SE20THE ANATOMY OF COMPLICATIONS IN THE UPPER LIMB

Purpose Specialist trainees and the specialty boards of the College of Surgeons expect that levels of supervision will not remain static during training. As training progresses the level of supervision will change, from an assistant role and direct supervision towards independent practice with consultation available as required. The Summary of Operative Experience may provide a de facto measurement of this. Methodology Assessment of the surgical logbook of an individual trainee to document the changes in the level of supervision that occur during a training term, the factors that influence it, and the degree of variation between posts. Results Upon arrival at a new institution supervision for most cases is direct. For minor and intermediate surgery that supervision is rapidly relaxed once it has been confirmed the trainee has acquired and demonstrated the required skills. In areas of complex surgery (such as neonatal surgery) there is a clear progression observable over the training period. In the early part of the term the trainee is assisting in complex surgery, with the surgeon supervisor operating. By the end of the term those roles may have reversed, but there are significant variations between posts. Conclusion It is possible to use the operative logbook as an indicator of the supervision provided by training centres to trainees. This could provide one mechanism to enable specialty boards to confirm that supervision for trainees is appropriate to their needs as they progress through their training. It also allows an indirect measure of the quality of the post for specialty training.     

游离腓骨复合移植重建上肢关节功能及骨缺损

目的：吻合血管的腓骨复合移植适用于一期修复上肢长骨骨缺损及重建关节功能。方法：自１９８５年以来，采用折叠腓骨段及复合组织瓣修复尺桡骨同时骨缺损４例；小儿肱骨近端肿瘤瘤段切除后采用吻合血管带腓骨小头的腓骨移植重建肩关节功能９例；桡骨远端肿瘤瘤段切除后取吻合血管带腓骨小头的腓骨移植重建桡腕关节６例。结果：经术后２～１０年随访，重建的肩关节、桡腕关节功能恢复令人满意，尺桡骨骨缺损一期修复，骨愈合良好。结论：复合的游离腓骨移植是扩大应用于关节功能重建的有效方法。     

UPPER LIMB BLOOD FLOW DURING THIOPENTONE-HALOTHANE ANAESTHESIA

The forearm blood flow changes produced by halothane anaesthesiaafter thiopentone induction were studied in 38 patients usingstrain gauge plethysmography. The effects of endotracheal intubationand surgery, premedication and nitrous oxide were also considered,and for this purpose the patients were allocated at random intofour groups, the factors being successively eliminated untilin the last group only thiopentone-halo-thane remained. It wasfound that thiopentone-halothane anaesthesia decreased the bloodflow to the forearm without any obvious effect from the otherfactors considered. ^* Present address: Clinica Anglo-Americana, San Isidro, Lima,Peru.     

EFFECT OF VARYING METHODS OF UPPER LIMB OCCLUSION ON FIBRINOLYTIC ACTIVITY IN MAN

Three techniques of intermittent venom occlusion (an oscillotonometercuff, pneumatic leggings and an automatic arterial pressuremonitoring cuff (Sentinel)) were applied to one upper limb ofseven healthy male volunteers. Fibrinolytic activity was assessedby the measurement of the euglobulin clot lysis time duringa control period followed by lh of intermittent venous occlusion.Although no statistically significant differences were foundwith any of the methods, between the control and experimentalperiods, there was a trend towards fibrinolytic enhancementwith intermittent pneumatic compression.     

