Necrotizing fasciitis is a severe and progressive infection of deep soft tissues which results in destruction of the fascia and overlying subcutaneous fat. We report a case of a 45-year-old diabetic gentleman who initially presented with left shoulder pain, which was treated symptomatically. Upon representation, he had fever and the pain extended to his left upper back. There was a warm, firm and mildly tender purplish swelling on his mid to the left upper back. Blood tests revealed significantly elevated white cell counts and C-reactive protein. A CT thorax showed extensive soft tissue gas within the deep and superficial fascial layers of his left upper back. Necrotizing fasciitis was confirmed intraoperatively. The diagnosis of this condition is often difficult as early symptoms can be mild and nonspecific. A high Laboratory Risk Indicator for NECrotizing fasciitis (LRINEC) score may be helpful to rule in this diagnosis and guide further management.
This study assessed the effects of progressive resistance exercise programmes on self-reported health related quality of life, body composition and muscle strength among patients with HIV. Twenty-nine men with HIV were randomly assigned to progressive resistance exercise programme using elastic band (PRE group) (n=14) or resistance exercise programme without elastic band (comparative group) (n=15). Both groups underwent exercise programmes for 12 weeks. Selfreported health related quality of life, body compositions and isometric shoulder lift strength were assessed at baseline and at week 12. Ten and nine men in the intervention and comparative groups, respectively, completed the 12-week programme. Participants in the comparative group showed significant improvements in the domain of mental health (p<0.05). No significant changes in all body composition parameters were found in both groups with time. Both groups showed significant improvements in peak and average shoulder lift strength (intervention, p=0.001; p=0.001; control, p=0.008; p=0.016). Progressive resistance exercise programmes significantly improves shoulder lift strength, showed positive effects on self-reported health related quality of life scores among patients with HIV.
Epidermoid cyst is a common benign cutaneous swelling frequently encountered in surgical practice. It usually presents as a painless lump frequently occurring in hairbearing areas of the body particularly the scalp, scrotum, neck, shoulder and back. Giant epidermoid cysts commonly occur in hairy areas such as the scalp. We present here the case of a rare occurrence of a giant epidermoid cyst in the less hairy area of the right upper thigh mimicking a soft tissue sarcoma. Steps are highlighted for the management of this unusual cyst.
Introduction: This is a cross-sectional study of 37 patients with AO type C (complete intra-articular) fractures of the distal radius, evaluating the functional, anatomical, and patient rated outcomes one year after primary fixation with a volar locking plate.
Methods: Functional outcomes were assessed based on the grip strength, and the range of motion of forearm and wrist. Anatomical outcomes were assessed based on the radial inclination, radial height, volar tilt, and articular step or gap. Patient rated outcome was measured with a Disability of arm, shoulder and hand (DASH) questionnaire.
Results: One year after surgery, 24 (64%) patients achieved good and excellent anatomical results, and DASH scores were acceptable in 73% of patients. Most of the patients had achieved 80% of their grip strength. The mean DASH score of 12.3 was comparable with other studies. Grip strength, radial inclination and volar tilt had a significant correlation with the DASH score.
Conclusion: Volar locking plates can be used to achieve optimal reduction in all three parameters in the treatment of AO type C fractures of the distal radius. Versatile fracture fragment reduction and angular stability enable rehabilitation hence obtaining good functional outcomes.
Fracture is common after trauma. Proximal humeral fracture can occur in the elderly after fall and in youngsters after motor vehicle accidents (MVA) and sport injuries. A 37-year-old man was admitted with a fracture of his left proximal humerus following an MVA. He sustained a 3-part fracture and treated surgically using a PHILOS plate. There are few options in managing proximal humerus fracture ranging from conservative to surgical intervention based on its severity. We reminiscent the usage of PHILOS plate as a mode of treatment of such fracture.
The aim of this descriotive study is to determine the incidence of injuries among recreational badminton players. We evaluated 86 recreational badminton players in the city of Malacca; 35 were excluded for fitting the exclusion criteria. The average recreational badminton player was 36.13 years old and had been playing badminton for the past 17.84 years at a frequency of 2.11 times per week. 39.21% of the recreational badminton players complained of recent injuries in relation to playing badminton. Our data showed that the most common injury sustained by recreational badminton players was pain and stiffness at the shoulder joint. None of the injuries sustained by the players in our data were serious enough to warrant any form of surgical intervention. We conclude that badminton is a sport of relatively low risk and that the majority of related injuries were chronic overuse injuries.
