A Rare Case of Bilateral Spaghetti Injuries in Children due to Assault by Mother and Analysis of Functional Outcome at Three Years.

Management of child abuse with flexor tendons, neurovascular injuries, and life-threatening conditions is challenging. It needs a multisectoral coordinated and synchronized team effort for successful outcomes. We present a case series of children abused by a parent with a sharp object. The children sustained multiple flexor tendon injuries, neurovascular injuries in upper limbs, and tracheal injury compromising respiration. We performed a tracheostomy to save a child and subsequently repaired numerous flexor tendons, nerves, and arteries. During follow-up, these children required secondary reconstruction (tenolysis, tendon lengthening, nerve reconstruction) for flexor contractures, stiffness, and sensory loss in distal forearms. We measured the range of movements and assessed the children's functional outcome using the Strickland score at 3-year follow-up. The range of movement and functional outcome was excellent in both children in our series. A timely performance of surgery, aided with efficient intensive care, therapy, and consistent posttraumatic psychosocial rehabilitation, produced excellent results in our series.

Distal transfers as a primary treatment in obstetric brachial plexus palsy: a series of 20 cases.

UNLABELLED: The purpose of this study was to examine the results of spinal accessory nerve to suprascapular nerve (with or without axillary nerve neurotization) and an Oberlin transfer as primary treatment in children with Narakas type I obstetric brachial plexus injuries, when parents refused to consent to conventional nerve trunk-/root-level reconstruction. A total of 20 children with poor shoulder abduction and no biceps antigravity function but with good hand function were treated with spinal accessory nerve to suprascapular nerve and an Oberlin transfer at a mean age of 5.8 months (SD 3.27; range 3-12.) All the patients were evaluated at a mean of 2.8 years (SD 0.8; range 1.5 to 3.8) post-operatively. Three patients were lost to follow-up. Of the remainder, 11 had grade 4+ power of elbow flexion and six patients had grade 4 power at 1 year follow-up; all had 4+ power of elbow flexion at final follow-up. At final follow-up the Mallet score was a mean of 15; (SD 4.22, range 9 to 20). Primary distal nerve transfers can give good outcomes in patients with obstetric brachial plexus injuries and may be an alternative to surgery on the nerve trunks LEVEL OF EVIDENCE: IV.

Treatment of radial dysplasia by a combination of distraction, radialisation and a bilobed flap - the results at 5-year follow-up.

Thirty-nine hands with radial dysplasia were prospectively treated between 1998 and 2005 by a combination of distraction, followed by radialisation, using bilobed flaps to redistribute the skin at the wrist. Correction of radial deviation and volar subluxation in 29 hands with an average follow-up of 6.5 years has been assessed. In 21 hands, the length and breadth of the ulna were measured in the corrected hands and compared to the contralateral normal ulna for length and contralateral normal radii for breadth at 5-year follow-up. The average length of the ulna was 72%, which was notably better than that reported in earlier series.

A microneurovascular study of the great saphenous vein in man and the possible implications for survival of venous flaps.

Cross sections (n = 372) of human long saphenous veins (n = 12) from unsalvageable fresh above knee amputation specimens brought to a trauma centre in a large metropolitan hospital were studied. The veins were harvested longitudinally with an amount of soft tissue equivalent to the diameter of the vein and sectioned at intervals of 5 mm. The sections were stained with haematoxylin and eosin for general study, Van Gieson for better delineation of different coats of the vessel wall and reticulin stain to differentiate between venules and arterioles. The vascular structures within the vein wall and its surrounds were analysed by using analySISpro via a CCD camera attached to a light microscope, with the help of a frame grabber card and image analysis software. Results show that the vein has vasa vasorum within its wall, a capillary network around it, arterioles, venules and the saphenous nerve and its branches with their vascular network a further distance apart. The relevance of the microsurgical anatomy of the saphenous vein and its soft tissue envelope in the survival of venous flaps is discussed.

The effect of sphincter pharyngoplasty on the range of velar movement.

The aim of this study was to assess the mobility of the soft palate following sphincter pharyngoplasty in patients with velopharyngeal incompetence of variable aetiology. Pre- and postoperative videotape recordings of lateral view videofluoroscopy of 24 patients were retrospectively studied and compared with regard to the range of velar movement. Tracings of the velopharyngeal port were made on acetate paper directly from the television monitor and absolute angle measurements were taken. Analysis of the results showed a highly significant increase in the range of palatal movement postoperatively. There was no evidence of correlation between the magnitude of the increase and the postoperative improvement in speech. The findings and their implications are discussed.

Use of type III venous flaps: single- and multistaged procedures.

Two cases are presented in which the principles of type III (arteriovenous) venous flaps were applied in single- and multistage procedures. In the first case, the flap was used for correction of a post-thermal burn adduction contracture of the first web space of the hand as a one-stage microvascular free flap and in the other for the resurfacing of a post-traumatic defect on the dorsum of the foot as a two-stage transfer. A brief review, along with the technique, advantages, mode of survival, and feasibility of using type III venous flaps, is presented. A simple classification of type III venous flaps is also suggested.

