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We report an unusual case of irreducible Galeazzi-equivalent fracture in a child and discuss the factors that prevented reduction in this case.

症例:57歳の女性。発熱,下痢,嘔吐を主訴に近医を受診し,補液などの治療を受けたが症状が改善しないため,紹介にて当院救急外来を受診した。来院時意識障害,発熱,項部硬直を認め,両下腿に紫斑を認めた。原因不明の感染症として入院し,第3病日両手指・足趾・足底に壊死が出現した。入院時の血液検体中からA群β溶連菌が検出されたことにより,toxic shock like syndromeの診断が強く疑われ,救急医学科へ転科となった。壊死部を切開しても,筋膜壊死や感染徴候を認めないことから,敗血症により,播種性血管内凝固(DIC)を生じ,symmetrical peripheral gangrene (SPG)となっていることが考えられた。敗血症に対し,ABPC 8g/dayとγ-グログリン投与,抗DIC療法(低分子ヘパリン,AT製剤,FFP)を行った。第6病日にはDICは改善し,第94病日に両手指(左第1指を除く)と両下腿の切断術を施行し,義足にてリハビリテーション後退院となった。考察:SPGとはDICによって生じた微小塞栓が微小循環を閉塞させるなどして末梢組織の壊死を起こすもので,敗血症によるものが多い。SPGとなる例は非常にまれであり,その発生には,基礎疾患(Raynaud's syndrome,動脈硬化,糖尿病など)の存在の他にスーパー抗原の関与が示唆されている。本症例では,ステロイド投与中であったこと以外には基礎疾患はなく,感染源も不明であった。

This paper reports a case of systemic emphysema associated with the use of the Esophageal-tracheal Combitube (ETC) during pre-hospital management of cardiac arrest. A 53-year-old female lost consciousness after serious hematemesis. Cardiopulmonary resuscitation was started and the ETC was inserted by emergency life saving technicians. About 55 minutes after arrival at the emergency room, the patient was declared dead. Computed tomography demonstrated the presence of air in the subcutaneous tissues, mediastinum, thorax, abdomen, hepatic vein, inferior vena cava and right ventricle. An autopsy was not performed, and the source of air leak could not be identified. However, computed tomography revealed that tracheal laceration had caused the air leak to the surrounding tissues. The systemic emphysema and tracheal laceration would not be main factors in the death of the patient presented here. However, the possibility of these complications should be kept in mind.

Thirteen hands in twenty one cases with Dupuytren's contracture treated surgically between 1973 and 1994 are reported. Subjects included 18 males and 3 females ranging in age from 34 to 88 years, with a mean of 63.1 years. The duration between onset and surgery ranged from one month to 10 years with an average of 3.7 years. Surgical treatment was performed in 8 cases with the right side affected, 4 with the left and 9 were bilaterally affected. Preoperative grade was classified according to Einarsson's modification of Meyerding's classification. Of the 32 hands, there were no hands of grade 0, 12 hands were grade I, 6 hands were grade II, 13 hands were grade III and 1 hand was grade IV. As to the types of surgical treatment, limited fasciectomy, including z-plasty or skin graft, was performed in 12 hands. The follow-up period lasted from one to 20 years, and averaged 6.4 years.The results were evaluated according to Tubiana's classification. They were very good in 10 hands (31.3%), good in 12 hands (37.5%), fair in 2 hands (6.3%) and poor in 8 hands (25.0%). The clinical results were significantly better in the limited fasciectomy group than in the fasciotomy group.

We studied the association between the type of external fixator and subsequent bone union achieved. During 1988-1994 we treated 15 cases (19 bones) of bone injury requiring an external fixator.These 15 cases were divided into a fracture group (11 cases, 13 bones), an osteomyelitis group, and a pseudoarthrosis group (5 cases, 6 bone).The type of external fixator used included orthofix, Ace-Fischer, Hoffmann, Mono-tube.Results for the fracture group were orthofix 6 cases, Ace-Fischer 3 cases, Hoffmann 3 cases, Mono-tube 1 case. Results for osteomyelitis; pseudoarthrosis group were orthofix 4 cases, Ace-Fischer 1 case, Hoffmann 1 case.Transverse fractures, and oblique fractures had an effect on primary bone union in the orthofix. Comminuted fractures had an effect on primary bone union in Ace-Fischer.Osteomyelitis, pseudoarthrosis had an effect on primary bone union in dynamization. External fixators are effective for helping bone union following fracture, osteomyelitis and pseudoarthrosis.