Recent evidences suggest functional thoracic hyperkyphosis (FTH) could be a different approach in the management of subacromial impingement syndrome (SIS). This case study aims firstly with the development of evidence informed FTH model for SIS. Secondly this study aimed to develop well defined multimodal physical therapy intervention for FTH and its related mechanical consequences in elderly patient with chronic SIS. As a result, Level IV positive evidence was found in both the short and long-term pain and disability of chronic SIS, using FTH model with 26 months of follow-up.
Introduction: Proximal humerus fracture fixation using plate osteosynthesis depends on the quality of the bone, design of the fixation devices and intra-operative soft tissue dissection. This study evaluates the functional outcome of minimally invasive percutaneous plate osteosynthesis using locking compression plate in proximal humerus fracture treatment. Materials and Methods: The study was conducted on 30 patients with complex proximal humerus fractures treated by minimally invasive percutaneous plate osteosynthesis using locking compression plate (PHILOS). There were 21 males and 9 females. The average age of our study group was 58.8 years. All the patients were evaluated at six weeks, three months, four months, six months and 12 months following surgery. Results: All patients had fracture union at an average of 13.2 weeks. The mean DASH score at the follow-up was 8.69 (2.5 to 17.16), the average range of flexion was 143.83 degrees (100 to 170 degrees) and abduction was 121.49 degrees (90 to 160 degrees). We had superficial infection in three patients which resolved with a short course of antibiotics. There was excellent outcome in 26 patients, good and fair in two patients each. Conclusion: Proximal humerus fractures treated with minimally invasive percutaneous plate osteosynthesis using locking compression plate with minimal soft tissue dissection, provides good functional outcome and early return of shoulder function.
Introduction: Degenerative disorder involving the acromioclavicular
joint (ACJ) is quite common especially in the elderly.
One of the surgical modalities of treatment of this disorder is the
Mumford Procedure. Arthroscopic approach is preferred due to
its reduced morbidity and faster post-operative recovery. One
method utilizes the anteromedial and Neviaser portals, which
allow direct and better visualization of the ACJ from the
subacromial space. However, the dangers that may arise from
incision and insertion of instruments through these portals are
not fully understood. This cadaveric study was carried out to
investigate the dangers that can arise from utilization of these
portals and which structures are at risk during this procedure.
Methods: Arthroscopic Mumford procedures were performed
on 5 cadaver shoulders by a single surgeon utilizing the
anteromedial and Neviaser portals. After marking each portals
with methylene blue, dissection of nearby structures were
carried out immediately after each procedure was completed.
Important structures (subclavian artery as well as brachial plexus
and its branches) were identified and the nearest measurements
were made from each portal edges to these structures. Results:
The anteromedial portal was noted to be closest to the
suprascapular nerve (SSN) at 2.91 cm, while the Neviaser portal
was noted to be closest also to the SSN at 1.60 cm. The
suprascapular nerve was the structure most at risk during the
Mumford procedure. The anteromedial portal was noted to be
the most risky portal to utilize compared to the Neviaser portal.
Conclusion: Extra precaution needs to be given to the
anteromedial portal while performing an arthroscopic distal
clavicle resection in view of the risk of injuring the
suprascapular nerve of the affected limb.
Acromioclavicular joint (ACJ) dissociation is one of the common injuries affecting adults. The stability of ACJ largely depends on the integrity of acromioclavicular ligament, coracoclavicular ligament, capsule, trapezius muscle and deltoid muscle. The injury has been classified by Rockwood into six types and treatment options can be guided by the classification. TightRope fixation is one of the many surgical procedures available to address acromioclavicular joint separation. It consists of tensioning of a no. 5 Fibrewire suture secured at both ends to low-profile metallic buttons. Despite various advantages of using this technique, complications such as suture cut-out, clavicle fracture and suture failure have been documented. The author presents a case of a type III acromioclavicular joint dissociation treated with TightRope which suture cutout was noted intra-operatively. Decision to amend the fixation using a cut one-third tubular plate as an additional anchor for the metallic button on the clavicle was made. Patient's progress was evaluated using the University of California at Los Angeles Shoulder Score (UCLA Shoulder Score) and significant improvement was noted six months post operatively. We propose this technique as a solution to the encountered problem.
