The art of the possible – two stories — Mohan Rangaswamy

The art of the possible – two stories

Submitted by Dr. Mohan on 08 December, 2011

A call came in from one of the other emirates in the UAE. It was from a friend of a traffic victim; this friend seemed to know me and claimed that I had removed a lump from his body. He had seen patients of hand injury sitting outside my clinic then and wondered if I could help his friend with his hand injury. Apparently the injury was severe and the orthopedic doctor had decided on an amputation at the wrist. The doctor in that hospital told me that it was a hopeless case with all soft tissue of the hand gone from the outer side and that the skeleton was all mangled up. I asked them to bring him over; if they were going to amputate, any salvage would be better anyway.

When I saw him, sure the outer aspect was all mangled but there was skin on the inner palmar aspect, the fingers had some blood supply and connections and surely some sort of salvage would be possible. We plastic surgeons never resort to amputation so easily particularly in the hand; anything is better than nothing in the upper limb.

This patient’s hand was then repaired: I fixed all 14 fractures, covered the hand with V.A.C dressings, and used delayed flap coverage of the bones by a reverse adipofascial flap. I kept an island of full thickness of skin over the knuckle joints for any future joint replacements. Only the ring finger was amputated. He later went on to five more surgeries over 18 months to have 2 joint replacements, 5 extensor tendon reconstructions and other minor corrections. He now has a fairly functional 4 fingered hand that can do most of the activities. He has retained his job and types with ease.

This case sticks in my mind for several reasons. The casual observation of another patient [the friend] that I do hand surgeries and his timely referral [the doctor had not thought of referring or consulting a plastic surgeon!], the total trust and faith the patient had in me and his courage as well as compliance with instructions were all significant. My surgeries might have left him with a useless hand if he had not followed the splinting and physiotherapy so diligently. It also brought home to me the fact that unfortunately most doctors are not aware of the tremendous possibilities in plastic surgery. I think this is a worldwide problem. Why is this so? Many reasons, the most important being that the basic doctor’s education does not include any exposure to plastic surgery. Further, the lay press is more interested in the cosmetic aspect of plastic surgery to the exclusion of the everyday magic that is created by plastic surgeons salvaging difficult near impossible situations. I think we plastic surgeons need to constantly remind them that we may have a solution for what to them is seemingly without solution. The next story really illustrates this aspect even better.