2008-Issue1.indd ABSTRACT Washing machines are part of every household and there are various reports of upper extremity injuries due to inad- equate safety precautions while operating the machine. Most of the injuries occur when an attempt is made to remove the clothes from the machine and the hand gets caught in the spinning machine. The presentation can vary from minor soft tissue injuries to a mangled upper extremity. The chance of neurovascular damage resulting in compartment syndrome is very high. The author reports three cases of washing machine injuries to draw attention to this not so uncommon injury. The relevant literature is also considered. Keywords: Injury, arm; Fracture; Child injuries; Washing machines; Case Report; Oman. Washing Machine Injuries of the Upper Extremity Case reports with a review of the literature S S Suresh Department of Orthopaedics, Ibri Regional Referral Hospital, Sultanate of Oman Email: dr.s.s.suresh@gmail.com مع حاالت تقرير - الغسيل مكائن عن الناجتة اصابات الطرف العلوي مراجعة أدبيات اس سوريش اس الالزمة السالمة أخذ احتياطات لعدم نظرا تقارير عديدة ألصابات الطرف العلوي وهناك ، من اثاث البيت مهما جزءا الغسيل امللخص: تعتبر مكائن خفيفة االصابة تكون أن ــن ميك . املاكنة في اليد حصر ــي ف ــبب تتس والتي منها املالبس رفع محاولة عند حتصل االصابات ــم معظ ــغيلها. تش ــاء أثن متالزمة عنها ينتج واألوعية الدموية والتي األعصاب الصابة كبير هناك احتمال . شديدة أخرى حاالت في بينما تكون فقط ، الرخوة االنسجة وتشمل ذات األدبيات الى أيضا التطرق مت . ــادرة الن غير االصابات هذه التوعية لتفادي أجل من ــيل الغس ماكنات الصابات حاالت لثالث هنا وصفا ــدم نق . ــز احلي . العالقة عمان. حالة ، تقرير الغسيل، مكائن اصابات اليد، كسر, ذراع، اصابة، الكلمات: مفتاح SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL MARCH 2008, VOLUME 8, ISSUE 1, P. 89-92 SULTAN QABOOS UNIVERSITY© SUBMITTED - 4TH SEPTEMBER 2007 ACCEPTED - 22TH JANUARY 2008 THERE HAVE BEEN VARIOUS REPORTS OF washing machine related injuries ever since MacCollum first published on ‘wringer arm’ injuries in 1938. 1, 2 He described the ‘wringer arm’ as an avulsion injury to the arm caused by the wringer wash- ing machines that were popular at that time.1, 2 Most of the washing machine related injuries were not clinically significant as most of the sufferers required only out- patient management, but a few were serious requiring inpatient management for many days. As the design of washing machine has changed in the recent times, most of the reports are of injuries caused by wringer wash- ing machines. In support of this view, according to the United States Consumer Product Safety Commission, 3 there were 19,109 injuries from 1993 till year 2000 due to washing machines. Most of the reported cases of washing machine injuries come from North America and were often due to a design that is now defunct. The present study documents three cases of injuries to the upper extremities caused by washing machines of more modern design. These were caused when the children were trying to unload the contents while the machine was still spinning, with or without their parents’ per- mission. C A S E 1 A 10 year old girl was admitted to Ibri Hospital, Oman, in September 2004 following injury to her right fore- C A S E R E P O R T S S S U R E S H 90 arm when she attempted to remove the clothes from a washing machine while the machine was spinning. She sustained a closed fracture of the radial and ulnar bones of the forearm. There was gross oedema of the forearm and she was hospitalized for observation. The position was not acceptable after closed manipulation and hence she was taken for closed intramedullary fixation. The fracture united in six weeks time and she re- gained full range of movements and full recovery of function [Figs. 1 & 2]. C A S E 2 A five year old boy presented to the Orthopaedic De- partment of Ibri Hospital in March 2007 with swelling of the right arm after it had been trapped in a spinning washing machine. He was diagnosed to have a closed comminuted fracture of the shaft of the right humerus which was treated conservatively. There was no neu- rovascular compromise in the extremity. The arm was immobilized in a back slab. The boy was admitted for three days to observe for compartment