STUDY OF DERMATOGLYPHICS PATTERN IN CONGENITAL HEART DISEASE
IN CHILDREN AT GOVERNMENT RAJAJI HOSPITAL MADURAI
DISSERTATION SUBMITTED FOR THE DEGREE OF M.D BRANCH VII
(PAEDIATRIC MEDICINE) APRIL 2017
THE TAMILNADU
D.R M.G.R MEDICAL UNIVERSITY CHENNAI, TAMILNADU
CERTIFICATE
This is to certify that the dissertation entitled “STUDY OF DERMATOGLYPHICS PATTERN IN CONGENITAL HEART DISEASE IN CHILDREN AT GOVERNMENT RAJAJI HOSPITAL MADURAI” is the bonafide work of Dr.S.R.RAJA in partial fulfilment of the university regulations of the Tamil Nadu Dr. M.G.R Medical University, Chennai, for M.D Degree Branch VII – PAEDIATRIC MEDICINE examination to be held in April 2017.
.
Dr. M.R. VAIRAMUTHURAJU M.D., Dean,
Madurai Medical College, Government Rajaji Hospital, Madurai.
CERTIFICATE
This is to certify that the dissertation entitled “STUDY OF DERMATOGLYPHICS PATTERN IN CONGENITAL HEART DISEASE IN CHILDREN AT GOVERNMENT RAJAJI HOSPITAL MADURAI” is the bonafide work of Dr.S.R.RAJA in partial fulfilment of the university regulations of the Tamil Nadu Dr. M.G.R Medical University, Chennai, for M.D Degree Branch VII – PAEDIATRIC MEDICINE examination to be held in April 2017
PROF. DR. K. MATHIARASAN M.D., D.C.H.
DIRECTOR
Institute of Child Health & Research Centre, Madurai Medical College,
Madurai – 625020
DECLARATION
I, DR.S.R.RAJA., solemnly declare that the dissertation titled “STUDY OF DERMATOGLYPHICS PATTERN IN CONGENITAL HEART DISEASE IN CHILDREN AT GOVERNMENT RAJAJI HOSPITAL MADURAI” has been conducted by me at the Institute of Child Health and Research centre, Madurai under the guidance and supervision of my unit Chief PROF. DR. K. MATHIARASAN M.D., D.C.H.
This is submitted in part of fulfilment of the award of the degree of M.D (Pediatrics) for the April 2017 examination to be held under the Tamil Nadu Dr. M.G.R Medical University, Chennai. This has not been submitted previously by me for any Degree or Diploma from any other University.
Place: Madurai Date:
Dr.S.R.RAJA
ACKNOWLEDGEMENT
I sincerely thank Prof. Dr.M.R.Vairamuthuraju, the Dean, Government Rajaji Hospital and Madurai Medical College for permitting me to do this study.
I express my profound gratitude to Prof. Dr. K. Mathiarasan, Professor and Director, Institute of Child Health & Research Centre, Madurai, for his able supervision, encouragement, valuable suggestions and support for this study.
I express my sincere thanks to Prof.Dr.M. Nagendran, Prof. Dr. S.
Balasankar, Prof. Dr. Rajarajeshwaran, Prof. Dr. M. Kulandaivel, Prof.
Dr. S. Shanmugasundaram, Prof. Dr. N. Muthukumaran , for their guidance and encouragement throughout the study.
I would like to extend my sincere thanks to former Director, Prof. Dr. G.
Mathevan for his valuable suggestions and guidance in doing this study.
I would like to express my sincere gratitude to former Chiefs Prof.
Dr.S.Sampath, Prof DR.Chitra Ayappan, for their timely support and encouragement.
I would like to thank the Registrar Dr. D. Rajkumar M.D for his valuable suggestions throughout the study.
I wish to express my sincere thanks to my guide and assistant professors Dr. P. Murugalatha, and Dr.S.Murugesalakshmanan, for their invaluable guidance, support and suggestions at every stage of this study.
I also express my gratitude to all other assistant professors of our department and my fellow post graduates for their kind cooperation in carrying out this study.
I also thank the members of the Ethical Committee, Government, Rajaji Hospital and Madurai Medical College, Madurai for allowing me to do this study.
I express my sincere thanks to my parents and my better half Dr.
M.Nirmala for their unending support throughout my study.
Last but not the least, I submit my heartfelt thanks to the children and their parents for extending full co –operation to complete my study successfully.
Dr.S.R.Raja
ABBREVIATIONS CHD Congenital heart diseases
UL Ulnar loop RL Radial loop
atd Rt atd angle right side atd Lt atd angle left side
TFRC Total finger ridge count a–bRC Rt a-b ridge count right side a–bRC Lt a-b ridge count left side
M Male
F Female
VSD Ventricular septal defect ASD Atrial Septal defect PDA Patent ductus Arteriosus TOF Tetralogy of Fallot COA Coarctation of Aorta MS Mitral Stenosis
DORV Double outlet right ventricle TGV Transposition of great vessels
ALCAPA Abnormal origin of left coronary artery from pulmonaryArtery
ABSTRACT Background and objectives:
Dermatoglyphics patterns develop between 6 -18 weeks of intrauterine life which is a common period for cardiac embryogenesis, thus any prenatal insult during that period may have an influence on the dermatoglyphics patterns.
Therefore dermatoglyphics study was carried out to elucidate the significance of their presence in congenital heart diseases (CHD).
Methods:
A hospital based case control study was conducted. 100 cases of proven congenital heart diseases who were admitted paediatric wards and OPD at Institute of Child Health and Research Centre, Government Rajaji Hospital Madurai. Another 100 normal children were included as controls. The palms and fingers were smeared with printer’s ink to bring out the dermatoglyphics patterns which were subsequently studied.
Results:
There was increased number of Whorls and decreased number of Arches in the congenital heart disease patients compared with normal children. Total finger ridge counting (TFRC) is increased in congenital heart diseases children, both male and female children. Distal placement of axial triradius is seen in congenital heart disease patients, with increase in the ‘atd’ angle.
Conclusion:
The dermatoglyphics variation in CHD may be suggestive of external imprint of genetic variation and may help as a diagnostic tool.
Key words: Dermatoglyphics, Congenital heart disease.
TABLE OF CONTENTS
Sl.No. Chapters Page No.
