Prevalence and risk factors for nerve injury following shoulder dislocation.

BACKGROUND: The glenohumeral joint dislocation can be associated with major nerve injury. The reported prevalence and risk factors for major nerve injury are variable and this injury can have a severe and life-long impact on the patient. The objectives of this study were to analyse the prevalence of major nerve injury following shoulder dislocation and examine risk factors. Management and outcomes of nerve injury were explored. METHODS: A 1 year retrospective cohort study of 243 consecutive adults who presented with a shoulder dislocation was performed. Data were collected on patient demographics, timings of investigations, treatment, follow-up, and nerve injury prevalence and management. The primary outcome measure was prevalence of nerve injury. Risk factors for this were analysed using appropriate tests with Stata SE15.1. RESULTS: Of 243 patients with shoulder dislocation, 14 (6%) had neurological deficit. Primary dislocation (p = 0.004) and older age (p = 0.02) were significantly associated with major nerve injury. Sex, time to successful reduction and force of injury were not associated with major nerve injury in this cohort. Patients with nerve injury made functional recovery to varying degrees. Recurrent shoulder dislocation was common accounting for 133/243 (55%) attendances. CONCLUSIONS: Shoulder dislocation requires careful assessment and timely management in the ED. A 6% rate of nerve injury following shoulder dislocation was at the lower border of reported rates (5-55%), and primary dislocation and older age were identified as risk factors for nerve injury. We emphasise the importance of referring patients with suspected major nerve injury to specialist services.

Plastic physicians: The surgical salamanders of the COVID-19 pandemic.

At the time of writing, coronavirus disease-2019 (COVID-19) has affected 6.42 million people globally and over 380,000 deaths, with the United Kingdom now having the highest death rate in Europe. The plastic surgery department at Leeds Teaching Hospitals put necessary steps in place to maintain an excellent urgent elective and acute service whilst also managing COVID-positive medical patients in the ward. We describe the structures and pathways implemented together with complex decision-making, which has allowed us to respond early and effectively. We hope these lessons will prove a useful tool as we look to open conversations around the recovery of normal activity.

Lower limb paediatric trauma with bone and soft tissue loss: Ortho-plastic management and outcome in a major trauma centre.

AIM: We examined the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss. METHOD: Patients were identified from our prospective trauma database (2013-2018). Inclusion criteria were age (<18 years) and open lower-limb trauma. We assessed severity of soft tissue and/or bone loss, fracture complexity, surgical techniques and time to surgery. Paediatric quality of life and psychological trauma impact scores (HRQOL and CRIES), Ganga Hospital Injury Severity score (GHISS), union and complication rates were measured. RESULTS: We identified 32 patients aged between 4 and 17 years. Twenty-nine patients had open tibia fractures including 14 patients with bone loss, one patient had an open femur fracture, one patient an open talus fracture and one an open ankle fracture with dorsal degloving. Thirty injuries were classified intra-operatively as Gustilo IIIB (or equivalent) and two injuries as Gustilo IIIC. In 10 patients primary skin closure was achieved by acute shortening following segmental bone loss. Twenty-two patients required soft tissue coverage: 17 free vascularised flaps, two fascio-cutaneous flaps and three split skin grafts were used. Two patients required vascular repair. Soft tissue coverage was achieved within 72 hours in 26 patients (81%) and within a week in 30 patients (94%). The surgical techniques applied were: circular fine wire frame (19), monolateral external fixator (4) and open reduction internal fixation (8). Median follow up time was 18 (7-65) months. Paediatric quality of life scores were available in 30 patients (91%) with a median total score of 77.2 out of 100. The psychological trauma impact scores showed one in three patients was at risk of developing post-traumatic stress symptoms (PTSD). The GHISS scores ranged from 6-13. All fractures went on to unite over a median time of 3.8 (2-10) months. Three patients (9%) had major complications; two flap failures requiring revision, one femur non-union requiring revision fixation. CONCLUSION: Limb salvage and timely fracture union is possible in children with complex lower limb trauma. Early intervention providing adequate debridement, skeletal stabilisation and early soft-tissue cover including the option of free microvascular reconstruction in small children when required, delivers acceptable outcomes. A multidisciplinary team approach including clinical psychologists to address the psychological impact of trauma provides optimal holistic care for these children and adolescents. Therefore, treatment for these patients should only be performed in paediatric major trauma centres.

