MOMMY THUMB Or TEXTING THUMB
“Mommy thumb” or “Texting thumb” is characterized by severe pain on the dorso-radial aspect of the wrist, typically provoked by thumb movement. It is caused by entrapment of two tendons on the dorsal side of the wrist. Medically the condition is termed de Quervain’s tenosynovitis and is the result of entrapment of abductor pollicis longus (APL) and extensor pollicis brevis (EPB)in the first dorsal compartment of the wrist. Increasing weight of a baby who is looked after by the Mom is a well-recognized cause, however with the liberal use of the cyber devices (such as the smart phone) where thumb is the main contributor to the texting process, we now frequently find this etiology among our patients these days.
The APL usually has multiple slips that insert on various anatomic locations around the thumb basilar joint. For instance, the thumb metacarpal, the trapezium. the volar carpal ligament, the opponens pollicis, and abductor pollicis brevis. The more problematic EPB tendon may be housed within its own separate tunnel within the first dorsal compartment.
The surgery is performed under local anesthesia. The surgical treatment aims to provide frictionless glide of the APL and the EPB tendons. The surgery typically provides instant relief of the disgustingly painful symptoms and the patients with bilateral disease eagerly return for surgery of the other side also.
Dr Muhammad Saaiq
MBBS, FCPS(Surgery), FCPS(Plastic Surgery)
Cosmetic, Hand and Burns Surgeon, Islamabad.
WRIST DROP SECONDARY TO HIGH RADIAL NERVE PALSY:
Wrist drop that develops in the aftermath of radial nerve injury, results in severely compromised function of the hand and wrist. There is loss of extension of the wrist, fingers and the thumb. To top them all, the most remarkable disability is weakness of the grip.
We label it as high radial nerve injury when the level of nerve injury is somewhere proximal to the division of the nerve into its terminal sensory and motor branches at the elbow. How is this injury sustained? Most often a humeral shaft fracture is the culprit. The palsy is termed primary if it develops with the fracture itself. It is called secondary or iatrogenic when it develops following some orthopedic intervention. Also not surprisingly we still continue to receive a small percentage of patients with iatrogenic radial nerve injury secondary to injections in the deltoid region.
The iatrogenic injuries of radial nerve are largely preventable. A proactive approach is prudent in this regard. At the time of orthopedic interventions, routine identification and isolation of the nerve helps to avoid serious iatrogenic injuries. Also avoid unnecessary injections by quacks.
Among judiciously selected late presenting patients, tendon transfers provide the most robust means of restoring hand function. In the FCR set of triple tendon transfers, the following tendons are transferred:
1- Pronator teres (PT) is transferred to the extensor carpi radialis brevis (ECRB).
2- Flexor carpi radialis (FCR) to the extensor digitorum communis (EDC) and
3- Palmaris longus (PL) to the re-routed extensor pollicis longus (EPL).
The ideal candidates for tendon transfers are those cases of high radial nerve injury which have neither showed signs of spontaneous recovery over 4-6 months nor where other treatments such as the nerve repair, nerve reconstruction or nerve transfers have not worked or not tried earlier. The tendon transfer ensures restoration of the critically important functions of hand opening, wr
FLAP COVERAGE FOR HEEL-PAD INJURIES:
Wheel Spoke injury to the heel is sustained by the rear seat occupant of motor bike. Unfortunately we encounter such patients at a frequency of 1-2 per month. More worrisome is the fact that we now receive children and women more often than men with such devastating injuries. These are largely preventable with use of proper wheel covers, awareness on part of the bike riders and avoidance of loose clothing by the occupant which easily get dragged in the spinning wheel.
We usually perform a two stage surgery to save the limb. We employ the reverse flow superficial sural artery flap in an interpolated design most often. In the first stage operation we transpose the flap onto the defect and in the second stage surgery (usually performed after 3 weeks) we divide the pedicle and inset the flap. Here is the case of a 10 years old child who presented with this gruesome injury and successfully rescued.
Dr Muhammad Saaiq
MBBS, FCPS(Surgery), FCPS(Plastic Surgery)
Cosmetic, Hand and Burns Surgeon, Islamabad.
