Adult distal radius fractures classification systems: essential clinical knowledge or abstract memory testing?

Classification systems should be tools for concise communication, which ideally can predict prognosis and guide treatment. They should be relevant, reproducible, reliable, properly validated and most importantly simple to use and understand. There are 15 described distal radius classification systems present in the literature in the past 70 years, of which 8 are discussed in this paper. For each classification, we give an insight into its history, strengths and weaknesses, and provide evidence from the literature on reliability and reproducibility. Sadly, on completion of this paper we have not found a distal radius fracture classification that proved to be useful. Failings range from poor reproducibility and reliability, and over-complexity mainly emanating from the inability to classify this spectrum of injury in all of its manifestations. Consequently, we would suggest that classification systems for acute adult distal radius fractures are not useful clinical knowledge but mainly historical and/or research tools. Moreover, we would discourage trainees from spending time learning these classifications, as they serve not as essential clinical knowledge but more as forms of abstract memory testing.

One-year outcome for elderly patients with displaced intracapsular fractures of the femoral neck managed non-operatively.

The outcome of patients with a displaced intracapsular femoral neck fracture treated non-operatively was assessed at 1 year and compared with patients managed operatively over the same time period. Data were collected prospectively for 102 consecutive patients. 80 patients underwent hemiarthroplasty and 22 were managed non-operatively. Patients were managed non-operatively if they were felt to have an unacceptably high risk of death within the perioperative period despite medical optimisation. Non-operative management entailed active early mobilisation without bed rest or traction. Patients managed non-operatively had a greater 30-day mortality compared with operatively managed patients. Deaths were due to pre-existing medical conditions or events, which had occurred at the time of hip fracture. No patient in the non-operative treatment group developed pneumonia, pressure sores or thrombo-embolic events. Patients treated non-operatively, who survived 30 days after fracture, had a mortality rate over the following year comparable with those who had undergone surgery. At 1 year, all non-operatively managed patients were able to transfer without pain and 6 of the 11 surviving patients were able to mobilise with walking aids. At 1 year, the majority of surviving non-operatively managed patients were living in their own homes. Surgical intervention is the treatment of choice for the majority of elderly patients with a displaced intracapsular femoral neck fracture. However, in patients with life-threatening medical co-morbidity, non-operative treatment with early mobilisation can yield acceptable results.

Giant lipomatous tumours of the hand and forearm.

This study examines the presentation, management and outcomes of a series of 10 patients with giant lipomatous tumours (defined as greater than 5 cm diameter) of the hand and forearm who presented to our orthopaedic oncology service. All patients underwent local staging and were discussed at our multidisciplinary tumour meeting prior to definitive surgery. In all cases, neurovascular structures required mobilization in order to excise the tumour. Seven of the tumours were benign lipomas and one was a neural fibrolipoma. The other two were well differentiated lipoma-like liposarcomas/atypical lipomatous tumours. Giant lipomas and well differentiated lipoma-like liposarcomas/atypical lipomatous tumours of the hand and forearm present infrequently and a multidisciplinary approach is recommended in the investigation and surgical management of these patients.

A cryoclamp for the rapid cryofixation of the isolated blood-perfused rabbit cardiac papillary muscle preparation at predefined times during the contraction cycle.

There is increasing evidence that the distribution of monovalent cations in cardiac cells may be non-uniform, particularly in the region immediately beneath the sarcolemma, and we have proposed that a build-up of sodium in this region could be an important factor in the development of ischaemia-reperfusion injury. Electron probe X-ray microanalysis is ideal for the study of such changes in distribution but the application of the technique to this problem imposes severe requirements on the specimen and on the method for cryofixation. The specimen must be perfused through its vasculature so that it can be made truly ischaemic and be successfully reperfused. It is necessary to be able to cryofix the specimen without disturbance of its blood supply, electrical stimulation or temperature. It is also important to know the time in the contraction cycle when cryofixation occurs. Here we describe the design of an automated cryofixation device which can be used to cryofix a blood perfused papillary muscle preparation at predetermined time points in the contraction cycle. Preliminary data obtained from the analysis of rabbit papillary muscles subjected to varying periods of ischaemia are included as an example of the use of the cryoclamp.

Sale of cigarettes to school children aged 14 and 15 years in New Zealand.