Chondrosarcoma is the third most common primary tumour of the bone, after myeloma and osteosarcoma. Most of the chondrosarcoma grow slowly and rarely metastasize, and they have an excellent prognosis after adequate surgery. However most of them are chemo or radio-resistant. We report a case of primary chondrosarcoma of proximal humerus in a 36-year-old female who presented with a six years history of left shoulder swelling and restricted range of motion. Trucut biopsy showed a well-differentiated chondrosarcoma. The patient underwent forequarter amputation of left upper limb and was started on chemotherapy following operation.
Differential scanning calorimetry (DSC) is developed and used for detection of butter adulteration with lard. Butter has the similar characteristics to lard makes lard a desirable adulterant in butter. DSC provides unique thermal profiling for lard and butter. In the heating thermogram of the mixture, there was one major endothermic peak (peak A) with a smaller shoulder peak embedded in the major peak that gradually smoothed out to the major peak as the lard percent increased. In the cooling thermogram, there were one minor peak (peak B) and two major exothermic peaks, peak C which increased as lard percent increased and peak D which decreased in size as the lard percent increased. From Stepwise Multiple Linear Regression (SMLR) analysis, two independent variables were found to be able to predict lard percent adulteration in butter with R2 (adjusted) of 95.82. The SMLR equation of lard percent adulteration in butter is 293.1 - 11.36 (Te A) - 2.17 (Tr D); where Te A is the endset of peak A and Tr D is the range of thermal transition for peak D. These parameters can serve as a good measurement parameter in detecting lard adulteration in butter. DSC is a very useful means for halal screening technique to enhance the authenticity of Halal process.
Bipolar segmental clavicle fractures are simultaneous clavicle fractures of both proximal and distal ends. Few case reports describing these fractures have been published, and the management of these injuries have remained controversial. Non-operative treatment is likely to result in poor shoulder function due to the instability of the fracture in patients with high physical demands. In contrast, surgical treatment with fixation of both proximal and distal ends of the clavicle possibly may cause life-threatening complications. We present a 74-year old female farmer who had injured her left shoulder and was diagnosed with a bipolar segmental clavicle fracture. Taking the fracture mechanism into consideration, we surgically treated only the distal end of the clavicle fracture with a locking plate. The proximal end of the clavicle fracture was treated without surgical intervention. Both fracture sites achieved bony union after four months and she returned to her activities as a farmer. Quick DASH score was 5.0 with excellent results at three years after operation.
The latissimus dorsi is a muscle of the back which forms the posterior fold of the axilla and its tendon twists to insert into the floor of the intertubercular sulcus of the humerus. Occasionally, the muscle has a muscular slip which crosses the axilla to insert into the pectoralis major. This muscular slip is often termed as "axillary arch." In the present study, we report bilateral axillary arch detected in a 45-year-old male cadaver. The average vertical length of the axillary arch measured 7 cm. The average maximum width of the uppermost, middle and lower part of the arch measured 2, 3.5 and 3.2 cm, respectively. The presence of the axillary arch is an uncommon finding in humans, considering the fact that it is solely found in the animals who prefer to hang on the trees. A histological study of the axillary arch was also performed and it showed skeletal muscle fibres which was uniformly arranged. The presence of the axillary arch may assist in the adduction of the shoulder. It may also compress the axillary vessels and nerves thereby causing resultant symptoms. Prior anatomical knowledge of the presence of axillary arch may be helpful for surgeons performing radical dissection of the axillary lymph nodes and ligation of axillary vessels, clinicians diagnosing abduction syndromes and interventional radiologists interpreting axillary mass in day to day clinical practice.
