1312

unacceptable to most old people and seldom

practicable in busy wards or in the community, mucheffort has been expended on the design of pressure-relieving mattresses that prevent sores without theneed to turn the patient. Flotation beds28 can do this,but are not portable and are unsuitable for emergencyuse. Moreover, they cannot be used for orthopaedicpatients (one of the groups most in need of pressurecare") and are disliked by most old people because oftheir instability. Air flotation beds are also

prohibitively expensive. 27Alternating pressure air mattresses (APAMs)

provide a more physiological approach. Like

repositioning, they aim to represent the naturalmethod of preventing pressure damage over bonyprominences-ie, by constantly changing the areas ofsupport, thereby allowing restoration of the bloodsupply and reactive hyperaemia and cell repair to takeplace. Large-celled APAMs have been shown incontrolled trials to prevent and heal pelvic and heelsores without repositioning29,3o and have the addedadvantage of providing a firm surface for nursing care.Unfortunately, ill-considered demands for cheapAPAMs in the past resulted in the production ofpoorly designed unreliable machines,31 but strongermodels are now available30 and the publication of aBritish Standard should ensure better performance infuture. The Pegasus bed3O is portable and easy to usein the community as well as in hospital, and evensimpler machines may be sufficient for most patients.Foolproof arrangements for distribution and servicingare essential.16 Only when every patient with a

suspected spinal cord injury, new stroke, or femoralneck fracture can be routinely admitted onto anAPAM and nursed on it-or provided with anequivalent manual method of pressure relief-

throughout the acute phase of his or her illness will webegin to see the end of pressure sores.1. Norton D, McLaren R, Exton-Smith AN. An investigation of geriatric

nursing problems in hospital. Edinburgh: Churchill Livingstone, 1975.2. Barbenel JC, Jordan MM, Nicol SM, Clark MO. Incidence of pressure

sores in the Greater Glasgow Health Board area. Lancet 1977; ii:548-50.

3. Warner U, Hall DJ. Pressure sores: a policy for prevention. Nursing Times1986; 82: 59-61.

4. Allman RM. Epidemiology of pressure sores in different populations.Decubitus 1989; 2: 30-33.

5. Blair SD, Wright DDI, Backhouse CM, Riddle E, McCollum CN.Sustained compression and healing of chronic venous ulcers. Br Med J1988; 297: 1159-61.

6. Ryan TJ. The management of leg ulcers. Oxford: Oxford UniversityPress, 1983.

7. Editorial. The TVS—has it achieved better patient care? Care Sci Pract1989; 7 (no 2): 30.

8. Livesley B. The prevention and management of pressure sores in Healthdistricts. King’s Fund Centre for Health Services Development: adocument produced by the Pressure Sore Study Group 1989. Availablefrom the Academic Unit for the Care of the Elderly, Charing CrossHospital, London.

9. Editorial. Pressure points. Decubitus 1990; 3: 10-11.10. Robertson JC. £100 000 damages for a pressure sore. Care Sci Pract

1987; 5 (no 3): 2.11. Versluysen M. How elderly patients with femoral neck fracture develop

pressure sores in hospital. Br Med J 1986; 292: 1311-13.12. Versluysen M. Pressure sores in an orthopaedic population: an

epidemiological survey. City and Hackney Health District, London:Nursing Research Papers 1983, no 1.

13. Strunk H, Osterbunk J. Pressure induced skin lesions in cardiac surgery.Care Sci Pract 1988; 6 (no 4): 113-15.

14. David J. The size of the problem of pressure sores. Care Sci Pract 1981; 1(no 1): 10-13.

15. Nyquist R, Hawthorn PJ. The prevalence of pressure sores within an areahealth authority. J Adv Nursing 1987; 12: 183-87.

16. Hibbs PJ. Pressure area care for the City and Hackney Health Authority.City and Hackney Health Authority, London, 1988.

17. Exton-Smith AN, Sherwin RW. The prevention of pressure sores—thesignificance of spontaneous bodily movement. Lancet 1961; ii: 1124-26.

