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FRACTURES OF THE SCAPHOID
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Board has provided funds to establish and equip laboratories for producing vaccine in several Middle Eastern and Asian countries. But there is no money to buy the vaccine now. S.A.T. 1 virus has stolen a long march while governments have been counting the cost or hoping that someone else would come to their aid. The director of the F.A.O. animal protection and health unit has pointed out that S.A.T. 1 moves very swiftly because sheep as well as cattle and goats are affected and that a severe invasion might cost Europe E350 million. The Indian subcontinent is also threatened, while trade in animal products throughout the Near East has come to a halt. F.A.O. is the only body which can deal effectively with this threat to the world’s protein supplies, but it urgently needs money to purchase vaccine before it is too late. ance
THE MIDSTREAM SPECIMEN
THE catheter has fallen out of fashion: often dangerous to the patient, it has been found unnecessary for procuring urine to be analysed. In women patients a midstream specimen, collected with care under expert guidance, serves admirably; but not so the specimen obtained after brief and hasty instruction. Picture the elderly patient, clad for inclement weather in heavy coat, scarf, hat, and gloves, and carrying a 1-oz. container, being directed to a toilet box with a few half-remembered words of instruction going round in her head. How can a suitable specimen be expected ? Usually the collection of a midstream specimen is supervised by a nurse. Nurses in training should be enabled to gain a sound knowledge of excretory anatomy; and they should practise passing on this knowledge clearly and forthrightly to patients, who will thus be given confidence in an unaccustomed situation. Teaching might be greatly aided by a short film. At present the collection and examination of midstream specimens is too often a time-wasting gesture. FRACTURES OF THE SCAPHOID
FRACTURES of the scaphoid continue to fascinate and baffle orthopaedic surgeons. They are of considerable economic importance, and ideas about their treatmentlike those about so many other treatments-tend to run in cycles. Before the days of radiology, fractures of the scaphoid were only recognised either as part of a more severe wrist injury which necessitated open operation or, occasionally, at postmortem examination. In 1895, Callender1 described a fracture of the scaphoid associated with fracture of the lower end of the radius; but not until the publication of Codman and Chase’s2 classical paper in 1905 did the profession as a whole become aware of the entity " fractured scaphoid ". There was then heated argument between the anatomist, who claimed that most so-called fractured scaphoids were congenitally bipartite scaphoids, and the practising surgeon, who held that they were truly fractured. But many indeed maintained that the functional efficiency of the wrist was not improved even if union was obtained. At that time, the recommended period of fixation was relatively short-some four weeks only. In 1915, Murphy3 distinguished three types of fractured scaphoid: the simple transverse, the transverse fracture with impaction, and the fracture of 1. 2. 3.
Callender, G. W. Trans. path. Soc. Lond. 1866, 17, 221. Codman, E. A., Chase, H. M. Ann. Surg. 1905, 41, 321. Murphy, J. B. Clin. J.B. Murphy, 1915, 4, 385.
