case presentation and discussion on extremity trauma
TRANSCRIPT
Case Presentation, Discussion and Sharing of Information on Skin and Soft Tissue Trauma
JGGuerra, M.D.
Level III Surgery ResidentOMMC092606
General Data
P.C., 29M
Tondo, Manila.
Chief Complaint
Lacerated wound, right wrist
History of the Present Illness
Few minutes PTA accidentally slashed
by a mirror sustaining injury to his right wrist
noted brisk bleeding hence
CONSULT
Initial Survey: Extremity TraumaInjured Extremity
Check Circulation
Control BleedingBP: 110/70 CR: 90
Diminished distal radial pulsePulsatile bleeding
Quick Neurologic Exam
Motor functionSensory function
Digital PressureProximal Torniquetapplication
Assessment Intervention
PNSSPain control
Initial Survey: Extremity TraumaAssessment of
nerve, muscle and tendon Injury
Splinting
Exposed transectedFlexor tendons
Definitive Repair
Diminished distal Radial pulse
Pulsatile bleeding
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Physical Examination(+) Laceration, wrist, right
(+) Pulsatile Arterial bleeding, ulnar side
(+) Diminished distal radial pulses
(+) Distal pallor
(+) Exposed transected flexor tendons
(+) Inability to Flex wrist
(+) Wrist extension
Intact Sensory function
No structural deformity
\
Secondary Survey
• Conscious, coherent, NICRD
• BP 110/70mmHg CR: 90bpm RR: 22cpm Temp: 37.1
• Pink palpebral conjunctivae, anicteric sclerae
• Supple neck, no cervical lymphadenopathy
Physical Examination
• Symmetrical chest expansion, no retractions, clear breath sounds
• Adynamic precordium, no murmur
• Flat abdomen, normoactive bowel sounds, soft, non-tender
Past Medical History
No known history of Allergy
Vaccinations – unknown
Salient Features
• 29M• (+) Laceration, wrist, right• (+) Pulsatile bleeding, ulnar side• (+) Diminished distal pulse, radial side• (+) Distal pallor• (+) Exposed transected flexor tendons• (+) Inability to Flex Hand• (+) Wrist extension• Intact sensory function• No structural deformity
AlgorithmInjured Extremity
Superficial Deep
Extent of Injury
Skin Subcutaneous Neurovascular Muscle
Tendon
PE
Clinical Diagnosis
Diagnosis Certainty Treatment
Primary
Deep Lacerated wound with
major vessel, and tendon
Injury
95%Surgical (formal wound
exploration)
Secondary
Superficial Lacerated
wound 5%
Surgical (suturing)
Paraclinical Diagnostic Procedure
• Do I need a paraclinical diagnostic
procedure?
NO
Pretreatment Diagnosis
Deep Lacerated wound, with Vascular and Tendon Injury, Wrist, Right
Goals of Treatment
• Control of bleeding
• Restore anatomy and function
• Prevent complication
TREATMENT OPTIONS( Vascular Injury)
BENEFIT RISK COST AVAILABILITY
Control bleeding
Restore function/anatomy
Primary Repair
/// /// Thrombosis 300 /
Ligation /// / Ischemia
Thrombosis
200 /
Saphenous Vein graft
/// /// Thrombosis
Rejection
Infection
1000 /
Treatment Options( Tendon Injury)
BENEFIT RISK COST AVAILABILITY
Immediate repair
Early restoration of function
Edema
Infection200 Available
Delayed Repair
Less chance to restore function
Adhesion
Scar tissue formation
Re-operation
Infection
500 Available
Plan of Operation
Wound Exploration
Primary repair of tissue, vascular and tendon injury
Pre-operative Preparation
• Informed consent -Plan Carefully explained to relatives
• Psychosocial support• Optimize patient’s health
- Resuscitation- Tetanus Immunization- Antibiotics
• Screen for any condition that will interfere with treatment
• Prepare materials for OR
Intra- Operative
• Patient placed supine with right arm extended
• Area prepared, Asepsis and antisepsis technique
• Sterile drapes placed
• Irrigation
Intra-Operative Findings
• Complete Transection of radial artery
• Partial transection of ulnar artery
• Transected Tendons
Flexor carpi radialis
Palmaris Longus
• Intact median, ulnar and radial nerve
Intra-Operative Findings
• End to End anastomosis of radial artery
using prolene 7-0 suture
• Repair of ulnar artery• Repair of transected
tendons using 3-0 prolene suture
• Debridement • Hemostasis checked
Intra- Operative
• Washing with NSS•Correct instrument, needle and sponge count•Closure of the skin•Dry sterile dressing•Immobilization
- splinting
Operation Done
Wound Exploration
Radial artery anastomosis
Repair of Ulnar Artery
Tenorrhapy
Final Diagnosis
Deep Lacerated wound wrist, right
Complete transection of radial artery
Partial transection of ulnar artery
Complete Transection of
Flexor carpi radialis, Zone IV
