260 Injury: the British Journal of Accident Surgery Vol. 11/No. 3

For all that can be done to reduce the infection of burns, the best way to prevent it is to prevent burns.

Lowbury E. J. L. (1979) Fact or fashion? The rationale of exposure method, vaccination and other anti,infective measures. Burns5, 149.

head and trunk but which may be accompanied by injuries ofother parts of the body.

Hindle J. F. (1978) The management of multiple injuries. Br. J. Hosp. Med. 19, 219.

Feet and ankle burns Contractures of the foot, ankle and toes were success- fully corrected or prevented by the use of light, thermoplastic splints applied to the dorsum. Once cor- rection had been achieved there was little tendency for contractures to recur.

Northdurft D., Pullium G. and Brusker J. (1979) Management offeet and ankle burns: orthotic manage- ment of pre-existing deformity and protocol for pre- vention of deformity. Burns 5, 221.

Milton in burn treatment Older surgeons may experience a sense ofd~ja vu when they read this paper because the advantages are much the same as those asserted by Stannard and Bunyan. In this case, however, irrigation is carried out not in a bag but by keeping dressings moist with 1/10 or 1/20 Milton solution. A Viaflow irrigation tube was wound round the lightly dressed burned area and covered by an occlusive dressing. Every eight hours Milton was run through the t u b e - - 5 0 ml for the upper and 100 ml for the lower.

Hirshowitz B., Moscona A. R. and Lefler E. (1979) Milton for the treatment of burns using the irrigation technique. Burns 5,282.

Clinical skin banking The authors describe the techniques they have adopted to process, store and retrieve (i.e. thaw) human cadaver skin for use in the Burns Unit at San Diego in California. The skin is treated in glycerol and stored in liquid nitrogen in tubes containing approximately 1 2 x l 5 i n (30x37"5cm) of allograft. Thawing is carried out by placing these tubes in a microwave oven. It takes about l to 1"5 minutes to thaw out a tube with the oven set at 'sautr'. The method is briefly and well laid out. It seems a very safe and straightforward procedure worthy of further development.

Ninnemann J. L., Fisher J. C. and Frank H. A. (1978) Clinical skin banking: a simplified system for processing, storage and retrieval of human allografts. J. Trauma 18, 723.

Mult iple injuries Management of multiple injuries In little more than two pages this article summarizes comprehensively the urgent requirements for life- saving diagnosis and treatment. It is interesting that the author defines multiple injuries as those affecting the

Thromboembol ism Pulmonary embolism Professor Mitchell looks critically at the current state of beliefs, assertions and practice, and contrasts the confidence with which methods of preventing throm- boembolism are advocated with the finding that the complexity of method and misgivings about results have apparently persuaded over 90 per cent of British surgeons against using warfarin, which is of proven efficacy even when looking after patients who are most at risk. Among the distinctions which are not always clearly made is the distinction between what patients die 'with' and what they die 'of'. Whatever the out- come of large scale trials of subcutaneous injections of heparin, they offer no protection when given after the thrombolic process has been set going by injury or operation. Thus it remains very difficult to give an honest and reassuring answer to a patient who wants to know how much benefit anticoagulants will offer him.

Mitchell J. R. A. 0979) Can we really prevent postoperative pulmonary emboli? Br. Med. J. 1, 1523.

Failure of low dose heparin This group of surgeons, radiologists and others at Groote Schuur Hospital obtained their findings from a prospective study of 200 patients that included the use of radioactive iodine, ultrasound, phlebography and studies of respiration which included perfusion of the lung. They found that thrombosis was reduced in the veins of the calf but not in those of the thigh and that there was no reduction in the incidence of pulmonary embolism that was not fatal. They conclude that the routine use of low doses ofheparin with major surgical operations in persons over 40 years of age may not be advisable.

Immelman E. J., Jeffery P., Benatar S. R. et al. 0979) Failure of low-dose heparin to preven t signifi- cant thromboembolism complications in high-risk surgical patients. Br. Med. J. l , 1447.

Amputat ions Finger amputations A detailed case report is given of a 53-year-old woman who suffered a clean guillotine amputation of the right index, middle and ring fingers through the base of the proximal phalanges. Surgical replacement was carried out five and a half hours aider injury; the operation itself lasted for six and a half hours. Review after three months shows a good cosmetic result and a steadily improving worthwhile range of function.

Bowen J. E. and Poole M. D. (1975) Multiple digital replantation: a case report. Br..I. Plast. Surg. 28, 8.