We performed 199 total knee arthroplasties (TKA) in 149 patients with rheumatoid arthritis and osteoarthritis from 1982 to 1994. From 1982 we used kinematic or mark 2 prostheses for TKA, KOM or KC-1 (ceramic type) from 1984, PCA from 1985, MG-1 from 1986 and PFC since 1992.We shidied 8 revision TKA (4%) performed in 8 patients with failed knees. The mean interval from initial to revision TKA was 5.8 years (range; 4.5 to 9.3 years). The most common reasons for failure were tibial component sinking due to technical failure, tibial component sinking due to bone weakness with RA, breakage of metal back patella component (MG-1) and loosening due to arthritis mutilans. When we used cementless porous coating total knee arthroplasty, more and more bone source was lost revision.

Purpose There is a growing body of evidence supporting the use of hyaluronan (HA) for treatment of injured tendons, although the mechanism of the healing effect has not yet been clarified. We therefore investigated the effects of HA on the proliferation and migration of tendon fibroblasts derived from rabbit flexor tendon epitenon and endotenon. Methods From explanted rabbit intrasynovial flexor tendons (n = 5), we cultured tendon fibroblasts derived from the epitenon and endotenon. CD44 expression on the tendon fibroblasts was detected by flow cytometric analysis. Various concentrations of HA (0.1–5.0 mg/mL) were added to monolayer-cultured tendon fibroblasts. We evaluated cell proliferation by recording changes in cell number, and measured cell migration by wound-healing assay. Results Flow cytometric analysis detected CD44 expression on the tendon fibroblasts. Treatment with HA at various concentrations notably and dose dependently inhibited cell proliferation and promoted cell migration. Conclusions Hyaluronan modulates the proliferation and migration of rabbit fibroblasts derived from the flexor tendon epitenon and endotenon.

We report a case with disorder of the hallux sesamoids in which the bone disappeared very rapidly. Some of the literature is also discussed. The patient was a 27-year-old woman who complained of pain in the plantar of the head of the 1st metatarsal bone without any prior causative factors. Mild swelling and marked tenderness were also observed at the same site. On x-ray, fragmentation, mottling, and irregularity were observed at the 1st tibial sesamoid bone. She was suspected of aseptic necrosis and underwent conservative therapy. X-ray taken 1 week after onset of symptoms revealed disappearance of the bone and clinical symptoms also disappeared. Six months after the onset of symptoms she had no pain or ADL disorder.

Background: Many studies on the etiology and operative treatment of locked metacarpophalangeal joints in fingers have been reported, but there have been few investigations on manual reduction. The rate of success of manual reduction in previous reports has been low, and no consensus has been reached with regard to the best method of manual reduction. On the basis of our experience with operative treatment, we devised a safe method of manual reduction. Methods: Between January 1987 and December 1995, we reduced a locked metacarpophalangeal joint in twelve female patients; every locked finger was successfully reduced, and complications such as fracture did not occur during manual reduction. The average duration of follow-up was five years and nine months (range, three years and two months to nine years and three months). Results: Six patients had no recurrence of the locking. Four of the six remaining patients had one or two incidents of locking, had no alteration in the activities of daily living, and did not want operative treatment. The two remaining patients reported that they had incidents of locking several times a day, and they requested operative treatment as they were afraid of additional recurrences. One patient had an open reduction fifteen months after the initial episode of locking, and the other patient elected not to have an operation for personal reasons. Conclusions: We believe that our method of manual reduction should be used to treat a locked metacarpophalangeal joint in a finger and that operative treatment should be limited to patients in whom manual reduction is unsuccessful or the reduction is unstable.

A 48-year-old woman developed lumbago in 1973 and pustulosis palmaris et plantaris (PPP) in 1976. In 1977, with curettage of right iliosacral joint, her lumbago and PPP were treated successfully.In May 1987, she was admitted to our hospital because of recurrence of lumbago, pain of the right hip and PPP. X-ray showed sclerotic and destructive changes of the joint in right iliosacrum and lumbar vertebral. 99mTc scintigraphy showed abnormal accumulation in cervical vertebral, sterno-clavicular joint, ribs, lumbar vertebral and iliosacrum. Histological examination of the right acetabulum showed the thickening of trabecular bone and the proliferation of lymphocyte.

We studied ten cases of Perthes' disease whose onset of the symptoms was over ten years old. These ten cases were classified into four groups by Catterall's classification. Although there was no tendency that they had rather severe involvement of the femoral head, the time durations to healing was almost more than three years.