Arterial injuries at the elbow carry a high risk of muscle necrosis and warrant urgent revascularisation.

INTRODUCTION: Revascularisation following axial arterial system injury is effective in upper limb salvage but necrosis of muscle, the tissue most sensitive to ischaemia, may still occur. We examined the frequency of necrosis, its related factors and its functional significance. METHODS: The clinical findings and operative management of 13 patients with injuries at the elbow referred to 2 plastic surgical hand surgery units over a 30-month period were reviewed. Good outcome was defined as minimal impairment with return to previous occupation, intermediate outcome as moderate impairment with change in occupation and poor outcome as major functional loss preventing work. RESULTS: Seven patients injured the brachial and six injured both the radial and ulnar arteries. Concomitant injuries were severe with nerve injuries in 11 and muscle damage in 12 patients. Functional outcome was good in four cases, intermediate in four and poor in five. Muscle necrosis developed in four brachial artery injuries. In all four cases, initial successful revascularisation failed post-operatively. Case review revealed delayed recognition in three cases where pain heralded ischaemia but distal skin circulation and pulses were adequate. Of patients with necrosis, three had a poor outcome and one had an intermediate outcome. CONCLUSIONS: The risk of muscle necrosis must be considered when managing these injuries, particularly if initial revascularisation is unsuccessful. Every effort should be made to optimise repair technique and post-operative monitoring. Limb salvage is no longer enough. Fully viable muscle is necessary to restore function and livelihoods.

"Gearing to a time table"; the evolution of earlier surgical eschar excision in massive burns by British burns surgeons at the battles of Cassino, 1944: an example of real-time audit.

The effectiveness of burns care delivery is difficult to measure within a realistic workload and resource framework. In addition, workers must develop new tools for this purpose. We describe a historical example from World War II describing the evolution of burns excision in the context of thorough outcome assessment, during the allied advance from North Africa up the Italian peninsular, including the battles of Cassino 1942-1945. Patrick Clarkson and Rex Lawrie working as plastic surgeons in a small forward Maxillofacial Unit were able to fully assess the management and outcome of 800 burnt servicemen. 192 burns were full thickness and required grafting. Prospective data revealed that those burns which were surgically excised and grafted between 12 and 18 days recovered more quickly than those managed by conservative dressings until the eschar had sloughed off followed by grafting. Burns managed by excision and grafting in less than 5 weeks following burning (n=86) healed 8.6 days faster than those grafted later (n=106). This difference was increased for massive burns of over 1000 cm(2), with those grafted in less than 5 weeks (n=17) healing 13 days faster than the delayed group (n=27). Their transparent and simple method of prospective audit is described.

Dupuytren's disease. The way forward?

Histologically, Dupuytren's disease has been compared to the process of neoplasia because of fibroblast proliferation, recurrence, chromosomal abnormalities and antigenic profiles. However, a comparison of Dupuytren's tissue with the granulation tissue formed in wound healing could be more valid. Histology reveals similarities in cell types, proliferation, vascularity and collagen morphology. Pharmacologically, both tissues have a similar range of agonist and antagonist responses. Biochemical analysis reveals new collagen synthesis, an increased ratio of type III to type I collagen, and similar changes of the ground substance in both processes. Considering such similarities perhaps it is possible to regard some of the models used for the investigation of wound healing and granulation tissue as the missing experimental "model" for the study of Dupuytren's disease. Recently great strides have been made in the basic understanding of wound biology, and such a comparison might well provide novel therapeutic options for Dupuytren's disease.

The qualities and conduct of an English surgeon in 1446: as described in a manuscript attributed to Thomas Morstede.

The year 1996 marks the 550th Anniversary of an anonymous manuscript which represents one of the earliest surgical works written in English. Generally attributed to Thomas Morstede, Serjeant-Surgeon to King Henry V, the book was for many centuries considered to have been lost and has escaped detailed examination by the surgeons of today. We present a modern translation of its first chapter in which the author outlines the range of equipment a fifteenth-century surgeon would use, the personal qualities all surgeons should possess, and the manner in which surgical practice should be conducted.

Back to the future for wound care?

