Letters to the Editor 671

would like to respond to several of their comments.First, the reviewers emphasise that in contrast toour opinion, their case suggests that self-inflictedabdominal stab wounds (ASW) can be lethal andcan injure the heart. Our conclusion based on alimited series of 23 cases has been that self-inflicted ASW in suicidal patients can induce sig-nificant although probably non-lethal abdominaland retroperitoneal injuries. We did not concludeor imply that lethality and cardiac injuries areimpossible in these settings, especially given thethoracoabdominal location of many of the wounds.Thus, the case presented by the reviewers com-plements rather than contradicts our findings.Furthermore, although the newly presented caseenriches our data, our original conclusion that thelikelihood of fatality and intrathoracic involve-ment is low, remains valid.

Second, the authors speculate that the concen-tration of self-inflicted ASW in the upper abdomenmay be due to the perpetrator’s intent to avoidanatomic obstacles like ribs and thus to seek accessto the heart via the abdominal cavity. We believethat it is very unlikely that the average suicidalpatient would have the anatomic knowledge andsophistication to pursue such an approach.

Third, we agree with the reviewers that onepossible explanation to the lack of cardiac injuriesin our patients could be the clinical rather thanforensic nature of our report, i.e., patients withmajor cardiac injuries are pronounced dead at thescene and are transported directly to the medicalexaminer rather than to the hospital.

References

1. Abdullah F, Neuberg A, Rabinovici R. Self-inflicted abdominalstab wounds. Injury 2003;34:35.

Reuven Rabinovici*Yale University School of Medicine,

New Haven, CT, USA

Fizan AbdullahJohns Hopkins Medical center,

Baltimore, MD, USA

*Corresponding author. Tel.: +1 203 785 2572;fax: +1 203 785 3950

E-mail address: reuven.rabinovici@yale.edu

10 January 2006

doi:10.1016/j.injury.2006.02.011

LETTER TO THE EDITOR

Comment on: ‘‘A novel method of applying a split

plaster cast’’ by Belthur MV, Jones S, FernandesJA [Injury 2005;36:1135—7]

Dear Sir,

We read with interest the above article and wouldlike to debate a few aspects of the method. As weunderstand the aim of this new method is to split aplaster cast safely and to accommodate theincreased intracompartmental pressure.2

Firstly we would like to ask the authors how‘moulding of a fracture reduction can be achievedand maintained’ by this method of cast applicationin the presence of their device. We suspect the‘novel device’ would obstruct/prevent mouldingof a plaster cast. One needs to know how flexibleor rigid is this device before application. Alsowith the two vertical pillars of the plastic cuttingtrack (Diagram 1 in the original article), how canone apply a well conforming plaster cast. In anycross-section of the limb the device is bound toleave two empty triangles on each side of thedevice depending on the height of the plastictrack.

After a closed manipulation of the fracture (hav-ing split the cast over the novel plastic cuttingdevice) how do the authors recommend removingthe device? Would they advise lifting the device outor sliding from above or below, as we predict sometechnical difficulties while doing this.

Though we agree that plaster back slabs do notprovide adequate stability, we fail to understandhow they cannot accommodate increased swelling.As we know that a simple longitudinal split all alongthe bandaged limb where the ‘near encircling’ backslab4 is open would give better release to accom-modate the swelling.

We think that cutting a ‘wet plaster’ with thesaw is not recommended for logical reasons as aplaster cutting saw can effectively be used only ona ‘dry plaster’. For obvious reasons attempts atsplitting a wet cast will cause distress to thepatient and difficulty to the surgeon.3 In factfrom our personal experience we suggest that ifthe limb is well padded a wet plaster cast canbe very easily split using a new blade by hand. Asingle clean stroke without undue pressure doesthe job.

Lastly the interesting aspect of note in the articleby Ansari et al.1 was that the incidence of injuriesfrom plaster cutting saw was only 0.72% and in factthe identified cause was due to an inexperienced,ill-trained user or a blunt saw blade.

