Preoperative management of the amputated limb.

Little literature exists on storage and preparation of an amputated limb prior to transfer to a reconstructive plastic surgical unit for possible macroreplantation. This paper describes practical measures used to prolong ischaemia time allowing macroreplantation, tissue harvesting, or fashioning of a useful stump. A simple protocol is used to summarise these points.

Free ulnar artery forearm flap: a modification.

We describe a modification of the free ulnar artery forearm flap that has the benefit of the anastomosis of large-calibre vessels and the reassurance of a reconstructed ulnar artery for perfusion of the donor hand.

A cheap, disposable external fixator for comminuted phalangeal fractures.

Reduction of a severely comminuted fracture of a long bone in the hand can be difficult to hold. An external fixator can be the best method of maintaining satisfactory reduction in such fractures. A small, disposable external fixator is described, made from a syringe barrel and K-wires. It allows accurate reduction with minimal soft tissue trauma and is easy to construct and apply. It allows early mobilization of the digit and is inexpensive.

Use of a vertical rectus abdominis myocutaneous flap in bilateral groin dissection for recurrent carcinoma of the penis.

We present a 42-year-old man requiring bilateral groin dissection for recurrent squamous cell carcinoma of the penis. Tissue cover was obtained using a pedicled vertical rectus abdominis myocutaneous flap. This case is made interesting by the use of a unilateral flap to cover a large bilateral lower abdominal tissue defect, enabling minimal weakening of the abdominal wall, primary skin closure, and allowing early mobilization and hospital discharge.

The neuroplastic phenomenon: a physiologic link between chronic pain and learning.

Recent advances in the understanding of how the mind works is the result of painstaking research which has isolated tiny regions of the spinal cord and brain, and singular chemical pathways or responses to sole neurotransmitters. The true nature of the central nervous system has eluded investigators because of its fully integrated, constantly changing structure and a symphony of chemical mediators. Each sensation, thought, feeling, movement and social interaction changes the structure and function of the brain. The mere presence of another living organism can have profound effects on the mind and body through imperceptible olfactory stimuli. Neuroplasticity is a general term referring to the ability of neurons to alter their structure and function in response to internal and external stimuli. Although differences occur with aging, this is a lifelong process. Physical and chemical neuroplastic changes occur with learning, memory and chronic pain. Evidence presented supports the notion that chronic pain is a maladaptive learned phenomenon. Further evidence supports that if severe pain is allowed to persist for more than 24 hours, the neuroplastic changes associated with the development of incurable chronic pain syndromes begin to take place. Even after chronic pain is well established, new thought and behavior patterns can be learned, allowing sufferers to restore more adaptive physiologic, cognitive and behavioral patterns.

Women and heart attacks: prevention, diagnosis, and care.

Despite being viewed as a male health problem, more women die from heart disease than men. The literature and preliminary research data reviewed clearly support that gender differences exist. The higher prevalence of myocardial infarction in older women and those with other known risk factors suggests the etiology, pathophysiology, and treatment is the same as for men. Differences in socioeconomic status, psychosocial profiles, presenting symptoms, disease progression, and a poorer response to treatment suggests that myocardial infarction in women is not fully understood. Women need to know they are at risk and not delay seeking treatment for subtle but important symptoms. Assessment strategies that take into account the woman's body, personal profile, and the female pattern of variant angina, non-Q wave, nonocclusive infarction are reviewed. Considering the literature that links social support with survival, mobilizing support to help the women direct energies to her own recovery becomes a necessary intervention. Implications to health teaching, diagnostic testing, diagnosis, referral, and the effective management of women with myocardial infarction are delineated.

The risk from radiation exposure during operative X-ray screening in hand surgery.

In response to legislation concerning the use of ionizing radiation, and to a case in which a patient developed multiple skin malignancies as a result of over-exposure to ionizing radiation, we set up an investigation to attempt to quantify the radiation dosage to which theatre personnel are exposed during X-ray fluoroscopy (screening) in hand surgery. It was found that the risk was small if sensible precautions were taken, but increased significantly if they were ignored. From these results specific measures are outlined which, when implemented, reduce the dose of scattered radiation to which theatre personnel and patients are subjected during screening in hand surgery.

The distally-based brachioradialis muscle flap.

We describe the brachioradialis muscle flap based distally on the radial artery. It is quickly raised and provides excellent cover for soft tissue defects of the hand. In the two clinical cases the brachioradialis tendon has also been used for extensor tendon reconstruction.

Management of symptomatic gallstones in the elderly.

In a study of 544 patients with symptomatic gallstones 158 subjects were aged greater than 70 years. Elderly patients had a significantly higher incidence of emergency presentation, jaundice, cholangitis, ductal stones, biliary drainage procedures, and acute complications requiring urgent or emergency surgery (P less than 0.001); they had more than twice the incidence of postoperative complications in comparison with patients aged less than 70 years. There was an increased perioperative mortality in the elderly (1.3 per cent after cholecystectomy and 2.9 per cent after bile duct exploration, P = 0.039). Conservative treatment in 11 per cent of elderly patients resulted in no mortality due to gallstones, but 3 of 17 patients had recurrent biliary symptoms. It was estimated that 38 per cent of the bile duct explorations in the elderly might have been avoided by referral for endoscopic sphincterotomy, but surgical treatment of gallstones in the district general hospital is relatively safe and specialist referral should be considered only in the relatively small number of 'high risk' cases.