Trauma induced testicular torsion is a well recognised entity, the incidence being 4-8% in most studies reporting on testicular torsion. The signs and symptoms of testicular torsion may easily be mistakenly attributed to preceding testicular trauma if there was such an event. A patient is described with trauma induced testicular torsion who presented on three occasions before a decision was made to perform scrotal exploration. Unfortunately, an orchidectomy was the outcome. The message that trauma can and not infrequently does precipitate torsion, needs to be reiterated. Awareness of the entity and constant vigilance is required of clinicians to avoid a delay in definitive treatment.
Twelve patients with drop-foot secondary to sciatic or common peroneal nerve palsy treated with transfer of the tibialis posterior tendon were followed-up for a mean of 90 (24-300) months. In 10 patients the results were 'excellent' or 'good'. In 11 patients grade 4 or 5 power of dorsiflexion was achieved, although the torque, as measured with a Cybex II dynamometer, and generated by the transferred tendon, was only about 30% of the normal side. Seven patients were able to dorsiflex their foot to the neutral position and beyond. The results appeared to be better in men under 30 years of age with common peroneal palsies. A painful flatfoot acquired in adulthood does not appear to be a significant long-term complication despite the loss of a functioning tibialis posterior tendon.
A system for assessing the results of tibialis posterior tendon transfers in the treatment of foot drop secondary to nerve palsy is proposed. There are seven sections to this scoring system: pain, need for orthosis, ability to wear normal shoes, activity level, muscle power of ankle dorsiflexion, degree of active ankle dorsiflexion, and foot posture. The total score is 100. The results are classified as excellent for scores between 85 and 100, good between 70 and 84, fair between 55 and 69, and poor for scores below 55. The results of 18 patients (mean followup, 64.6 months) who had a tibialis posterior tendon transfer were assessed using this method. Four patients (22.2%) had an excellent result, seven (38.8%) had a good result, two (11.1%) had a fair result, and five (27.7%) had a poor result. The average score was 67.2, suggesting an overall fair result for this operation. In nine patients, there was correlation between the outcome when assessed with this method and with patient rating. In two patients, the outcomes were better when assessed with this method than with patient rating, whereas the reverse was true in seven other patients. Thus, this system may provide a more objective and critical evaluation of tibialis posterior transfers for foot drop.
Postal surveys are becoming an increasingly popular method of conducting research in Malaysia. However, the response rates from these surveys have not been well studied. All postal surveys published in the Medical Journal of Malaysia between 1991-2000 were therefore reviewed to provide an overview of the response rates that may be expected, and to assess if this is a valid method of conducting research here. The response rates of postal surveys ranged from 30-87.5%. Seven of 13 postal surveys (54%) had a response rate of less than 50% and only 2 of 13 (15.4%) had a response rate of more than 70%, raising doubts on the use of postal surveys as a research tool.
Motorcycle helmets have been proven to prevent head injury and reduce fatality in road crashes. However, certain studies indicate that the helmet increases the mass to the head, and thus the potential of neck injury due to the flexion/extension of the head-neck segment in a road crash may increase. This study was conducted to evaluate the effects of motorcycle helmets and the ways in which the accidents that occurred affected the incidence of cervical spine injury. Nevertheless, it is not intended to and does not discredit the fact that helmet use prevents many motorcyclists from sustaining serious and fatal head injuries. A total of 76 cases were collected and analyzed based on the data collected from real-world crashes. The Abbreviated Injury Scale (AIS) was used to assess the severity of injury, whereas the statistical Pearson χ(2) correlation method was used for analysis. The results showed that motorcycle helmets did not affect the severity of cervical spine injury. However, when the samples were further subcategorized into different crash modes, it was found that helmets affect the incidence of a severe cervical spine injury. In frontal collisions, the use of helmets significantly reduces the severity of cervical spine injury, whereas in rear-end, side impact, and skidded accidents, the use of helmets increases the probability of a severe cervical spine injury. However, in the latter crash modes, a motorcyclist without a helmet will have to trade-off with head injury. A logistic regression model has been developed with respective crash modes and the probabilities of risk in having severe cervical spine injury have been calculated. Future designs in motorcycle helmets should therefore consider the significance of nonfrontal accidents and the interaction of helmet with other parts of the body by possibly considering the weight of the helmet.
