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Atlanto-occipital dislocation occurs more often in children due to the laxity of the ligamentous structures anchoring the occiput to the axial skeleton. The mechanism of action usually involves a sudden acceleration-deceleration force on the head of the child. The dislocation usually severs the spinal cord at the foramen magnum, resulting in acute respiratory arrest. We have managed four patients who sustained this injury and arrived at our trauma center with signs of life. Two patients were hemodynamically unstable, had positive diagnostic peritoneal lavage, and underwent splenectomy. Both patients had obvious separation of the occiput and C1 on lateral cervical spine films. Both remained very unstable and died soon after celiotomy. The other two patients were stabilized, and both met criteria for brain death; one family agreed to organ donation. A 5-year analysis revealed 57 pediatric deaths, with 10 patients sustaining atlanto-occipital dislocations (17.5%). Nine of 10 patients sustained other injuries, but in only 2 patients were the injuries immediately life-threatening. With continued improvement in emergency medical systems and pediatric trauma care, we can expect to see more pediatric patients with this injury arriving in trauma centers with signs of life. In our experience, 50 per cent of patients may meet organ donor criteria, and our incidence of this injury (17.5%) reveals atlanto-occipital dislocation as a major contributor to pediatric trauma mortality.

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The significance of a large, bulky digastric muscle in contributing to an objectionable neck contour should be appreciated in aesthetic surgery. Over the last several years, patients have achieved improved correction of neck contour problems by precise anatomic diagnosis followed by appropriately planned and executed repair. The submental contour correction in the past addressed only problems of the skin, subcutaneous fat, platysma muscle, subplatysmal fat, submaxillary glands, thyroid cartilage, and hyoid bone. Techniques that address each of these components can result in excellent rejuvenation of the neck and mandibular border. However, on occasion, after application of these conventional techniques, a still less than adequate neck contour may result. This results from a fullness in the submental region. Careful preoperative and intraoperative assessment may reveal the etiology to be a large, bulky anterior belly of the digastric muscle. To address this problem, the surgical technique of partial resection (tangential excision) of the anterior belly of the digastric muscle is performed. To date, this technique has been performed on 21 patients who demonstrated an objectionable bulge in the submental region after correction of skin, fat, platysma, and submaxillary gland problems. No untoward result or complication has been associated with this procedure. The benefits have been a pleasing, well-contoured submental area, prevention of residual fullness, ease of procedure, and avoidance of the need for secondary neck contouring procedures.

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In performing breast reconstruction with autogenous tissue, it has become useful to have accurate documentation of the weight and skin dimensions of the resected specimen. This enables the plastic surgeon to reconstruct a more natural and aesthetic breast. Oftentimes this information is not available and requires, at best, an estimate based on the size and shape of the remaining contralateral breast. To help take the guesswork out of an already artistic endeavor, this important information can make a substantial difference in the results obtained.

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Patients in extremis following penetrating cardiac injury must be rapidly and effectively resuscitated. Treatment priorities are relief of tamponade with control of hemorrhage. Rapid closure of cardiac wounds is necessary to achieve hemostasis and preservation of cardiac function. A simple and rapid technique of emergency cardiorrhaphy is described utilizing the skin stapling device.

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A case of right parietal abscess following esophageal dilatation for peptic stricture secondary to hiatus hernia with reflux in an 18-month-old male child is reported. Prior cases of brain abscess following esophageal dilatation are reviewed. The combination of history, clinical findings, and computed tomography scan in the current case allowed confident preoperative diagnosis of brain abscess and allowed emergency treatment of the lesion by simple aspiration through a burr hole.

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Surgical treatment of complicated peptic ulcer disease (PUD) is associated with a high mortality in selected, high-risk patients. The authors reviewed their operative experience for PUD over a five year period beginning in July 1982. One hundred and sixty-two operative procedures were performed on 160 patients. The indications for surgery were intractability (18); perforation (50); hemorrhage (81); and obstruction (13). The average ages of the survivors and those who died was 49.0 and 65.7 years respectively. Partial gastric resection (PGR), with or without vagotomy, was the most commonly performed procedure (54% of cases) while vagotomy and drainage (V & D) was used in 31 per cent of patients. The overall mortality in this series was 8 per cent; it was highest in the hemorrhage group (10%). Pre-operative transfusion requirements in this population were greater in those who died versus those who survived (12.1 and 7.3 units respectively, P less than 0.005). In addition, 75 per cent of the deaths were over 60 years of age. In elderly patients operated upon for hemorrhage, the procedure-related mortality for V & D and PGR was 24 per cent and 13 per cent respectively. (These groups were similar with regard to co-morbidity, hemodynamic stability, and transfusion requirements). It is the authors contention that PGR may be safely used for the treatment of bleeding peptic ulcer disease (particularly GU) in selected elderly, high-risk patients.

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A case of cystic mesenchymal hamartoma in a 2-year-old boy is presented. The overall angiographic appearance closely resembled that of the more common renal angiomyolipoma, with the addition of multiple focal avascular areas representing the cystic component of the lesion. The coexistence of these angiographic findings in a young patient with an otherwise asymptomatic upper abdominal mass should suggest cystic mesenchymal hamartoma.

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Transcatheter biopsy is presented as an alternate method of obtaining a histopathologic diagnosis in cases with evidence of direct neoplastic intravascular involvement and when conventional biopsy methods may be contraindicated.

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