Clinician expectation and anatomical studies suggest that the distribution of sensory dysfunction in carpal tunnel syndrome (CTS) should be confined to the thumb, index, middle and half of the ring fingers. We mapped the distribution of disturbance to evaluate the accuracy of these assumptions.

We evaluated 64 wrists in 64 patients with nerve conduction study confirmed CTS. Each patient filled out a Katz hand diagram and we collated the distribution of pain and non-painful (tingling, numbness & decreased sensation) sensory disturbance. Frequency of reporting was analysed; dividing symptoms into thenar and hypo-thenar eminence, distal palm, each digit, posterior hand and forearm.

Non-painful sensory disturbance occurred in all patients. The index finger was the most common location (94%) followed by the middle finger (91%), the distal palm (84%), the ring finger (72%), the thumb (69%), the thenar eminence (63%), the little finger (39%), the dorsal hand (31%), the hypothenar eminence (25%) and the forearm (13%).

Pain was less common, reported in 59% of cases. Pain occurred most frequently over the wrist crease (33%) followed by thenar eminence (27%), the forearm (20%), the middle finger (23%), the index finger (22%), the ring finger (19%), the distal palm (16%), the thumb (14%), the dorsal hand (11%), the little finger (11%) and least frequently the hypothenar eminence (6%)

In CTS sensory disturbance occurs most frequently in the median nerve distribution; however it occurs almost as often elsewhere. An atypical distribution of symptoms should not discourage diagnosis of CTS.

Introduction: Elevated plasma elastase levels have been reported following major trauma and isolated femoral fracture. Reamed femoral nailing has been shown to further increase plasma elastase levels. The aim of this study was to investigate neutrophil (PMN) priming for degranulation following major trauma and isolated long-bone pelvis fracture by assessing the ability of PMN to release elastase in-vitro in response to phorbol myristate acetate (PMA) an analogue of dia-cylglycerol (DAG) a component of the “second messenger” system.

Methods: 11 major trauma (ISS≥18) patients and 18 patients with isolated long-bone/pelvis fracture, were consented to enter the study. Patients in the isolated fracture group were further stratified depending upon the type of fracture stabilization they underwent [reamed nail (n=12), Ex-Fix (n=6)]. Blood samples were obtained on admission, at 24 hours post injury, at day 3 and day 5. 11 healthy volunteers were used as controls. PMN were isolated by dextran sedimentation and ficoll-hypaque density gradient centrifugation. The ability of PMN to degranulate was assessed by an elastase substrate assay.

Results: A significant increase in the capacity of PMN to release elastase in response to a PMA stimulus was seen in major trauma patients on admission as compared with healthy volunteers. However in patients with isolated long-bone/pelvis fracture, there was no difference in levels of elastase release. Further no difference in the ability of PMN to release elastase was seen between the reamed nail and Ex-Fix groups.

Conclusions: In conclusion we show that PMN are primed for increased degranulation (elastase release) following major trauma but not following isolated long-bone/pelvis fracture. These primed PMN are capable of increased tissue damage following major trauma thus increasing the risk of development of multiple organ failure.

Aims: Neutrophil (PMN) dysfunction is implicated in both acute respiratory distress syndrome (ARDS) and sepsis. We aimed to determine the PMN response following isolated long-bone/pelvic fracture by investigating temporal changes in PMN migration and surface receptor expression (CXCR1, PECAM- 1, & CD18/ CD11b) following injury. Methods: Of the 20 patients consented to enter the study, 14 underwent reamed nailing/ORIF within 24 hours, and 6 were treated with an Ex-Fix or conservatively. 11 normal volunteers (NLV) were used as controls. Blood samples were obtained within 2 hours of admission, at 24 hours, at day 3 and day 5. PMN were isolated and the number of PMN migrating across porous collagen IV coated tissue culture inserts, in response to IL-8 were quantitated by myeloperoxidase activity. PMN surface receptor expression was assessed by whole blood FACScan analysis. Results: Signiþcantly greater numbers of fracture patient PMN migrated on admission as compared with NLV. In the Ex-Fix group the numbers migrating declined steadily and showed a hypo-response on day 5. In the reamed nailing group there was a further elevation in the PMN numbers migrating post-operatively. CXCR1 & CD18 expression was signiþcantly increased on admission. PECAM-1 was signiþcantly down-regulated on admission.

Conclusions: Following isolated long-bone/pelvic fracture PMN are primed for increased migration in response to IL-8. This is associated with up-regulation of CXCR1 and CD18, and down-regulation of PECAM-1. Treatment by reamed nailing and ORIF confers a Ç second hit È manifest as a further increase in IL-8 mediated PMN migration.

To promote cultural awareness and acceptance of clinical governance by developing a simple, reproducible model for reporting critical incidents and near misses within our department.

An A4 sized departmental proforma was developed to parallel the Trust’s official adverse incident register. Prospective reporting of adverse events using the proforma was encouraged between August 2000 and June 2001. Incidents were discussed in an anonymised and a blame-free setting, at the monthly multidisciplinary clinical governance meeting and appropriate action taken.

In the 6 months prior to commencing this study only 4 adverse events were reported with no discernible action taken. Following the introduction of the proforma 61 critical incidents and near misses were reported in the period August 2000 to June 2001. As a result of effective reporting of adverse events we have developed a number of protocols to improve patient care.

A simple model for reporting critical incidents and near misses has been established. This has fostered a cultural change within the department and all members of staff feel more comfortable with reporting such incidents. The process is seen as educational and an important part of continuing professional and departmental development. Protocols and changes in organisational practice have been developed to reduce and prevent the occurrence of adverse events and offer our patients continuous improvement in care.