The European Renaissance was a time of enormous change and rapid progress in the arts, sciences, and medicine. A glimpse of wound care in the last phase of the European Renaissance is provided by the analysis of work by Wilhelm Fabry, the "father of German surgery," as provided in his book De Combustionibus ("Burns") which details his range of treatments for the burn wound, as well as his approach to the later problems of scarring and contracture. We describe some of the historic events which may have stimulated Fabry's writings, in particular, the influences passed down from the medical school of Padua which thereby advanced the cause of wound care and surgery. Finally, we briefly explore the potential of such an approach to the works of our medical forefathers.

Human skin histology as demonstrated by Herovici's stain: a guide for the improvement of dermal substitutes for use with cultured keratinocytes?

The potential for the widespread use of cultured keratinocytes for burns treatment is handicapped by practical problems such as fragility, poor take and, often, unsatisfactory cosmesis. Although dermal equivalents reduce these problems there remains a lack of consensus on what is the best structure of such equivalents. At present the commonest support is type I collagen. This histological study, however, using Herovici's stain, clearly shows that in human skin from a variety of anatomical sites the epidermis is not in direct contact with type I collagen but rather with a distinct layer of type III collagen. We suggest that dermal equivalents may have to be constructed so as to include a layer of type III collagen at the interface between the keratinocytes and a type I collagen neo-dermis, so mimicking normal skin structure more closely.

Hydrofluoric acid burns: a review.

Hydrofluoric acid (HF) is a highly dangerous substance with a wide range of industrial as well as domestic applications. It is unique in both the severity of the cutaneous burns it may produce, and its potential for systemic and occasionally lethal toxicity. The literature on the treatment of HF injuries is extensive, though occasionally confusing and often contradictory, with no coherent management policy emerging. In this paper we present a comprehensive account of the evolution of therapy, drawing on clinical reports and experimental studies.

An algorithmic approach to the treatment of hydrofluoric acid burns.

Hydrofluoric acid (HF) injuries have a potential for both systemic toxicity as well as severe tissue destruction. We present an algorithm for the management of HF burns. This algorithm addresses these issues emphasizing the differences between major and minor cutaneous burns, and includes the approach to inhalation, ingestion and eye injuries. Although algorithms can never be complete, we hope this algorithm will be used as an aid in the clinical management of these patients.

A modern translation and interpretation of the treatise on burns of Fabricius Hildanus (1560-1634).

At the beginning of the seventeenth century, some surgeons were as interested in the classification, prognosis and treatment of burns as their successors are at the close of the twentieth century. We present extracts from our translation of the visionary treatise on Burns by Fabricius Hildanus (Wilhelm Fabry), the "Father of German surgery", and show how some of the present day approaches to burns have their origins almost 400 years ago.

A picropolychrome staining technique applied to Dupuytren's tissue.

Although the histology of Duputyren's tissue is well-documented, conventional stains do not distinguish between the different types of collagen which biochemistry and immunochemistry suggest are present. Duputyren's specimens [nodules (n = 26), cords (n = 15) and dermofasciectomies (n = 6)] were stained with haematoxylin and eosin, Van Gieson's Mallory's, Masson's, and Herovici's picropolychrome stain, and examined for both cellularity and collagen staining characteristics. All stains illustrated the marked cellularity of the nodules, contrasting with a paucity of cells within the cords. The first four stains demonstrated uniformity of the collagen staining within the tissues. Herovici's picropolychrome, however, showed distinct staining patterns for the dermis, nodules and cords, with both purple/red and blue areas. Other studies suggest that those fibres stained purple/red and blue are types I and III collagens respectively. These findings may shed further light on the tissue of origin of Duputyren's disease.

A pigmented lesion clinic: analysis of the first year's 1055 patients.

The Pigmented Lesion Clinic (PLC) at Frenchay Hospital was started in January 1993 to deal rapidly and effectively with a growing number of referrals of suspicious pigmented lesions. Its objectives were to offer expert assessment and either reassurance or excision at the first PLC following referral by the patient's general practitioner. During 1993, 1055 patients were seen in 37 PLCs and 357 excision biopsies were performed. We have compared the Breslow thicknesses of malignant melanomas diagnosed from the PLCs with those of all other (non-PLC) malignant melanomas referred to our unit over the same period. We discuss the development and results of the first year of our PLC and the advantages it confers.