Saturday, January 25, 2020

Bilateral Trans-Scaphoid Perilunate Fracture Dislocation

Bilateral Trans-Scaphoid Perilunate Fracture Dislocation BILATERAL TRANS-SCAPHOID PERILUNATE FRACTURE DISLOCATION OF THE CARPUS. (CASE REPORT) Abstract: Trans-scaphoid perilunate fractures-dislocations are rare lesions. They occur in a high-energy trauma. The concomitent lesion of both wrists is exceptional. We report a case of bilateral trans-scaphoid perilunate dislocated wrist fracture in a 21-year-old man. The dislocation was treated by opened reduction and fractures by internal fixation. The functional outcome was satisfying after two years of follow-up. Introduction: Trans-scaphoid perilunate fracture-dislocations are relatively uncommon.1 These are the most common form of the complex carpal dislocations2,3 causing marked disruption of the carpal anatomy. Time from injury to treatment (delay in treatment), anatomic classià ¯Ã‚ ¬Ã‚ cation, and open or closed nature of the injury are the major factors that determine the clinical outcome in trans-scaphoid perilunate fracture-dislocations.4,5 Late presentation combined with missed diagnosis often causes critical delay in the treatment of these injuries. If the acute phase is missed, then some authors recommend alternative procedures such as wrist arthrodesis and proximal row carpectomy which are relatively mutilating surgeries that leave a significant functional deficit.4,6,7 The acute phase is defined as the first week after injury, whereas the delayed phase is the period between the seventh and 45th day and after 45 days the injury is said to be in the chronic phase.4 We report the case of a patient who referred to our department two weeks after the initial trauma with bilateral dorsal trans-scaphoid perilunate fracture-dislocations of the carpus. Anatomic reduction, percutaneous pin fixation of the carpus and fixation of scaphoid fractures of both wrists were performed by opened reduction under fluoroscopic control. Presentation of case: A 21-year-old, right-hand-dominant man sustained an isolated injury to his both wrists after a fall from a height of approximately 4.5 m. The carpal injuries of both wrists were missed initially and both wrists had been bandaged for two weeks after the trauma. He was referred to our department two weeks later with increasing pain. The patient reported that he fell on his outstretched hands with both wrists in extension. Both wrists were deformed in marked dorsiflexion, painful, swollen, and tender to palpation, with limitation of movement. The patient complained of paresthesia in both of his hands. On physical examination, meticulous cutaneous sensory mapping was performed of both hands to determine the area of decreased sensation. This was done with the use of the sharp end of a paperclip while applying a constant pressure. This revealed minor numbness in the median nerve distribution area of both hands (thumb, index, middle finger, and the radial side of the ring finger). The two-point discrimination was normal on both sides. The mobility of the fingers was normal but painful, and there was a slight decrase in grip strength of both hands. Motor power in abductor pollicis brevis and opponens pollicis muscles was full (5/5) on both sides. The Tinels sign was negative over the carpal tunnel in both sides. The f indings of the patient led us to think that there is not any condition like acute carpal tunnel syndrome due to fracture-dislocation.We thought that the numbness of the patient was due to temporary traction injury of the median nerve caused by dislocation on both sides. The vascular status was normal on physical examination. Study of the anteroposterior, oblique and lateral plane radiographs showed that the patient had bilateral dorsal trans-scaphoid perilunate fracture-dislocations of the carpi (Fig. 1). According to the classification described by Herzberg et al., the fracture-dislocations were trans-scaphoid as path of trauma and Stage 1 as displacement of capitate on both sides.4 The patient was informed about his pathology and advised to undergo surgery. If possible the patients preference was closed treatment. Therefore, we initially recommend closed reduction and percutaneous fixation. However, if this was not possible or in the situation of a failure we informed him about the open procedure. Under general anesthesia, a closed reduction was attempted with traction manoeuvre described by Tavernier8under fluoroscopic control. The reduction was not satisfactory,we opted for the open reduction by posterior approach.After anatomical reduction was achieved, intercarpal fixation was applied to carpal bones using three K-wires. The first K-wire was applied to scaphoide- lunate, the second K-wire was applied to- lunate-triquetrum and the third K-wire was applied to capitatum-lunate. After the procedure, reduction and fixation of carpal bones was confirmed under fluoroscopy. The same procedure was repeated for the other wrist. We noticed that the scaphoid fracture was reduced spontaneously along with the reduction of the carpal bones. So we performed   fixation of the left scaphoid fracture using a 3.5 mm mini Acutrak headless compression screw through the fracture line from a dorsal-proximal to a volar-distal direction. Intraoperative fluoroscopic control confirmed anatomic redu ction of the scaphoid fracture.. Finally, standard radiograms were obtained and both wrists were immobilized in a short arm cast (Fig. 2). The patient noted complete relief of symptoms the day after surgery. The pain and the paresthesia that the patient complained preoperatively was relieved dramatically and the function recovered. The post-operative period was uneventful. Four weeks after surgery, the casts and the K-wires were removed. New casts were applied for another 4 weeks when union was visible on radiographs. The casts were removed eight weeks after surgery. There was radiographic evidence of union of the scaphoid on the left side, but on the right side radiography revealed delayed union of the scaphoid. The patient subsequently underwent 3 months of intensive range-of-motion and