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Subtrochanteric fractures of femur
318
INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY
although an unnecessary delay was introduced into the treatment of a small proportion of cases. On the other hand, in a substantial number laparotomy was avoided. Perhaps only to be acted upon by the very experienced. RlCm'ER, R. M., and ZAKI,M. H. (1970), ' Selective Conservative Management of Penetrating Abdominal Injuries ', Surgery Gynec. Obstet., 130, 677. Reducing the Number of Unnecessary Laparotomies after Stab Wounds A contrast medium such as is employed for pyelography is used for injection into abdominal stab wounds. Radiography is then intended to show whether the wound enters the peritoneum or not. Details of technique and precautions are given. The reliability of the positive and negative test results is analysed. HADDAD, G. H., FLEISCHMANN, E. P., and MOYNAHAN, J. M. (1970), ' A b d o m i n a l Signs and Sinograms as Dependable Criteria for the Selective Management of Stabwounds of the Abdomen ', Ann. Surg., 172, 61.
Possible Cause for Post-traumatic Pulmonary Insufficiency Syndrome The pressure required to force blood through a micromesh is an investigation that reveals the presence of debris. Considerable debris was found in banked blood. Microscopic examination of the lump suggests that the debris is filtered out by the pulmonary capillary bed causing micro-emboli. McNAMARA, J. J., MOLOT, M. D., and STREMPL~, J. F. (1970), 'Screen Filtration Pressure in Combat Casualties ', Ann. Surg., 172, 334. Strictured Urethra It is now possible to repair and totally reconstruct the whole length of the urethra so that within the limits of pre-existing sphincter damage, efficient micturition should be possible without the need for subsequent dilatation. The authors stress that every patient with. a stricture should be very carefully assessed. If treatable, the option lies between repeated urethral recalibration (dilatation with or without internal urethrotomy) and urethroplasty appropriate to the particular type of stricture. Permanent urinary diversion is now very rarely required, and even patients who have had a cystostomy for a number of years should be reviewed with a view to urethroplasty. There are indeed occasions when the definitive repair of a urethral injury must take second place • in a patient with multiple injuries, and it is important for all those engaged irt accident surgery to know something of the techniques and possibilities of treatment of one of the major complications. In this country and Western Europe most urethral strictures follow injury or the ill-advised and prolonged use of indwelling urethral catheters following urinary retention from various causes. This article, which is well illustrated and full of detail, repays very careful study. It ends with an excellent short list of the more important recent relevant literature. TURNER-WARWICK, R., and WORTH, P. H. L. (1970), ' Strictured Urethra ', Br. J. hosp. Med., 3, 860.
Injury April 1971
FRACTURES AND DISLOCATIONS
Subtrochanteric Fractures of Femur This is a very practical description of the treatment of these fractures by internal fixation. Adequate assessment of preoperative and operative blood-loss is advocated. Valuable operative details are given, such as the rotation position of the leg and the use of Lowman clamp and circlage wires. The Jewitt nail must be heavy duty. The postoperative rdgime is sensible. A small series is described FROIMSON, A. I. (1970), ' T r e a t m e n t of Cornminuted Subtrochanteric Fractures of the F e m u r ' Surgery Gynec. Obstet., 131, 465. Pretibial Skin Defects Unstable scars over the front of the tibia present serious difficulties in treatment. A large flap is usually needed and local flaps such as the bipedicled strap flap can rarely be used as easily or as safely as appears in diagrams illustrating their possible use. Cross-leg flaps are mutilating to the donor site and cannot always be made large enough to cover adequately the pretibial defects. The authors describe 4 cases in which two bipedicled flaps were raised side by side and moved anteriorly, leaving a longitudinal defect over the calf muscles which was closed with a sheet split-skin graft. A vertical incision is made in the skin and deep fascia in the midline of the calf, with a Y extension at each end of the incision. The two skin-flaps are then raised on each side of this incision by dissection between the crural fascia and the calf muscles. This does not disturb the relationship of the skin, fat, and fascia and therefore helps to safeguard the viability of the flaps. After complete release, the two flaps are sutured together in the pretibial area anteriorly. The secondary defect on the calf is covered with a skingraft. This is a safe and sensible method of dealing with a difficult problem, described in a paper worth study. HARTWELL, S. W., and EVARTS, C. M. (1970), ' Secondary Coverage of Pre-tibial Skin Defects ', Plastic reconstr. Surg., 46, 39. Epiphyseal Fracture of the Humerus A discussion on this injury is initiated by a description of the course of events in a boy of 15 years. Closed reduction without anaesthesia failed. Reduction under general anaesthesia was successful but the deformity recurred within a week. Another manipulation under anaesthesia was unsuccessful and open reduction with fixation by three screws produced a good, stable position. The various types of epiphyseal injuries at the upper end of the humerus are outlined and the treatment recommended was manipulation followed by traction or shoulder spica. In this case loss of position after successful reduction was related to the method of post-reduction splintage (swathe dressing with layer of plaster over the swathe, and sling). The main value of this article is the dissertation on the anatomy of the proximal humeral epiphyses. AUFRANC, O. E., Jor~s, W. N., and BIERBAUM, B. E. (1969), ' Epiphyseal Fracture of the Proximal Humerus ', J. Am. reed. Ass., 207, 727.
INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY
although an unnecessary delay was introduced into the treatment of a small proportion of cases. On the other hand, in a substantial number laparotomy was avoided. Perhaps only to be acted upon by the very experienced. RlCm'ER, R. M., and ZAKI,M. H. (1970), ' Selective Conservative Management of Penetrating Abdominal Injuries ', Surgery Gynec. Obstet., 130, 677. Reducing the Number of Unnecessary Laparotomies after Stab Wounds A contrast medium such as is employed for pyelography is used for injection into abdominal stab wounds. Radiography is then intended to show whether the wound enters the peritoneum or not. Details of technique and precautions are given. The reliability of the positive and negative test results is analysed. HADDAD, G. H., FLEISCHMANN, E. P., and MOYNAHAN, J. M. (1970), ' A b d o m i n a l Signs and Sinograms as Dependable Criteria for the Selective Management of Stabwounds of the Abdomen ', Ann. Surg., 172, 61.
Possible Cause for Post-traumatic Pulmonary Insufficiency Syndrome The pressure required to force blood through a micromesh is an investigation that reveals the presence of debris. Considerable debris was found in banked blood. Microscopic examination of the lump suggests that the debris is filtered out by the pulmonary capillary bed causing micro-emboli. McNAMARA, J. J., MOLOT, M. D., and STREMPL~, J. F. (1970), 'Screen Filtration Pressure in Combat Casualties ', Ann. Surg., 172, 334. Strictured Urethra It is now possible to repair and totally reconstruct the whole length of the urethra so that within the limits of pre-existing sphincter damage, efficient micturition should be possible without the need for subsequent dilatation. The authors stress that every patient with. a stricture should be very carefully assessed. If treatable, the option lies between repeated urethral recalibration (dilatation with or without internal urethrotomy) and urethroplasty appropriate to the particular type of stricture. Permanent urinary diversion is now very rarely required, and even patients who have had a cystostomy for a number of years should be reviewed with a view to urethroplasty. There are indeed occasions when the definitive repair of a urethral injury must take second place • in a patient with multiple injuries, and it is important for all those engaged irt accident surgery to know something of the techniques and possibilities of treatment of one of the major complications. In this country and Western Europe most urethral strictures follow injury or the ill-advised and prolonged use of indwelling urethral catheters following urinary retention from various causes. This article, which is well illustrated and full of detail, repays very careful study. It ends with an excellent short list of the more important recent relevant literature. TURNER-WARWICK, R., and WORTH, P. H. L. (1970), ' Strictured Urethra ', Br. J. hosp. Med., 3, 860.
Injury April 1971
FRACTURES AND DISLOCATIONS
Subtrochanteric Fractures of Femur This is a very practical description of the treatment of these fractures by internal fixation. Adequate assessment of preoperative and operative blood-loss is advocated. Valuable operative details are given, such as the rotation position of the leg and the use of Lowman clamp and circlage wires. The Jewitt nail must be heavy duty. The postoperative rdgime is sensible. A small series is described FROIMSON, A. I. (1970), ' T r e a t m e n t of Cornminuted Subtrochanteric Fractures of the F e m u r ' Surgery Gynec. Obstet., 131, 465. Pretibial Skin Defects Unstable scars over the front of the tibia present serious difficulties in treatment. A large flap is usually needed and local flaps such as the bipedicled strap flap can rarely be used as easily or as safely as appears in diagrams illustrating their possible use. Cross-leg flaps are mutilating to the donor site and cannot always be made large enough to cover adequately the pretibial defects. The authors describe 4 cases in which two bipedicled flaps were raised side by side and moved anteriorly, leaving a longitudinal defect over the calf muscles which was closed with a sheet split-skin graft. A vertical incision is made in the skin and deep fascia in the midline of the calf, with a Y extension at each end of the incision. The two skin-flaps are then raised on each side of this incision by dissection between the crural fascia and the calf muscles. This does not disturb the relationship of the skin, fat, and fascia and therefore helps to safeguard the viability of the flaps. After complete release, the two flaps are sutured together in the pretibial area anteriorly. The secondary defect on the calf is covered with a skingraft. This is a safe and sensible method of dealing with a difficult problem, described in a paper worth study. HARTWELL, S. W., and EVARTS, C. M. (1970), ' Secondary Coverage of Pre-tibial Skin Defects ', Plastic reconstr. Surg., 46, 39. Epiphyseal Fracture of the Humerus A discussion on this injury is initiated by a description of the course of events in a boy of 15 years. Closed reduction without anaesthesia failed. Reduction under general anaesthesia was successful but the deformity recurred within a week. Another manipulation under anaesthesia was unsuccessful and open reduction with fixation by three screws produced a good, stable position. The various types of epiphyseal injuries at the upper end of the humerus are outlined and the treatment recommended was manipulation followed by traction or shoulder spica. In this case loss of position after successful reduction was related to the method of post-reduction splintage (swathe dressing with layer of plaster over the swathe, and sling). The main value of this article is the dissertation on the anatomy of the proximal humeral epiphyses. AUFRANC, O. E., Jor~s, W. N., and BIERBAUM, B. E. (1969), ' Epiphyseal Fracture of the Proximal Humerus ', J. Am. reed. Ass., 207, 727.