Phenytoin Induced Purple Glove Syndrome: An Effective Management Technique.

Background: Purple glove syndrome (PGS) is a rare condition characterized by limb edema, discoloration, and pain associated with intravenous and oral phenytoin administration. The pathophysiology is poorly understood, and there is no established treatment. Simple cases have previously been managed with hyaluronidase subcutaneous injections, with more severe cases resulting in compartment syndrome, debridement, or even amputation. Methods/Results: In this case report, a 2-year-old boy with status epilepticus developed PGS after receiving intravenous phenytoin via a cannula on the dorsum of the right hand. The patient was successfully managed by locally infiltrating subcutaneous hyaluronidase diffusely to the affected area, titrating its dose to effect, rather than aiming to adhere to any specific dosing limitation. The child was reviewed daily by the Plastic Surgery team until being discharged, and focal lesions began to demarcate after 48 hours, with epidermal loss but no deeper trauma. The epidermis peeled within one month, with healthy underlying skin found underlying when followed up in clinic. Conclusions: This case illustrates that subcutaneous administration of hyaluronidase and titrating to effect provides an effective and safe treatment for treating distal cases of early PGS in children.

Free jejunum reconstruction of upper esophageal defects.

The free jejunum has become an important method for reconstructing extensive oncologic defects of the upper esophagus and pharynx. The advantages of a single-staged reconstruction with a low incidence of morbidity have generally outweighed criticisms such as the requirement for a laparotomy and poor voice quality. The aim of the study was to present the technique and outcomes of free jejunal reconstruction of the upper esophagus in 31 consecutive cases. We reviewed our experience of free jejunal flaps undertaken over a 6-year period. Our surgical approach, complications, and results of swallow and speech restoration are described. A functional swallow was achieved by 27/31 patients. However, satisfactory voice restoration was seen in only a small proportion of patients. Complications at the donor site occurred in just one patient. The current review confirms the jejunal flap as a reliable reconstructive option with minimal donor site morbidity.

Head and neck reconstruction using cephalic vein transposition in the vessel-depleted neck.

In microvascular reconstructive surgery the patency of the recipient vessels is the key to successful outcome. In head and neck surgery there is often a lack of adequate recipient vessels as a result of chemoradiation therapy and ablative surgery. To overcome this it is crucial to identify vessels of adequate length and diameter outside the field of injury. We report our experience with cephalic vein transposition for drainage of seven free flaps--six intestinal and one osteocutaneous--for head and neck reconstruction. In five cases the cephalic vein was used during the free flap transfer and in two cases in salvage re-exploration surgery. All flaps survived completely. The anatomical course and location of the cephalic vein allow good patency and straightforward harvesting. Its vascular properties are predictive of reduced incidence of complications such as flap congestion and failure. We suggest that the cephalic vein offers a high venous flow drainage system for large free flaps and advocate its use in free intestinal transfer in the vessel-depleted neck as well as in re-exploration surgery.

Massive lipoma of the posterior neck.

Giant lipomas are a rare, benign cause of painless neck mass. We describe the case of a 63-year-old man with a giant lipoma of the left posterior neck, which presented with intermittent upper limb paraesthesia. Surgical excision confirmed the diagnosis of spindle-cell lipoma and resulted in complete resolution of neurological symptoms.

Gluteal compartment syndrome with severe rhabdomyolysis.

Gluteal compartment syndrome is a rare entity but a recognised complication of prolonged immobilisation. It can present as renal failure as a result of severe rhabdomyolysis and can lead to sepsis and death. We report a case of gluteal compartment syndrome in a 25-year-old man who was found unconscious following intoxication with alcohol and cocaine of an unknown duration. He presented with tense tight left buttock swelling, right thigh swelling, cold immobile extremeties and acute renal failure. Immediate left gluteal, thigh and calf fasciotomy resulting in an improvement of lower limb and renal function.

Pattern and mechanism of traumatic limb amputations after explosive blast: experience from the 07/07/05 London terrorist bombings.

BACKGROUND: Traumatic amputation of limbs caused by bomb blast carries a high mortality; we present our experience of 07/07 London terrorist bombing that resulted in a large number of survivors with amputated limbs. We think that the unique underground bombing, the shape of the carriages, and the enclosure by the underground tunnel caused amputation of the limb by the channeling of the blast wave as a result of the device being floor based, which resulted in lower-limb amputation without other fatal primary blast injuries. We present our results of the traumatic amputation in the fatalities and survivors as well as the possible mechanism and protective measure that could save lives. METHODS: Data for traumatic amputations were collected from several sources and made anonymous. Traumatic amputations were specifically classified in both the survivors and the fatalities. RESULTS: Our results have shown that 24.5% of those with traumatic amputations will survive. Most of the lower-limb amputations occurred in the shaft of the long bones. Only one person with an upper limb amputation survived the injuries. CONCLUSION: This study does not support the previously held belief that traumatic amputations from a bomb blast results from simple avulsions by the blast winds. However, it reinforces the belief that the principal mechanism of primary traumatic amputation of the limbs in such circumstances occurs primarily [corrected] from the direct coupling of blast waves, resulting in a fracture of the long bone rather than at a joint. This study is unique because it looks at the effects of blast at a very close range (<2 m) at the four London bombing scenes. LEVEL OF EVIDENCE: Epidemiological study, level V.

Tympanic membrane rupture in the survivors of the July 7, 2005, London bombings.

OBJECTIVE: The goal of this study was to analyze the prevalence of tympanic membrane rupture in the survivors of the London bombings of July 2005 and to assess whether tympanic membrane rupture provides a useful biomarker for underlying primary blast injuries. STUDY DESIGN: Cross-sectional study. SUBJECTS AND METHODS: Survivors of the 4 blasts of London bombings on July 7, 2005. Data were gathered from medical records and the London's Metropolitan Police evidence documenting the injuries sustained by 143 survivors of the blasts. All patients with tympanic membrane rupture or primary blast injury were identified. Analysis was made of distance against prevalence of tympanic membrane rupture. Correlation between tympanic membrane rupture and other forms of primary blast injury was then assessed. RESULTS: Results from the 143 survivors showed a 48% prevalence of tympanic membrane rupture across all 4 sites. Fifty-one patients had isolated tympanic membrane rupture with no other primary blast injuries. Eleven patients had tympanic membrane rupture and other primary blast injuries, but only one of these was an initially concealed injury (blast lung). CONCLUSIONS: Tympanic membrane rupture in survivors of the London bombings on July 7, 2005, had a high prevalence affecting half of patients across a range of distances from the blasts. Tympanic membrane did not act as an effective biomarker of underlying blast lung. In a mass casualty event, patients with isolated tympanic membrane rupture with normal observations and chest radiography can be monitored for a short period and safely discharged with arrangement for ear, nose, and throat follow-up.

Biological foreign body implantation in victims of the London July 7th suicide bombings.

On the morning of July 7, 2005, a co-ordinated attack by suicide bombers on the London public transport system resulted in four explosions at densely packed civilian targets. Of the victims of these attacks, 194 were treated at the Royal London Hospital, where among the most severely injured an unusual pattern of injury was seen. Bone fragments from other victims (or possible the bomber) were found embedded as biological foreign bodies within the soft tissues of several patients. We present case reports of five of these patients, and discuss problems arising from the management of their injuries. Allogenic bony foreign bodies, rarely reported in the medical literature, present unusual problems in their management, in particular the risk of transmitting blood borne diseases, which should be anticipated and addressed in a hospital's major incident planning.