1 Introduction 1
2 Objectives 4
3 Review of literature 5
4 Methodology 37
5 Observation & Results 48
6 Discussion 74
7 Conclusion 78
8 Summary 79
9 Bibliography 81
10
Annexure
Proforma of the study
Master chart
INTRODUCTION
DERMATOGLYPHICS originates “from the Greek words ‘DERMA’
which means SKIN and ‘GLYPHE’ which means” to CARVE. The “term
‘Dermatoglyphics’ was coined by Cummins and Midlo. Dermatoglyphics is the study of epidermal ridges and their configurations on the palmar and the plantar”regions. The fine ridge patterns of the fingers, palms and soles have intrigued humans since primitive times. The “skin on the palmar and plantar surfaces of humans is not smooth. It is grooved by numerous ridges which form a variety of configurations. The ridge configurations have attracted the attention of common man for” centuries.
“Papillary ridges are confined to the palms and soles and the flexor
surfaces of the fingers and toes where they form narrow parallel or curved arrays separated by narrow furrows. The epidermal ridges correspond to an underlying interlocking pattern of dermal papillae, an arrangement which helps to anchor the two layers firmly together. The pattern of dermal papillae determines the development of the epidermal ridges. This arrangement is stable throughout life, unique to the individual and therefore significant as a means of identification1”.
From cradle to grave, ‘Hastarika’ the science of palmistry, is a legacy bequeathed to humanity by ancient seers & saints of India. The roots of this science can be traced to the Ancient East – according to Kunagusu Minakatas notes in Nature. Chinese records mention the use of fingerprints in very ancient
times in India. Ancient system of Indian palmistry called ‘Samudrik Mudra’
classified ridge patterns into Padma (lotus), Sankha (conch shell) and Chakra (wheel). These patterns are also found expressed on the palms, soles and digits of the sculptured images of Lord Buddha seen in Indian museum at Kolkata.
Bidloo provided a description of ridge patterns in the Seventeenth century. Later on, “additional information has been added by anthropologists, biologists, geneticists and anatomists2.”
During “the last century, the fact that each individual’s ridge patterns are unique has been” utilized “as a means of personal identification especially” for legal purposes. Medical interest in epidermal ridge patterns have increased in the last few “decades when it” was found” that many patients with chromosomal aberrations had unusual ridge” patterns. “Inspection of epidermal ridge patterns therefore provided a simple, inexpensive means” “of information to determine whether a patient could have a particular chromosomal”
abnormality. Geneticists were able to demonstrate that the inheritance of the dermal ridge conformations depended on multiple gene effect.3
Abnormal variations in epidermal ridge patterns are noticed in genetic disorders like Down syndrome, Turner syndrome, Klinefelter syndrome. Lately association of epidermal ridge patterns with congenital heart disease, leukaemia, idiopathic mental retardation, dental caries and in many other diseases where aetiology is obscure has been studied4.
Congenital heart diseases are a heterogeneous group of diseases in which aetiology, importance of genetic as well as environmental factors have been recognized. These defects show a familial tendency but no Mendelian pattern of inheritance has been described.5
The mode of inheritance is represented by somatic traits such as dermatoglyphics as supported by some earlier studies showing association of epidermal ridge patterns with congenital heart defects by Hale A. R(1961)6, A Cascos (1964)7, Brurghat W (1968)8, Mutalik G S (1968)9, Magotra ML (1976)10 ,Renuka Nair (1986)11, Brijendra Singh (1996)12 , Anita khalil (1998)13 .
In the present study finger and palmar dermatoglyphic patterns in congenital heart diseases are studied and compared with controls. An attempt is made to determine a significant finger and palmar dermatoglyphic pattern criteria applicable to patients with congenital heart disease, which can be used as a diagnostic tool in the identification of congenital heart diseases.
AIMS AND OBJECTIVES
The present study is undertaken with the following aims and objectives;
1. To study the finger and palmar dermatoglyphic patterns in patients with congenital heart diseases.
2. To evaluate and compare finger and palmar dermatoglyphic configurations of children with congenital heart disease and that of normal healthy children.
3. To find out whether a specific finger and palmar dermatoglyphic traits in children with congenital heart disease is significant.
4. To use finger and palmar dermatoglyphic patterns as a tool for diagnosis and counselling purpose.
REVIEW OF LITERATURE
A HISTORICAL REVIEW
Dermatoglyphics arises from the ancient art of palmistry which was practiced from ancient times and is still followed throughout India by the Joshi caste. It appears that the art of palmistry was initially practiced by great seers and saints who lived in the ancient Hindu temples. From here, this art has spread throughout the world.
In Greek civilization “cheir”, the finger and palmar ridge patterns were studied in depth. Anaxagoras taught and practiced palmistry in 423 BC. This dermatoglyphics study was sanctioned and encouraged by Aristotle and other great minds like Pliny. Albertus Magnus and Emperor Augustus Anaxagorus have said, “The superiority of man is owing to his hands". In Aristotle has written "the hand is the organ of organs, the active agent of the passive powers of the entire system".14
The early records show that our ancestors had acquaintance with the traceries of fine ridges on fingers, palms and soles long before the period of scientific study. One example of this is aboriginal Indian carving found at the edge of Kejimkoojik Lake in Canada. It shows a human hand carved in stone with lines representing epidermal ridges and flexion creases. This pictograph is
atleast several centuries old. Such ancient stone epidermal ridge cravings are found throughout the world.
Another example is Utah Basketmaker pictograph which consists of several human figures accompanied by designs of questionable significance including four isolated concentric and spiral patterns resembling whorl pattern of finger prints. The most famous of ancient “finger print” designs is the carving on the walls of Neolithic burial passage situated in the island of Brittany15.
A Chinese seal belonging to third century B.C showed recording of a finger print in clay which could have been imprinted on documents, letters or packages. De Barras has mentioned that Chinese in 16th century has a custom of recording ink prints of fingers on the deeds of sale16.
Thomas Bewick, an engraver and a naturalist had made wood engravings of his own fingers patterns. Evidently, he was among the few persons of his time who had good knowledge of dermatoglyphics.17
EARLY SCIENTIFIC RECORDS
A scientific approach to dermatoglyphics was made long before the first records about them were written. A clear cut demarcation cannot be made between what that is considered as scientific knowledge of dermatoglyphics and the primitive knowledge. The evidence for this is the aborigines who carved the hand in a rock at the edge of Kejimkoojik Lake in Nova Scotia. This carving is truly scientific in spirit and in method according to the author.15
In the later part of the 17th century scientific interest in epidermal ridges aroused. Mehemiah Grewin in 1684 presented before the Royal society of London a description regarding the sweat pores and the epidermal ridge arrangements of fingers and palms along with a drawing showing the configurations of dermatoglyphics of hand. Later in 1685, his book on human anatomy ‘Bidloo’ included an account on epidermal ridges of hand.18
In 1686, Malphigi briefly described the configuration of epidermal ridge patterns of fingers19. In the eighteenth century, Hintz did several works in Dermatoglyphics. In 1747, along with Albinus and Mayer, Hintz described papillary ridges of the feet.
