Vol 1 | Issue 1 | July – Sep 2015 | page:3-6| Dr. Dilip D Tanna, Dr. Ashok Shyam
Author: Dr. Dilip D Tanna [1], Dr. Ashok Shyam [2, 3]
[1] Lotus Clinic, Charni Road, Mumbai, India.
[2] Indian Orthopaedic Research Group, Thane, India
[3] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India
Address of Correspondence
Dr. Dilip D Tanna
Lotus Clinic, Charni Road, Mumbai, India.
Email: ddtanna@gmail.com
Dr DD Tanna – Story of a Legend
This interview was conducted at the famous Lotus Clinic at Mumbai. Interview of Dr DD Tanna (DDT) was personally conducted by our Editor Dr Ashok Shyam (AK). It was an interesting two hours talk in late evening and we are presenting here the salient features of the interview.
AK: First let me thank you for this interview. Let’s begin by asking about your family and where you grew up?
DDT: I grew up in Kalbadevi area in Bombay in a typical Gujrati locality. I had four brothers so we were five of us together with my father and mother. At that time education was not something very popular in our family and when I graduated I was among the handful in 2 mile radius and when I completed post-graduation there were none in the entire area. The trend was that people used to go to college just for the stamp of collage and then join the father business. But I was a good student and so I did complete my studies
AK: Tell us something more about your childhood?
DDT: I had a very eventful childhood, we used to play many sports. I was very good at cricket and even at medical college I was captain of the cricket team. But along with cricket I played many local sports kho-kho, langadi, hoo-to-too, football, volleyball, swimming etc. Didn’t get chance to play hockey but I did play everything I came across.
AK: I understand you have seen Mahatma Gandhi and heard him speak. Please share your remembrance of that?
DDT: Once Gandhiji was holding a meeting in Bombay and my father said to me ”let’s go see Gandhiji”. I went with him and there was a huge crowd and I felt quite uncomfortable. I wanted to leave when my father said to me ‘why are you afraid of the crowd, these are all your fellow human beings, not cattle herd”. That statement touched me very much and till today, I am not afraid of any crowd. Understanding that all are my fellow human beings, took away my stage fright forever. I can speak my thoughts clearly and without fear and I can dance with the crowd with equal ease.
I have seen Mahatma Gandhi at close distance and he appeared to be a very frail man. At first I wasn’t impressed, but then I realised that this frail man can have the huge crowd following him just because of his thought process. That understanding has helped me a lot in my life.
AK: So why did you become a doctor, what was your inspiration?
DDT: I was good in studies and in those days there were only two choices either to be an engineer or to be a doctor. I had decided that I would be an engineer with no doubt in my mind. One day one of my uncles, who happened to be an engineer, visited us. When asked I told him my intention to become an engineer, to which he replied ”In that case you have to take up a government job all your life”. In those days the only scope for an engineer was to be in government job, but the idea of being a enslaved for life by an organisation was something I couldn’t accept. My freedom was very dear to me and overnight I changed my decision and pledged to become a doctor.
AK: How was your MBBS term? Why did you choose orthopaedic surgery?
DDT: I was quite casual in MBBS and was more involved in sports. I got serious in last year to get good grades. Frankly speaking there were none who influenced me in the undergraduate college. After joining medicine developed a natural liking to surgery and always wanted to become a surgeon. Doing general surgery and then super specialisation for another two years seemed to be a long time. Orthopaedic surgery was a new branch at that time and offered direct super specialisation. And so I joined orthopaedic surgery.
AK: What were your early influences in medical college?
DDT: I wasn’t a very serious student in medical college. Possibly I became a bit serious in my last year of MBBS to score marks to get the branch of my choice. After MBBS and before joining post-graduation I had some spare time at hand which I utilise in reading. That period was a period of change I my life. I read authors like Bertrand Russel who had a major influence in my life. I read ‘Altas shrugged’, ‘We the Living’, and ‘Fountainhead’ and these three books had deep impact on me. I also read The Manusmrti’s specifically for their philosophical treatise and not the religious aspect. I still like to ponder on these philosophical aspects from time to time. By the time I joined as an orthopaedic registrar, I was a pretty serious person. In first 6 months of my orthopaedic residence I was fascinated with basics specially the histopathological aspect of orthopaedics. I read all about the histiocytes, the fibroblasts etc and even today I still think in these terms when I think about orthopaedics.
AK: You joined the B Y L Nair Hospital, Mumbai in 1965. Tell us something about your life at Nair Hospital?
DDT: Well in fact I passed my MS in 1965. I joined possibly in 1954 as a medical student. I was a student, house surgeon, lecturer, honorary surgeon all at Nair hospital. I was one of the youngest consultant as I became consultant at Nair hospital at age of 28, merely 8 months after passing MS exams. Possibly God was kind to me. Nair hospital was a decent place, but it became a force once Dr KV Chaubal joined Nair. Earlier KEM hospital had big name because of Dr Talwalkar and Dr Dholakia. I was lecturer when Dr Chaubal joined. He changed Nair hospital with his modern and dynamic approach. He gave me an individual unit within 3 years. Our rounds would be more than 4 hours in Nair hospital and had great academic discussions.
AK: We have heard about a very famous incident when you operated Dr Chaubal? Do tell us something about that
DDT: Well Dr Chaubal was suffering from a prolapsed disc and he had taken conservative management for some time with recurrent episodes. At one point we went ahead and got a myelogram done (no MRI in those days), and a huge disc was diagnosed. He called me the next day and asked to operate on him. I was 10 years his junior and moreover he was my boss and there were many more senior surgeons who were available. It came as a shock to me that he would chose me to operate on him [and of course it was an honor to be chosen]. Dr Laud and Dr Pradhan assisted me in operating him and it was big news at that time
AK: You were pioneer in bringing C-arm to India? Tell us something about the C-arm Story?
DDT: We used to do all surgeries under X ray guidance in those days, at the most we had 2 x-rays set together by Dr Talwalkar to get orthogonal views. I used to go to USA and they would do all surgeries under C-arm. I came back and contacted Mr Kantilal Gada who used to manufacture X ray machines. He agreed to try to make a C arm if I pay him one lakh rupees [in those days]. The condition was if he succeeded, he would give the c arm to me at no profit rate and if he failed my money would be lost. He did succeed and we had India’s first C-arm at my place. It helped me at many times in clinical practice. One specific incidence about an Arab patient who had a failed implant removal surgery previously and Icould remove the implant within 30 mins because I could clearly see the distal end of the nail entrapped. This patient was a friend of The Consulate General of UAE and since then I started getting lot of patients from there. So that was a wise investment I think.
AK: You were specifically instrumental in developing trauma surgery in India. Why focus of Trauma Surgery?
DDT: Dr Chaubal the first person to start trends in everything. At first we were spine surgeons as Dr Chaubal was very interested in spine surgery. Dr Bhojraj and Dr VT Ingalhalikar were our students. I was one of the first people to do total hip and total knee surgeries very soon after Dr Dholakia did it for the first time in India. But somehow I felt these surgeries did not hold much challenge. Trauma surgeries were challenging and each case was unique and different. So I decided to stick to trauma surgery for the sake of sheer joy of intellectual and technical challenges it offers.
AK: A lot has happened in the field of Orthopaedic Trauma in and you are witness to these growth and development. What according to you are the important landmarks in History of trauma Surgery?
DDT: Interlocking is the major change. I used to go to AAOS meeting every year where people were talking about interlocking when we were doing only plates. I decided to make an interlock nail by drilling holes in standard K nail. There was no C-arm in those days and surgeries were done on X rays. We got a compound fracture tibia and I made a set of drilled K nails for this patient as per his measurements. We successfully did the static locking using K nail in this patient. We slowly developed the instrumentation and jigs for it and developed commercially available instrument nail. Interlocking spread like wild fire and I was called as the Father of Interlocking Nail in India.