The functional outcome of 27 patients (16 males, 11 females) with a proximal humeral fracture was evaluated using the Simple Shoulder Test. Fifteen patients were also assessed using the Constant system. The mean age of the patients was 46.3 years (range 16-90 years) and the mean follow-up was 14 months (range 6-29 months). There were ten 2-part fractures, eight minimally displaced fractures, two 3-part fractures, three 4-part fractures, three 1-part fracture-dislocations and one 3 parts fracture-dislocation. Twenty-four fractures were treated conservatively and 3 surgically. Thirteen patients (48%) regained full function on the simple shoulder test and almost all regained range of movement sufficient for activities of daily living. Six patients were not able to return to their previous job. All patients were pain free at rest and were able to sleep on the affected side comfortably, although 9 patients had pain with activity, even though most pain were mild in nature. The mean Constant scores for the fractured arm and the normal arm were 72.5 points and 91 points respectively. The strength of shoulder abduction was reduced by a mean of 34%. Although the outcome was generally satisfactory, there was nevertheless a statistically significant deterioration of function following the fracture.
A 14 year-old boy with an epiphyseal fracture of the distal right tibia and fibula developed compartment syndrome of the calf and foot. The diagnosis of compartment syndrome was delayed and a fasciotomy resulted in uncontrolled infection, which ultimately resulted in an above knee amputation. Constant vigilance is necessary in uncooperative or non-complaining patients to detect the signs and symptoms of compartment syndrome, even where the injury is not often associated with this complication. The difficulties in management, following a fasciotomy for delayed diagnosis of compartment syndrome, are discussed.
The national clinical practice guideline has recommended that prophylactic antibiotic be given in orthopaedic surgery involving joint replacements and internal fixation of fractures. The aim of this study is to assess the current antibiotics prophylaxis practice in a state level hospital. One hundred and three patients (68 males, 35 females; mean age 41.6 +/- 22.2 years) undergoing internal fixation for closed fractures and joint replacement surgery were included in this prospective study. The choice of pre and post-operative antibiotics, their dosages and duration of administration were recorded. The pre-operative antibiotics were only deemed to have been given if it was documented in the case notes and in the case of post-operative antibiotics if it was signed on the drug chart. Eighty eight percent were given pre-operative prophylactic antibiotics and 92% were given post-operative antibiotics. For patients undergoing internal fixation of fractures, the most commonly used antibiotic for both pre and post-op is intravenous cefuroxime. For joint replacement surgery, the most commonly used antibiotic is intravenous cefoperazone. The duration or number of doses of post-operative antibiotics was highly variable. It was not stated in 56% of the post-operative instructions. Post-operative antibiotic was ordered for 48 hours or longer in 10%. In conclusion, prophylactic antibiotics appear to be widely practised. The first line antibiotics as recommended by the present guideline were not given in any of the patients. Second generation followed by third generation cephalosporins are the most popular antibiotics, with a trend towards using third generation cephalosporins in arthroplasty patients. Single dose prophylaxis was rarely practised.
