An epidemiological study of traumatic brachial plexus injury patients treated at an Indian centre

Background:

Epidemiological studies on traumatic brachial plexus injuries are few and these studies help us to improve the treatment, rehabilitation of these patients and to allocate the resources required in their management. Epidemiological factors can vary in different countries. We wanted to know the situation in an Indian centre.

Materials and Methods:

Data regarding age, sex, affected side, mode of injury, distribution of paralysis, associated injuries, pain at the time of presentation and the index procedure they underwent were collected from 304 patients. Additional data like the vehicle associated during the accident, speed of the vehicle during the accident, employment status and integration into the family were collected in 144 patients out of the 304 patients.

Results:

Road traffic accidents accounted for 94% of patients and of the road traffic accidents 90% involved two wheelers. Brachial plexus injury formed a part of multitrauma in 54% of this study group and 46% had isolated brachial plexus injury. Associated injuries like fractures, vascular injuries and head injuries are much less probably due to the lower velocity of the vehicles compared to the western world. The average time interval from the date of injury to exploration of the brachial plexus was 127 days and 124 (40.78%) patients presented to us within this duration. Fifty-seven per cent had joined back to work by an average of 8.6 months. It took an average of 6.8 months for the global brachial plexus-injured patients to write in their non-dominant hand.KEY WORDS: Epidemiological study, Indian centre, nerve injury, traumatic brachial plexus injury     

Wound coverage considerations for defects of the lower third of the leg

Anatomical features of the lower third of the leg like subcutaneous bone surrounded by tendons with no muscles, vessels in isolated compartments with little intercommunication between them make the coverage of the wounds in the region a challenging problem. Free flaps continue to be the gold standard for the coverage of lower third leg wounds because of their ability to cover large defects with high success rates and feasibility of using it in acute situations by choosing distant recipient vessels. Reverse flow flaps are more useful for the coverage of the ankle and foot defects than lower third leg defects. The perforators in the lower third leg on which these flaps are based are often damaged during the injury. In medium-sized defects of less than 50 cm² size, local transposition flaps, perforator flaps, or propeller flaps can be used. Preoperative identification by the Doppler is essential before embarking on these flaps. Of the muscle flaps, the peroneus brevis flap can be used in selected cases with small defects. In spite of all recent developments, cross-leg flaps continue to remain as a useful technique. In rare occasions when other flaps are not possible or when other options fail it can be a life boat. In the author''s practice free flaps continue to be the first choice for coverage of wounds in the lower third leg with gracilis muscle flap for small and medium defects, latissimus dorsi muscle flap for large defects and anterolateral thigh flap when a skin flap is preferred.KEY WORDS: Free flaps, perforator flaps, lower leg defects     

Bleeding Post Constriction Ring Release Surgery Causing Lower Limb Ischemia in an Infant with Undetected Hemophilia B

Bleeding in the immediate postoperative period causing compromised limb circulation is an alarming complication. It is known to occur in coagulation disorders like hemophilia. When such complications happen in a child with no previous history of bleeding problems, one has to have a low threshold for suspecting a coagulation disorder. Repeated diffuse bleeding in the whole of the surgical wound with no specific bleeders must raise the suspicion and appropriate laboratory tests must immediately be ordered. Bleeding in coagulation disorders can stop only with supplementation of the appropriate missing clotting factor. Early diagnosis is important to avoid excess morbidity. We are reporting a 6-month-old child who underwent surgery for constriction ring syndrome in the limbs with Z-plasty and developed impending limb ischemia due to bleeding in the immediate postoperative period. The article emphasizes the need to think of the possibility while encountering recurrent bleeding in the postoperative period.     

Technical considerations in replantation of total scalp avulsions.

Total scalp avulsions are devastating injuries and replantation is the best form of reconstruction. We present our experience of replantation of six totally avulsed scalps done between 1996 and 2004. All were technically successful, but one was lost in the post-operative period due to accidental shearing of the scalp during nursing care. A single team performed the surgery in all cases and the average operating time was 6 h. No vein grafts were used. Hair growth was satisfactory in all cases. None underwent formal nerve repair but there was adequate sensory recovery in all of them by 6-9 months. A small area of skin necrosis in the occipital area (three cases), telecanthus and epiphora (two cases) were the minor complications. The available Literature highlights the need for multiple teams to reduce the long operating time, the use of multiple vein grafts and the complexities involved. Since, they are rare injuries, gaining wide experience is difficult. In this article we offer recommendations in pre-op preparation, vessel identification, technique of anchoring the avulsed scalp prior to vessel anastomosis and post-op care to make this rare procedure quicker, easier and successful.     

'Jumping' cross finger flaps: a useful technique for salvaging parts in mutilating hand injuries.

