Protecting the exposed skin graft--the Norwich cage.

A simple method of protecting an exposed skin graft is presented. It is cheap, easy to use, and applicable to most sites of the body, even in areas with contours that might otherwise be thought difficult to protect.

Lyell's syndrome on a burns unit.

Two cases of Lyell's syndrome (toxic epidermal necrolysis) managed on a burn unit are presented. The various methods of management are discussed, and the arguments for treating this life-threatening condition on an intensive care burn unit are analysed.

Split earlobes: a method of repair preserving the hole.

A method of repairing split earlobes preserving the hole is presented. It is simple, sound, has a good cosmetic appearance, and is more resistant to recurrence of the split than other methods.

Is iliac node clearance necessary for stage II melanoma?

In a retrospective review (1970-1983), survival following block dissection of the groin was compared in two groups with clinical stage II melanoma. Twenty patients under one surgeon had ilioinguinal (high) block dissection, and 22 patients under another surgeon had inguinal (low) block dissection. The high block 5-year survival was 40 percent, and the low block 5-year survival was 35 percent. There was no statistical difference between groups on life-table or log-rank test analysis. It is concluded that the extent of groin dissection has no effect on survival of stage II melanoma.

Malignant melanomas of eyelid skin.

Four cases of malignant melanoma of eyelid skin are reported. Management of the condition is discussed, with a review of the literature. The conclusions lead us to recommend wide surgical excision for those melanomas arising on the lash margins. If the melanoma is clear of the eyelid margin, smaller margins may be adequate.

Further experience with the lateral arm free flap.

Our experience with the lateral arm free flap over the last 7 years was reviewed in detail, placing emphasis on the clinical aspects and modifications of the flap. A total of 150 patients have undergone reconstructive procedures with the flap for small to medium-sized defects. This included 18 split flaps, 11 osteocutaneous flaps, 6 with vascularized triceps tendon, 5 neurosensory flaps, and 5 fascia-fat flaps. The donor-site scar was generally acceptable; only 3 patients required scar revision and 15 patients required debulking of the flaps. With use of the split flap for wide defects, tension-free primary closure of the donor site can be achieved. In most cases, a two-team approach may be adopted, thereby increasing the efficiency of this microvascular transfer.

Total anomalous pulmonary venous drainage into the right superior vena cava.

An unusual case of total anomalous pulmonary venous drainage (TAPVD) is described with four anomalous veins draining separately into the posterolateral wall of the right superior vena cava (SVC). The defect was successfully reconstructed with a pericardial patch, sutured to the posterior wall of the right SVC, right atrium and the margins of an artificially enlarged inter-atrial communication, thereby directing the pulmonary venous return into the left atrium. The right SVC was reconstructed with a further pericardial patch. Initially autologous pericardium was used, but due to contraction this had to be replaced at a further procedure with heterologous pericardium.

Anatomy of the blood supply to the flank of the sheep.

The anatomy of the a circumflexa ilium profunda supplying the flank of the sheep was investigated in 25 sheep. Two constant branches were identified by dissection and angiography, and the cutaneous areas they supply identified. The arterial system was put to two separate experimental uses successfully.

Full thickness grafts taken from the plantar instep for syndactyly release.

Thirteen digital clefts (eight patients) were reviewed in which full-thickness plantar instep skin was used in syndactyly release. The results are presented, emphasising the good colour match of plantar instep skin with digital skin. There was a surprising lack of morbidity in the thirteen donor sites.

Analgesia in the acute abdomen.

In a prospective sequential double blind trial 288 patients with acute abdominal pain were given sublingual buprenorphine 200 mcg, sublingual buprenorphine 400 mcg, or placebo. Pain relief was proportional to the number of tablets administered; buprenorphine had no difference in effect compared to placebo. Physical signs altered in proportion to dosage, but this had no effect on clinical diagnosis. We conclude that patients with acute abdominal pain may be given buprenorphine without fear of masking the diagnosis.

Adequacy of general practitioners' premises for minor surgery.

OBJECTIVE: Assessment of facilities for minor surgery in general practitioners' premises. DESIGN: Independent inspection of premises and equipment. SETTING: Large urban district. SUBJECTS: Premises of all general practitioners who applied to be reimbursed for minor surgery. MAIN OUTCOME MEASURE: Fullfilment of 14 pre-selected criteria. RESULTS: 69 of 111 premises met all criteria and were approved; 23 failed on only one criterion. The commonest reasons for failure were inadequate record keeping and lack of resuscitation equipment. Twelve practices had out of date adrenaline. CONCLUSIONS: Most premises are suitable for minor surgery, some with attention needed to record keeping. Practices must pay careful attention to the expiry date of adrenaline.

The hit and miss of ISS and TRISS. Yorkshire Trauma Audit Group.

OBJECTIVE: To measure interobserver variation in recording injury from case notes and its effect on calculating injury severity scores (ISS) from identical data and predicting probabilities of survival by using the combined trauma and injury severity score (TRISS). DESIGN: Observer variation study using injury severity scoring and subsequent calculation of probability of survival based on combined trauma and injury severity scores. SUBJECTS: 16 patients with a range of injury severity scores, and 15 observers. RESULTS: There was a wide variation in recorded injury severity scores, the probability of two observers agreeing on the score being 0.28 (28%). The probability of any two observers agreeing over which severity band the patient should be in was 0.5 (50%). Observer variation was independent of the training and type of observer. Survival probability (calculated by combined trauma and injury severity scoring methodology from individual observers' scores) varied by over 0.2 in six of the 16 patients and by over 0.5 in three. CONCLUSIONS: There is wide observer variation in injury severity scoring, which highlights a potential fallibility in its use for trauma audit. The use of combined trauma and injury severity scoring for individual prediction of survival is potentially inaccurate except at the extremes of probabilities. The use of the 0.5 survival line on a combined trauma and injury severity score "pre-chart" is statistically and clinically inappropriate.

Forearm split-skin donor sites: are they cosmetically acceptable?

The cosmetic end result was assessed in a small series of volar forearm donor sites taken under identical conditions. In most cases the donor site remained paler. This was cosmetically acceptable to all patients except 2 young women.

Rules for collection of clinical data: the eight Rs.

Many reports in medical journals give advice on statistical analysis of data collected in clinical studies. The terms used are statistical, and clinicians often ponder how their data stand up to these analyses. Eight simple, easy to remember words are suggested that will help clinicians both to interpret their own data and to assess the accuracy of presented or published data.

Fractures of the body of the hamate.

Eight cases of fracture of the body of the hamate are presented, with descriptions of the injury and management. This fracture may be considerably more common than indicated by standard texts and previous published reports.