AIMS: To determine the sources of cigarettes and extent of illegal sales to 14 and 15 year old children, and to examine associated risk factors in order to more effectively reduce tobacco access to children. METHOD: Nationwide cross sectional survey of fourth form school children in New Zealand by means of an anonymous self administered questionnaire. RESULTS: Questionnaires from 14,097 fourteen and fifteen years olds were analysed, with over one third smokers. Twenty four percent of the whole group (3432) had bought cigarettes in the last year. Of smokers, 59.9% bought their own, with the great majority (68.9%) from dairies, particularly females. Ninety five percent said it was "easy" or "very easy" to buy cigarettes, and this was a major risk factor for this behaviour (relative risk (RR) = 2.01, 95% confidence interval (CI) 1.74, 2.32, RR = 2.54, CI 2.28, 2.83, respectively). Only 24.6% children had ever been refused cigarettes because of age and all points of sale were comparable in this respect. Heavy smokers and males were more likely to have been refused. While refusal was associated with a fourfold increase in the perception that it was difficult to buy cigarettes, there was only a minimal reduction in the risk of children buying their own cigarettes (RR = 0.95, CI 0.91, 1.00). CONCLUSION: We have shown that the illegal sale of cigarettes to children is unacceptably easy and accurately perceived as such by children who smoke. The active enforcement of existing or future legislation is essential, with prosecution of offending retailers, if we are to make any progress to reduce the high prevalence of smoking in New Zealand children.

A national survey of cigarette smoking in fourth-form school children in New Zealand.

AIMS: To determine the prevalence of cigarette smoking in 14 and 15 year old school children in New Zealand and to examine associated risk factors. METHODS: Nationwide cross-sectional survey of fourth-form school children in New Zealand by means of an anonymous self administered questionnaire in November 1992. RESULTS: Questionnaires from 14,097 fourteen and fifteen year-olds were analysed. 65.6% had tried smoking, and 36.1% regarded themselves as smokers. Females and Maori had significantly higher prevalence rates. Of Maori females 44.6% were current smokers (more than one per month) compared to 24.0% for the whole group, and 33.0% were daily smokers. Pacific Island students, who have similar socioeconomic disadvantage to Maori, have a lower relative risk of smoking (RR) 0.79, (95% confidence interval (CI) 0.68, 0.91), than Europeans. Major independent risk factors were identified and population attributable risk was calculated for parental smoking (22.9%), poor knowledge of adverse health effects (7.3%) and watching televised sports (13.4%). These three modifiable factors accounted for 36.1% of the total smoking prevalence in these children. CONCLUSION: The continued high prevalence of smoking in New Zealand children, especially in Maori and in females, prove current public health measures to be inadequate. Our results suggest that strategies aimed at decreasing parental smoking, improving student knowledge of adverse health effects and preventing tobacco sponsorship of television sports could greatly decrease the smoking prevalence in this age group.

Immunomagnetic bone marrow purging of common acute lymphoblastic leukemia cells: suitability of BioMag particles.

Immunomagnetic bone marrow purging is becoming a widely used technique in many bone marrow transplant centres. Most centres use Dynabead magnetic particles to facilitate the procedure. The suitability of a novel magnetic particle (BioMag) for immunomagnetic purging was addressed in this study. Common acute lymphoblastic leukemia (ALL) cells were targeted using CD9 and CD10 mouse monoclonal antibodies prior to attachment of magnetic particles coated with anti-mouse immunoglobulin and depleted with samarium cobalt magnets. Immunofluorescent and clonogenic assays capable of measuring more than four log depletions of the Nalm 6 cell line showed that a single cycle of purging reduced target cells by 3.1 +/- 0.9 BioMag particles and 1.8 +/- 1.0 logs with Dynabeads. A second cycle of purging was advantageous, increasing target cell depletions to more than 4.5 logs with either particle type. Bone marrow granulocyte-macrophage colony-forming units were not significantly reduced. The results indicate that BioMag particles can be used for the efficient depletion of common ALL cells from bone marrow for transplantation.

'Safe oxygen' in acute asthma: prospective trial using 35% Ventimask prior to admission.

There is still some uncertainty as to the best inspired oxygen concentration to use in the treatment of acute asthma before measurement of arterial blood gases can be made. In the absence of published data, we report a prospective study in which 35% oxygen was the initial therapy given to patients with moderate to severe asthma, and arterial blood gases were taken to assess the adequacy of oxygenation and the safety of this method. Forty-five episodes were analyzed and a wide range of PaO2 was observed (8.8-21.3 kPa 66-160 mmHg). No relationship was shown between PaCO2 and either PaO2 or duration of oxygen treatment. It was concluded that 35% oxygen given in acute asthma is both safe and probably adequate. A lesser concentration of oxygen could expose asthmatics to an unacceptable risk of significant hypoxaemia.

Fractures of the fifth metacarpal neck: is reduction or immobilisation necessary?