AK: Your specific focus was on Intramedullary nailing and you have also designed the ‘Tanna Nail’ How did you think of designing the nail? Tell us about the process of designing the nail, the story behind it?
DDT: Like said above, I developed the nail and instrument set with one Mr Daftari in Bombay. This was sold as ‘Tanna nail’ in Bombay. Slowly implant companies from other states also copied the design and started selling it as ‘Tanna NAIL’. I had no objections to it and I didn’t have a copyright anyway. Slowly I phased away the name as the design progressed and asked them to call it simply interlocking nails.
AK: You are known for Innovation. Tell us something more about it?
DDT: I specifically remember C-arm guided biopsy which I used successfully for tumor lesions. The same principle I used for drilling osteoid osteoma under CT guidance, which avoided an open surgery. There are many more technical tips and surgical techniques that I have been doing and some of them are listed in my book named ‘Orthopaedic Tit Bits’
AK: The last two decades have seen a tremendous increase in the choices of implants available in the market. Many of these implants were sold as the next “new thing”. Do you feel these new implants offer justifiable and definite advantage over the older ones? How should a trauma surgeon go about this maze of implants and choose the best for his patients?
DDT: There is no easy way to do that, because most implants comes with a huge propaganda and body of relevant research. Many senior faculties will start talking about it and using it. For example, distal femur plates have now reported to have 30% non-union rate. Earlier I had myself been a strong supporter of distal femur plate but through my own experience I saw the complications. Now I feel the intramedullary nail is better than the distal femur plat in indicated fractures. Same with trochanteric plates or helical screws in proximal femur fracture. So we learn the hard facts over a period of time and by burning our own hands. But then you have to be progressive and balance your scepticism and enthusiasm. In my case the enthusiasm wins most of the time.
AK: Share your views on role of Industry in dictating terms to trauma surgeons?
DDT: I feel it’s very difficult to bypass the industry. Also because the industry is supported by orthopods. But again like I said we learn from our own errors and something that does not have substance will not last for long. For example clavicle plating, I supported clavicle plating for some time [and it felt correct at that time], but now I do not find wisdom in plating clavicle and so I have stopped. So I believe it’s a process of constant learning and also realising and accepting mistakes. Once I was a great proponent of posterolateral interbody fusion (PLIF) in spine but after few years of using it I realised the fallacy and I presented a paper in WIROC (Western India regional orthopaedic conference) titled ‘I am retracting PLIF’ and it was highly appreciated by the audience.
AK: Tell us about your move toward joint replacement surgeries?
DDT: I was one of the first one after Dr Dholakia to start joint replacement surgeries in India and I continue to do many joint surgeries. And of course ‘cream’ comes from joint replacement surgeries (laughs heartily)
AK: You have been active in teaching and training for over 4 decades, how has the scene changes in terms of teaching methods and quality of surgeons undergoing training?
DDT: Teaching is now become more and more spoon feeding and I think it is not real teaching. Even in meetings I enjoy the format where there is small number of faculty and case based discussion on practical tips and surgical technique. The 8 minute talk pattern is something I think is not very effective. Real teaching of orthopaedics cannot be done in classroom or in clinics. In clinics we can teach students to pass exams but not orthopaedics. Dr Chaubal always used to say that real orthopaedics is taught in practical patient management and in operation theatres. I tell my fellows that I wont teach much, but they have to observe and learn. In medical colleges there is no teaching at all, its almost died off.
AK: What you feel is the ‘Way of Working’ of Dr Tanna that makes him a successful Orthopaedic Surgeon? Your Mantra?
DDT: Always do academically correct things. Like I have been practicing 3 doses of antibiotics since last 20 years. I read a lot and then distil the academic points and follow them in practice. I get up at 4 am and read everyday.
AK: What technical tips would you give for someone who has just embarked on his career as an Orthopaedic surgeon?
DDT : I have given one oration which is also on you tube, you should listen to that. Anybody who becomes an orthopaedic surgeon is actually cream of humanity and are capable of doing anything. The only thing required is a strong will to excel and passion to succeed
AK: I understand that you are a very positive person, but do you have any regrets, specifically related to orthopaedics. Something that you wished to do but couldn’t?
DDT: Honestly nothing. Today when people ask me ‘How are you’ I say ‘can’t be better’. I couldn’t have asked for a better life
AK: Any message you will like to share?
DDT: I think passion to be best is essential. Even if one patient does not do well or if we do a mistake in a surgery, it causes huge distress and misery to us. We as doctor should be truthful to your patients. Between you and your patient there can’t be any malpractice. You should treat every patient as if you are doing it on your son or daughter. Always keep patient first
AK: What degree or accolades would you like me to mention in your introduction?
DDT: Nothing just plain MS Orth, I have no other degrees. In fact after my MS I attempted to give D orth exam. My boss at that time Dr Sant, said ‘are you crazy, after passing MS you want to give KG exam?’ He actually did not allow me to appear (laughs). Never felt like having any more degrees, degrees won’t take me ahead, its only my orthopaedic skill that will be take me ahead in life.
| How to Cite the article: Tanna DD, Shyam A. Dr DD Tanna – Story of a Legend. Trauma International July-Sep 2015;1(1):3-6 |
Dr Dilip D Tanna
Dr DD Tanna – Story of a Legend
/in July Sep | Volume 1 | Issue 1Vol 1 | Issue 1 | July – Sep 2015 | page:3-6| Dr. Dilip D Tanna, Dr. Ashok Shyam
Author: Dr. Dilip D Tanna [1], Dr. Ashok Shyam [2, 3]
[1] Lotus Clinic, Charni Road, Mumbai, India.
[2] Indian Orthopaedic Research Group, Thane, India
[3] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India
Address of Correspondence
Dr. Dilip D Tanna
Lotus Clinic, Charni Road, Mumbai, India.
Email: ddtanna@gmail.com
Dr DD Tanna – Story of a Legend
This interview was conducted at the famous Lotus Clinic at Mumbai. Interview of Dr DD Tanna (DDT) was personally conducted by our Editor Dr Ashok Shyam (AK). It was an interesting two hours talk in late evening and we are presenting here the salient features of the interview.
AK: First let me thank you for this interview. Let’s begin by asking about your family and where you grew up?
DDT: I grew up in Kalbadevi area in Bombay in a typical Gujrati locality. I had four brothers so we were five of us together with my father and mother. At that time education was not something very popular in our family and when I graduated I was among the handful in 2 mile radius and when I completed post-graduation there were none in the entire area. The trend was that people used to go to college just for the stamp of collage and then join the father business. But I was a good student and so I did complete my studies
AK: Tell us something more about your childhood?
DDT: I had a very eventful childhood, we used to play many sports. I was very good at cricket and even at medical college I was captain of the cricket team. But along with cricket I played many local sports kho-kho, langadi, hoo-to-too, football, volleyball, swimming etc. Didn’t get chance to play hockey but I did play everything I came across.
AK: I understand you have seen Mahatma Gandhi and heard him speak. Please share your remembrance of that?
DDT: Once Gandhiji was holding a meeting in Bombay and my father said to me ”let’s go see Gandhiji”. I went with him and there was a huge crowd and I felt quite uncomfortable. I wanted to leave when my father said to me ‘why are you afraid of the crowd, these are all your fellow human beings, not cattle herd”. That statement touched me very much and till today, I am not afraid of any crowd. Understanding that all are my fellow human beings, took away my stage fright forever. I can speak my thoughts clearly and without fear and I can dance with the crowd with equal ease.
I have seen Mahatma Gandhi at close distance and he appeared to be a very frail man. At first I wasn’t impressed, but then I realised that this frail man can have the huge crowd following him just because of his thought process. That understanding has helped me a lot in my life.