Multilocus phylogeography reveals nested endemism in a gecko across the monsoonal tropics of Australia.

Multilocus phylogeography can uncover taxonomically unrecognized lineage diversity across complex biomes. The Australian monsoonal tropics include vast, ecologically intact savanna-woodland plains interspersed with ancient sandstone uplands. Although recognized in general for its high species richness and endemism, the biodiversity of the region remains underexplored due to its remoteness. This is despite a high rate of ongoing species discovery, especially in wetter regions and for rock-restricted taxa. To provide a baseline for ongoing comparative analyses, we tested for phylogeographic structure in an ecologically generalized and widespread taxon, the gecko Heteronotia binoei. We apply coalescent analyses to multilocus sequence data (mitochondrial DNA and eight nuclear DNA introns) from individuals sampled extensively and at fine scale across the region. The results demonstrate surprisingly deep and geographically nested lineage diversity. Several intra-specific clades previously shown to be endemic to the region were themselves found to contain multiple, short-range lineages. To infer landscapes with concentrations of unique phylogeographic diversity, we probabilistically estimate the ranges of lineages from point data and then, combining these estimates with the nDNA species tree, estimate phyloendemism across the region. Highest levels of phyloendemism occur in northern Top End, especially on islands, across the topographically complex Arnhem escarpment, and across the sandstone ranges of the western Gulf region. These results drive home that deep phylogeographic structure is prevalent in tropical low-dispersal taxa, even ones that are ubiquitous across geography and habitats.

Cross-over limb replantation: a case report.

Following traumatic bilateral arm amputation in a 46-year-old woman, orthotopic replantation was not possible. The patient underwent replantation of the left forearm to the right proximal forearm. At two years she has a sensate hand, with good recovery of her long flexors of the hand and wrist extensors. DASH score is 93.9 and Chen's score is III (medium). We demonstrate a high level of function compared to the contralateral prosthetic limb. There have only been four similar cases described. Although a rare circumstance, a cross-limb replant can provide a level of function and independence superior to a simple prosthesis. Cross-limb transfer should be considered in situations where bilateral arm amputation is present and neither can be orthotopically replanted.

Fanconi's anaemia and unilateral thumb polydactyly--don't miss it.

Fanconi's anaemia (FA) is a rare, life threatening inherited syndrome. Patients usually present late in the first decade of life with aplastic anaemia or acute myeloid leukaemia. FA children are also at high risk of solid organ tumours, anogenital squamous cancers, and endocrinopathies. These patients can present with unilateral radial abnormalities including thumb duplication. Hand surgeons can help achieve early diagnosis and improved survival in this group by early referral for screening. In a retrospective study of 202 children with radial ray anomalies seen over a 20 year period seven children had FA. Of these seven with FA, four had bilateral thumb hypoplasia and three had unilateral thumb anomalies--two unilateral thumb hypoplasias and one thumb duplication. The three children with unilateral anomalies were diagnosed late, presenting with bone marrow failure. All three have subsequently died following late bone marrow transplants. This study highlights the link between unilateral radial anomalies, including thumb duplication and FA and the importance of early genetic referral for diagnosis and surveillance.

Two for the price of one: recycling a free flap.

Free flaps are now an established, successful, method of reconstruction for complex soft tissue defects. Improvements in microsurgical techniques, anatomical understanding and instruments have resulted in the evolution of free flap surgery to now encompass synchronous double free flap surgery and "free style" type flaps based on perforators. Although there have been reports of a single free flap split in two to reconstruct a defect at a single site, we report what we believe to be the first case of a single free groin flap used to reconstruct two distant and separate defects sequentially.

Trends in medical student use of tobacco, alcohol and drugs in an Irish university, 1973-2002.

Questionnaire surveys of medical students in an Irish university were carried out in 1973 (n=765), 1990 (n=522) and 2002 (n=537), with differentiation of western students (e.g., from the Republic of Ireland, the UK, or Australia) and non-western students (e.g., Malaysia). We report on changes in tobacco smoking, drinking and drug-taking over three decades, and we note that, among western students, estimated prevalence of being a current smoker has declined overall from 28.8% in 1973 to 15.3% in 1990 to 9.2% in 2002 (p<0.001), falling in both males (p<0.001) and females (p<0.01). Ex-smokers rose from 5.9% to 15.1% between 1990 and 2002, corresponding with the decline in current smokers. The prevalence of current drinkers has risen over the period, to 82.5% among western students in 2002 (p<0.05); female drinking has increased steadily since 1973 (p<0.001), and the overall proportion of CAGE-positive drinkers has risen since 1990 (p<0.001). The mean weekly alcohol consumption has risen in both sexes since 1990 (males 14.3 units to 19.4, p<0.01; females 6.0 to 9.5, p<0.001). There was an increase in the proportion of students ever offered drugs between 1973 and 2002 (p<0.001). Although smoking rates have fallen, our findings show a marked increase in alcohol and drug consumption between 1973 and 2002. Personal misuse of addictive substances by doctors may mean that doctors will fail to take misuse by patients seriously. A need for preventative and ameliorative action during the medical school years is clear.

