i

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

ii

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.

iii

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

iv

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

v

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.

vi

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

vii

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

viii

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.

ix

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.

x

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

1

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

2

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.

3

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.

4

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.

5

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

6

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

7

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

8

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

9

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

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

11

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

12

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.

13

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

14

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 primates (plastic mould method)45.

15

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.”

16

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.

17

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

18

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.

19

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.

20

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

21

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.

22

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

“

23

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.”

24

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.”

25

Figure No. 8. Palmar flexion creases

Figure No. 9. Simian crease & Sydney line

26

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.”

27

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.

28

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.”

29

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.

30

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.

31

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.

32

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%

Coarctation of Aorta 5%

33

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

34

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

palmar crease was abnormally common. ‘atd’ angle of both hands were widened

35

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

36

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.

37

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

38

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.

• Rubber roller.

39

• 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.

40

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

areas. The ink is easily removed from the hand by washing with soap and water.

41

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.

42

Figure No. 14. Materials used to record dermatoglyphic patterns

Figure No. 15. Method of recording palmar dermatoglyphic patterns

43

Figure No. 16. Right & Left hand rolled patterns

44

Figure No. 17. Measurement of left & right atd angle

45

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.

46

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

the number of rows in the table minus one.

47

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.

48

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

occurred in about 58.1% among male children and 41.9% among female

55%45%

CHD

male

female 57%

43%

control

male

female

49

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.

50

Pictorial representation of distribution of CHD according to gender is shown

below.

Figure19: Distribution of CHD according to gender

25

15

7

32 2

10

18

14

7

10

2 21

0

5

10

15

20

25

30

VSD ASD TOV PDA DORV TGV AS ALCAPA

Number

Male Female

51

Figure20: Gender wise distribution of CHD- Component Bar diagram

52

Figure21: Distribution of CHD among cases- Pie chart

VSD is common followed by ASD among congenital heart diseases

53

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.

54

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

55

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

56

Figure24: Comparison of finger patterns among cases and controls-

Females

0

1

2

3

4

5

6

7

UL RL Arches Whorls

controls

cases

57

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.

58

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

UL RL ARCHES WHORLS

Cyanotic

Acyanotic

59

Figure27: Prediction of CHD by Finger pattern- ROC curve

60

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.

61

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.

62

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

63

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

64

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

65

0

10

20

30

40

50

60

controls cases

atdRT

atdRT

0

10

20

30

40

50

60

controls cases

atdLT

atdLT

30

31

32

33

34

35

36

37

38

39

controls cases

abRT

abRT

31

32

33

34

35

36

37

38

39

controls cases

abLT

abLT

0

20

40

60

80

100

120

140

160

180

controls cases

TFRC

TFRC

66

Table11: Comparison of dermatoglyphic patterns among cases and

controls-Female

Parameter group Mean Std. Deviation P value

atdRT Controls 36.72 2.938 <0.0001

Cases 47.31 8.591

atdLT Controls 37.60 3.048 <0.0001

Cases 46.51 6.751

TFRC Controls 128.47 16.244 <0.0001

Cases 157.96 35.410

abrt Controls 32.95 3.779 <0.0001

Cases 36.89 4.839

ablt Controls 34.23 3.822 <0.0001

Cases 37.64 3.472

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 female congenital heart

disease children were significantly increased when compared to the normal

female children.

67

Figure 31: Comparison of dermatoglyphic patterns among cases and

controls-Female

0

5

10

15

20

25

30

35

40

45

50

controls cases

atdRT

atdRT

0

5

10

15

20

25

30

35

40

45

50

controls cases

atdLT

atdLT

30

31

32

33

34

35

36

37

38

controls cases

abRT

abRT

32

33

34

35

36

37

38

controls cases

abLT

abLT

0

20

40

60

80

100

120

140

160

180

controls cases

TFRC

TFRC

68

Figure32: 95% CI Comparing dermatoglyphic patterns among male and

female CHD children

This figure demonstrates the distribution of dermatoglyphics patterns among

male and female congenital heart disease children lying between the 95%

confidence interval.

69

Figure33: 95% CI Comparing TFRC among male and female CHD

children

This figure demonstrates the distribution of TFRC patterns among male

and female congenital heart disease children lying between the 95% confidence

interval.

