A snake in the clinical grass: late compartment syndrome in a child bitten by an adder.

Snakebite envenomation is an uncommon condition in the UK, but requires vigilance with regard to both the systemic effects of the venom and the locoregional impact on the soft tissues. We describe a case requiring delayed fasciotomies for closed compartment syndrome of the leg and thigh, and discuss in detail the controversies surrounding decompression in such a case. Adder bites are uncommon in the UK, but can result in envenomation of varying severity. Apart from the numerous possible systemic effects that require attention, there are local effects that, very rarely, can be limb threatening. Of these, elevated limb compartment pressures are of paramount importance, and recognition of closed compartment ischaemia is vital if the limb is to be saved by surgical decompression. Guidelines on threshold compartment pressures and fasciotomies are indistinct regarding snakebite, with diagnostic emphasis still placed on clinical signs and symptoms. In the paediatric setting, measurement of compartment pressures is a valuable adjunct to clinical suspicion in the diagnosis of acute compartment syndrome secondary to snakebite.

Aggressive limb salvage using tibio-pedal bypass grafting with free tissue transfer in a diabetic patient.

A 63-year-old man presented with intermittent claudication, diabetes, and an ischaemic heel ulcer. After control of infection, the os calcis was left exposed. An aggressive combined infra-inguinal revascularization and reconstruction procedure involving free-tissue transfer resulted in rapid wound healing with independent walking by day 26. Recent improvements in surgical techniques mean that this approach should be considered in selected patients.

Injuries to the nail bed in childhood.

Many fingertip injuries in childhood involve the nail bed. Deformities of the nail are a frequent result of failure to repair the nail bed at the time of injury. Secondary correction of nail deformities seldom achieves good results. We present the results of our experience in the management of 19 children with 22 injuries involving the nail bed. All achieved normal nail growth and the overall result of the repair was good in 91%. Complications were few and parental satisfaction with the management was high. Every effort should be made to perform a meticulous primary repair of all nail bed injuries.

Fracture of the radial forearm osteocutaneous donor site.

Since the introduction of the osteocutaneous radial forearm flap in 1983, fractures of the radius have been reported to occur in approximately 30% of cases. Fracture of the donor forearm has been the cause of the most significant morbidity, and the difficulty in management of these fractures has been reported. We report our experience in managing three fractures involving the donor forearm. Optimum results can be achieved by early stabilization with external fixation and vascularized bone grafting. Excessive resection of the radius should be avoided and alternative sources of vascularized bone used to avoid mutilation of the forearm.

Aggressive pilomatricoma in childhood.

Pilomatricoma (calcifying epithelioma) is a benign tumor of the hair matrix cells that presents most frequently in childhood. Most are benign and slow growing and do not recur after excision. A small number of aggressive or malignant variants have been reported that recur if not widely excised. We report on an aggressive variant occurring in a 4-year-old boy and advise caution in treating cutaneous "cysts."

Closure of the second toe transfer donor site without disruption of the deep transverse metatarsal ligament.

The second metatarsal is routinely excised to facilitate closure of the defect created by the harvest of a second toe transfer. However, if the deep transverse metatarsal ligament is not disrupted by the harvest, it seems unnecessarily destructive to remove the metatarsal. A small arterialized venous flap provides a logical solution to the problem of wound closure in this circumstance. This paper describes such a reconstruction, discusses the reasons for its selection and the long term outcome, which has been very satisfactory.

An audit of peripheral nerve blocks for hand surgery.

A prospective audit of 140 median, radial and ulnar blocks, given for 70 hand operations is described. The surgery was completed successfully in every patient. A further injection of local anaesthetic was required in 13 operations. Four patients experienced severe tourniquet pain. The results of the audit have shown that if a careful technique is used, a wide range of minor hand operations can be performed under regional nerve block.