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Background Hand fractures are common and sometimes require surgery to restore function. Placement of Kirschner wires (K-wires) is the most common form of surgical fixation. After placement, a key decision is whether to bury the end of a K-wire or leave it protruding from the skin (exposed). A recent systematic review found no evidence to support either approach and a national clinician and surgeon survey demonstrated further uncertainty. We aim to determine the design of a definitive randomised controlled trial assessing the cost and clinical effectiveness of buried versus exposed Kirschner wires for adults with metacarpal or phalangeal fractures. Methods We will employ three methodologies: a national service evaluation of current clinical practice, patient and surgeon focus groups and a consensus meeting to finalise the protocol for a randomised controlled trial. For the service evaluation, all outcomes will be summarised using descriptive statistics overall and split by group (buried versus exposed K-wires). Information collected in the patient focus groups will be analysed thematically. The surgeon consensus meeting will address each part of the design in turn and through discussion agree a final protocol. Discussion The study may be monitored, or audited in accordance with the current approved protocol, Good Clinical Practice (GCP), relevant regulations and standard operating procedures. The Chief Investigator will submit and, where necessary, obtain approval from the above parties for all substantial amendments to the original approved documents. A feasibility study report will be published by the Wire Study Steering committee. Additional members of the steering group and citable collaborators will be listed within the manuscript and their roles identified.

Background: Electively-managed conditions account for over 100 000 inpatient surgeries a year in the English National Health Service alone, with further procedures in other regions of the UK, or performed on an outpatient basis. To quality assure this care and to conduct research, effective outcome measurement is critical. Traditional surgeon-centric outcome measures correlate poorly with hand function and are seldom important to patients. There has been an advent in the use of patient reported outcome measures (PROMs) in hand surgery although consensus of PROM choice appears to be lacking. This systematic review aimed to describe the use of relevant PROMs in clinical research of electively-managed hand conditions. Methods: A PRISMA-compliant methodology was used. A bespoke search strategy was developed in conjunction with a search strategist, and applied to Medline, EMBASE, CINAHL and PSYCHINFO from 1992 to June 2017. Pre-specified stepwise inclusion criteria were used to identify studies describing adult patients undergoing treatment for electively-managed hand conditions distal to the distal radius, with clinical outcomes measured using one or more PROMs. Results: Of 4554 results, 834 met inclusion criteria. PROMs identified included 9 disease-specific, 8 site-specific and 4 generic quality of life measures. Across all, the Disabilities of the Arm, Shoulder and Hand (DASH) was the most commonly used (overall frequency 41.0%). The most commonly reported disease-specific measure was the Boston Carpal Tunnel Questionnaire (overall frequency 23.0%). The most commonly reported generic quality of life of measure was the SF-36 (overall frequency 4%). Time-analysis demonstrated predominance of site-specific PROMs since the year 2000. Conclusions: Various PROMs have been used to study electively-managed hand conditions, with site-specific PROMs most popular. However, there appears to be limited consensus on choices. A future systematic evaluation of the published psychometric properties of identified PROMs may inform standardisation of measurement.

The mainstay of autologous breast reconstruction involves abdominal wall-based tissue transfer in the form of free or pedicled TRAMs or more recently free DIEP flaps. Although excellent choices for breast reconstruction, all of these techniques do have significant morbidity when considering donor-site pain. This can lead to other complications such as reduced mobility, deep vein thrombosis, pulmonary emboli, respiratory infections, heavy opiate use, constipation and prolonged in hospital stay. Minimising postoperative donor-site pain is therefore of paramount importance. This article provides a review of the forms of analgesia available in the literature and in use in clinical practise. It is a summary of the published studies and exciting future options in this field. A literature search was performed through Medline, EMBASE, Cochrane database and Google Scholar for any previous research publications pertaining to postoperative analgesia in patients undergoing autologous breast reconstruction using abdominal tissue. We reviewed all articles with the aim to evaluate the current knowledge and evidence of analgesic techniques in autologous breast reconstruction including benefits, limitations, indications and patient outcomes. The literature search yielded a total of 31 articles identifying 6 analgesic techniques: patient-controlled analgesia (PCA), epidural analgesia, continuous wound infusion with local anaesthetic, intermittent boluses of local anaesthetic, transverse abdominis plane (TAP) blocks and slow release bupivicaine. Various anaesthetic techniques are used to reduce postoperative mortality in autologous breast reconstruction. Knowledge of these techniques is paramount as it reduces complications and expedites discharge in this group of patients. Level of Evidence: Not ratable.

