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To The Editor: I am writing in response to "Pain: Friend or Foe?" (2001;83-A:1424-5), an Orthopaedic Forum article by Dr. Whitesides. As an Acute Pain Clinical Nurse Specialist, I took great exception to his blanket condemnation of acute pain services. As a trained orthopaedic nurse, I began my practice as an Acute Pain Nurse at Sandwell NHS Trust. The orthopaedic consultants within the Trust were confident in my ability to recognize the complications of orthopaedic surgery. However, the general surgeons, similarly to Dr. Whitesides, did not trust the clinical judgment of a pain specialist. After four years, I have gained their trust, through my recognition of complications and my alerting them to situations such as anastomosis rupture and peritonitis, in which the chief symptoms were a sudden increase in pain. The risky clinical situations that are described in the article seem to be attributed to an overzealous use of analgesia in "overtherapeutic" doses. The dosages of epidural analgesia were not stated, but if low-dose local anesthesia is used in combination with low-dose opioids, then a "mobilizing epidural" may be achieved. In this state of medication, the patient is able to move his or her limbs easily, and any decrease in motor function will facilitate the discontinuation of the epidural to allow for evaluation of a true clinical picture. However, for patients with a tibial fracture treated with surgery, a patient-controlled intravenous system of analgesia that utilizes morphine may be more appropriate, as the vasodilating effects of the local anesthetic could aggravate any compartment syndrome formation. The …

Residual morbidity from congenital dislocation of the hip is for the most part preventable. Prevention is possible, however, only by establishing the diagnosis early and undertaking treatment which leads to stable reduction and avoids complications. To attain these goals, hip examination whould be a routine part of all newborn care. When dislocation is found in a newborn and early treatment initiated, the anatomic abnormalities are minimal, the dislocation is rasily reduced, and the treatment is simple. When diagnosis and treatment are delayed, the soft-tissue and bony abnormalities become established and therapy becomes more complicated.

We have reported the results of a preliminary experimental study designed to determine if radioiodinated human serum albumin (RISA I131) can be used in a clinically applicable method to predict the degree of tissue loss soon after frostbite. The RISA was injected either immediately after the freezing injury or twenty-four hours after the injury. The pattern of daily counts permitted the accurate prediction of tissue loss forty-eight to ninety-six hours after the injection. The counts on the group of rabbits whose paws subsequently showed loss of tissue were higher than those which did not. The difference was statistically significant, but there was some overlap in the values of the two groups. The accuracy of predicting tissue loss based on the plateau count was 100 per cent for paws with counts above the mean for the groups with tissue loss. The predictability of tissue loss for each group as a whole was approximately 80 per cent when one standard deviation below the mean for loss was used as the determinant. This preliminary study would indicate that this method of predicting tissue loss soon after frostbite could be of use in the clinical evaluations of therapeutic measures and in the triage of casualties.

A total of 36 patients (42 hips) with frank congenital hip dislocation were studied. The initial clinical and x-ray signs were evaluated according to the age at which the patient was first seen and treatment started.

Determination of tissue damage soon after frostbite would permit an evaluation of treatment. We reported a preliminary study using 131I-RISA to determine tissue loss soon after frostbite. We now present further studies with 131I-RISA, 51Cr-tagged red blood cells and 24NaCl. Each isotope was evaluated in a separate group of New Zealand rabbits under the same test conditions. We have reported the freezing and counting methods. We graded tissue damage as tissue loss and no loss by dissection after 3 weeks. Tissue damage could be predicted with 85% accuracy with 131I-RISA. Values for no tissue loss differed significantly from tissue loss at the .05 level. We could not predict tissue loss with 51Cr-tagged red blood cells or 24NaCl. Mean counts of 51Cr and 24Na were increased in paws with tissue loss but the groups with and without tissue loss were not different at the .05 level. The findings with 51Cr-tagged red blood cells are compatible with an increased blood flow and capillary stasis soon after frostbite as suggested by others. The increased 24Na probably parallels the swelling of the paw without a predictable relationship to tissue damage. 131I-RISA permits prediction of tissue loss soon after frostbite. We believe 131I-RISA provides an index of capillary damage and that the severity of capillary damage correlates with the ultimate fate of the part.

A carbon black transference technique was used to determine the contact area in twenty-three dissected tibiotalar articulations, with the talus in neutral position and displaced one, two, four, and six millimeters laterally. The greatest reduction in contact area occurred during the initial one millimeter of lateral displacement, the average reduction being 42 per cent. With further lateral displacement of the talus the contact area was progressively reduced but the rate of change for each increment of shift was less marked.

A 20-year-old Negro man, with a history of febrile disease, was diagnosed to have noncaseating granulomatous inflammatory disease. He was placed on Prednisone therapy for several years. Subsequently, he was found to have osteocartilagenous separation of the lateral condyle of the right femur. This was preceded by symptoms of recurrent pain and swelling of the knee. The surgical treatment employed was anatomic repositioning of the osteocartilagenous fragment with an interposed corticocancellous graft. The postoperative management was non weight-bearing for a 6 months' period and a cast brace. The patient was symptom free at 20 months' follow-up.