Injury
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The decision to insert an intercostal drain in chest injury must occasionally be made without a chest radiograph. A prospective analysis of the reliability of physical examination in penetrating pleural injuries was undertaken. A total of 51 consecutive patients were examined before obtaining a chest radiograph. ⋯ Physical examination accurately diagnosed 13 of the 14 large pneumo- or haemothoraces. This reliability combined with the selective drainage policy showed that physical examination accurately predicted the need for tube thoracostomy with a sensitivity of 96 per cent and a specificity of 93 per cent. This study suggests that experienced clinicians should not hesitate to institute immediate life-saving intercostal drainage when needed, before a chest radiograph is obtained.
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A series of 95 patients with fresh fractures of the shaft of the tibia, treated primarily with a Vidal-Adrey transfixation frame, was studied retrospectively. Only 20 fractures (21.0 per cent) attained clinical and radiological consolidation within 4 months after injury. Pseudoarthrosis was seen in 12 patients (12.9 per cent). ⋯ In difficult fractures we feel that change from external to internal fixation should be performed earlier; it makes early removal of the fixator pins possible and prevents the problems associated with prolonged use of fixator frames. The internal fixation, eventually combined with a transplantation of cancellous autografts, creates a mechanical and biological stimulus for bone consolidation. Functional recovery may also be improved because of a shorter healing time.
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Two cases of ulnar artery aneurysm, with concomitant ulnar nerve compression in the palm are presented. Both followed acute injury and presented with an increasingly painful, warm swelling within 2 weeks of injury. An initial diagnosis of infection was made by experienced clinicians in each case. ⋯ It is suggested that simple excision of the aneurysm and ligation of the ulnar artery is the treatment of choice. Angiography should be reserved for those cases where there is doubt about the diagnosis or adequacy of the collateral circulation. Ulnar nerve deficit may be a result of direct injury rather than a neuropraxia from compression by the aneurysm.
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Details of 473 aircrashes throughout the world for the period 1977-1986 were obtained from the Civil Aviation Authority. 114 occurred on or near and 359 away from airfields. In 188 there were survivors and in 285 none. ⋯ Acted out disaster exercises with mock casualties should not have more than 50 injured casualties, of whom not more than 20 should have serious injuries (i.e. need admission to hospital). The problems of crashes with much larger casualty figures should be worked through in table-top exercises.