Experience of managing open fractures of the lower limb at a major trauma centre.

INTRODUCTION: In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network. METHODS: From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC. RESULTS: Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover. CONCLUSIONS: Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.

Extravasation injuries: a review.

Extravasation injuries are common emergencies in clinical practice. If they are not recognized and treated promptly, they can lead to deleterious functional and cosmetic outcomes. There is a vast range of agents involved in these injuries and marked paucity of evidence to support their specific management. Following an extensive literature review, we outline management principles for clinicians involved in the care of patients with extravasation injuries. Key parameters in deciding appropriate management plans include the volume/toxicity of the agent, the necrosis interval of the injury, patient-related factors, as well as the facilities and expertise available in the setting of individual cases of extravasation.

Rupture of flexor tendon following volar plate of distal radius fracture. Report of five cases.

We report three cases of complete rupture of the flexor pollicis longus (FPL) tendon, one case of complete rupture of the index and middle finger flexor digitorum profundus tendons and one case of rupture of the flexor digitorum profundus tendon to the index finger after placement of a volar plate for distal radius fracture. We review the literature and discuss the aetiology of tendon ruptures and techniques to prevent tendon attition.

[Cleft hand: a review of 33 cases and new ideas about classification]. / Les fentes médianes de la main: revue de 33 cas.

Cleft hand is an uncommon congenital malformation, which is defined as a deficiency of the central part of the hand. It is the result of the absence or altered development of the central rays. The aim of treatment is to optimise the function of the hand at a young age and to improve its aesthetics. A retrospective review of 33 cases is presented and, with reference to their treatment, ideas about the classifications of cleft hand are discussed. The various anomalies seen and the management for each type of cleft hand are presented.

Anatomical study to investigate the feasibility of pedicled nerve, free vessel gastrocnemius muscle transfer for restoration of biceps function.

A challenging problem is the patient with a total brachial plexus injury with nerve root avulsions. In these patients nerve repair is not possible and no local functioning muscles are available for transfer. Current techniques involve either nerve repair using donor nerves from the contralateral limb or free muscle transfer neurotized by intercostal nerves. The problem with both these techniques is that they are dependent on neural regeneration, which is imperfect. To overcome the problem we propose a technique of transferring a distant muscle whilst retaining its neural supply. Gastrocnemius is a strong muscle and one suitable for free tissue transfer. This study assessed the possibility of transferring gastrocnemius on its neural supply by determining the length of nerve available and whether it was possible to dissect the nerve to gastrocnemius from the main body of the sciatic nerve. We found that the latter was possible, and that the length of dissected nerve would allow transfer of the innervated muscle from the calf to the axilla.

The management of nasoseptal perforation.

The most recent comprehensive review of the literature on repair of nasoseptal perforations dates back to 1985, since then there have been developments in the repair of very large perforations, previously thought to have been untreatable by surgical methods. The purpose of this article is to review the various methods which have been used to repair perforations, and their reported efficacies, with particular reference to the problem of large perforations. The article reviews the methods in use for providing mucosal cover for perforations; the options for a supporting layer; and the more recent solutions to mending perforations greater than 4 cm diameter. In conclusion, nasoseptal perforations of up to 4 cm diameter have been reported to be closed reliably with bilateral mucoperichondrial flaps and a connective tissue autograft. However, for larger perforations the only methods successfully used have been a three stage, composite graft and intranasal tissue expanders.