PS10PHAEOCHROMOCYTOMA IN CHILDREN

Purpose Phaeochromocytomas are rare tumours of the sympathoadrenal neuroendocrine system. It is known that these tumours are associated with Von Hippel Lindau (VHL) disease, multiple endocrine neoplasia type II and neurofibromatosis type I. Recently an association with succinate dehydrogenase type B and D gene mutations has been described. Discovery of a SDHB mutation in a girl at our hospital prompted us to review our experience with phaeochromocytoma in children. Methodology Retrospective review of case notes of all children treated for phaeochromocytoma over the period 1997–2006 at Starship Children’s Hospital, NZ. Results Seven patients with 8 tumours were identified with average age of 10 years and average systolic BP of 161. The tumours were adrenal in location in 37.5% and 62.5% extra‐adrenal. Our malignancy rate was 12.5%. Familial disease was noted in two patients with one girl having VHL disease and the other found to carry a mutation in the SDHB gene. All children received preop antihypertensives and were treated operatively with seven open resections and one laparoscopic converted to open resection. One child received adjuvant radiotherapy. There were no recurrences or deaths. Conclusions Phaeochromocytoma in children varies from the adult form. It is more likely to be extra‐adrenal and have a greater chance of a familial genetic syndrome. The discovery of SDH mutations has altered the diagnosis of familial disease and carries implications for family screening, prognosis and surveillance. We emphasize the importance of taking a good family history and suggest screening for SDH mutations in all patients with phaeochromocytoma.     

乳癌术后上肢淋巴水肿的微波治疗

采用微波烘绑疗法治疗肢体淋巴水肿已有报道，但对乳癌根治术后所致的治疗效果报道甚少。对６４例患者采用微波治疗，每天微波照射１小时，２０天为一个疗程治疗，经过二个疗程治疗。治疗后随访１个月～２年。结果显示：症状明显消退，患侧肢体的水肿消退明显，经统计学分析有显著差异（Ｐ＜０．０１）；“丹毒”样发作的频率较治疗前明显减少，也有显著差异（Ｐ＜０．０１）；患肢的弹性得到恢复。无一例出现治疗后并发症。认为，对乳癌根治术后引起的上肢淋巴水肿，采用微波治疗，可获得较好效果，是保守治疗淋巴水肿的有效方法。     

四肢动脉伤后合并缺血性肌挛缩分析

旨在分析四肢动脉损伤后合并缺血性肌挛缩的原因并讨论其预防措施。１９６０年～１９９５年收治的四肢动脉损伤２６９例，合并缺血性肌挛缩１９例，发生率为７．０６％。上肢５例，下肢１４例。月国动脉伤５１例中９例（１７．６％）发生缺血性肌挛缩。入院前１１例曾在他院手术处理，３例未探查处理血管，１例结扎，７例修复损伤动脉均失败；５例伴行静脉损伤，３例结扎。仅１例作了深筋膜切开术。受伤至来院时间：８～１４小时４例，３４～５７小时８例，１９天～１９个月７例。入院后１７例修复了损伤动脉。８例伴行静脉伤，５例修复，３例结扎。８例作深筋膜切开术。随访３个月～２８年（平均５年），修复的１７例动脉１６例通畅。１１例缺血性肌挛缩肢体作了矫形手术，外观及功能明显改善。证明，早期诊治、正确处理损伤动静脉和深筋膜切开术是预防缺血性肌挛缩的关键。月国动脉损伤是发生缺血性肌挛缩的最常见部位，应予认真处理。     

EFFECT OF PETHIDINE PREMEDICATION AND HALOTHANE ANAESTHESIA ON UPPER LIMB BLOOD FLOW

Forearm blood flow (FBF), hand blood flow (HBF) and arterialpressure were measured in 12 patients, before and after premedicationwith pethidine and during halothane anaesthesia. After pethidinethere was a significant (P<0.01) increase in HBF (180%) anddecreased hand vascular resistance; heart rate also increasedsignificantly (P<0.05), whilst mean arterial pressure (MAP)did not change. The large increase in HBF without hypotensionsuggests a local effect. With halothane, there was a significant(P<0.05) decrease in MAP, increase in HBF and decrease inhand vascular resistance compared with either control or effectsproduced by pethidine; there was a significant decrease in FBFand reversal of the action of pethidine on forearm vascularresistance. Present address: Department of Anesthesia, Bowman Gray Schoolof Medicine Center Blvd Winston-Salem, NC 27157-1009, U.S.A.     

