Injury
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Thirty-two cases of penetrating injuries of the diaphragm are reviewed. The problems of clinical and radiological diagnosis are outlined and the pitfalls of barium contrast studies are illustrated. ⋯ Surgical access via laparotomy is recommended in both acute and chronic cases and where additional thoracotomy is necessary, separate abdominal and thoracic incisions are advised. The presence of colonic injury is shown to increase the risk of both wound sepsis and empyema postoperatively, whilst other visceral injuries do not appear to affect postoperative morbidity.
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In multiply injured patients with major blunt thoracic injuries, the continued high mortality is mainly caused by the additive effect of the unstable flail chest associated with pleural and lung injuries upon the pulmonary gas exchange disturbance caused by haemorrhagic shock. A more active approach with early thoracotomy and chest wall stabilization is recommended. Three groups of injuries provide the appropriate indication: 1. ⋯ In all cases the thoracotomy should be performed after resuscitation of the patient on the day of the accident or within 3 days. Screwless elastic self-clasping rib plates were used in 15 multiply injured patients and in 5 isolated thoracic cases with good results and a low complication rate. The mortality was reduced from 64 per cent to 36 per cent in the patients with multiple injuries.
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Heat necrosis of bone is described after the insertion of Steinmann or Denham pins using a powder drill, in four patients. Troublesome infection developed in all of these patients and fracture occurred through the pin site in two. Block excision of the affected area appears to have eradicated the infection in three patients. One an did not require operation.
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The advantages of the Ender technique over the other methods of treatment of trochanteric fractures of the femur have been emphasized by several authors but the difficulties and complications of the method have perhaps not been sufficiently highlighted. With this imbalance in mind, 60 patients treated by the Ender method have been reviewed with particular emphasis on the problems encountered during treatment. ⋯ The main postoperative complications were the cutting out of the nails from the head and neck fragment with weight bearing, backing down of the nails at the knee, and external rotation deformity. The early mortality, infection, delayed union and non-union rates were low.