152 Injury: the British Journal of Accident Surgery Vol. B/No. 2

Dislocation of hip and femoral fracture

Four cases of dislocation of the hip joint with frac- ture of the shaft of the femur on the same side and one case of dislocation of both hips with fracture of one femoral shaft are reported. Four of the disloca- tions were posterior and one anterior. Following primary reduction of the fracture and fixation with an intramedullary nail, it was possible to reduce one of the posterior dislocations by manipulation, the others required open reduction. Complications included delayed union of two fractures, avascular changes in femoral heads with delayed reduction and stiffness and early arthritic change in the hips.

Ehtisham S. M. A. (1976) Traumatic dislocation of hip joint with fracture of the shaft of the femur on the same side. J. Trauma 16, 196.

Injuries of the head and spine Predicting outcome

This is the report of a study based on 600 persons treated in Glasgow and in the Netherlands who had been in coma for at least 6 hours. The authors set out to discover to what extent it was possible to predict the outcome in individual patients using the purely clinical findings such as are available in any hospital. They used 5 grades of outcome: death (50 per cent), persistent vegetative state (2 per cent), severe disability (7 per cent), moderate disability (15 per cent) and good recovery (25 per cent). Nearly half the patients had intracranial clots.

The mean age of those that died was 40 years and of those that survived, 30. Both mortality and dis- ability were greater over the age of 20 but beyond this there was no obvious difference between patients in different decades of life.

The most useful physical signs were movements of the eyes, reactions of pupils, plantar responses and depth of coma.

Using Bayesian statistics and a computer, they found that 24 hours after injury, 44 per cent of 200 predictions were confident with regard to death or persistent vegetative state on the one hand, or to a better recovery on the other, and 97 per cent of these confident predictions were accurate.

After 3 days it was possible to predict confidently in 61 per cent of the 200 which of two categories of recovery the patient would achieve, and in 52 per cent a confident prediction was made of which of 3 degrees of recovery would occur; in both cases the predictions were 97 per cent accurate.

Prediction would be improved by studying a larger range of evidence based on more elaborate investi- gations but may be spoiled by unforeseen complications.

Jennett B., Teasdale G., Braakman R. et al. (1976) Predicting outcome in individual patients after severe head injury. Lancer 1, 103 1.

Fracture of transverse process

Four cases are reported of patients with fracture of the transverse process of the seventh cervical and/or

first thoracic vertebrae. They were associated with the deceleration type of road traffic accidents. All were drivers and were wearing seat belts with shoulder and lap straps. The fractures were on the left (the side of the shoulder strap). The proposed mechanism and implications of the injury are discussed.

Arndt R. D. (1975) Cervical-thoracic transverse process fracture: further observation on the seat-belt syndrome. J. Trauma 15, 600.

Fat embolism Fat embolism in dogs

In experimental animals, triolein was injected intra- venously. In some of the animals the fat was marked with laC. The well-recognized hypoxia was observed, also other changes such as pulmonary hypertension. Fat emboli were found in various organs. The immediate cause of death is discussed.

Shaffer J. W., Sealy W. C., Seaber A. V. et al. (1975) Effects and distribution of acute fat embolism in spontaneously breathing dogs using radioactive carbon triolein. Surg. Gynecol. Obstet. 141, 387.

Blood lipid changes

Serum cholesterol, triglycerides, phospholipids and lipoprotein levels were studied by electrophoresis in 43 patients with multiple fractures. Ten healthy volunteers were used for control studies. The fat embolism syndrome was diagnosed in 8 of the 43 patients. The lipid values of all the patients were lower than the control values. A decrease in choles- terol and phospholipids was observed in the patients with fat embolism lasting for 4 days; these changes were not observed in the other patients. An early increase in the CQ lipoprotein fraction simultaneously with a decrease in the pre-a lipoprotein fraction was noted in those with fat embolism and not in the other patients. The lipid concentrations of plasma and serum did not change with filtration with 1,2,5, and 8~ Millipore filters. No differences were noted between the femoral and cubital vein samples.

Lepisto P. V. (1976) Post-traumatic blood lipid changes and fat embolism. J. Trauma 16, 52.

Plastic Surgery Free musculocutaneous flap This paper, from the Japanese team in Tokyo pioneer- ing microvascular surgery in plastic work, reports the transfer in one stage of a free musculocutaneous compound flap, including the gracilis muscle. Three clinical cases are described in detail and the possi- bilities of this technique are indicated.

Harii K., Ohmori K. and Sekiguchi J. (1976) The free musculocutaneous flap. Plast. Reconstr. Surg. 3, 294.

Reconstruction of articular cartilage This is the first published paper of total reconstruction of articular cartilage in a degenerated metacarpo- phalangeal joint, following suppurative arthritis in a