Pattern and profile of electric burn injury cases at a Burn centre.

BACKGROUND: Electrical burns are quite different from thermal and chemical burns. This study is from a centre which deals with job related electric burn injuries alone and thus can give a pure account of the electric burns and discuss the related peculiarities. Study aims to highlight the differences in the mechanism of electric burn injury, its mode of presentation, morbidity, complications and thus the treatment strategies as compared to rest of the burn injuries. METHODS: This is a descriptive case series study of first consecutive 61 electric burn victims treated at a Burn Unit and Plastic Surgery centre. Cases were admitted and resuscitated at the emergency, and further treated at burn unit. Thorough history, examination findings and operative procedures were recorded. Patients were photographed for record as well. Emergency operative procedures, wound management, soft tissue coverage procedures and complications during the hospital stay were recorded and studied. RESULTS: Twenty cases (33%) were in the fifth decade of life. High voltage electric burn injury was seen in 42 (69%) of the cases. Whereas only 9 cases were treated conservatively, other 52 cases had 24 fasciotomies and 71 debridements. Series witnessed 10 expiries, and 22 amputations and all these were result of high voltage electric burns. Twenty eight soft tissue coverage procedures were carried out. CONCLUSIONS: Electric burn injuries are altogether different from rest of the burn injuries and must be treated accordingly. These injuries are peculiar for ongoing damage, extensive trauma, complications and prolonged morbidity. Treatment requires a high degree of suspicion, more aggressive management to unfold and minimize the deep seated insult.

Role of reverse sural artery flap for soft tissue defects of lower limb: experience with 66 cases.

BACKGROUND: Reverse sural artery flap has proved to be a good option to reconstruct soft tissue defects of lower limb and foot region. Different studies, however, speak of its use in different areas depending upon the individual experiences. Various modifications of the flap technique have been described in various studies. This study highlights many of the modifications in a single series and the fact that extending its arc of rotation, flap has capacity to deal with defects of middle and lower thirds of leg, heel, ankle, sole, dorsum and forefoot. METHODS: In this case series, flap. was utilized in 66 cases. Extension of skin paddle up to knee joint crease level increased the are of rotation and as a result series witnessed this flap covering defects at the forefoot level. A good number of modifications suggested in literature were utilized to get optimal results. RESULTS: Lower leg defects were covered in 26 cases. Heel was the site of defect in 18 patients. Dorsum foot needed soft tissue cover in other 15 cases. Flap was successful in 62 cases and it failed in 4 cases. CONCLUSIONS: Flap due to its long arc of rotation has the capacity to deal the defects of middle and lower thirds of leg, heel, ankle, sole, dorsum and forefoot. Various modifications can be wisely utilized to increase the efficacy of the flap.

Frequency of sensory deficit in terms of two point discrimination in split thickness skin grafts and local flaps for soft tissue defects of fingers.

BACKGROUND: The minimum distance between two stimulus points on the skin, which are perceived as distinct points, is defined as two point discrimination (TPD). Among the two types of TPD, i.e., static and dynamic, static two-point discrimination (STPD) is commonly used to determine digital nerve integrity. Local flaps usually do well in maintaining sensibility of the covered area in terms of two-point discrimination in contrast to split thickness skin grafts (STSG). Aim was to determine the frequency of sensory deficit in terms of Two Point Discrimination (TPD) in Split Thickness Skin Grafts (STSG) and local flaps for soft tissue defects of fingers three months postoperatively. METHODS: Thirty-five patients underwent local flap coverage and other thirty-five had split thickness skin grafting for soft tissue defects of fingers depending upon nature of defect. Patients were followed up at 2, 4, 8 and 12 weeks. TPD, measured at 3 months of follow-up, of 7 mm was considered normal (no sensory deficit) and TPD of 8 mm or more was considered as sensory deficit. RESULTS: The sensory deficit observed at the end of 12th week post operatively was 8.6% in the patients with local flap coverage (3 patients) and 45.7% with STSG (16 patients). Patients with no sensory deficit were 91.4% (32 patients) in the local flap coverage and 54.3% (19 patients) in the STSG at 12th week of follow up. The relative ratio (RR) of sensory deficit in local flaps and STSG was 5 (> 2). CONCLUSIONS: Local flaps are better options in terms of TPD preservation as opposed to STSG for soft tissue defects of fingers.

