Immediate simultaneous bilateral breast reconstruction with deep inferior epigastric (DIEP) free flap and transverse rectus abdominis musculocutaneous (TRAM) pedicled flap.

Breast reconstructive surgery has evolved tremendously since its inception. Following tumour clearance surgery, physical restoration with breast reconstruction is an important aspect of physical and emotional rehabilitation. Various methods have been described to suit patients demand for the best aesthetic outcome. Surgeon's preference, experience and practicality of differing procedures must be considered. We describe a simultaneous bilateral breast reconstruction with free deep inferior epigastric (DIEP) flap and pedicled transverse rectus abdominis musculocutaneous (TRAM) flap immediately post mastectomies for bilateral breast cancers. The surgery described has resulted in a reasonable technical ease, acceptable flap and abdominal morbidity and good aesthetic outcome.

Double trouble: rugby associated simultaneous rupture of flexor digitorum profundus tendon in zones I and III.

Sporting-related finger injuries are common in the setting of contact sports. Traumatic rupture of the flexor digitorum profundus tendon (FDP) from its insertion point has been described as 'jersey' or 'rugger' finger. We report a case of jersey finger associated with a zone III intra-tendinous rupture in a 13 year-old boy who presented seven weeks post injury. In the literature to date, only one previous case has described a sporting-related simultaneous 'double' FDP rupture.

Risk factors for surgical site infection following operative ankle fracture fixation.

BACKGROUND: Ankle fracture is a common injury and there is an increasingly greater emphasis on operative fixation. AIM: The purpose of the study was to determine the complication rate in this cohort of patients and, in doing so, determine risk factors which predispose to surgical site infection. METHODS: A prospective cohort study was performed at a tertiary referral trauma center examining risk factors for surgical site infection in operatively treated ankle fractures. RESULTS: Univariate and multivariate analysis was performed. Female gender and advancing age were determined to be the risk factors in univariate analysis. Drain usage and peri-operative pyrexia were found to be significant for infection in multivariate analysis. CONCLUSION: This study allows surgeons to identify those at increased risk of infection and counsel them appropriately. It also allows for a high level of vigilance with regard to soft tissue handling intra-operatively in this higher risk group.

The effect of inclement weather on ankle fracture management in an Irish trauma unit.

INTRODUCTION: Ireland is unfamiliar with extreme weather conditions. Such conditions occurred in winter 2009-2010 and 2010-2011, with much of the country being affected by snow and ice. We reviewed the effect that these conditions had on the treatment of ankle fractures in our trauma unit. MATERIALS AND METHODS: The study period was from November until February for four consecutive years from 2008-2009 until 2011-2012. We compared two winters with extreme weather with two winters with regular weather conditions. Information from Met Eireann was compared with demographics from patient records to differentiate ice-related injuries from non-ice-related injuries. Ankle fractures were classified using the Lauge-Hansen classification. We compared waiting times in A&E, waiting times for theatre, delays relating to injury severity, and overall length of stay for both groups. RESULTS: We identified 44 ice-related injuries and 67 non-ice-related injuries. Ice-related injuries trended towards more severe fracture configurations using the Lauge-Hansen classification. Patients sustaining ankle injuries during inclement weather were significantly younger than patients sustaining injuries during regular weather conditions. There were no other significant differences between the two groups. DISCUSSION: Ice-related injuries trended towards a greater severity of fracture configuration. We identified no significant increase in the time to treatment or overall length of stay of patients sustaining ankle fractures during these times. Ice-related injuries did not have greater rates of complications. These results are a testament to the trauma staff in this unit who absorbed the increased workload without compromising patient care.

An unusual finding in the inguinal canal of a 26-week pregnant patient.

Inguinal herniae are a common pathology found in both paediatric and adult populations. The presence of bowel in the hernia sac is anticipated; however, occasionally other structures may be found within the sac. We describe a case of a leiomyoma that had undergone red degeneration in the inguinal canal of a 26-week pregnant female. With this case report, we hope to expand the diagnostic paradigm in the setting of a painful swelling in the inguinal canal of a pregnant female.

Leucocyte esterase in the rapid diagnosis of paediatric septic arthritis.