AK: So why did you become a doctor, what was your inspiration?
DDT: I was good in studies and in those days there were only two choices either to be an engineer or to be a doctor. I had decided that I would be an engineer with no doubt in my mind. One day one of my uncles, who happened to be an engineer, visited us. When asked I told him my intention to become an engineer, to which he replied ”In that case you have to take up a government job all your life”. In those days the only scope for an engineer was to be in government job, but the idea of being a enslaved for life by an organisation was something I couldn’t accept. My freedom was very dear to me and overnight I changed my decision and pledged to become a doctor.
AK: How was your MBBS term? Why did you choose orthopaedic surgery?
DDT: I was quite casual in MBBS and was more involved in sports. I got serious in last year to get good grades. Frankly speaking there were none who influenced me in the undergraduate college. After joining medicine developed a natural liking to surgery and always wanted to become a surgeon. Doing general surgery and then super specialisation for another two years seemed to be a long time. Orthopaedic surgery was a new branch at that time and offered direct super specialisation. And so I joined orthopaedic surgery.
AK: What were your early influences in medical college?
DDT: I wasn’t a very serious student in medical college. Possibly I became a bit serious in my last year of MBBS to score marks to get the branch of my choice. After MBBS and before joining post-graduation I had some spare time at hand which I utilise in reading. That period was a period of change I my life. I read authors like Bertrand Russel who had a major influence in my life. I read ‘Altas shrugged’, ‘We the Living’, and ‘Fountainhead’ and these three books had deep impact on me. I also read The Manusmrti’s specifically for their philosophical treatise and not the religious aspect. I still like to ponder on these philosophical aspects from time to time. By the time I joined as an orthopaedic registrar, I was a pretty serious person. In first 6 months of my orthopaedic residence I was fascinated with basics specially the histopathological aspect of orthopaedics. I read all about the histiocytes, the fibroblasts etc and even today I still think in these terms when I think about orthopaedics.
AK: You joined the B Y L Nair Hospital, Mumbai in 1965. Tell us something about your life at Nair Hospital?
DDT: Well in fact I passed my MS in 1965. I joined possibly in 1954 as a medical student. I was a student, house surgeon, lecturer, honorary surgeon all at Nair hospital. I was one of the youngest consultant as I became consultant at Nair hospital at age of 28, merely 8 months after passing MS exams. Possibly God was kind to me. Nair hospital was a decent place, but it became a force once Dr KV Chaubal joined Nair. Earlier KEM hospital had big name because of Dr Talwalkar and Dr Dholakia. I was lecturer when Dr Chaubal joined. He changed Nair hospital with his modern and dynamic approach. He gave me an individual unit within 3 years. Our rounds would be more than 4 hours in Nair hospital and had great academic discussions.
AK: We have heard about a very famous incident when you operated Dr Chaubal? Do tell us something about that
DDT: Well Dr Chaubal was suffering from a prolapsed disc and he had taken conservative management for some time with recurrent episodes. At one point we went ahead and got a myelogram done (no MRI in those days), and a huge disc was diagnosed. He called me the next day and asked to operate on him. I was 10 years his junior and moreover he was my boss and there were many more senior surgeons who were available. It came as a shock to me that he would chose me to operate on him [and of course it was an honor to be chosen]. Dr Laud and Dr Pradhan assisted me in operating him and it was big news at that time
AK: You were pioneer in bringing C-arm to India? Tell us something about the C-arm Story?
DDT: We used to do all surgeries under X ray guidance in those days, at the most we had 2 x-rays set together by Dr Talwalkar to get orthogonal views. I used to go to USA and they would do all surgeries under C-arm. I came back and contacted Mr Kantilal Gada who used to manufacture X ray machines. He agreed to try to make a C arm if I pay him one lakh rupees [in those days]. The condition was if he succeeded, he would give the c arm to me at no profit rate and if he failed my money would be lost. He did succeed and we had India’s first C-arm at my place. It helped me at many times in clinical practice. One specific incidence about an Arab patient who had a failed implant removal surgery previously and Icould remove the implant within 30 mins because I could clearly see the distal end of the nail entrapped. This patient was a friend of The Consulate General of UAE and since then I started getting lot of patients from there. So that was a wise investment I think.
AK: You were specifically instrumental in developing trauma surgery in India. Why focus of Trauma Surgery?
DDT: Dr Chaubal the first person to start trends in everything. At first we were spine surgeons as Dr Chaubal was very interested in spine surgery. Dr Bhojraj and Dr VT Ingalhalikar were our students. I was one of the first people to do total hip and total knee surgeries very soon after Dr Dholakia did it for the first time in India. But somehow I felt these surgeries did not hold much challenge. Trauma surgeries were challenging and each case was unique and different. So I decided to stick to trauma surgery for the sake of sheer joy of intellectual and technical challenges it offers.
AK: A lot has happened in the field of Orthopaedic Trauma in and you are witness to these growth and development. What according to you are the important landmarks in History of trauma Surgery?
DDT: Interlocking is the major change. I used to go to AAOS meeting every year where people were talking about interlocking when we were doing only plates. I decided to make an interlock nail by drilling holes in standard K nail. There was no C-arm in those days and surgeries were done on X rays. We got a compound fracture tibia and I made a set of drilled K nails for this patient as per his measurements. We successfully did the static locking using K nail in this patient. We slowly developed the instrumentation and jigs for it and developed commercially available instrument nail. Interlocking spread like wild fire and I was called as the Father of Interlocking Nail in India.
AK: Your specific focus was on Intramedullary nailing and you have also designed the ‘Tanna Nail’ How did you think of designing the nail? Tell us about the process of designing the nail, the story behind it?
DDT: Like said above, I developed the nail and instrument set with one Mr Daftari in Bombay. This was sold as ‘Tanna nail’ in Bombay. Slowly implant companies from other states also copied the design and started selling it as ‘Tanna NAIL’. I had no objections to it and I didn’t have a copyright anyway. Slowly I phased away the name as the design progressed and asked them to call it simply interlocking nails.
AK: You are known for Innovation. Tell us something more about it?
DDT: I specifically remember C-arm guided biopsy which I used successfully for tumor lesions. The same principle I used for drilling osteoid osteoma under CT guidance, which avoided an open surgery. There are many more technical tips and surgical techniques that I have been doing and some of them are listed in my book named ‘Orthopaedic Tit Bits’
AK: The last two decades have seen a tremendous increase in the choices of implants available in the market. Many of these implants were sold as the next “new thing”. Do you feel these new implants offer justifiable and definite advantage over the older ones? How should a trauma surgeon go about this maze of implants and choose the best for his patients?
DDT: There is no easy way to do that, because most implants comes with a huge propaganda and body of relevant research. Many senior faculties will start talking about it and using it. For example, distal femur plates have now reported to have 30% non-union rate. Earlier I had myself been a strong supporter of distal femur plate but through my own experience I saw the complications. Now I feel the intramedullary nail is better than the distal femur plat in indicated fractures. Same with trochanteric plates or helical screws in proximal femur fracture. So we learn the hard facts over a period of time and by burning our own hands. But then you have to be progressive and balance your scepticism and enthusiasm. In my case the enthusiasm wins most of the time.
AK: Share your views on role of Industry in dictating terms to trauma surgeons?
DDT: I feel it’s very difficult to bypass the industry. Also because the industry is supported by orthopods. But again like I said we learn from our own errors and something that does not have substance will not last for long. For example clavicle plating, I supported clavicle plating for some time [and it felt correct at that time], but now I do not find wisdom in plating clavicle and so I have stopped. So I believe it’s a process of constant learning and also realising and accepting mistakes. Once I was a great proponent of posterolateral interbody fusion (PLIF) in spine but after few years of using it I realised the fallacy and I presented a paper in WIROC (Western India regional orthopaedic conference) titled ‘I am retracting PLIF’ and it was highly appreciated by the audience.
