We identified eight independent predictors of mortality that provided useful information on the severity of NF and guidance for treatment. Prospective studies are required to examine the fitness and sufficiency of these variables as effective predictors of NF mortality.

Traumatic injuries to the digits resulting in soft tissue or bone loss require reconstruction. Traditionally, local flaps, such as homodigital flaps, heterodigital flaps, pedicled flaps, or distant flaps, are used for digital resurfacing. However, free tissue transfers can be used in selected patients. In this study, we present the use of different free flaps including groin skin flaps, groin osteocutaneous flaps, groin chimeric flaps, second dorsal metacarpal artery flaps, and partial toe flaps for digital reconstruction. A total of 19 digits were treated with 16 free flaps in our hospital. Of the flaps used, 5 were free groin skin flaps, 4 were free partial toe flaps, 3 were free groin chimeric flaps, 2 were free groin osteocutaneous flaps, and 2 were free second dorsal metacarpal artery flaps. The average flap size was 4.7 × 2.0 cm (range, 1.5 × 1 to 5 × 4 cm), and the average operative time was 6.0 hours (range, 4-9 hours). All flaps survived without partial or total necrosis. In conclusion, the free flap is a reliable and safe alternative for digital reconstruction. Moreover, the free groin flap provides not only a chimeric pattern for multiple fingers coverage but also an osteocutaneous pattern for thumb lengthening. The free second dorsal metacarpal artery flap provides a tenocutaneous pattern for tendon reconstruction and soft tissue coverage simultaneously, and the free partial toe flap is an excellent alternative for pulp reconstruction in terms of aesthetic appearance and functional outcome.

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A 70-year-old man was admitted to hospital because of multiple injuries from a traffic collision. On day 16 after admission, he started to complain of pain, weakness and numbness in his right leg.A contrast-enhanced computed tomographic scan of the lumbar spine showed a displaced sacral fracture with compression of the S1 ventral ramus (Appendix 1, available at www . cmaj .ca /cgi /content /full/cmaj.091534/DC1). The patient's symptoms persisted despite treatment with diclofenac, chlorzoxazone, fursultiamine and betamethasone. Severe tingling pain and allodynia (pain with light touch) developed seven days later. Thirty days after admission, several painful grouped erythematous plaques with vesicles were found on his right buttock and the posterior aspect of his right leg ( Figure 1). The distribution was consistent with the S1 dermatome, and a diagnosis of herpes zoster was made. The patient was prescribed valacyclovir hydrochloride, 500 mg three times daily for five days. The cutaneous lesions healed about seven days after the treatment was started and the tingling pain resolved gradually. We discharged the patient 42 days after admission.Older age, altered cell-mediated immunity and diseases such as malignancy, chronic lung disease, renal failure and liver disease are common risk factors for herpes zoster.1 Thomas and colleagues 2 reported a case-control study based in general practice in London, UK, of the determinants of zoster in adults without underlying immunosuppression. They concluded that recent trauma is associated with an adjusted 12-fold increased risk of herpes zoster at the site of injury, but not at other body sites. The increase in absolute risk was 3.9%. In our patient, the major cause of reactivation of herpes zoster would seem to be the recent trauma. Direct stimulation of the nerve may have triggered reactivation of the virus in the dorsal root ganglion. The pain associated with herpes zoster mimicked post-traumatic sciatic pain, which made the diagnosis difficult. Although sacral segments rarely show involvement of herpes zoster, 3 clincians should consider this possibility when patients are suffering from intractable pain after recent trauma.This article has been peer reviewed.Competing interests: None declared.

2. Chua TC, Bester L, Saxena A, Morris DL. Radioembolization and systemic chemotherapy improves response and survival for unresectable colorectal liver metastases.

metabolic alkalosis in HPS, with marked reduction in the time to pyloromyotomy. 3 We believe that it is important for surgeons and anaesthetists to be aware of the possible effect that H2-antagonists may have in reducing the electrolyte disturbance in infants with HPS; such awareness may result in a more expeditious pyloromyotomy. References1. Smith GA, Mihalov L, Shields BJ. Diagnostic aids in the differentiation of pyloric stenosis from severe gastroesophageal reflux during early infancy: the utility of serum bicarbonate and serum chloride. Am. J. Emerg. Med. 1999; 17: 28-31. 2. Shaikh MG, Anderson JM. Omeprazole may delay the diagnosis of pyloric stenosis. Acta Paediatr. 2004; 93: 283. 3. Banieghbal B. Rapid correction of metabolic alkalosis in hypertrophic pyloric stenosis with intravenous cimetidine: preliminary results. Pediatr. Surg. Int. 2009; 25: 269-71.

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