Free phalangeal transfer: donor-site outcome.

The role of non-vascularised free proximal phalangeal transfer in digital reconstruction in children remains controversial. Significant cosmetic and functional deficits can result in the donor foot. We compare the donor-site outcome following a new technique of reconstruction using a cylindrical iliac-crest bone graft (n = 11) with the outcome following the technique previously described by Buck-Gramcko (n = 18). We have found better preservation of toe stability and length following the bone-graft technique.

Predictors of first hip fracture and mortality post fracture in older women.

BACKGROUND: Hip fracture causes significant morbidity and mortality in older women. AIM: To document factors contributing to the risk of hip fracture in older women and to assess the effect of hip fracture on subsequent mortality. METHODS: Case-control study of 89 women with hip fracture and 89 controls, with two-year follow-up. Singh index and bone mineral density were calculated. RESULTS: Osteoporotic indices did not differ significantly between cases and controls. Significant predictors of risk were sleeping tablets, perception of health as fair/poor and a lower mental status score. Patients were 3.57 times more likely to die in the first year after fracture, with no difference between the groups in year two. After adjustment, hip fracture did not remain significantly associated with mortality. Inability to walk 100 yards alone prior to fracture and lower social class were significantly associated with mortality at 12 months. Age alone was significantly associated at 12-24 months. CONCLUSIONS: Factors related to falls and fracture may be more discriminatory predictors of hip fracture risk than osteoporosis in older females. Medications for sleep should be prescribed with caution. Hip fracture may have an independent effect on one year mortality, this effect is not seen in the second year.

Evaluation of quantitative CT vertebral bone mineral density measurement and the Singh index in elderly females with hip fractures--a case control study.

This study aims to evaluate the ability of quantitative computed tomography (QCT) bone mineral density (BMD) measurement of vertebral bodies to predict risk of hip fracture. We also examine the predictive value of the radiographic Singh index and its relationship to the vertebral BMD. The vertebral BMD (using a QCT protocol) and radiographic Singh index were evaluated in 86 white females who had sustained a hip fracture after minor trauma. 86 age-matched female controls were also studied. All patients were post-menopausal, the age range was 52-95 years. BMD values were found to be low in both the study group and controls; there was no statistically significant difference between the groups. A low Singh index did not correlate with hip fracture, nor did it correlate with low vertebral BMD measurement. We conclude that vertebral BMD and radiographic Singh index are not reliable predictors of hip fracture in the elderly female.

Pelvic distraction to improve exposure in radical surgery for pelvic tumours in children.

We describe one patient who had pubic osteotomy and three who had symphysiotomy as an aid to radical tumour resections over the last 7 years. In each it was possible to distract the pelvis so improving access to the tumour. All four patients had pelvic rhabdomyosarcomata, three primarily in the prostate and lower bladder and one was a large tumour filling the pelvis, probably of bladder origin. No immediate or long-term complications of the procedure occurred, and in the two patients who died (2.5 years and 1 year post-surgery) or in the two survivors.

Histological comparison of the third interdigital nerve in patients with Morton's metatarsalgia and control patients.

This study compares the histology of the plantar-digital nerve supplying the third web space in asymptomatic patients with those who have clinically diagnosed Morton's metatarsalgia. Despite several studies concentrating on the histological changes in the interdigital nerve, the relevance of these changes is a matter of contention while the exact pathological process responsible for the symptoms has not been determined. The histological findings in control patients were identical to Morton's patients with the exception of demyelination, which was more common in the Morton's group. This suggests that the characteristic nodule and fibrotic changes seen in the interdigital nerves of patients with Morton's neuroma cannot account for the symptoms and that the changes seen in the neurovascular bundle are degenerative in origin and are found in asymptomatic patients.