AK: Tell us about your move toward joint replacement surgeries?
DDT: I was one of the first one after Dr Dholakia to start joint replacement surgeries in India and I continue to do many joint surgeries. And of course ‘cream’ comes from joint replacement surgeries (laughs heartily)
AK: You have been active in teaching and training for over 4 decades, how has the scene changes in terms of teaching methods and quality of surgeons undergoing training?
DDT: Teaching is now become more and more spoon feeding and I think it is not real teaching. Even in meetings I enjoy the format where there is small number of faculty and case based discussion on practical tips and surgical technique. The 8 minute talk pattern is something I think is not very effective. Real teaching of orthopaedics cannot be done in classroom or in clinics. In clinics we can teach students to pass exams but not orthopaedics. Dr Chaubal always used to say that real orthopaedics is taught in practical patient management and in operation theatres. I tell my fellows that I wont teach much, but they have to observe and learn. In medical colleges there is no teaching at all, its almost died off.
AK: What you feel is the ‘Way of Working’ of Dr Tanna that makes him a successful Orthopaedic Surgeon? Your Mantra?
DDT: Always do academically correct things. Like I have been practicing 3 doses of antibiotics since last 20 years. I read a lot and then distil the academic points and follow them in practice. I get up at 4 am and read everyday.
AK: What technical tips would you give for someone who has just embarked on his career as an Orthopaedic surgeon?
DDT : I have given one oration which is also on you tube, you should listen to that. Anybody who becomes an orthopaedic surgeon is actually cream of humanity and are capable of doing anything. The only thing required is a strong will to excel and passion to succeed
AK: I understand that you are a very positive person, but do you have any regrets, specifically related to orthopaedics. Something that you wished to do but couldn’t?
DDT: Honestly nothing. Today when people ask me ‘How are you’ I say ‘can’t be better’. I couldn’t have asked for a better life
AK: Any message you will like to share?
DDT: I think passion to be best is essential. Even if one patient does not do well or if we do a mistake in a surgery, it causes huge distress and misery to us. We as doctor should be truthful to your patients. Between you and your patient there can’t be any malpractice. You should treat every patient as if you are doing it on your son or daughter. Always keep patient first
AK: What degree or accolades would you like me to mention in your introduction?
DDT: Nothing just plain MS Orth, I have no other degrees. In fact after my MS I attempted to give D orth exam. My boss at that time Dr Sant, said ‘are you crazy, after passing MS you want to give KG exam?’ He actually did not allow me to appear (laughs). Never felt like having any more degrees, degrees won’t take me ahead, its only my orthopaedic skill that will be take me ahead in life.
Dr Dilip D Tanna
(Abstract) (Full Text HTML) (Download PDF)
Trauma International – Truly New, Truly International
/in July Sep | Volume 1 | Issue 1Vol 1 | Issue 1 | July – Sep 2015 | page:1-2 | Dr. Ashok Shyam.
Author: Dr. Ashok Shyam [1,2].
[1] Indian Orthopaedic Research Group, Thane, India
[2] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India
Address of Correspondence
Dr. Ashok Shyam
IORG House, A-203, Manthan Apts, Shreesh, CHS, Hajuri Road, Thane, India. 400604
Email: drashokshyam@yahoo.co.uk
Editorial: Trauma International – Truly New, Truly International
Trauma is one of the most basic faculty of medicine and treatment of injured is the oldest known speciality. The burden of trauma in immense and with current technological developments road traffic accidents and industrial accidents present with varied patient profiles. There is always a need for personalised care which also depends on the expertise of the surgeon involved. The infrastructure and facilities for trauma care also vary across the world and many practices are modified according to local needs. Care of the injured involves orthopaedic surgeon, general surgeon, plastic surgeon and occasionally vascular surgeon, neurosurgeon and other allied faculties. Multispecialty collaboration is needed for successful treatment of any trauma scenario. The entire point of the first paragraph is that trauma surgery is a very multifaceted speciality and involves complex decision making and requires equally complex specialities to be symbiotic. The same should reflect in the Trauma literature and this is the basic aim of starting the new journal. Trauma International is primarily a journal of Orthopaedic trauma and surgery, but it will also provide platform for all specialities involved in trauma care.
Many a times while reading a journal we feel that many articles are almost irrelevant as far as practical patient care is concerned. There are many articles that wouldd focus on statistical or analytic part more than the actual clinical relevance of the study. Trauma International will focus on publishing most clinically relevant articles that will be useful in day to day clinical practice. The format of the articles will be easy to read with clinical relevance highlighted separately. Editors will be frequently commenting on the articles and will be clarifying any difficult issues that they feel require simplification . Readers will be allowed to comment online as well as through letter to editor channel. On other hand we will be including formats like technique videos, tips and tricks, innovations, most memorable patient etc where surgeons would be encouraged to share their experience and also help other learn from their experiences. The whole exercise is to provide the reader something that they can interact with and not something dead and unresponsive. Only participation from the readers and surgeon community can help us realise this dream
There exists a lot of resistance especially from the surgeons from publications. This resistance is mostly because they are not familiar with the format of articles and submission process. Trauma international will be providing few solutions to overcome this resistance and encourage surgeons to publish. Firstly, as mentioned earlier we will be keeping simple formats of article submission which will be easy for beginners to write. Secondly, we have a collaboration with the orthopaedic research group and they have taken up the responsibility to guide the authors in terms of writing manuscript. This will be helpful, especially to authors who do not have English as their first language. The process will involve review and revision of primary draft and also help in formatting article as per journal guidelines. Thirdly along with Trauma International we are also launching a dedicated Journal of Trauma and Injury Case Reports. This journal will focus on providing platform to first time authors . This will be done through a special peer review process we call as ‘assistive peer review’. Here the along with providing the review, the reviewers will also suggest and correct the manuscript at most places. This will help the authors understand their errors and also help them learn methods used to correct the errors. This Assistive Peer Review will also be provided for Trauma International. We believe these initiatives will help trauma surgeons to publish more and participate in creating a global literature.
Trauma International has received great support especially from the international community and we are proud to say that members of more than 40 countries have joined the Editorial board of Trauma International. This makes the journal a truly international journal. Since trauma is one of the most widespread practiced branch, we will be including more members till we have at least one member form each country in the world. This will help us collaborate and learn from each other in much better ways. We would like to thank all our contributors of the first issue. Special thanks to Dr DD Tanna for sharing his life experiences with us and letting us know about his journey as a trauma surgeon.
I think we have promised a lot in this opening editorial but then we are equally passionate about holding ourselves to every promise that we made here. We invite suggestions and also invite you all to participate actively with the journal. With this we leave you to enjoy the issue.
Dr Ashok Shyam
Editor – Trauma International
Dr Ashok Shyam
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Terrorist Bomb Blasts: Emergency department management of multiple incidents
/in July Sep | Volume 1 | Issue 1Vol 1 | Issue 1 | July – Sep 2015 | page: 36-40 | Muhammad Saeed Minhas[1], Kashif Mahmood[1], Jahanzeb Effendi[1], Ranjeet Kumar[1], Anisuddin Bhatti[1]
Author: Muhammad Saeed Minhas[1], Kashif Mahmood[1], Jahanzeb Effendi[1], Ranjeet Kumar[1], Anisuddin Bhatti[1]
[1] Jinnah Post Graduate Medical center, Karachi, Pakistan.
Address of Correspondence
Dr Muhammad Saeed Minhas.
Associate Professor Orhopaedics, Jinnah Post Graduate Medical center, Karachi, Pakistan.
