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INTRODUCTION: Adaptation is vital to ensure successful healthcare recovery during the COVID-19 pandemic. Hand trauma represents the most common acute emergency department presentation internationally. This study prospectively evaluates the COVID-19 related patient risk, when undergoing management within one of the largest specialist tertiary referral centres in Europe, which rapidly implemented national COVID-19 safety guidelines. MATERIALS AND METHODS: A prospective cohort study was undertaken in all patients referred to the integrated hand trauma service, during the UK COVID-19 pandemic peak (April-May 2020); all were evaluated for 30-day COVID-19 related death. Random selection was undertaken for patients with hand trauma who either underwent non-operative (control group) or operative (surgery group) management; these groups were prospectively followed-up within a controlled cohort study design and telephoned at 30 days following first intervention (control group) or postoperatively (surgery group). RESULTS: Of 731 referred patients (566 operations), there were no COVID-19 related deaths. Both groups were matched for sex, age, ethnicity, body mass index, comorbidities, smoking, preoperative/first assessment COVID-19 symptoms, pre- and postoperative/first assessment isolation and positive COVID-19 contact (p > 0.050). There were no differences in high service satisfaction (10/10 compared with 10/10; p = 0.067) and treatment outcome (10/10 compared with 10/10; p = 0.961) scores, postoperative/first assessment symptoms (1%, 1/100 compared with 0.8%, 2/250; p = 1.000) or proportion of positive tests (7.1%, 1/14 compared with 2.2%, 2/92; p = 0.349), between the control (n = 100) and surgery (n = 250) groups. CONCLUSION: These data support continued and safe service provision and no increased risk to patients who require surgical management. Such findings are vital for healthcare providers when considering service adaptations to reinstate patient treatment.

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BACKGROUND: Skin cancer represents the most common malignancy worldwide and it is imperative that we develop strategies to ensure safe and sustained delivery of cancer care which are resilient to the ongoing impact of COVID-19. OBJECTIVE: This study prospectively evaluates the COVID-19 related patient risk and skin cancer management at a single tertiary referral centre, which rapidly implemented national COVID-19 safety guidelines. METHOD: A prospective cohort study was performed in all patients who underwent surgery for elective skin cancer service management, during the UK COVID-19 pandemic peak (April-May 2020). 'Real-time' 30-day hospital database deceased data were collected. Random selection was undertaken for patients who either underwent operative (surgery group) management or remained on the waiting list (control group); these groups were also prospectively followed-up within a controlled cohort study design and telephoned at the end of June 2020 for the control group or 30 days post-operatively. RESULTS: Of the 767 patients who had operations, there were no COVID-19 related deaths. Both the surgery (n = 384) and control (n = 100) groups were matched for age, sex, ethnicity, BMI, presence of comorbidities, smoking and positive COVID-19 contact. There were no differences in post-operative versus any symptom development (1.3%, 5/384 vs. 4%, 4/100, p = 0.093), or proportion of positive tests (8.6%, 33/384 vs. 8%, 8/100; p = 0.849), between the surgery and control groups. CONCLUSION: These data support continued and safe service provision, and no increased risk to skin cancer patients who require surgical management, which is vital for continuation of cancer treatment in the context of a pandemic. LEVEL OF EVIDENCE: II.

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INTRODUCTION: This study evaluates COVID-19 related patient risk, when undergoing management within one of the largest specialist centres in Europe, which rapidly implemented national COVID-19 safety guidelines. METHOD: A prospective cohort study was undertaken in all patients who underwent surgical (n = 1429) or non-operative (n = 191) management during the UK COVID-19 pandemic peak (April-May 2020); all were evaluated for 30-day COVID-19 related death. A representative sample of elective/trauma/burns patients (surgery group, n = 729) were selected and also sub-analysed within a controlled cohort study design. Comparison was made to a random selection of non-operatively managed (non-operative group, n = 100) or waiting list (control group, n = 250) patients. These groups were prospectively followed-up and telephoned from the end of June (control group) or at 30 days post-first assessment (non-operative group)/post-operatively (surgery group). RESULTS: Complex general (9.2%, 136/1483) or regional (5.0%, 74/1483) anaesthesia cases represented 14.2% (210/1483) of operations undertaken. There were no 30-day post-operative (0/1429)/first assessment (0/191) COVID-19 related deaths. Neither the three sub-speciality plastic surgery, or non-operative groups, displayed increases in post-operative/first assessment symptoms in comparison to each other, or to control. The proportion of COVID-19 positive tests were: 7.1% (1/14) (non-operative), 5.9% (2/34) (burns) and 3.0% (3/99) (trauma); there were however no significant differences between these groups, the elective (0%, 0/54) and control (0%, 0/24) groups (p = 0.236). CONCLUSION: We demonstrate that even heterogeneous sub-speciality patient groups, who required operative/non-operative management, did not incur an increased COVID-19 risk compared to each other or to control. These highly encouraging results were achieved with described, rapidly implemented service changes that were tailored to protect each patient group and staff.

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Severe injury to the middle finger often compromises both the appearance and function of the hand. This report discusses the use of total middle ray amputation at the time of primary trauma surgery to avoid predictable problems that arise when the ray, or part of it, is retained. Primary ray amputation eliminates the defective middle finger, avoids a gap hand, and reunites the dissociated radial and ulnar segments of the hand to create a useful, three-fingered hand.

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Thirteen painful end-neuromas of nerves of the palm and the dorsum of the hand were treated by resection of the neuroma and relocation of the nerve ends into the pronator quadratus muscle proximal to the wrist in ten patients. The effectiveness of this treatment was assessed by measurement of changes in level of spontaneous pain, pain on pressure, pain on movement and hyperaesthesia at the original site and at the site to which the nerve was relocated. Subjective comments on changes of hand function and ability to return to work were also recorded. All ten patients reported total relief or marked improvement in each of the four modalities of pain assessed. In the five patients in whom the neuromas were the only significant cause of hand dysfunction, there was sufficient improvement in hand function to allow the patients to return to work. In this series, the pronator quardratus muscle has proved a suitable site for relocation of sensory nerve ends after resection of painful neuromas in the proximal part of the hand and wrist.

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Sixteen patients with paralysis of the anterior interosseous nerve (AIN) in 19 limbs who were treated in a single unit were reviewed at a mean of 6.4 years (range 2-14 years) following onset of the paralysis. There was a high incidence of incomplete lesions (seven limbs) and of associated neurological lesions (six limbs) in the same or opposite upper extremity. Patients treated conservatively and with surgical exploration showed no difference in the time of onset of recovery, the time taken to achieve complete recovery or the extent of recovery. Those with incomplete lesions recovered well irrespective of the type of treatment. A distinct cause of compression of the AIN or visible changes in the AIN were seen in just three of the eight limbs that were explored. Surgery is indicated in complete lesions with no evidence of recovery for at least 6 months; incomplete lesions and other neurological signs are indications for conservative management in the first instance.

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An unusual congenital anomaly of a bilateral complete cleft of the primary palate, a complete cleft of the left secondary palate with abnormal nostrils without external openings and right choanal atresia is presented. The child also has a lachrymal fistula below the right lower eyelid and a coloboma of the same eyelid medially. Neither lachrymal system drained into the nose.

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