Split-thickness skin excision can be used as a one-stage procedure for the accurate diagnosis of flap viability and the immediate treatment of friction-avulsion injuries in severe open fractures. After cleaning the wound, the avulsed flap is temporarily sutured back to its original bed and a split thickness graft is taken from it and meshed to a 1:3 ratio. Surface dermal capillary bleeding then serves as an indicator of viability, clearly displaying a line for the excision of devascularized skin and correlating well with a concomitant fluorescein test. The wounds are re-opened and, after fixation of the fracture, the viable part of the flap is returned to its original bed and the remaining defects are covered with the meshed graft. We have treated 16 patients with extensive degloving injuries in this way, 15 needing only the single surgical procedure. All retained flaps survived, no other donor sites were needed and the split-thickness grafts took with 90% to 100% success.

Reports of spondylolysis in vertebrae other than those of the lower lumbar spine are rare. We report 32 patients with upper lumbar spondylolysis who have been studied clinically, radiologically and scintigraphically. Twenty patients had bilateral lesions, and seven of those with unilateral lesions had structural changes or anomalies in the opposite posterior arch. Positive scans were found to be associated with a short clinical history, and indicated stress-related lesions. Our findings suggest that mechanical factors may play a role in the aetiology of spondylolysis in the upper lumbar spine similar to that which they play in the lower lumbar spine, and that local structural anomalies may contribute to abnormal loading of these vertebrae.

The outcome of various types of treatment for femoral fracture in children with head injury was studied retrospectively in 51 patients with 56 fractures. Of these, 36 patients (71 per cent) were in deep coma and scored 5 to 7 on the Glasgow scale. Forty-three children (84 per cent) were eventually able to walk freely. Open reduction and internal fixation proved an attractive solution for femoral fractures in children with head injury who could tolerate general anaesthesia: intramedullary nailing was safe and gave satisfactory results in 16 fractures but infection complicated three of the five fractures which were plated.

Paraplegia occurred in an adolescent girl with osteogenesis imperfecta after chiropractic manipulation. The child had been able to walk freely out of doors. Complete motor paralysis with sensory sparing resulted due to anterior compression of the cord by spondyloptotic cervical vertebrae. Reconstructed computerised tomography was very helpful in demonstrating the abnormality. Anterior and then posterior decompression relieved the tethered spinal cord and were supplemented with bone grafting. Early diagnosis and surgical treatment will prevent similar neurological accidents.