muscle-strengthening exercises. Intermediate clinical and radiographic examinations were performed 6 and 12 months after surgery. At the two-year follow-up, the radiographs showed normal carpal bone relationships on both sides, complete union of the scaphoid on the left side(Fig.3). Wrist motion on the left side was excellent with 70 ° of palmar flexion, 80 ° of dorsiflexion, full supination and pronation, full radial and ulnar deviation. The right wrist could achieve 60 ° of palmar flexion and 70 ° of dorsiflexion, full supination and pronation, but with a mild decrease in radial and ulnar deviation. The grip strength of the right hand was 30 kg while that of the left side was 38 kg, measured with the Jamar dynamometer (J.A. Preston, Jackson, Michigan) . Fig.3 Right wrist and Left wrist anteroposterior and   lateral view after two-years. At the two-year follow-up, the patient was symptom-free concerning median nerve functions. The patient was free of pain on the left side. On the right side there was mild pain with wrist motions due to non-union of the scaphoid.The patient was able to perform activities of daily living and he had returned to all of his previous activities. The functional outcome was good on the left side, with a Mayo wrist score of 80/100. The functional outcome was satisfactory on the right side, with a Mayo wrist score of 65/100. Radiographs of both wrists revealed no evidence of radiocarpal or midcarpal arthritis. No osteonecrosis of the lunate or the scaphoid was evident. The lunate position was correct, without signs of instability. Anatomic relationships of the carpal bones were maintained. Discussion Carpal fracture-dislocations are rare injuries; thus their classification and treatment are rather difficult. Osseous variants of this injury are common; the trans-scaphoid perilunate fracture-dislocation constitutes 61% of all perilunate dislocations and 96% of fracture-dislocations.4 The trans-scaphoid perilunate fracture-dislocation is an uncommon injury sustained due to force transmission through a hyperextended wrist.9,10 These injuries may be easily overlooked or misdiagnosed.4 After a delay in diagnosis of several weeks or months, the clinical prognosis is poor compared with injuries that are treated acutely.11 According to the classification described by Herzberg et al., we initially diagnosed our patient in the delayed phase.4Regarding the literature, the management of such injuries in case of delayed presentation is rare.12,13Dislocation in this region requires rapid realignment, as untreated perilunate dislocation will lead to serious secondary damage.13,14 Perilunate fracture-dislocations are high-energy injuries, produced by wrist hyperextension.3,15 There is disruption of the palmar capsuloligamentous complex, starting radially and propagating through the carpus in an ulnar direction.3,15 This dislocation takes a transosseous route through the scaphoid resulting in a trans-scaphoid perilunate fracture-dislocation.10 In trans-scaphoid perilunate dislocations the fractured scaphoid is the initial destabilizing factor of the carpus.16 Regarding the literature, we believe that the mechanism of injury in our patient was fall from a height on the outstretched hands. Treatment options currently used for perilunar instability patterns include closed reduction and cast immobilization, closed reduction and percutaneous pinning, and open reduction. As the awareness of the anatomy and biomechanics of these injury patterns has evolved, authors have tended toward treatment approaches that attempt to repair the injured intrinsic and extrinsic carpal ligaments, that is, open techniques.4,8,11 Most authors agree that closed reduction is the initial treatment of choice for trans-scaphoid perilunate fracture-dislocations.2,8,17 In addition, treatment often requires intercarpal fixation within the proximal carpal row. Most authors have agreed that the key to a good clinical result in the management of trans-scaphoid perilunate dislocation is the anatomic union of the scaphoid and the restoration of proper alignment of the carpal bones.17 In this case, we prefer a opened reduction and intercarpal fixation with K-wires, as well as screw fixation of the scaphoid, because we didnt achieve a good fracture alignment after closed reduction . Gellman et al. suggested that anatomical reductions of the scaphoid, as well as the mid-carpal joint, and the restoration of the articular surface of the lunate are the most important aspects determining the prognosis.11An open reduction further increases the risk of a scaphoid blood supply interruption, whereas percutaneous screw fixation of the scaphoid minimizes this risk.3,17,18 In addition, a rigid fixation with a percutaneous screw can also reduce the immobilization period and allow for an earlier rehabilitation. Acutrak screw fixation allows earlier discontinuance of the cast than K-wire fixation. In our case, the range-of-motion exercises of the wrist were started earlier after the initial operation. The nonunion rate was relatively higher in the series that were treated by closed reduction.19,20 In our case study the radiographs obtained two years after surgery revealed a non-union of the right scaphoid. We believe that the delay in treatment and maybe the malrotation of the scaphoid that we overlooked on the initial radiographs led to the interruption of the blood supply which was possibly responsible for the non-union of the scaphoid. Despite the non-union of the scaphoid, the functional outcome of our patient was satisfactory, with mild pain, good range of movement and good grip strength. Similarly, Herzberg et al.4 reported that unsatisfactory radiographs did not equate to a poor clinical outcome. We planned to perform open reduction and internal fixation with grafting for the non-union of the right scaphoid. Conclusion As the injury have led bilateral dorsal trans-scaphoid perilunate fracture-dislocations,  we therefore recommend minimally invasive techniques if an anatomical closed reduction and  a percutaneous rigid fixation of the scaphoid is achieved on the intraoperative evaluations.