Email: orthominhas@hotmail.com
Abstract
Objective: To assess the preparedness of the hospital emergency system and medical personnel’s in dealing trauma victims of terrorist bomb blasts in Accident and Emergency.
Patients and Methods: Four major terrorist bomb blasts incidents occurred in Karachi from December 2012 to May 2014. All patients of these 4 incidents were brought to Accident and emergency of Jinnah Postgraduate Medical Center. Place and type of bomb blast, their initial search and rescue, transfer and transportation noted. Data collected of these patients at Accident and emergency of Jinnah Post Graduate Medical Center, regarding triage, primary and secondary survey with adjuncts performed. Data was also collected from emergency operation theatres, Intensive care unit and admissions in wards. Time taken for early and effective management and disposal to different departments noted.
Results: Total victims of these four bomb blast incidents were 179. Nineteen were brought dead, 8 more died within two hours, due to multiple system involvement which made total deaths 27 (15%). The patients were triaged with color coding, 44% of these patients were red and yellow, and 41% patients were of minor injuries and were labeled green. Total 67 (41.8%) underwent damage control surgery within two hours of arrival at accident and emergency. Most of the admissions were of Orthopedics and Chest surgery.
Conclusion: Effective and early disposal of patients from Accident and Emergency needs collaborative efforts of hospital administration following comprehensive disaster plan & preparedness. Trained triage team with quick surgical response needs trauma training, disaster management courses and drill exercises for doctors and health workers.
Keywords: Terrorist bombing, Preparedness, Triage, mass casualties, management.
Introduction
Pakistan is the most affected country by terrorism in the world after Iraq & Afghanistan, where severity of terrorist incidents is considerably more than these two countries[1]. In the year 2012 alone, Pakistan suffered from 1404 terrorist attacks, surpassing Iraq (1271) and Afghanistan (1023)[2]. On analyses from the year 2001 to 2013, there were 13,721 incidents in Pakistan. The number of suicide bombing between 2001 to 2007 were 15 only, but from 2007 to end 2013, suicide attack jumped to 358 the highest anywhere in the world.[3]
Karachi is the largest and the most populated city of Pakistan which spreads over 3530 Sq. kilometers with disorganized slums and the presence of 1.5 million illegal immigrants. This all makes the Karachi one of the most attractive place for terrorist activities.[3]
Bombs are attractive to terrorists as they are relatively easy to design, assemble, and deliver by changing modalities, and because they are sudden and violent in nature. Large explosions attract media coverage and produce large numbers of casualties, and increases the sentiments and anger of general public resulting in violence & disruption.[4]
Anticipation of disaster and the possibility of an influx of terrorist bomb blast victims are present at any time and day of the year. The number of patients with different grades and severity of injuries and multisystem involvement requiring management by different specialties.[5]This can disrupt the functioning of A&E in providing definitive medical care to all victims. Overcrowding overwhelms hospital resources, a term referred to as Main Gate Syndrome[6] Preparedness and planning for such events is the key to prompt and proper management.[7]Early disposal of all victims from A&E is also important as there is always threat of secondary blast at site and at hospital A&E. [8]
Pre-hospital decontamination of victims, triage and early stabilization or management capabilities are sparse and not coordinated in Karachi and Sindh. Victims are rushed as “Scoop & Run” in private vehicles, public transport and ambulances without trained staff, which further disrupts disaster management. [9]
Security at the hospital’s Accident and Emergency entrance is very important for smooth functioning during disaster management. Media handling is important by providing information and facilitations at one place. For all these tasks prior training & drill of Accident & Emergency staff and the surgical team is very important which enhances collaboration and coordination during the disaster.[10, 11, 12] This study is performed to access the preparedness and effectiveness of the A&E department after series of training workshops and disaster drills carried out for the security personals, media managers, paramedics, medical staff and doctors.
Methods
This is the study of four major events of bomb blast which occurred in last sixteen months in Karachi. All victims of these four bomb blast were transferred immediately from scene of blast to A&E by “scoop & run” in different vehicles mainly ambulances without any treatment on the way to hospital.
Incident 1: All 50 victims of an incident of terrorist bomb blast in a bus at Karachi Cantonment Station on 29th December 2012, at 1530 hours, reached JPMC within 10 minutes by ambulances and private vehicles. The bomb was placed at the roof of stationary bus with few passengers. Victims were mostly hawkers and shopkeepers. Blast site was within 1 km of hospital, blast was heard & felt in A&E and preparation started. All patients were triaged at A&E department entrance, categorized in four groups and directed to pre-designated areas for further management. (Table I)
Incident 2: A bomb blast at Ghaghar railway track on 4th February 2014 at 0400 hours resulted in 20 casualties. Distance from site to JPMC is 40 km (24.85 Miles). Casualties started coming to A&E after 50 minutes. (Table I) All the staff from security personal to surgeons & anesthetist were prepared. In next ten minutes all patients were triaged, primary survey was performed and patients were immediately shifted to designated areas.
Incident 3: Seventy Special Security Unit (SSU) personnel of police going for duty in a bus were struck with an Improvised Explosive Device (IED) implanted in a roadside vehicle on 13th February 2014 at 0748 hours near Police Training Centre. The distance from police training centre to JPMC is 29.2 km (18.02 Miles) and travel time is approximately 37 minutes. The first wave of casualties began to arrive in A&E in ambulances (Table 1). All specialties staff & consultants were available in A&E when first patient reached hospital.
Incident 4: Delhi Colony Bazaar blast took place on 25th April 2014 at 1400 hours. The distance of the blast site from JPMC is 3.5 Km (2.17 Miles). The first casualties started reaching after 10 minutes. 29 injured and 3 dead victims were received at the A&E. (Table I).
Hospital administration and A&E department got immediate blast incidents information through media. Emergency plan for bomb blast were activated immediately, information conveyed to surgical specialties and departments through hospital operator. Security came into action; they controlled the designated spots as per plan. Space was created in A&E by sending the existing patients to respective wards. As soon as triage was performed, patients were assessed with primary survey, all adjuncts were performed in resuscitation bay and secondary survey of every patient done as soon as patient got stable after primary survey. Urgent procedures performed immediately in A&E in few red tagged patients & others shifted to operation theatres. Yellow tagged patients requiring surgery were also shifted to operation theatre recovery room; other patients were admitted in wards for care. All dead bodies were kept at one place for medico legal proceedings away from working area. It was noted that most of the trained A&E staff was speaking the same language and managing patient according to trauma course protocol.
Results
All one hundred sixty patients presented with wounds of splinters, shrapnel or burns along with specific injuries to different body parts. Nearly all patients required wound debridement and wound dressings. Sixty seven patients underwent damage control surgery within next two hours. Orthopedic surgery was the busiest specialty, and common procedures performed were wound debridement, amputations, putting Steinman pin and application of external fixator in 37.33% of patients. (Table II) Next common involvement was of chest and sixteen patients required chest tube insertion for open & closed chest injuries. Nine patients required laparotomy. Eight patients died in A&E department within 2 hours of their arrival. They were having multi system involvement and having more than 70% burns in three patients. 75(41%) patients in green category were detained and managed with dressings of minor and medium size wounds. Secondary survey of all the patients was performed. It had been observed that around 15% of the victims of bomb blast died at site or within two hours, 44% of patients were in red & yellow category and 41% in green. All the patients who were labeled green were also kept under observation for at least six hours. Administration displayed & circulated computerized lists of all the victims of the blast and their place of admission. It was noted that after arrival of last patient of the incident, emergency was free of all the patients of bomb blast incident in thirty minutes time.