70

Table12: Distribution of dermatoglyphic patterns between cyanotic and

acyanotic heart diseases

Pattern

Group N Mean Std.

Deviation

Pvalue

atdRT Cyanotic 20 48.75 10.442

Acyanotic 80 47.38 6.136 0.445

atdLT Cyanotic 20 45.50 4.707

Acyanotic 80 48.10 5.957 0.073

TFRC Cyanotic 20 165.50 39.347

Acyanotic 80 164.36 32.646 0.894

abrt Cyanotic 20 38.05 4.796

Acyanotic 80 37.54 5.212 0.691

ablt Cyanotic 20 38.50 4.123

Acyanotic 80 38.01 3.817 0.616

From the above table, there is no significant change in the atd angle in

right and left hand, a-b ridge count in right and left hand and total finger ridge

count of acyanotic congenital heart disease children when compared with

cyanotic congenital heart disease children.

71

Figure34: Distribution of dermatoglyphic patterns between cyanotic and

acyanotic heart diseases

Table13: Distribution of dermatoglyphic 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)

atdRT 42() 44(6) 42.5() 52(21) 52(31) 44.5(7) 48(9)

atdLT 49() 45(7) 45() 51.5(14) 46(11) 46(11) 49(7)

TFRC 198 172(4

6)

175() 183.5(59

)

167(10

8)

180.5(6

3)

163(29)

a-bRT 37() 37(4) 33.5() 39(8) 34(11) 37(6) 37(6)

a-bLT 39() 37(7) 33.5 40(7) 36.5(7) 39(4) 37(5)

A narrow Inter Quartile Range indicates that data are very consistent.

0

20

40

60

80

100

120

140

160

180

atdRT atdLT TFRC abRT abLT

cyanotic

acyanotic

72

Figure35: Prediction of CHD by Dermatoglyphics- ROC curve

Table14: Prediction of CHD by Dermatoglyphics

Parameter AUC Pvalue Cut off Sensitivty Specificity

TFRC 0.878 <0.0001 130 88 67

ATD- R .958 <0.0001 40.5 92 88

ATD-L .932 <0.0001 40.5 92 78

AB-R .775 <0.0001 34.5 74 71

AB-L .803 <0.0001 35.5 75 75

Area under Receiver Operating Characteristic curve is significant predictor of

CHD for all dermatoglyphic patterns with significant p-value.

73

Table15 : Presence of simian crease and Sydney line among cases and

controls

Creases Controls Cases

N % N %

Simian

crease

0 0 1 100

Sydney

crease

1 50 1 50

Occurrence of Simian creases in the cases (1%) of CHD group, so a

larger sample is required to ascertain the significance. Sydney line in the cases

and controls is almost similar with no statistical significance.

74

DISCUSSION

The association of altered dermatoglyphic patterns with various

congenital disorders including congenital heart disease was well known, as

reported by several workers. In this section an attempt is made to compare the

observations seen in our study with previous studies conducted to compare the

dermatoglyphic patterns in congenital heart diseases in children.

Finger tip patterns:

The present study showed increased numbers of Whorls and decreased

numbers of Arches in patients with congenital heart diseases which were in

agreement with the studies conducted by Mutalik et al (1968)9, M.L. Magotra

etal (1976)10, Brijendra Singh et al (1996)12

Comparison of finger print patterns in congenital heart diseases

Name of the study

No of

cases

Ulnar

loops

Radial

loops

Whorls Arches

Present study (2016) 100 +* X +* _*

Mutalik et al9 (1968) 12 X X +* _*

Magotra et al10 (1976) 50 X + +* _*

Brijendra et al10

(1996)

50 + X +* _*

(+) Increased, (-) decreased, (x) no significant change, (*) statistically

significant

75

Further analysis of the finger patterns shows, increased Whorls in both

males and females of congenital heart diseases group, which is different from

the Anita Khalil et al study (1998)13 which showed decreased whorls in both

males and females of congenital heart diseases. Most of the study did not show

any statistical significance between the male and the female group of the

congenital heart diseases.