In the early years of 19th century, Purkinje classified epidermal patterns of fingers into nine configurations of Rugae and Sulci on the terminal phalanges of fingers. SirFrancis Galton, in the year 1890 pointed out that the complex pattern of parallel ridges and furrows of fingers and palms remain unchanged
throughout life, thus making finger prints areal means of personal identification.13
Dermatoglyphic patterns has now been increasingly analyzed to establish its importance in clinical medicine. Though interest in the study of epidermal ridges in relation to clinical medicine increased during the later part of 17th century, progress in the study was slow due to absence of a well defined classification.
Systematic and well defined classification of the epidermal ridge pattern of fingers, palms and soles was given by Sir Francis Galton in 1892. He developed a subject on good scientific basis which we now know as dermatoglyphics. It was Harold Cummins who first started making use of epidermal ridge patterns of palms and fingers in clinical medicine. In 1936 he reported that patients with Downs syndrome showed characteristic dermatoglyphic patterns.21
Holt reported that the total epidermal ridge count was determined by the cumulative effect of genes. Abnormal dermatoglyphics pattern has been established in Trisomy 13 and 18 by Holt. It is found that dermatoglyphic patterns are under genetic control. There are reports of fingers and palm epidermal ridge pattern studies in relation to inherited chromosomal disorders such as Wilson’s disease, Mental Retardation, Leukaemia, Congenital heart diseases and Indian Childhood cirrhosis.22
EMBRYOGENESIS OF DERMAL RIDGES
Dermal ridge differentiation takes place early in fetal development. The resulting ridge configurations are genetically controlled and influenced by environmental factors. The final epidermal ridge patterns of an adult are found to be intimately related to the fetal volar pads because epidermal ridge patterns form at the sites of these volar pads.
Fetal volar pads have mound-shaped elevations of mesenchymal tissue above the proximal ends of the distal phalanges on each finger, in each interdigital area, in the thenar and hypothenar areas of the palms and soles and in the calcar region of the sole. The development of these pads is first visible on the fingertips during 6th to 7th week of embryogenesis. The pads become very prominent during the subsequent weeks, decrease in size during the 5th month and disappear completely in the 6th month. The presence of volar pads, as well as their size and location are responsible for the configuration of papillary ridge patterns17.
4-6 weeks: Early lines develop; arm buds appear, hands and feet develop, digits separate.
6-8 weeks: Volar Pads appear in the following order: III, IV interdigital areas, central palmar area, digital apex, thenar and hypothenar, proximal phalanges.
10-12 weeks: Beginning of volar pad regression, ridges appear at dermo- epidermal junction.
13 weeks: Ridge formation increases, identifiable configurations noted on skin surfaces.
21 weeks: Definite epidermal ridge patterns formed by this time.
The epidermal ridge patterns are formed only after the sixth intrauterine month when the glandular folds are fully developed and after the sweat gland secretion and keratinization have begun. At this time, the configurations on the skin surface start to develop to reflect the underlying patterns. The surface epidermal furrows correspond to the furrow folds of the stratum germinativum and each epidermal ridge is develops above a glandular fold. Ridge differentiation progresses from the apical region of digits proximally and in a radio-ulnar, tibio-fibular direction. The embryogenesis of the epidermal ridges on the feet is identical to that of the hand, except that each step occurs 2 or 3 weeks later.
Several hypotheses have been postulated regarding the factors that are responsible for the development of specific ridge patterns. It was speculated that the epidermal ridge configurations were the result of physical and topographic growth forces23. It is believed that the tensions and pressures in the skin during early embryogenesis determine the directions of the epidermal ridges. Some workers believed that the finger tip epidermal patterns depended on the
arrangement of underlying peripheral nerves, while others suggested that the ridges followed lines of greatest convexity of the embryonic epidermis.
The” present knowledge concerning the” formation “of glandular folds and in turn the formation of epidermal ridges” was made” based on observations” of arrangements of the blood vessel – nerve pairs under the smooth corium border of epidermis which exists shortly before the formation of the glandular folds24. It has been proved that insufficient”supply of oxygen to the tissues”, defects” in the formation and distribution of sweat glands, disturbances in proliferation of the epithelial basal layer and defects in keratinization of the epithelium are the other factors that may influence epidermal ridge patterns. Even environmental factors such as external pressure on the fetal volar pads and fetal movements particularly finger” movements influences ridge formation.
There is wide agreement that the mechanism of inheritance of many dermatoglyphic patterns is due to the polygenic system with each gene contributing a small additive effect. Examples of these dermatoglyphic traits are the transversality of the ridges on the palm25,26, the a-b ridge count27,28,and the atd angle29.
Information on the loci that influence dermatoglyphics is still uncertain but various reports implicate chromosome 21 in the determination of finger ridge count30,31and the position of the axial triradius31. Other chromosomal loci
of genes determining dermatoglyphics include the X chromosome32,33 and chromosome1834.
Recently, it has been reported that exogenous environmental factors, such as rubella infection may also derange dermatoglyphics and so can be helpful in providing evidence of such an exposure in the fetal period.35-37
Figure No. 1. The development of epidermal ridges.
METHODS OF RECORDING DERMATOGLYPHICS
Dermatoglyphic patterns are seen by the naked eye preferably with a magnifying lens, “but permanent impressions are necessary for quantitative
“analysis.
“To enhance the quality of the prints, it is necessary to remove sweat, oil
and dirt from the skin by washing the ridged areas with soap and water and with ethyl alcohol or ether. Care must be taken to print the ridged areas completely by rolling the digits, palms, and soles to ensure obtaining a” print of the whole pattern.38
STANDARD METHODS Ink Method:
“It is the standard method used by law enforcement agencies for
identification purposes”. The necessary “equipment consists of printer’s ink, a roller, a glass or metal inking slab, a sponge rubber pad, and good quality paper”. After the area is inked perfectly, the palm is rolled over a paper covered cylinder” to avoid imperfect printing of hollow areas39”.