Friday, January 17, 2020

Arctic Survival Simulation

Arctic Survival – From Success to Failure Contrary to the outcome exhibited by most other groups during the Arctic Survival exercise, our team score (34) was lower than my individual score (64). This is not to suggest that group collaboration is detrimental; in fact, our outcome was unique among the class and of great surprise to uk/the-professor-is-a-dropout/">the professor and entire class section. To be sure, pooling resources, elaboration of material, and support and motivation, while perhaps more time consuming, typically offer improved results.In theory, this model implies that a team’s collective knowledge can maximize utility and ensure the best outcome given the available information and perspectives. In our case, our group dynamics were such that we did not effectively utilize the resources we had, and consequently pooled a very limited amount of information. Rather than minimizing our risk, we increased it. I attribute much of our group’s failure at th is simulation to process loss, which is defined as the problems that arise from lack of effective coordination among group members.A number of factors at play could explain the process loss which led to our counterintuitive results. First and foremost, one must consider the way in which group dynamics impact the overall productivity of group collaboration. Our team consisted of K, R, W, J and myself. K and W were quite opinionated, and in contrast, both R and J were quiet – I did not have a sense of what their true opinions were. K dominated the group by putting forth an idea and adhering to that idea in spite of other opinions. Both K and W were vocal in reiterating what they thought were the most important elements of survival.In our case, we took no measures to counteract the impact of clashing personalities. Subsequently, a lack of civil discussion led to uncoordinated efforts with regards to how we should begin to approach a systematic analysis of the situation. An effec tive manager, however, should be skilled at identifying employee team dynamics and personalities; in order to maximize potential, the manager must have the emotional intelligence (that is, the ability to perceive, decipher, use, and pinpoint emotions accurately) to understand how team members differ with respect to emotions, motivation, perspectives, experience, and intentions.For example, though J was quiet and rarely spoke up or defended her ratings, I knew of J’s work ethic from class and understood that it was not as though she avoided work or pulling her weight. In other words, I recognized that her behavior was not attributed to social loafing, but to some other phenomenon. In this case, our group members seemed to exhibit varying levels of psychological safety, which is the belief that little to no risk exists in a particular group environment, and consequently each member feels free to contribute their true thoughts. I presumed that J and R did not feel psychologicall y safe.Anytime a group member disagreed and pressed them to argue for their position, they wavered and complied, indicating that they felt uncomfortable in taking a risk and voicing dissenting views. Their low psychological safety led to an apparent mode of groupthink, in which R and J preferred unanimity in the group over their perceived accurate valuations of arctic survival tools. Similar to the Asch experiment in which a dissenter purposely responded with the wrong answer regarding which stick length was equal, R and J were often silent even though their scores later revealed that their ranking of the rope was more in line with the ideal.Indeed, both R and J, but particularly J, demonstrated a primary symptom of groupthink by censoring herself and failing to communicate her unique viewpoints. Managing a group of people requires careful consideration of the group dynamics in play, paying close attention to symptoms of groupthink and low psychological safety which might lead to pr ocess loss. A manager must use his or her emotional intelligence and leverage group members’ differing perspectives.In doing so, team members will not fall victim to process loss, but will instead pool resources and elaborate on them, thereby facilitating healthy debate and a better end result than one could achieve on his or her own. In addition to identifying how team members differ with respect to emotions, motivation, perspectives, experience, and intentions, a manager must be cautious about his or her own actions and biases. While being confident and resolute is often positive, it can also blind a manager or group member to other valid viewpoints.Many fall victim to commitment and consistency, which is the tendency for individuals to adhere very strongly to a course of action because they feel pressure to act in line with their original declared commitments. Indeed, K exhibited strong commitment and consistency to certain declarations and did not back down. In particular , he was quite stubborn in his opinion that rope was the second most important asset for survival behind matches. When pressed to explain his case, his justifications were