Managing severe hand deformities in Cambodia

V Rajaratnam, Senior Consultant Hand SurgeonKhoo Teck Puat Hospital, Singapore

W Lam, J K Yong, Keo V, J Gollogly

This work is licensed under a Creative Commons Attribution 4.0 International License.

Aim: Developing a targeted surgical training programme for the

sustainable ,management of severe hand Deformities in CSC

Methodology

Severe trauma

Severe burn contractures

Severe venomous injuries

• Community-oriented curriculum• Needs analysis of surgeons• Personalised programme• Targeted training • Feedback and Practice• Assessment• Evaluation of the programme

Methods – Community-oriented Curriculum

DELIVER Curriculum (Pedagogy Specific to Cambodia)

Assessments INDEPENDENT PRACTICE & TEACH OTHERS

DESIGN Curriculum (around Training Needs)Targeted Competency Based

DISCERN Community NeedsVisiting Centre Plan Training Needs based on

Community Needs

Discerning the Community Needs:A Compilation of 600 Cases (before visit)

Cases Percentage

Burns and trauma deformity 453 76%Congenital 142 23.2%

Nerve (not brachial plexus) 5 0.80%

Total 600 100%

Designing the Curriculum TOPICS LEARNING PROCESS TIME

Basic Science Hand Assessment Workshop

6 mths

Deformity 1:Burn contractures

Flap design workshop

1-2 yrs

Deformity 2: Tendons Tendon workshop 6 mths

Deformity 3 Fracture and dislocations Osteomyelitis

Fracture fixation workshop

1 yr

Nerve 1: Paralysis, cerebral palsy and spasticity

Micronueral workshop

1-2 yrs

Nerve 2: Brachial plexus

Micronueral workshop

1-2 yrs

Congenital Hand Deformities Lectures, tutorials, supervised operating

2-3 yrs

✔

✔

✔

✔

Learning needs analysis of surgeons1. Identify surgeon2. Assess skill level3. Develop personalized training program4. Show and Supervise5. Assess independent practice

Selected Workshops Microneural Workshop Nov 2013

Tendon Workshop May 2014

Fracture Fixation Workshop May 2015

English slides, but local language (Khmer)Live and Online

Information Technology Workshop Nov 2014

GoPro Camera

https://www.youtube.com/channel/UCbjUKspmSoIuOq2FUiPGt_g

Personalised program

• Deformity assessment - CBD• Decision making and planning - CBD• Surgical option generation – Lectures, CBD• Selection/execution under supervision - DOP• Deliberate practice - DOPS• Independent performance/assessment - DOP

Results: Management of Deformities

Cases Percentage

Burn and trauma deformity 36 40%

Congenital 18 18%Nerve Injuries 23 24%

Tumour 3 3%

Brachial Plexus 16 16%

Total: 96 100%

66%

Results: Management of Deformities (59)

Burns

Paralyti

c Diso

rders

Ischemic

Contractu

re

Lace

rations

Snak

e Bites

Defects0

5

10

15

20

25

Targeted Training principles: flaps and skin grafts

The pedicled groin flap

The reversed radial forearm flap

Evaluation of the programme

BEFORE AFTER THE FUTURE

1.375 4.46 4.875

DEFORMITY

BEFORE AFTER THE FUTURE

1.625 4.41 4.5

CONGENITAL HANDS

BEFORE AFTER THE FUTURE

1.25 4.375 4.28

BRACHIAL PLEXUS INJURIES

Not confident Very confident

1 2 3 4 5

Thank you