The bacterial colonisation of silicone oil used in the management of wounds of the hands--a source of nosocomial infection?

For 30 years, silicone oil has been used for the management and rehabilitation of the injured hand. Its benefits accrue from its providing a non-irritant, bland, air-free medium in which the hand can undergo early movement, which prevents drying out of the tissues and helps in the separation of necrotic and infected tissue. It has been reported, however, that the silicone oil might act as a reservoir for nosocomial infection after two patients developed epidemic methicillin-resistant Staphylococcus aureus (EMRSA) infections. Since no firm guidelines exist with regard to open and/or infected wounds and the continued use of the same oil, a prospective study was set up to study the bacterial colonisation of the silicone oil. Thirty-five consecutive patients were entered into the study. The oil for each patient was changed each week but if any wound became clinically infected the oil was changed earlier. Treatment was continued until the wound was healed or until the treatment was stopped by the referring doctor. Bacteriology swabs taken from the wound and the oil before each treatment and from the oil after each treatment were analysed for bacterial colonisation. The results indicated that while bacteria were transferred into the oil from the wound, the inoculum was small and had no effect on wound healing. There was no evidence that wounds were being re-infected from the oil. The conclusion was that silicone oil remains a safe medium in which to exercise injured hands.

Hamato-lunate impingement: an uncommon cause of ulnar-sided wrist pain.

It has been reported that almost 50% of lunates have a separate medial facet on the distal surface for articulation with the hamate; about a quarter of these have erosion of the cartilage with exposed subchondral bone on the proximal pole of the hamate. We describe 4 cases of ulnar-sided wrist pain caused by hamato-lunate impingement that resulted in chondromalacia. The pain could be reproduced by a modification of the Lichtman test. The diagnosis was confirmed by arthroscopy. All 4 patients responded favorably to resection of the head of the hamate.

Of blood, inflammation and gunshot wounds: the history of the control of sepsis.

Galen (AD 129-199) propounded the notion that all wounds healed by second intention and the concept of laudable pus became unshakeable for almost 15 centuries. But William of Saliceto (AD ca 1210-1280) held quite firmly that pus formation was bad for both wound and patient and proclaimed that wounds should heal by first intention. The first rational theory of the nature of infection was by Fracastoro (1478-1553), a physician of Verona who regarded infection as being due to the passage of minute bodies from one person to another. But it was not until the work of Pasteur (1822-1895) that bacteriology took a significant leap forward. The association between bacteria and infection was slow to be accepted. The work of Semmelweis (1818-1865) is notable for his association between bacterial infection and puerperal fever. Lister (1827-1912) began the modern movement to control infection with his pioneering work in antiseptic surgery. Other contributions came from von Bergman (1836-1907; steam sterilization of instruments) and Halstead (1852-1922; rubber gloves for surgeons). The aseptic system has changed very little since then except for the innovations of Sir John Charnley (1911-1982; the laminar flow enclosure). The development of safe antibacterial drugs has been confined to the 20th century. This was led by Domagk (1895-1964; sulfonamides) and was followed by Sir Alexander Fleming (1881-1955), Sir Howard Walter Florey (1898-1968) and Sir Ernest Boris Chain (1906-1979; penicillin) and Selman Waksman (1888-1973; actinomycin).

Conservative and surgical treatment of tennis elbow: a study of outcome.

BACKGROUND: Tennis elbow is one of the most common lesions of the arm. The first description is attributed to Runge in 1873 but the name derives from 'Lawn Tennis Arm' described by Morris in 1882. The majority of cases are believed to be caused by a musculo-tendinous lesion of the common extensor origin at or near the attachment to the lateral epicondyle. While there are some comprehensive reports in the literature of patients treated by one technique or another, there are no comprehensive reports of groups of patients for whom various techniques were employed in a logical sequence until a resolution was reached. METHODS: This paper presents a retrospective analysis of case notes and an analysis of questionnaires completed by the patients. RESULTS: In this study we found that 67% of patients who presented with tennis elbow received relief through steroid injections either alone or in combination with a tennis elbow band or nonsteroidal anti-inflammatory drugs. The use of either a tennis elbow band or non-steroidal anti-inflammatory drugs or injected steroids made no statistical difference to the outcome. CONCLUSIONS: We also found that the patients who did not respond adequately to conservative measures were relieved of their symptoms by surgery.

Safety of silicone liquid in the postoperative management of Dupuytren's contracture.