Sixty two patients with fractures of the neck of the little finger metacarpal have been studied. Treatment consisted of unrestricted exercises without any splintage or attempts at reduction, irrespective of the degree of angulation of the fractures. Patients were reviewed at one or two-weekly intervals until movement had recovered and return to work was possible. One year after injury, patients were recalled for examination. Recovery was rapid with no long-term functional restriction, although 14% of patients noted minor cosmetic deformity.

Peripheral neurotoxicity of 2-chloroprocaine and bisulfite in the cat.

The responses of peripheral nerves less than 6 hr after and 2 weeks after exposure to 2-chloroprocaine (2-CP) and bisulfite (BS) were studied in cats using electrophysiologic techniques and by light and electron microscopy. Three percent 2-CP with 0.07% or 0.2% BS was not toxic to peripheral nerves. Three percent 2-CP with 1.2% BS and 1.2% BS (pH 2.8) alone had an acute effect on the peripheral nerves but no chronic effect. Ten percent BS (pH 2.8) caused Wallerian degeneration. However, at pH 4.8, no chronic toxicity was observed. Using conductivity measurements, it was shown that 2-CP and BS, when mixed, form an ion pair in solution that lowers the effective concentration of BS.

Fractures of the phalanges: results of internal fixation using 1.5mm and 2mm A. O. screws.

Thirty-six patients were treated for 38 phalangeal fractures using 1.5 mm and 2 mm A. O. screws. Plates were not used in the fingers. Oblique fractures of the condyles, shafts or bases of the proximal or middle phalanges were treated by internal fixation because of instability, displacement or rotation. 40% of fractures had associated skin wounds, were comminuted or had damage to the extensor mechanism. The mean duration of post-operative immobilization was 9 days and the mean time off work was 6 weeks. Total active movement in the involved ray was 220 degrees or greater in 24 cases, 180 degrees to 215 degrees in eight cases, and less than 180 degrees in two patients at follow up. The patients were reviewed between three and 54 months after treatment and the mean duration of follow up was 24 months. The most frequent complication was 10 degrees to 30 degrees of flexion deformity of the proximal interphalangeal joint after internal fixation of condylar fractures. Results were satisfactory in 90% of cases.

Fractures of the metacarpals: treatment by A. O. screw and plate fixation.

Twenty-two patients with 26 fractured metacarpals were treated by internal fixation using A. O. mini-fragment screws and plates. This form of internal fixation was reserved for metacarpal fractures which were multiple, unstable, displaced or rotated. Nine patients had open fractures, two had divided extensor tendons and four had multiple fractures. Fractures consistently united without infection or deformity. The mean duration of postoperative immobilization was seven days and mean time off work was six weeks. All but one patient did manual work. No patients had persistent symptoms which caused difficulty with work or sport. Fourteen patients regained full movement. Four had total active movement of 220 degrees or more in the involved ray and 6 patients had total active movement of between 180 and 220 degrees. Restricted movement was present in patients with open fractures and divided extensor tendons or intra-articular fractures of the metacarpal head. Uniformly satisfactory results were found after mini-screw and plate fixation of metacarpal fractures.

The Herbert screw for fractures of the scaphoid. A review of results and technical difficulties.

We have reviewed 22 patients with scaphoid fractures treated by internal fixation with the Herbert screw. Three patients had trans-scaphoid perilunar dislocations, one had an oblique displaced fracture of the waist of the scaphoid and 18 had fractures with delayed or non-union. Corticocancellous bone grafts were added in nine of the cases of non-union. Results were excellent or good in 80% of cases after a mean duration of postoperative immobilisation of four weeks. The technical difficulties are analysed and the problems of applying the jig and of operative exposure are discussed.

Acute carpal tunnel syndrome. Complications of delayed decompression.

Five patients suffered injuries around the wrist complicated by acute tunnel syndrome. Pain associated with median nerve paraesthesia or hypo-aesthesia are indications for urgent treatment; in four patients where operation was delayed, the outcome was poor.

Post mastectomy pain after brachial plexus palsy: metastases or radiation neuritis?

Three patients have been reported who developed metastatic tumour within the neural tissue of the brachial plexus three years, four years and fourteen years respectively after treatment of breast carcinoma by simple mastectomy and postoperative radiotherapy. A fourth patient who developed bilateral upper limb paralysis after radiotherapy for a lymphoma is also reported. At exploration of the brachial plexus extensive fibrosis was present in all cases with metastases only diagnosed through biopsy of neural tissue. The clinical features and the role of surgery are discussed in the light of our experience and a review of available literature.