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Twenty patients treated with a Herbert screw for scaphoid fractures (acute or non-union) were reviewed and X-rayed 5-10 years later to assess whether there were degenerative changes in the scapho-trapezial joint due to insertion of the screw. Six had some irregularity in the lateral part of that joint, three of which followed backing-out of the screw. Two others were described as showing irregularity all round the scaphoid but, apart from these, no radiological abnormalities were seen in the central or ulnar part of the scapho-trapezial joint, or on the proximal tip of the scaphoid.

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The aim of this study was to identify the number of accidents and types of injury related to the Supertram system in Sheffield. Data was collected prospectively over an 18 month period, commencing in April 1994, on all patients attending the Accident and Emergency department at the Royal Hallamshire Hospital whose injuries were related to the tram system. Ninety patients were included in the study, 54 males and 36 females with a median age of 39 years (range 16-82), representing approximately 0.13% of the patients attending the department during the study period. Forty one patients were cyclists, twenty three pedestrians, twelve were motorists or motorcyclists and fourteen sustained injuries due to ongoing construction work. Thirty one patients sustained fractures, most commonly involving the upper limb/shoulder girdle (63%), with cyclists suffering 83% of these serious upper limb injuries. Following assessment 38 patients were discharged, 29 patients were referred to fracture clinic, 12 were sent for physiotherapy and 11 admitted to hospital. Eight patients required a total of 13 operations during the study period. We have demonstrated a significant number of injuries in this study related to the tram system in Sheffield. Cyclists appear to be the group at highest risk, followed by pedestrians and motor vehicle users.

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The author describes experiences gained over 18 years of conducting a therapy group for chronically ill psychiatric patients that focuses on spiritual beliefs and values. The group is held in a day treatment center and is attended by both men and women, whose ages have ranged from 22 to 60 years. Staff concerns that discussion of religious and spiritual material would foster patients' delusional ideation or strengthen their defenses and be counterproductive to treatment or that patients could not tolerate diverse systems of beliefs have not been borne out. Such groups foster tolerance, self-awareness, and nonpathogenic therapeutic exploration of value systems. Group rules contributing to its success are tolerance of diversity, respect of others' beliefs, a ban on proselytizing, and open membership.

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The long-standing success of a Spiritual Beliefs and Values Group supports the potential value of discussing spiritual issues and challenges the assumption that religious concerns voiced by people with serious mental illness should be considered pathological.

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We have used the "S" Quattro Turbo to treat four neglected dorsal interphalangeal joint dislocations. At an average follow up period of 45 months, there was a mean increase in the range of movement of the PIP joints by 74 degrees and of the IP joint of the thumb or DIP joints by 45 degrees. We recommend this technique for treating dorsal dislocations of the interphalangeal joints of more than 3 weeks duration.

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Solitary benign peripheral-nerve tumours are rare and may be difficult to diagnose correctly. Surgical excision may increase the patient's symptoms and may not be necessary. We have reviewed the presentation, clinical findings and histology of 104 solitary tumours presenting at one centre between 1959 and 1990. Male patients predominated for both schwannoma and neurofibroma. There was considerable but variable delay before presentation; 94% of patients complained primarily of a mass and less than half had pain or paraesthesia. The correct diagnosis had been made in only a few cases before operation, and the incidence of neurological symptoms doubled after exploration. We emphasise the need for vigilance, accurate preoperative diagnosis, and careful surgery.

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The "S" Quattro has proved its value in the treatment of acute displaced comminuted intraarticular phalangeal fracture dislocations. We have used the system to treat five cases of chronic fracture-dislocation or subluxation of the PIP joint. At an average follow-up period of 16.4 months, there was a mean increase in the range of movement of the injured joint by 75 degrees. We recommend this technique for selected cases.

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Patients may present with pathology that is not directly related to their primary complaint. The possibility of the presence of an infecting agent may not be considered and precautions that should be taken may be inappropriately forsaken. A multispecialty study is being undertaken at the University of Zambia to assess the influence of the human immunodeficiency virus (HIV) on the presentation, treatment and outcome of surgical pathology. This study examines the HIV status of 100 patients presenting through the Accident Department with long bone fractures. Assessment using the World Health Organization (WHO) clinical staging system for HIV disease has been compared with the patient's response to the potential immunological challenge and HIV serological status. Thirty-two per cent of adults in the age range 16-55 years were seropositive for HIV but this rose to 50 per cent in those aged between 21 and 40 years. The majority of patients were male, but both sexes had similar patterns of serological status. All patients were in WHO stage 0, 1 or 2 but assessment with the WHO clinical criteria alone led to a high level of diagnostic inaccuracy. Clinical assessment of 18 patients suggested freedom from HIV influence but their serum was seropositive on ELISA testing. The absolute lymphocyte count was below 2000 cells/mm3 in patients found to be seropositive and with disease of clinical stage 1 or 2.

PIP: The specific effect of HIV on the presentation and progression of skeletal disease has yet to be fully determined. This paper reports findings from a long-term, multidisciplinary study being conducted at the University of Zambia to assess the influence of HIV on the presentation, treatment, and outcome of surgical pathology. Approximately 25% of Zambia's urban adult population is HIV-seropositive. The study assesses the magnitude of the HIV problem in injured patients and the discrepancy between clinical and hematological evidence of HIV disease. It specifically examines the HIV status of 100 patients presenting through the Accident Department with long bone fractures. Researchers compared assessment using the World Health Organization (WHO) clinical staging system for HIV disease to the patient's response to the potential immunological challenge and HIV serological status. 107 consecutive patients over the period April-August 1992 aged 16-55 years of median age 19 years with long bone fractures requiring inpatient treatment were studied prospectively. Children were excluded from study to permit specific assessment of the age group most exposed to sexually acquired HIV infection. 32% of adults aged 16-55 years and 50% of those aged 21-40 years were HIV-seropositive. The majority of patients were male, but both sexes had similar patterns of serological status. All patients were in WHO stage 0, 1, or 2, but assessment with the WHO clinical criteria alone led to an high level of diagnostic inaccuracy. Clinical assessment of 18 patients suggested freedom from HIV influence, but their serum was seropositive on testing with ELISA. The absolute lymphocyte count was below 2000 cells per cubic millimeter in patients found to be seropositive and with disease in clinical stage 1 or 2. The authors conclude that HIV infection is becoming more common and may be coincidental to the presenting pathology. Physicians and other concerned health personnel need to be aware of this phenomenon. Alterations in the indications for specific therapeutic regimens may need to be made as the results of further studies on the effects of HIV become available.

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The psychiatric literature suggests that religion and spiritual issues are significant and meaningful forces in the lives of patients with mental disorders, particularly when they confront suicide. Yet scales assessing suicidal risk almost entirely fail to consider religion and spirituality. The authors review a series of suicide rating scales to demonstrate this omission and suggest possible reasons for it. A definitive answer awaits research that addresses the question of why patients' religious and spiritual dimensions are neglected by psychiatric clinicians.

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The authors report on a case in which the shared belief system of patient and therapist acted as a resistance. Discussion focuses on analysis of this problem from clinical and religious viewpoints, and some technical suggestions on management of the resistance are offered.

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