ankle jerks and vibration sense at the first metatarsophalangeal joint). Vibration perception threshold at the great toe was measured in 101 of the diabetic patients (23 with periosteal reaction) and was significantly higher in those with periosteal reactions (median 30 5 v 20 units, p<0O05). CommentPeriosteal reaction has been observed in diabetes' and in association with trophic ulcers2 and neuropathic joint disease.3 It was not, however, mentioned in a review of foot radiographs in 162 diabetic patients with gangrene.4 Formation of new bone at the metatarsal periosteum, perhaps resulting from previous fracture, has been reported in diabetes,' but its nature seems quite different from the pattern of periosteal changes described here.Periosteal reaction in an ulcerated foot is generally believed to indicate infection in or around the affected bone. We found metatarsal periosteal reactions in radiographs of asymptomatic diabetic feet without evidence of infection, fracture, or ulceration. The cause is unknown, but the association with raised vibration perception threshold suggests a common (perhaps vascular) aetiology. overall. It was lower for drivers (1-2%) and front seat passengers (2 4%) but significantly higher for rear seat passengers (8 2%) (X2=42-5; df= 1; p=<0-001).The table shows the consequences of ejection in terms of increased severity of injury and death. Being ejected was associated with a significantly greater incidence of severe or critical injury (X2 =51K1, p<0-0001) and a higher incidence of fatal injuries. Deaths were due to severe head injury (two), laceration of the aorta (one), and multiple fractures of long bones with severe contusion of the lung (one). The most important sites of injury in severely injured patients were the abdomen (five patients), chest (two), head (two), and spine (one).None of the ejected rear seat passengers were wearing a seat belt. Of the 834 occupants known to be wearing seat belts, only five were ejected (two front seat passengers and three drivers). We did not know whether the remaining 218 drivers and front seat passengers were wearing seat belts; six of them were ejected. Two small children travelling on the laps of front seat passengers were ejected. Ejection occurred most commonly in accidents at high speeds and those in which the vehicle rolled over. CommentOur data show that rear seat passengers have a higher risk of ejection. None of the ejected rear seat passengers were wearing seat belts. In the front seats five ofthe 20 ejected occupants (drivers and passengers) were known to be wearing seat belts. The rate of ejection was 0-6% for those known to be wearing seat belts and 7-3% for those known not to be wearing them. Clearly seat belts safeguard against ejection, and this is particularly relevant in the rear seat, an observation in keeping with the findings of Hobbs.'When ejection occurred the incidence of fatal injury was over twice that for the non-ejected group, a finding supported by other studies.'4 The difference between ejected and non-ejected pe...
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