SCALDING INJURIES IN IMMIGRANT FAMILIES

From 1990 to 1996, 214 patients aged up to 6 years were treated at our inpatient burns unit. Ages ranged from 3 to 70 months. Scalding was the cause in 186 cases. The median size of the burned areas was 5.0% (range 0.5%-40%). One hundred and nine were deep dermal burns that required surgical treatment, but this was refused in seven instances. Duration of hospital stay was 11 days (2-45). The number of follow-up visits ranged from 0 to 17. Secondary reconstructions for scarring have been done for seven children so far. Ninety-eight (46%) came from immigrant families, mostly from the Middle East and the Balkans. Of the 186 scalded children, 94 (51 %) were immigrants, and they also had a tendency to have more severe injuries. Explanations might be that they were more likely to cook with water and oil, they were unfamiliar with Swedish safety standards and measures, and they had difficulty in communicating (language) and a limited social network. The ensuing scar also may disturb ordelay the child's adaptation to the new environment. Our preventive work is now based on a model that states that frequency, type, and severity of injury is dictated by the variables: risk, personality, supervision, and education.     

无伴行动脉损伤的肢体静脉干损伤的修复

目的探讨无伴行动脉损伤的肢体静脉干损伤的机制,以及诊断、救治和修复方法. 方法 1993年1月～2002年6月共收治12例患者,均为男性,年龄18～35岁.受伤至手术时间30 min～2 h.均为锐器刺伤.在积极抗休克的同时进行血管修补7例,端端吻合5例.合并头颅胸腹部损伤患者同时给予相应手术处理. 结果除1例患者因严重的脑外伤死亡外,余11例患者伤口均Ⅰ期愈合.随访1～5年,平均2年4个月,彩色多普勒检查见血流通畅,无血栓形成.其中8例肢体功能和血循环恢复良好;3例合并伴行神经损伤者血循环恢复良好,但肢体功能恢复欠佳,遗留感觉及运动障碍. 结论无伴行动脉损伤的肢体静脉干损伤是一种严重的损伤,采取应急止血、积极抗休克、及早修复损伤血管和合理处理合并伤等是挽救患者生命的重要措施.     

UPPER LIMB BLOOD FLOW DURING HEXAMETHONIUM-INDUCED HYPOTENSION: Studies in Patients Anaesthetized with Halothane

We report the effect of hypotensive anaesthesia on blood flowin the upper limbs of 17 patients before the start of surgery.Under light halothane-oxygen anaesthesia, patients (n = 17)were given hexamethonium 0.5–1.0 mg kg^–1. Forearmblood flow (FBF), hand blood flow (HBF) and systemic arterialpressure (AP) were measured before, and 9 and 18 min after theadministration of the hexamethonium. During the control periodof halothane anaesthesia, HBF was AP-dependent, but FBF wasnot. Hexamethonium produced a statistically significant (P <0.001) decrease in systolic AP by 9 and 18 min, but significantreductions in FBF and HBF were seen only at 9 min. During thehypotensive period neither HBF nor FBF correlated with the systolicAP, which had decreased from an average of 98 mm Hg to an averageof 65 mm Hg (range 95–50 mm Hg), but the changes in HBFand FBF did correlate with the changes in systolic AP. As asecondary factor, the control FBF correlated inversely withthe reduction in FBF after hexamethonium. We concluded thathypotension induced by hexamethonium during halothane anaesthesiaproduced a transient reduction in limb blood flow that was dependenton the change in AP. A range of systolic AP from 95 to 50 mmHg did not correlate with either FBF or HBF during the hypotensiveperiod.     

