Honduras: Day Five

Source: Blog Post

We left for the hospital at 7AM this morning and started cases quickly. Today I covered pediatric cases, including a scar excision over the antecubital fossa and a hamartoma debulking with Dr. Fufa as well as a Vicker’s ligament resection, dome osteotomy and ulnar shortening for Madelung’s deformity with Dr. Lauder.

My day started on the ground floor with a scar excision was on a 12 year-old girl whom had been burned by scalding water a year prior over her dominant arm. She had pain with elbow extension and was hypersensitive over the area of scarring, particularly over the lateral aspect of the region. We excised the area and placed a full thickness skin graft from her ipsilateral groin. We placed a bolster dressing after we finished the procedure, and the local doctors at the clinic will take the dressing down in five days and check her graft site for us.

The second case in our room was a debulking of a hamartoma of a 16 year-old girl’s dominant index finger. The hamartoma affected the patient’s pinch and was interfering with her ability to work. The tumor had been previously worked up by her local doctor with advanced imaging but no one in the region was able to take on her surgery. We started by drawing out her incisions in the preoperative holding area. We planned to excise a significant flap of skin and warned her that her radial digital nerve might be affected postoperatively. As expected, the nerve was encased by tumor. We were able to preserve the dorsal branch of her digital nerve, but had to sacrifice a segment of the volar nerve as we could find no normal nerve that could be dissected distally. We reconstructed the eponychial fold and we closed her finger, leaving a normal contour and surface for pinch.

I later went to the first floor operating rooms to help Dr. Lauder with a dome osteotomy for a Madelung deformity in a 12 year-old girl. We began with the normal FCR approach to the distal radius and isolated Vickers ligament, which we resected. Immediately upon releasing Vickers ligament, it seemed that the wrist gained significant mobility. I had never seen a Vickers ligament release, so I thought that was pretty amazing. We next turned our attention to the dome osteotomy. Although, the center of rotation and angulation of her radial deformity in the sagittal plane was diaphyseal, we followed the principles of the classic metaphyseal dome osteotomy in the metaphyseal region. Restoring the extension of her wrist required that we additionally included an opening wedge component with our osteotomy. We were limited by the availability of plates and chose an L-type plate in order to get enough distal fixation to hold her correction.  Finally, we moved to the ulnar shortening portioning of the case. We radiographically measured out the desired correction using our depth gauge and agreed on a 12 mm shortening. We fixed our plate distally and placed a working screw proximally to utilize a pull screw after making our cuts. We didn’t have any cutting jigs, so we made two free hand parallel cuts and used a Verbrugge clamp along with our working screwing to reduce our osteotomy. We fixed the plate in compression.  Finally, we used the resected ulna to graft the site of our opening wedge osteotomy. She’ll stay in a cast for 4 weeks and we’ll see her when we return in March to see how she’s doing and potentially correct her contralateral wrist as well.

After all of the cases were done for the day, we headed over to the girls’ orphanage where we were greeted with a song and dance. They showed us their classroom and the jewelry that they made, which they took great pride in. Finally, we gave them a set of Christmas gifts and stocking stuffers and were able to spend some time opening their treats and playing with them, which was a great treat for us at the end of a long day.

Working with the whole team of attendings, fellows, anesthesiologists, nurses, OTs and reps has been amazing. It has been a huge privilege to work with a group of such exceptional people who each took a week out of their busy lives to come to Honduras and to help this country. I feel like I really lucked out in being able to be on this team as a resident and I feel like I have truly gained so much in working with each of my teammates. Getting this exposure early has been truly formative, and I certainly hope to continue this work as I continue through my career.