Limb Saving & Reconstructive Surgery

A 27 years old young labourer staying at Bangarwadi Mahakali, presented with history of fall from bike and tempo running over his right elbow 5 months ago on 28 January 22 at 10.30 pm and was taken in emergency to Municipal hospital. His right hand was crushed completely at the elbow and the entire hand was hanging with de-gloved skin holding it with complete loss of blood supply and sensation. He was referred to higher hospital from there. After running pillar to post, he then came to holy spirit hospital at night 2.30 am. He was immediately seen by casualty officers and attended promptly by our surgery residents. Dr Nitin Ghag, Plastic Surgeon was contacted and as per advise immediate CT angiogram was arranged and done at that time at night. His right upper limb was completely cold, avascular with complete loss of sensation and no movements in hand. On CT Angiogram there was no blood flow from the junction and below the bifurcation of the the brachial artery and no collaterals.

He was young and only earning member of his family with his right dominant working hand, he requested us to save his right hand and help him not be handicapped and dependent.

The ishemia time was rising, already crossed 4 hours by the time he reached our emergency. Then he was worked up and stabilised. Considering high ishemia time, major limb revascularisation, high chances of complications and failure, still weighing all the factors and explaining everything to the patient it was decided not to amputate but to make an attempt to save his right upper limb.

He was immediately wheeled in the operation theatre it was around 9 am. Our routine OT list was packed. But this being an emergency, we really appreciate the efforts of Sister Vasanthi and Sister Raji who went ahead and stopped the routine OT list and reshuffled those case and immediately wheeled in the patient in OT.

He was efficiently anaesthetised by Dr Deepika.

Orthopaedic department Dr Antao Sir and team promptly supported and gave the patient the required bony stabilisation by applying external fixator timely done by Dr Paras Banka and Dr Clevio Dsouza before revascularisation. Exploration was done. His brachial artery was completely crushed and damaged with complete thrombus in both radial and ulnar artery. The crushed segment was immediately excised, Thrombectomy was done followed by critical revascularisation. After that Immediately on table the hand turned pink and there was radial pulsation. Seeing his avascular hand get life back was such satisfactory and happy feeling and the entire atmosphere in the OT was of celebration. Then all the nerves were explored radial nerve was found to be transected and ulnar and median nerve were severely crushed. Nerve repair as well as neurolysis was done. All the muscles were repaired.

After a week patient was taken back for debridement of the de-gloved skin and Vacuum dressing was applied. He was discharged with vascular surving right upper limb. He was followed closely in the OPD. Once wound was ready he was again admitted and skin grafting was done.

Once entire wound healed he was subjected to rigorous physiotherapy. His elbow was severely crushed so there are high chances that there would be no much movement at the elbow. With the efforts of our physiotherapist Dr Simone Mitchel and her team we were able to achieve full range of movements at the wrist, shoulder as well some extension at the elbow.

Presently he has regained complete sensation in his right upper limb. He is being able to do majority of his routine activity.

Seeing his phenomenal recovery and results we thought of sharing this with all. This would not have been possible without the efforts of everyone involved in this case.

Special thanks to the surgery and orthopaedic residents and casualty doctors for efficient management in emergency. Special thanks for Sr Vasanthi and Sr Raji for going out of the way and getting the OT arranged in minutes.

Thanks to our Anaesthesiologist team specially Dr Deepika for prompt anaesthesia.

Thanks to Orthopaedic team Dr Nicholas Antao, Dr Paras Banka and Dr Clevio Dsouza for efficiently and quickly stabilising the bone.

Thanks to social worker for helping this patient financially.

Above all thanks to the Sisters, staff and admin of Holy Spirit Hospital. This is truly a result of team approach.