GIANT LIPOMA:
How much is too much and how big is too big? Whereas our judgments are usually subjective, here is a 47 years old gentleman who presented with a painless and progressive swelling of the right thigh. It took many months for this massive mass to evolve to this size. His main issue was that he was often embarrassed by security guards on various security checkpoints for suspecting him to be carrying something dangerous along with his thigh.
As a surgeon our main concern was to rule out malignancy particularly a rhabdomyoma or a sarcoma. Luckily it turned out to be a lipoma, but of enormous dimensions.
Now coming to the question of how big is too big? Objectively speaking, we label it as a “Giant” lipoma when it measures ≥10-cm in one dimension or weighs at least 1-Kg. In this case it measured approximately 36× 28× 10 cm and the weight was 5.3 Kg. So it was a giant one and we took it all in Toto under spinal anesthesia. The patient is now enjoying a happy and smooth postoperative course.
In fact it is the biggest lipoma I ever operated upon during my 20-years of romance with surgery. Why did the patient not seek surgeon’ advice at an early stage? Why was the pathology allowed to grow to this enormous size? What if it were a malignant growth with mets? Does this relate to ignorance, poverty or lack of access to appropriate professionals? These are the queries that often float in our mind while reflecting on such cases, however we often remain clueless.
Dr Muhammad Saaiq
MBBS, FCPS(Surgery), FCPS(Plastic Surgery)
Cosmetic, Hand and Burns Surgeon, Islamabad.
ABDOMINAL FLAP FOR HAND TRAUMA:
Occupational hand injuries are fairly common in the developing nations like ours. This is because of the recognized limitations of high-risk workplace-environments. In the developed world, for all industrial, agricultural, electrical and other manual workers, well-grounded safety codes and occupational safety protocols are robustly followed and the workers regularly receive safety trainings too. As medical professionals, we can contribute to creation of public awareness and emphasize on prevention strategies.
The spectrum of occupational hand injuries ranges from minor cuts and abrasions to more devastating injuries such as the traumatic amputation of the fingers or hand.
Here is a 51-years old worker who sustained devastating blast injuries to his left hand in the aftermath of some accident with the explosives employed for mining. There was loss of the skin from the dorsal aspect of the hand. The bones of the hands (i.e. metacarpals and phalanges) were broken into pieces beyond description.
Abdominal pedicled flap was employed for coverage of the soft tissue defect of the hand and K-wires were passed to achieve maximum possible alignment of the fractured pieces of bones. Following a two staged-flap-coverage, the hand could be salvaged with reasonable function. The story certainly can’t be a one with fairy-tale-endings as these patients often need multiple secondary procedures and long term Rehabilitation.
Dr Muhammad Saaiq
MBBS, FCPS(Surgery), FCPS(Plastic Surgery)
Cosmetic, Hand and Burns Surgeon, Islamabad.
FOREIGN BODIES:
Foreign bodies (FBs) constitute a common condition for surgical intervention where judiciously indicated. For instance, when these cause pain, restriction of movement, impingement of neurovascular structures and cosmetic disfigurement. Deep seated FBs which cause no problems or pose no threats are best left alone most often.
Here is a 30-years old patient who presented with two sewing needles in the left leg. These were self-inserted 3-months ago and were causing pain on walking. Grossly the patient did not show any major symptoms which could suggest any psychiatric disorder. One needle which appeared to be vertically lying was actually buried under the periosteum of the tibia. With careful dissection, the two were safely removed. There was a smooth postoperative course.
Dr Muhammad Saaiq
MBBS, FCPS(Surgery), FCPS(Plastic Surgery)
Cosmetic, Hand and Burns Surgeon, Islamabad.
INGROWN TOE NAILS:
Ingrown toenail (aka IGTN) or Onychocryptosis is a common and disabling disorder. Typically a sharp edge/spike of the nail plate presses against the soft tissues of the toe and the lateral nail fold. There is an inflammatory response with formation of granulation tissue that grows over the nail. The condition not only causes severe persistent pain but also problems with shoe-wearing and walking. Additinally secondary infections with bacteria and fungi may ensue, particularly among diabetics.
