Hand-arm vibration in orthopaedic surgery: a neglected risk.

Background: Hand-arm vibration syndrome is an occupational disease caused by exposure to hand-arm transmitted vibration. The Health and Safety Executive has set limits for vibration exposure, including an exposure action value (EAV), where steps should be taken to reduce exposure, and an exposure limit value (ELV), beyond which vibrating equipment must not be used for the rest of the working day. Aims: To measure hand-arm transmitted vibration among orthopaedic surgeons, who routinely use hand-operated saws. Methods: We undertook a cadaveric study measuring vibration associated with a tibial cut using battery-operated saws. Three surgeons undertook three tibial cuts each on cadaveric tibiae. Measurements were taken using a frequency-weighted root mean square acceleration, with the vibration total value calculated as the root of the sums squared in each of the three axes. Results: A mean (SD) vibration magnitude of 1 (0.2) m/s2 in the X-axis, 10.3 (1.9) m/s2 in the Y-axis and 4.2 (1.3) m/s2 in the Z-axis was observed. The weighted root mean squared magnitude of vibration was 11.3 (1.7) m/s2. These results suggest an EAV of 23 min and ELV of 1 h 33 min using this equipment. Conclusions: Our results demonstrate that use of a battery-operated sagittal saw can transmit levels of hand-arm vibration approaching the EAV or ELV through prolonged use. Further study is necessary to quantify this risk and establish whether surveillance is necessary for orthopaedic surgeons.

Massive haemorrhage after a low-energy pubic ramus fracture in a 71-year-old woman.

We describe a case of a patient receiving warfarin who presented with a superior pubic ramus fracture after a trivial fall at home. She developed a massive retroperitoneal haematoma as a result of vascular injury and subsequently died. This case emphasises the importance of admitting and observing patients with pubic rami fractures who are receiving antithrombotic treatment, and haemorrhage should be considered if they become haemodynamically compromised.

Carotid artery dissection after treadmill running.

The case is presented of carotid artery dissection causing Horner's syndrome in a 25 year old woman after treadmill running. She presented with characteristic eye signs and mild pain. Early diagnosis and treatment was associated with no long term, serious complications. It is now recognised that carotid artery dissection is more common than previously thought. Better imaging of the carotid artery has facilitated the diagnosis, and it is now essential to rule out this potentially fatal condition in patients presenting with postganglionic Horner's syndrome. It is accepted that relatively trivial trauma can cause a carotid artery dissection, and many sporting activities may place young, fit, healthy people at risk.

Case presentation: a novel way of treating acute cauliflower ear in a professional rugby player.

Acute auricular haematoma is a common problem in rugby players and can be difficult to treat due to re-accumulation of the fluid and can subsequently cause the unsightly cauliflower ear. We present a case of auricular haematoma affecting the central part of the pinna in a professional rugby player. This was treated successfully by aspiration and the use of silicone splints which allowed the player to continue training and competing.

Small bowel obstruction in a twin pregnancy due to fibroid degeneration.

Small bowel obstruction in pregnancy is unusual. It is a difficult diagnosis to make, as vomiting and abdominal distension are commonly associated with pregnancy, and x-rays are avoided if possible. We present a case of small bowel obstruction caused by uterine fibroid degeneration in a 37 year old with a twin pregnancy. Following a period of observation an x-ray was performed which prompted surgical exploration, relief of the obstruction and myomectomy. This case highlights that x-ray is essential if there is a clinical suspicion of small bowel obstruction in pregnancy as delay in diagnosis can be catastrophic. As childbearing is increasingly delayed into later life it is possible that pregnancy complicated by fibroids will be seen more frequently.