The ‘atd’ angle :

In the present study the ‘atd’ angle was increased in both right and left

palms of the congenital heart disease patients due to distal placement of tri

radius when compared o normal children, which correlates with many studies

done previously like Alfred Hale et al6 study, Sanchez Cascos et al7 study,

Burghat Collard et al8 study, Brijendra Singh et al12 study.

Study No of cases

Increased ‘atd’ angle

Right Left

Present study (2016) 100 Present Present

Alfred Hale et al (1961) 143 Present Present

Sanchez Cascos et al (1964) 150 Present Present

Burghat Collard et al (1968) 98 Present Present

Brijendra Singh et al (1996) 50 Present Present

76

Total finger ridge count (TFRC)

In present study, TFRC is increased in congenital heart diseases as

compared to controls which correlates with Brijendra Singh et al study, whereas

Anita Khalil et al13 study showed decreased in TFRC in all congenital heart

diseases.

Comparison of TFRC in different studies

Study TFRC in different studies

Present Study (2016) Increased, p=0.001(p<0.05)

Brijendra Singh et al (1996) Increased, p=0.001(p<0.05)

Anita Khalil et al (1998) Decreased, p=0.003(p<0.05)

a - b ridge count:

In our present study, a - b ridge count both in right and left hand is found

to have increased in congenital heart disease children which is statistically

significant. Interestingly a-b ridge count is found to have no statistically

significance in the Alter M et al2 study (1967), and Anita Khalil et al study13

(1998).

So a study on a larger sample is required to ascertain the findings.

77

Simian crease and Sydney line:

In our study, Simian crease and Sydney line were found to have no

significant change in cases as compared to the controls which is consistent with

Renuka Nair et al11 study, Anita khalil et al13 study.

Name of the Study No of cases Simian crease Sydney line

Present Study (2016) 100 Not signicant Not signicant

Renuka Nair et al (1985) 927 Not signicant Not signicant

Anita khalil et al (1998) 50 Not signicant Not signicant

78

CONCLUSION

The dermatoglyphic patterns of 100 congenital heart diseases patients

have been studied and compared with those of 100 normal control children.

Increased number of Whorls and decreased number of Arches are seen in the

congenital heart disease 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.

The above parameters may help as a diagnostic aid in diagnosis of

congenital heart diseases in children. They may also help in distinguishing

congenital heart diseases from the functional and acquired heart diseases.‘ a–b’

ridge count is found to have significant difference when compared between the

congenital heart disease group and the normal control group. But as there are

other studies in which there is no significant difference in ‘a-b’ ridge count

when compared between the congenital heart disease group and the normal

control group, a larger sample study is required to ascertain the value of this

dermatoglyphic parameter as a diagnostic tool in congenital heart diseases in

children.

79

SUMMARY

Dermal ridge differentiation takes place during fetal development. Hence

the resulting ridge configurations are genetically determined and influenced by

prenatal insult during the period of formations of these ridges, which can be

studied by method of dermatoglyphics. Thus dermatoglyphics is helpful as a

diagnostic aid in diseases which have a strong genetic background such as

congenital heart diseases.

Dermatoglyphics are studied in 100 children with congenital heart

diseases who were admitted in paediatric wards and OPD at Institute of

childhealth and research centre, Madurai Medical College, Madurai.

Increased number of Whorls and decreased number of Arches, are seen in

the congenital heart disease children. Total finger ridge counting (TFRC) is

increased among children with congenital heart diseases irrespective of sex.

Distal placement of axial triradius is seen in congenital heart disease patients,

with increase in the ‘atd’ angle.

Thus dermatoglyphic patterns may provide a means of identifying the

genetically determined fraction of patients of congenital heart diseases and may

also be of some diagnostic value.

80

RECOMMENDATION

(1) In this study, only palm and finger print dermatoglyphic patterns were

studied. A study of plantar prints could provide additional information.

(2) The study of dermatoglyphics of congenital heart diseases patients with

relation to the dermatoglyphics of their parents would throw further light on the

relationship between genetic influence on the causation of congenital heart

diseases and dermatoglyphic patterns.

