Role of a Plastic Surgeon in the Management of Local Manifestations of Snakebite in a Tertiary Care Hospital: A Prospective Single-Center Case Series.

Background There is a paucity of literature regarding the management of snakebite site complications. The wound complications can have debilitating sequelae, most of which may require reconstruction. Methods This is a prospective single-institution observational study conducted from November 2019 to December 2021. Patient demographic characteristics and snakebite-related information, length of hospitalization, surgical lesions encountered, the type of treatment offered, and complications were recorded. Results Fifteen patients (10 males and 5 females) with ages ranging from 10 to 53 years (mean: 36.5 years) were included in the study. Urgent fasciotomy was performed in three patients with compartment syndrome of the upper limb. Facial reconstruction was performed in one patient. One patient required distraction, cross-finger flap, and bone grafting of the index finger, while another patient required a pedicled groin flap for digital salvage. Below knee amputation was done for Marjolin's ulcer in a chronic snakebite case. Few patients required skin grafting. No major complications were encountered. Conclusions Plastic surgeons play an important role in the management of bite site effects for restoration of form and function, which goes a long way in rehabilitating these patients back in the society. This case series presents a varied range of bite site complications and their management that would serve as a guide to plastic surgeons for better outcome.

Open tendoachilles injuries due to squatting type of toilet seats: Five-year prospective observational study from a tertiary care center in India.

BACKGROUND: Open traumatic tendoachilles injuries due to toilet seats are least reported. The exact mechanism of such injuries is debatable. None of the studies have reported associated neurovascular injuries and the need for microvascular tissue transfer. METHODS: It is a 5-year prospective observational study from Sep 2013 - Aug 2018 at a tertiary care center on 26 patients who had sustained foot injuries due to squatting type toilet seats. All the patients were managed by thorough wound irrigation and debridement followed by repair of cut tendoachilles, other tendons and neurovascular structures. All the complications and secondary procedures required were recorded. Functional outcome was assessed by Boyden clinical outcome score. Follow up ranged from 1 to 5 years. RESULTS: All the 26 patients reported a particular mechanism of injury. Complete transection of tendoachilles was seen in 23 (88.5%) patients and partial transection in three (11.5%) patients. Microvascular repair of cut posterior tibial artery was undertaken in three and posterior tibial nerve in two cases and microvascular parascapular flap in one case for soft tissue reconstruction. Twenty-three (88.5%) patients had good to excellent Boyden score while three patients (11.5%) had fair to poor score at 1 year. Such severe injuries due to toilet seats have never been reported in literature. CONCLUSIONS: Squatting toilet seats can cause devastating foot injuries involving tendons and neurovascular structures and may require microvascular tissue transfer for definitive wound management. The risk of such injuries will continue unless some modifications are undertaken in the design of the seat.

Role of customised negative-pressure wound therapy in the integration of split-thickness skin grafts: A randomised control study.

BACKGROUND: Split-thickness skin grafting (STSG) is a time-tested technique in wound cover, but many factors lead to suboptimal graft take. Role of custom-made negative-pressure wound therapy (NPWT) is compared with conventional dress in the integration of STSG and its cost is compared with widely used commercially available NPWT. MATERIALS AND METHODS: This is a parallel group randomised control study. Block randomisation of 100 patients into one of the two groups (NPWT vs. non-NPWT; 50 patients each) was done. Graft take/loss, length of hospital stay post-grafting, need for regrafting and cost of custom-made negative pressure wound therapy (NPWT) dressings as compared to widely used commercially available NPWT were assessed. RESULTS: Mean graft take in the NPWT group was 99.74% ± 0.73% compared to 88.52% ± 9.47% in the non-NPWT group (P = 0.004). None of the patients in the NPWT group required second coverage procedure as opposed to six cases in the non-NPWT group (P = 0.035). All the patients in the NPWT group were discharged within 4-9 days from the day of grafting. No major complication was encountered with the use of custom-made NPWT. Custom-made NPWT dressings were found to be 22 times cheaper than the widely used commercially available NPWT. CONCLUSIONS: Custom-made NPWT is a safe, simple and effective technique in the integration of STSG as compared to the conventional dressings. We have been able to reduce the financial burden on the patients as well as the hospital significantly while achieving results at par with other studies which have used commercially available NPWT.

Perforator Flaps for Reconstruction of Lower Limb Defects.