syndrome. There was uneventful healing of the fracture with nor- mal elbow and hand function [Figs. 3 & 4]. C A S E 3 A 14 year old boy presented in the Accident and Emer- gency Department of Ibri Hospital in May 2007 with pain of his right middle finger. The injury was sus- tained while attempting to remove the clothes from the washing machine while the machine was still spin- ning. He had sustained a closed undisplaced fracture of the proximal phalanx of his middle finger, which was managed conservatively by strapping it to the neighbouring finger. At follow up he had full range of movements without residual deformity [Fig. 5]. D I S C U S S I O N Washing machines have been part of the household ever since the earliest washing machine, ‘the scrub board’, was invented in 1797. Injuries occur when at- tempts are made to remove clothes from the machine and the hand gets entangled in the spinning laundry, leading to soft tissue injuries and fractures. In the pre- viously reported studies, this occurs most in children. This present study is consonant with this view. It has been speculated that such vulnerability is probably due to parental negligence. Figure 1: (Case 1) Fracture of the humerus Figure 2: (Case 1) Post operative X-ray showing intramedullary K wires in situ WA S H I N G M A C H I N E I N J U R I E S O F T H E U P P E R E X T R E M I T Y 91 In most machines there is a safety mechanism to stop the drum from spinning once the loading door is opened. There should be two safety features in the machine: one to keep the door shut and locked during the operation and the other to stop the machine from spinning when the door is opened. But usually there is a time delay and the machine continues to spin even when the door is open. To prevent injury, the washing machine lid, which blocks access to the spinning drum, should be locked in the closed position during the wash and spin cycles; however, most machines continue to spin even when the lid is open causing injury to people trying to remove clothes. A time-delay feature in the lid lock using a thermal element4 is a recently patented improved safety feature. Previous wringer machines had ‘instinctive’ release mechanisms which stopped the machine to prevent hand injuries. Usually, when the arm is trapped, an attempt is made to pull out the arm instead of activating the safety release. The severity of the injury, which occurs due to me- chanical and thermal damage, is not obvious initially, but only a few hours later. These children need to be hospitalised and observed for soft tissue injuries and compartment syndromes.1, 5 The vascular status of the extremity has to be periodically assessed and fascioto- my done if required. In rare cases, a child can present with degloving or mangled extremity. Many authors recommend hospitalization for 48 hours since the magnitude of the soft tissue injury is not obvious at presentation, with initial assessment of neurovascular integrity and radiological survey to rule out skeletal injuries.1, 5 Simple elevation compared to compres- sion dressings is found to be effective in preventing vascular compromise. In an animal study by Adams and Fowler,6 they found maximum damage to tissues at 24 hours, although it began at three to five hours. In their study, striated muscle was found to have the maximum injury. Injuries that can occur include: fric- tion injuries; compression causing contusion of skin and muscles; fractures and haematomas, and deglov- ing injuries.5 Deshmukh in 2005, 7 reported a case of irreducible volar subluxation of the proximal inter- phalangeal joint of the index finger in a woman, sus- tained when she attempted removal of clothes while the washing machine was slowing down. Most of the injuries caused now are due to auto- matic machines as the United States stopped produc- tion of wringer machines in 1983.3 The injuries in the present series were due to top loaded machines which Figure 3: (Case 2) Post operative X-ray showing fractured humerus Figure 4: (Case 2) X-ray showing united fracture S S S U R E S H 92 are popular in Oman. The injuries occurred during the spin cycle when patients tried to remove clothes while the machine was still running. Front loading ma- chines use 40-60% less water and 30-50 % less energy than top-loaders, but are expensive. Child injury could be due to specific preventable factors and inadequate child supervision. There should be attentive supervi- sion around known hazards that are frequent sites of injury. 