Psychiatric assessment of patients with self-inflicted lacerations to the wrist and forearm admitted to a nonpsychiatric ward: the experience of a regional plastic surgery unit.

In 1984, the Department of Health (DoH) recommended that all patients with deliberate self-harm (DSH) must have a mental assessment before discharge. DSH patients, especially those with lacerations to wrist and forearm, are a regular source of admission to plastic surgery units. In Northern Ireland, the regional plastic surgery service is provided at the Ulster Hospital, which does not have an on-site psychiatric department. Consequently, it was often difficult to arrange a psychiatrist assessment for these patients on the ward even when the assessment was required urgently. The objective of this study was to develop and validate a protocol that would ensure that these patients were assessed and followed up for their mental health as recommended by the DoH. In the absence of clear guidelines from the DoH and utilising the existing arrangement between Accident and Emergency (A&E) and the psychiatric services, all referring A&E departments were instructed at the time of referring patients with DSH to wrist and forearm to arrange a psychiatric examination before transferring the patient to the plastic surgery unit. Data were collected retrospectively (August 2002-October 2002) and prospectively (November 2002-October 2003) and comprised demographic features, previous history of self-harm, conduct of the patient in A&E and the ward, length of stay in the hospital and various aspects of psychiatric assessment and follow-up. In total, 42 referrals were made during the period studied. The average age was 28 years with a male to female ratio of 2:1. The average hospital stay was two days. Despite difficulties, our practice was found effective in ensuring psychiatry assessment and follow-up without risking the patient's physical health. The study also highlighted the need for collaboration between plastic surgeons and psychiatrists to improve services in regards to DSH patients.

Island flap reconstruction of the web space in congenital incomplete syndactyly.

A number of techniques have been described for the correction of incomplete syndactyly, some of which may produce obvious dorsal scarring of the fingers or hand while others rely on the use of skin grafts. Many of the methods require complex planning. We present our experience of a new technique which simplifies the operative planning, allows a natural looking web space to be reconstructed with minimal dorsal scarring and should minimize the need for skin grafts. Seven patients (nine webs) who underwent correction of incomplete syndactyly were reviewed (follow-up range, 6-32 months). Only one patient early on in the series required a small skin graft to cover a residual defect, following which modifications to the flap design were made. All the web spaces healed without complication and at review there were good functional and aesthetic results.

Missed injuries in the acutely traumatised hand.

A prospective study of 500 consecutive patients referred from accident and emergency departments in Northern Ireland with acute hand injuries was performed to assess the incidence of missed injuries. An injury was 'missed' if a patient was receiving inappropriate treatment or returned due to persistent symptoms despite being examined, treated and discharged. There were 16 (3.2%) missed injuries. Seven involved tendon only, four were isolated nerve injuries and four were mixed tendon and nerve injuries. The remaining case was a ruptured ulnar collateral ligament of the thumb metacarpophalangeal joint. Thirteen injuries were open, with a glass laceration being the most common mechanism of injury. The time to detection of a missed injury was on average 11 days (range 1-62 days). Missed hand injuries in Northern Ireland are uncommon but do occur. A thorough clinical examination and accurate injury documentation remain fundamental in their prevention.

Upper root brachial plexus trauma; patient selection and reconstruction.

Injury to the brachial plexus is increasingly common and the initial management of these patients is usually focused on associated life threatening injuries. Appreciation of the management of the brachial plexus injury can greatly assist with subsequent reconstruction and thus we review our experience in this field. A total of nine patients who underwent upper root brachial plexus reconstruction over the period 1980-1998 were reviewed. Causes of injury included road traffic accidents (n=6), open injuries (n=2) and the remaining case was iatrogenic. All patients had cabled grafting of the plexus while one patient had neurotization of the plexus in addition to grafting. Sixty six percent (n=6/9) of patients had a good outcome with return of elbow flexion. Patients with an open injury to the plexus had a better prognosis than those who had a closed injury. Polytrauma patients and those with penetrating neck injuries should be assessed to exclude brachial plexus injury. Baseline assessment and early involvement of surgeons with an interest in this area will help select those patients who will benefit from brachial plexus reconstruction.

A 10-year review of high-pressure injection injuries to the hand.

High-pressure injection injuries to the hand are uncommon, but often result in poor outcome or even amputation. We report a review of the 28 cases treated surgically in our department over the last 10 years and have examined the factors leading to increased morbidity. The severity of these injuries was related to the nature of the injected material, involvement of the tendon sheath and proximal spread of the injected substance. All cases in which the digit was noted to be poorly perfused from the outset resulted in amputation. We conclude that early amputation should be considered in cases in which the affected digit is initially cool or poorly perfused.

A regional audit of hand and wrist injuries. A study of 4873 injuries.

