‘Ganglions’

The ganglion cyst is the commonest soft-tissue swelling in the hand and wrist. It is a fibrous swelling that arises near a joint or tendon sheath, and contains clear mucinous fluid. The exact pathogenesis of the ganglion is unknown, although various theories quote anatomical and physiological evidence to support them. Ganglia can occur near any joint in the body, although they are encountered most commonly in the wrist and hand. They can present in a diverse number of ways. In cases of diagnostic uncertainty, they can be investigated by imaging techniques. If a ganglion is symptomatic, it should be treated by conservative means initially including aspiration. Steroids have no place in their management. If this strategy fails, then excision is required, it should be radical to minimise the risk of recurrence. Further research into the pathophysiology may allow improvement in treatment.     

‘STAB AND SPLIT’: A ‘BLOODLESS’ AND ‘SCARLESS’ SKIN INCISION TECHNIQUE FOR MINOR SURGERY

The ‘stab and split’ skin incision technique was applied to children requiring minor surgery. A small stab incision was made on a skin crease and split open with mosquito forceps. After the surgical procedure was completed, the wound was closed in layers with a subcuticular suture to the skin. In all cases, splitting caused virtually no blood loss because subcutaneous veins were left intact, and the wounds healed well, especially in infants. ‘Stab and split’ is an effective alternative incision technique for minor surgery in younger children.     

‘CELLO SCROTUM’ HOAX

Renal cell carcinoma (RCC) is among the most resistant tumours to chemotherapy, radiotherapy and hormonal therapy. Cytokine therapy is effective in a small subset of patients, but it is associated with substantial toxicity and rarely benefits patients with extensive tumour burdens or adverse prognostic factors. Since 2005, clinical trials have shown significant clinical benefits for five molecularly targeted therapies in patients with advanced RCC. These agents constitute two mechanistic classes: (i) angiogenesis inhibitors targeting the vascular endothelial growth factor (VEGF) ligand (bevacizumab, in combination with interferon‐a) or VEGF receptors (sunitinib, sorafenib); and (ii) inhibitors of the mammalian target of rapamycin (mTOR) signalling (temsirolimus, everolimus). This review assesses the mechanistic distinctions and functional overlaps of these classes of agents, and discusses key characteristics of their respective clinical efficacy and side‐effect profiles in patients with RCC, some of which might affect patient selection and treatment strategies. Current research is designed to optimize the use of these agents, as well as the development of new investigational therapies within these mechanistic classes. The differences and synergies are particularly important for understanding the best ways to integrate VEGF/VEGF receptor inhibitors and mTOR inhibitors for combination or sequential treatment of patients with advanced RCC.     

‘Soccer supporter''s wrist’

Hyperextension injury to the wrists occured in seven adolescents attending football matches in this country. Clinical details of these injuries are recorded and the mechanism of injury is discussed.     

EXTRAPERITONEAL ‘LAPAROSCOPIC’ ADRENALECTOMY

The technique of extraperitoneal ‘laparoscopic’ adrenalectomy is described in two cases, a left sided 1 cm Conn's tumour and a right sided 3.5 cm incidental non-functioning tumour. The extraperitoneal approach has the advantage of direct access to the adrenal gland without the need to mobilize abdominal organs, while maintaining all the advantages of minimal access surgery.     

‘Small blocks’ in paediatric patients

Regional anaesthetic techniques are now extensively used in paediatric anaesthesia. A better understanding and conceptualization of them has led us to define a new category of blocks, termed compartment blocks, in which the structure that has to be identified is a fascial plane, not the nerve to be blocked itself. Some of these compartment blocks, most of which have been described decades ago but fell into disuse, have now been rediscovered as they offer many advantages in terms of safety, efficiency and simplicity. These ‘small blocks’ share the same high benefit/risk ratio and, basically, the same technique of fascial plane localization; this makes them look very similar even though they involve various structures and nerves with no real anatomical link. In this category are included the peri-umbilical, ilioinguinal/iliohypogastric, pudendal, penile, fascia iliaca, saphenous nerve, metacarpal and laryngeal nerve blocks. These small blocks provide adequate analgesia for a number of very common procedures in paediatric patients; they do not require special skills, training, complicated or expensive devices. Their success rate is extremely high and they have no true contraindications or significant adverse effects. They are effective with only small amounts of local anaesthetics and thus, due to their many advantages, should be used extensively in children.