5, 8-10 C O N C L U S I O N Given the risk, there are various measures that would prevent washing machine injuries to children. Parents should be counselled regarding the proper lo- cation of the machine; the need to keep it unplugged to prevent injury and better child supervision. Injuries could also be prevented by improved safety features such as a triggering system, sensitive enough to detect even a small opening of the lid. A further improve- ment would be a list of safety features and measures clearly displayed in Arabic on a visible area of the ma- chine. R E F E R E N C E S 1. Posch JL, Weller CN. Mangle and severe wringer in- juries of the hand in children. J Bone Joint Surg 1954; 36:57-63. 2. Kwan MK, Saw A, Ahmad TS. Automatic top loader washing machine related injury. A report of four cas- es with serious injury. Med J Malaysia March 2005; 60:112-114. 3 Warner BL, Kenney BD, Rice M. Washing machine re- lated injuries in children: a continuing threat. Inj Prev 2003; 9:357-360. 4. Osvatic MS. Washing machine lid lock with memory wire actuator. New patent. From http://www.freep- atentsonline.com/20060101869.html 18/5/2006. Ac- cessed Aug 2007. 5. Golden GT, Fisher JC, Edgerton MT. Wringer arm reevaluated - A survey of current surgical management of upper extremity compression injuries. Ann Surg 1973; 177:362-369. 6. Adams JP, Fowler FD. Observations in Wringer inju- ries - an experimental study. J Bone Joint Surg 1961; 43:1179-1186. 7. Deshmukh NV, Sonanis SV, Stothard J. Irreducible volar dislocations of the proximal interphalangeal joint. Emerg Med J 2005; 22:221-223. 8. Landen MG, Bauer U, Kohn M. Inadequate supervision as a cause of injury deaths among children in Alaska and Louisiana. Pediatrics 2003 Feb; 111:328-331. 9. Press E, Lederer M, O’Shoughnessy, Andelman SL. Wringer washing machine injuries. Am J Public Health 1964; 54:812-822. 10. Hyder AA. Childhood injuries (guest editorial). Inj Prev 2003; 9:292. Figure 5: (Case 3) Fracture of proximal phalanx A 30 YEAR OLD MULTIGRAVIDA PRESENTED TO the Gynecology Department of Sultan Qaboos University Hospital, Oman, at 32 weeks pregnancy. Both parents were healthy and the marriage was nonconsanguineous. There was no familyhistory of birth defects. An antenatal ultrasound study, Prenatal MRI Image of a Fetus with Semilobar Holoprosencephaly *Sukhpal Sawhney,1 Lovina Machado,2 Rajeev Jain1 SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL MARCH 2008, VOLUME 8, ISSUE 1, P. 93-94 SULTAN QABOOS UNIVERSITY© SUBMITTED - 2ND JULY 2007 ACCEPTED - 21ST NOVEMBER 2007 I N T E R E S T I N G M E D I C A L I M A G E جنني عند الفصي نصف الدِّماغ مِ دَّ قَ مُ اجُ مَ ِالنْدِ صور الرنني املغناطيسي احلمل أثناء جني راجيف لوفينا ماجادو˛ سخبال سوهني˛ 1Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman; 2Department of Gynecology and Obstetrics, Sultan Qaboos University Hospital, Muscat, Oman; 3Department of Radiology and Molecular Imaging, Sultan Qaboos University, College of Medi- cine & Health Sciences, Muscat, Oman *To whom correspondence should be addressed. Email: sukh@squ.edu.om 1a. Coronal plane at the level of the thalami: Central horseshoe-shaped single monoventricle (arrows) with absent frontal horns, absent ante- rior midline falx and inter-hemispheric fissure, absent septum pellucidum with failure of cleav- age of frontal and parietal lobes anteriorly; rudi- mentary temporal horns (arrowheads); thalami are partially separated with rudimentary third ventricle (marked *) 1b. Sagittal plane: Corpus callosum (arrow) is absent in the uncleavaged frontal region. Tem- poral horn (arrowhead) is identified. Note the proptosis. Figure 1a: Heavily T2W (HASTE) images in the fetal cranial coronal and sagittal planes. S U K H PA L S AW H N E Y, L O V I N A M A C H A D O A N D R A J E E V J A I N 94 at 32 weeks pregnancy, raised the suspicion of a brain malformation, but it was suboptimal due to maternal habitus. An MRI of the