Mallet finger: long-term review of 100 cases.

One hundred cases of mallet finger are reviewed to assess the significance of the results of treatment. This study revealed that the mallet fingers with chip fractures and those without fractures showed satisfactory results in 85% of cases in the long term (32 months) with conservative treatment. Even though there was a statistically significant difference between the satisfied and unsatisfied patients in extensor lag (P less than 0.0001), arc of movement (P greater than 0.001) and pinch grip (P greater than 0.001), none of these patients was willing to undergo surgery to improve their fingers.

Effect of an algorithm on the treatment of knee injuries.

An audit was performed of the treatment of patients presenting with acute knee injuries to the accident and emergency department of a district general hospital. This showed that for patients requiring follow-up the majority were reviewed by the casualty officers themselves in the accident department, with the result that definitive diagnosis and treatment for patients with continuing symptoms was often delayed. Once the current treatment had been discussed at an audit meeting, a protocol (in the form of an algorithm) of the treatment of knee injuries was produced. A further audit was performed after the protocol had been in use. This demonstrated that the protocol was effective in encouraging the casualty officers to seek the help of more senior members of staff and also reduced the time taken to definitive diagnosis and treatment.

On immediate functional bracing of Colles' fracture.

A prospective randomized trial was carried out in 60 consecutive patients with Colles' fractures requiring manipulation. They were treated by either a standard Colles' plaster (control group) or in a functional plaster brace applied immediately after reduction of the fracture. The brace extended from the proximal radius and ulna to the level of the radial styloid and allowed a full range of movement at the radiocarpal joint. Both groups comprised 30 patients and were matched for age, sex and dominance of hand. There was no significant difference in initial severity of fracture or the quality of reduction. Radiological results on cast removal (35-42 days) were significantly better in the brace group compared with those treated with a below-elbow cast (P less than 0.05). Wrist function was also significantly better in the brace treated group at 12 weeks after fracture (P less than 0.05). This brace has a number of advantages over standard plaster treatment, but requires a degree of skill and experience in its application. A prefabricated brace has now been developed with a similar 'built in' three-point loading which will be easier for inexperienced staff to apply.

Audit of ankle injuries in an accident and emergency department.

OBJECTIVE: To determine whether the treatment of ankle injuries in an accident and emergency department could be improved by an audit of existing treatment and the creation and use of a protocol. DESIGN: The study consisted of three parts: a review of the current treatment and published reports on treatment, the formation of a protocol, and a study of treatment after introducing the protocol. SETTING: Accident and emergency department of a district general hospital. PATIENTS: 550 patients attending the department with ankle injuries over four months. RESULTS: The review of treatment showed that patients with fractures were detected and treated adequately, but most had radiography. Patients with ligamentous injuries may have been undertreated. After introducing the protocol the number of patients undergoing radiography was reduced from 205 (80%) to 186 (70%) (0.0027 less than p less than 0.01). In 87% of the notes reviewed the protocol had been completed. Sixty six patients with ligamentous injuries were reviewed in the department or soft tissue clinic compared with 20 before the protocol was introduced. There was a 53% reduction in inappropriate referrals to the fracture clinic (13 before v nine after). CONCLUSIONS: Using a protocol can, at little expense, improve the treatment of ankle injuries and reduce the cost of radiology in an accident and emergency department. IMPLICATION: Treatment of other conditions may be improved by introducing a protocol.

Lichen sclerosus et atrophicus. A common and distinctive cause of phimosis in boys.

Lichen sclerosus et atrophicus, a disease said to be rare in boys, was found in 14 of 100 prepubertal boys undergoing elective circumcision for disease of the foreskin. The clinical features of the disease, in particular the acquired scarring phimosis of the tip of the prepuce, were distinctive. Extragenital involvement was not found. Scarring phimosis in boys must be considered to be one of the most common manifestations of lichen sclerosus et atrophicus.