The causes of injuries requiring admission to hospital in the 1970s

One thousand four hundred and seventeen patients admitted to hospital as a result of injury have been investigated as to the aetiology of the injury. The commonest cause of injury was road traffic accidents but there were many other causes including domestic accidents, sport, alcohol, assault, and injuries sustained at work and in the street. Many of these accidents were avoidable and it is suggested that large publicity campaigns to make people aware of the possible hazards they face in their home, at work, on the playground and on the street might be indicated.     

Intramedullary nailing for fractures of the femoral shaft

The results of a survey of 136 fractured femoral shafts treated by open reduction and intramedullary nailing between 1963 and 1970 are presented.Complications of the operation such as mechanical failure of fixation, wound infection, delayed union and non-union are discussed.The final results based on the range of knee flexion and freedom from complications are given: 80 per cent of the results were good.     

Isovolumic relaxation period in hypertrophic cardiomyopathy

Previous reports have demonstrated that patients with hypertrophic cardiomyopathy have a prolonged isovolumic relaxation period as a result of a delay in mitral valve opening, reflecting a reduced rate of fall of left ventricular pressure. This period as measured from the aortic closure sound (A2 on phonocardiogram) to the opening of the mitral valve (on echocardiogram) was determined in 84 patients with hypertrophic cardiomyopathy and compared with findings in 31 normal volunteers. The duration of the isovolumic relaxation period in the 84 patients had a wide range from 0 to 160 ms (mean 71 +/- 32) that was not significantly different from that in normal subjects (63 +/- 11 ms). However, it was possible to identify a group of 15 patients with an extremely short isovolumic relaxation period, 2 standard deviations below the normal range. This shortening was due to a marked delay in aortic closure sound (A2) due to late left ventricular-aortic pressure crossover, as well as early opening of the mitral valve secondary to elevated left atrial pressure, which was confirmed by hemodynamic correlations and digitized echocardiographic data. In this subset of patients, A2 is a poor marker of the onset of rapid left ventricular pressure decline and, thus, the interval from A2 to mitral valve opening is not a valid reflection of left ventricular relaxation. It is concluded that in hypertrophic cardiomyopathy, both the timing and sequence of relaxation are abnormal, as is the rate of relaxation. Furthermore, the isovolumic relaxation period is multifactorially determined and depends not only on the rate of left ventricular pressure decline, but also on the magnitude of the pressure drop from A2 to mitral valve opening. All of these determinants must be kept in mind when the isovolumic relaxation period is used as a measure of left ventricular relaxation.     

Late results after vertical fracture of the talus

Twenty-seven patients were examined on an average of 5 years after sustaining a vertical fracture of the talus. One patient had bilateral fractures. In spite of degenerative osteoarthrosis being visible on the radiographs, the functional results were good. Necrosis of the talus with deformity was consistent with surprisingly good function of the foot, subjectively and objectively. Operative reduction of the fracture had a high frequency of complications. The indications for primary talectomy in a fracture of this bone, as advocated by some other authors, is discussed. Closed reduction should be tried before open reduction is performed. If operation is necessary, the soft tissues must be treated with the utmost care in order to avoid necrosis and infection.     

Traumatic lumbar hernia

An unusual case of lumbar hernia is described, in which the iliac crest had been avulsed from the iliac bone producing a muscular defect through which the small bowel had herniated and become obstructed.     

A useful method of fixing split-skin grafts

An n-butyl ester of cyanoacrylate monomer which polymerizes in 10 seconds when in contact with OH ions has been used for fixing skin grafts. It can be used for gluing graft to skin, or graft to graft. It is easy and rapid to apply, both in the theatre and on the ward, and has caused no side effects in 18 burn cases. It gives a stronger join than suturing in thin skin grafts.     

Fatal road accidents in Birmingham: Times to death and their causes

The intervals between injury and death in the 254 fatalities after road traffic accidents in Birmingham during 1969 and 1970 were analysed and correlated with other data. Sixty-three per cent were pedestrians and 23 per cent were passengers and drivers of vehicles. In round figures, about a third of the series died within half an hour, a half by 2 hours, two-thirds by 24 hours, and three-quarters by 2–4 days. The patterns of survival-time could be divided into three phases. There was an early steep decline, with 36 per cent dying during the first half-hour and 44 per cent within 1 hour of the accidents. This was followed by a longer stage during which the rate of dying decreased progressively in logarithmic fashion. The cumulative tolls were 51 per cent by 2 hours, 58 per cent by 4 hours, 68 per cent by 24 hours, and 83 per cent by 7 days. The curve then flattened into a prolonged tail. Between 7 and 28 days another 10 per cent died, making 93 per cent by 28 days. The remaining 7 per cent succumbed during the subsequent weeks and months, 3 patients surviving longer than a year.

Fifty-six per cent of vehicle occupants and 40 per cent of pedestrians died within an hour of injury, and the excess of rapid deaths among vehicle occupants was mainly due to a higher proportion of rupture of the aorta. All the ruptured aortae in vehicle occupants occurred after accidents at night or the early hours of the morning. Many of the affected drivers and passengers had consumed alcohol and their injuries were more rapidly lethal than after accidents at other times. Serious cerebral trauma dominated all groups of road users and multiple injuries were common. Included among the fatality tail was a group of subjects, mainly pedestrians, with relatively modest injuries who might have survived had they not developed pulmonary embolism, respiratory infection, or other complications.     

Patterns in traumatic rupture of the bronchus

Some ruptures of the bronchus are diagnosed early but in many there is a long delay. This is because there are two distinct clinical patterns, one of which is not well recognized.In the first there is free communication between the bronchus and the pleura and the diagnosis is easily suspected when the lung fails to re-expand with adequate pleural suction.In the second there is little or no communication between the rupture site and the pleura. The peribronchial tissues maintain a conduit and ventilation of the lung continues until obstruction is produced by granulation tissue after a week or more. The lung then becomes airless and a mistaken diagnosis of retained secretions is easily made.The two types are illustrated by case reports.