18. Barrett E. A review of risk assessment methods. Care Sci Pract 1988; 6 (no2): 49-52.

19. Guttman L. The prevention and treatment of pressure sores. In: KenediRM, Cowden JM, Scales JT, eds. Bedsore biomechanics. London:Macmillan, 1976: 153-59.

20. Leung KH. Interface pressure: can blood pressure be the equation?Decubitus 1989; 2: 8.

21. Bader DL, Grant CA. Changes in transcutaneous oxygen tension as aresult of prolonged pressure at the sacrum. Clin Physics Physiol Meas1988; 9: 33-40.

22. Barton A, Barton M. The management and prevention of pressure sores.London: Faber and Faber, 1978.

23. Kaminski MV, Pinchcofsky-Devin R, Williams S. Nutritional

management of decubitus ulcers in the elderly. Decubitus 1989; 2:20-30.

24. Clark M, Rowland LB, Wood HA, Crow RA. Measurement of soft tissuethickness over the sacrum of elderly hospital patients using B-modeultrasound. Decubitus 1989; 2: 63.

25. Young JB. Aids to prevent pressure sores. Br Med J 1990; 300: 1002-04.26. Lowthian P. Pressure sore prevention. Nursing 1989; 3: 17-23.27. Bliss MR. Prevention and management of pressure sores. Update 1988;

36: 2258-68.28. Krouscop T, Williams R, Krebs M. The effectiveness of air flotation

beds. Care Sci Pract 1984; 4: 9-11.29. Bliss MR, McLaren R, Exton-Smith AN. Preventing pressure sores in

hospital: controlled trial of a large celled Ripple mattress. Br Med J1967; i: 394-97.

30. Exton-Smith AN, Overstall PW, Wedgewood J, Wallace G. Use of the’Air Wave System’ to prevent pressure sores in hospital. Lancet 1982; i:1288-90.

31. Bliss MR. The use of Ripple beds in hospitals. Hosp Health Serv Rev1979; 74: 190-93.

The underclass

The underclass, the hostile alternative society of thedispossessed and excluded, haunts modem Americaand is coming to haunt Britain too, as board andlodging houses, cardboard "Thatcher bungalows"under bridges, and proliferating beggars attest.’

Moreover, the British Government seems strangelyattracted to this brainchild of the American politicalscientist, Charles Murray. Murray has espoused thetopic, often in print; his latest book, The Pursuit ofHappiness, is not yet published but Kenneth Baker,Chairman of the Conservative Party, has seen a copy."Brilliant", he commented, when he deviated from hisprepared keynote speech before a small audience at theCentre for Policy Studies on May 9.3 Murray was alsospeaking at the conference.However, there is nothing new about the

underclass: awareness of a submerged, angry, andunbiddable society under the surface of their well-ordered cities is an old fear of the bourgeoisie, fed, inEurope, by memories of what happened during theFrench revolution. One of its greatest exponents wasZola, in his Rougon-Macquart novels. He contrivedthen to raise a great many of the issues which

sociologists are raising now, from social injustice togenetic determinism (this latter notion is presumablywhat appeals to Mr Baker).

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If we are sociologists addressing this phenomenonwe need to begin with definitions, as Mincy and hisco-workers lately tried to do.2 What is an underclass?Not simply the poor whom we have always with us.One measure would be to count the intergenerationalpoor who have never worked, whose parents havenever worked, and whose children have no prospect ofdoing so, "leading to a total lack of social mobility andthereby capturing at least part of what is meant by theterm ’class"’. That would apply to American innercities and pockets in Britain, but the growingunderclass in British cities represent the downwardlymobile-people from whom support and emergencyresources (housing, social security, long-term hospitalplaces) built up since Dickens described hisunderclass have been suddenly and ideologicallywithdrawn. Not all underclasses are the same. TheRoman underclass were the slaves who did all the

work, while the upper class were unemployed anddepended on handouts from patrons or the state-thereverse of our own situation.

