Delayed amputation following trauma increases residual lower limb infection.

INTRODUCTION: Residual limb infection following amputation is a devastating complication, resulting in delayed rehabilitation, repeat surgery, prolonged hospitalisation and poor functional outcome. The aim of this study was to identify variables predicting residual limb infection following non-salvageable lower limb trauma. METHODS: All cases of non-salvageable lower limb trauma presenting to a specialist centre over 5 years were evaluated from a prospective database and clinical and management variables correlated with the development of deep infection. RESULTS: Forty patients requiring 42 amputations were identified with a mean age of 49 years (±19.9, 1SD). Amputations were performed for 21 Gustilo IIIB injuries, 12 multi-planar degloving injuries, seven IIIC injuries and one open Schatzker 6 fracture. One limb was traumatically amputated at the scene and surgically revised. Amputation level was transtibial in 32, through-knee in one and transfemoral in nine. Median time from injury to amputation was 4 days (range 0-30 days). Amputation following only one debridement and within 5 days resulted in significantly fewer stump infections (p = 0.026 and p = 0.03, respectively, Fisher's exact test). The cumulative probability of infection-free residual limb closure declined steadily from day 5. Multivariate analyses revealed that neither the nature of the injury nor pre-injury patient morbidity independently influenced residual limb infection. CONCLUSION: Avoiding residual limb infection is critically dependent on prompt amputation of non-salvageable limbs.

Permanent scarring in a partial thickness scald burn dressed with Biobrane.

Biobrane is a biosynthetic wound dressing which has shown to be effective in partial thickness burns by improving wound healing, reducing the pain in dressing changes, and the need to use skin grafts. In addition, it has been shown to reduce both in-patient and outpatient hospital costs and incur no increase in infection rates. Recently, the first reported case of punctate scarring from the use of Biobrane in a paediatric scald was published [Hassan Z, Shah M. Punctate scarring from use of porous Biobrane. Burns 2006;32:258-60]. We now report a second case of scarring with Biobrane, in which the Biobrane was left in place for a full 14 days, as recommended by the manufacturers.

Metastatic adenocarcinoma of the colon presenting as a monarthritis of the hip in a young patient.

BACKGROUND: Malignant arthritis is a rare manifestation of metastatic disease. We describe the case of a previously well 28 year old man in whom hip pain was the presenting symptom of disease. We describe the case and discuss the aetiology of colorectal cancer in young patients. We then review the literature and discuss the investigation and management of malignant joint arthritis. CASE PRESENTATION: We present the case of a 28 year old man who presented to the emergency department with an acute monoarthritis of the hip. He had an unremarkable past medical history and was systemically well. A diagnosis of malignant joint effusion was reached after a heightened index of clinical suspicion, magnetic resonance imaging and cytological evaluation of the synovial fluid. Computed tomography and bone scan confirmed widespread metastatic disease from a primary colonic adenocarcinoma. The patient tolerated three cycles of oxaliplatin and capecitabine but died 4 months after presentation. CONCLUSION: The metastatic spread of cancer to the joint and the synovium is one of the rarest manifestations of malignant disease and has not been previously reported as the presenting symptom of disease. The diagnosis is a difficult one to reach and is associated with a poor prognosis. This case illustrates the importance of thorough investigation in reaching this diagnosis and entertaining the possibility in individuals who do not respond to conventional management of acute monoarthritis, even in young patients and individuals who do not display any other symptoms of disease.