Hand amputations: epidemiology, management and resurfacing options for soft tissue coverage.

OBJECTIVE: Agricultural hand injuries occur mainly among young adults, many affecting the dominant hand, thereby impeding patients' ability to work or cope with social obligations. This study was carried out with the aim of collecting data on the epidemiology and management of agricultural hand injuries in Indian subjects. METHOD: The study was conducted in the Department of Plastic and Reconstructive Surgery, JN Medical College, AMU, Aligarh, India, from October 2009 to December 2013. Patients with agricultural hand injuries were included. Data collected included socio-demographic details, mode and type of injury, type of reconstruction, complications, length of hospital stay and assessment of post-reconstruction status. These data were tabulated and analysed. RESULTS: The typical patient was young (mean 33.2 years), of lower socio-economic status and with a total disregard for safety regulations. There is clustering of cases during the wheat harvest season (April-June). Wheat thresher injuries were the most common cause of partial hand amputation (51%), especially during this season. This was followed by fodder cutting (kutti/chara) machine injury, especially in females and children (36%). A simple classification for these injuries has been described and Grade II injury was the commonest. Reverse radial forearm flap was the most suitable regional flap for coverage, whereas thoraco-umbilical flap was the most commonly used distant flap. Patients who had the single-stage procedure had a significantly shorter stay. CONCLUSION: Agricultural hand injuries are not totally avoidable and their incidence can be reduced by proper education, but the low economic and literacy status of the patients is a big hurdle. The forearm offers many flaps for reconstruction of hand, which can be used in defects on dorsal or palmar aspect of hand and results in early discharge from the hospital and early rehabilitation. In patients with associated injury to the forearm, abdominal flaps can be used for cover.

Coincidental diagnosis of tuberculous lymphadenitis: a case report.

The aim of this case report was to present a case of multiple calcified tuberculous lymph nodes found on a panoramic radiograph coincidently diagnosed in an endodontic clinic. A detailed discussion on the differential diagnosis of similar such calcification found in the same region is also presented. A 14-year-old girl was referred to our department with the complaint of painless swelling in the left side of the lower jaw. Clinical and radiographical examinations were performed, leading to the initial diagnosis of chronic periapical abscess. The patient's medical history was re-evaluated. Advanced imaging and excisional biopsy were performed in order to confirm the final diagnosis. Regarding the presenting signs and symptoms of bilateral carious mandibular molars, a periapical inflammatory process was considered in the provisional diagnosis. A thorough examination and investigations were suggestive of cervical tuberculous lymphadenitis (scrofula), and the patient underwent excision of the same. The clinician should consider the possibility of chronic granulomatous inflammatory lesions in the differential diagnosis of radiopaque lesions.

Study of maxillofacial trauma, its aetiology, distribution, specturm, and management.

Between October 2008 and January 2011, a total of 1202 patients with soft tissue and hard tissue injuries of face were studied. Of whom 1057(88%) were male and 145 (12%) female. Injuries were most common 389(32.36%) in the third decade of life and there were 282 (23.46%) in the 4th decade. The most common cause was road traffic collisions (n=682; 56.73%) and the second most common was a fall from a height (n=330; 27.45%). Total number of isolated soft tissue injury was 1038, forehead being the most common site of injury. There were 164 hard tissue injuries; the mandible was the most common bone to be fractured in 106 patients, followed by the zygoma in 47 patients. There were 31 patients with fractured maxilla, 15 nasal bone and 11 orbital bone fracture.

Clinical study of dorsal ulnar artery flap in hand reconstruction.

Soft tissue defects of hand with exposed tendons, joints, nerves and bone represent a challenge to plastic surgeons. Such defects necessitate early flap coverage to protect underlying vital structures, preserve hand functions and to allow for early rehabilitation. Becker and Gilbert described flap based on the dorsal branch of the ulnar artery for defects around the wrist. We evaluated the use of a dorsal ulnar artery island flap in patients with soft tissue defects of hand. Twelve patients of soft tissue defects of hand underwent dorsal ulnar artery island flap between August 2006 and May 2008. In 10 male and 2 female patients this flap was used to reconstruct defects of the palm, dorsum of hand and first web space. Ten flaps survived completely. Marginal necrosis occurred in two flaps. In one patient suturing was required after debridement and in other patient wound healed by secondary intention. The final outcome was satisfactory. Donor areas which were skin grafted, healed with acceptable cosmetic results. The dorsal ulnar artery island flap is convenient, reliable, and easy to manage and is a single-stage technique for reconstructing soft tissue defects of the palm, dorsum of hand and first web space. Donor site morbidity is minimal, either closed primarily or covered with split thickness skin graft.