Inkless method:
This method makes use of a commercially available patented solution and specially treated sensitized paper. The “method is suitable for printing hands or
feet with well-demarcated dermal patterns, such as those of older children andadults40.”
Transparent Adhesive Tape Method:
In this method, the print is produced by applying a dry colouring pigment to the skin and lifting it off with the transparent adhesive tape. The colouring agent may be coloured chalk dust, Indian ink, standard ink, carbon paper, graphite stick or powdered graphite, common oil pasted crayon etc. This method is inexpensive, rapid and easy to use with all types of patients. Prints are clear and not smudged. They can be preserved for an indefinite period of time41. Photographic method:
This technique is based on the principle of frustrated total internal reflection which occurs when an object is pressed against a prism. The magnified image is photographed by a Polaroid camera. It needs relatively expensive equipment. Recently, even ordinary photographic method has been tried out42.
Special methods:
These methods are not widely used. However, they may have some advantages that the standard methods cannot offer, such as allowing the study of the correlation between the epidermal patterns and the underlying bone structures (radio/dermatography)43, study of sweat pores (hygrophotography)44,or study of the spatial shape of ridged skin areas, for eg,
In 1989, some authors have developed a method wherein the investigating region is blackened with graphite smeared on a piece of cardboard.
The print is taken by the Tesa film and then adhered to a transparent film strip or photo printing foil. Such a negative could be enlarged five to six times. An automatic apparatus for taking finger prints without ink and also to count ridge numbers between any 2 given points was developed in 199046.
Technologies have been improved in the finger print identification. With a single small chip, technology provides the basis for fingerprint identification devices that can prove the users identity using a fingerprint. Optical fingerprint scanner is a device for computer security featuring superior performance, accuracy, durability based on unique NITGEN fingerprint Biometric Technology.
“DERMATOGLYPHIC PATTERN CONFIGURATIONS47:”
“Numerous investigators have proposed rules, principles and definitions
that allow reliable analysis of dermatoglyphic data. The widespread interest in this field and a need for a standardized dermatoglyphic terminology stimulated an international symposium. As a result, “A Memorandum on Dermatoglyphic Nomenclature” was published in 1968. The memorandum listed and defined dermatoglyphic features, outlined accepted methods of dermatoglyphic analysis and provided a nomenclature that was intended to serve as a universal standard.”
Ridge detail (Minutiae):48
“The intricate details of ridge structure, termed minutiae by Galton, are highly
variable and their number, type, shape and position are unique to the individual.
The minutiae therefore, are valuable and reliable tools for personal identification.”
Six common types of minutiae were initially used in dermatoglyphics and they are – Island or point, short ridge, fork, enclosure, end and interstitial line with addition of one more type later, called comb.
Figure No. 2. The nomenclature of minutiae.
Finger tip Pattern Configurations2;
The ridge patterns on the distal phalanges of the fingertips are generally categorized into following groups ;
1. Arch 2. Loop 3. Whorl 4. Composite ARCH:
The ridges pass from one margin of the digit to the other with a gentle distally bowed sweep which gives the name to the pattern type. It is actually pattern less as there is no triradius and the topographic zones of the other fingerprint type are lacking. Galton has described many types of arches depending on the shape. These are plain arch, tented arch, arch with ring etc.
The plain arch is composed of ridges which pass across the finger with a slight bow distally. There is no triradius.
Tented arch has a triradius located in or near the mid axis of the digit. The erect distal radiant is associated with abrupt elevation of the transversely curving ridges forming the tent which gives the name to the pattern15.
LOOP:
It possesses only one triradius. Instead of coursing in complete circuits as in whorl, the ridge course around only one extremity of pattern forming the
head of the loop, from the opposite extremity the pattern ridges flow to the margin of the digit. This extremity of the pattern may be considered as open. If the loop opens to the Ulnar margin it is called an Ulnar loop (U, Lu) and if it opens to the Radial margin it is a Radial loop(R, Lu ).
According to the flow of the ridges of loop, loops can be further differentiated into the following types.
Plane loops: Composed of succession of ridges which regularly follow a looped course.
Transitional loops: Present more complex pattern. These are associated with degenerated loops.
WHORL:
The Whorl is regarded as the primitive pattern from which loops and arches are formed, as simplification of design. The majority of ridges make circuits around the core in the pattern area. The Whorl is completely and continuously circumscribed by the type lines. These type lines are radiants extending from the two triradii. This area enclosed by type lines is the pattern area. The type lines are considered as the skeleton of the pattern. That proximal to the pattern area is proximal transverse system and distal one is the distal transverse system.
Typically Whorls have two triradii. Each triradii is placed at either side of pattern area, where three ridge systems meet i.e.:
(1) Pattern area
(2) Proximal transverse system (3) Distal transverse system
Whorl core is an internal feature of pattern. In a typical Whorl the core may appear as an island, a short straight ridge, a hook shaped ridge or a circle or an ellipse.
TYPES:
Concentric whorls- The ridges are arranged as concentric rings or ellipse (around the core)
Spiral whorl – The ridges spiral around the core in clockwise or anticlockwise direction.
Mixed whorl- It contains circle and ellipse or spirals in the same pattern.
Central pocket whorl- It contains a smaller whorl within a loop. It is sub classified as Ulnar and Radial according to the side on which outer loop opens.
Lateral pocket whorl or twin loop-These types are morphologically similar, have2 triradii. In lateral pocket whorl, both ridges emanating from each core emerge on the same side of the pattern. In twin Loop whorl, the ridges emanating from each core open towards the opposite of margin of the finger.
Accidentals (whorls) - Complex patterns, which cannot be classified as one of the above patterns are called accidentals, they represent a combination of two or more configurations.
COMPOSITES22:
The composites form a heterogeneous pattern. Two or more designs are combined in one pattern area. Two or more triradii are present. There are four types:
(1) Central pocket loops (2) Lateral pocket loops (3) Twin loops
(4) Accidentals
Simple Arch Tented Arch
Figure No. 3 Finger pattern Arch
Ulnar loop Radial loop
Figure No. 4. Finger pattern Loop
Single pocket whorl Double pocket whorl
Figure No. 5. Finger pattern Whorl
RADIANTS:
The” three basic dermatoglyphic landmarks found on the fingertip patterns are the triradii, cores and radiants.”
