Monday, August 17, 2009


Date: Sat, 22 May 1999 02:54:59 +1000
From: Philip O'Neill
Reply-To: The GREYtalk Discussion List

> > Fever: I'll say it again. A fever is not something good. A low-grade fever is not harmful, but once it goes over about 39C you really start to worry -- febrile convulsions are not pretty and they CAN cause brain damage when your cerebral proteins start denaturing. Any child not responding to antipyretics for a fever should be taken to a hospital or doctor ASAP.
> I've looked and I can't find anything to either support or disprove this
> (brain damage that is).. I've looked in 2 meurology texts, the Merck
> manual of pediatrics (and adults), Goldblume's text on Pediatrics and
> Harrison's textboon on INternal Medicine..the only thing i can find
> relating febrile seizures to brain damage is if the seizure lasts for >5
> minutes (VERY uncommon), regardless of temperature, the chance of
> developing epilepsy is greater than 5%..however, none of these texts ever
> say that it can or cannont cause brain damage..

"Textbook of Medical Physiology (7th Edition)": Guyton (p 859)

"When the body temperature rises beyond a critical temperature, into the range of 106F to 108F [41-42C], the person is likely to develop heat stroke. They symptoms include dizziness, abdominal distress, sometimes delirium and eventually loss of consciousness if the body temperature is not soon decreased. Many of these symptoms probably result from a mild degree of circulatory shock brought on by excessive loss of fluid and electrolytes in the sweat before the onset of symptoms. however, the hyperpyrexia [high fever] itself is also EXCEEDINGLY DAMAGING TO THE BODY TISSUES, ESPECIALLY TO THE BRAIN [emphasis mine], and therefore is undoubtedly responsible for
many of the effects. In fact, EVEN A FEW MINUTES OF VERY HIGH BODY TEMPERATURE CAN SOMETIMES BE FATAL [emphasis mine]..."


"When the body temperature rises above 106F to 108F, the parenchyma [organ tissue] of many cells begins to be damaged. The pathological findings in a person who DIES [emphasis mine] of hyperpyrexia are local haemorrhages and parenchymatous degeneration of cells throughout the entire body, but especially in the brain."

Add that to the many patients I nursed in the 80s in a brain-injury rehab unit who had suffered varying degrees of brain damage (primarily cognitive) as a result of high fevers, and I am reasonably confident in asserting yet again that a high fever is a dangerous, potentially life-threatening condition.

> > Fair enough. Yes, they SET the fractures -- but I doubt they reduced them correctly (meaning realigned the broken ends so that the bone healed
> > straight). For all but the most minor fractures, a reduction is carried out surgically under anaesthetic -- there is simply no other way of getting it right. Without a correct reduction, the bone heals oddly, impairing
> > movement.

I'll answer this one bit by bit...

> True again, however, the vast majority of fractures are minor, and can be
> treated with closed reduction (in a cast)..everything from lower leg
> fractures

Nope. A large proportion, probably around 50% (and that's being generous) come under that class -- hardly a "vast majority". Fracture your tibia and you need it plated or it won't heal. There is no way it can heal while weight-bearing, and if you just get slapped in a cast, the fracture site is under constant strain. The only way to avoid this is to screw a plate over the break to immobilise and support it.

>, to hand, wrist, forearm and upper arm fractures can be done in
> a cast.

Uh-uh. Occasionally an orthopaedic surgeon will attempt to reduce a fractured radius or humerus in a closed manner with x-ray visualisation, but these are the exceptions.
A simple Colles fracture can usually be done via closed reduction, as can some minor fractures elsewhere (most often in children as greenstick fractures don't mobilise and don't need much reduction), but the majority of fracture reductions are of the "ORIF", or "Open Reduction, Internal Fixation" type, where an incision is made and plates and screws of various types are inserted.

> Usually on the hingh energy fractures (resulting in an open wound)
> require surgery

Again, no. Compound fractures most certainly DO require surgery, but so do many, many low-energy simple fractures. In the operating theatre where I currently work, I would estimate the number of open reductions exceeds closed by around 5:1. And please note, I AM considering the fact that the patient needs to come to theatre in the first place, thus increasing the chance that they require surgery. A fracture reduction is EXTREMELY painful and is always performed under an anaesthetic of some type: either a regional block (like an epidural except in a limb) or a general -- either way, it's done in theatre. So a good three-quarters of fractures coming thru emergency are routed thru theatre as it is only the undisplaced fractures (minority)
which can be set without reduction.

Any comminuted fracture requires surgery (meaning where the bone breaks into several pieces) and these are exceedingly common in anyone performing any sort of physical labour, or running, or jumping, horse-riding, skiing etc etc. IOW, anyone living a very physically active life suffering a fracture has a very good chance of suffering a comminuted one.

..although fractures around a joint are different..they get
> surgery, not because they won't heal, but because of the greatly increased
> risk of arthritis. Bone healing in misalignment can cause impared
> movement, but depends on which bones...forearm and hand fractures do this,
> as well as fractures around a joing (hip, elbow, etc)..however, upper arm,
> lower leg, etc fractures don't casue any problems in movement (although it
> may very well hurt a considerable bit for a long time...)