81

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87

88

PROFORMA

Dermatoglyphics in congenital heart diseases in children

NAME: DOA:

AGE: DOE:

SEX: I.P/O.P:

Mother’s Education:

Father’s Education:

ADDRESS:

Presenting complaints:

History of present Illness:

Repeated respiratory infections:

Breathlessness:

Cyanosis:

Feeding difficulties:

89

Edema:

Past History:

Family History:

Antinatal History:

Consanguineous / non Consanguineous:

Mother’s age at birth of child:

Father’s age at the birth of the child:

Birth order of child:

History of drug intake during pregnancy:

History of Exanthematous Fevers:

Histroy of exposure to X-rays:

History of oral pills:

History of smoking:

Natal History:

Post natal History:

Developmental History:

Immunization history:

90

General Examination:

Anthropometry:

Cardiovascular system:

Major findings:

HR

RR

Cyanosis

Clubbing

Pedal Edema

Cardiac auscultation:

Respiratory system:

Abdomen:

CNS:

Congenital anomalies:

X-ray chest:

ECG:

91

Clinical diagnosis:

Echocardiography Diagnosis:

RECORD OF DERMATOGLYPICS

FINGER PATTERNS

Right hand rolled prints

Thumb Index Middle Ring Little

Left hand rolled prints

Thumb Index Middle Ring Little

92

TOTAL FINGER RIDGE COUNT:

SIMIAN CREASE:

SYDNEY LINE:

‘atd’ ANGLE:

a-b Ridge count:

KEYNOTE TO MASTER CHART

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–b RC Rt a-b ridge count right side

a–b RC Lt a-b ridge count left side

M Male

F Female

VSD Ventricular septal defect

ASD Atrial Septal defect

PDA Patent ductus Arteriosus

93

TOF Tetra logy 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 pulmonary artery

94

MASTER CHART

Normal children (control group) n=100

S.

NO SEX UL RL Arches Whorls

atd

RT

atd

LT TFRC

a-b

RC

RT

a-b

RC

LT

Simian

crease

Sydney

crease

1 M 6 4 0 0 35 32 121 33 32 0 0

2 M 8 1 0 1 32 39 123 34 36 0 0

3 M 6 0 1 3 33 35 119 22 21 0 0

4 M 7 2 1 0 38 40 120 33 35 0 0

5 M 5 0 0 5 39 40 136 33 31 0 0

6 M 8 0 0 2 41 41 132 34 37 0 0

7 M 7 0 1 2 39 41 112 36 37 0 0

8 M 10 0 0 0 39 41 97 37 33 0 0

9 M 4 1 1 4 32 39 127 32 34 0 0

10 M 5 1 2 2 37 39 129 32 34 0 0

11 M 7 0 3 0 33 33 78 34 33 0 0

12 M 5 1 2 2 42 43 111 34 33 0 0

13 M 9 1 0 0 37 37 116 33 33 0 0

14 M 9 1 0 0 37 40 116 34 35 0 0

15 M 4 0 2 4 37 35 97 28 36 0 0

16 M 10 0 0 0 36 36 107 34 33 0 0

17 M 9 1 0 0 39 39 124 33 32 2 0

18 M 5 0 5 0 37 42 119 35 34 0 0

19 M 4 0 2 4 37 35 92 32 33 0 0

20 M 7 1 1 1 39 39 102 33 34 0 0

21 M 2 0 0 8 34 34 128 33 33 0 0

22 M 5 0 1 4 36 38 133 35 32 0 0

23 M 9 0 0 1 36 38 107 32 33 0 0

24 M 6 0 0 4 40 38 137 35 34 0 0

25 M 6 0 3 1 37 42 94 32 33 0 0

26 M 6 0 0 4 37 32 127 34 34 0 0

27 M 0 0 0 10 41 41 129 33 33 0 0

28 M 4 0 1 5 43 42 135 32 33 0 0

29 M 4 0 0 5 38 39 132 35 37 0 0

30 M 7 0 1 2 38 49 117 36 33 0 0

31 M 7 0 1 2 38 39 144 26 30 0 0

32 M 4 0 1 5 40 40 133 30 32 0 0

33 M 9 0 0 1 43 43 127 33 32 0 0

34 M 8 0 1 1 39 30 123 34 36 0 0

35 M 3 1 0 6 38 36 138 32 34 0 0

36 M 4 0 0 6 38 36 83 28 30 0 0

37 M 2 1 0 7 36 35 107 29 31 0 0

38 M 7 0 1 2 36 40 133 28 32 0 0

95

S.

