The effect of local anaesthetic cream (EMLA) applied with an occlusive dressing on skin thickness. Does it matter?

EMLA cream is used in plastic surgery as a topical anaesthetic to harvest split skin grafts. It has been observed that the skin appears pale and oedematous after the application of EMLA. The aim our study was to determine the effect of EMLA with an occlusive dressing on skin thickness using a high frequency ultrasound. Twenty volunteers took part in this study after approval from the ethics committee. An area of skin was marked on both thighs and the skin thickness of each, measured using ultrasound. EMLA with an occlusive dressing was applied to one thigh. This was removed after at least 2 h of application time but at different time points and skin thickness of each thigh measured again. Data was analysed using t-test and Pearson's correlation. Mean age in years +/- SD (range) was 36.1 +/- 12.1 (23 - 61). Male:female ratio was 8:12. Mean skin thickness +/- SEM increased from 1.86 +/- 0.055 mm prior to EMLA application to 1.96 +/- 0.051 mm post-EMLA application p= 0.02. There was a significant correlation between the increase in skin thickness and duration of application of EMLA cream (p = <0.001, R2 = 0.59). The results conclude that EMLA applied under an occlusive dressing has an effect on skin tissue thickness and any surgeon who harvests split skin grafts under EMLA should be aware of this. Further research is needed to compare laser treatments performed under local anaesthetic creams against general anaesthesia as an increase in skin thickness may affect the depth of laser penetration.

The role of antibiotic prophylaxis in clean incised hand injuries: a prospective randomized placebo controlled double blind trial.

A prospective, randomized, double blind, placebo controlled trial was designed to investigate the effect of prophylactic flucloxacillin on the infection rate in clean incised hand injuries, which included trauma to skin, tendon and nerve in adults. Using strict exclusion criteria, a total of 170 patients were recruited into one of three trial groups; Group A - intravenous flucloxacillin on induction followed by an oral placebo; Group B - intravenous flucloxacillin on induction followed by an oral flucloxacillin course or Group C - oral placebo. Thirteen of the patients were subsequently withdrawn, leaving 92% available to complete the trial. Infection was diagnosed using clinical criteria. The infection rates in the three groups were Group A - 13%, Group B - 4% and Group C - 15%. Strictly, the results demonstrate no statistically significant difference in the infection rates between the groups.

A prospective, controlled, randomized trial comparing early active extension with passive extension using a dynamic splint in the rehabilitation of repaired extensor tendons.

This prospective, randomized, controlled trial compared two methods of rehabilitating extensor tendon repairs in zones IV-VIII. Group A patients followed an early active mobilization regimen and Group B patients followed a dynamic splintage regimen. Data on 19 patients in Group A and 17 patients in Group B were collected at 4 weeks and at final follow-up (3 months median follow-up for both groups). Extension lag, flexion deficit and total active motion (TAM) were measured. At 4 weeks, patients in Group B had a better TAM (median 87%, range 56-102%) compared to patients in Group A (median 77%, range 52-97%). At final follow-up, there were no significant differences in the results of the two groups. There were no ruptures in either group.

Intratendinous rupture of flexor digitorum profundus caused by non-specific synovitis.

Closed ruptures of flexor tendons in the hands of patients without rheumatoid arthritis are rare. We report a case of closed rupture of the flexor digitorum profundus of the middle finger in zone II, secondary to acute florid synovitis forming a tumour-like mass. No similar case has been reported to our knowledge. The management of this unexpected finding at surgical exploration is discussed.

Objective assessment of post-traumatic nerve repairs and neuromas.

The assessment of a nerve repair usually focuses on the level of sensory and motor recovery distal to the site of the repair. However, the development of a painful neuroma or nerve junction, particularly in a digit, can be just as disabling to the patient as an area of anaesthesia. An instrument has been developed to assess objectively the severity of neuroma formation at nerve-repair sites by measuring the threshold percussive force required to elicit a Tinel's sign using standard weights dropped from a uniform height in a tube.

Donor finger morbidity in cross-finger flaps.

We reviewed 16 patients who had cross-finger flap procedures carried out between 1991 and 1996 at the West Midlands Regional centre for Plastic and Reconstructive Surgery. We looked specifically at the donor finger morbidity of each patient with a median follow up interval of 43 months.At follow up there were 10 patients with cold intolerance, eight patients with subjective joint stiffness and a documented reduced range of finger joint movement. Skin graft reconstruction of the secondary defect was associated with poor colour match in eight cases (seven hyperpigmented, one hypopigmented) and visible contour deformity in eight cases. There were no clinically significant differences between split skin graft or full thickness skin graft for donor finger reconstruction. Although cross-finger flaps may provide soft tissue cover in a variety of finger pulp injuries, these results show an alarming incidence of donor finger morbidity associated with such procedures.

Dilute adrenaline infiltration and reduced blood loss in reduction mammaplasty.

The aim of this review was to assess the use of dilute adrenaline infiltration in reduction mammaplasty and to determine whether it had any associated complications. The closed technique for adrenaline infiltration was used with no reported infection. One hundred breast reductions in 50 patients were compared by dividing them into two groups of 25 patients each. Group A had 1:500,000 adrenaline in normal saline infiltration; group B did not. Both groups were matched equally for age and general health. Results showed that blood loss was less for group A when measured by the fall in postoperative hemoglobin (2.5 g per deciliter vs. 3.5 g per deciliter). This was statistically significant (p < 0.05). There was no significant difference in postoperative drainage (group A, 158 ml; group B, 182 ml). Group A required fewer blood transfusions (two vs. eight), without the risk of increased complications. Blood transfusions were given in the earlier part of the study, but currently are rarely needed. Adrenaline infiltration at this dilution is virtually free from any side effects. It decreases intraoperative blood loss and facilitates the operation without the need for blood transfusion.

Defining a normal finger web in children.

We calculated the interdigital web ratios for children between the ages of 5 and 6 and 10 and 11 years. We compared these ratios with those seen in adults and conclude that there is a change in finger web morphology with age. We found that a photocopier provided images of similar quality to conventional photography.

The natural history of cold intolerance of the hand.

When cold intolerance occurs in the injured hand, it is persistent in the majority of cases (79 per cent). Statistically, there is a link between the development of cold intolerance and the incidence of early postoperative pain. Postoperative pain relief should be of high quality and may possibly prevent the onset of cold intolerance.

Dupuytren's disease affecting the wrist.

A unusual example of Dupuytren's disease occurred in a black patient with a strong diathesis. The disease affected the insertion of flexor carpi ulnaris at the wrist as well as the palm.