Volkmann's ischemic contracture; post-circumferential contracture of the forearm

Objective: To share our experience of post-circumferential Volkmann's Ischemic Contracture [VIC] of the forearm seen in our setup. Design: A descriptive case series study. Setting: National Orthopedic Hospital, Bahawalpur, Pakistan. Period: January 2005 to December 2013

Methodology: A total of 42 patients were registered during the study period. Patients with VIC of the forearm resulting from direct circumferential compression were included in the study. Patients who developed VIC of forearm indirectly secondary to arm pathology or other causes were excluded from the study. Assessment was made by detailed history, clinical examination and radiographs of the involved extremity. The age, sex, duration, side and type of contracture, length and width of forearm and resulting deformities were all documented on a detailed proforma. Patients were categorized into three types accordingly

Results: Forty two patients comprising 29 males and 13 females were seen. Their ages ranged from 1 to 53 years with mean age of 14.47 years. Duration of established VIC of the forearm after insult ranged from 3 months to 6 years with mean duration of 2 ½ years. Most frequent type of contracture was moderate variety seen in 19 patients [45.23%] with 14 cases on the right and 5 cases on left side followed by severe varieties which were present in 13 patients [31%] with 10 cases on the right and 3 cases on left side. Mild contractures were found in 10 patients [23.9%] with 6 cases on the right and 4 cases on left side. In 26 of 42 patients, a difference in forearm length that ranged from 79% to 94% [mean, 80%] was observed. Majority of cases [37 cases] of VIC occurred after TBS for radius and ulna fractures while in the remaining 5 cases, contractures of forearm occurred due to tight plaster of paris [POP] splint

Conclusions: Post-circumferential forearm contractures after Traditional Bone Setters [TBS] are common in our society. Community awareness through health education and conducting medical camps and seminars might play a role in decreasing the influence of TBS

Burn patients; causes of death and factors affecting mortality a 4 years study at a tertiary care hospital

To determine major risk factors of mortality and causes of death in patients presented with burn injury. Prospective Descriptive Study. Setting and duration: Department of Burns and Plastic Surgery, Khyber Teaching Hospital, Peshawar, Pakistan from April 2008 and June 2012. A prospective descriptive study was performed among the patients who admitted to the Department of Burns and Plastic Surgery, Khyber Teaching Hospital, Peshawar, Pakistan between April 2008 and June 2012. All relative information was collected through a detailed proforma and patient's treatment files. Patients of any age, any degree of burns and burns exceeding 10% TBSA were included. Patients presenting after more than one week post burn or patients referred from other hospitals were excluded. Within this period, demographic data, treatment, and outcomes of treatment were reviewed and analyzed. Survivors and non-survivors among burn patients were compared to define the predictive factors of mortality. Between April 2008 and June 2012, 1850 patients were admitted with burn injuries. There were 1150 male patients [62%] and 700 female patients [38%]. Mean age was 36 years with range of 1-70 years. Inhalation injuries were present in 45 patients [2.40%]. Causes were flame burns [65.0%], electrical burns [15%], scalds [13%] and chemical burns [7.0%]. The total body surface area [TBSA] burn ranged from 10- 100%, with a mean of 38% TBSA burn. Mean length of hospital stay was 12 days [ranging from 24 hours to 170 days]. Mortality rate was 11.2%. Higher age, larger burn area, wound infection, longer hospital stay and the presence of multi-system organ failure significantly predicted increased mortality. Prevention is a key factor in reducing the morbidity and mortality associated with burn injury. A campaign to educate people that burns can be prevented will be important in our community. The prevention of multi-organ failure and septicemia are likely to be more effective than their treatment

Metacarpal and phalangeal lengthening of the hand; utility of distraction osteogenesis

To present our experience of distraction osteogenesis in Metacarpal and Phalangeal lengthening of the hand and analyze the factors which influence the period of healing. Experimental study. Period: December 2008 to April 2011. Department of Plastic and Reconstructive Surgery, Khyber Teaching Hospital, Peshawar. The patients were admitted through out-patient department and detailed history, clinical examination and necessary investigations were carried out. Informed consent was taken. Distraction has been performed in six metacarpal bones and four phalangeal bones in nine patients. The age ranged from 3 to 59 years. All the digits had traumatic amputations. The injury was in the right hand [dominant] in 6 patients and in the left hand in 3 patients. An isolated injury to the thumb was seen in 4 patients, while in the remaining patients other fingers had been injured. All patients were operated by the same surgeon using similar lengthening technique. Patients were followed regularly and assessed for bone lengthening by clinical and radiological methods. The achieved elongation of the metacarpal bones varied from 26 mm to 30 mm [average 27.66 mm], and of the digital phalanges from 10 mm to 17 mm [average 13.5 mm]. Average healing time was 2.05 months [range from 1.8-2.5]. Average healing index was 0.75 month/cm [range from 0.65-0.88]. Complications observed were pin tract infection [3 cases], necrosis of free grafted skin [2 cases], delayed spontaneous bone union [2 cases] and volar angulation [1 case]. Webplasty was performed in all cases. Strength of pinch improved by an average of 37% and that of grasp by 48% compared to the preoperative values. All patients were able to pick up a paper and a cup of water. Distraction osteogenesis is a successful and reliable method for the lengthening of short metacarpals and phalanges. However, severe complications such as stiffness, angulation, subluxation of the MCP joint and delayed union or non-union are associated with this procedure. To avoid these complications, we suggest protection of the periosteum, refraining from distraction rates of more than 2x0.25 mm/day and, if possible, avoid lengthening a bone by more than 40% or not more than 20 mm of the preoperative bone length