Another index is behavioural-these people do notconform to the mores of the prosperous, among whom"it is generally expected that they will complete theireducation ... delay childbearing until they are able tosupport their offspring, and work" unless or until tooold or sick to do so. Underclasses displaydysfunctional behaviour-they do none of the above,they use or push drugs other than alcohol, and theycommit crime with alarming insouciance. Mincy’steam show an unease with this one which does themcredit- underclasses do indeed do these things, butthe actions and omissions are very much a mirror and

consequence of the nightmare in which they findthemselves. Drugs, used or pushed, are an escapehatch and crime likewise, since deprived of supportone must either beg or steal, and if the theft miscarriesone at least gets a roof over one’s head and three mealsa day courtesy of the prison service. It says much forthe thousands of teenage victims of our New Orderthat they so often stick to such crimes as prostitution,of which they themselves are the only victims.

The third measure is what American insurers call

redlining-the underclass has its neighbourhoods andif you live there you are of that class. Oddly enoughthese happen to be places where the weight of povertyand unpopular ethnicity also fall most heavily. With asensitivity unusual in social scientists coining a phrase,Mincy et al are clearly queasy about all thesedefinitions--chronic poverty, bad behaviour, living inghettoes. Nonetheless there is an underclass, define ithow you will. It is growing in America and it is

growing in Britain, according to the Institute ofEconomic Affairs, and we should be concernedbecause it "imposes costs on the rest of society". So itdoes. It always has done. There was a time whencompassion and public policy, although they never gotrid of an underclass, at least attempted, through suchactivities as the new deal and the welfare state, to do

something about it. It is the reversal of this consensuswhich is inflating, if not creating, our underclassestoday.

America did at least take one step forward when

people-power enforced the civil rights movement, butthe benefits have been limited; Britain is now reapingthe consequences of taking two, three, or more stepsback from the posture of more decent and humane

political attitudes and towards a policy which, in thewords of one member of the underclass, "doesn’t givea monkey’s". The emotion of the well-heeled towardsunderclasses is fear, often voiced as blame andarticulated in exhortation to uphold the family, obeythe law, be industrious, and make use of the

opportunities of the market. More appropriateemotions might be shame and indignation. Onecannot walk about in London-an exercise eschewed

by Prime Ministers-without a strong measure ofboth.

1. Murray C, et al. The emerging British under class. London: Institute ofEconomic Affairs, 1990.

2. Dean M. Christmas, the poor, and the development of a UK underclass.Lancet 1989; ii: 1536-37.

3. James O. Crime and the American mind. Independent May 21, 1990.4. Mincy RB, Sawhill IV, Wolf DA. The underclass: definition and

measurement. Science 1990; 248: 450-53.

LATE CONSEQUENCES OF SPRAINED ANKLE

Ankle injuries are among the commonest presentations inaccident departments; most patients have sustained injuriesto the ligaments that stabilise the ankle joint. Controlledstudies have shown that early mobilisation is the besttreatment for lateral ligament injuries,l,2 but a few patientshave distressing residual symptoms.3,4 There are manyreasons for such persistent complaints. Fractures may bemissed on the initial radiographs, but can usually bedetected later. Stress fractures may be seen in this way, but ifthere is any doubt a bone scan may be helpful.Osteochondral fractures of the dome of the talus are easilyoverlooked, especially if the bone fragment is small;occasionally computed or conventional tomography isuseful in delineating these lesions. Tendons (especiallyperoneal) may be ruptured or dislocated, and these injuriesmay be associated with tenosynovitis. Injuries to tendonsand ligaments are often associated with haemorrhage, rarelywith the later complication of myositis ossificans. All ankleinjuries, especially if pain persists, may be complicated byreflex sympathetic dystrophy. Surprisingly few patients areleft with either chronic instability of the ankle or

degenerative arthritis or both. Instability is commonly dueto injuries to the anterior talofibular ligament;5 variousingenious reconstructions, using all or part of the peroneousbrevis tendon, are usually effective in controlling this

instability. Symptomatic post-traumatic degenerativechanges of the ankle joint are managed conservatively. Mostsurgeons resort to arthrodesis rather than arthroplasty whensurgery is indicated, because artificial ankle joints have notproved successful in this condition.6

Several "impingement" syndromes have been described.Athletes’7 and footballers’8 ankle were described many yearsago, and are thought to be due to production of tractionspurs by chronic hyperplantar flexion strains of the anteriorjoint capsule. These symptoms respond well to surgical