This study reports the characteristics, causes and disposal of isolated injuries to the hand and wrist presenting to six accident and emergency departments over a period of 4 months. The rate of isolated injury to the hand or wrist was 6.6%. The male: female ratio was 2.2: 1, with the mean age for injury being 26.4 years in men and 29.2 years in women. The modal age group for injury was 21-25 years in men and 11-15 years in women. The right and left hand were injured almost equally. The dominant hand was more commonly injured although this was influenced by the cause of injury: 16.3% were caused by a fall; 15% by sport; and 7% were work/machinery related. 13.3% were referred to specialities for further treatment.

Early active mobilization after second stage flexor tendon grafts.

We assessed the results of nine two-stage tendon reconstructions. The tendon graft was the ipsilateral palmaris longus tendon inserted into a tunnel which had been previously created by a silicone spacer. Early active mobilization was commenced 48 hours after surgery according to a previously described protocol (Small et al, 1989). Using the grading system of Kleinert and Verdan (1983) the results were: one excellent, two good, five fair and one poor. Using the Buck-Gramcko et al (1976) grading system there were three excellent, two good, two satisfactory and two poor results. There were no cases of tendon graft rupture or dehiscence of the junction between tendon and graft.

The second dorsal metacarpal artery neurovascular island flap.

The clinical applications of the second dorsal metacarpal artery island flap are illustrated by selective case reports from a series of 12 consecutive cases carried out in this Unit. In five cases the flap was transferred as a neurovascular island flap for sensory resurfacing of the thumb. There were no failures and no donor site complications. The anatomy and clinical dissection of the flap are described.

Early active mobilisation following flexor tendon repair in zone 2.

In a prospective study, 114 patients with 138 zone 2 flexor tendon injuries were treated over a three-year period. Early active mobilisation of the injured fingers was commenced within 48 hours of surgery. 98 patients (86%) were reviewed at least six months after operation. Using the grading system recommended by the American Society for Surgery of the Hand, the active range of motion recovered was graded excellent or good in 77% of digits, fair in 14% and poor in 9%. Dehisence of the repair occurred in 11 digits (9.4%) and in these an immediate re-repair followed by a similar programme of early active mobilisation resulted in an excellent or good outcome in seven digits.

The first dorsal metacarpal artery neurovascular island flap.

A first dorsal metacarpal artery island flap from the index finger was used in 20 cases for reconstruction of defects in the hand. In six cases it was used as a neurovascular flap for sensory resurfacing of the thumb and in five cases for release of a contracted first web. One flap underwent necrosis and there was a complication in one donor site.

Experience with the tensor fasciae latae free flap.

Six cases of reconstruction using the tensor fasciae latae myocutaneous free flap are described and in three of these a neuro-sensory flap was used. Four cases involved a lower limb reconstruction, one an upper limb reconstruction and one an abdominal wall reconstruction. Reduction of the bulk of the flap by transection of the muscle between the superior and inferior branches of the vascular pedicle was performed in four cases. One case of partial failure occurred in the lower limb group.

A comparative study of the haemostatic properties and cardiovascular effects of adrenaline and ornipressin in children using enflurane anaesthesia.

In a randomized, double-blind trial, haemostatic and cardiovascular effects of ornipressin and adrenaline were compared in 30 children requiring surgery for "bat-ear" deformity. Mean total blood loss was 14.3 ml with ornipressin and 11.7 ml with adrenaline, this difference being insignificant. There was a significant and progressive reduction in mean heart rate in children who received ornipressin, from 134 to 116 bpm (P less than 0.05), and a significant rise from 127 to 134 bpm (P less than 0.05) with adrenaline. Mean systolic pressure was unaltered by ornipressin but was significantly increased from 97 to 105 mmHg (P less than 0.05) in children receiving adrenaline. Ornipressin is as effective a haemostatic agent as adrenaline and the rises in heart rate and systolic pressure associated with adrenaline, which are factors known to predispose to the onset of ventricular dysrhythmias, do not occur with ornipressin.

The use of continuous temperature monitoring in the post-operative management of microvascular cases.

Continuous temperature measurement and recording has been carried out on all microvascular cases performed in the Northern Ireland Plastic and Maxillo-facial Service since 1976. The method is described and illustrative temperature graphs are presented. It is felt to be a simple technique which allows early detection of vascular complications and enhances the safety of microvascular tissue transfer.

Patency rates in end to side anastomoses in the rabbit.

It is suggested that more widespread use of the end to side microvascular suturing technique should be made, especially in arteries. A simple experimental practice model in the rabbit is suggested. Patency rates comparable to end to end anastomosis can be achieved.

Simultaneous double toe transfer for severely disabled hands.

Two cases are presented in which a severely damaged hand was reconstructed by the simultaneous transfer of two toes using microvascular techniques. A two year evaluation of the functional result is made in both cases. Conventional reconstructive methods have little place in the reconstruction of these severe disabilities.