The three radiants of a triradius are traced on the print “by following the ridges which issue from the triradius.” In some triradii these rays are easily defined as the starting points for tracing.
From their typical association with pattern the three radiants are named according to their relation with the finger and with the pattern;
1. Marginal radiant passing to the digital border.
2. Distal pattern radiant distal relation to the pattern area.
3. Proximal pattern radiant proximal relation to the pattern area.
TRIRADII:
A triradius is the central meeting point of the three opposing ridge system. In a typical whorl or loop such a point occurs at the confluence of three topographic zones- the pattern area, the distal transverse system, and the proximal transverse system. These three ridges are radiating from a common point.
Figure No. 6. Triradii
“
PALMAR PATTERN CONFIGURATIONS2”
“In order to carry out dermatoglyphic analysis that can be compared indifferent individuals, the palm has been divided into several anatomically defined areas. The areas approximate the sites of” embryonic volar pads and include the thenar area, four interdigital areas (designed I1 I2 I3 I4 from radial to ulnar side)and the hypothenar area.
Figure No. 7. Palmar pattern configurations
“Palmar flexion Creases49”
“Flexion creases represent the location of firmer attachment of the skin to
indulging structures. Although they differ in origin from the epidermal ridges and do not belong strictly to the dermatoglyphic system, palmar creases are usually included in routine dermatoglyphic analysis because their alterations may be of diagnostic value in a variety of medical disorders.”
The palmar creases are divided “into three groups: major, minor and secondary”creases.
1. Major creases: There are three major creases – - The radial longitudinal crease.
- The proximal transverse crease.
- The distal transverse crease.
“The first to appear is the radial longitudinal crease that borders the
thenar eminence, followed by the proximal transverse crease (PTC) and distal transverse crease. Sometimes the proximal and distal transverse creases are replaced or joined into one single crease that traverses the whole palm. This single transverse flexion crease is usually referred to as Simian crease or line.”
“Variants of single palmar crease have been noted. They are transitional
type I(proximal and distal creases connected by the bridging crease) and transitional type2 (fusion of the transverse creases with branching proximal and distal segments, incomplete single palmar crease). A variation in appearance of PTC is the Sydney line (SL) after the city in Australia where it was observed first. Sydney line represents proximal transverse crease beyond hypothenar eminence to the ulnar margin of the palm.”
Figure No. 8. Palmar flexion creases
Figure No. 9. Simian crease & Sydney line
Figure No. 10. Palmar dermatoglyphic areas
2. “Minor creases: In addition to major creases, several minor creases are often present on the palm.” The most commonly reported minor creases are;
a)” Three longitudinal creases running from the central part of the wrist towards the 3rd, 4th and 5th digits.”
b) The accessory distal crease “found under the 3rd and 4th digits, beyond the distal transverse crease.”
c) “‘E line’ located at the distal ulnar edge of the palm between the origin of the distal transverse crease and the metacarpophalangeal creases of 5th digit.”
d) “A hypothenar crease in the hypothenar eminence, running in a proximal to distal direction concave toward the ulnar side of the palm.”
3. Secondary creases: “Any visible palmar creases other than major and minor creases. Their number, length, depth and direction vary widely in different individuals.”For the present study, only major flexion creases are included.
RIDGE COUNT:
The characteristics of dermatoglyphics can be described quantitatively i.e., by counting the number of ridges within a pattern and measuring angles or distances between specified points of triradii.
The counting was done along a straight line connecting the triradii point to the point of core. Ridge counts were recorded in order, beginning with thumb to little finger of both right hand and left hand.
Figure No. 11. Ridge counting in finger patterns
The Total Finger Ridge Count (TFRC)
The TFRC was derived by adding the ridge counts on all ten fingers. In a loop, there is one triradius and so one ridge count. In a whorl with two triradii, there are two counts and the higher is used. Only the“ larger count was used on those digits with more than one ridge count. For an” arch, the score is zero. For double loop whorls, the ridge numbers between the two cores was added to the conventional count.
“Absolute Finger Ridge Count (AFRC)”
The AFRC was calculated by summing up the ridge counts of all the“fingers.
The TFRC and AFRC are the same if no whorls are present.”
a-b Ridge Count :
The ridge count most frequently obtained is the a-b ridge count. Counting was carried out along a straight line connecting the triradii ‘a’ and ‘b’. The count excludes the ridges forming the triradii.“When an accessory triradius ‘a’
is present in the second interdigital area, counting is still done from the ‘a’
triradius which is invariably the more radial of the two.”
Figure No. 12. Method of a-b ridge count The ‘atd’ Angle :
It was recorded by drawing lines from the digital triradius ‘a’ to the axial triradius ‘t’ and from this to digital triradius ‘d’. In palms with more than one triradius, the atd angle originating from each axial triradius was measured.
Figure No. 13. Method of measuring atd angle
CONGENITAL MALFORMATIONS OF DERMATOGLYPHICS Dermatoglyphics are studied in congenital malformations and as a
physical sign in pediatrics diagnosis. It is not often recognized, that they can be malformed also. They pass either unrecognized or abandoned as freak pattern.
There are five classified malformations.
1. Aplasia 2. Hypoplasia 3. Dissociations 4. Off the end
5. Off the end with ridge dissociation.
APLASIA: Congenital absence of ridges over entire palm, plantar surfaces.
Palmar, interphalangeal flexion creases remain normal or with great excess of very small creases. It is thought to be autosomal dominantly inherited. It may be due to disordered keratin production.
RIDGE HYPOPLASIA : Ridges are not absent but reduced in height. It is confused with ridge atrophy seen in mental retardation, old age, celiac diseases.
It probably indicates hidden celiac diseases. It is seen in autosomal aneuploidy.
It is thought to be autosomal dominant trait.
RIDGE DISSOCIATION: Ridges instead of running neatly in parallel lines are broken into dots, short ridges and are completely disorganized, mostly seen on the thumb and palmar triradius, followed by index, middle, ring, and little finger in the order of frequency. It is autosomal dominant trait or sporadically inherited. It is confused with scarring after burns. In 430 patients with congenital heart disease, two had this ridge dissociation. One had multiple cardiac defects and the other had Truncus Arteriosus, VSD and harelip. It is sometimes seen in normal people4.
OFF THE END RIDGES: Ridges instead of running transversely are vertical to the end of finger tip.
OFF THE END RIDGES WITH DISSOCIATION: It is rare. No disease is associated with it. Hypoplasia of the ridges is the commonest.