the tuberosity. He concluded-wrongly, as it transpiredthat scaphoid fractures do not, as a rule, unite. In 1934, Watson-Jones4 analysed 100 fractures of the carpal scaphoid and claimed that, in recent fractures, bony union was secured in 98%; but, in the interests of union, he was prepared to immobilise the wrist for as long as twenty-two months. The teaching and example of Watson-Jones had a tremendous influence on the profession, and, in the early years of the 1939-45 war, long-continued plaster fixation was the common treatment for fractured scaphoid. In days when man-power was scarce, the economic wisdom of such treatment was bound to be questioned: various operative procedures were said to ensure quicker and more frequent union, and the ill-effects of too-prolonged immobilisation also became apparent. There was also considerable interest in the operative treatment of the painful osteoarthritic wrist resulting from an old-standing un-united scaphoid. London5 now advocates a comparatively short period of immobilisation-from six to eight weeks-and recommends that, even if the fracture is not then united, the patient should be allowed to use his wrist normally since union will probably occur. Baumann and Campbell 6 have reviewed the results of treating 164 recent fractures of the scaphoid. They found that all the undisplaced fresh fractures healed by bone if properly immobilised shortly after the time of the injury. Immobilisation was continued for between one and a half and three and a half months: the more proximal the fracture, the longer the immobilisation necessary for healing. Baumann and Campbell conclude that delay in immobilisation, or displacement of the fragments, invites delayed union and, in proximal scaphoid fractures, late treatment inevitably results in non-union. Moreover, if displacement is significant in fractures of the middle third, and especially in what they call the horizontal-oblique types, open reduction and internal fixation may be advisable, since closed treatment will have to be continued for a long time. Repair of non-union of the proximal third of the scaphoid in 4 cases of pseudoarthrosis, excision of the third fragment in 2, and repair of non-union in the middle third in 5 resulted in function no better than that in cases of similar pseudoarthroses for which no operation was performed. The authors plead for more care in the recognition and treatment of these fractures, since treatment begun early meets with almost uniform success. To many surgeons, these results will appear neither exciting nor new. Yet we still see untreated fractures and osteoarthritis of the wrist resulting from non-union. Early diagnosis is all-important and depends on good radiography. If the fracture is overlooked it may lead to considerable functional impairment and economic loss. Undisplaced fractures will unite in a comparatively short time if immobilised in plaster; but if union has not occurred after, say, three months, there is probably little point in continuing the immobilisation any longer, and a decision must then be made whether to perform a bonegrafting operation or to accept the pseudoarthrosis. The advocates of early operation have not yet shown that it produces a better functional wrist which will stand up to the stresses and strains of many years of hard work. What treatment is best for a displaced fracture of the proximal pole is still uncertain; but the surgeon should at least warn the patient that the fracture is a difficult one which may not unite. 4. 5. 6.
Watson-Jones, R. Brit. med. J. 1934, i, 937. London, P. S. J. Bone Jt Surg. 1962, 44B, 246. Baumann, J. U., Campbell, R. D. J. Trauma. 1962, 2, 431.
Board has provided funds to establish and equip laboratories for producing vaccine in several Middle Eastern and Asian countries. But there is no money to buy the vaccine now. S.A.T. 1 virus has stolen a long march while governments have been counting the cost or hoping that someone else would come to their aid. The director of the F.A.O. animal protection and health unit has pointed out that S.A.T. 1 moves very swiftly because sheep as well as cattle and goats are affected and that a severe invasion might cost Europe E350 million. The Indian subcontinent is also threatened, while trade in animal products throughout the Near East has come to a halt. F.A.O. is the only body which can deal effectively with this threat to the world’s protein supplies, but it urgently needs money to purchase vaccine before it is too late. ance
THE MIDSTREAM SPECIMEN
THE catheter has fallen out of fashion: often dangerous to the patient, it has been found unnecessary for procuring urine to be analysed. In women patients a midstream specimen, collected with care under expert guidance, serves admirably; but not so the specimen obtained after brief and hasty instruction. Picture the elderly patient, clad for inclement weather in heavy coat, scarf, hat, and gloves, and carrying a 1-oz. container, being directed to a toilet box with a few half-remembered words of instruction going round in her head. How can a suitable specimen be expected ? Usually the collection of a midstream specimen is supervised by a nurse. Nurses in training should be enabled to gain a sound knowledge of excretory anatomy; and they should practise passing on this knowledge clearly and forthrightly to patients, who will thus be given confidence in an unaccustomed situation. Teaching might be greatly aided by a short film. At present the collection and examination of midstream specimens is too often a time-wasting gesture. FRACTURES OF THE SCAPHOID
FRACTURES of the scaphoid continue to fascinate and baffle orthopaedic surgeons. They are of considerable economic importance, and ideas about their treatmentlike those about so many other treatments-tend to run in cycles. Before the days of radiology, fractures of the scaphoid were only recognised either as part of a more severe wrist injury which necessitated open operation or, occasionally, at postmortem examination. In 1895, Callender1 described a fracture of the scaphoid associated with fracture of the lower end of the radius; but not until the publication of Codman and Chase’s2 classical paper in 1905 did the profession as a whole become aware of the entity " fractured scaphoid ". There was then heated argument between the anatomist, who claimed that most so-called fractured scaphoids were congenitally bipartite scaphoids, and the practising surgeon, who held that they were truly fractured. But many indeed maintained that the functional efficiency of the wrist was not improved even if union was obtained. At that time, the recommended period of fixation was relatively short-some four weeks only. In 1915, Murphy3 distinguished three types of fractured scaphoid: the simple transverse, the transverse fracture with impaction, and the fracture of 1. 2. 3.
