Ernest Bors

Extremity fractures of patients with spinal cord injuries

Abstract 1. 1. In a group of 1,363 patients with traumatic spinal cord injuries, 156 (11 per cent) sustained fractures of the extremities; no comparable study has been noted in the literature. 2. 2. The case material was divided into four groups; Group I contained twenty-eight patients with thirty-four fractures of the upper extremities incurred in the accident which caused the spinal cord injury; Group II contained fifty-two patients with eighty-one fractures of the lower extremities incurred in the accident which caused the spinal cord injury; Group III contained eight patients with eight fractures of the upper extremities incurred after the spinal cord injury; Group IV contained eighty-one patients with 119 fractures incurred after the spinal cord injury. Within this group the most common fracture in forty patients was an impacted supracondylar fracture of the distal femur which was termed “the paraplegic fracture.” 3. 3. Groups I and II comprise 44 per cent; Group III, 4 per cent and Group IV, 52 per cent of all patients. 4. 4. In Group IV fractures occurred more often with lower than with upper motor neuron lesions and more frequently with complete than incomplete cord or cauda injuries. The significance of these findings is discussed. 5. 5. Fractures of the 156 patients occurred most frequently in the age group of twenty-one to forty years. 6. 6. Open fractures occurred in 41 per cent in Group I, 18 per cent in Group II, 0 per cent in Group III and 1.7 per cent in Group IV; there were sufficient battle injuries in Groups I and II to explain this distribution of open fractures. 7. 7. The magnitude of the trauma was sufficient in Groups I to III to cause the fracture. On the contrary, 44 per cent of the patients in Group IV sustained fractures of the lower extremities with so minimal an amount of trauma, that the fracture was called “pathologic.” 8. 8. Renal calculosis among 156 patients with fractures was twice as high (14.1 per cent) as that in 1,485 patients without fractures (6.8 per cent). Stones formed in patients with lower motor neuron lesions more often than in those with upper motor neuron lesions. 9. 9. The same fundamental principles of fracture management were applicable in patients with functional extremities and cord damage as in those without cord damage. However, another type of fracture therapy should be applied in patients whose cord injury has rendered their extremities useless so that alignment is only of secondary importance. This therapy consists of “pillow-splints,” sandbag splints and placing on Foster bed in preference to casts which carry the danger of pressure sores or operative procedures which may lead to more complications in the paraplegic than in the neurologically normal individual. 10. 10. “Exuberant” callus was most frequently encountered in Group IV, less in Group II and was inversely related to the degree of alignment. 11. 11. Nonunion occurred in 16 per cent of the patients in Group I, in 5.7 per cent in Group II, in 12.5 per cent in Group III and in 3.7 per cent in Group IV. The potential role played by the interruption of the sympathetic outflow has been discussed. 12. 12. Braces of the lower extremities may be an important factor in preventing these fractures since none of our patients was thus protected at the time of fracture.

An unusual urethral fistula site

Abstract Two cases studies of unusual urethral fistulas, complicated by bilateral removal of the ischium have been presented.

A study of vascular changes during surgery of paraplegic patients

1. Ninety-seven patients with 257 surgical procedures were evaluated in regard to their blood pressure responses during various types of anaesthesia.2. It was found that blood pressure changes during anaesthesia depended upon (a) the level of the lesion and (b) on the magnitude and site of the procedure.3. When the level was above the splanchnic outflow, the blood pressure rise, caused by autonomic dysreflexia, was frequently observed.4. Renal operations, cervical laminectomies and spinothalamic tractotomies, and operations on the bladder and perineum on patients with high lesions, or with previous spinothalamic tractomies tend to raise the blood pressure.5. In order to counteract these blood pressure rises, deepening the plane of anaesthesia was found preferable to the abrupt effect of ganglioplegic agents (hexamethonium chloride) because of better control.

Urinary tract disease in spinal cord injury patients. I. A brief outline of the problem.

AMELIORATION of urinary tract disease remains a challenging problem in patients with spinal cord injury. Renal failure due to infection is the most frequent cause of death (Jousse, 1967; Nyquist and Bors, 1967). Antibiotic therapy has not proven adequate in many cases. Studies now appearing in the current literature indicate a resurgence of interest in the role of antibodies and other host immunity factors in urinary tract disease (Quinn and Kass, 1960; Kass, 1965). We were interested to explore the usefulness of autogenous vaccines in urinary tract disease. We are not aware of any previous clinical trials. The Spinal Cord Injury Service at the Veterans Administration Hospital, Long Beach, California, is well suited for such studies because these patients present an unusually high risk population for urinary infection. Although a long list of bacterial species are involved in urinary tract disease, only four or five Gram-negative bacilli are known to account for the large majority of cases. We hope to develop, eventually, autogenous vaccines that would help circumvent the considerable problem of serological heterogeneity within each bacterial species. Prior to considering clinical application of vaccines, it was necessary to answer the question: do antibodies play an important role in the pathogenesis of urinary tract infections? We have been studying the natural history of urinary tract infection and antibody response in selected spinal cord injury patients over periods of many months (more than three years in some cases). Our initial purpose was to accumulate data that would enable appraisal of: (1) the diagnostic and prognostic significance of a patients antibody titre to his own urinary flora, and (2) the reliability of antibody titre versus urine culture as a guide to the etiology of urinary tract disease.