A new species of Leptostraca, Nebalia terazakii sp. n. is described and figured. The species was sampled from the coral reefs of Pulau Payar Marine Park, Langkawi, Malaysia. There are 32 existing species of Nebalia but Nebalia terazakii sp. n. can be distinguished from the other known species of Nebalia by the following combination of characters: the rostrum is 1.89 times as long as wide and the eyes have no dorsal papilla or lobes. Article 4 of the antennular peduncle has one short thick distal spine. The proximal article of the endopod of maxilla 2 is shorter than the distal, a feature peculiar to Nebalia terazakii sp. n., the exopod of maxilla 2 is longer than article 1 of the endopod, the posterior dorsal borders of the pleonites 6 to 7 are provided with distally sharp denticles, anal plate with prominent lateral shoulder and finally, the terminal seta of the caudal rami is 1.17 times the length of the entire rami.
Occupational tasks of linemen are highly associated with the development of work related musculoskeletal disorders (WRMDs). Although linemen are prone to develop WRMDs, there is paucity of information on the prevalence of WRMDs and related occupational causative factors. Therefore, the present review was conducted to report on the prevalence of WRMDs and to outline causative risk factors within occupational tasks in the lineman profession. Literature search was conducted in various databases such as Scopus, PubMed and ScienceDirect for articles published between 1996-2013. The articles were analyzed, selected and retrieved based on predetermined objectives, inclusion criteria and Medical Subject Headings (MeSH). In the review process only articles published in English were considered. The review identified moderate to high prevalence of WRMDs among the linemen population. Back and shoulder regions were highly affected compared to the other body regions. The review also reported occupational tasks such as bar installation, insulator fixation and manual handling of tools as high risk tasks that lead to the development of WRMDs. In addition, occupational tools such as ladders, manual cutters and manual presses were also identified as a potential ergonomic hazard. In conclusion, the current review identified that WRMDs are common in the back and shoulder regions among linemen. Also, a number of occupational risk factors were identified to be associated with WRMDs among the linemen. Hence, future research on prevention and intervention studies concerning lineman profession population in order to develop a good job practice are recommended. Int J Occup Med Environ Health 2016;29(5):725-734.
Working in a safe working posture is a necessity to enhance occupational health of industrial workers. Poor
working posture may lead to injuries, discomfort and fatigue to the workers. The objective of this study is to survey the
postures practised by the Malaysian industrial workers. A questionnaire survey was performed among 282 Malaysian
industrial workers in 10 different industries. From the answered questionnaire, it was observed that shoulder at chest
level (30.1%), back in a bent forward (33.3%) and lifting heavy load (44.7%) are the major work postures practised by
most of industrial workers. This survey identifies that working with shoulder and hand at chest level and back region
moderately bent forward is the main working posture practice by worker. Workers also reported lifting load below 5 kg
at the workstation. This survey recommended for industrial workers to be aware of the comfortable working posture
to avoid injury.
The aim of this study was to investigate the work-related musculoskeletal disorders (WMSDs) among workers in wall plastering jobs within the construction industry.
The occurrence of axillary artery injury following proximal humerus fracture dislocation in elderly patient with low velocity fall is uncommon. The patient could have diverse clinical presentations in spite of intact peripheral pulses. We report the case of an 85-year-old lady who presented to our emergency department with greater tuberosity fracture of the humerus with dislocation of the right shoulder. After closed manipulative reduction of the dislocation, it was observed that the patient had brachial plexus palsy with intact radial pulse. An expanding swelling and bruise around the shoulder was noted and a steady drop in haemoglobin level. CT angiogram revealed avulsion of the posterior circumflex artery which was then treated successfully with stenting.
A 29-year-old man, who was a medical intern presented with history of recurrent shoulder dislocation. Radiographs
and computed tomography imaging revealed a bony bankart lesion with glenoid bone loss of 25% with moderate
Hill- Sachs lesion. Latarjet surgery was performed. At post-operative 8 months, the patient experienced pain and
clicking in the left shoulder while performing cardiopulmonary resuscitation. At post-operative 1 year, magnetic resonance arthrography showed a united coracoid graft and intact posterior labrum. Left shoulder diagnostic arthroscopy and removal of Latarjet screws through a limited anterior deltopectoral approach were performed. The symptoms
pain, clicking and instability sense was caused by either the prominent distal screw or the remnant suture material
from the anchor which resulted in impingement of the infraspinatus muscle. We recommend the use of image intensifier to check on the position and length of the screw at the end of the surgery to avoid this complication