CONGENITAL HEART DISEASES Incidence & Prevalence:
The incidence of congenital heart disease at birth is estimated to be 6 to 8per 1000 live birth in the western countries. The prevalence of congenital cardiac lesions in India is not known. Recently it has been realized that the incidence is higher, specially, if all of the newborns are followed up to the age of one year, Since some of the conditions may not manifest in the first few weeks oflife51.
INCIDENCE OF COMMON CONGENITAL CARDIAC LESIONS50 Left to right shunt
Ventricular septal defect 36%
Atrial septal defect 5%
Patent ductus Arteriosus 9%
Atrioventricular septal defect 4%
Obstructive lesions
Pulmonary stenosis 9%
Aortic stenosis 5%
Cyanotic lesions
Transposition of great vessels 4%
Tetralogy of Fallot 4%
ETIOLOGY:
It is often considered POLYGENIC INHERITENCE, in which inherited and environmental factors combine to cause the malformation.
INHERITED OR GENETIC FACTORS:
Cardiac defects are associated with large number of chromosomal and genetic factors, 40% of infants with Trisomy 21 have congenital heart diseases.
It is usually Atrio-ventricular defect or Ventricular septal defect52. There is high incidence of congenital heart diseases in Trisomy13, Trisomy18 and Turner’s syndrome is associated with left heart lesions. Some of the cardiac diseases have autosomal inheritance. In DeGeorge syndrome inherited as autosomal dominant, 75% of these children have cardiac (conotrucal) defects. Noonan syndrome, Holt Orm syndrome and Williams syndrome are transmitted autosomal dominantly have congenital heart diseases. Autosomal recessively transmitted disorders are Pompe’s and Friedreich’s ataxia which have congenital cardiac diseases5.
TERATOGENS:
In early pregnancy, maternal infections, illness or ingestion of certain drug can result in cardiac abnormality. Congenital Rubella syndrome is
commonly associated with peripheral pulmonary stenosis or PDA. Uncontrolled Maternal Phenyl Ketonuria is associated with heart defects. Maternal ingestion of Lithium (Ebsteins anomaly), Phenytoin (semilunar valve stenosis, COA) are also known to cause to CHD. Thus cardiac embryogenesis and dermatoglyphics development and differentiation takes place at the same time (6 weeks to 18weeks). The analysis of family history will help to unravel the interplay of genetic and environmental factors. Dermatoglyphics study can be carried out to elucidate the significance of their presence in congenital heart disease5.
DERMATOGLYPHICS AND CONGENITAL HEART DISEASE:
Hale (1961), studied 287 pairs of palmar prints, of which 157 had CHD and 143 as control group (NO CHD). He found that in CHD patients, the frequency of occurrence of axial tri-radius in the distal position in approximately double than that found in control group6. Sanchez Cascos (1964), studied fingerprints & palmar prints of 150 congenital heart disease pts and 50 normal subjects. He reported Ulnar loops in 60 % - 70% of CHDs, of which 75% were VSD, Whorls were seen in 15 % of CHD, of which 30% were AS, COA, TOF, Radial loops were seen in 3% of CHD. In case of palmar prints in the same patients, Sanchez found that distal and radial displacement of axial triradius inmost of congenital heart diseases7.
Burghat.W. Collard, (1968), studied palm prints of 98 CHD patients as compared to 198 normal children. According to this study, single transverse
in many pts with CHD owing to distal displacement of axial triradius, more in VSD& PDA as compared to other forms of CHD8. G .S Mutalik and Lokhandwala,(1968) studied 12 cases of CHD in which loops were more common in ASD, whereas whorls were more common in VSD9.
Magotra and Chakraborti (1976), studied Dermatoglyphics in 50 cases of congenital heart diseases and 100 cases of normal children. He found out that Ulnar loops were predominant in all cases of congenital heart diseases, more so in VSD, whorl patterns were found more in ASD & TOF, increased Arch patterns in Pulmonary stenosis. In their data, position of axial tri-radius in congenital heart diseases when compared with normal controls, didn’t show any significantdifference10.
Renuka Nair (1986), studied 927 pts with CHD, 169 blood donors were taken as normal sample for comparison. The study showed increase in frequency of Sydney line (6-24%of in males &12- 23% in females with CHD compared to7&10% in normal males and females respectively. Distally placed axial triradius was more frequent in male CHD Patients. Another interesting thing in this study was Dermatoglyphics of pts were compared with dermatoglyphics of the parent sand they found uniform patterns in III &IV interdigital areas11.
Brijendra Singh, (1996) studied Dermatoglyphics of 50 CHD patients comparing them with 50 normal children dermatoglyphics. This study showed increase in whorls (55-80%) as compared to control, Total finger ridge
count(TFRC) was increased in CHD pts, especially in VSD& ASD. The ‘atd’
angle was widened (distally placed ‘t’ triradius) in CHD12.
Anita Khalil, 1998, studied Dermatoglyphics in congenital heart diseases in 50 cases as compared to 50 normal children. This study showed increased frequency of Ulnar loop patterns and decreased frequency of whorl patterns in male cyanotic and female cyanotic and acyanotic groups. Decrease TFRC was significant in CHD, more so in males patients13.
MATERIALS AND METHODS
Study design:
Type of study: Hospital based case control study.
Duration of study: March 2014 – August 2016 Source of Data:
The study was carried out at Institute of Child Health and Research Centre, Madurai Medical College, Madurai.
Inclusion Criteria:
Children having congenital heart diseases (cyanotic and acyanotic) proven by echo-cardio graphy were included in the study.
Exclusion criteria
1. Children having doubtful congenital heart diseases.
2. Children having acquired heart diseases.
3. Children having deformities of the hand.
METHODS
Dermatoglyphics are studied in 100 children with congenital heart diseases, both males and females, who were admitted in paediatric wards and OPD at Institute of Child Health and Research Centre, Madurai Medical College, Madurai. For each of congenital heart diseases child included in the study, detailed history including consanguinity, birth order of child, drug intake
during prenatal period and family history of congenital heart diseases were taken.
Electrocardiogram, X-Ray chest were obtained. A provisional diagnosis of congenital heart disease was made and later confirmed by echocardiography.
The control group consisted of 100 healthy children, both males and females, who were thoroughly examined clinically for any other congenital anomalies or having acquired heart diseases. Those having them were excluded from the study.
