Comparison of pain perceived when using pneumatic or silicone ring tourniquets for local anaesthetic procedures in the upper limb.

The aim of this study was to evaluate the level of pain felt when silicone ring and pneumatic tourniquets were applied to the upper arm and to determine which was more suitable for use in local anaesthetic procedures. Pain was measured using a visual analogue score pain scale on application and at 1, 5, and 10 minutes in 30 volunteers. Volunteers experienced significantly more pain on application and at 1 and 5 minutes with the silicone ring tourniquet. This difference in pain was most marked on application. Two volunteers could not tolerate application of the silicone ring tourniquet. We conclude that the silicone ring tourniquet would not be suitable for local anaesthetic procedures in the upper limb due to the severe pain experienced on application, which may reduce the patients' confidence and adversely affect their experience of the procedure. The pneumatic tourniquet is more suitable for local procedures.

An approach to the diagnosis of chronic wrist pain.

A clinical algorithm was developed to help to establish a diagnosis in patients with chronic wrist pain. The accuracy of the algorithm was examined in a prospective blind study of 40 patients presenting to the Hand Unit with undiagnosed wrist pain and compared with the later findings at arthroscopy, which were believed to be as accurate as currently possible. Using simple examination techniques and conventional radiographs, an accurate diagnosis was made in 80% of cases. Examination techniques including the scapholunate shear test and the presence of local tenderness or pseudostability were found to be particularly accurate.

An approach to the diagnosis of chronic wrist pain.

A clinical algorithm was developed to help establish a diagnosis in patients with chronic wrist pain. The accuracy of the algorithm was examined in a prospective blind study of 40 patients presenting to the Hand Unit with undiagnosed wrist pain and compared with the later findings at arthroscopy, which were believed to be as accurate as currently possible. Using simple examination techniques and conventional radiographs, an accurate diagnosis was made in 80% of cases. Examination techniques including the scapho-lunate shear test and the presence of local tenderness or pseudostability were found to be particularly accurate.

Fracture of the lateral process of the talus: computed tomographic scan diagnosis.

Fracture of the lateral process of the talus is rare but can be mistaken for a simple ankle sprain. A case with normal conventional radiographs is presented to draw attention to this diagnosis in the resistant ankle sprain, and to highlight some of the problems that may be encountered with treatment.

Investigation of the irritable hip.

The respective roles of conventional radiography, ultrasound scanning, and radionuclide scintigraphy in the investigation of 62 children with the irritable hip syndrome are compared. It is recommended that conventional radiography and ultrasound scanning be routinely performed, but scintigraphy should be reserved for those with positive findings on ultrasound, as an abnormal scintigram is unusual in the presence of a normal ultrasound scan.

Dupuytren's and epilepsy revisited.

The incidence of Dupuytren's disease amongst the residents of two epileptic centres was found to be 12.0% in one and 38.1% in the other. The overall incidence at the second was significantly higher than a control population (16.0%) and this difference was particularly apparent in patients over 50 years old. The distribution of the Dupuytren's disease was found to be very similar to that of non-epileptic patients. At both centres, the disease process was more severe, with an increased incidence of contractures. Drug therapy was not clearly implicated in the aetiology of this condition.

The association between alcohol, hepatic pathology and Dupuytren's disease.

We have looked at the incidence of Dupuytren's disease in alcoholics, those with non-alcoholic liver disease and a control population. Both alcoholic patients and those with non-alcohol related liver disease had a higher rate (28% and 22% respectively) than the controls (8%), but this did not quite reach statistical significance (p greater than 0.05). In addition we found no Dupuytren's disease in 50 Egyptian patients with bilharzia and no consistent biochemical abnormalities in 134 patients with significant Dupuytren's disease. We conclude that alcoholics probably do have a higher rate of Dupuytren's disease and that this effect is largely due to the liver disease caused by alcohol abuse, but that the genetic factors are of greater aetiological importance.

The irritable hip. Scintigraphy in 192 children.

