Reconstruction of disruptions of the deep transverse metacarpal ligament of the ring finger using the A1 pulleys.

There is little information in the literature regarding the clinical features, investigation, diagnosis and treatment of closed rupture of the deep transverse metacarpal ligament. We demonstrate a case with previously undescribed features and describe the surgical management.

Paediatric friction hand injuries caused by domestic vacuum cleaners-a review from one unit.

The management of seven children with vacuum cleaner friction burns is described. Six of the children sustained full thickness burns. Four were treated operatively. Indications for surgery are outlined and important accident prevention strategies are highlighted.

Functional outcomes following surgical repair of wrist extensor tendons.

The long term results following the repair of open injuries to extensors carpi radialis longus and brevis and extensor carpi ulnaris have not previously been reported. A retrospective case note review was performed and patients were called back for assessment following surgical repair. Grip strength and pinch strength were reduced by 9.9% (p=0.017) and 11.5% (p=0.049). Wrist movement was also reduced. This demonstrates that the division of these tendons should not be regarded as trivial as they may have long-term adverse effects on wrist function. Information gained from this study may be beneficial in patient education at the time of injury and may provide useful information when preparing medico legal reports.

Burn wound management in patients with epilepsy: adopting a multidisciplinary approach.

Many burns that occur following an epileptic seizure are deep due to prolonged contact with the thermal source. Primary care staff need to be aware of this and ready to refer patients to a burns unit.

Salvage of major joint prostheses in aggressive non-specific panniculitis.

Panniculitis is a relatively rare condition, which is usually treated non-operatively. We present a case of panniculitis causing an acute septicaemic episode and threatening the integrity of underlying joint prostheses. The situation was salvaged by radical debridement of the affected areas, and reconstruction using split-skin grafts. Considerations in the management of patients with this condition are discussed.

Vaccum assisted closure: an alternative strategy in the management of degloving injuries of the foot.

A case of a degloving injury to the foot is presented in a patient who also sustained severe contralateral lower-limb trauma. We report a technique for salvaging the foot by replacing the degloved skin as a full-thickness graft and securing it using the vacuum-assisted closure (VAC) device. A good outcome was achieved and technical tips are provided to facilitate reproduction of the procedure.

An unusual schwannoma of the median nerve: effects on the motor branch.

An unusual case of a schwannoma of the median nerve is presented where pressure due to the tumour on the motor branch to the thenar muscles caused weakness and wasting of the abductor pollicis brevis muscle, a previously unreported phenomenon. The patient achieved a full functional recovery after enucleation, which is also unusual considering the patient's age. Aspects of schwannoma biology, differential diagnosis, investigation and treatment are discussed.

Severe extensor tendon attrition and multiple tendon ruptures resulting from Kienböck's disease.

Kienböck's disease is a rare but recognized cause of chronic wrist pain. Occasionally, complications arise leading to tendon rupture. The authors present the first reported case of attrition to all extensors of the hand, and extensor tendon rupture to the little finger in a patient with a 45-year history of Kienböck's disease. This is also the first reported incidence of this complication in whites. Clinical features, surgical management, and the successful outcome are discussed.

Lime burns in a professional football goalkeeper - an unusual hazard.

Burns due to lime, although well reported as a result of occupational exposure, are uncommon in the sports arena. A case of such a chemical burn, which required surgery in a football goalkeeper is presented. There are safe alternatives to line marking on football pitches the use of which will prevent such injuries and avoid litigation.

Burns in patients with epilepsy: changes in epidemiology and implications for burn treatment and prevention.

PURPOSE: To determine the epidemiology of burns in patients with epilepsy and to identify changes in epidemiology compared with previous studies; to identify further strategies that can be used in the primary and secondary prevention of such injuries in this group of patients. METHODS: A retrospective case note review of 111 patient episodes to a regional burns unit where the admission criterion was a burn secondary to an epileptic seizure. RESULTS: The majority (60 of 111) of burns were due to scald injury and were sustained in a domestic setting. This group of patients (mean age, 42.7 years) accounted for 1.6% of admissions during the study period. The data demonstrate a change in the epidemiology when compared with previous studies. Most burns were small (mean area burnt, 2.2%) but deep, and 72 of 111 patient episodes required surgery, and 12% of patients had reburn injuries requiring readmission. CONCLUSIONS: Scald injuries are now the major cause of burns in those with epilepsy, and the proportion of such patients admitted to a regional burns unit has reduced. Patients and health professionals need to be aware of such injuries and of appropriate prevention strategies.

Grip and pinch strength variations in different types of workers.

We measured grip and pinch strengths in non-manual, light manual and heavy manual workers using a Jamar dynamometer and a pinch measuring device. Heavy manual workers had the strongest grips with the least difference between sides. Office workers had the weakest grips and the greatest difference between sides. Light manual workers were between these two groups. Consequently, the occupation of the patient must be taken into account when using grip and pinch strength measurements to assess the need for rehabilitation and in medicolegal reports.

Ciprofloxacin and the fluoroquinolones. New concepts on the mechanism of action and resistance.

Ciprofloxacin, a new fluoroquinolone, is a potent, broad-spectrum antibacterial agent. It rapidly blocks bacterial deoxyribonucleic acid (DNA) replication by inhibiting DNA gyrase, an essential prokaryotic enzyme that catalyzes chromosomal DNA supercoiling. Molecular genetic approaches have been used to study the interaction of 4-quinolones with DNA gyrase from quinolone-sensitive strains and from uropathogenic quinolone-resistant clinical isolates of Escherichia coli. An important mutational locus in the gyrase A gene that confers resistance to ciprofloxacin and other quinolones has been identified, and a new, rapid method to examine clinical isolates for the presence of mutations at this position has been devised. A quinolone resistant gyrA gene has been previously cloned and sequenced from an E. coli clinical isolate. Genetic analysis indicated that resistance resulted from a Ser-83----Trp change in the 875 residue gyrase A protein: two other changes observed in the protein, Asp-678----Glu and Ala-828----Ser, were neutral. GyrA genes carrying these mutations have now been expressed, corresponding mutant gyrase A proteins purified, and their quinolone resistance properties tested by complementing with gyrase B protein and studying the resulting gyrase activity in an adenosine triphosphate-dependent DNA supercoiling assay. The in vitro DNA supercoiling activity of the A (Ser-83----Trp) mutant subunit complemented with wild-type gyrase B subunit was highly resistant to ciprofloxacin and other 4-quinolones. In contrast, A subunit carrying codon 678 and 828 changes reconstituted a quinolone-sensitive gyrase activity. Thus, quinolone-resistant gyrase A proteins may be readily obtained for study by using high-copy gyrA plasmids. In addition, other quinolone-resistant strains of E. coli have been examined for the presence of mutations at gyrase A codons 82 and 83 using a new analytical method based on a restriction fragment length polymorphism (RFLP). This analysis revealed that seven of eight resistant clinical isolates of E. coli examined carried gyrA mutations at codon 82 or 83, whereas five sensitive strains appeared to possess wild-type sequence. Thus, mutations at codon 83 (and possibly 82) in the gyrA gene frequently confer resistance to 4-quinolones, including ciprofloxacin. The RFLP method described should prove useful in examining strains for such mutations. These results are discussed with regard to the mode of interaction of the 4-quinolones with gyrase.