Clenched fist human bite injuries.

A prospective study has been made of 29 human bite injuries caused by the clenched fist, 27 over M.P. joints and two over P.I.P. joints. All were treated by surgical exploration, within 24 hours in 84% of cases. In 62% the wound had entered the underlying joint and in 58% the bone was injured. Significantly less morbidity was noted in those cases where there was no joint injury (P less than 0.001). Early surgical exploration to identify and to treat the joint injury is recommended.

Ulnar collateral ligament repair of the metacarpo-phalangeal joint of the thumb: a study comparing two methods of repair.

25 patients were assessed following repair of an acutely ruptured ulnar collateral ligament of the thumb metacarpo-phalangeal joint. The patients were divided into two groups, repaired by either a horizontal mattress suture using 4/0 polybutylate (nine patients), or a pre-fashioned steel wire (16 patients). Assessment included a physical examination and functional testing at a mean of 12.9 months (range 4-36 months) after the operation. Both techniques were equally effective, and the use of the more expensive steel wire, while technically satisfying and easy to perform, offers no clinical advantage over simple suture. This pre-fashioned steel wire is, however, recommended in those cases with an avulsion fracture or where distal avulsion of the ligament is associated, since the technique allows easy secure reduction.

The conservative management of volar avulsion fractures of the P.I.P. joint.

A retrospective study was made of 74 volar avulsion fractures of the P.I.P. joint in which there was no radiological evidence of subluxation. Overall, 96% of those reviewed achieved good results but morbidity was increased by immobilisation. Providing the joint is stable, simple neighbour strapping is recommended for these injuries.

Deaths following trauma: an audit of performance.

The TRISS methodology was applied to identify preventable trauma deaths in a retrospective audit of 267 (M = 0.908) patients admitted to a teaching hospital through the resuscitation room of its accident and emergency department during a 1-year period. No unexpected survivors were identified; of the 44 deaths (Z = 5.35), 25 (56.8%) were judged preventable by the TRISS method. Those deaths deemed preventable were subjected to peer review by a panel of six consultants. The findings are discussed in respect of recommendations made for UK trauma centre provision by the Working Party Report of the Royal College of Surgeons of England on the management of patients with major injuries.

Blood alcohol concentration measurement using a salivary reagent stick: a reliable tool for emergency departments?

Measurements of blood alcohol concentration (BAC) were made on patients who presented to an accident and emergency department with acute alcohol intoxication. A correlation of r = 0.418 was noted to exist between BAC as measured by sampling saliva and blood. Blood alcohol concentrations as measured by salivary reagent strip (ALCO-SCREEN, Chem Elec.) were significantly lower (p less than 0.0001) than those determined by gas chromatography of serum. Although such reagent strips offer a rapid measurement of BAC, it is concluded that they are unreliable for the quantitative measurement of BAC in accident and emergency departments.

Preventable deaths after head injury: a clinical audit of performance.

A retrospective trauma audit of 267 consecutive patients presenting to the resuscitation room of an accident and emergency department identified 107 (M = 0.73) patients with CNS predominant injuries in a period of 1 year. The mortality rate was 33 per cent. Application of the TRISS method indicated that 18 (51 per cent) of the 35 deaths (Z = 5.74, P less than 0.001) were mathematically unexpected; no unexpected survivors were identified. Subsequent peer review agreed that death was preventable in 11 cases. The peer panel suggested that the lack of an on-site neurosurgical service may have affected the outcome of this group of patients adversely.

The emergency department: an appropriate referral rate for radiography.

AIM: To evaluate the hypothesis that where there is good clinical practice in an emergency department (ED), there is a low uptake of plain radiography. MATERIALS AND METHODS: Emergency notes and radiography records were reviewed over one week in January 1999, to determine the rate of radiography of first time attenders at the North Staffordshire NHS Trust. The clinical appropriateness of the imaging was assessed by pairs of radiology specialist registrars and casualty physicians. They judged the appropriateness of the imaging by the 1998 Royal College of Radiologists (RCR) guidelines and/or their clinical judgement, by consensus. Where there was no consensus or the data appeared incomplete, the radiology and ED consultant reviewed the notes. RESULTS: A total of 1615 notes were found out of 1643 (98%). Of these, 147 (9%) return attenders were excluded and 32 patients left without being seen. The number of first time attenders was 1436 (87%), of whom 637 (44%) were radiographed; 95% of these radiography examinations were appropriate and 5% were inappropriate. Of the first time attenders who were not radiographed the decision was appropriate in 95% of cases, and inappropriate for 5%, i.e. 5% of those who had no radiography, should have been X-rayed. There were no disagreements between RCR guidelines and the clinical judgements, but in 16% there were no suitable RCR guidelines. Junior doctors were not always able to find the relevant RCR guideline (relevant clinical guideline found in 73% of cases) in the guideline book, compared to the consultants (relevant clinical guideline found in 84% of cases). CONCLUSION: The application of the RCR guidelines is taken as representing good clinical practice in determining when to refer a patient for radiography. Based on this assumption, a referral rate for radiography of 44% of first time attenders was found to be appropriate. This referral rate can be taken as a benchmark. A benchmark is necessary in order to allow departments to make a local assessment as to whether their local referral rate is likely to be too high or too low.