soft tissue loss. The fracture was stabilized with a monolateral external fixator devised in our clinic, and the soft tissue loss was covered with a distally based sural artery flap. The flap is simple, can be done quickly, and a surgeon does not need microsurgical or specialty training to perform the operation. This combined use of external fixation and distally based sural artery flap is a straightforward technique in distal tibial open fractures of children with soft tissue loss.

BACKGROUND The purpose of this study was to determine the safety of early weight-bearing after statically locked reamed nailing of comminuted fractures of the femoral diaphysis, and to assess the rate of implant failure and fracture healing. METHODS Thirty consecutive patients with comminuted diaphyseal femur fractures (Winquist type II, III, and IV) were treated with statically locked reamed intramedullary nailing. Six patients were lost to follow-up, and the remaining 24 patients were followed at least 1 year. Early weight-bearing was allowed and encouraged in the first 2 weeks after the operation. The nail diameters were 13 mm in 16 patients, 12 mm in 6 patients, and 14 mm in 2 patients. RESULTS Most of the patients could start weight-bearing between the first 2 and 4 weeks postoperatively. None of the patients, except one, were using any walking aids at the second month postoperatively. All the fractures healed without any significant complications. Nail bending or breakage did not occur in any patients, but there was slight bending in one distal interlocking screw and one proximal interlocking screw. The fractures of the patients with bent screws healed uneventfully. CONCLUSION This study showed that early weight-bearing after reamed static interlocking nailing of Winquist type II, III, and IV femoral fractures is a safe and effective method, and the risk of implant failure does not preclude the procedure.

The role of preliminary traction before closed reduction in the treatment of developmental dysplasia of the hip has been questioned by many authors lately. However, the studies advocating or opposing the use of this treatment modality include several other parameters besides traction. Thus, it is unclear whether the affection is the result of preliminary traction or concurrent variables such as the "human position." This study aimed to put forward the effect of preliminary traction as a single determinant of avascular necrosis. We had two groups of patients who had developmental dislocation of the hip. The first group consisted of 52 patients treated with preliminary traction before closed reduction and the other group comprised 40 patients treated with closed reduction without preliminary traction. Both groups were similar in age, gender, side, level of dislocation, and method and duration of immobilization. Three patients from the first group developed avascular necrosis, which was not statistically significant. Preliminary traction did not affect the rate of avascular necrosis.

Ipsilateral elbow and forearm fractures are quite rare in children. We present a Monteggia lesion with ipsilateral supracondylar humerus fracture in a 13-year-old girl. Through early surgical management, a successful result was achieved. We believe that, to minimize any initial or subsequent complications in such fractures, early surgical management should be the first treatment choice.