Discussion
Terrorist are using different and newer methods, places and timings for bomb blast activities. It is sudden and tends to disrupt the functioning of Accident & emergency department. To combat and to give best medical relief to the bomb blast victims; planning, preparation & drills are key elements.[11,12] Communications and coordination with security, media and local administration is important for smooth functioning. Hospital administration is an integral part of the in-hospital response to a major incident and is involved in training exercises with a clear chain of command and communication. An operational room, along with telephone switch room is set up for coordinating the in-hospital response and liaison with other hospital and other emergency services as per disaster plan. [13] Hospital security is immediately enhanced after a terrorist bomb blast, as hospitals themselves may become targets for terrorism8. This also makes sure that all the Emergency Department staff is working with full concentration without any fear or pressure of mob or violence directed towards them. Significant overcrowding is also noted in Accident & emergencies which can be controlled at gate, early shifting of patients to concerned units, creation of a holding unit in OPD or recovery rooms and active inter-facility transfer. [14]
Patients triage on site and transfer under supervision of trained ambulance staff is sparse in our country and most patients reach hospital in ambulance or in private vehicles as “Scoop & Run”.[15] This has been seen in most of the urban disasters, as in Bali 2002 and New York 2001 blasts, where patient with significant injuries and burn leave the scene quickly and reach hospital on their own.[13] It is very important that experienced and trained senior medical officer perform the triage of blats victims at A&E entrance and from there flow of triaged cases should be uni directional.[16] Frequent reassessment of the victims by senior surgeon enhances the detection of missed injuries and diagnosis of pulmonary blast injuries.[13] In this series of events triage was performed and supervised by Primary trauma Care (PTC) and Hospital Preparedness for Emergencies (HOPE) course graduates and Instructors. A study conducted in Karachi, in July 2008, at two major hospitals, including the Jinnah Postgraduate Medical Center, to evaluate the preparedness and self-identified deficiencies of doctors involved in massive trauma and casualty management, 7 revealed that only 3.3% of doctors working in accident & emergency department were confident about their management of bomb blast victims. No simulated drills or courses had been conducted for disaster management in the emergency department of the surveyed hospitals5. After this survey 12 two day courses & workshops of PTC and HOPE were conducted for doctors and nurses working in Jinnah Post Graduate Medical Center Karachi.[17,18] One hundred doctors and twenty nursing staff were trained for triage and golden hour management. This was stated in a similar study that Trauma course like ATLS also improves the outcome of victim’s management in mass casualty events.[19, 20]It is also observed that simplified triage scheme and table top exercises for Emergency staff, enhances their performance in multiple casualty incidents. [21]
During the four reported bomb blast incidents, a media staging area was designated, where regular updates were provided by the concerned officials. This media relation with hospital administration also improves patient’s management. It was observed that man power resources like OT staff, nurses, surgeons and anesthetist were always adequate as most live within hospital compound and everybody respond within 10-15 minutes.
Primary survey, stabilization of patients and documentation started at the same time. 15% of patients of blast injuries were brought dead or died within two hours of their arrival during management; this corresponds to figure in most of the series.[9, 16]Those who required immediate surgery were shifted to operation theatres. All the other patients were dealt accordingly in Accident and Emergency Department, and within 30 minutes of arrival of last patient of the blast incident, these patients were shifted to respective departments according to the nature of their injuries. Immediate & early deaths in A&E, operation room and ICU were around 5%, which corresponds to other studies in similar circumstances.[15, 22]All data was recorded and analyzed. Complete list of the victims, their status and place of admission were displayed at a prominent place in hospital and briefed to media as well. Quick disposal of patients is very important from the Accident and Emergency Department as this can be a soft target for a secondary blast.[4, 22] Also, city wide riots can start in response to a bomb blast and new influx of patients start coming to the department[8]. It is also noted that clinical manifestation of pulmonary barotraumas may take time to appear. In this series of incidents also 16 patients underwent Chest tube insertion due to detection of blast lungs. Minimally Injured patients (Green) also require a minimum of 6 hours observation before being discharged[13]. All the measures taken in A&E department were for best management of patients of terrorist bomb blast; smooth functioning of hospital and utilization of resources effectively.
Conclusion
Early and effective management at A&E needs collaboration of different agencies, pre event planning and preparation. A collaborative effort in a mass casualty incident can be achieved by repeated training courses and drill exercises for trauma, triage & disaster which results in reduced morbidity and mortality of the victims. Emergency medical technicians should be trained in on-site triage and following an Incident Command System. A centralized hospital communication can limit the burden of trauma on one particular A&E and the patients may be taken to other tertiary and trauma centers. The coordinated team achieves quick disposal of patients from A&E in 25-30 minutes and can save lives in the event of a second disaster.
References
1. Prommersberger KJ, Fernandez DL. Nonunion of distal radius fractures. Clin Orthop Relat Res. 2004 Feb;(419):51-6.
2. McKee MD, Waddell JP, Yoo D, Richards RR. Nonunion of distal radial fractures associated with distal ulnar shaft fractures: a report of four cases. J Orthop Trauma. 1997 Jan;11(1):49-53.
3. Segalman KA, Clark GL. Un-united fractures of the distal radius:Areport of 12 cases. J Hand Surg. 1998;23A:914–919
4. Gómez EA, Mena RV. [Treatment of distal radius non-union in a three-stage procedure. Case report]. Acta Ortop Mex. 2009 Jan-Feb;23(1):26-30
5. Prommersberger KJ, Fernandez DL, Ring D, Jupiter JB, Lanz UB. Open reduction and internal fixation of un-united fractures of the distal radius: does the size of the distal fragment affect the result? Chir Main. 2002 Mar;21(2):113-23
6. Watson-Jones R. Fractures and other bone and joint injuries. 2nd edition. Edinburgh: Livingstone; 1942.
7. Karuppiah SV, Johnstone AJ. Sauvé-Kapandji as a salvage procedure to treat a nonunion of the distal radius. J Trauma. 2010 May;68(5):E123-5
8. Hamada G. Extra-articular graft for non-union in Colles’s fracture. J Bone Joint Surg 1944;26:833-835.
9. Bacorn RW, Kurtzke JF. Colles’ fracture: a study of two thousand cases from the New York State Workmen’s Compensation Board. J Bone Joint Surg 1953;35A:643-658.
10. Harper WM, Jones JM. Non-union of Colles’ fracture: report of two cases. J Hand Surg 1990;15B:121–3.
11. Saleh M, Ribbans WJ, Meffert RH. Bundle nailing in nonunion of the distal radius: case report. Handchir Mikrochir Plast Chir 1992;24:273-275.
12. Smith VA, Wright TW. Nonunion of the distal radius. J Hand Surg Br. 1999 Oct;24(5):601-3
13. Fernandez DL, Ring D, Jupiter JB. Surgical management of delayed union and nonunion of distal radius fractures. J Hand Surg 2001;26A:201–9.
14. Grecco Marco Aurélio Sertório, Angelini Luis Carlos, Oliveira Marcelo Tavares de, Trombini Nelson, Martins Francisco Carlos, Barbosa Sônia Maria de Almeida Pacheco. Treatment of nounion in the third distal of the radio. Acta ortop. bras. 2005;13(2): 95-99.
15. Ring D. Nonunion of the distal radius. Hand Clin. 2005 Aug;21(3):443-7
16. Crow SA, Chen L, Lee JH, Rosenwasser MP. Vascularized bone grafting from the base of the second metacarpal for persistent distal radius nonunion: a case report. J Orthop Trauma. 2005 Aug;19(7):483-6
17. De Baere T, Lecouvet F, Barbier O. Breakage of a volar locking plate after delayed union of a distal radius fracture. Acta Orthop Belg. 2007 Dec;73(6):785-90.