BACKGROUND: Recently the New Zealand Department of Health expressed concerns about the safety of applying silicones to open wounds and banned their use. For 30 years silicone liquid has been used for the management and rehabilitation of the injured hand. It has been reported that the application of silicone fluids to the skin and ordinary handling over a period of years of various methyl and phenyl polymers by laboratory workers caused no skin disorders or sensitization, nor was absorption observed. There are no reports in the literature of the safety of the use of silicones applied to open wounds. METHODS: In the present study, 116 hands that had been mobilized in silicone liquid following surgery for Dupuytren's contracture over the last 12 years were reviewed. In the cases of 64 hands, the patients could be traced and contacted, and 47 patients (hands) agreed to attend for a clinical review. The hands were examined for areas of inflammation, granuloma formation and abnormal scar formation. RESULTS: No patient showed any evidence of adverse effects from the use of silicone liquid. CONCLUSIONS: There is no evidence that the use of silicone liquid, in contact with open wounds of the hands, for the mobilization of the hand following surgery for Dupuytren's contracture has any of the adverse effects reported as being associated with implanted silicone prostheses.

Post-traumatic radio-ulnar synostosis treated by surgical excision and adjunctive radiotherapy.

The management of three cases of traumatic radio-ulnar synostosis involved surgical excision of the synostotic bone followed by radiotherapy. Irradiation was commenced on the first postoperative day and was continued daily. The first patient received 20 Gy midline in 10 fractions and the second and third patients 10 Gy in five fractions. No acute side effects were observed. All three patients regained a good, functional range of forearm rotation with no evidence of recurrence of the synostosis after 2 years. This method of treatment is recommended as an alternative to other adjunctive therapies including interposition of material such as silicone sheet between the bones or peri-operative pharmacological suppression.

Bennett's fracture: a medium to long-term review.

Seventy-six patients who had sustained Bennett's fractures before 1985 comprised the patient base. Of these, 21 could be contacted and were reviewed at an average of 7 years 7 months after fracture to determine the effect of the quality of reduction on clinical and radiological outcome. Those cases that healed with up to 1 mm of fracture displacement were found to have superior results to cases where the reduction was less accurate. However even in those cases where a good reduction was not achieved the results were generally satisfactory with only one of 76 patients being known to have required a subsequent fusion of the first carpo-metacarpal joint. The subjective results in most patients had not deteriorated with time. It is recommended that a reduction with less than 1 mm displacement of the fracture be achieved in cases of Bennett's fracture. The particular technique by which the reduction is achieved and held is immaterial.

Pivot osteotomy for the correction of malunion of metacarpal neck fractures.

A new configuration of osteotomy has been developed which combines the principles and benefits of opening and closing wedge osteotomies without the degree of shortening associated with the closing wedge osteotomy and the tension imposed on the soft tissues by the opening wedge osteotomy. It is ideally suited to the correction of angular malunions in the long bones of the hands. Ten osteotomies of malunions of the metacarpals have been performed in nine hands giving good correction of the malunion in all cases.

Bizarre parosteal osteochondromatous proliferation of the hand in a young man.

We report a case of a solitary osteochondromatous tumor on the hand of a 38 yr old man. This had radiological and histological features distinct from an osteochondroma and demonstrated the features first described as bizarre parosteal osteochondromatous proliferation. These lesions have a tendency for local recurrence but no metastatic behaviour has yet been reported. We highlight 2 histological features which have not been previously described.

The possible role of vascular congestion in carpal tunnel syndrome.

A study of interstitial pressures within the carpal tunnel using a slit catheter found that, in some patients, an initial rise in pressure is recorded when the wrist is passively extended and this continues to rise to a plateau if the position is maintained. A rise above a critical pressure brought about by congestion would explain the clinical picture of predominantly nocturnal symptoms and no electro-physiological evidence with the wrist in a neutral (resting) position. The results also bring into doubt published results of the pressure within the carpal tunnel with the wrist flexed or extended, since the pressure can be changed at will, depending on the flexion or extension force used.

Conservative surgery for Dupuytren's contracture.

The trend towards conservativism in the management of Dupuytren's contracture has resulted in less radical surgery than was previously advocated to release disabling contractures of the fingers. 38 cases of Dupuytren's contracture in the palm have been treated by Z-plasty of skin and underlying contracted band without fasciectomy. Proximal interphalangeal joint contractures were treated by fasciectomy and skin closure with Z-plasties as required. Only one of 16 patients reviewed after two years had evidence of recurrence. Skin compliance has been measured and a return to near-normal levels was found in all but the one patient with a recurrence.