Don't bet on it (the immobility thing, that is, not the pain). You fracture your tibia and have it set incorrectly, you'll walk with a limp the rest of your life. It is a long, straight bone that is MEANT to be straight. If it isn't, it means your ankle isn't resting correctly which throws off your weight on your foot. In addition to leading to further problems due to abnormal gait, it simply DOES cause movement problems.

> >
> > For first aid, perhaps. Not for long-term recovery -- you're risking causing further damage to the ends of the bone, damaging muscle tissue or blood
> > vessels around the bone (which can lead to a further compication -- not
> > uncommon -- called "compartment syndrome" which results in muscle death and gangrene if untreated) and the release of "fat emboli", especially if long bones like the femur, tibia or humerus are involved, where fragments of
> > marrow are released into the blood stream, acting like a blood clot to lodge in the lungs to kill of portions of lung tissue (pulmonary emboli).
> Fat amboli is caused by long bone fractures as a result of the injury, not
> the treatment...we haven't seen a significant reduction in fat emboli in
> the last century, because we can't do anything about it. Compartment
> syndrome is also incited by the initial injury, and a splint
> treatment. Its a swelling of the muscles within a fixed space ( for
> example (for those who don't know) in your lower leg, you have four
> compartments of essentially fixed space in while lie your various muscles,
> blood vessels and nerves) casued by the injury. Often, its the cast
> itself that causes compartment syndrome, and the symptoms can be relieved
> by splitting the cast. I will admit though, that if you got a compartment
> syndrome back then, you were prety much assured of losing your leg (or
> dieing if they didn't get it off in time)

Fair enough. I didn't word it very well -- yes, fat emboli are caused by the injury, but emboli can be released by careless manipulation of a fracture: the THROMBUS (an "in-place" embolus) is created by the fracture, but it may not EMBOLISE (be released into the bloodstream) until disturbed.

As far as no significant reductions go, I don't know. I haven't seen or heard any info so I'll take your word for it.

> > >an abnormal gait has never been shown to cause back problems...sore hips yes, but I've never seen a study prove that bad gait casues back pain
> > >*shrug*
> > >
> > Well, I haven't seen a study to demonstrate it, but it's pretty much
> > accepted within the medical / para-medical fields that an altered gait
> > forces the muscles of the back to realign themselves to compensate,
> > resulting in a poorer posture and a lessening of muscular support for the spinal column.
> Its not accepted in these parts by any orthopedic surgeon I know...the
> rehab docs are split on the issue, but the physiotherapists and people who
> make orthotics think it is the case.

Hmm. I haven't spoken to any orthopods specifically on it -- I'll mention it next time I'm at work and see if I can gauge a response. It was something very strongly pushed when I was working in rehab, however, and as you said, the physios and OTs are convinced.

> > And yet we still grow stronger and taller, run faster, jump higher and reach puberty earlier with each generation. That's why Olympic records keep
> > getting broken.
> we've stopped growing taller in the last 20-30 years, and as far as the
> Olympics go, do you really want to get in a discussion of the rampant use
> of anabolic steroids in professional (not to mention amateur and even high
> school) sports these days?

Nope! *grin* I think we're far enough off-topic as it is! Okay, I shouldn't have thrown in the Olympics bit, I guess. Growing taller, that right, that we've stopped in the last generation or so? I wasn't aware of that -- I always thought it was still continuing.

I did, however, think of an example after I sent the last post (of good nutrition leading to bigger people): where my wife did her midwifery training in Sydney, there was a large ethnic Chinese population. Most had come from the poorer areas of China, and tended to be very slightly built. When they had babies, however, the foetuses were being nourished with nutrients gained from a more substantial diet, and as such, these women had an astonishingly high rate of Caesarean sections due to cranio-pelvic disproportion, where the baby's head simply won't fit thru the woman's
pelvis. They were just damn big babies in comparison to the mothers!

In addition (and this is purely anecdotal, so take it with a grain of salt if you wish! *grin*), most of the Australian-born Chinese we lived and worked with didn't share their parents' slight stature; they tended to be as tall and muscular as any Caucasian in Australia. I can't think of anything to attribute this to except that they had a more substantial diet from infancy than their parents did.

> > Granted, but most people are AWARE that it is a good practice to wash one's hands before preparing food etc. I'm not saying it is 100% fool-proof, just that the awareness makes a difference, as we are still more likely to do it than someone who has absolutely no idea that it makes any difference.
> Awareness doesn't stop disease, only doing what you are supposed to
> we could do a quick survey on this many people know
> taht smoking is bad for how many of you smoke anyway? I think
> you'd have a hard time finding anyone whio doesn't know smoking casues
> cancer, lung and heart problems, low birth weight babies, etc, etc,
> however, as many people smoke now (as a percentage of teh population) as
> they did 20 years ago..with the exception of women..more of them are
> smoking now than ever before (lung cancer just passed breast cancer as the
> #1 cause of death in women...congrats *shrug*)

Yeah, fair enough. It's at least a first step, I guess, however. Without the awareness, there's NO chance of the action.

*big sigh*

The interesting thing here is, of course, the fact that we pretty much DO agree on most of the broader details. Still, I like a good debate as much as the next man *grin*

What say we call it quits after your reply to this? I feel like we're being glowered at by the rest of the list! *self-consciously pulling on my asbestos jammies*

Phil O'Neill
"May I find you with peace, and leave you with hope..."

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