Cervical spine injuries such as subluxation and fracture dislocation have long been known to result in severe consequences, as well as the trauma management itself. The injury to the region has been identified as one of the major causes of death in Malaysian motorcyclists involved in road crashes, besides head and chest injuries (Pang, 1999). Despite this, cervical spine injury in motorcyclists is not a well-studied injury, unlike the whiplash injury in motorcar accidents. The present study is a retrospective study on the mechanisms of injury in cervical spine sustained by Malaysian motorcyclists, who were involved in road crash using an established mechanistic classification system. This will serve as an initial step to look at the cervical injuries pattern. The information obtained gives engineer ideas to facilitate design and safety features to reduce injuries. All cervical spine injured motorcyclists admitted to Hospital Kuala Lumpur between January 1, 2000 and December 31, 2001 were included in the present study. Based on the medical notes and radiological investigations (X-rays, CT and MRI scans), the mechanisms of injuries were formulated using the injury mechanics classification. The result shows that flexion of the cervical vertebrae is the most common vertebral kinematics in causing injury to motorcyclists. This indicates that the cervical vertebrae sustained a high-energy loading at flexion movement in road crash, and exceeded its tolerance level. The high frequency of injury at the C5 vertebra, C6 vertebra and C5-C6 intervertebral space are recorded. Classification based on the Abbreviated Injury Scale (AIS) is made to give a view on injury severity, 9.1% of the study samples have been classified as AIS code 1, 51.5% with AIS 2 and 21.2% with AIS 3.
The radiographs of 115 anterior shoulder dislocations (100 patients; 74 males, 26 female were reviewed to assess the radiographic views used in the management of this dislocation. Eighty-eight patients (88%) had only the anteroposterior (AP) view, 10 patients had 2 radiographic views taken and only 2 patients had three radiographic views. Hill-Sachs lesions were found in 18%, and glenoid rim fractures in 3% of the patients. A greater tuberosity fracture was found in 18% of the patients. Therefore, the current practice in the management of an acute anterior shoulder dislocation appears to be to perform a single view (AP) pre-reduction radiograph to confirm the diagnosis and a single view (AP) post reduction radiograph to confirm reduction after a close manipulative reduction has been performed. This practice is likely to result in an underestimate of associated Hill Sachs lesion and glenoid rim fractures, but not greater tuberosity fractures.
The case notes of 102 patients (117 shoulder dislocations) were reviewed retrospectively to improve the understanding of the epidemiology of this common injury. Eighty-one dislocations were primary and 36 dislocations were second or recurrent dislocations. The age distribution was characterized by a peak in male patients aged between 21-30 years. The mean age for males was 30.5 years and 47.7 years for females. The male:female ratio in first time dislocations was 5:2, while it was 5:1 in recurrent dislocations. Ninety-eight percent were anterior dislocations and 2% were posterior dislocations. Greater tuberosity fractures were found in 17 patients and almost half of these patients were aged between 41-50 years. The most common cause of first time dislocation was a direct blow or fall onto the shoulder, accounting for 42 patients (55%). The majority of these patients were aged 40 years and above. Next common cause was motor vehicle accident which occurred mostly in the younger age group. Dislocations due to sporting injuries accounted for only 5.3% of all first time dislocations. Nearly 97% were successfully reduced without a general anaesthesia. Seventy-seven percent of the patients had their shoulders immobilized after reduction, mostly with body strapping only. Fifteen patients (14.7%) were referred for physiotherapy for stiffness. Few operations were performed for recurrent dislocations but surgery does not appear to be well accepted as yet by our patients.
A retrospective study was conducted to determine the incidence of nerve injuries in anterior dislocations of the shoulder and to determine if a neurological examination is routinely performed in such cases. One hundred and fifteen shoulder dislocations in 100 patients (74 males, 26 females; mean age 35+/-18 years) were reviewed. Eighty-seven patients were examined for neurological injuries prior to reduction and 8 of these patients (9.2%) were found to have sustained neurological injuries. Following reduction, neurological examination was performed in 85 patients. Three patients who were not examined initially prior to reduction were subsequently found to have nerve injuries after reduction. Seven patients (7%) were not examined for neurological injury both before and after reduction of the dislocation. Eleven patients were found to have sustained nerve injuries in the final analysis. Axillary nerve injuries were the most common, occurring in 8 patients. In conclusion, nerve injuries are common in shoulder dislocations. The importance of performing and documenting the findings of neurological examination anterior shoulder dislocations needs to be reiterated.