Congenital dislocation of hip in the newborn: a postnatal survey.

The results of a postnatal survey carried out for congenital dislocation of hip in children born at the Wellington Hospital maternity unit over a ten year period is presented. Of the 15,000 neonates born during this period, 91% underwent hip examinations. Abnormality was recorded 1.8% (n = 247) 78% (n = 192) of whom had clinically stable hips when re-checked seven to ten days later. In all, 60 children had unstable hips requiring definitive treatment, five of whom missed the neonatal screening and presented late. In this latter group, 77% (n = 46) had normal hips by six months of age following conventional splintage. Eight point two percent (n = 5) were unstable after six months of splintage, 5% (n = 3) were lost to follow-up, 1.6% (n = 1) presented late and in 8.2% (n = 5) the hip examination was either not done or instability not detected. We conclude that, in spite of the great awareness and known long term benefits of early neonatal hip examinations, late presentations because of missed examinations continue to be significant.

Clinical fracture of the carpal scaphoid--an illusionary diagnosis.

The management of patients with clinical evidence of a fracture of the carpal scaphoid bone but without radiological evidence of a fracture is based on dogma emphasizing the need to immobilize the wrist in all cases. Because of the apparently high proportion of patients who spend up to six weeks in a plaster cast and in whom no fracture is ever demonstrated radiologically, a study was undertaken to determine the fate of those wrist injuries diagnosed as clinical fractures of the scaphoid. All patients who presented with clinical or radiological evidence of fractures of the scaphoid over a one year period were reviewed. Of the 108 patients in whom the diagnosis of clinical fracture of the scaphoid was made at the time of presentation none was proved radiologically to have a fracture of the scaphoid subsequently after a period of mobilization. These patients spent an average time of 21.9 days in a plaster cast which represents a significant loss of productivity to the community and inconvenience to the patient.

Tourniquet pressure: the effect of limb circumference and systolic blood pressure.

Complications attributable to direct pressure may result from the use of pneumatic tourniquets during surgical procedures. Traditional estimates have determined the pressures employed rather than the minimal pressure necessary to produce a bloodless field. To determine this pressure, pre-operative and post-operative systolic blood pressures and the tourniquet pressure at which capillary bleeding occurred were measured in a group of patients undergoing elective surgery of the upper and lower limbs. From these results two equations were derived, one for each of the upper and lower limbs, which give the minimum tourniquet pressures to produce bloodless fields. In an average sized, normotensive patient, 200mm Hg was found to be adequate for the upper limb and 250mm Hg for the lower limb.

Spinal and pelvic kinematics in osteoarthrosis of the hip joint.

Angular displacement of the pelvis and the lumbar spine was measured in a group of 19 patients with unilateral osteoarthrosis of the hip joint and a group of 10 control subjects of similar ages for comparison, and the means for each were calculated. All of the patients showed an increase in both sagittal plane (P less than 0.005) and coronal plane (P less than 0.01) movements of the pelvis, when compared with the control group. Two patterns of spinal movement were evident. One group showed a significant decrease in coronal plane movements and the other group showed a significant increase in coronal plane movements. Characteristic patterns of movement were identified and the variations between different patients recorded.

Normal kinematics of the lumbar spine and pelvis.

A study was undertaken to provide a data base of pelvic and lumbar spinal movement during walking. The movements of the pelvis and lumbar spine in 48 male volunteers of age range 16 to 74 years were measured using a television/computer motion analysis system. The results were presented both as a range of movement in each plane and as a wave pattern for the movement in each plane. Cadence, the movements of the pelvis and spine in the sagittal plane, and the movement of the pelvis in the transverse plane all showed a negative correlation with age. Analysis of the wave patterns showed that the movements of the pelvis and lumbar spine relate to identifiable events in the gait cycle.

Repeatability studies of a television/computer system for measuring spinal and pelvic movements.

Repeatability of a television/computer system for measuring spinal and pelvic movements has been studied using both a movement simulator and human subjects. The movement simulator was capable of reproducing independent movements of either pelvis or spine about any one of three mutually perpendicular axes. When the system was tested using this simulator, the least accurate measurement was of the transverse plane movements of the spine. The scatter of the samples about the zero position in each plane for the condition of no movement was also measured using the movement simulator. The standard deviation of the measurements from the mean zero was 1.09 percent in the worst case. The scatter was greatest for transverse plane measurements. Repeatability of measurements using human subjects showed the greatest variation in sagittal plane movement of the pelvis (mean = 3.4 degrees, s.d. = 0.90).