Diagnosing and managing a giant primary cutaneous malignant melanoma of the lower limb.

We present a woman who was referred to our plastic surgery unit with a suspected squamous cell carcinoma following a 3-year history of an enlarging mass on her thigh. Surprisingly, histopathological assessment confirmed the diagnosis of nodular malignant melanoma measuring 77×77×54 mm with a Breslow thickness of 52 mm, making it the largest recorded lower limb primary cutaneous malignant melanoma in the UK.

Preoperative antibiotics for septic arthritis in children: delay in diagnosis.

PURPOSE: To review the records of 50 children who underwent open joint washout for septic arthritis with (n=25) or without (n=25) preoperative antibiotics. METHODS: Records of 50 children who underwent open joint washout for presumed septic arthritis with (n=25) or without (n=25) preoperative antibiotics were reviewed. 17 boys and 8 girls aged 3 weeks to 16 years (median, 1.5 years) who were prescribed preoperative antibiotics before joint washout were compared with 12 boys and 13 girls aged one month to 14 years (median, 2 years) who were not. Following arthrotomy and washout, all patients were commenced on high-dose intravenous antibiotics. Patients were followed up for 6 to 18 months until asymptomatic. RESULTS: Patients who were referred from places other than our emergency department were twice as likely to have been prescribed preoperative antibiotics (p=0.0032). Patients prescribed preoperative antibiotics had a longer median (range) time from symptom onset to joint washout (8 [2-23] vs. 4 [1-29] days, p=0.05) and a higher mean erythrocyte sedimentation rate (93.1 vs. 54.3 mm/h, p=0.023) at presentation. Nonetheless, the 2 groups were comparable for weight bearing status, fever, and positive culture, as well as the mean (range) duration of antibiotic treatment (4.9 [4-7] vs. 4.7 [1-8] weeks, p=0.586). CONCLUSION: Preoperative antibiotics should be avoided in the management of septic arthritis in children. Their prescription delays diagnosis and definitive surgery, and leads to additional washouts and complications. A high index of suspicion and expedite referral to a specialist paediatric orthopaedic unit is needed if septic arthritis is suspected.

Surgical management of bronchopleural fistula in pediatric empyema and necrotizing pneumonia: efficacy of the serratus anterior muscle digitation flap.

PURPOSE: Surgical management of bronchopleural (B-P) fistula associated with thoracic empyema and necrotizing pneumonia is challenging. We evaluated the treatment and outcome of early surgical intervention with limited decortication and insertion of a serratus anterior muscle digitation flap. METHODS: A retrospective review during a 10-year period of children with empyema and B-P fistula secondary to necrotizing pneumonia was performed. During this period, 335 children with empyema were admitted, of which 20 developed a B-P fistula. All underwent a thoracotomy with insertion of a serratus anterior muscle digitation flap. RESULTS: Prethoracotomy chest computed tomographic scan was performed to define the pathologic characteristic. Streptococcus pneumoniae was identified by pus culture (n = 6) and by polymerase chain reaction (n = 4). The median postoperative time with pyrexia after surgical intervention was 2 days (range, 1-3 days). The median period of thoracostomy drain was 7 days (range, 5-15 days). Length of hospital stay was 21 days (range, 7-43 days). This parenchyma-preserving technique was able to control the B-P fistula successfully in all cases. No reintervention was necessary in any case. Respiratory symptoms and radiology improved in all children on follow-up, except for 3 who required oral antibiotics for subsequent chest infections. CONCLUSION: Early surgical intervention with insertion of a serratus anterior muscle digitation flap is effective and safe and avoids morbidity associated with conservative management and necrotic lung resection surgery.