Fractures of the distal phalanges.

A prospective study of 110 patients with fractures of the distal phalanx indicates that less than one in three patients with such injuries will have recovered after six months. Less than one half of distal phalangeal fractures will have united by then. Factors that carry a poor prognosis include osteolysis of fractured fragments, subungual haematomas and non-union of fractures.

Achilles paratendonitis: an evaluation of steroid injection.

A prospective, randomised, double-blind study of 28 patients presenting with Achilles paratendonitis was undertaken in order to evaluate the role of peritendonous injection of methy prednisolone acetate (Depo Medrone). At presentation patients were either administered peri-tendonous injection of 40 mgs of methyl prednisolone acetate suspended in 1 ml of 0.25% marcaine or 2 ml of 0.25% marcaine alone. Response was gauged by resolution of pain, tenderness and return to normal activity. Patients who failed to respond to initial treatment were crossed over to the other group at 12 weeks. All patients received standardised physiotherapy. Results indicate that peri-tendonous injection of methyl prednisolone acetate is of no value in Achilles paratendonitis.

Ultrasound assessment of the suspected scaphoid fracture.

A prospective study of 111 patients thought to have sustained a recent scaphoid fracture on clinical grounds but who were radiologically negative was undertaken over a period of 7 months. All such patients were subjected to ultrasound scanning within a week of their injury under double blind conditions. All patients were re-X-rayed 2-3 weeks after their injury. The authors' results suggest that ultrasonic diagnosis of the possibly fractured scaphoid is unreliable.

The suspected fracture of the scaphoid: a rational approach to diagnosis.

It has been the policy of the accident and emergency department in Leicester to treat all clinically suspected fractures of the carpal scaphoid in plaster for 2 weeks, even after negative radiology. A preliminary audit of policy revealed that 150 wrists had been immobilized in plaster during a 6-month period and yet only eight fractures of the scaphoid were identified in this group. In order to reduce the degree of 'overkill' a new policy was introduced for the management of the clinically suspected, radiologically negative fracture of the scaphoid and results were assessed prospectively. The new policy was based on resting all such injuries in broad arm slings until review by a more senior member of staff was possible, always within 1 week. Results indicate that it is easier to make a definitive soft tissue diagnosis a few days after such injuries and, therefore, the number of plasters applied dropped substantially. Not all fractures of the scaphoid were apparent on initial radiographs, but despite this it was possible to treat all such injuries appropriately on the strength of their clinical signs when reviewed. The new scheme of management is recommended for general use in accident and emergency departments on the strength of a prospective study of 111 patients with pain after injury, tenderness and swelling in the anatomical snuffbox.

Detection of hypertension in accident and emergency departments.

Routine blood pressure measurements are performed on all non-ambulatory patients attending the Accident and Emergency Department, Leicester Royal Infirmary, England. However, the patient's general practitioner is not always informed of the reading, even if it is found to be raised. One of the chief reasons for this omission is the fact that single, elevated blood pressure readings taken in an accident and emergency department are considered to be of doubtful significance. Sixty patients with a single, elevated blood pressure measurement were studied. Fifteen of these patients were found to continue to have an elevated blood pressure measurement when reviewed in a quiet, relaxed environment. Fourteen of these 15 patients are currently being treated for hypertension after independent assessment by their family practitioners. It was concluded that single, elevated blood pressure readings are useful indicators of hypertension in non-ambulatory patients attending accident and emergency departments. It is, therefore, important to inform general practitioners of incidentally raised blood pressure readings.