Septic arthritis may affect any age group but is more common in the paediatric population. Infection is generally bacterial in nature. Prompt diagnosis is crucial, as delayed treatment is associated with lifelong joint dysfunction. A clinical history and application of Kocher's criteria may indicate that there is a septic arthritis. However, definitive diagnosis is made on culture of septic synovial fluid. The culture process can take over 24h for the initial culture to yield bacterial colonies. Leucocyte esterase is released by leucocytes at the site of an infection. We hypothesise that leucocyte esterase can be utilized in the rapid diagnosis of septic arthritis and shorten the time to decisive treatment whilst simultaneously decreasing unnecessary treatment of non-septic joints.

Major injuries occurring during use of a golf cart.

Major trauma following a mishap with a golf cart is an unreported problem. This study details injury types and the various mechanisms by which the accidents occurred. Recommendations are made regarding preventive measures that should be observed for safe operation of a golf cart. Two hundred eighty orthopedic surgeons from 37 states were polled concerning their experience with injuries directly resulting from use of a golf cart. One hundred nineteen surgeons reported a total of 111 injuries with adverse outcomes including death, spinal cord injury, and various chronic disabilities of an extremity. The use of a golf cart has the potential to cause serious trauma. The mechanisms of the accident indicate that obvious measures may be observed to lessen the likelihood of an injury.

High free fall with survival.

A free fall, the unimpeded drop of a body from a known point to a known impaction point, is common in modern society. Death usually results when distance is more than six stories. The following case report describes the circumstances which allowed a young man attempting suicide to survive a 17-storey free fall. Although his impact velocity was estimated to be 72 m.p.h. (uncorrected for air drag), he impacted in a supine position on an automobile trunk lid so that some of the force was dissipated by tires and shock absorbers. Multiple fractures and soft-tissue injuries and a subsequent stress ulcer were successfully treated and the patient has a satisfactory level of physical activity while remaining under psychiatric care 1 year postinjury.

Orthopedic management of the patient with a spinal injury.

I have tried to make clear that there are no absolute principles in the orthopedic management of patients with a spinal cord injury. Although debate continues regarding the approach to the problem, the goals remain optimal patient care, free of complications, and preparation for a smooth transition of the patient into a new life with handicaps. Most strides in spinal cord injury care have been made in improvement of internal fixation and immobilization, advances in rehabilitation techniques and marked shortening of hospitalization. Active research continues to investigate the pathophysiology of the injury and a means of reversing or impeding the damage to neural tissue. Currently, certain spinal cord injuries are considered irreversible despite treatment with spinal cord hypothermia, reanastomosis of spinal cords or administration of enzyme injections. The person with a spinal cord injury and paralysis rarely loses the hope that a cure might be the next great discovery of medical science and active spinal cord injury research centers have the same goal.

Gunshot wounds of the spine: the effects of laminectomy.

In a review of 185 patients with gunshot wounds of the spine from low-velocity missiles, 106 were found to have a complete lesion and seventy-nine, an incomplete lesion. Fifty-six patients with complete lesions underwent laminectomy and only one had a partial (sensory) return of function. The fifty patients with complete lesions who had no laminectomy also had no spontaneous improvement. There were forty-five patients with incomplete lesions who had laminectomy and thirty-two (71 per cent) of them showed measurable improvement. For comparison, thirty-four patients with incomplete lesions had no operative treatment and in twenty-six (76.5 per cent) there was some spontaneous return of neural function. Four wound infections and six spinal fistulae developed in the operative group (a complication rate of 10 per cent). Spinal instability developed in six patients because of the laminectomies.

Fracture-dislocations of the cervical spine. Instability and recurrent deformity following treatment by anterior interbody fusion.

Anterior intervertebral-body fusion has been advocated by various authors for management of several varieties of fracture and fracture-dislocation of the cervical spine. This report is a retrospective study of sixteen patients, all of whom had a fracture-dislocation of the cervical spine, who were treated with an anterior dowel interbody fusion. All had postoperative instability with recurrence of angular deformity, and all sixteen were shown to have disruption of the posterior ligaments. Three patients had a progressive neurological deficit postoperatively. Thirteen patients required two or more operative attempts at stabilization. Anterior fusion should not be performed as primary surgical treatment for fractures of the cervical spine when there is either evidence of disruption of the posterior ligaments or a strong presumption that such disruption exists.