fetus, at 34 weeks pregnancy, demonstrated semilobar holoprosencephaly. The baby was born at term with microcephaly, proptosis, and dysmorphic features. The diagnosis was confirmed by a postnatal computed tomography (CT) scan. C O M M E N T Holoprosencephaly (HP) is a congenital anomaly char- acterized by lack of cleavage of the prosencephalon. Although relatively rare, it is the most common anom- aly that involves both the brain and the face. Prenatal diagnosis of this anomaly using ultrasonography, par- ticularly of the less severe forms, is difficult. Magnetic resonance imaging (MRI) has recently become an im- portant complement to ultrasound in prenatal diagno- sis of central nervous system anomalies.1 HP is the most common anomaly affecting the ven- tral forebrain, occurring in 1/250 embryos and 1/8300- 16,000 live births.2, 3 HP refers to a spectrum of disorders resulting from absent or incomplete cleavage of the forebrain (prosen- cephlon) during early embryologic development (days). HP is usually categorized as alobar, semilobar or lobar depending on the degree of forebrain cleavage. 4 Alo- bar is the most severe form with complete failure of cleavage of the two cerebral hemispheres. It results in a monoventricular cavity; fusion of the thalami; absence of the corpus callosum; falx cerebri; optic tracts and ol- factory bulbs. Semilobar HP shares many of these same features, but demonstrates partial segmentation of the ventricles and incomplete fusion of thalami. Septo-op- tic dysplasia, the least severe type of HP, results in sepa- ration of the ventricles and thalami and absence of the septum pellucidum.5 The advent of high-resolution real-time ultrasound imaging equipment has allowed detection of the group of holoprosencephalies, but lack of familiarity with uncommon forms may lead to diag- nostic confusion. Coronal sonograms of the fetal head, in addition to standard axial projections, should be per- formed whenever an intracranial cystic abnormality is identified.6 Several characteristic midline facial malfor- mations are associated with holoprosencephaly, includ- ing hypotelorism. The degree of facial dysmorphism tends to parallel the severity of holoprosencephaly and, therefore, sonographic evaluation of facial morphol- ogy may aid in prenatal diagnosis.7 Recently, diffusion tensor imaging and fiber tracking have revealed white matter structures not apparent on routine MRI imag- ing sequences, which are in agreement with pathologic descriptions of the holoprosencephalic brain.8 R E F E R E N C E S 1. Wong Alex MC, Bilaniuk LT, Ng KK, Chang YL, Chao AS, Wai YY. Lobar holoprosencephaly: Prenatal diagno- sis with post natal MR correlation. Prenat Diagn 2005; 25:296-299. 2. Roessler E, Muenke M. Holoprosencephaly: A paradigm for the complex genetics of brain development. J Inher Metab Dis 1998; 21:481-497. 3. Golden JA. Towards a greater understanding of the pathogenesis of holoprosencephaly. Brain Dev 1999; 21:513-521. 4. De Myer W. Holoprosencephaly (cyclopia arhinenceph- aly). In: Yinken PJ, Bruyn GW, eds. Handbook of clini- cal neurology, Vol 30. Amsterdam: Netherlands. 1977. p. 431-478. 5. Byrd SE, Harwood-Nash DC, Fitz CR, Rogovitz DM. Computed tomography evaluation of holoprosencephaly in infants and children. J Comput Assist Tomogr 1997; 1:456-463. 6. Cayea PD, Balcar I, Oswaldo A Jr, Jones TB. Prenatal di- The ICU Book SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL MARCH 2008, VOLUME 8, ISSUE 1, P. 95-96 SULTAN QABOOS UNIVERSITY© SUBMITTED - 7TH NOVEMBER 2007 The book, running to more than 1000 pages, has 53 chapters in 16 sections covering: Basic Science Review; Preventive Practices in the Critically ill; Vascular Access; Haemodynamic Moni- toring; Disorders of Circulatory flow; Critical Care Cardiology; Acute Respiratory Failure; Mechanical Ventilation; Acid Base Disorders; Renal and Electro- lyte Disorders; Transfusion Practices in Critical Care; Disorders of Body Temperature; Inflammation and Infection in the ICU; Nutrition and Metabolism; Criti- cal Care Neurology; Toxic Ingestions.The appendices include Units and Conversions, Selected Reference Ranges and Clinical Scoring Systems. The ICU book is excellent reference material