Frequency of fistula formation after two stage repair of cleft palate

To estimate the frequency of fistula formation after two stage repair of cleft palate. A total of 50 patients having completed cleft palate repair with or without lip repair were recruited from December 2007 to February 2009. Patients were diagnosed on history and oral examination. Informed consent was taken from parents. Width of the cleft measured preoperatively. Two stage repairs were done by a single surgeon with a time lapse of six months. Five patients developed clinically significant oronasal fistula. All these fistulas occurred at the junction of hard palate and soft palate within 3 weeks time. The overall rate of true fistula development was 12% over a mean follow up period of 6 months. The incidence of true fistulas that were symptomatic and subsequently required surgical repair was 10%. Fistula rates were higher for more wide clefts but were not affected by gender or age

Our experience of pectoralis major myocutaneous pedicled flap

The pectoralis major myocutaneous pedicle flap [PMMPF] has been considered to be the "workhorse" of pedicled flaps in head and neck reconstruction. Despite the use of free flaps, this flap is still considered the mainstay of head and neck reconstruction. The flap is usually associated with a high incidence of complications compared with the free fasciocutaneous flaps yet its size, viability, and versatility make it a valuable tool for extending the limits of resectability and reconstruction. It is type V muscle flap with the dominant vascular supply from the pectoral branch of thoracoacromial artery. To share our experience of pectoralis major myocutaneous pedicle flap in selected cases of head and neck reconstruction. The indications, type of reconstruction and complications of the flap utilization were evaluated. Between March 2005 and August 2010, a 37 head and neck reconstructive procedures using the PMMPF were carried out. The indications for the flap use were defects due to resection of stage II-IV cancer in the head and neck region. The site, stage of the disease and the postoperative complications were all documented. Pectoralis major myocutaneous pedicled flap reconstructions were used to reconstruct defects in the following sites: oral cavity [25 patients]; oropharynx/ hypopharynx, [7 patients]; and neck or face [5 patients]. Of the 37 PMMPF reconstructions, 30 flaps were carried out as primary reconstructive procedures, whereas 7 flaps were "salvage" procedures. Twentyfive patients [67.59%] had complications. A higher complication rates were associated with the utilization of the flap as a salvage procedure, number of co- morbidities, and in oral cavity reconstructions. The pectoralis major myocutaneous pedicled flap is still an acceptable method of head and neck reconstruction. It is fast, reliable, provides safe repair and is indicated especially where bulk is needed

Our experience with macrodactyly: a rare congenital anomaly

To present our experience with [Macrodactyly] a rare congenital anomaly and its associated anomalies. Macrodactyly is an increase in the size of one or several fingers or toes. The overgrowth is limited to or predominantly affects the digits. It is characterized by an increase in all mesenchymal elements particularly fibro-adipose tissue. It does not appear to be an inherited condition and is thought to be caused by abnormal nerve supply, abnormal blood supply or abnormal humeral mechanisms. Pathologically, they are benign, soft tissue growths. Macrodactyly is commonly an isolated condition but other congenital anomalies are associated with it. It can be static or a progressive disorder. Soft tissue debulking, phalangectomies, ray resection, ostetomies and arthrodesis of interphalangeal joints are different modes of treatment. Descriptive case series. This study was conducted in Plastic Surgery Unit of Hayatabad Medical Complex Peshawar and Orthopaedic unit of Khyber Teaching Hospital, Peshawar from April 2007 to December 2009. A total of 32 patients were registered during the study period. Patients were admitted through out patient department, written informed consent was obtained from all individuals. Detailed history was taken, every patients was assessed clinically and radiologically. All patients were followed for recurrence. 2 patients were lost in follow up and the study was completed on 30 patients. Mean age of the patients was 13.7 years. Out of 30 patients, 19 were male and 11 were female. Hands were involved in 20 patients and feet in 10 patients. There was no bilateral hands or feet involvement. Eighteen patients had progressive and 12 patients have static macrodactyly. Seventeen patients had isolated macrodactyly while in 13 patients macrodactyly was associated with other congenital anomalies most commonly syndactyly. Most commonly involved digit was index finger in hand and big toe in foot. Macrodactyly is a rare congenital anomaly but cosmetic and functional disability of the patient is significant. Although it is mostly isolated but a significant number of cases were associated with other congenital anomalies which necessitate further research in this field

Anterolateral thigh flap: versatility and anatomic variations

To determine the pattern of the cutaneous perforator of the lateral circumflex femoral artery in anterolateral thigh perforator flap. Antero lateral thigh flap has become one of the most commonly used flap for the reconstruction of various soft tissue defects. The anterolateral thigh flap is known for variations of its vascular pedicle. Its major limitation has been uncertainty in predicting perforator anatomy, with the occasional absence of suitable perforators and high variability in their size and course. Reconstruction of 13 composite defects in 13 consecutive patients by free microvascular anterolateral thigh flap at the Department of Plastic and Reconstructive Surgery, Hayatabad Medical complex, Peshawar. Thirteen patients were operated and free microvascular anterolateral thigh flap was used. In 12 patients the main vascular supply was through the descending branch of the lateral circumflex artery [LCFA]. One patient has a vascular supply through the transverse branch of the lateral circumflex femoral artery. Transmuscular perforators [mostly 3,] were found in all the patients, commonly arising from descending branch of lateral circumflex femoral artery