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OBJECTIVES: Injuries due to hot-air ballooning accidents are uncommon but may be severe. In this study we examined the factors contributing to ballooning accidents in the UK and the type of injuries sustained. METHODS: The post-investigation reports of ballooning accidents from 1976 to 2004 were reviewed. They were analysed to determine type and severity of injuries, phase of flight at time of accident and causative or contributory factors. RESULTS: Sixty-one people were seriously injured in 98 ballooning accidents, with 2 fatalities. The majority of these accidents occurred during the approach and landing phase of flight. Ground collisions and crashes with power lines accounted for the majority of accidents. Adverse weather conditions were present in a significant number of crashes. Equipment failure was an uncommon cause of accidents. Fractures and burns were the most common form of injuries sustained. CONCLUSIONS: Changes in design and materials used, as well as adherence to specific recommended safety protocols, may aid to decrease the risk of severe burns in ballooning accidents. We discuss these factors illustrated by our experience of the worst recorded ballooning accident in Britain.

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Successive improvements in burn care have steadily increased the survivability of many major burn injuries, however for some patients with the most severe injuries comfort care rather than active resuscitation has been seen as the correct course of action. A survey of UK burn unit directors by postal questionnaire sought details of current practice regarding comfort care, the factors involved in the decision making process and their response to eight hypothetical case histories. An 84% response to the survey showed that units would, on average, actively resuscitate thirty-seven patients a year and administer comfort care three times per year. Opinion was often divided regarding the decision to resuscitate in the cases presented.

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Temperature and resuscitation profiles of 15 non-survivors were compared with matched survivors of major burns. All patients were intubated and ventilated for smoke inhalation injury, survived more than 3 days postburn and had a cutaneous burn greater than 15 per cent of the body surface area (mean 32.3 +/- 11.0 per cent SD). Cases were matched for similar ages (within 10 years) and total body surface area burn (within 10 per cent). The rate of core temperature rise following admission to the burn unit was significantly greater in survivors (mean 0.46 +/0 0.18 degree C/h) compared with matched non-survivors (mean 0.30 +/- 0.15 degrees C/h; p < 0.01). Core temperature increased at a rate of 0.27 degrees C/h or greater in all survivors, whereas 7 non-survivors raised their core temperature at a rate less than this. The rate of skin temperature rise was also significantly greater in the survivors (mean 1.35 +/- 0.91 degrees C/h) compared with matched non-survivors (mean 0.63 +/- 0.43 degrees C/h, p < 0.01). In 13/15 survivors, the skin temperature increased at a rate of 0.6 degree C/h or greater, whereas in 8/15 non-survivors skin temperature increased at a rate less than this. There was a negative relationship between initial core temperature and delay from time of burn to admission to the burns unit in non-survivors (correlation coefficient = -0.92; p < 0.01), whereas there was no effect of delay in the survivors. These findings suggest that patients with a high mortality probability can be detected early in their clinical course by means of temperature profiles.

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A retrospective review is presented of 64 patients with infections of the hand requiring admission to hospital. We present an account of the different types of hand infection encountered, together with details of the various aetiologies and microbiological findings where these are available. The management of hand infections is discussed with reference to the patients in our series, and in terms of the general principles involved.

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A historical series of patients with primary cutaneous malignant melanoma is reviewed. These patients had been treated with a single therapeutic dose of irradiation to the tumour and surrounding skin immediately before surgical excision. Some patients had also received a single necrotising dose of radiotherapy to the tumour itself. Recurrence and survival rates have been examined retrospectively in the light of reviewed histology, and compared with other published series. Preoperative radiotherapy was found to have no significant influence on the outcome of surgical treatment of primary malignant melanoma.

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Large burns continue to pose the problem of providing sufficient autologous skin cover. The experience of this unit using cultured keratinocytes as a substitute for split-skin grafts has been disappointing; at the same time, we have been obliged to abandon human allograft skin from cadavers and other patients because of the possibility of infection with HIV. Our favoured method for resurfacing large-area burns in children is to use widely meshed autologous skin overlaid with meshed allograft from a parent (to minimise the risk of HIV transmission). We report our experience using this technique in 10 children. The fate of the intermingled grafts has been followed clinically, and in some cases histologically and by Y-chromosome identification. There has generally been long-term persistence of the parental skin without rejection, and allograft dermis appears to contribute to the final cover. Evidence suggests, however, that cellular elements of the parental skin do not survive.

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Machine meshing a split skin graft is a valuable technique. Expansion ratios vary depending on the dermacarrier used. We present a method in which different expansion ratios can be obtained using the same dermacarrier.

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A case is reported in which metacarpophalangeal joint capsulotomy is augmented by the use of a flap of fibrous tissue from around previously implanted silicone sheet as a form of capsular reconstruction.

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