Driving with a forearm plaster cast: patients' perspective.

BACKGROUND: Forearm plaster casts are commonly used in orthopaedic practice for the treatment of fractures of the wrist and carpal bones. A common question put by patients seeks to clarify suitability to drive a motor vehicle. DVLA guidelines do not specifically comment about temporary immobilisation in a cast. METHODS: A questionnaire was sent to 248 adult patients who had recently been treated in Colles' or scaphoid-type casts to determine the driving habits of the patients and their attitudes to the legality and safety of driving with a cast. RESULTS: Of those who responded, 87% considered it unsafe to drive a car with a plaster cast. 79% thought it should be illegal. Only 9% of patients reported driving while immobilised, and these tended to be young men who did not inform any authority. Previous literature is confusing and there appears to be little consensus among orthopaedic surgeons about letting these patients drive. Clarification is reported from the Medical Advisory Group at the DVLA and the Head of Road Policing Business Area for the Association of Chief Police Officers. CONCLUSION: It is recommended that all medical professionals advise their patients that they should not drive while immobilised in an upper limb plaster cast.

Preventing fragility hip fracture in high risk groups: an opportunity missed.

OBJECTIVE: The national guideline recommends selective case finding as the main strategy by identification of high risk people. This study assessed whether high risk patients were identified before their presentation with fragility fracture. METHODS: A prospective study for 3.5 consecutive months on patients with low energy hip fractures to Brighton and Sussex University Hospital NHS Trusts, which serves a population of 460,000. Data were collected by interview using standardised form, medical record review, and communication with family physicians. Definition of high risk: (1) untreated hypogonadism (2) corticosteroid users (3) disorders with increased bone loss (4) previous fragility fractures. RESULTS: 98 patients were admitted with hip fracture. Thirty nine (40%) had at least one high risk factor. High risk patients (7 of 39, 18%) were no more likely to receive prophylaxis compared with patients without high risk factor (5 of 59, 8%) (p = 0.21). Previous fragility fracture (23) was the commonest risk factor followed by disorders with increased bone loss (10), premature menopause (10), and corticosteroid users (5). Fifteen patients (15%) had susceptibility to frequent falls and two had maternal history of osteoporosis. The proportion of treated patients were 20% (2 of 10) in premature menopause, 10% (1 of 10) in diseases with secondary osteoporosis, 13% (3 of 23) in previous fragility fracture, and 80% (4 of 5) in corticosteroid users (p = 0.01) CONCLUSION: Prevention of hip fracture is still inadequate in high risk patients. Discrepancy seemed to exist in treatment frequency among different high risk groups suggesting that emphasis on prevention of osteoporosis has not been reinforced in all people at risk.

Surgery for cerebral palsy part 3: classification and operative procedures for thumb deformity.

Spastic thumb deformity is the result of imbalance between intrinsic and extrinsic forces acting across unstable joints. This paper presents a classification of spastic thumb deformity based on the accurate assessment of the deforming forces, outlines methods for their correction and reviews the results of our surgery. Thumb reconstruction procedures were performed in 32 patients with 33 spastic thumb deformities. All patients were assessed pre- and postoperatively using the same functional assessment system which was performed by the same team. The thumb was maintained out of the palm in 29 patients and lateral pinch was established in 26 patients.

The surgical treatment of metastatic disease of the spine.

BACKGROUND AND PURPOSE: The spine is the commonest site for skeletal metastases. The majority of patients with spinal metastases can be managed conservatively, at least initially, but a significant number will develop complications, either neurological or mechanical, requiring surgical intervention. This paper emphasizes the need for a spinal surgeon to be involved early in the care of these patients. MATERIALS AND METHODS: Forty-two patients undergoing surgery for metastatic disease of the spine between January 1995 and June 1997 were reviewed. Thirty-five of the patients had 'instability' pain secondary to pathological vertebral fracture, 25 of whom also had radicular pain secondary to nerve root compression. Six patients had radicular pain but no symptoms of instability. Two of these patients had symptoms of spinal claudication and one further patient had symptoms of spinal claudication alone. Forty of the patients had evidence of thecal compression on magnetic resonance imaging scans and 29 had neurological signs. According to the grading of Frankel (Paraplegia 7 (1969) 179), 14 had a major neurological deficit and 15 had a minor neurological deficit. All patients underwent decompression of the cord or nerve roots and spinal stabilization, 25 via a posterior approach, 15 via an anterior approach and two combined. RESULTS: Post-operatively pain improved in 38 of the 42 patients (90%), the neurological deficit in 20 of the 29 patients with a deficit (69%) and the ambulatory ability in 25 of the 32 patients (78%) with very restricted mobility. CONCLUSIONS: Identification of the cause of a patient's symptoms allows appropriate surgical intervention with favourable results.

The hip in children with cerebral palsy. Predicting the outcome of soft tissue surgery.

This study reviewed 56 hips in 37 children with cerebral palsy who had undergone an adductor tenotomy alone or in combination with an anterior obturator neurectomy. The mean review period was 5.3 years. At latest review, 25 of 30 (83%) hips with a preoperative migration percentage of less than 40% were reduced, but 20 of 26 (77%) hips with a preoperative migration percentage of 40% or more were subluxated or dislocated. Surgery was unsuccessful for 13 of 15 hips with an acetabular index of more than 27 degrees. Percutaneous adductor tenotomy alone was as effective as the combination of an open procedure with an anterior obturator neurectomy. The age at the time of surgery did not have a significant effect on the outcome. The preoperative migration percentage was the only significant predictor of outcome in this group of children.