Prevalence and distribution of hand fractures.

A retrospective survey of the medical charts of all 36,518 patients attending the Accident and Emergency Department of the VU University Medical Centre, in Amsterdam, from January 1 to December 31, 1996 was performed. Of these, 4303 sustained one or more fractures, and hand fractures accounted for 19% of all fractures. Patients with hand fractures were typically men aged between 15 and 35 years. The right hand was involved as often as the left. Most of the hand fractures involved the metacarpals but, as a group of bones, the combined phalanges were most commonly fractured. The little finger ray was most commonly injured of the hand. We found no seasonal variability in the incidence of hand fractures.

The 'mirrored' Bennett fracture of the base of the fifth metacarpal.

Fractures of the base of the metacarpals are usually treated conservatively. The intra-articular fracture of the base of the first metacarpal ('Bennett fracture') is an exception to this rule because inadequate repositioning and fixation of the dislocated radial fragment lead to permanent deformity of the joint and subsequent degenerative joint disease. The dislocated intra-articular fracture of the base of the fifth metacarpal is similar to a Bennett fracture in many aspects. Repositioning of this 'mirrored' Bennett fracture cannot be guaranteed by a plaster cast. Inadequate repositioning will lead to pain, reduced strength and early degenerative joint disease. We present six patients with dislocated intra-articular fractures of the base of the fifth metacarpal to illustrate the necessity of surgical reduction and fixation.

Factors related to multiple organ system failure and mortality in a surgical intensive care unit.

We retrospectively studied the relative contribution of factors related to the extent of multiple organ system failure (MOSF) and mortality, using multivariate methods to account for the interactions between studied factors, in 538 consecutive patients admitted to a surgical intensive care unit during a 1-year period. MOSF (MOSF score > or = 5) occurred in 88 (16%) of patients. Multiple linear regression selected advancing age, malnutrition, APACHE II score, shock and coma on admission, number of blood transfusions, use of H2 receptor antagonists or antacids, bacteraemia and intra-abdominal infection as independent factors related to the MOSF score. MOSF mortality was 52% and was a major cause of death in critically ill surgical patients. Multiple logistic regression selected advancing age, malnutrition, bacteraemia, APACHE II and MOSF score as major predictors of mortality. Advancing age, malnutrition, shock and coma on admission, transfusion requirement and use of H2 receptor antagonists or antacids may impair host defences of the gastrointestinal tract and enhance the vulnerability for invasive infection, thereby aggravating the severity of existing MOSF. Together with the predominance of Enterobacteriaceae in infected patients, these results suggest that translocation of intestinal bacteria and endotoxin may be important in the evolution and perpetuating the MOSF syndrome. Our results may be useful in devising strategies to prevent or limit the evolution of MOSF and to improve survival in patients with critical illness.