672 Letters to the Editor

To conclude this debate we think that this ‘noveldevice’ may be safe and inexpensive but not neces-sarily quick and convenient. In fact it may risk thefracture reduction due to problems explainedabove.

References

1. Ansari. et al. Oscillating saw injuries during removal of plaster.Eur J Emerg Med 1998;5(1):37—9.

2. Belthur. et al. A novel method of applying a split cast. Injury2005;36:1135—7.

3. Katz. et al. Anxiety reaction in children during removal of theirplaster cast with a saw. J Bone Joint Surg Br 2001;83(3):388—90.

4. Spain D. Casting acute fractures. Part 6. Aust Fam Phys2001;30(3):261—4.

Avinash Joshi*Umesh Nagare

Gloucester Royal Hospital, Gloucester,United Kingdom

Satish KaleCooper Hospital, Mumbai, India

*Correspondence address: 5, Marlborough Flats,Eugene Street, Bristol BS2 8EY, United Kingdom.

Tel.: +44 7899080055E-mail address: nashjoshi@hotmail.com

(A. Joshi)

doi:10.1016/j.injury.2006.02.020

LETTER TO THE EDITOR

‘‘Painless reduction of anterior shoulder dis-location by Kocher’s method’’ by Chitgopkarand Khan

We read with interest the article ‘‘painless reduc-tion of anterior shoulder dislocation by Kocher’smethod’’ by Chitgopkar and Khan.1 However wedisagree with the authors’ claim that the originalarticle of Theodore Kocher was misinterpreted.2 Infact, the technique described by Kocher was inten-tionally modified by many authors including Gregg,McRae, McLatchie, and Connolly who recommendedthe use of traction during reduction. Nevertheless,it is very important to notice that Kocher’s originaltechnique is described thoroughly in one of the mostwidely accepted and readily available books in

DOI of original article: 10.1016/j.injury.2006.02.021.

orthopaedic and emergency departments: ‘‘Apley’ssystem of orthopaedics and fractures’’. The bookstates clearly that Kocher’s technique does notinvolve the application of traction.3 On balance,we believe that traction is being used in order torelieve muscle tension according to recommenda-tions by many other independent authors andnot as a result of a misinterpretation of Kocher’stechnique.

On the other hand, we support the authors’claim that initiating movement by patients shouldbe encouraged. Our previous experience between1997 and 2002 in Techreen Teaching Hospital inSyria reinforces this claim. The majority ofpatients with anterior shoulder dislocations wereable to initiate adduction, external rotation andflexion movements described in Kocher’s techni-que, eventually establishing successful reductionwith little help from the supervising doctor. Therole of doctors in our practice used to be support,assurance and gentle guidance of the humeralhead inferiorly towards the glenoid at the end offlexion — the final part of Kocher’s manoeuvre — ifneeded.

References

1. Chitgopkar SD, Khan M. Painless reduction of anterior shoulderdislocation by Kocher’s method. Injury 2005;36(10):1182—4.

2. Kocher T. Eine neue Reductionsmethode fur Schulterverren-kung. Berl Klin Wochenschr 1870;9:101—5.

3. Solomon L, Warwick DJ, Nayagam S. Injuries of the shoulder,upper arm and elbow. In: Apley’s system of orthopaedics andfractures. 8th ed., 2001, p. 587 [chapter 24].

A. AI Khayer*Spinal Unit, Queens Medical Centre,

University Hospital NHS Trust,Nottingham NG7 2UH, United Kingdom

I. SedkiT&Q St. Richard’s Hospital, United Kingdom

K. AdraT&Q Techreen Teaching Hospital, Syria

*Corresponding author.Present address: 18 Flamingo Court,Castle Marina, Nottingham NG71GJ,

United Kingdom.Tel: +44 115 924 9924x1711

E-mail address: hamadafirst@yahoo.com(A. AI Khayer)

doi:10.1016/j.injury.2006.02.022