Over a 4-year period, 192 patients with a typical transient synovitis syndrome underwent radionuclide scintigraphy shortly after presentation. Three different patterns were found suggesting that all the cases may not be of the same etiology. Fifteen patients had evidence of ischemia of the femoral head, but only 4 patients went on to develop the typical radiographic features of Perthes' disease. The other 11 patients are thought to represent a minor, radiographically silent form of Perthes' disease.

The role of tissue pressure recording in forearm fractures in children.

During a 25-month period, 15 children with severe forearm fractures had signs and symptoms suggestive of an early compartment syndrome and underwent tissue pressure measurements. Of these, seven were found to have elevated intracompartmental pressures and had decompressive fasciotomies performed. The remaining eight patients had normal pressures and subsequently made uneventful recoveries. Tissue pressure recording is a useful adjunct to clinical diagnosis in suspicious cases of compartment syndrome, particularly in children.

The diagnostic potential of synovial effusion in meniscal pathology.

During a 20-month period, 382 arthroscopies were performed and the type of washout fluid obtained was noted. When a torn meniscus was found, the fluid was macroscopically abnormal in 97.4% of cases. A crystal clear washout was associated with no demonstrable pathology in over half the cases, the remainder having mainly patellofemoral joint pathology and other articular lesions. Only 6.3% of those with a clear fluid washout had meniscal pathology. Of those with abnormal fluid, 68% had meniscal pathology, with a normal arthroscopic examination being found in only 8.5%. In addition, when the fluid from traumatic effusions was examined microscopically, a typical droplet containing lipid crystals was found to be present and to account for an oily macroscopic appearance. These data support the use of fluid irrigation of the knee as a screening test for intraarticular pathology, especially of the menisci, that may allow a reduction in the number of negative arthroscopies.

Posterior dislocation of the elbow.

Posterior dislocation of the elbow is associated with significant morbidity and incomplete recovery. In this series of 32 patients, those with associated fractures, posterolateral dislocations, delayed reduction, and rigid immobilization had the least satisfactory outcome.

The significance of chondromalacic changes on the patella.

A total of 500 arthroscopies were performed in a 2-year period, with special reference made to the patellofemoral joint. In those with pain thought to be arising from this joint, 63% had chondromalacic changes on the posterior surface of the patella compared with a 45% incidence in those with meniscal pathological findings at arthroscopy. This study demonstrates that those with patellofemoral pain do not always have patellar articular changes, and patellar pathology is often asymptomatic. As a result, treatment directed at these lesions must be used with great caution.

Ulna neuropathy after elbow injury in children.

Six children developed seven cases of ulna neuropathy between 7 days and 6 years after significant elbow injury. None had evidence of acute nerve damage at the time of initial trauma. This complication, which develops soon after injury, has not been well documented. For this reason, the mode of presentation, treatment options, and review of the literature is presented.

Compartment syndrome following forearm fracture in children.

Six cases of acute compartment syndrome of the forearm following displaced fractures of the distal radius and ulna are presented. In children the diagnosis can be difficult to make, and can be helped by the use of compartment pressure measurements. Children with this type of fracture are at risk of developing this complication, and careful observation and assessment following injury is recommended. The use of early decompression has given better results in this younger age group than that reported in adults.

Rotational deformity following metacarpal fracture.

Ninety-one consecutive patients with 98 metacarpal fractures were looked at prospectively for rotational deformity. Whilst a quarter had minor rotation of the fracture of less than 10 degrees, only five had more than this. In just two cases, was there rotational instability requiring operative intervention. Assessment of rotational deformity must include an end-on view of the finger-nail, as there is often restricted movement at the metacarpal phalangeal joint following fracture.

Perforation of the jejunum secondary to a duplication cyst lined with ectopic gastric mucosa.

We present a case of jejunal duplication with a localized perforation of the adjacent normal intestine into the substance of the liver in a 3-month-old baby. This was successfully treated by resection of the duplication and a short segment of the normal jejunum. The diagnosis was made preoperatively by pertechnetate technetium 99m isotope scanning and a barium meal examination, and we discuss the use of these investigations in children presenting with melena.