18. Villamor A, Rios-Luna A, Villanueva-Martínez M, Fahandezh-Saddi H. Nonunion of distal radius fracture and distal radioulnar joint injury: a modified Sauvé-Kapandji procedure with a cubitus proradius transposition as autograft. Arch Orthop Trauma Surg. 2008 Dec;128(12):1407-11.
19. Cao J, Ozer K. Failure of volar locking plate fixation of an extraarticular distal radius fracture: A case report. Patient Saf Surg. 2010 Nov 25;4(1):19.
20. Koo Siu-Cheong Jeffrey Justin, Ho Sheung-Tung, Non-union of Fracture of Distal Radius: A Case Report and Literature Review, Journal of Orthopaedics, Trauma and Rehabilitation, June 2011; 1(1):21-24
21. Nusem I, Moghaddam AK. Darrach’s ulnar resection and ulna intercalary bone graft for non-union of the distal radius: two birds one shot. Eur J Ortho Surg Traumatol 2011;21:345-349
22. Rappo TB, Kanawati AJ. Non-Union Of Fractured Distal Radius Treated With A Volar Locking Plate: A Case Report. The Internet Journal of Orthopedic Surgery. 2012 Volume 19 Number 2.
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Modified dorsal tension band suture technique for management of finger tip injuries: A series of 288 fingertip injuries
/in July Sep | Volume 1 | Issue 1Vol 1 | Issue 1 | July – Sep 2015 | page: 41-44 | Dumbre Patil Sampat[1], Patil Shailesh[1], Dumbre Patil Vaishali [1], Wavre Shankar[1], Karkamkar Sachin[1], Gandhalikar Manish[1].
Author: Dumbre Patil Sampat[1], Patil Shailesh[1], Dumbre Patil Vaishali [1], Wavre Shankar[1], Karkamkar Sachin[1], Gandhalikar Manish[1].
[1]Department of Aster Orthopaedics, Noble Hospital, Hadapsar, Pune- 411013
Maharashtra, India.
Address of Correspondence
Dr. Dumbre Patil Sampat.
Director and Head, Orthopaedic Department, Noble Hospital, Hadapsar, Pune- 411013, Maharashtra, India.
Email: sampatdumbre@gmail.com
Abstract
Fingertip injuries are extremely common injuries and generally result from blunt or crushing trauma that causes compression of the nail plate to the underlying bony surface. This may result in nail plate disruption, nail bed laceration, volar pulp loss or even amputations. Modified dorsal tension band suture technique is a well established, simple and useful procedure for the management of dorsal element disruptions. Partial or complete nail plate avulsion, nail bed lacerations with or without fracture of the distal phalanx can be treated by this technique. We treated 260 patients with 288 fingertip injuries by modified dorsal tension band suture technique that resulted in the reformation of normal nail plate. All patients showed excellent aesthetic and functional outcome and returned to their pre-injury occupational activity. The purpose of presenting this article is to evaluate and document the clinical outcome associated with this simple surgical technique which does not require specific hand surgery training.
Keywords: Finger tip injury; nail bed laceration; partial nail plate avulsion; complete nail plate avulsion; figure of 8 loop.
Introduction
Most fingertip injuries are caused by blunt or crushing trauma involving mainly children and young adults. About 50% of cases are associated with phalangeal fractures1,2. If not treated properly, complications such as scarring, obliteration of nail fold, destruction of nail plate with abnormal nail plate growth, and infections may occur3,4. Therefore, proper management of fingernail disruptive injuries is essential to avoid cosmetic and functional impairment.
The recommended management strategy for disrupted finger nail injuries is evacuation of the subungual hematoma and removal of nail plate. This is followed by meticulous repair of the nail bed. Reduction and stabilisation of any fracture of the distal phalanx and approximation of the finger pulp is performed. The nail plate is then repositioned under the proximal nail fold and sutured to the hyponychium and the proximal nail fold 5-8. Numerous techniques have been described in the literature to suture the nail plate. However, attempt to repair nail bed increases trauma to this already disrupted tissue.
In the tension band suture technique, which is originally described by Bindra6 in 1996, removal of nail plate and formal repair of the nail bed are avoided. The nail bed, distal phalanx and finger pulp are approximated as one unit. This technique was modified by H Patankar 9 by the use of Kirschner wire (K-wire) or an additional midline dorsal suture along with the tension band suture. He presented a case series of 66 patients with 70 finger nail disruptive injuries. He has reported uncomplicated re-formation of the nail plate in all of the cases.
Materials and Methods
We have treated 260 patients with 288 fingertip injuries between January 2005 to August 2013. Patients included 168 males and 92 females of mean age 27.8 years (range, 2 to 55). Injuries with disrupted dorsal elements (nail plate, nail bed) with or without fracture of distal phalanx were selected for tension band suturing (Fig. 1).
They were associated with varying degrees of injury to the volar pulp. Volar pulp injuries with intact dorsal elements, amputations, volar pulp loss and subungual hematoma were not managed by this technique.
Different injury elements selected for repair are described in Table 1.
The cases were followed up for a mean of 10.4 months (range 3 to 96). Meticulous analysis and repair of finger tip injuries is important for healing, maintaining sensation and function of finger tips. In our series, we have used tension band suture (Fig. 2a), additional midline dorsal suture (Fig. 2b), K-wire (Fig 2c) and stent as described in the Table 2.
Surgical Technique
Preoperative Evaluation
Injuries with disrupted dorsal elements (nail plate, nail bed) with or without fracture of distal phalanx are selected for tension band suturing. They are associated with varying degrees of injury to the volar pulp. Volar pulp injuries with intact dorsal elements, amputations, volar pulp loss and subungual hematoma are not managed by this technique.
Detailed clinical history regarding mechanism of injury is taken. No specific laboratory tests are required. Anterior and lateral radiographs of the injured finger are taken to assess for fracture of the distal phalanx. Circulation of the finger tip is clinically assessed.
Modified dorsal tension band suturing is performed in the emergency department or operating room. Suturing is done under local anaesthesia in adults, while children require general anaesthesia. Tourniquet is not used in any case. Local anaesthesia is given by ring block method using 2% plain xylocaine (Neon laboratories Limited, Andheri, Mumbai, India) with sterile one inch 26 guage needle and 5 ml syringe. The hand is prepped with liquid Povidone- Iodine 10% Solution (Ramadine Solution, manufactured by Nanz Med Science Pharma Pvt Limited, Himachal Pradesh, India) and draped under sterile conditions. The hand is thoroughly washed with normal saline.
When the nail plate is partially avulsed, the subungual hematoma is dislodged with a jet of normal saline from a syringe. The nail plate is repositioned below the eponychium and tension band suture is performed in the form of figure of ‘8’ as described below.
When the nail plate is completely avulsed, and brought by the patient, it is cleaned with normal saline and kept in Chlorhexidine solution (Manufactured for 3M India: by PSK Pharma Pvt Limited, Karnataka, Banlglore, India) for 5 minutes. This nail plate is repositioned below the eponychium and tension band suture is performed.
Technique of tension band suture:
Nonabsorbable unbraided Ethilon 3-0 in adults and Ethilon 4-0 (Ethicon, manufactured in India by Johnson and Johnson Limited, Himachal Pradesh, India) in children is used on an atraumatic cutting needle. First the suture is passed 5 mm proximal to the eponychium on one corner and then it is passed transversely to the other corner of eponychium (Fig 3). Care should be taken to pass the suture proximal and superficial to the nail fold to avoid injury to the germinal matrix. Then the suture is passed distally on the opposite corner of the volar pulp and then from there to the other corner of the volar pulp. Lastly, the suture is taken to the starting point to complete the figure of ‘8’ loop (Fig 3) dorsally. The loop is kept loose and the nail plate or the stent is reduced below eponychium. With the help of an assistant, reduction is maintained and the figure of 8 loop is tightened. After tightening, if the reduction of nail plate is not satisfactory, then an additional dorsal suture is passed below the proximal and dorsal loops in the midline (Fig. 4a to c).This additional suture is passed through the proximal and distal suture loops and not through the skin.
