The diagnostic yield of blind percutaneous liver biopsy is improved when two or three specimens are taken during the procedure by redirecting the needle through a single entry-site, without exposing the patient to a greater risk of complications provided that standard precautions are taken. This study was designed to obtain further data on the safety of this procedure at King Edward VIII Hospital, Durban. During the period 1984-1990 (inclusive) a total of 2,646 biopsies were carried out: a single specimen was obtained in 834 patients, two specimens in 983 patients and three in 829 patients. Complications directly attributable to the procedure occurred in 24 patients who had one specimen, 20 who had two, and 19 who had three specimens taken during the biopsy. A single specimen had been obtained from three of the eight patients who had died, two specimens had been taken from another patient, and three specimens were obtained from the other four patients, i.e. patients in whom two or three specimens were taken did not have a higher incidence of pain, symptomatic hypotension, biliary peritonitis or death than those in whom one specimen was taken. Accordingly, when blind percutaneous needle biopsy of the liver is carried out, two specimens should be obtained by redirecting the needle through a single entry site as this improves the diagnostic yield without increasing complications. The morbidity and mortality associated with liver biopsy in this hospital is, however, high. Good technique, careful monitoring of patients after biopsy and prompt and aggressive resuscitation are essential if the mortality rate is to be reduced.

Ann R Coll Surg Engl 2008; 90: 488-491 488Carpal injuries are common presentations to emergency departments, general practitioners and orthopaedic clinics. The scaphoid bone is the most commonly injured of the carpal bones accounting for 50-80% of carpal injuries and predominantly occurs in young. healthy individuals. 1,2Scaphoid fractures are the most problematic to diagnose in a clinical setting because it can take up to 6 weeks for scaphoid fractures to become conclusive on plain X-ray films. It is estimated that up to 40% of scaphoid fractures are missed at first presentation. 3,4 A recent metaanalysis of scaphoid fractures calculated that the positive predictive value of clinical examination (those who proved to be 'clinical scaphoid' warranted X-rays of scaphoid views who subsequently had scaphoid fracture) is in the range 13-69% with an average of 21%. 5This means that four out of five patients without a fracture will be unnecessarily immobilised before radiological diagnosis is confirmed. Patients and MethodsWe conducted a retrospective, chronological review of patients who attended an upper limb fracture clinic from January 2001 to October 2003 in a district general hospital. Patients with negative X-ray findings but positive clinical signs for scaphoid injury satisfied the criteria for CT. We defined clinical signs for a scaphoid injury as tenderness over the anatomical snuffbox, pain on axial loading of first metacarpal and tenderness over scaphoid tubercle in the presence of normal plain films and included patients whose plain X-rays proved inconclusive.Patients with clinical indications of scaphoid fracture but negative plain films had their wrists immobilised in a scaphoid cast in the accident unit while awaiting a hand clinic appointment.CT scans, where necessary, were carried out on the same day as review on the first presentation to the fracture

In this study, the use of computed tomography (CT) early in the management of suspected occult scaphoid fractures was evaluated. We retrospectively reviewed the notes and radiology of patients who had scaphoid CT scans over the preceding 3 years. Eighty-four patients that had CT scans within 14 days from injury were identified. Of the CT scans, 64% (n = 54) excluded a fracture and these patients were promptly mobilized. No patients returned with any complications from this management. Overall, 36% of CT scans were abnormal (n = 30), 7% revealed occult scaphoid fractures, 18% revealed occult carpal fractures of the triquetrum, capitate, and lunate, respectively, and 5% revealed distal radius fractures. All patients diagnosed with fractures were successfully managed with plaster immobilization and there was one case of complex regional pain syndrome. Early CT alters therapeutic decision making in suspected occult fractures preventing unnecessary immobilization in a working population without increase in cost.

Ultrasound scan of the shoulder is an accurate and reliable method of detecting full thickness RCTs. The one-stop clinic significantly shortened the interval between GP referral and definitive management.

We report seven patients (eight wrists) with osteoarthrosis of the wrist associated with an exostosis arising from the dorsal aspect of the scaphoid. We believe that the exostosis is secondary to impingement of the scaphoid on the radial styloid process and is a consequence rather than a cause of osteoarthrosis. Conservative management is advised.