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Prospective evaluation of the one-stage procedure in 32 patients who suffered from 37 severe friction-avulsion injuries was carried out. Most injuries (81%) were in the lower extremity. Split-thickness skin excision was used for immediate diagnosis of flap vascularity and wound coverage. Split-thickness skin was harvested from the avulsed flap surfaces after they were temporarily sutured back to their original bed. Dermal capillary bleeding served as an indicator for tissue viability, thus delineating a clear line for debridement. All compartments were decompressed, and debridement of all devascularized tissues was performed. Most fractures were fixed with interfragmentary screws and external fixators. Viable parts of the avulsed flaps were sutured back to their original bed and exposed bones were covered with transposed muscles. Skin defects were grafted with the split-thickness skin that was harvested in the first stage and was meshed 1:3 to allow drainage. Most patients (26 out of 32) had only one surgical procedure for their extensive injuries. The split-thickness skin excision is effective in the establishment of debridement borders and helps in saving maximal viable flap area (49.4%). All wounds healed with no major wound complications. The split-thickness skin excision can be used immediately in the care of severe crush injuries, compartment syndromes, and open fractures as a one-stage procedure with the following advantages: (1) reliable diagnosis of flap vascularity, (2) immediate wound coverage with the possibility of drainage, (3) elimination of further debridements procedures, (4) elimination of distant skin donor wounds, and (5) less hospitalization.

Fracture dislocation at the base of the fifth metacarpal is a rare injury. Fewer than 25 cases have been published in the English-language literature. A force acting along the longitudinal axis of the fifth metacarpal causes a fracture dislocation at the base of the bone in a dorsal-ulnar direction, because of the anatomy of the joint and the mechanical properties of the bone and the intermetacarpal ligament. The mechanism of other types of injury to this joint, namely dorsal-radial or palmar-radial dislocation of the base of the fifth metacarpal is different. A case is presented which demonstrates the mechanism of the fracture dislocation.

The motor points of spastic wrist and finger flexors were identified using a nerve stimulator. These motor points were injected percutaneously with either a 3% or 5% aqueous solution of phenol in 11 patients with brain injury. The effectiveness of the blocks was assessed by recording the resting angle of the wrist, active extension of the wrist, and passive extension of the wrist--first with the fingers flexed and then with the fingers extended. The blocks were repeated once in two patients and twice in one patient for return of muscle tone which interfered with hand function. Relaxation of muscle tone persisted for up to two months following the injections. The resting angle of the wrist improved a mean of 25 degrees. Active wrist extension improved an average of 30 degrees. The changes in wrist measurements represent the effects of different processes: 1) the neurolytic effect of the phenol block; 2) improvement in the neurologic status of the patient; and 3) regeneration of the motor end plate. This procedure is an effective method of temporarily controlling spasticity and allowing functional hand training while neurologic recovery is occurring.

An unusual fetal heart rate (FHR) pattern was detected in a patient with sickle cell crisis in early labor. Despite the potentially ominous significance of this pattern, immediate delivery by cesarean section had to be deferred because of maternal contraindications. Institution of treatment directed at possible etiologic factors failed to correct the heart rate abnormalities. An attempt at symptomatic treatment by administration of propranolol to the mother was successful and was associated with good fetal outcome.

The instantaneous heart rate of 65 healthy neonates was continuously monitored during labor and the first 30 minutes of neonatal life. It was found that infants who had moderate or severe variable decelerations in utero had a significantly delayed neonatal heart rate (NHR) reactivity without any evidence of perinatal asphyxia. The NHR pattern of infants with and without variable decelerations is described and possible mechanisms which could explain the delayed NHR reactivity are discussed.

The present study utilizing an open label design evaluates the efficacy of prostaglandin F2alpha in the induction of labor in normal and complicated primigravid and multigravid pregnancies and in particular in patients with an unripe cervix. The results reveal that labor was successfully induced in 33 of 38 (86.8 per cent) normal patients in the 0 to 5 Bishop group and in 17 of 18 (94.4 per cent) in the 6 to 13 Bishop group. In the complicated pregnancies (abnormal group) 26 to 28 (84 per cent) in the 0 to 5 Bishop group and 13 of 13 (100 per cent) in the 6 to 13 Bishop group were successfully induced. There were two cesarean sections for obstetric indications. Hypertonus occurred only four times and responded to dose reduction. The most common problem--nausea and vomiting (29 per cent)--was easily controlled. Prostaglandin when judiciously used appears to be a safe drug for the induction of labor at term in normal as well as complicated pregnancies and in patients with low inducibility scores.

Simultaneous bilateral fractures of either the femoral necks or the humeral heads are rare injuries. Four simultaneous fractures of both femoral necks and humeral heads have not been previously described. The case reported occurred after an epileptic convulsion in a woman with multiple metastases from breast cancer.