Fractures of the upper extremity are common with bones in the hand most frequently fractured. Hand fractures are typically seen in men of working age, distal radius fractures in an older population following a fall and supracondylar fractures in children.1 Kirschner wire (K-wire) fixation is the most common method of surgical fixation. One of the key decisions is whether to bury or not to bury the wire ends. Current popular opinion suggests that buried wires reduce infection rates. However, burying wires still retains a risk of erosion through the skin with subsequent pin site infection. It is also unclear whether a pin site infection of a non-buried wire affects outcomes and is significant risk factor for deep bone infection. The aim of this systematic review was to evaluate the current evidence to support decision-making as to whether K-wires should be buried or not buried following fracture fixation in the upper extremity with regards to post-operative outcomes.

Autologous nerve grafts are the current criterion standard for repair of peripheral nerve injuries when the transected nerve ends are not amenable to primary end-to-end tensionless neurorrhaphy. However, donor-site morbidities such as neuroma formation and permanent loss of function have led to tremendous interest in developing an alternative to this technique. Artificial nerve conduits have therefore emerged as an alternative to autologous nerve grafting for the repair of short peripheral nerve defects of less than 30 mm; however, they do not yet surpass autologous nerve grafts clinically. A thorough understanding of the complex biological reactions that take place during peripheral nerve regeneration will allow researchers to develop a nerve conduit with physical and biological properties similar to those of an autologous nerve graft that supports regeneration over long nerve gaps and in large-diameter nerves. In this article, the authors assess the currently available nerve conduits, summarize research in the field of developing these conduits, and establish areas within this field in which further research would prove most beneficial.

The penis is a vascular organ that acts as a conduit for urine and semen as well as allowing men to engage in penetrative sexual intercourse. Several techniques have been described over the years which aim to restore both its form and function but these are difficult to perform in cases of advanced malignancy, which extensive surgical resection resulting in large defects in the pubic and inguinal area and also the perineum. Therefore an understanding of plastic surgery techniques helps to ensure that defects following surgery can be closed.

Melanoma is a common malignancy with a high survival rate amongst those diagnosed early. The management of advanced disease is challenging, and current chemosurgery techniques have minimal effect on survival. Nanotechnology, offers great potential in revolutionizing the management of melanoma. New molecules and nanoparticles are designed worldwide in an aim to improve the diagnosis and spread to sentinel lymph nodes and other organs. Novel drug delivery systems are formulated to optimise the distribution and pharmacokinetics of chemotherapeutic agents while reducing their toxic effects. The scope of such molecules extends to therapeutic applications including photodynamic and photothermic therapy where light is converted to heat to combat neoplastic lesions; immunotherapy where nanoparticles are used as immunomodulators or vaccines against cancer cells; and gene therapy which targets pro-oncogenes on signal transduction pathways. This review paper presents current knowledge of the use of nanotechnology in the management of cancer, with a focus on melanoma.

Background: The exponential development of the Internet and mobile phone technology has led clinicians to interact with a more informed patient population with higher expectations. Health care providers on the other hand are under duress to deliver quality care within their financial constraints. Trauma registries are an integral component of a comprehensive trauma care system. They are used for research, education, performance improvement, and patient and public involvement (PPI). Hand trauma registries with patient and therapy outcomes are virtually nonexistent. There is a critical need for a bespoke system that addresses the current issues, multilingual, and resilient to future developments. Materials and Methods: We have collaborated with several key stake holders in the field of hand trauma and designed a Hand Trauma Registry that can be easily customizable and used across various parts of the world. We have chosen PostgreSQL, which is the world’s most advanced open source database for our design. The chosen platform for the front-end framework is Bootstrap, which has a fluid grid layout that dynamically achieves responsiveness. The registry incorporates all popular patient-related outcome measures (PROMs) with a provision to add multiple customizable PROMs. Results: The registry is a collective database of traumatic injury event as well as their outcome measures. This allows us to compare against multiple data sets: different clinicians, institutions, patient population, and national and international standards. Conclusion: To address the demands of the 21st-century patients, we have designed and developed a bespoke system that is both redundant and resilient. This is an invaluable tool for improving outcomes for patients and the international health care community as a whole.

Summary Complex regional pain syndrome (CRPS) is a chronic progressive disease characterised by severe pain, swelling and changes in the skin. Precipitating factors include injury and surgery, and a variety of causes have been described. We present the case of a 68-year-old lady who presented with features indicative of a CRPS following steroid injection for a ‘trigger' thumb.

A 6-year-old boy presented following a transient crush injury to his forearm. He displayed mild abrasions but no laceration or associated fractures. The injury resulted in traumatic rupture of the ulnar artery, which caused a large forearm haematoma and an acute forearm compartment syndrome. Prompt clinical diagnosis and operative intervention were required to prevent disastrous consequences.