1/36. The role of cranial MRI in identifying patients suffering from child abuse and presenting with unexplained neurological findings.OBJECTIVE: The aim of this study was to demonstrate the usefulness of cerebral MRI to detect possible child abuse in children with unexplained neurologic findings. METHOD: Between 1990 and 1997, 208 children were referred for suspected physical child abuse to the Child Protection Clinic of Ste-Justine Hospital, a tertiary care pediatric hospital. Among them, 39 children presented initially with neurological findings. For 27 of them, the CT Scan results prompted the diagnosis of child abuse. However, in 12 children, even if a CT-Scan was performed, the diagnosis and/or the mechanisms of the neurologic distress remained obscure. Investigation was completed with MRI study in those 12 cases. RESULTS: MRI findings were diagnostic for physical abuse in eight cases. A diagnosis of child abuse was made in two more cases by a combination of MRI and skeletal survey findings. In one case, MRI was suggestive but the diagnosis of child abuse could not be confirmed. One case was misinterpreted as normal. CONCLUSIONS: MRI is the test of choice to rule out child abuse when faced with a child presenting unexplained neurologic signs lasting for few days. The fact that MRI can better differentiate collections of different ages makes this imaging test particularly useful in identifying cases of child abuse. These results, however, always have to be integrated in a well conducted multidisciplinary clinical approach.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/36. Unilateral osseous bridging between the arches of atlas and axis after trauma.STUDY DESIGN: This is a case report. OBJECTIVE: To present a case of osseous bridging between C1 and C2 of posttraumatic origin and with an associated closed head injury and to discuss its pathogenesis and clinical outcome after surgical resection. SUMMARY OF BACKGROUND DATA: Heterotopic ossifications of posttraumatic origin in the spine are rare. To the authors' knowledge, no cases have been reported of spontaneous bony bridging between C1 and C2 with a posttraumatic origin. methods: Heterotopic ossifications were detected when pain and limited axial rotation (left/right 10 degrees/0 degree/20 degrees) were persistent, despite intensive physical therapy. Because heterotopic ossifications were ankylosing C1 and C2, the decision was to resect the osseous bridge in combination with a careful mobilization of the cervical spine. Functional computed tomography was performed for analysis of the postoperative results. RESULTS: Four months after surgery, clinical examination showed asymptomatic increased axial rotation. Functional computed tomography indicated that left C1-C2 axial rotation was reduced, possibly related to impingement caused by residual bony spurs. Pathologic changes in the surrounding soft tissue may be another important factor in the persistent limitation of rotation. CONCLUSIONS: Osseous bridging between C1 and C2 may be considered when persistent pain and limited axial rotation are observed after trauma. Operative resection, together with careful intraoperative and postoperative mobilization, may be the treatment of choice.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
3/36. Selective laser sintering: application of a rapid prototyping method in craniomaxillofacial reconstructive surgery.Advances in technology have benefited the medical world in many ways and a new generation of computed tomography (CT) scanners and three-dimensional (3-D) model making rapid prototyping systems (RPS) have taken craniofacial surgical planning and management to new heights. With the development of new rapid prototyping systems and the improvements in CT scan technology, such as the helical scanner, biomedical modelling has improved considerably and accurate 3-D models can now be fabricated to allow surgeons to visualise and physically handle a 3-D model on which simulation surgery can be performed. The principle behind this technology is to first acquire digital data (CT scan data) which is then imported to the RPS to fabricate fine layers or cuts of the model which are gradually built up to form the 3-D models. Either liquid resin or nylon powder or special paper may be used to make these models using the various RPS available today. Selective laser sintering (SLS), which employs a CO2 laser beam to solidify special nylon powder and build up the model in layers is described in this case report, where a 23-year old Chinese female with panfacial fracture and a skull defect benefited from SLS biomodelling in the preoperative workup.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
4/36. Secondary enuresis: post-traumatic stress disorder in children after car accidents.BACKGROUND: In our experience, secondary enuresis nocturna is a common complaint among children after a motor vehicle accident. However, as these children are often brought for examination as part of an insurance compensation claim, this complaint is not always reliable. OBJECTIVE: To describe a series of children in whom secondary enuresis occurred after a motor vehicle accident. methods AND RESULTS: Five children were brought to our clinic for evaluation of secondary nocturnal enuresis. review of past history revealed a car accident preceding the onset of the enuresis. All but one had additional behavioral symptoms typical of post-traumatic stress disorder. Four children had evidence of head trauma, and one had psychological but no physical trauma. CONCLUSIONS: nocturnal enuresis can occur after a motor vehicle accident due either to purely psychological trauma or organic head trauma. While nocturnal enuresis is generally attributed to organic causes, psychological mechanisms also play a significant role.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
5/36. Injury caused by deeply penetrating knife blade lodged in infratemporal fossa.Knife-inflicted, deeply penetrating head and neck trauma is an uncommon life-threatening injury and a challenging problem. An examination of the neurovascular and systemic physical status is a first requirement and the decision as to which approach to adopt for the removal of the blade is of critical importance. Here we report a rare case of a pre-auricular stab wound with the knife blade deeply lodged in the extracranial infratemporal fossa. Radiological investigations showed that the knife blade had entered from the temporomandibular joint and become lodged through the anterior margin of foremen magnum below the petrosal bone. Minimal left vocal cord paresis, left palatal weakness and a slight deviation of the tongue towards the left side were observed. The other neurological and systemic physical evaluations were normal. Simple withdrawal of the blade in the operating room did not cause serious neurovascular injury. Here we discuss and compare the expanded exposure of anatomical structures for blade removal and simple withdrawal in similar injuries.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