NO SEX UL RL Arches Whorls

atd

RT

atd

LT TFRC

a-b

RC

RT

a-b

RC

LT

Simian

crease

Sydney

crease

39 M 3 0 1 6 36 36 118 37 35 0 0

40 M 8 0 1 1 37 35 76 34 34 0 0

41 M 7 1 0 2 37 33 126 33 34 0 0

42 M 3 0 1 6 37 38 142 32 33 0 0

43 M 8 0 0 2 32 38 138 36 32 0 0

44 M 3 4 2 1 42 40 142 37 35 0 0

45 M 5 0 5 0 33 35 68 37 43 0 0

46 M 9 0 1 0 40 43 136 40 42 0 0

47 M 9 0 1 0 36 38 124 33 34 0 0

48 M 4 2 3 1 40 42 136 36 32 0 0

49 M 9 0 0 1 35 36 112 36 36 0 0

50 M 5 1 2 2 38 40 97 38 37 0 0

51 M 8 0 1 1 38 32 102 32 30 0 0

52 M 4 0 1 5 36 37 124 32 32 0 0

53 M 7 1 0 2 38 43 87 30 26 2 0

54 M 10 0 0 0 35 35 143 32 33 0 0

55 M 3 1 0 6 38 36 136 35 32 0 0

56 M 3 4 2 1 38 43 69 29 43 0 0

57 M 7 2 1 0 38 42 123 38 41 0 0

58 F 3 0 5 2 41 41 137 34 39 0 0

59 F 3 0 5 2 41 41 138 32 33 0 0

60 F 9 0 1 0 37 36 98 32 33 0 0

61 F 8 2 0 0 40 34 136 31 36 0 0

62 F 5 1 2 2 28 32 126 28 29 0 0

63 F 4 0 0 6 39 42 116 38 37 0 0

64 F 5 0 0 5 38 34 97 30 32 0 0

65 F 7 0 0 3 36 34 116 24 28 0 0

66 F 8 0 1 1 42 38 108 34 32 0 0

67 F 9 0 1 0 42 47 138 34 38 0 0

68 F 8 2 0 0 33 38 134 38 40 0 0

69 F 6 1 0 3 32 37 128 30 24 0 0

70 F 9 0 0 1 36 34 163 34 35 0 0

71 F 8 0 0 2 36 38 123 31 33 0 0

72 F 6 0 0 4 37 38 118 35 37 0 0

73 F 6 0 3 1 35 37 102 32 33 0 0

74 F 5 1 2 2 34 35 127 38 35 0 0

75 F 9 0 0 1 36 34 123 34 35 0 0

76 F 4 1 1 4 37 39 142 40 36 0 0

77 F 7 0 0 3 37 39 121 36 39 0 0

78 F 10 0 0 0 40 41 147 32 33 0 0

79 F 6 1 0 3 34 35 128 30 24 0 2

80 F 8 0 1 1 37 41 119 36 32 0 0

96

S.

NO SEX UL RL Arches Whorls

atd

RT

atd

LT TFRC

a-b

RC

RT

a-b

RC

LT

Simian

crease

Sydney

crease

81 F 5 3 0 2 40 40 120 28 32 0 0

82 F 4 0 0 6 42 43 129 32 33 0 0

83 F 3 0 2 5 37 39 129 39 42 0 0

84 F 8 1 0 1 38 40 148 35 33 0 0

85 F 5 3 0 2 39 40 129 28 32 0 0

86 F 8 0 2 0 39 40 112 30 34 0 0

87 F 5 2 0 3 35 35 146 40 35 0 0

88 F 6 1 0 3 34 38 113 28 32 0 0

89 F 6 0 0 4 36 38 127 34 37 0 0

90 F 4 0 0 6 33 38 134 36 40 0 0

91 F 5 3 1 1 39 40 123 28 32 0 0

92 F 7 0 3 0 36 37 133 32 34 0 0

93 F 5 1 3 1 33 36 112 30 33 0 0

94 F 5 1 0 4 34 35 120 33 33 0 0

95 F 8 1 0 1 37 33 133 29 35 0 0

96 F 4 1 1 4 37 37 178 33 33 0 0

97 F 6 1 1 2 36 37 121 34 39 0 0

98 F 8 1 1 0 35 35 157 33 35 0 0

99 F 5 1 2 2 36 37 129 31 34 0 0

100 F 4 3 0 3 35 34 146 41 41 0 0

97

MASTER CHART

Congenital heart disease (case group) n=100

S.