Comparison of outcomes between linear versus triangular flap repair techniques at vermilion in unilateral cleft lip repair.

BACKGROUND: Surgery for unilateral cleft lip repair has evolved over centuries. Many studies give detailed inside to this process of evolution of various techniques and their modifications. Objectives were to compare linear repair of Millard rotation advancement technique and triangular flap technique of Nordhoff, at vermilion in unilateral cleft lip repair. METHODS: This cross-sectional analytical study was conducted at Departments of Plastic Surgery, Services Institute of Medical Sciences, and WAPDA Teaching Hospital Complex, Lahore form Jan 2004 to Dec 2011. Patients presenting with unilateral cleft lip deformity were included in the study. In the early part of the study (2004-2008), only Millard linear repair at vermilion was the routine practice. Last consecutive 40 cases repaired with this technique during this period were selected for the study. From 2009 to 2011 the unilateral cases were operated with Nordhoff triangular flap repair. A group of 40 consecutive cases repaired with this technique was also selected for the study. In both groups, the postoperative period exceeded one year. Results were compared for the presence of notch on repaired vermilion area. RESULTS: Notch was absent in 29 cases (72%) treated with Millard Technique whereas Noordhoff Technique Group showed a higher number of 34 cases (85%). On other extreme, a notch of more than 1 mm was evident in two cases (5%) of Millard technique only and Noordhoff technique did not show this wide notch at vermilion. Similarly, two subgroups of 0.5 mm notch and 0.5-1 mm notch had a slightly higher number of cases in group dealt with Millard technique (5 and 4 cases respectively) as compared to cases dealt by Noordhoff technique (3 cases in each subgroup). CONCLUSION: Nordhoff triangular flap repair at vermilion reduces the chances of notching to minimum due to break in the linear repair in vermilion and also helps in reconstructing a symmetrical vermilion by bringing in the vermilion from lateral to medial segment.

Reverse ulnar parametacarpal artery flap for soft tissue defects of hand.

BACKGROUND: Burn injuries and post burn contractures of the little fingers and areas around are quite common. Release of these contractures may lead to full thickness soft tissue defects which need soft tissue cover. Similarly, mechanical trauma and also road traffic accidents, quite often lead to soft tissue defects of hand. Objective of this study was to evaluate the role of reverse ulnar parametacarpal artery flap in providing soft tissue cover for various full thickness soft tissue defects at the base of little finger and adjacent areas on palmar and dorsal aspects. METHODS: It was an observational study, conducted at Department of Plastic Surgery, Services Hospital, Lahore. Study included ten cases with three females and seven male patients. Six of the patients had severe post-burn contractures of little finger, two had the involvement of the adjacent palm areas as well and one case had contracture along the mid palm crease. One case had post mechanical trauma soft tissue defect at dorsal aspect of 4th web space. Contractures were released and resulting soft tissue defects were reconstructed with reverse ulnar parametacarpal artery flap. Age ranged from 9 to 42 years with a mean age of 20.3 years. RESULTS: This flap was utilised in ten cases. All flaps survived, one of the cases developed epidermolysis of whole of the flap which healed uneventfully. CONCLUSION: Flap is a local option to cover the soft tissue defects of little finger and areas around thus involves the same operative field. Skin texture and features of the donor site also resemble the recipient area. The defect site is closed primarily.

Effects of Propranolol in Accelerating Wound Healing and Attenuation of Hypermetabolism in Adult Burn Patients.