Callender, G. W. Trans. path. Soc. Lond. 1866, 17, 221. Codman, E. A., Chase, H. M. Ann. Surg. 1905, 41, 321. Murphy, J. B. Clin. J.B. Murphy, 1915, 4, 385.
the tuberosity. He concluded-wrongly, as it transpiredthat scaphoid fractures do not, as a rule, unite. In 1934, Watson-Jones4 analysed 100 fractures of the carpal scaphoid and claimed that, in recent fractures, bony union was secured in 98%; but, in the interests of union, he was prepared to immobilise the wrist for as long as twenty-two months. The teaching and example of Watson-Jones had a tremendous influence on the profession, and, in the early years of the 1939-45 war, long-continued plaster fixation was the common treatment for fractured scaphoid. In days when man-power was scarce, the economic wisdom of such treatment was bound to be questioned: various operative procedures were said to ensure quicker and more frequent union, and the ill-effects of too-prolonged immobilisation also became apparent. There was also considerable interest in the operative treatment of the painful osteoarthritic wrist resulting from an old-standing un-united scaphoid. London5 now advocates a comparatively short period of immobilisation-from six to eight weeks-and recommends that, even if the fracture is not then united, the patient should be allowed to use his wrist normally since union will probably occur. Baumann and Campbell 6 have reviewed the results of treating 164 recent fractures of the scaphoid. They found that all the undisplaced fresh fractures healed by bone if properly immobilised shortly after the time of the injury. Immobilisation was continued for between one and a half and three and a half months: the more proximal the fracture, the longer the immobilisation necessary for healing. Baumann and Campbell conclude that delay in immobilisation, or displacement of the fragments, invites delayed union and, in proximal scaphoid fractures, late treatment inevitably results in non-union. Moreover, if displacement is significant in fractures of the middle third, and especially in what they call the horizontal-oblique types, open reduction and internal fixation may be advisable, since closed treatment will have to be continued for a long time. Repair of non-union of the proximal third of the scaphoid in 4 cases of pseudoarthrosis, excision of the third fragment in 2, and repair of non-union in the middle third in 5 resulted in function no better than that in cases of similar pseudoarthroses for which no operation was performed. The authors plead for more care in the recognition and treatment of these fractures, since treatment begun early meets with almost uniform success. To many surgeons, these results will appear neither exciting nor new. Yet we still see untreated fractures and osteoarthritis of the wrist resulting from non-union. Early diagnosis is all-important and depends on good radiography. If the fracture is overlooked it may lead to considerable functional impairment and economic loss. Undisplaced fractures will unite in a comparatively short time if immobilised in plaster; but if union has not occurred after, say, three months, there is probably little point in continuing the immobilisation any longer, and a decision must then be made whether to perform a bonegrafting operation or to accept the pseudoarthrosis. The advocates of early operation have not yet shown that it produces a better functional wrist which will stand up to the stresses and strains of many years of hard work. What treatment is best for a displaced fracture of the proximal pole is still uncertain; but the surgeon should at least warn the patient that the fracture is a difficult one which may not unite. 4. 5. 6.
Watson-Jones, R. Brit. med. J. 1934, i, 937. London, P. S. J. Bone Jt Surg. 1962, 44B, 246. Baumann, J. U., Campbell, R. D. J. Trauma. 1962, 2, 431.