NO Sex CHD UL RL Arches Whorls

atd

RT

atd

LT TFRC

a-b

RC,

RT

a-b

RC,

LT

Simian

crease

Sydney

crease

1 M TOF 5 1 0 4 44 47 187 37 43 0 0

2 M TOF 0 0 0 10 45 52 198 37 41 0 0

3 M VSD 6 0 0 4 47 49 154 33 36 0 0

4 M ASD 7 0 0 3 47 49 156 33 36 0 0

5 M VSD 6 0 0 4 47 52 154 35 36 0 0

6 M VSD 5 0 0 5 49 48 163 32 28 0 0

7 M VSD 5 1 0 4 44 51 164 31 32 0 0

8 M ASD 3 0 0 7 44 51 172 32 36 0 0

9 F VSD 7 0 1 2 44 47 184 35 36 0 0

10 M VSD 1 0 0 9 45 45 188 33 39 0 0

11 F TOF 5 1 0 4 42 45 197 36 38 0 0

12 F VSD 1 0 1 8 47 49 187 38 38 0 0

13 M TGV 0 1 0 9 53 51 147 33 34 0 0

14 M VSD 4 2 0 4 44 49 147 37 41 0 0

15 F VSD 1 0 0 9 49 47 145 27 29 0 0

16 F AS 3 1 0 6 42 44 201 37 38 0 0

17 M VSD 8 1 1 0 48 53 167 41 41 0 0

18 F VSD 8 0 0 2 55 57 137 29 35 0 0

19 F VSD 2 1 0 7 56 59 242 39 41 0 0

20 F VSD 4 0 1 5 54 63 161 43 39 0 0

21 F VSD 6 1 0 3 57 47 187 41 37 0 0

22 M VSD 5 1 0 4 61 59 143 33 37 0 0

23 M VSD 5 2 0 3 47 45 133 29 31 0 0

24 M VSD 8 0 1 1 51 49 123 37 41 0 0

25 M VSD 6 2 0 2 51 59 147 33 37 0 0

26 M ASD 7 0 1 2 45 45 179 39 41 0 0

27 F TOF 8 1 1 0 53 47 187 37 39 0 0

28 M PDA 2 0 1 7 57 59 203 39 38 0 0

29 M PDA 9 0 0 1 63 52 164 47 43 0 0

30 M ASD 6 1 1 2 51 53 145 39 43 1 0

31 F ASD 1 0 0 9 43 47 187 39 42 0 0

32 F VSD 8 0 1 1 57 61 169 33 35 0 0

33 F VSD 4 2 1 3 49 51 183 51 42 0 0

34 F VSD 0 1 0 9 53 55 163 29 31 0 0

35 F VSD 4 1 0 5 53 59 148 32 36 0 0

36 M VSD 8 0 1 1 45 44 164 43 39 0 0

37 F VSD 8 0 0 2 43 41 170 33 34 0 0

38 M ASD 2 2 0 6 46 49 166 53 47 0 0

98

S.