BACKGROUND: Reconstruction of soft tissue defects in the lower third of the leg remains challenging. Anatomical constraints limit the local options available for complex defects especially lower third of leg. Local flaps based on perforator vessels are raising interest in reconstructive surgery of the limbs. We present our experience with perforator flaps for reconstruction of soft tissue defects in the lower limb. METHODS: The study was carried prospectively and 23 patients with lower limb defects treated with various perforator flaps (both elective as well as emergency) were included in the study. A hand-held ultrasound Doppler was used preoperatively and intraoperatively to detect the perforator vessels. RESULTS: Out of 23 patients, we witnessed partial flap loss in 1 and distal flap necrosis in 3 patients. Four patients had minor complications which included infection, wound dehiscence and congestion of flap. CONCLUSION: Perforator flaps may represent a good alternative to the free flaps in the areas were other local reconstructive procedures are not possible. This is a versatile technique and with decreased donor site morbidity limited to a single body area. There is a specific like to like soft tissue replacement leading to a better cosmetic and reconstructive outcome. The main drawback of the perforator flaps however is the higher risk of venous congestion.

Bear maul craniocerebral trauma in Kashmir Valley.

Craniocerebral injuries constitute the bulk of the trauma patients in all the tertiary-care hospitals. Bear attacks as a cause of trauma to the brain and its protective covering are rare. This was a hospital-based retrospective (January 1990 to July 2005) and prospective study (August 2005 to December 2010). Craniocerebral trauma was seen in 49 patients of bear maul injuries. Loss of scalp tissue was seen in 17 patients, 13 of whom had exposed pericranium and needed split-thickness skin grafting, while 4 patients with exposed skull bones required scalp transposition flaps as an initial procedure. Skull bone fractures without associated brain injury were observed in 24 cases. Frontal bone was the site of fracture in the majority of cases (95%). Surgical intervention was needed in 18 patients for significantly depressed fractures. Three of these patients had depressed frontal bone fractures with underlying contusions and needed brain debridement and duraplasty. Injury to the brain was observed in 8 patients. Trauma to the brain and its protective coverings as a result of bear attacks is rarely known. Brain injury occurs less commonly as compared to soft tissue and bony injury. Craniocerebral trauma as a result of bear assaults has been a hitherto neglected area of trauma as the past reported incidence has been very low. Of late, the incidence and severity of such attacks has assumed grave proportions in areas adjacent to known bear habitats. An innocuous-looking surface wound might be the only presentation of an underlying severe brain trauma. Public awareness has to be generated to protect the people living in hilly areas.

Giant lipoma: a case report.

A lipoma is a fatty tissue tumor presenting as a painless slowly growing mass that can affect any part of the body rich in adipose tissue. Lipomas can be present in the thigh, shoulder, trunk, etc, although they are usually small. We are reporting a 65-year-old man with a giant lipoma involving his left buttock and lumbar region.

Outcome of treatment of the mismanaged pediatric elbow trauma: a series of 73 cases.

PURPOSE: To analyze the outcome of the management of pediatric elbow trauma referred to our hospital after initial intervention by traditional bone setters. METHOD: Retrospective study of 73 patients, presenting to the hospital with a complication attributable to the initial mismanagement of their injuries. RESULTS: The mode of presentation was directly related to the type of initial intervention on the basis of which we were able to quantify bone setters into two groups. The first group using a rather rough method of trauma treatment involving the application of tight local bandages, massage and manipulation and a second group having a relatively less rough approach, applying splints to the injured extremity without tight bandages and manipulation. The result of treatment of these injuries was determined by the delay in presentation and the type of injury. CONCLUSION: This study highlights the importance of dealing with the unchecked and unsupervised practice of bone setting in the developing world. We believe that training these people on the pattern of traditional birth attendants can at the very least lower the occurrence, if not entirely eliminate the problem of mismanaged trauma in this part of the world.

An unusual case of frost bite autoamputation of toes.

BACKGROUND: We report a case of a 15 year old young female who suffered autoamputation of left mid foot and four digits of right foot following repeated application of snow to relieve the pain in her frost bitten feet. CASE PRESENTATION: The sociodemographic background, cause, resulting injury and subsequent management are discussed. CONCLUSION: Such injuries are relatively rare but awareness of the risk of this type of injury is important.