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.

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.

Complications of long operations: a prospective study of morbidity associated with prolonged operative time (> 6 h).

Reconstructive surgical procedures often take a long time to perform and duration of surgery is frequently cited as a major risk factor for postoperative complications. Whether operative time is an independent risk factor is unknown, as patients undergoing long operations may have numerous other risk factors. From September 1996 to September 1997, we prospectively assessed those patients undergoing reconstructive surgery lasting 6 h or more. A total of 62 patients were studied and they were grouped into three categories: head and neck surgery (n = 23), breast reconstruction (n = 18) and upper and lower limb surgery (n = 21). Postoperative complications were recorded and the results of each group compared. Each of the three patient categories had a similar mean duration of surgery but there were large differences in postoperative morbidity between the three groups, e.g. within the head and neck group postoperative respiratory and wound complications occurred in 43% and 26% of patients, respectively. In the limb surgery group, however, only 5% of patients had respiratory complications and 5% had wound complications. Despite having similar duration of surgery the differences in postoperative complications between the three groups suggest that duration of surgery alone is not a major determinant of postoperative morbidity and that the type of surgery performed and the patient's general health are more important predictors of outcome.

Firework related injury and legislation: the epidemiology of firework injuries and the effect of legislation in Northern Ireland.

The efficacy of legislation in reducing firework associated injuries is uncertain as is the nature of the problem within the United Kingdom (UK). In September 1996 the legislation governing firework sale in Northern Ireland was relaxed thus equalling that of the rest of the UK. For the 2 years following the change in legislation we prospectively assessed those patients who were admitted with a firework injury over the Halloween period. We then compared these results with retrospective data for the 3 years prior to the change in firework law. In the pre-legislation series the mean number of patients admitted annually was 0.38 per 100,000 while in the post-legislation series the mean was 0.43 per 100,000. Blast injury to the hand was the commonest injury accounting for 53% of cases in both series. Burn injuries were the second commonest form of injury comprising 30% of all admissions. Of those admitted with a hand injury 47% had at least one finger terminalised and nearly half of those patients admitted with burns (44%) required skin grafting. We conclude that early evidence suggests that liberalisation of the law on firework sale has not resulted in a significant increase in firework related injuries requiring hospital admission.

Drug induced blistering and the plastic surgeon: a case of amitriptyline induced skin necrosis.

We report a case of patchy full thickness skin necrosis following drug overdose with amitriptyline, that required excision and split skin grafting. To our knowledge this is the first report of amitriptyline induced skin necrosis that can be definitively attributed to this drug. The implications of drug related skin necrosis for the surgeon are discussed.

Renal dysfunction in obstructive jaundice.

The association between renal dysfunction and obstructive jaundice is well established. Despite a substantial number of clinical reviews and prospective studies, the exact incidence and extent of the problem has not been determined accurately. Various pathogenic mechanisms and therapeutic strategies have been proposed but renal dysfunction remains a persistent problem in hepatobiliary practice. The intention of this review is to determine the current extent of the problem, outline the proposed pathophysiological mechanisms and assess the current therapeutic options.