The dermatoglyphic patterns of palms and fingers were studied and the information was recorded systematically
METHOD OF RECORDING DERMATOGLYPHIC PATTERNS:
The ‘INK METHOD’ was selected from the various methods described in literature because of following advantages:
• Simple Technique.
• Low cost.
• Clarity of prints.
• Less time consuming.
MATERIALS USED:
• Camel quick drying duplicating ink.
• Inking slab-thick sheet fixed over wooden support.
• Century board.
• White ‘map Litho’ paper with a glazed surface on one side.
• Pressure pad made up of rubber foam.
• Cotton puff and spirit.
• Scale.
• Pencil pen.
• Protractor- To measure the ‘atd’ angle.
• Needle with a sharp point for ridge counting.
• Magnifying lens (X5 Magnification).
• Readings on: overhead projector, scanning, computerized magnification.
TECHNIQUE OF RECORDING DERMATOGLYPHIC PATTERNS:
PROCEDURE:
The hands of the subject are first cleaned with soap and water and dried.
Subsequently the hands are wiped with spirit lightly to remove any greasy particles. A smaller “amount of ink is placed on the ink slab and spread with the roller to a thin film”-not too thick or too light. The subject is made to relax, giving the operator complete freedom in manipulations. The whole of the palm and fingers are covered with ink using the roller directly.
PALMS:
Either the palm alone or palm and fingers are taken first. While inking the following areas require special attention- the zone of flexion creases on the wrist, the Ulnar margins, the Flexor creases where the finger join the palm and the central hollow of the palm. After inking, the operator brings the ulnar margins of the subject’s hand, rolled palm downwards, against the paper on the curved pressure pad. Pressure is exerted specially over the central region of the handover the knuckles, to ensure printing of the hallow of the palm and distal border.
FINGERS PRINTS:
Two types of prints are taken – plain and rolled prints.
A PLAIN print is made by contact of the ball of the finger without rotation of the finger.
A ROLLED print involves rotation of the finger both in inking and in printing.
In plain prints the details are sharp, but often incomplete and this is the reason for rolled prints, to avoid erroneous classification. In making a rolled print, the finger is first placed edge down on the ink film and then rolled until the opposite margins are in contact. For ease, the thumb should be placed downwards and rolled towards the body and the other fingers placed radial edge downwards and rolled away from the body. Soon after the print is taken, it should be examined for details and clarity in the different fingers and the palmar
There are many inkless methods for taking prints. But for medical purposes the above method is simple and adequate.
Further the impression is analyzed either by magnifying lens, or by scanning and computerized reading, or by Xerox, on overhead projector, or using compound microscope.
The prints are studied for the following features:
• Frequency of finger patterns- whorls, loops, arches etc.
• Total finger ridge count (TFRC) obtained by summing of ridges from the core to radius of each finger and for whorls having two triradii the larger count was considered.
• ‘a-b’ ridge count
• ‘atd’ angle measured separately for each hand.
• Presence of Simian creases and Sydney lines.
Figure No. 14. Materials used to record dermatoglyphic patterns
Figure No. 15. Method of recording palmar dermatoglyphic patterns
Figure No. 16. Right & Left hand rolled patterns
Figure No. 17. Measurement of left & right atd angle
STATISTICAL METHODS:53,54,55,56.
Data was entered into Ms excel and analyzed using SPSS v20. Qualitative data were summarized as frequencies and percentages. Quantitative data were checked for normality. Normally distributed data were summarized using mean and standard deviation. Non-normally distributed data were summarized using Median and inter-quartile range.
Interquartile range (IQR), also called the mid spread or middle fifty, or technically H-spread, is a measure of statistical dispersion, being equal to the difference between the upper and lower quartiles, IQR = Q3 − Q1. In other words, the IQR is the 1st quartile subtracted from the 3rd quartile; these quartiles can be clearly seen on a box plot on the data. It is a trimmed estimator, defined as the 25% trimmed range, and is the most significant basic robust measure of scale.
The interquartile range (IQR) is a measure of variability, based on dividing a data set into quartiles. Quartiles divide a rank-ordered data set into four equal parts. The values that divide each part are called the first, second, and third quartiles; and they are denoted by Q1, Q2, and Q3, respectively.
Association between qualitative variables was tested using chi-square test. The chi-square test for independence is used to determine the relationship between two variables of a sample. In this context independence means that the two factors are not related. In the chi-square test for independence the degree of freedom is equal to the number of columns in the table minus one multiplied by
Difference in distribution of quantitative variables across two groups was tested using independent t test and Mann Whitney U test for normal and non- normally distributed variables respectively. The Mann–Whitney U test (also called the Mann–Whitney–Wilcoxon (MWW), Wilcoxon rank-sum test, or Wilcoxon–Mann–Whitney test) is anon parametric test of the null hypothesis that two samples come from the same population against an alternative hypothesis, especially that a particular population tends to have larger values than the other.
Statistical significance was interpreted using an arbitrary cut off p=0.005.
RESULTS
It is a Case-control study consisting 100 congenital heart disease patients and 100 controls undertaken to study the pattern of dermatoglyphics in congenital heart diseases.
In our study, it is observed that males constitute about 55% in CHD group and 57% in Control group, females 45% in CHD group and 43% in control group respectively. It is shown in Table No.1.
Table 1: Gender distribution of study participants
Sex CHD Controls
Male 55 57
Female 45 43
Pictorial representation of gender distribution is depicted in Figure No.
Figure18 : Gender distribution among GHD and control group
As VSD is the most common CHD about 43% in our study. Of which it
45% 55%
CHD
male
female 57%
43%
control
male female
children. The second most common CHD is ASD occurred in about 29% of children. Of which it occurred in about 51.7% among male children and 48.3%
among female children. Below table represents gender distribution of CHD.
Table2: Distribution of CHD according to gender
CHD Male N(%) Female N(%) N /%
ALCAPA 0 1(100) 1
AS 1(33.3) 2(66.7) 3
ASD 15(51.7) 14(48.3) 29
DORV 2(100) 0 2
PDA 3(75) 1(25) 4
TGV 2(50) 2(50) 4
TOF 7(50) 7(50) 14
VSD 25(58.1) 18(41.9) 43
TOF constitute about 14% of CHD children with equal distribution among both gender. PDA occurred in about 4% of CHD children with predominance among male children. TGV occurred in about 4% of CHD children. The incidence of AS, DORV and ALCAPA is about 3%, 2% and 1% respectively.
Pictorial representation of distribution of CHD according to gender is shown below.
