Gavin J. Love

Routine coagulation screening in the management of emergency admission for epistaxis is it necessary

The role of routine coagulation studies in the management of patients suffering from epistaxis is unclear. In an attempt to address this issue the case notes of all emergency admissions for epistaxis to a large Scottish teaching hospital were retrospectively reviewed over a one-year period. One hundred and forty patients (63 male, 77 female) were admitted between January and December 1998. The patients who had coagulation studies were identified and their results analysed. A total of 121 patients (86.4 per cent) had coagulation studies performed. Of these, 10 (8.3 per cent) had abnormal results and all were taking warfarin or a combination of warfarin and aspirin. No other coagulation abnormalities were identified. This study supports the view that there does not appear to be a role for routine coagulation studies in patients admitted with epistaxis. The investigation for potential haemostatic disorders should be performed when clinically indicated and, if necessary, in consultation with the haematology service.

Ulnar Subluxation of the Extensor Tendons in Elderly Osteoarthritic Females: A Neglected Diagnosis

Ulnar subluxation of the extensor digitorum communis tendons at the metacarpophalangeal joints occurs rarely in the absence of rheumatoid disease or a history of trauma. Three elderly women presented with chronic ulnar subluxation of the extensor tendons of spontaneous onset. They did not have rheumatoid arthritis and had suffered no acute injury. Seven extensor tendon relocations were performed. The treatment options for this condition are discussed. Recognition of this condition is important if permanent loss of function and disability is to be avoided.

The use and efficacy of intra-operative stress tests in supination-external rotation IV ankle fracture fixation

This study examines stress radiograph use in SER IV ankle fracture fixation; the efficacy of external rotation (ERST) and lateral hook (LHST) stress tests with incidence of subsequent fixation failure secondary to syndesmotic diastasis. 154 skeletally mature patients were admitted to our unit with ankle fractures in 12 months. 42 non-SER fractures and 32 SER fractures treated without ORIF were excluded, as were 14 which featured a syndesmotic screw in the primary ORIF. The remaining 66 SER IV fixations were included in the final sample (17 men, 49 women; median age 49 years). No stress test was performed in 51.5% of cases without a single subsequent failure in these fixations. ERST was the more commonly performed test (incidence 30.3%); negative predictive value (NPV) 0.95. Incidence of LHST was 18.2%; NPV 0.83. Both tests were performed in 6.1% of cases; NPV 0.75. The incidence of failure secondary to syndesmotic diastasis was 6.1% (4/66). Notably, there were no failures in the cases where no stress test was performed. Use of either or both external rotation and lateral hook stress tests resulted in failures to detect syndesmotic diastasis with consequent failure of fixation. This study suggests that syndesmotic injuries are not missed due to an absence of a stress test but that stress tests are not sufficiently sensitive or correctly interpreted. Clinical judgement in cases where syndesmotic injury is not present appears accurate. If syndesmotic injury is clinically suspected, apply caution and insert a syndesmotic screw rather than relying on stress test results.

Intra-operative deviation in limb alignment occurring at implantation in total knee arthroplasty

BACKGROUND Long-term survival of knee replacement depends on accurate alignment. Despite improvements in cut accuracy mal-alignment of 3° or more is still seen. All methods share common implantation techniques. This study examines the effect of implantation on overall limb alignment relating it to cut alignment and trial alignment. METHODS A retrospective review of navigated primary knee replacements was undertaken (n=113). Overall coronal limb alignments for the aggregated cuts, trial and final implanted components were examined. RESULTS All 113 knees had coronal aggregated cut alignment within 2° of neutral (range: 2° varus to 2° valgus). With trial components 99 knees (88%) had an overall coronal limb alignment within 2° of neutral (range: 3° varus to 4° valgus). After final implantation 106 knees (94%) were within 2° of neutral (range: 4° varus to 4° valgus). Forty eight knees (42%) showed no alignment deviation occurring between trial and the final implanted prostheses and 16 knees (14%) shoed a deviation of 2° or more. There was a correlation of both aggregated cut (r=0.284, p=0.002) and trial (r=0.794, p<0.001) with final alignment. There was no significant difference between the final alignment and the aggregated cut alignment(mean difference=-0.15°, p=0.254) or trial alignment (mean difference -0.13°, p=0.155). CONCLUSIONS Even when the aggregated alignment produced by the bone cuts is accurate, inaccuracy in final alignment can result from the implantation process. It may be productive for surgeons to concentrate on the implantation process to improve alignment and reduce outliers.

Two cases of neurofibromatosis presenting with a foot deformity.

Two children presented with an isolated foot and ankle deformity. Examination in each suggested a plexiform neurofibroma although this diagnosis had not been considered before referral. Diagnosis of neurofibromatosis type 1 was confirmed by MRI scanning and on investigation both patients were proved to have widespread disease. One had a plexiform neurofibroma encasing the aorta and oesophagus. Both cases remain under observation and have not undergone surgery for their disease. Neurofibromatosis can present with isolated foot and ankle deformity and when such a diagnosis is suspected thorough investigation is important in a condition in which unsuspected widespread disease may exist.

Allergic contact dermatitis from an electronic facial toner.

* 4th-year medical student. steroids on the 1st occasion. She also displayed a scaly erythematous rash over the back of her neck, under her chin and anterior neck, and over her knees and legs. Her mixture of immediate and delayed-type hypersensitivity symptoms had no obvious trigger. She was investigated for food allergy with IgE and RAST tests for mixed foods and was patch tested to the European standard series and her own products using Finn Chambers on Scanpor tape. Her eczema responded to a moderately potent topical corticosteroid and an emollient, and she was commenced on cetirizine. Her immunopathology results showed borderline antinuclear factor, Ro and La, with a low C4 complement level. Patch test readings at D4 showed a ππ reaction to para-phenylenediamine and πππ to nickel. Dimethylglyoxime testing of her facial toning machine showed a strong positive to the metal applicator pad (Fig. 1), and she was given information on nickel and PPD avoidance.