One of the three common causes are usually identifiable among the sufferers. Firstly the condition may ensue following use of recently purchased tight-fitting shoes (especially tight in the forefoot region). Secondly the condition may date back to an event of improper nail cutting (in longitudinal direction). Thirdly there might have been some traumatic insult to the forefoot/ toes. In the first case the condition tends to affect both feet whereas in the other scenarios there is usually affliction of one side only.
A wide spectrum of treatment options exists that range from conservative wound care to various forms of surgical treatments. The spectrum of operative treatments include wedge excision of the involved side of the nail-plate, total nail removal, chemical ablation of the nail root with phonol and Zadek’s procedure of partial surgical ablation of the nail root. Many more surgical techniques have been described in the textbooks.
In the past we performed Wedge excisions quite often, but with these we not only faced a high frequency of recurrence but also poor cosmesis of the toes with the surgical scars. Now the author’s preferred method is removal of the entire nail plate, curettage of the infected exuberant granulations, subsequent standard wound care, antibiotic and analgesic therapy. The nail removal allows resolution of infection and regrowth of the nail plate in a proper direction over the healed nail bed. The growth of the new nail plate is us
GANGLION CYSTS ON THE WRIST:
Ganglions cysts constitute the commonest cause of palpable swellings in the wrist and hand. Most often these occur in visible locales of the wrist and hand, near a joint capsule or a tendon sheath. These are rarely seen elsewhere. For instance, around the ankle and in deeper locations in the fingers and the palm.
Histologically these are benign cysts with a thin connective tissue capsule, formed by compressed stroma, but no true synovial lining. These are filled with mucinous gel-like material. The cyst usually communicates with the underlying joint or tendon sheath through a pedicle.
A plethora of treatment modalities is currently employed to address ganglions. There exists a conflicted body of evidence with no consensus guidelines. The treatment options include watchful wait, aspiration alone, aspiration combined with steroid injection, surgical excision and some more extensive procedures such as arthroscopic ganglionectomy and use of hyaluronidase to improve liquefacation in the cysts. All these modalities are attended by advantages and disadvantages of their own. Recurrence is a formidable foe of all treatment modalities.
By the time a patient presents to the plastic surgeon, he/she often has already tried the option of conservative treatment or has a painful symptomatic ganglion. So we have to proceed with some intervention. Over a period of time, the author now prefers to initially proceed with aspiration and steroid injection. Under standard aseptic precautions and topical anesthesia with Xylocaine, the ganglion is first aspirated with a 16-G IV cannula and then 40mg triamcinolone acetonide (diluted in Xylocaine) is injected using another needle already passed into the cyst before aspiration. Crepe bandage is applied with advise to keep the wrist relatively immobilized for 01 day. Cases which present with recurrence after two trials of injection/ aspiration are recommended surgical excision which entails excision of the entire cyst complex including
CORRECTIVE SURGERY FOR DEFORMED EARS:
Prominent ears are one of the common congenital problems. The child is often brought by worried parents who seek plastic surgery because the child has a serious sense of social embarrassment.
The problem often stems from poorly developed anti-helix. Sometimes other abnormalities such as redundant choncha accompanies too.
Corrective surgery is performed through a hidden incision on the back of the ear. It restores shape, symmetry and harmony to the ears.
Dr Muhammad Saaiq
MBBS, FCPS(Surgery), FCPS(Plastic Surgery)
Cosmetic, Hand and Burns Surgeon, Islamabad.
CENTRAL VENOUS CATHETERIZATION
Central venous catheterization is an important invasive procedure often indicated among patients with major burns. It not only provides safe portal for infusion of large volumes of fluids but also helps with the much needed hemodynamic monitoring at the same time (i.e. Central Venous Pressure monitoring). The catheterization is performed in one of the major central veins. For instance, the subclavian vein, the jugular vein or the femoral veins. Seldinger’s technique is the safest method. The Plastic surgeon dealing with burns should have a mastery of the procedure.
The Videos are for educational purpose, hence relatively slow for better understanding.
Dr Muhammad Saaiq
MBBS, FCPS(Surgery), FCPS(Plastic Surgery)
Cosmetic, Hand and Burns Surgeon, Islamabad.
