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We have studied the effects of sustained local anaesthesia on postoperative mobilization of the injured hand. Small epidural catheters were placed adjacent to the peripheral nerves providing sensation to the involved part of the hand under direct vision in the distal forearm. Repeated doses of 0.5% bupivacaine were then administered during mobilization therapy to relieve pain. Fourteen out of 24 digits (60%) recorded 30° or more increases in active range of motion after bupivacaine injection. The cases that failed to improve had suffered severe injuries. Complications were few and were easily managed as the catheters were distal, superficial and accessible. This is an effective, specific and safe method of providing sustained postoperative analgesia for mobilization.

Fixation of small bones in the adult and the child’s hands remains a challenge. The authors present a technique of bone fixation using customized staples made intraoperatively from K-wires (0.9–1.6 mm in diameter). Their specific purpose was to provide axial alignment and rotational stability for carpal bone fixation and for epiphysiodesis in phalanges. This technique was used in 14 cases (11 adult and three paediatric). No bone shattering, implant breakage, implant loosening or infection occurred. As K-wires are quite malleable, custom sized and shaped staples which follow the bone contours could be made to give a more exact fixation. All cases had satisfactory outcomes, achieving the preoperative objectives of bony fixation. This method is safe, precise and technically easy. It is also relatively cheap and only requires simple, standard instruments.

Glomus tumour is a benign lesion arising from the glomus apparatus of the skin and subcutaneous tissue. Glomangioma is the angiomatous variant, which is uncommon. We report a very rare presentation of a glomangioma with multiple recurrences. We advocate preoperative angiography to delineate the extent of the lesion to facilitate complete excision.

A rare case of an epitheloid haemangioendothelioma presenting as an aggressive soft tissue mass in the wrist of an infant is presented. The management of the lesion presents particular difficulties because of its diffuse involvement of surrounding muscles, tendons and neurovascular bundle and the importance of preserving hand function. The epitheloid haemangioendothelioma rarely occurs extravascularly with less than 15 such cases reported in the literature.

An anatomical study in 25 cadaveric upper limbs quantified the communications between the radial and ulnar arteries immediately proximal to the carpus. These studies suggest that the reverse radial forearm flap can safely be used in severe hand trauma where reliable pre-operative assessment of the palmar collateral circulation is not possible. It is recommended that the pedicle is pivoted 4 cm from the styloid process at which point there is a 96% probability of leaving the superficial palmar branch and one other communication intact and a 77% probability of leaving two other communications intact. Two clinical cases are outlined for illustration.

Three patients presented with upper limb problems caused by the loss of the proximal ulnar shaft due to osteomyelitis which occurred in early childhood. The three patients had several features in common: instability of the elbow, dislocation of the radial head and shortness and bowing of the forearm, but hand and wrist function were largely unaffected. One patient had evidence of impaired function of the posterior interosseous nerve, presumably a traction injury. The treatment of these problems is discussed. In one patient, a child who had a functioning ulno-humeral joint, successful reconstruction of the ulna using a vascularised fibular graft was possible.

A case of traumatic skin and bone loss at the elbow is described. This was treated by a long brachioradialis flap, allowing early movements with thick and sensate cover. Anatomical studies delineate the extent of this flap.

Histological studies of vascularised nerve graft versus conventional nerve graft were performed in eighteen rat femoral nerves using microsurgical technique. The experiment showed that there was no difference in the degree of vascularisation, reticulin framework collapse, rate and extent of axonal regeneration and remyelination between the two groups.

A forty year old housewife presented with a recurrent chondrosarcoma in a vascularised fibular transplant for a tumour in the proximal humerus. The Tikhoff-Linberg procedure was carried out with satisfactory results. The case report serves to emphasize the need to be aggressive in the initial management of malignant bone tumours. Careful planning and execution of a further aggressive procedure in the presence of a recurrence, ensures adequate clearance of tumour while still preserving a functional and useful limb.