Interposition arthroplasty in post-traumatic temporomandibular joint ankylosis: A retrospective study.

Temporomandibular joint ankylosis which is most frequently caused by trauma, presents with restriction in mouth opening in early stages and if children are the victim and not treated early, it presents with growth retardation of the involved mandibular side. Various methods are available for surgical correction. We have reviewed our experience with the efficacy of different interpositional materials in post-traumatic cases in our set up with special reference to temporal fascia over last three years. Twenty seven patients with history of trauma, mostly fall from height, have been studied. They were evaluated clinically and by computed tomography (CT) scan, orthopantogram and x- ray lateral oblique view. The most common age group was 10-15 years with mean 12.5 years and male to female ratio 1:2. Preoperative mouth opening (inter incisor distance) was 1-2 mm in 17 cases and 2-4 mm in 10 cases. We have used temporalis fascia in nine, costochondral graft in seven, silastic sheets in five and T-plates in six cases. Post-operatively, adequate mouth opening of 30-50 mm was observed in six months follow-up and more than 50 mm at one year follow up in 21 cases out of which nine cases have interpositional material as temporalis fascia alone. The postoperative period was uneventful in all cases and none required re-operation for recurrences. We conclude that interpositional arthroplasty, especially with pedicled temporal fascia, is the best method to prevent recurrences and establish good mouth opening and full range of jaw movements.

An isolated bilateral pure macrostomia in a 2-year-old girl.

Congenital macrostomia is a lateral orofacial cleft between the maxillary and mandibular components of the first branchial arch. Bilateral macrostomia is a rare entity. To date, 17 cases have been reported in the literature, with more than 50% isolated. We present a case of bilateral transverse facial cleft (macrostomia) in a 2-year-old girl. It was not associated with any other anomaly. The cleft involved only the soft tissues of the face. Hence, it was a pure macrostomia. She was the third female child of the family, with 2 elder sisters normal. Nutritional deficiency during intrauterine life and/or advanced maternal age can be causative factors. Transverse facial cleft was closed by Z-plasty incision, with good functional and aesthetic result.

Burnt pregnant wives: a social stigma.

The incidence of burns in pregnant females is on the rise in villages in and around Aligarh. Hence, the study of such cases epidemiologically is of paramount importance to throw light on the exact nature of the incidents. This study was done on 1200 patients over a period of 5 years in JNMCH, AMU, Aligarh and data revealed 384 (32%) cases of burnt pregnant females who were in the age group of 19-35 years (median age = 27 years). Maximum number of deaths occurred in patients with a TBSA more than 50 and 70% burns. Period of amenorrhoea ranged from 1 to 8 months. Number of patients who expelled the dead foetus were 86. This study throws light on the bias against pregnant females, dowry factor and still further, female foeticide and oedipal dominance of mother in law over the grooms.

Tobacco and alcohol consumption in relation to oral cancer.

The present case control study was done on 50 cases of oral cancer and 50 controls These two groups are compared after taking the history in detail with special emphasis on the tobacco and alcohol intake. My various statistical tests, we correlated the strength of association between tobacco/alcohol intake and development of oral cancer. Tobacco only and combined exposure to tobacco and alcohol was found to be strongly related to the development of oral cancer but alcohol alone does not have significant role in causation of oral cancer.

Total auricular reconstruction with autogenous costal cartilage framework for congenital microtia (grade-III).

The Auricular deformity of congenital microtia (Grade-llll can cause devastating physical and psychological trauma in children. liven crude duplications of the normal ear are of great emotional value to the child or adult who is horn with only a nubbin. Diverse materials ranging from altografts (polyethylene, nylon mesh. Teflon. Silicone,etc), cartilage homo and hcterografts haw been tried for framework construction of the ear. Converge (1985) and Tanzer (1959) popularized the use of autogenous rib cartilage, carved in a solid block. We describe our experience with autogenous costal cartilage graft as framework for total auricular reconstruction in 13 patients (15 ears) with congenital microlia(grade-lll). Atresia repair was performed in two patients. with bilateral grade-Ill deformity.