vague; yet, he was very insistent.I mentioned, for example, that rope was not necessary in killing prey for food (in comparison to the hand ax), and challenged him to elaborate on his view. He tried to reason by convincing me that rope was the better choice, but ultimately did a poor job at elaborating. The more we debated, the more steadfast he became – he had committed to a course of action, ranking the rope highly, and felt the pressure to follow through. He couldn’t back down now. Rather than counteracting my challenge that a hand ax was more important, he simply offered that he did not agree without any explanation as to why.What’s more, he did not listen to the ways in which an alternative solution might be better (in this case, the hand ax), but instead disregarded my perspective and st ood firm that the rope was more crucial to survival, thus confirming his previous beliefs. He defended his position and avoided information that potentially proved his theory wrong. Not only does this exemplify commitment and consistency, but also confirmation bias, which is an individual’s tendency to disregard information that would contradict his or her views and instead only focus on those explanations that confirm them.K’s adherence was convincing to W, who soon after agreed with his valuation of the rope. W’s support coupled with the others group members’ lack of any objections whatsoever throughout the simulation led to my almost immediate compliance on the subject matter. I let them have the rope, and they let me have the hand ax to follow. The next point of contention was the canvas. Though they all agreed that the hand ax was important, they did not believe the canvas to be significant. I was the only obstacle who expressed a different opinion.K and W’s mutual agreement coupled with R and J’s silence, seemed to bolster their insistence that the canvas was unnecessary. Eventually, J broke the silence and agreed with K and W. J was more likely to feel as though the canvas was insignificant given K and W’s dominant opinion regarding the matter. Once again, I succumbed and agreed to rank the canvas lower down. Though I certainly did not consider myself a manager in this simulation, it allowed me to reflect on my own dealings within a group context and as a potential manager.I was aware of the group dynamics and recognized the limitations that commitment and consistency, social proofing, confirmation bias, and groupthink provided, but also knew that likeability was a key strategy for influencing others. I prodded R and J to offer more insight, but my efforts often fell short. Rather than taking any methodical approach, K and W would dominate conversation, and I assumed the role of mediator, trying to compro mise between all perspectives. I could not claim to have expert power, but perhaps I could convince the group that we should take a more systematic and methodical approach to analyzing this situation.Unfortunately, my efforts probably provided more harm than good. I used reciprocity by telling K and W that he could have rope, if I could have the hand ax next. We continued to negotiate – W could have navigation guide next if the canvas could follow shortly after. The simulation consisted of many exchanges such as these. Reciprocity, which is the tendency for members to agree to a course of action of an individual who has done them a favor, miserably backfired in our case.Not only did group members (myself included) interrupt each other and fail to exert any sort of coordination, but my attempt to give everyone what they wanted eventually led to a higher valuation of the navigation guide. I should have known that R and J were easily persuaded and would not speak up about this u nwise decision, and yet I went through with it. In an effort to gain support through likeability and reciprocity, I sacrificed an effective decision-making process that would have led to a higher probability of success.Group collaboration is typically expected to prevail in this simulation due to pooling of resources and elaboration of material, and in retrospect, our group did a poor job of doing so; framed this way, it is not surprising that our outcome was the exact opposite of the simulation’s intended effect. Though only a simulation, the Arctic Survival exercise certainly illuminated the various ways in which I could be susceptible to ineffective managing. These models and concepts are not simply applicable to this and other simulations, but also provide insight into my potential downfalls.Perhaps it is necessary to assign a devil’s advocate to the group so that teams are not victimized by groupthink; instead a concerted effort to have varying opinions would insp ire thoughtful debate and ultimately more effective outcomes. Likeability is an important weapon of influence, but should not come at the expense of sound decisions – a manager must always exhibit a healthy balance of likeability and firm consideration of all the options. I must be cognizant of my team members and make sure to harness each individual’s strengths, going to great lengths to avoid the common pitfalls exhibited in this simulation.