6/36. The injured coach.The patient in this case was diagnosed as having an epidural hematoma (shown in x-ray at right). This results from hemorrhage between the dura mater and the skull. The hemorrhage may result from a traumatic insult to the side of the head, which can fracture the temporal bone and lacerate the middle meningeal artery. Since the hemorrhage is arterial in nature, the patient may deteriorate quickly. These patients may present with what is referred to as a "lucid interval." The patient typically has a significant blow to the head that results in a short period of unconsciousness. They then regain consciousness at a time that frequently coincides with the arrival of EMS. Once conscious, they are in a period known as the lucid interval. They will still have a headache, but may otherwise be acting normally and show no other physical findings on examination. Many such patients refuse treatment and transport. [table: see text] Inside the skull, however, the problem will grow. Broken arterial vessels are bleeding, causing an expanding hematoma. The patient typically will soon complain of a severe headache along with other associated complaints, such as nausea/vomiting, then will lose consciousness again and/or have a seizure. Initial physical findings may include contralateral weakness and a decreased Glasgow Coma score. As the hematoma expands, cerebral herniation may occur, compressing the third cranial nerve, which presents as a "blown pupil." EMS providers should have a high suspicion of injuries that affect the side of the head and the base of the skull. It is important to not only assess such injuries, but also the mechanism of injury, and to know the complications or later presentation that can arise from such injuries. Given that this patient was alert, oriented, not obviously intoxicated, and accompanied by his wife, the providers in this case would have had no choice but to abide by a refusal of treatment and transport. However, that could lead to serious complications, such as ongoing minor neurological deficits, later on. If this is the case, contacting medical control should be the priority.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
7/36. Bilateral internuclear ophthalmoplegia and clivus fracture following head injury: case report.Internuclear ophthalmoplegia is a remarkable finding, particularly in patients victims of head injury. The medial longitudinal fasciculus, which is believed to be lesioned in cases of internuclear ophthalmoplegia, has an unique brain stem position and the mechanism involved in brain stem contusions implies a maximal intensity of shearing forces on the skull base. We describe a very rare association of bilateral ophthalmoplegia and clivus fracture following head injury, without further neurological signs. The patient history, his physical examination and the image investigation provide additional evidence to some of the mechanisms of injury proposed to explain post-traumatic internuclear ophthalmoplegia.- - - - - - - - - - ranking = 1.5812352254883keywords = physical examination, physical (Clic here for more details about this article) |
8/36. Human osteology: key to the sequence of events in a postmortem shooting.Forensic anthropologic examination of human skeletal remains found when a field was plowed provides evidence of both perimortem trauma, suggesting cause of death, and of subsequent shooting of the disarticulated skeleton. The case exemplifies the application of the specialized skills and knowledge of the physical anthropologist to determination of the postmortem sequence of events.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
9/36. Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained?Authors of recent studies have championed the importance of maintaining cerebral perfusion pressure (CPP) to prevent secondary brain injury following traumatic head injury. Data from these studies have provided little information regarding outcome following severe head injury in patients with an intracranial pressure (ICP) greater than 40 mm Hg, however, in July 1997 the authors instituted a protocol for the management of severe head injury in patients with a glasgow coma scale score lower than 9. The protocol was focused on resuscitation from acidosis, maintenance of a CPP greater than 60 mm Hg through whatever means necessary as well as elevation of the head of the bed, mannitol infusion, and ventriculostomy with cerebrospinal fluid drainage for control of ICP. Since the institution of this protocol, nine patients had a sustained ICP greater than 40 mm Hg for 2 or more hours, and five of these had an ICP greater than 75 mm Hg on insertion of the ICP monitor and later experienced herniation and expired within 24 hours. Because of the severe nature of the injuries demonstrated on computerized tomography scans and their physical examinations, these patients were not aggressively treated under this protocol. The authors vigorously attempted to maintain a CPP greater than 60 mm Hg with intensive fluid resuscitation and the administration of pressor agents in the four remaining patients who had developed an ICP higher than 40 mm Hg after placement of the ICP monitor. Two patients had an episodic ICP greater than 40 mm Hg for more than 36 hours, the third patient had an episodic ICP greater than of 50 mm Hg for more than 36 hours, and the fourth patient had an episodic ICP greater than 50 mm Hg for more than 48 hours. On discharge, all four patients were able to perform normal activities of daily living with minimal assistance and experience ongoing improvement. Data from this preliminary study indicate that intense, aggressive management of CPP can lead to good neurological outcomes despite extremely high ICP. Aggressive CPP therapy should be performed and maintained even though apparently lethal ICP levels may be present. Further study is needed to support these encouraging results.- - - - - - - - - - ranking = 1.5812352254883keywords = physical examination, physical (Clic here for more details about this article) |
10/36. Homicidal cerebral artery aneurysm rupture.When a normally natural mechanism of death is induced by physical injury or intense emotional stress, it is appropriate to rule the manner of death as something other than natural. When the case-specific circumstances are such that the death occurs as a result of the criminal activity of another person, it is acceptable to rule such deaths as homicides. Presented herein is a case of homicidal cerebral artery aneurysm rupture occuring in an intoxicated, 46-year-old man who was punched in the face by another individual. The details of the case are presented, followed by a discussion of the controversies that exist when dealing with such cases. Guidelines for investigating similar deaths are presented, with emphasis on the timing of the trauma in relation to onset of symptoms due to aneurysm rupture.- - - - - - - - - - ranking = 0.5keywords = physical (Clic here for more details about this article) |
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