In multi-digital injuries, soft tissue from non-adjacent injured fingers, which would have otherwise been discarded, can be used to cover small defects in salvageable digits. This was found useful in the salvage of four digits and one thumb. Anticipation of the need for a flap cover, and the possible availability of tissue in non-adjacent digits, is of paramount importance during the planning process in these injuries. This technique of using 'jumping' cross finger flaps is a useful method, when dealing with multiple finger mutilations that need soft tissue cover.     

Exposure and health assessment during application of lambda-cyhalothrin for malaria vector control in Pakistan.

Icon 10 WP insecticide, a wettable powder formulation containing 10% lambda-cyhalothrin, was evaluated for possible adverse effects on the health of spraymen and villagers during treatment of dwellings for malaria vector control. Skin sensory effects and occasional coughing and sneezing in confined spaces were the only symptoms noted by the workers resulting from the handling and spraying of the insecticide. Absorption of lambda-cyhalothrin was estimated by determining its metabolites in urine and serum. The average amount of lambda-cyhalothrin absorbed by the workers per day (54 micrograms) represents less than 0.0001% (< 1 micrograms.kg-1.day-1) of the average daily amount of the substance handled. Only a small proportion of villagers showed detectable levels of lambda-cyhalothrin metabolites in their urine. Absorption of lambda-cyhalothrin from the formulation tested was therefore very low and, apart from the nuisance of skin sensory effects, there should be no risk to the health of workers or to the villagers whose dwellings are treated.     

Compliance following referral in the early detection of oral cancer and precancer in Sri Lanka

An innovative approach for the early detection of oral cancer and precancer within the context of the primary health care system has been field tested in Sri Lanka. The overall compliance in accepting this particular PHC approach for cancer screening, as estimated by arrival at a referral centre manned by consultant staff, was 54.1%. Nearly 80% of those who turned up without needing an additional reminder, did so within the first 2 weeks of case finding. There was a variation in the degree of compliance depending on the primary health care worker who did the screening and referral. Compliance was greater when the screening area was nearer to the referral centre and in subjects who were diagnosed as having a more advanced stage of the disease. Certain practical considerations that contributed to noncompliance were identified. Postal reminders were seen to increase overall compliance by 10.9%.     

The antiapoptotic DeltaNp73 is degraded in a c-Jun–dependent manner upon genotoxic stress through the antizyme-mediated pathway

p73, the structural and functional homologue of p53, exists as two major forms: the transactivation-proficient, proapoptotic TAp73 or the transactivation-deficient, antiapoptotic DNp73. Expectedly, expression of both these major forms has to be coordinated precisely to achieve the desired cellular outcome. Genotoxic insults resulting in cell death lead to the stabilization of TAp73, mainly through posttranslational modifications, and the concomitant degradation of DNp73, through poorly understood mechanisms. We have therefore investigated the possible mechanisms of stress-induced DNp73 degradation and show here that c-Jun, the AP-1 family member activated by stress signals and involved in stabilizing TAp73, promotes DNp73 degradation. Genotoxic stress-mediated DNp73 degradation was found to occur in a c-Jun–dependent manner through a ubiquitin-independent but proteasome-dependent mechanism. Absence or down-regulation of c-Jun expression abrogated the reduction of DNp73 levels upon stress insults, whereas overexpression of c-Jun led to its degradation. c-Jun controlled DNp73 degradation through the nonclassical, polyamine-induced antizyme (Az) pathway by regulating the latter’s processing during stress response. Consistently, expression of c-Jun or Az, or addition of polyamines, promoted DNp73 degradation, whereas silencing Az expression or inhibiting Az activity in cells exposed to stress reduced c-Jun–dependent DNp73 degradation. Moreover, Az was able to bind to DNp73. These data together demonstrate the existence of a c-Jun–dependent mechanism regulating the abundance of the antiapoptotic DNp73 in response to genotoxic stress.     

Technical considerations and functional outcome of 22 major replantations (The BSSH Douglas Lamb Lecture, 2005)

Twenty-two consecutive major replantations carried out over a 5-year period were assessed with a minimum follow-up of 2 years. Only two patients suffered guillotine amputations. The remainders were either crush, or crush avulsion amputation. Replantation was successful in 20 cases. When analysed by Chen's criteria, there were three Grade I, nine Grade II, six Grade III and two Grade IV results. Most patients with successful replants put the hand to greater use with time and replantation greatly added to the overall well-being of the patient. We consider major replantation as a worthwhile procedure. Radical debridement, bone shortening and well laid out protocols to reduce the ischaemia time are important for success. The technical details which we believe to be important for success are outlined. With decreasing numbers of such injuries in most countries, this paper may help surgeons faced with an occasional patient with a major amputation to make the right decisions.