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.

Functional absence of flexor digitorum superficialis to the little finger and absence of palmaris longus--is there a link?

We examined 150 men and 150 women aged 18-40 years to assess flexor digitorum superficialis function to the little finger and the incidence of palmaris longus absence. All patients had flexor digitorum superficialis function to the little finger assessed by standard and modified tests. The presence or absence of palmaris longus was assessed by clinical inspection. Following modified testing, ten subjects (14 hands) displayed absolute superficialis deficiency to the little finger. Forty-nine subjects had unilateral absence of palmaris longus (16%). This tendon was absent bilaterally in 26 subjects (9%). On combining the clinical findings, one subject had unilateral absence of flexor digitorum superficialis function to the little finger with contralateral absence of palmaris longus, and one subject had bilateral absence of flexor digitorium superficialis function with unilateral absence of palmaris longus. We conclude that there is no link between an absent little finger flexor digitorium superficialis and an absent palmaris longus.

Effects of the endothelin receptor antagonist Bosentan on ischaemia/reperfusion injury in rat skeletal muscle.

We examined the role of endothelin in ischaemia/reperfusion injury in skeletal muscle, using the endothelin receptor antagonist Bosentan. In the rat hindlimb tourniquet ischaemia model, one hindlimb was rendered ischaemic for 2 h at 36 degrees C, then blood flow was re-established for either 24 h to assess muscle survival or 1.5 h for a study of capillary perfusion. In the first set of rats, the gastrocnemius muscle was removed from the postischaemic limb and assessed for viability histochemically using the nitro blue tetrazolium stain. Tissue water content (a measure of oedema) and myeloperoxidase activity (a measure of neutrophil accumulation) were also assessed in the ischaemic muscle, the contralateral non-ischaemic muscle and the lungs. In the second set of rats, the hind limb was infused with India ink after 2-h ischaemia and 1.5-h reperfusion and the muscle was harvested, fixed and cleared. In control rats, muscle viability was 17+/-2% (S.E.M.). In rats treated with Bosentan (10 mg/kg, i.p.) 30 min before release of the tourniquet, muscle viability (48+/-7%) was significantly increased compared to the control group (P<0.01). Bosentan treatment had no significant effect on tissue water content or myeloperoxidase activity in the ischaemic muscle, the contralateral non-ischaemic muscle or the lung. Immunoreactive endothelin levels in serum increased to a peak at 90 min of reperfusion and returned to control levels by 24-h reperfusion. India ink studies demonstrated a significantly increased functional capillary density in postischaemic Bosentan-treated muscles compared with postischaemic control muscles (P<0.05). These results suggest that endothelin plays an important role in the necrosis which results from a period of ischaemia and reperfusion in skeletal muscle, by mediating a decrease in postischaemic microvascular perfusion.

Atlantoaxial subluxation after otoplasty.

A case of iatrogenic atlantoaxial subluxation after bilateral otoplasty is presented. Cineradiography was required for definitive diagnosis. Bed rest and Halter traction successfully resolved the condition. Great care is required while turning the head during skin preparation, draping, planning, and surgery, especially in young children. A high index of suspicion is necessary when a child develops torticollis after otoplasty.

Chondrodermatitis nodularis chronica helicis et antihelicis.

A retrospective study of 50 patients (25 male, 25 female) suffering from chondrodermatitis nodularis chronica is presented. There was equal distribution between male and female, with the nodule being situated on the helix in 36 cases (23 male, 13 female), and on the antihelix in 18 cases (4 male, 14 female). Four patients had bilateral lesions. All the patients complained of severe pain in the affected ear when they slept on it at night. Of the 54 ears in this study, 23 had undergone previous surgery for the complaint. These recurrences occurred when either skin alone, or a disproportionately large piece of skin relative to cartilage, was excised. A treatment technique is described involving minimal skin excision combined with extensive cartilage resection. There has been no recurrence following our technique and postoperative deformity has been minimal.

The deltoid muscle flap: anatomical studies and case reports.

Anatomical studies of the deltoid muscle were performed on 16 cadaver shoulders. The anatomy of the axillary nerve, the vascular pedicles, and the musculocutaneous perforators was assessed. These studies confirmed that part of the deltoid muscle can be used as a vascularised flap to cover defects of the shoulder while leaving some viable functioning muscle intact. We report the use of hemideltoid flaps to treat chronic radionecrotic ulcers involving the shoulders of two patients. In the first, the posterior part of the muscle was used as a local muscle flap. In the second, the anterior part of the muscle was raised with overlying skin to form a musculocutaneous flap. The flaps remained healed at one year follow-up. These soft tissue radionecrotic defects over the shoulder are an uncommon late complication of radiotherapy for breast cancer. Pedicled or free flaps are now recognised as the preferred methods of treatment.

Assessing blood loss in cleft lip and palate surgery.

A method of continuously assessing peroperative blood loss is presented. A calibrated trap which collects all the blood loss is placed in the suction tubing. Bipolar diathermy and suction maintain a bloodless wound. A test using 20 ml of fresh venous blood showed that approximately 5 ml remained clotted in the tubing and 15 ml entered the trap. The method is particularly applicable to cleft lip and palate surgery.