NO Sex CHD UL RL Arches Whorls

atd

RT

atd

LT

TFR

C

a-b

RC

RT

a-b

RC

LT

Simian

crease

Sydney

crease

39 M VSD 4 2 0 3 53 48 175 33 35 0 0

40 M ASD 1 1 1 7 53 49 187 39 37 0 0

41 M VSD 1 0 0 9 49 48 198 39 41 0 0

42 M TOF 3 1 0 6 49 49 190 39 38 0 0

43 F ASD 2 1 0 7 39 44 193 37 42 0 0

44 F ASD 1 1 0 8 49 47 190 38 35 0 0

45 F ASD 2 0 0 8 41 40 185 39 34 0 0

46 M VSD 8 0 1 1 43 41 158 35 38 0 0

47 M TOF 3 0 0 7 43 41 197 37 39 0 0

48 F VSD 6 0 0 4 47 51 176 37 37 0 0

49 M TOF 5 0 0 5 44 47 179 43 39 0 0

50 M VSD 4 0 1 6 57 48 153 43 37 0 0

51 M ASD 4 1 0 5 43 53 194 40 43 0 0

52 F ASD 2 0 0 8 44 44 154 34 36 0 0

53 M VSD 4 1 0 5 48 52 156 41 39 0 0

54 M VSD 6 1 0 3 55 48 168 39 40 0 0

55 M VSD 6 0 0 4 49 48 167 39 35 0 0

56 M VSD 3 1 0 6 58 56 187 39 41 0 0

57 F AS 7 0 0 3 42 49 178 37 39 0 0

58 M DORV 8 0 1 1 43 43 163 35 37 0 0

59 F ASD 6 0 1 3 43 44 141 37 37 0 0

60 F ASD 1 0 1 8 46 45 188 36 41 0 0

61 F ASD 3 1 0 6 37 42 137 37 38 0 0

62 M VSD 6 0 0 4 43 47 187 36 42 0 0

63 M ASD 3 1 0 6 48 47 178 37 37 0 0

64 M ASD 7 0 0 3 43 40 179 39 35 0 0

65 F TOF 8 0 1 1 43 44 123 33 34 0 0

66 M TOF 7 1 0 2 41 42 182 37 39 0 0

67 M ASD 6 0 1 3 43 44 126 43 35 0 0

68 F VSD 7 0 0 3 47 43 137 37 37 0 0

69 F TOF 3 0 5 1 47 36 83 43 38 0 0

70 F TOF 7 0 1 2 53 47 160 37 35 0 0

71 F PDA 3 1 1 4 47 51 163 39 42 0 0

72 M ASD 0 0 1 10 49 53 211 37 43 0 0

73 M ASD 2 0 0 8 43 45 232 37 35 0 0

74 M TOF 6 1 1 2 43 44 131 47 49 0 0

75 M ASD 5 0 0 5 49 43 232 49 39 0 0

76 F ALCAPA 6 0 2 2 43 51 117 39 38 0 0

77 M VSD 6 1 0 3 44 52 187 41 45 0 0

78 F VSD 6 0 0 4 41 40 166 38 38 0 0

79 M ASD 7 1 1 1 59 57 147 46 44 0 0

80 F TGV 7 1 0 2 89 43 187 33 39 0 0

99

S.

NO Sex CHD UL RL Arches Whorls

atd

RT

atd

LT

TFR

C

a-b

RC

RT

a-b

RC

LT

Simian

crease

Sydney

crease

81 F ASD 6 1 1 2 43 49 148 32 36 0 2

82 M VSD 5 0 1 4 59 49 169 39 39 0 0

83 M VSD 7 1 0 2 36 42 142 46 38 0 0

84 M DORV 4 0 0 6 42 47 187 32 30 0 0

85 M PDA 6 0 0 4 38 41 229 37 35 0 0

86 F VSD 4 1 4 1 49 49 62 43 43 0 0

87 M TGV 2 0 0 8 51 49 239 47 41 0 0

88 F VSD 4 0 0 6 39 37 138 27 37 0 0

89 F ASD 4 1 1 4 38 37 111 36 35 0 0

90 F ASD 0 0 1 9 49 41 137 32 32 0 0

91 F VSD 1 1 0 8 39 37 159 37 37 0 0

92 F ASD 5 1 1 3 48 42 97 43 41 0 0

93 M VSD 4 2 1 3 47 43 92 34 34 0 0

94 M ASD 4 1 5 0 43 43 67 27 33 0 0

95 F ASD 4 1 0 5 47 49 197 45 47 0 0

96 F TOF 7 0 2 1 46 41 97 36 39 0 0

97 F TGV 7 0 2 1 49 39 109 35 34 0 0

98 F TOF 7 1 0 2 55 56 167 47 44 0 0

99 F ASD 1 0 0 9 32 36 160 37 39 0 0

100 M AS 2 1 0 7 54 55 198 46 45 0 0

100

101

102