CATASTROPHIC INJURY. GRATIFYING RESULT

22 years girl got an epileptic fit while in the bathroom and the handremained immersed in the bucket of boiling water for about 3o minutes.

The ensuing oedema appeared like a compartment syndrome. Prompt fasciotomy of the palm was done. This was not of much help. The discolouration of all the digits followed, which had started to appear ominously shrivelled and black. With this discolouration, she had been advised amputation through the wrist

This was the status at presentation at 3 days. A young petite girl with aset of pale and black shrivelingdigits with all the apprehension written on her face and yet conveying in the unspoken words her desire, lay on the examination couch in front of me. The option of a quick amputation of the hand weighed heavily in my heart against an attempt at possible salvage with all the possible risks. Black digits would mean amputation.  The mere idea of possible salvage meant an uphill task. It involved an unending saga of reconstructive procedures, each step likely to fail and fail miserably. The failure would have such a cascading effect that all previous procedures will be negated. This will end in amputation, where in fact, one had thought of it to start with.

With all the experience and courage onmy part and faith and trust on the part of the girl and her parents and relatives, we embarked on journey of reconstruction, the stakes were high, not in terms of finances, but in terms of reputation for me and frustration on the part of patient.And most insurmountable was the question of survival of thehand. Will this girl have two hands? Will the hand survive? Will the hand work?

The aim was clear. She needed a working hand. The time schedule was clear. It has to be fast and in quick succession, without a break for a few months to start with, at least. We knew the cost of failure. It was amputation! There was not much to talk but everything to execute.

 

The wound was debrided and all the apparently and definitely dead part of skin and bone were excised. There were grey areas which appeared potentially salvageable.These were painstakingly saved.  After a thorough debridement which lasted for hours, the patient was left with fingers which had lost a certain length and the palm. The salvaged finger and the back of the hand were bare as the dead skin had been removed totally. A huge stock of bare skeleton needed cover and that too immediately.

The time was not to wait till next morning .The time was running out. In fact, it had already run out. We were on spare fuel. It was now.

Such a large area of skin loss could only be transferred from a very few selected parts of the body.We chose the safety and colour match from her abdominal skin.The bare skeleton of the hand was buried in a pocket created in the abdominal wall.

The skin healed nicely over the next few weeks. On the part of the patient, she tolerated the relatively awkward position of letting the hand remain attached to her tummy for several weeks. There were several hitches in the healing. Certain length of the phalanges were lost. In spite of these minor hitches, the wound healed eventually but surely in the projected time frame.

There was no infection, the most dreaded complication. We had overcome the first hurdle.The bare skeleton of the hand had been covered with the protective shield of soft, supple and pliable skin.

All the fingers and the thumb were within the cocoon of the new skin cover.

injury-web-8

Now the next step was creating a thumb.The thumb makes the hand, an organ for grasp. All the fingers and the thumb had been enveloped in the common sheet of skin. The skin had to be separated in such a way that the thumb could be separated from digits. Put simply, this step was reconstruction of the first web space.

Another successful step had been accomplished. Yet there were miles to go before I……..  

The injury had left the thumb short. The plan was to give a longer thumb. The author had designed a mini external fixation device. The device was used to lengthen the thumb. The short thumb grew painlessly over the device. Over the next few months, the growth was considered satisfactory, both on observation and on x ray. The device was than dismantled. Fig 6,7

One more mile stone achieved. We had a thumb and it was mobile! Does it  appear that the experience of prolonged treatment was harrowing ? Probably yes and probably not.Probably yes ‘cos the mother accompanied the daughter, travelled a distance of 6hours by regular state transport bus and stayed with their local relatives. I feel probably ‘no’ ‘cos the result of each surgery unfolded something  significantly beneficial. The stakes were too high to be compromised at any stage, by anything. My job was to make things as easy as possible, which came with constant communication. Figure8.

 

injury-web-14

One should admire, applaud and appreciate the help, cooperation, patience, inconvenience and tolerance of the local relatives who went all out to extend them all possible help and letting them be guest for unscheduled, unrestricted and repeated stay in their small houses. Heart was big, the house may have been small.

The thumb was long and strong. But it was curved. We wanted it to be straight and out or extended so that she can grasp larger objects. An extension osteotomy was done to achieve a wider web. This gave a good pinch with the other digits.

While the patient did better with each step, the mother returned every time only to ask if anything else, anything more, can still be done.

On the social front, the girl pursued her graduation and post graduation and finished her masters in a science stream. If this was not enough, she had a driving licence issued by the Regional transport Office, the RTO!

What send us into euphoria is the fact, she got employed as a professor! She can write on the black board!

Encouraged, by her determination, perseverance for getting the hand look and function closer to normal, we created the second web. Creation of the second web gave her an index finger and a middle finger.The fingers were short, but for her, they were still, the index and middle fingers!

 The fingers were slightly bulky with all the fat which came bundled with the abdominal skin which had been transferred initially. The extra fat and the skin were trimmedover the fingers,for the fingers to look slimmer.

At an earlier occasion, a titanium screw had been insertedin the index finger to augment the length.This had done well without any sign of loosening, pain or infection. The second web created another independent finger; the middle finger. So, another pair of titanium screw were inserted into the middle finger to augment its length too.

How long this took? Of course years. But there were gaps of months and years between each secondary surgery. In those intervening periods, the girl continued her studies, exams, interview for jobs to name a few.

The mobility and flexibility of the digits was achieved by providing dynamic splints, which helped prevent stiffness of these tiny joints.

The option of toe transfer was there. This procedure involves dissecting out a toe and transferring it to the hand. This was not accepted. The community practice of wearing a ring in the toe was respected.

It must have cost a fortune would be the next question obviously. Well, we were all very supportive. The hospital , the anesthetists and I were more than reasonable and saw to it that it did not financially  pinch the family.

Most of these procedures were scheduled on outpatient basis avoiding hospitalization, thus cutting cost and inconvenience to   accompanying family members.

Is the treatment over finally? Honestly, like the patient and her family, I am also looking for improving her hand further, though I wish to declare, that the treatment is over and you do not have to return as the hand is functional.

 Am I stretching the treatment? Well, probably yes, if amputation is to be called a treatment. In that case, probably the treatment would have been over years back. If reconstruction is called art and science, this is a true example. There are no true guide lines for such an injury, and yet a useful hand was reconstructed.

We started off with a few questions.In the end, the girl has  not only two hands and but they are both working hands. She is independent, gainfully employed and is not stamped an amputee!

About Dr. Jindal

There is a phenomenal effort put into introduction of innovation and application of current method of treatment in ALL patient care.

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