Venous flaps.

One of the earliest postulates concerning the physiological basis of flap survival is attributed to Sushruta, who, in his inimitable style, very succinctly noted in Sanskrit verse the following words: "through continuity survives." Sanskrit being a very telegraphic language, what derives from these words is as follows: Through (the flap's) continuity (with its original location) (it) survives. The principle of continuity has survived through the ages, though continuity has come to imply vascular continuity based on the Harvesian model of circulation. No matter how we classify flaps, i.e., random or axial, the Harvesian model of circulation is the key to the mechanism of survival. Lately, however, a new category of flaps, that is, "venous flaps," have been reported by a number of investigators where the classical Harvesian model is not in evidence, at least apparently. The following effort is directed toward presenting the existing data on this subject for future guidance in research and clinical applications.

A radical approach in the treatment of the deviated nose.

Surgical attempts to straighten a deviated nose do not always produce a satisfactory result, partly due to the surgeon's inability to straighten the anterior part of the nasal septum or to maintain it in a correct position postoperatively. In a radical departure from accepted norms we have, in eight cases, excised the deviated part of the anterior nasal septum and replaced it with a bone graft. The background and the need for this procedure are explained, followed by a case report in some detail. Details of the eight cases are given in a table and representative cases are presented with illustrations and comments regarding the problems encountered with the present method.

The saphenous venous flap.

Eight cases, in which a new single-pedicled venous flap, based on the long saphenous vein, was used to close defects around the knee, are presented with the details of indications, size and survival. Of the eight cases, seven achieved their aim; five flaps survived completely, two had partial distal loss and one died completely. This clinical work is further confirmation that fasciocutaneous island flaps of fairly large dimensions, with a single cephalad vein, survive and can be used to cover defects in their adjacent areas.

Static and dynamic computerised radioactive tracer studies, vital dye staining and theoretical mathematical calculations to ascertain the mode of survival of single cephalad channel venous island flaps.

Experiments were performed to ascertain the perfusion and drainage of single cephalad channel saphenous venous flaps in dogs. In the first experiment a standard saphenous flap and a single cephalad channel saphenous venous island flap were dissected on contralateral thighs of dogs. A radioactive tracer, 99mTc, was injected into a foreleg vein and its appearance in both flaps was monitored with the use of a static and dynamic scanner. After this experiment, Evans blue, a vital dye, was injected into the foreleg vein of the dog. Five minutes later both flaps were excised and the dye in the flaps was assayed quantitatively. In the third experiment radioactive tracer was injected into the single cephalad channel venous flap subcutaneously and its decay in the flap as well as its uptake in the rest of the body were measured dynamically. The experiments show that the single cephalad channel venous island flap is perfused by and drains through its single cephalad vein. A mathematical model to justify the above conclusion was worked out independently, based on standard values involved in mammalian circulatory mechanisms as in dog and man.

Cephalic venous flap: a series of 8 cases and a preliminary report on the use of 99mTc labelled RBCs to study the saphenous venous flap in dogs.

From December 1985 to December 1987 a total of eight fasciocutaneous island flaps with only a proximal venous pedicle were performed. Seven of these eight survived completely. The standard flap design and operative technique are given. The results are presented in a tabulated form. One case is presented with illustrations. A preliminary report on the appearance of 99mTc tagged RBCs and Evans blue in a proximal venous saphenous island flap in the dog is included. Comments on the survival of these flaps and the solitary case where the flap necrosed completely are added.

Cephalic venous flap.

A case is reported in which an island fasciocutaneous flap from the radial side of the forearm, with only the cephalic vein connecting it to the rest of the body (Fig. 1) was successfully transposed to cover part of a defect on the ulnar side of the elbow. An earlier case in which such a venous flap was raised but not used for cover is also detailed. A brief discussion speculating on the way this flap survived without any arterial inflow and only proximal venous drainage is included.

A study of the saphenous venous island flap in the dog without arterial inflow using a non-biological conduit across a part of the length of the vein.

This paper includes material which is a follow-up on the work of Se Min Baek et al. (1985) who demonstrated that in dogs a saphenous flap could survive without arterial inflow. Here we have repeated part of their work and confirmed it. In addition, this paper shows that in dogs a saphenous venous flap with only the cephalad venous channel intact can survive even if the vein is cut and replaced by a non-biological conduit (a polyethylene tube). A total of 13 dogs and 19 flaps were studied. The possible reasons for the survival of these flaps are discussed.

Successful detachment of cross-leg fasciocutaneous flaps on the tenth day: a report of 10 cases.

A series of 10 patients is presented in whom cross-leg fasciocutaneous flaps were detached on the tenth day without any subsequent complication or loss. All the flaps were designed with a distal fascial extension that might have helped neovascularisation of the flap. The paper also includes a description of the nature of the fasciocutaneous flap in the leg, comments on the neovascularisation of flaps and a brief analysis of the economics of a skin flap transfer.