In cases of complete avulsion and loss of nail plate, sterile foil of the suture material is cut into the shape of a nail plate and used as a stent. This stent is repositioned below the eponychium over which the tension band suture is performed (Fig. 5a to c). In cases associated with comminuted phalangeal fractures or soft tissue injuries on the volar aspect, adequate stability is not achieved on tightening the figure of 8 loop. In these situations, the figure of 8 loop is loosened, a retrograde K-wire is inserted in the distal phalanx with an electric drill and the figure of 8 loop is retightened (Fig. 1c). In children 1.2 mm and in adults 1.5 mm K-wire is used. Sterile dressing is applied keeping the volar tip open to assess the figure tip circulation.
Postoperative Care
No splinting is given in adults while buddy strapping is done in children. Patients are advised elevation of the hand. Broad spectrum oral antibiotics are given for 3 days. Dressing is changed twice in the first week and then once weekly. The tension band suture is removed after 3 weeks in the outpatient department. If a stent or K-wire is used, it is removed after 4 weeks along with the suture. Patients are advised to continue follow up in the outpatient clinic to note soft tissue healing and nail plate growth abnormalities.
Results
We have repaired 288 disrupted finger tip injuries using modified dorsal tension band suture technique. Soft tissue healing was noted in 3 to 4 weeks (Fig 6 and 7). We did not monitor the bony healing. Near normal movements of distal interphalangeal joint were achieved (Fig. 7d).
Nail bed infection occurred only in one case and responded well to incision, drainage and use of antibiotics.
Deviation and shortening of the distal phalanx occurred in one case which was due to badly communited fracture of the distal phalanx. One patient complained of pain at the suture site which was due to tight suturing. Pain was relieved on loosening the suture. Abnormal nail plate growth was reported in a 4 year child (Fig 8). The abnormal growth of the nail plate was attributed to the injured germinal matrix at the time of trauma & not to suturing as the suture was well passed proximal and superficial to the nail fold to avoid injury to the germinal matrix.
Rest all patients healed well with near normal nail plate formation. They returned to their preinjury occupational activity without disability.
Discussion
General orthopaedic surgeons get opportunity to treat finger tip injuries very often. Meticulous analysis and repair of finger tip injuries is important for healing, maintaining sensations and function of finger tips. There is a spectrum of finger tip injuries which include nail plate avulsion, nail bed injury, phalangeal fracture, soft tissue loss or amputation.
Out of all these various types of injuries, disruptive injuries to dorsal elements (nail plate and nail bed with or without fracture distal phalanx) can be treated successfully with dorsal tension band suture technique 6, 9. In this technique, repositioned nail plate or the stent acts as a splint to the nail bed. The nail plate also acts as a natural dressing for healing of the nail bed. Reduction of the nail plate or stent below the eponychium prevents formation of adhesions between nail folds and the germinal matrix 5, 10-12. Hence partially avulsed nail plate should not be removed from its residual attachment 9 .Completely avulsed nail plate should not be discarded. It should be cleaned and repositioned anatomically in the nail fold. Sometimes the nail plate is completely avulsed, lost and is not available for reconstruction. In these situations, foil of sterile suture material can be used as a stent. This serves the same purpose as that of the nail plate. The dorsal tension band suture technique helps to hold and secure the reduced nail plate in the anatomical position.
Conclusion
Injuries to the dorsal elements of the finger tip (nail plate and nail bed with or without fracture distal phalanx) can be successfully managed by dorsal tension band suture technique. This was described in the literature by Bindra and then modified by H Patankar. We have used the modified dorsal tension band suture technique over 9 years in 260 patients involving 288 finger tips. We found that this technique is very simple and reproducible which can be used by a general orthopaedic surgeon without the help of hand surgeon or plastic surgeon. This technique does not require removal of the nail plate or meticulous repair of the nail bed.
The dorsal tension band suture technique helps to hold the reduced nail plate in anatomical position. As the suture passes through the intact skin, it is non traumatising to the disrupted elements. Considering the less number of complications in our series of 288 fingers over 9 years, we feel that the modified dorsal tension band suture is a safe, simple and effective technique with low morbidity at an average orthopaedic surgeon’s hand.
References
1. Guy RJ. The etiologies and mechanisms of nail bed injuries. Hand Clin. 1990; 6(1):9-19.
2. Zook EG, Brown RE. The perionychium. In: Green DP, ed. Operative hand surgery, 3rd edn. Vol. 1. New York: Churchill Livingstone; 1993: 1283–1287.
3. Ashbell TS, Kleinert HE, Putcha SM, et al. The deformed fingernail: a frequent result of failure to repair nail bed injuries. J Trauma. 1967; 7(2):177-190.
4. Hart RG, Kleinert HE. Fingertip and nail bed injuries. Emerg Med Clin North Am. 1993; 11(3):755-765.
5. Al Qattan MM, Hashem F, Helmi A. Irreducible tuft fractures of the distal phalanx. J Hand Surg Br.2003; 28(1):18–20.
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Academic Partners
/in UncategorizedIndian Orthopaedic Research Group
The mission of the Indian Orthopaedic Research Group (IORG) is to promote orthopaedic research in India by helping individual orthopaedic surgeons and clinical departments throughout the country. The focus of the group is to:
– Help publish research studies in various international and national peer-reviewed journals
– Design and conduct research studies
– Establish academic research divisions in institutions that will initiate and sustain research projects
– Conduct high quality basic and clinical research studies through collaboration with various institutions and industries
– Publish peer-reviewed journals to provide a platform for Indian Orthopaedic researchers to publish their work
Sancheti Institute for Orthopaedic & Rehabilitation was established in 1965 & Sancheti Hospital for Specialized Surgery was started in 2008. Sancheti Hospital has state of the art infrastructure and equipments to conduct all the Specialities and Super-specillities services.
At Sancheti Hospital, we render highly specialized services in all areas of orthopaedic, which include Joint Replacement, Arthroscopy, Spinal Surgery, Rheumatology and Arthritis, Shoulder Surgery, Plastic and Reconstructive Surgery, Neurology, Hand and Microvascular Surgery, Faciomaxillary and Dental Surgery, Sports Injuries, Anaesthesiology and so on. “it’s a comprehensive orthopaedic super specialty hospital with all sub specialties of orthopaedic available under one roof ”
Sancheti Hospital is a final destination and a tertiary reference centre for most complicated cases in orthopaedic across the country. It was also the official reference centre for the Commonwealth Youth Games 2008-responsible for rendering all required medical services to athletes, coaches, support staff and spectators.
“Sancheti Hospital’s Sports Medicine Division caters to all the national and international teams in various sports, hence Sancheti acted as a medical partner for Commonwealth Games 2010 held in New Delhi, and the World Series Hockey held in 2012 at Pune.”
Today it stands as one of the most important centres for quality orthopaedic care, education and research. The fruits of research are seen in the form of products such as the Indus Knee Joint, India’s first completely indigenous knee implant that has helped arthritic patients, across the country to achieve pain free mobility at an affordable price.
Asia’s Leading Single Speciality Hospital for Orthopedics and Advanced Surgeries
It has received accolades worldwide for its services. According to The Week magazine, One of the top three Orthopaedic Hospitals in India. Sancheti Hosptial has been enriching lives, not only through treatment in the hospital, but through various Social Activities as well. A number of free medical camps and other social initiatives are organized on a regular basis to benefit the poor and needy.
Achievements / Awards
“Sancheti hospital “Honoured with the “Healthcare Leadership Award” citation. 20th November 2019
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