An Otorhinological study of patients with cleft lip and palate.

32 patients of cleft palate with or without cleft lip were subjected to otorhinological study from January 1998 to September 2000, with special attention to the rhinological anomalies, ear pathology, any deafness, discharge or any other findings relevant to the middle ear. Hearing loss and ear changes were not seen in any patient with cleft lip alone, hence these patients were not included in this study. These changes were confined to the patients with cleft palate only, with or without cleft lip. High incidence of otological anomalies (75%) and rhinological anomalies (deviated nasal septum in 40.6%) were seen in patients with cleft palate with or without cleft lip. Hearing loss has been seen (37.5%) in patients with cleft palate and was purely conductive in nature.

A clinicopathological study of infections in burn patients and importance of biopsy.

Thirty-four patients with burns were subjected to the clinicopathological study with special reference to culture of the wound and histological examination of the burned tissue. The commonest cause of burn was thermal burn (91.18%) followed by electric burn (5.88%) and chemical burn (2.94%). The maximum number of patients belonged to second and third decades of life (61.78%). Females were commonest victims, with male:female ratio was 1:1.6. On the 1st to 3rd postburn day (PBD) most of the wound remained sterile and Strept haemolyticus was first bacteria isolated on 1st PBD. Gram-positive and Gram-negative bacteria, specially pseudomonas, invaded the burn wound as early as 3rd PBD, it was more so with the patients of extensive burn. Among the Gram-positive bacteria Staph aureus was most notorious and invaded burn wound very early. Pseudomonas had maximum growth followed by klebsiella and Esch coli, multidrug resistance was more common with pseudomonas. Among the fungal infections Candida albicans had maximum incidence. Positive blood cultures for bacteria were seen during 2nd, 3rd and 4th postburn weeks. Pseudomonas was the commonest bacteria isolated. Biopsies were done in 17 patients and showed maximum incidence of bacterial infection followed by fungal infection. Patients with burn more than 60% of total body surface area (TBSA) had 100% mortality, while patients with 20-30% of TBSA burn had 20% mortality, the overall mortality was 50%. Biopsies of the burn wound played an important role in the accurate diagnosis and thus helped in starting early specific therapy to prevent death from sepsis.

Serum levels of immunoglobulins in thermal burns.

Thermal injury is known to induce alterations in the immune system. Sixty-four patients of thermal burns have been studied for serum immunoglobulins. Concentrations of IgG, IgA and IgM were decreased immediately after injury and gradually increased up to normal limits on the 30th postburn day.

Blood gas studies in thermal burns.

In the present study we have included 25 cases with a relatively small extent of burns as compared to those described in many of the other published work. We have chosen the 3rd post-burn day as the day of reference (because most of the patients did not turn up before that day) from which day onwards adequate number of observations were available. Arterial blood gas studies revealed significant decrease in arterial partial pressure oxygen on 5th and 8th post-burn days with lowest mean value on 8th post burn day and then a gradual rise towards the normal value. Arterial partial pressure of carbon dioxide fell after the burn to reach the lowest value on the 5th post burn day and then returned towards the normal value. Arterial hydrogen ion concentration also fell (i.e. arterial blood pH rise) in the post-burn course. This was significant on the 11th post burn day.

Respiratory functions in thermal burns.

In our present series, respiratory functions were observed in patients with a relatively small extent of burn compared to that commonly represented by the published works, and for a considerable duration of time (three weeks), commencing soon after the burn trauma. Respiratory rate increased in the post burn trauma and the peak expiratory rate was observed on the 8th post burn days and then it gradually fell but still remaining much higher than the control normal value. The minute volume and tidal volume also showed similar rise on the 8th post burn day and then gradually fell to below the mean level of 3rd post burn day before the 3rd post burn week. Forced vital capacity, forced expiratory volume in one second, forced expiratory volume in three seconds, forced expiratory volume in one second as a percentage of forced vital capacity, forced expiratory volume in three seconds, as a percentage of forced vital capacity and peak expiratory flow rates, did not vary much and indicated no significant respiratory abnormality.

Traumatic avulsion of penile and scrotal skin.

Due to the use of high speed machinery in industry and the rapid mechanisation of agriculture an increasing number of avulsion injuries are being referred for treatment. This paper describes our experience in the management of ten patients with extensive traumatic avulsion of the penile and scrotal skin, treated by primary split-thickness skin grafting.