Thursday, January 9, 2020

The United States versus Paramount Pictures, Inc. Essay

The United States v. Paramount Pictures, Inc. (1947) case deals with monopolies and antitrust laws. I chose the trusts/monopolies topic due to my interest in finance and economics. Since elementary school, I have been fascinated by John D. Rockefeller’s story about his oil monopoly. This history has caused me to be interested in monopolies and trusts. I began enjoy reading about the elite who obtained their wealth illegally. After reading and watching The Great Gatsby and watching the movie Catch Me If You Can, I have been fascinated with counterfeit wealth and how people may have gotten away with breaking the law. My favorite thing about APUSH is learning how the economy has changed over time and how that has affected the lifestyle of the†¦show more content†¦These â€Å"Big Five† created an alliance of theater chains that monopolies on the profits of movies’ first-run and absolutely crushed other independent production countries. The Paramount case wen t into Federal Court in New York in 1940. The was a consent decree; the compromise allowed the Big Five to retain their chains in exchange for restriction on block-booking(selling multiple movies to a theater as a unit). This also outlawed blind bidding, so all films were required to be shown to the buyers before selling them (SIMPP, 2002). The independent exhibitors were unhappy with this decision, because it still gives a tremendous amount of power to the Big Five. Companies like Universal and Columbia didn’t own theaters and relied heavily on block-booking. The independent producers created the Society of Independent Motion Picture Producers (SIMPP). The case turned around when SIMPP was created (SIMPP, 2002). There was an opposition to the Big Five, but the problem was the independent producers weren’t united. The Consent of Decree of 1940 expired and the Justice Department began the â€Å"New York Equity Suit† (SIMPP, 2002). This case now involved the original Big Five producing companies and three smaller companies who were unhappy with the ruling of the consent of decree such as Universal and Columbia. These three companies were known as the â€Å"Little Three† SIMPP spent $10,000 to unsuccessfully file an amicus curiae brief. They didn’t have enough time for the approvalShow MoreRelatedThe Studio System Essay14396 Words   |  58 Pagesbiggest industries in the United States, indeed the World, the internal workings of the dream factory that is Hollywood is little understood outside the business. The Hollywood Studio System: A History is the first book to describe and analyse the complete development, classic operation, and reinvention of the global corporate entities which produce and distribute most of the films we watch. 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Wednesday, January 1, 2020

Science Technology Company - 709 Words

Company Background : Science Technology Company was a leading manufacturer of computer-controlled automated test equipment (ATE) that was used to monitor and manage quality over the life cycle of electronic products. With 31% market share, the company was the dominant firm in the design and manufacture of testers and test software for printed circuit boards. Its second business was its semiconductor test operation, which manufactured complex systems that cost in excess of $1 million and were used to test state-of-the-art very large scale integrated (VLSI) circuits. Other Products included a system to test electronic products in the field; systems used to test a products mechanical and structural integrity under stress and computer aided†¦show more content†¦However because of the unpredictability of the past sales for 1978 to 1984, the ability to accurately project sales in the next 5 years will be low. 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