[Traumatic rupture of the cardiac auricle after forceful blunt abdominal trauma]. / Traumatische Ruptur des Herzohrs nach einem massiven stumpfen Abdominaltrauma.

Rupture of the heart after blunt trauma has been attributed to multiple mechanisms. We present a patient in whom massive abdominal blunt trauma leading to massive venous return resulted in rupture of the auricle without pericardial rupture.

[Treatment of penetrating injuries of neck, chest and extremities]. / Behandlung von penetrierenden Verletzungen an Hals, Thorax und Extremitäten.

Penetrating injuries such as gunshot wounds have traditionally been rare in Europe, with the result that European surgeons have only limited experience in their management. Socio-economic changes in the last decade have led to an increase in the frequency of injuries of this type, partly due to the expansion of organized crime and partly because of involvement of the European military in peace-keeping missions in Europe and elsewhere in the world. The purpose of this article is to offer some guidelines in the management of extremely serious or rarely encountered injuries to the neck, chest and peripheral arteries and discuss controversies and possible future changes in their management as a result of the extensive experience of treating penetrating trauma in our hospital.

Ketamine in war/tropical surgery (a final tribute to the racemic mixture).

A technique of continuous intravenous anaesthesia with ketamine was used successfully during the Somalia civil war in 1994 and in north Uganda in 1999 for 64 operations in 62 patients, aged from 6 weeks to 70 years, undergoing limb and abdominal surgery including caesarian sections and interventions in neonates. Operations lasting up to 2h could be performed in the absence of sophisticated equipment such as pulse oximeters or ventilators in patients on spontaneous ventilation breathing air/oxygen only. After premedication with diazepam, glycopyrrolate and local anaesthesia, and induction with standard doses of ketamine, a maintenance dose of 10-20 microg/kg/min of ketamine proved safe and effective. Emphasis was placed on bedside clinical monitoring, relying heavily on the heart rate. Diazepam, unless contraindicated or risky, remains the only necessary complementary drug to ketamine as it buffers its cardiovascular response and decreases the duration and intensity of operative and postoperative hallucinations. Local anaesthetic blocks were useful in decreasing the requirement for postoperative analgesia. An antisialogue was usually unnecessary in operations lasting up to 2 h, glycopyrrolate being the best choice for its lowest psychotropic and chronotropic effects, especially in a hot climate. Experience in war/tropical settings suggests this technique could be useful in civilian contexts such as outdoor life-saving emergency surgery or in mass casualties where, e.g. amputation and rapid extrication were required.

Pitfalls in surgical resuscitation.

Timing of diagnosis and intervention, together with understanding of physiology and knowledge of anatomy, are essential for success in the practice of surgery in general, and emergency surgery in particular. Either excess of treatment, for example fluid overload in tamponated haemorrhage such as a ruptured retroperitoneal Abdominal Aortic Aneurysm, or defect of treatment such as delayed arrest of life threatening bleeding from a transected Superficial Femoral Artery above the knee, can both lead to disastrous outcome or death. Proximal control of damaged arteries is an obligatory step before repair and in emergency situations must be effected rapidly: the femoral artery can be easily aggressed at the groin under local anaesthesia; the abdominal aorta can be rapidly controlled with digital compression at the hiatus through the avascular area of the gastrohepatic ligament.

[Echographic study of the embryonal and fetal hand]. / Etude échographique de la main de l'embryon et du foetus.

The morphological aspects of the limbs as well as several details in the forearm and in the hand were observed from the seventh week of gestation on by routine sonographic examination of the embryo and the fetus. This examination was performed once a week beginning in the first months of life. The authors emphasize the value of sonography in the detection of fetal and embryonic malformations of the upper limb. The method has its limits however and remains to be perfected but it has already proved to be efficient for future studies, essentially because of its innocuousness. The images obtained between the 9th and 33d weeks of gestation are presented.

Surgical treatment of Kirner's deformity.

In 1927 Kirner described a congenital deformity of the fifth finger. Since then only 68 cases have been reported and to date many different views in the pathogenesis and treatment exist. The authors report a case of a 13 years-old girl. By a dorso-lateral approach, the distal phalanx was exposed and bone resection performed; alignment was maintained by Kirschner longitudinal wires, parosteal for the left digit and intramedullary for the right. The cosmetic and functional results were good.