Three new Lycopodium alkaloids comprising two lycodine-type alkaloids (1, 2) and one fawcettimine alkaloid (3), in addition to 16 known alkaloids, were isolated from Lycopodium platyrhizoma. The structures of these alkaloids were elucidated based on analysis of their NMR and MS data. Lycoplatyrine A (1) represents an unusual lycodine-piperidine adduct. The structures and absolute configurations of lycoplanine D (hydroxy-des- N-methyl-α-obscurine, 10) and lycogladine H (11) were confirmed by X-ray diffraction analysis.
A new linearly fused macroline-sarpagine bisindole, angustilongine M (1), was isolated from the methanolic extract of Alstonia penangiana. The structure of the alkaloid was elucidated based on analysis of the spectroscopic data, and its biological activity was evaluated together with another previously reported macroline-akuammiline bisindole from the same plant, angustilongine A (2). Compounds 1 and 2 showed pronounced in vitro growth inhibitory activity against a wide panel of human cancer cell lines. In particular, the two compounds showed potent and selective antiproliferative activity against HT-29 cells, as well as strong growth inhibitory effects against HT-29 spheroids. Cell death mechanistic studies revealed that the compounds induced mitochondrial apoptosis and G0/G1 cell cycle arrest in HT-29 cells in a time-dependent manner, while in vitro tubulin polymerization assays and molecular docking analysis showed that the compounds are microtubule-stabilizing agents, which are predicted to bind at the β-tubulin subunit at the Taxol-binding site.
Fourteen previously undescribed alkaloids comprising two N-1-hydroxymethylmacroline alkaloids, one talpinine-type oxindole acetal, a pair of equilibrating talpinine-type oxindole hemiacetals, eight oxidized derivatives of sarpagine- and akuammiline-type indole alkaloids, in addition to alstochalotine a diastereomer of gelsochalotine recently isolated from Gelsemium elegans, were isolated from the leaf and stem-bark extracts of Alstonia penangiana. The structures and relative configurations of these alkaloids were established using NMR, MS, and in one instance, confirmed by X-ray diffraction analysis. An NMR-based method is described as a useful chemotaxonomic tool for differentiating between A. penangiana and A. macrophylla. Several of the alkaloids isolated showed appreciable growth inhibitory effects when tested against a number of human cancer cell lines.
Reexamination of the absolute configuration of recently isolated eburnane alkaloids from Malaysian Kopsia and Leuconotis species by X-ray diffraction analysis and ECD/TDDFT has revealed the existence of biosynthetic enantiodivergence. Three different scenarios are discerned with respect to the composition of the enantiomeric eburnane alkaloids in these plants: first, where the new eburnane congeners possess the same C-20, C-21 absolute configurations as the common eburnane alkaloids (eburnamonine, eburnamine, isoeburnamine, eburnamenine) occurring in the same plant; second, where the new eburnane congeners possess opposite or enantiomeric C-20, C-21 absolute configurations compared to the common eburnane alkaloids found in the same plant; and, third, where the four common eburnane alkaloids were isolated as racemic or scalemic mixtures, while the new eburnane congeners were isolated as pure enantiomers with a common C-20, C-21 configuration (20α, 21α). Additionally, the same Kopsia species (K. pauciflora) found in two different geographical locations (Peninsular Malaysia and Malaysian Borneo) showed different patterns in the composition of the enantiomeric eburnane alkaloids. Revision of the absolute configurations of a number of new eburnane congeners (previously assigned based on the assumption of a common biogenetic origin to that of the known eburnane alkaloids co-occurring in the same plant) is required based on the present results.
A methanol extract of the stem bark of the Malayan Alstonia penangiana provided seven new bisindole alkaloids, comprising six macroline-sarpagine alkaloids (angustilongines E-K, 1-6) and one macroline-pleiocarpamine bisindole alkaloid (angustilongine L, 7). Analysis of the spectroscopic data (NMR and MS) of these compounds led to the proposed structures of these alkaloids. The macroline-sarpagine alkaloids (1-6) showed in vitro growth inhibitory activity against a panel of human cancer cell lines, inclusive of KB, vincristine-resistant KB, PC-3, LNCaP, MCF7, MDA-MB-231, HT-29, HCT 116, and A549 cells (IC50 values: 0.02-9.0 μM).