OBJECTIVE: To compare the mean duration of wound healing and attenuation of muscle wasting in adult burn patients treated with propranolol and control group. STUDY DESIGN: A randomised controlled trial. PLACE AND DURATION OF STUDY: Allied Burn and Reconstructive Surgery Center, Faisalabad from March to August 2018. METHODOLOGY: Seventy adult burn patients with 20-40% burn of the total body surface area (TBSA) were included in the study and divided into two groups; propranolol group and control group. Propranolol was administered at dose of 0.5-3 mg/Kg body weight per day along with standard burn care treatment during the entire period of treatment. RESULTS: Faster healing of the superficial burns was noticed in the patients of propranolol group. In superficial burns lesser time was needed for adequate healing; 13.20 ±1.90 days versus 20.34 ±2.32 days (p <0.001). At the same time, lesser time was required for deep burn patients treated with propranolol to be ready for skin grafting; 23.87 ±2.36 versus 33.64 ±3.15 days; p <0.001) comparing control group. Mean mid-arm circumference was 27.57 ±1.62 cm in study group and 24.46 ±1.77 cm in control group (p<0.0001) which was statistically significant. This result showed that hypermetabolic response of burn in terms of muscle wasting was clearly modulated by betablocker therapy. CONCLUSION: Propranolol administration in adult burn patients appears to be beneficial in reducing morbidity, mortality and hospital stay by enhancing earlier wound healing and attenuating the catabolic muscle wasting in response to stress caused by burn.

Reverse radial artery flap for soft tissue defects of hand in pediatric age group.

BACKGROUND: To highlight the usefulness of reverse radial artery flap in covering various soft tissue defects of hand in paediatric age group. METHODS: A total of 16 reverse radial artery flaps were utilized in a period of three years to cover various soft tissue defects of hand for paediatric age group patients. The age ranged from 5-18 years. The two common causes of soft tissue defects in this series were mechanical trauma and fireworks trauma with five cases in each group. Three of the cases were burn victims and other two presented with earth quake injuries. One patient had wound because of road traffic accident. Soft tissue defects of palm were covered with this flap in eight cases while in three cases it was wrapped around the thumb. First web space defects were covered with this flap in two cases. Two cases required coverage of amputation stump at transmetacarpal level and yet another required a big flap to cover the soft tissue defects at palm, dorsum and thumb. Donor site was covered with split skin graft in all cases but one, which was closed primarily. RESULTS: We had partial loss of flap in one case. Grafted donor sites healed uneventfully and were quite acceptable to the patients in due course of time. CONCLUSION: Reverse radial artery flap has a quite long arc of rotation which brings it great ease to cover the soft tissue defects of various areas of hand like palm, dorsum, first web space and thumb.

Five cases of rhinocerebral mucormycosis.

Rhinocerebral mucormycosis is a rare and often fatal fungal infection in immunocompromised patients. We encountered three women and two men with diabetes and mucormycosis in a period of 4 years. Two of the patients died.

Incidence and causes of maxillofacial skeletal injuries at the Mayo Hospital in Lahore, Pakistan.

Between January 2001 and December 2002, we studied a total of 702 patients with facial skeletal injuries, of whom 590 (84%) were male and 112 (16%) female. Injuries were most common (218 patients, 31%) in the third decade of life and there were 167 (24%) in the second decade. The most common cause was road traffic collisions (382 patients, 54%) and the second most common was a fall from a height (135 patients, 19%). The mandible was the most common bone to be fractured (473 patients, 67%) followed by the zygoma (209 patients, 30%). There were 199 patients with fractured maxillas (28%).

Severe postburn contracture of cheek mucosa leading to false temporomandibular joint ankylosis.

A case of burn injury to lips and cheek mucosa is reported who developed severe contracture of cheek mucosa leading to inability to open mouth. Patient was misdiagnosed as a case of temporomandibular ankylosis and was managed on those lines to no relief. When the contracture was released and soft tissue defect repaired with nasolabial flap, patient gained near normal mouth opening.

Temporal fascia as interpositioning material in cases of temporomandibular ankylosis.

