John J. Nicholas

Delayed traumatic vertebral body compression fracture; part II: Pathologic features

T HE DELAYED appearance of the clinical manifestations of traumatic compression of vertebral bodies, or Kiimmell disease, has not been reviewed in the English language literature since 1951.’ Much information bearing on the pathophysiology of this disputed and now rarely diagnosed ailment has been published since then. Recently having seen three patients to whom this diagnosis may apply, we have formulated a concept of the pathogenesis of Kiimmell disease and present up to date osteologic and biomechanical data in explanation and support of this hypothesis.

Cervical spondylotic myeloradiculopathy in dystonia.

Previous reports have attributed the development of premature cervical spondylosis to movement disorders such as torticollis and athetosis. This case report describes the clinical, electromyographic, and radiographic findings in a 34-year-old man who developed a myelopathy and cervical radiculopathy superimposed on a chronic dystonia of his neck and left arm. Cervical myeloradiculopathy should be suspected in any patient with a chronic movement disorder of the hand, neck, or arms, who presents with neurologic deterioration. Early diagnosis will lead to treatment that may improve symptoms. Anterior cervical bony fusion appears to be the preferred surgical treatment in these patients.

CONTRALATERAL V IPSILATERAL CANE USE: Effects on Muscles Crossing the Knee Joint

Although using a cane contralaterally has been shown to reduce muscular activity across the hip joint, little is known about effects on the knee. We measured muscular activity around the knee in 10 able-bodied subjects. We simultaneously recorded integrated rectified surface electromyographic activity from the right quadriceps, medial and lateral hamstrings, gastrocnemius and hip abductors during various standing maneuvers: two-legged stance, unsupported one-legged stance and one-legged stance putting maximal, moderate (20% body weight) or minimal (10% body weight) force through an ipsilateral or contralateral cane. Electromyographic activity was expressed as the percentage of that recorded during unsupported one-legged stance in each muscle. Hip abductor activity was lowest when maximal weight was placed through a contralateral cane (66%) and highest with maximal weight ipsilaterally (424%). Medial hamstrings activity increased by 404% and 200%, respectively, when maximal and moderate force was applied to a contralateral cane, although there was no change with ipsilateral cane. Lateral hamstrings were also most active during contralateral cane use. Quadriceps activity decreased using a cane in either hand with moderate or minimal force (range 57 to 84%). Gastrocnemius activity decreased during contralateral (60 to 66%) and ipsilateral (75 to 96%) cane use. This data suggests that forces generated by muscular activity around the knee are not uniformly diminished by holding a cane in the contralateral hand and may even be increased.

Delayed traumatic vertebral body compression fracture; part I: Clinical features

We have described three patient who sustained trauma to their spines followed by persisting pain. Initial radiographs were negative, but on subsequent examinations compression fractures were demonstrated. This sequence of events resembles the clinical picture described by Kümmell in 1895 with significant differences. A plethora of early written description with minimal radiographic documentation suggests that this is a relatively rare condition. It is appropriate, therefore, to present these cases with the suggestion that traumatic injuries with persisting thoracic or upper lumbar back pain should be followed up radiographically in order to demonstrate the occurrence of subsequent compression fractures. These fractures may be treated with simple braces.

Bone-forming gastric metastases in muscle—Computed tomographic demonstration

Bone-forming metastases to soft tissues and muscle are a rare entity. An unusual case of heterotopic ossification occurring within metastases to muscle arising from a primary gastric adenocarcinoma is reported. No bone was found in the primary gastric malignancy. There is one prior report of ossification in muscle occurring in metastases from gastric malignancy, but no previous computed tomographic demonstration of this. The mechanism of osseous metaplasia is discussed, but its precise morphogenesis remains obscure.

Amputations associated with arteriovenous access.

This study was performed to investigate the common characteristics of hemodialysis patients who need upper limb amputations. An index case was identified and involved questioning physicians and reviewing hospital and office records. Hemodialysis patients who have diabetes and leg amputations are at high risk for ischemic episodes that may lead to amputation of the arm, distal to the arteriovenous access site.

Diaper doer's hand: stenosing tenosynovitis in the postpartum period

Three cases of stenosing tenosynovitis occurred three to six months postpartum. Childcare activities aggravated the symptoms of pain and swelling in both patients. In two cases, a specific method of carrying the child was implicated as the mechanism of injury. Although there was no evidence of generalized inflammatory arthritis, all patients had very low positive titres of anti-nuclear antibodies. While it is likely that tenosynovitis was caused by mechanical factors, the possibility of increased susceptability to inflammatory disease in the postpartum period cannot be discounted. The patients were successfully treated with a low temperature plastic splint, superficial heat and gentle mobilization.