Figure19: Distribution of CHD according to gender
25
15
7
3 2 2
1 0
18
14
7
1 0
2 2
1 0
5 10 15 20 25 30
VSD ASD TOV PDA DORV TGV AS ALCAPA
Number
Male Female
Figure20: Gender wise distribution of CHD- Component Bar diagram
Figure21: Distribution of CHD among cases- Pie chart
VSD is common followed by ASD among congenital heart diseases
Table3: Distribution of finger patterns across various CHDs Pattern AS
Median (IQR)
ASD Median (IQR)
DORV Median (IQR)
PDA Median (IQR)
TGV Median (IQR)
TOF Median (IQR)
VSD Median (IQR)
UL 3() 3(5) 6() 4.5(6) 4.5(7) 5.5(4) 5(2)
RL 1() 0(1) 0(1) 0.5(1) 0.5(1) 0(1)
Arches 0(1) 0.5(1) 0.5(1) 0(2) 0(1) 0(1) Whorls 6() 6(5) 3.5() 4(5) 5(8) 2(4) 4(3)
A narrow Inter Quartile Range indicates that data are very consistent.
Table4: Comparison of finger patterns among CHD and controls
Finger Pattern
Controls CHD P*
Median IQR Median IQR
UL 6 4 5 4 <.0001
RL 0 1 0 1 0.847
Arches 1 1 0 1 0.010
Whorls 2 3 4 5 <0.0001
In both, the cases and controls group, it is found that the majority are ulnar loops followed by whorls and then the arches. The increase in ulnar loops and whorls in congenital heart diseases is statistically significant with p value
<0.0001.
Figure22: Comparison of finger patterns among CHD and controls
Table5: Comparison of finger patterns among cases and controls- Males
Pattern Controls Cases P*
Median IQR Median IQR
UL 6 4 5 3 0.006
RL 0 1 0 1 0.276
Arches 1 1 0 1 0.002
Whorls 2 4 4 4 <0.0001
From the above table the ulnar loops, whorls and arches were statistically significant when normal male children compared with male congenital heart disease children. Arches were not significant.
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
UL RL ARCHES WHORLS
control CHD
Figure 23: Comparison of finger patterns among cases and controls- Males
Table6: Comparison of finger patterns among cases and controls- Females
Pattern Controls Cases P*
Median IQR Median IQR
UL 6 3 4 5 0.002
RL 0 1 0 1 0.330
Arches 0 1 0 1 0.639
Whorls 2 2 4 6 <0.0001
From the above table ulnar loops and whorls patterns have significant difference when normal female children compared with female congenital heart disease children. Arches and radial loops were not significant.
0 1 2 3 4 5 6 7
UL RL Arches Whorls
controls cases
Figure24: Comparison of finger patterns among cases and controls- Females
0 1 2 3 4 5 6 7
UL RL Arches Whorls
controls cases
Figure25: 95% CI Comparing finger patterns among male and female CHD children
This figure demonstrates the distribution of finger patterns among male and female congenital heart disease children lying between the 95% confidence interval.
Table7: Distribution of finger patterns between cyanotic and acyanotic heart diseases
Finger pattern
Cases N Mean Std.
Deviation
Pvalue
UL Cyanotic 20 5.10 2.553 0.193
Acyanotic 80 4.40 2.369
RL Cyanotic 20 .45 .510 0.686
Acyanotic 80 .55 .654
ARCHES Cyanotic 20 .70 1.218 0.539
Acyanotic 80 .46 .826
WHORLS Cyanotic 20 3.70 3.028 0.114
Acyanotic 80 4.59 2.589
When comparing finger patterns between cyanotic and acyanotic heart diseases there is no statistical significance.
Figure26: Distribution of finger patterns between cyanotic and acyanotic heart diseases
0 1 2 3 4 5 6
Cyanotic Acyanotic
Figure27: Prediction of CHD by Finger pattern- ROC curve
Table8: Prediction of CHD by finger pattern
Parameter AUC Pvalue Cut off Sensitivity Specificity
UL 0.667 <0.0001 6.5 75 44
RL 0.507 0.864
Arches 0.594 0.021 0.5 63 51
Whorls 0.723 <0.0001 2.5 71 63
Area under Receiver Operating Characteristic curve is significant predictor of CHD for Ulnar loop and Whorl pattern with significant p-value.
Table9: Comparison of dermatoglyphic patterns among cases and controls
Parameter Group Mean Std. Deviation P value
atdRT Controls 37.10 2.740 <0.0001
Cases 47.65 7.161
atdLT Controls 37.97 3.365 <0.0001
Cases 47.58 5.802
TFRC Controls 122.28 18.830 <0.0001
Cases 164.59 33.879
abRT Controls 33.07 3.397 <0.0001
Cases 37.64 5.112
abLT Controls 33.94 3.623 <0.0001
Cases 38.11 3.864
In my study, the atd angle in right and left hand, a-b ridge count in right and left hand and total finger ridge count of congenital heart disease children were significantly increased when compared to the normal children. Axial triradius is distally placed in congenital heart disease children than controls.
Figure 28: Comparison of dermatoglyphic patterns among cases and controls
0 10 20 30 40 50 60
controls cases
atd RT
atd RT
0 10 20 30 40 50
controls cases
atdLT
atdLT
30 31 32 33 34 35 36 37 38
controls cases
abRT
abRT
31 32 33 34 35 36 37 38 39
controls cases
abLT
abLT
Figure29: 95% CI Comparing dermatoglyphic patterns among cases and controls
This figure demonstrates the distribution of dermatoglyphic patterns among cases and controls lying between the 95% confidence interval.
0 50 100 150 200
controls cases
TFRC
TFRC
Table10: Comparison of dermatoglyphic patterns among cases and controls- Male
parameter Group Mean Std. Deviation P value
atdRT Controls 37.39 2.569 <0.0001
Cases 47.93 5.805
atdLT Controls 38.25 3.587 <0.0001
Cases 48.45 4.780
TFRC Controls 117.61 19.427 <0.0001
Cases 170.02 31.873
abrt Controls 33.16 3.110 <0.0001
Cases 38.25 5.289
ablt Controls 33.72 3.483 <0.0001
Cases 38.49 4.149
From the above table, the atd angle in right and left hand, a-b ridge count in right and left hand and total finger ridge count of male congenital heart disease children were significantly increased when compared to the normal male children.
Figure 30: Comparison of dermatoglyphic patterns among cases and controls- Male