OBJECTIVE: To evaluate the efficacy of temporal fascia as interpositioning material after treatment of TMJ ankylosis with gap arthroplasty. DESIGN: An interventional study. PLACE AND DURATION OF STUDY: The study was carried out at the Department of Oral and Maxillofacial Surgery, Mayo Hospital, Lahore, during June 1999 to June 2001. PATIENTS AND METHODS: A total of 51 patients, 23 males and 28 females, of temporomandibular ankylosis were treated with gap arthroplasty and temporal fascia was used as interpositioning material. RESULTS: Out of 51 cases, 28 had excellent results, 20 were declared good and 3 presented with recurrence. CONCLUSION: Temporal fascia works as excellent interpositioning material with minimum morbidity and no complications. Moreover, it is easier to raise, comes from same operation field and is dispensable.

Pedicled on-top plasty for thumb reconstruction: utilization of proximal phalanx of an injured ring finger.

Thumb has a critical role in the hand function. It is the most important digit for pinching and grasping. Therefore, thumb amputation demands its replantation or reconstruction to restore the hand functions. A case of hand injury which involved multiple digits along with amputation of thumb is reported. The thumb had amputation level just distal to Metacarpophalangeal joint (MPj) along with amputation of other 3 fingers at different levels. Proximal phalanx of ring finger based on palmar vessels was utilized for on-top plasty to build thumb post and restore hand function. On-top plasty for thumb is quite useful, dependable, easier, time saving option which does not increase the morbidity associated with other options of thumb reconstruction. It may especially be a very useful option for the centres lacking the facility and equipment for micro-vascular surgeries and expertise of the trained micro-vascular surgeons.

Zygomatic bone fracture.

OBJECTIVE: To find out the number and etiology of fractures of zygomatic bone. DESIGN: Observational study. PLACE AND DURATION OF STUDY: This study was carried out at the Department of Oral and Maxillofacial Surgery, Mayo Hospital, Lahore from January 2001 to December 2002. PATIENTS AND METHODS: A total of 209 cases were treated during a period of two years. A detailed history and examination was done and findings were confirmed radiologically. RESULTS: There were 184 (88.04%) male and 25 (11.96%) female patients. In 117 (56 %) cases only the zygomatic bone was involved while in the rest of the 92 (44 %) cases, fracture occurred in combination with fracture of other facial bones. The youngest patient in the series was 9 years of age and the oldest of 80 years. Most of the patients were in the third decade of life (35%). Most common etiology was road traffic accidents, followed by interpersonal violence. In half of the road traffic accidents, motorcyclists were involved. CONCLUSION: Most common etiology of the fractured zygomatic bone was road traffic accidents. Measures, like various awareness campaigns, raising the traffic sense in public, wearing helmets while driving the motorcycle, can minimize number of these cases.

An analysis of deformities in revision surgeries for secondary unilateral cleft lip.

OBJECTIVE: To analyze the secondary cleft lip deformities and the possible causes in a cohort of cases. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Services Institute of Medical Sciences and WAPDA Teaching Hospital Complex, Lahore, from September 2008 to March 2012. METHODOLOGY: Consecutive cases of secondary unilateral cleft lip deformities were selected for the study. These cases were interviewed and deformities recorded. Pre and postoperative photographs were taken for comparison. Per operative photographs were taken, after marking of the incisions, to keep a record of the intervention needed to correct the deformities. These cases were then further analyzed to know the deformities and interventions needed for correction of these deformities. RESULTS: Study subjects comprised 114 males and 75 females. Secondary correction was the most common in second decade of life with 82 cases in this group. The most common deformity was unfavorable scar in 150 cases followed by notch at the vermilion border in 124 cases. Short lip was found in 119 cases. Complete revision of the repair was required in 158 cases and 25 cases required partial redo of the initial repair. In other 6 cases, only scar revision was carried out. CONCLUSION: Unfavorable scar followed by vermilion notch and short lip were the most common secondary cleft lip deformities. Better technique helps favorable scar. Vermilion notch and short lip can be overcome by switching from rotation advancement repair to the triangular flap repair of Noordhoff.