No abstract

Tendon transfer of the flexor digitorum longus tendon (FDLT) or the flexor hallucis longus tendon (FHLT) into the tibialis posterior tendon is carried out in patients with tibialis posterior dysfunction. FDLT and FHLT are connected in the region of the knot of Henry. The present study has investigated the anatomical variations of this tendinous interconnection. The results could be used to determine which of the two tendons should be transected proximal to the region of the knot of Henry in the surgical treatment of tibialis posterior dysfunction. In over two-thirds of cadaver specimens investigated, tension applied solely to FHLT resulted in flexion of all digits and the hallux. On the basis of these results, we propose that identification of the tendon to be transected should be decided at the time of surgery depending on the anatomical pattern. Based on the evidence provided by 16 cadaveric dissections, transection of FDLT proximal to the region of the knot of Henry for the repair of tibialis posterior dysfunction would result in retention of function of the hallux and lesser digits in the majority of cases.

The incidence of bullet wounds in civilian trauma has increased in many parts of the world, sometimes approaching epidemic level.1 For surgeons with limited experience there is a bewildering range of apparently contradictory advice on management. 2-4 An attempt to clarify this for gunshot injuries of the limbs, without major vascular injury, must include current concepts of ballistic wounding, the pathology of soft-tissue wounds and fractures, and of bacterial contamination. Advice on clinical practice and treatment options cannot be prescriptive because of the wide range of injury patterns and settings, but an understanding of the general principles can guide clinical management. WOUND BALLISTICSThe interaction of projectiles and biological targets 5 should not be considered merely in terms of the missile velocity or its available energy. The important factor is its tissue interaction: a 'high-energy' bullet may sometimes produce a low-energy transfer wound. 6Energy transfer. The available kinetic energy of a missile depends on its mass (m) and velocity (v) according to the equation E = 1/2 mv 2 , but the tissues involved and other projectile factors will determine the amount of energy which is transferred (⌬ E). The rate of energy transfer (dE/ dt) is also important; this may vary along the wound track (dE/dx) and in terms of energy flux (⌬E/cross-sectional area). These unfamiliar terms are the major determinants of the pathological effects, 3,7 and mean that wound management cannot be based on the characteristics of the weapon, be it handgun, rifle, or shotgun. The key is to "treat the wound, not the weapon". 4

No abstract

Military surgical doctrine has traditionally taught that all ballistic wounds should be formally managed by surgical intervention. There is now, however, both experimental and clinical evidence supporting the nonoperative treatment of selected small fragment wounds. Low energy-transfer wounds affecting the soft tissues, without neuro-vascular compromise and with stable fracture patterns, may be suitable for early antibiotic treatment. The management of ballistic wounds to the gastrointestinal tract requires surgical intervention but, advances in the treatment of these wounds, especially those involving the colon, may allow more effective treatment with a reduced morbidity.