Outcome of tissue sparing surgical intervention in mine blast limb injuries.

OBJECTIVE

To describe the pattern of mine blast limb injuries in civilian population of Kashmir, to evaluate the outcome of tissue sparing surgical intervention in these injuries and to determine the sensitivity of hand-held percutaneous Doppler for tissue viability.

DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

Combined Military Hospital, Muzaffarabad and Islamic International Medical College Hospitals at Rawalpindi/Islamabad from November 1997 to May 2005.

PATIENTS AND METHODS

One hundred and three patients who sustained mine blast injuries to upper or lower limbs, along side the line of control between the Indian-held Kashmir and Azad Kashmir, regardless of age and gender, were included in this study. Patients who already had amputation after injury at some other place were excluded. All patients were initially managed in emergency and had more than one surgical intervention. Transcutaneous Doppler was used to evaluate the vascularity of the remaining tissue. All patients were operated under spinal or general anaesthesia and had repeated debridements followed by skin cover by split skin graft, full thickness skin graft or rotational flaps. Every patient received at least 5 days course of antibiotics and tetanus prophylaxis. Postoperative rehabilitation and follow-up was conducted for at least 6 months after discharge from the hospital.

RESULTS

Mean age of victims in this study was 22 years. Out of 103 patients, 72 (69.9%) received initial wound care in the peripheral primary health care centre but were not amputated while 31 patients (30%) were just dressed and referred for further treatment at tertiary care hospitals. Eighty-five patients (82.5%), out of the total, had some sort of traumatic amputation at presentation due to the original injury. That included loss of limb below knee in 19 (18.45%) patients, at distal tibiofibular region in 13 (12.6%), mid tarsal amputations in 39(37.9%), and hemi foot amputation in 15 (14.6%) patients. Nine (8.7%) patients had losses of two or less than two toes, 1 (0.97%) patient had injury at mid palmer region, and 5 (4.9%) patients had 2 fingers traumatic amputation. Eighteen (17.5%) patients had soft tissue ( with or without bony injury) injury only without any actual traumatic amputation. Infection rate was 27% in patients who did not have wound care in the periphery. Those who had wound toilet in-the peripheral hospital had infection rate of 16%. Two patients developed fulminating multi-resistant progressive infection requiring below knee amputation.

CONCLUSION

Conservative wound debridement and early skin coverage by different means and preserving maximum soft tissues and bone results in functionally and cosmetically better limb in victims of land mine.