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Tuberous sclerosis complex (TSC) is now known to be associated with pulmonary lymphangiomyomatosis (PLAM). Patients with either isolated PLAM or pulmonary involvement in TSC suffer from progressive respiratory failure and death within ten years of diagnosis. We report a case of TSC with PLAM, and a short review of recent literature regarding the conditions.

Background: A study to assess the use of the external fixator in the treatment of intra-articular fractures of the distal radius was initiated in late 1994., Method: Thirty patients with these fractures have been treated at our hospital between 1991 and 1994 with the use of either the AO or the Pennig external fixator. The patients were assessed at least one year post-operatively (mean 90.2 weeks) after a course of physiotherapy., Results: The majority of patients (65%) had either good or excellent results, based on objective and subjective criteria. The common complications included early finger stiffness, pintract infections and loss of reduction.

Thirty-five patients who sustained humeral shaft fractures were treated by open reduction internal fixation using AO techniques between 1992 and 1997. Open fractures occurred in 8 patients. Primary radial nerve palsy was present in 5 cases. In 16 patients an open fracture or multiple trauma, or both were indications for surgery. Eight osteosynthesis were performed after failed conservative treatment. The complications encountered were non-union (2 cases), osteomyelitis (2 cases), secondary radial nerve palsy (3 cases) and repeat surgery (4 cases). Bony union averaged 5.3 months radiographically. All cases of radial nerve palsy recovered eventually. Twenty-seven patients reported no pain. Twenty-six patients had full range of motion in the shoulder and elbow. Thirty-three patients had full muscle strength. Open reduction internal fixation gives good results provided correct indications and principles of fixation are adhered, and is a good alternative to conservative treatment. We advocate operative reduction internal fixation and nerve exploration in fractures associated with radial nerve palsy.

Simultaneous dislocations of the interphalangeal and metacarpo-phalangeal joints are rare. Most of the previous reports in the literature concerned closed injuries which were not associated with neurovascular involvement and were easily reduced and had favourable outcomes. They were also mainly due to a dorsally directed force on a hyperextended digit. We report a case of this rare injury due to a torsion force in a power drill accident resulting in an open injury with neurovascular damage and gangrene of the thumb distal to the wound despite re-vascularisation attempts.

We report a case of massive chylothorax occurring postoperatively in a patient with Potts paraplegia who underwent transthoracic anterior debridement and fusion of the T7 and T8 vertebrae. This is an uncommon complication of anterior spinal surgery but has a significant morbidity and mortality. Diagnosis of the condition and the institution of the appropriate therapy will reduce this significantly. The treatment principles are continuous tube drainage, nutritional support and reduction of chyle production. In 50% of cases a surgical procedure will be required. There are a variety of techniques available. We describe a technique that uses a pedicled intercostal muscle flap, which to our knowledge, has not been described previously. Among the other techniques, video-assisted thoracoscopic surgery is the most promising because of its low morbidity.

Simultaneous metatarsophalangeal and interphalangeal dislocations of the big toe are rare injuries. Gangrene of the big toe following open dislocations was reported in a 20-year-old man.

Necrotising fasciitis is a disease that still carries a high morbidity and mortality despite our better understanding and advances in treatment since 1924 when Meleney first studied it. In our Department of Orthopaedics, this condition appears to be on the increase, and we therefore felt this entity deserved a restudy. Since 1985, 15 cases were seen, of which 10 were encountered in 1989. There were no recorded case prior to 1985. Our initial results show that the background and outcome parallel that of previous authors. Most were elderly with some form of underlying chronic disease. The duration from symptom onset to presentation was short, with many being in a state of septicaemia at the time of admission with fever, metabolic acidosis and marked leucocytosis. Repeated desloughings were common, and four ended up with some form of limb amputation. As with Meleney's study, the consistent pathogen cultured was B-haemolytic streptococcus. Our recommendation is that we should be more aware of this entity in view of its fulminant course, with early and aggressive surgical intervention being the keystone to management.

Septic arthritis is an uncommon, yet serious disorder in the newborn. Most patients survive with permanent handicaps. We encountered 11 cases of neonatal septic arthritis in the Hospital over the past 17 years (1971-87), an incidence of 0.12 per 1000 livebirths or 0.67 per 1000 admissions to the neonatal nursery. The clinical experience is presented. The diagnosis of septic arthritis in the newborn is more difficult than in the older children. Joint swelling (10/11), tenderness (9/11) and limitations of joint movement (8/11) were the common presenting clinical signs. Constitutional symptoms (fever, leucocytosis, gastrointestinal disturbances) were unremarkable. More than half of the babies (6/11) were prematurely born. The knees and the hips were frequently infected, many had multiple joint involvement (6/11). Septic arthritis commonly manifested between 20-40 days of life. The causative agents viz. Staphylococcus aureus (4/11), Candida (2/11), Citrobacter (1/11) and Methicillin Resistant Staphylococcus aureus MRSA (4/11) showed that septic arthritis was a nosocomial infection. Many babies (9/11) had insertion of intravascular catheter for 1-3 weeks and 9/11 babies had concomitant positive blood culture, 2/11 coexisting osteomyelitis and 1, meningitis. Though there was no death, majority of the babies had joint destruction and severe handicap. Early diagnosis including frequent examinations of joints, prompt treatment and control of nosocomial infection are important in management.