Timothy P. Crowley

The Flexor Tendon Pulley System and Rock Climbing

Rock climbing has increased in popularity over the past two decades. Closed traumatic rupture of the finger flexor tendon pulleys is rare among the general population but is seen much more commonly in rock climbers. This article reviews the anatomy and biomechanics of the finger flexor tendon pulleys, how they may be injured in rock climbing and how these injuries are best diagnosed and managed.

Early active mobilization following UCL repair With Mitek bone anchor.

Ulnar collateral ligament (UCL) injuries of the thumb are common. Surgical repair is accepted as the treatment of choice for complete rupture of the ligament. Biomechanical studies have suggested that Mitek bone anchor repairs are potentially safe and strong enough to allow early controlled active mobilization. To date, there have been no studies to compare early active mobilization following Mitek bone anchor repair to standard postoperative rehabilitation involving thumb spica immobilization for the first 4 to 6 weeks. We performed a small pilot randomized control trial to assess the outcome of this new rehabilitation technique to that of standard immobilization following UCL repair with Mitek bone anchor. Our results show that on average early active mobilization leads to an earlier return to full hand function (6 vs. 8 wk) and an earlier return to work (7 vs. 11 wk). There is no difference in the final range of motion achieved. We suggest that Mitek bone anchor repairs for UCL ruptures are robust enough to allow early active mobilization and that a larger trial is warranted to assess whether early active mobilization is superior to standard rehabilitation.

Current concepts, which effect outcome following major hemorrhage

There are a multitude of factors, which effect outcome following major trauma. The recent conflict in the middle-east has advanced our knowledge and developed clinical practice, here within the UK. This article reviews the current and emerging concepts, which effect the outcome of patients sustaining major hemorrage in trauma.

A free anterolateral thigh flap for pharyngeal reconstruction following dynamic hip screw femur fixation

Dear Sir, The free anterolateral thigh flap (ALT) is a fasciocutaneous flap first described in 1984 by Song, Chen, and Song (1984) and is usually based on either the musculocutaneous or septocutaneous perforators of the descending branch of the lateral circumflex femoral artery. It was first described for use in head and neck reconstructive surgery by Koshima et al. (1993) and has grown in popularity due to its long pedicle length, ease of harvest, and large amount of skin available. It is also used as a tubed fasciocutaneous flap for complete pharyngeal reconstruction. Dynamic Hip Screw (DHS) procedures are a well-established open reduction and internal fixation method for the treatment of extracapsular neck of femur fractures. AO guidelines state that a lateral approach to the proximal femur should be performed and following incision of the fascia lata the vastus lateralis muscle can be either reflected anteriorly if bulky or split longitudinally if atrophic (Raaymakers, Schipper, Rogier, & Werken, 2010). If split, this can result in damage to the musculocutaenous perforating vessels needed for a fasciocutaneous ALT flap. We recently encountered a case of a 54-year-old man who had previously undergone bilateral DHS procedures following extracapsular neck of femur fractures a number of years back. He was diagnosed with a laryngeal squamous cell carcinoma (SCC) and had a laser resection procedure followed by a functional laryngectomy for severe dysphagia. The pharynx was reconstructed with an anterior patch using a fasciocutaneous medial sural artery perforator free flap. An ALT flap was avoided due to previous DHS procedures and scarring on the lateral thigh. The procedure was successful but unfortunately histology of the resected larynx revealed recurrent SCC deposits with incomplete margins. It was decided to attempt a salvage procedure with redo total pharyngectomy and bilateral neck dissections. Total pharyngeal reconstruction with anterior neck skin replacement was indicated. Our flap of choice in this situation would be a chimerised tubed fasciocutaneous ALT free flap. We sought advice as to whether an ALT would be possible following DHS femur fixation and found that there was little published literature. Thankfully we were able to confirm that the orthopedic surgeon who performed the DHS reflected the vastus laterallis muscle rather than split it. This combined with good pre-operative handheld Doppler signals for perforators from the descending branch of the lateral circumflex femoral artery reassured us and we chose to proceed. (Figure 1). Intraoperatively, the flap was found to be pristine with virgin perforators and was raised and chimerised on these perforators before

Herpes Zoster Masquerading as a Chemical Burn Secondary to Hair Dye.

Chemical burns secondary to hair dye are very rare but have been reported. Here, we present a case of herpes zoster, which was initially mistaken for a chemical burn. Herpes zoster reactivation (shingles) is common and can give rise to skin loss clinically similar to that of a burn. It is important that clinicians consider this alternative diagnosis to ensure that timely antiviral therapy is initiated so as to reduce further skin loss and future scarring.

A Novel External Fixator Used to Treat Open Comminuted Fractures of the Middle and Distal Phalanges With Concomitant Fdp Avulsion Injury

The use of external fixators for treating comminuted hand fractures has become popular with commercially available or handmade fixators assembled in the operating theater. We present a case of a Zone I flexor digitorum profundus (FDP) avulsion fracture that was complicated by the presence of open, comminuted fractures of the distal and middle phalanges. The injury was treated using an external fixator constructed in the operating theater from readily available materials and with a 4-strand pullout suture technique tied over a button to repair the FDP avulsion. This technique facilitated treatment of the comminuted and contaminated fractures while allowing reconstruction of the Zone I FDP injury and allowing relatively early mobilization of the FDP repair.

Spontaneous auricular seroma

We present a case of spontaneous seroma of the ear, which can be encountered in the plastic surgery clinic. We describe our management and briefly review the literature regarding this interesting condition.