for all physicians, not just intensivists. It is a valuable resource for any health professional, from medical student to ex- perienced physicians and a must for anyone entering critical care medicine, anaesthesia, accident and emer- gency, medicine or surgery and even for critical care nurses as well. It provides a superior review for resi- dents preparing for board examinations and the essen- tial background for ICU rotations. The ICU Book is a very complete overview of fun- damentals and the physiology behind patient care pre- sented in a succinct manner. The latest complex physio- logical findings are broken down into simple concepts, accompanied by important straight to the point facts and easy to understand illustrations. The short para- graphs prevent you from getting lost in the subject. The text is brilliantly written and easy to read and learn from, with simple English for those who speak Eng- lish as a foreign language; every nurse can follow it as well. The emphasis on managing critically ill patients in a simple manner with the support of evidence-based medical literature is also useful for patient care outside the ICU. B O O K R E V I E W املركزة العناية وحدة �كتاب مارينو ال. بول : املؤلف Author: Paul L Marino Publisher: Lippincott Williams and Wilkins. Third Edition 2007 ISBN: 13: 9 78-0-07817-4802-5 Price: OR 24 Available at: Al Manahil Educational Email: manahil@omantel.net.om AU TH O R I N F O R M ATI O N Dr. Marino is Chairman of the Department of Medicine and Critical Care Director of Saint Vincent’s Midtown Hospital in New York City. He is also clinical Associate Professor of New York Medical College in Valhalla. The third edition of the ICU Book welcomes Dr. Kenneth Sutin, Department of Anaesthesiology and Surgery at Bellevue Hos- pital Centre and Associate Professor of Anaesthesiology and Surgery at University School of Medicine in New York City, who adds his expertise to the final 13 chapters of the book. TH E I C U B O O K 96 The ICU book covers a broad spectrum of critical care topics. The third edition has undergone extensive revision in content and most of the chapters have been rewritten. Newly renamed and refocused chapters on hot topics are: acute coronary syndromes, severe airflow obstruction and anaemia and red blood cell transfusion in the ICU. Additional new chapters in- clude hyperthermia and hypothermia syndromes and infection control in the ICU. Close to 400 new tables and figures including radiographs, CT scans, electro- cardiograms and microscopic images have been added to provide visual references, which aid in comprehen- sion of the text. The editor is to be congratulated on enforcing the original aim to produce a book that is well organised, with topics that are easy to find for quick reference and exam review. The majority of chapters make good use of tables and figures. Critical points and contro- versies are bold faced throughout the text. Most chap- ters include a so-called Final Word with an important take-home message. Each chapter has an extensive and generally up-to-date reference list, subdivided into specific topics as an easy link to further readings, and with emphasis on evidence-based clinical practice guidelines. In general, the ICU book has good quality paper and binding. The large print and solid text unbroken by illustrations and brilliant simple figures with great message make the book pleasant to read. A future edi- tion should not be any larger so that the book retains its handy portability. However, I found there were too few details about Non-Invasive–Ventilation. Also the Ramsay Score, which assesses the level of ICU seda- tion, although described in the text, should be includ- ed in the appendix of clinical scoring systems. As an owner of the previous edition and the Ger- man translation, I am even more impressed with this third edition. The ICU Book has been always a great guide for my everyday practice as anaesthetist and I highly recommend this excellent reference book, avail- able at a reasonable price that will disappoint nobody. R E V I W E R Karin Nollain Department of Anesthesia and Intensive Care Unit, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman Email: karin@squ.edu.om