皮下组织抽吸加弹力压迫治疗乳腺癌术后上肢淋巴水肿

目的 探讨乳腺癌术后上肢淋巴水肿的治疗方法。方法 2001年6月～2003年9月选择乳腺癌术后上肢淋巴水肿2年以上的患者11例，患侧上肢明显水肿，外观增粗，前臂中点周径与健侧平均相差4．4cm，上臂中点周径与健侧平均相差6.6cm，活动受限，其中2例有丹毒反复发作。利用肿胀吸脂技术，对其水肿的上肢进行皮下组织抽吸去除，术后弹力加压3个月后，改为每晚弹力加压，观察疗效。结果 经6～15个月随访，11例患者的上肢淋巴水肿明显减轻，外观缩小，平均上臂周径较术前减小4cm，无丹毒发生。结论 皮下组织抽吸加适时弹力压迫治疗乳腺癌术后上肢淋巴水肿，方法简便，近期有效。     

MISSED INJURIES IN THE MULTIPLY TRAUMATIZED

The delayed diagnosis of injuries in traumatized patients is a recognized problem. A retrospective review of trauma patients admitted to a major teaching hospital has been performed. The records of all patients admitted to the intensive care unit (ICU) have been checked to determine the incidence of late diagnosed injuries. The notes written by the staff of the emergency department and the ICU, and the attending surgical registrars have been used as the criteria of initial diagnosis. Comparing them to the injuries listed in the progress notes, investigation reports, discharge summary and follow-up outpatient notes led to the discovery of a number of missed injuries (19 of 50 patients had one or more). In 4 cases the management involved further surgery due to new diagnoses. This is consistent with overseas literature. A review of the literature is presented and methods to improve the missed diagnosis rate are discussed.     

LIMB LENGTH DISCREPANCY IN CONGENITAL TALIPES EQUINOVARUS

A retrospective analysis was performed to establish the prevalence and clinical significance of limb length discrepancy in congenital talipes equinovarus. Of 536 patients with the diagnosis of congenital talipes equinovarus, 259 were unilaterally affected and 277 bilaterally affected. Fifty-eight patients were identified with limb length discrepancy greater than 0.5 cm. Forty-six patients had unilateral foot deformity and in 12 cases that was bilateral. This represented a prevalence of documented limb length discrepancy in 18% of unilateral cases and 4% of bilateral cases. The discrepancy resulted in a surgical procedure to equalize the limb lengths in fourteen unilateral cases (5%). A further six unilateral cases were deemed likely to require limb length equalization, increasing the rate to 8%. Only three bilateral cases required or will require surgery for equalization (1%). There was a weak but significant correlation between the number of operations undergone and the magnitude of discrepancy. The tibia was as important in its contribution to the shortening in these patients as the foot. A total of 89% unilateral cases studied had at least 0.3 cm of tibial shortening and 43% had ipsilateral femoral shortening of at least 0.3 cm.     

ACUTE EFFECTS OF HALOTHANE, NITROUS OXIDE AND THIOPENTONE ON THE UPPER LIMB BLOOD FLOW

The individual immediate effects of thiopentone, nitrous oxideand halothane on the forearm and hand blood flows were studiedin normal unpremedicated volunteers and in patients prior tosurgery. A mercury-in-rubber strain gauge and a water displacementplethysmograph were used on the forearm and hand respectively.Following the administration of the anaesthetics there was ashort-lived decrease in hand blood flow in some of the subjectsfollowed by a considerable increase in all subjects in comparisonto their control measurements. The forearm blood flow was notaffected by nitrous oxide except during mild excitement, whenit increased. Thiopentone had no effect on forearm blood flowor cascular resistance. Holothane produced an increase in flowof 1–3 minutes duration followed by decrease which reachedsignificant levels.     

IPSILATERAL ELBOW AND FOREARM INJURIES IN CHILDREN

Twenty-five children with combined elbow injury and forearm bone fractures have been reviewed. The incidence of serious complications was low, and only one patient was significantly handicapped. Open reduction and internal fixation of the supracondylar fracture with closed treatment of the forearm fracture gave the best results.