Palmaris Longus, Zone IV
Post-operative Management
• Basic needs supplied– Nutrition– Antibiotics
– Analgesia
– Comfort
Post-operative Management
• Maintain dorsal splint at 30º wrist flexion
• Proper monitoring of limb perfusion
• Elevate affected extremity
• Wound checked
Follow Up care
• 2 weeks post Op
- removal of sutures
• 6 weeks post op
- refer to rehabilitation medicine for active range of motion exercise
Sharing of Information
• Upper extremity injuries 30-40% of peripheral vascular injuries
• 15-20% of peripheral vascular traumas
-ulnar and radial arteries
• Penetrating trauma -most common cause
Assessment and Management of Extremity Injuries
• Trauma to the extremities falls into two basic categories – penetrating (vascular or neurologic injury)– blunt (fractures and the soft tissue injuries)
• Unless active bleeding is present, injuries to the extremities are less urgent than injuries to the trunk, the head, or the neck
Assessment and Management of Extremity Injuries
• most extremity injuries are not immediately life-threatening and thus can be treated more deliberately
• Massive Hemorrhage: goal is to control bleeding and transport to the OR
Initial Assessment
• History
• PE
• Time of Injury if vessels are involved
• Mechanism of Injury
• Presence of major vascular injury
Initial Assessment
• The initial examination should first be directed toward the circulation
• Blood pressure and temperature in both the injured limb and its contralateral counterpart should be determined
Initial Assessment
• The circulatory examination should be followed first by a quick neurologic examination aimed at assessing motor function in the hands and feet
• Ascertain the presence or absence of sensation and later by a proximal examination of sensory and motor function
Initial Assessment
• Gross deformity is pathognomonic of fracture or dislocation
• Soft tissue defects should be noted
• If oozing is present, particularly in the hand, proximal application of a tourniquet– may facilitate examination– permit definitive control of the bleeding point– determine nerve, muscle, or tendon
Injuries to Blood Vessels
• Arterial injuries in an upper extremity are generally a less demanding problem than corresponding injuries in a lower extremity
• main reasons:– that upper extremity vessels have much better
collateral flow– remain viable except when extensive soft
tissue damage is present
Injuries to Blood Vessels
• Injuries from blunt trauma usually result in thrombosis of a vessel
• Penetrating injuries that completely divide the vessel may be manifested by thrombosis rather than hemorrhage
• If the vessel is only partially divided, it contracts and will continue to bleed.
• Partial transections are more dangerous than complete ones
Injuries to Blood Vessels
• If the location of the penetrating injury is obscure or if multiple injuries may exist, angiographic or ultrasonographic evaluation may be appropriate
• Extremity arteriography in the OR can be performed by injection into the axillary artery (for upper extremity injuries) or the common femoral artery (for lower extremity injuries).
Injuries to Blood Vessels
• Exposure of the x-ray plate immediately after injection of 15 to 20 ml of full-strength contrast material usually results in visualization of the injured area
Injuries to Blood Vessels
Classic signs of tissue Ischemia• Pain
• Pallor
• Paralysis
• Paresthesia
• Poikilothermia
Injuries to Blood Vessels
Hard signs o Diminished or absent pulses o Ischemia o Pulsatile or expanding hematoma o Bruit
Injuries to Blood Vessels
Equivocal or soft signs o Wound proximity to a major vessel o Small, stable hematoma o Nearby nerve injury
Injuries to Blood Vessels
• Hard signs
-indicative of an underlying arterial injury
-requires immediate operative exploration and repair.
• Soft signs
-further evaluation • Critical time for restoration of perfusion is 6-8
hours following extremity vascular trauma
Complications
• Occlusion and bleeding -early complications -necessitate reoperation.
• Muscle edema• Nerve injury • Arteriovenous fistulas and false
aneurysms -late complications
Muscle Layers
Relevant Anatomy:• Superficial layer
pronator teres- most radialflexor carpi radialis palmaris longus flexor carpi ulnaris
• Intermediate layer FDS• Deep layer
FDPFPL
TENDON INJURIES
• Flexor tendon injuries cause less impairment of hand function than extensor tendon injuries
• This is mainly due to the redundancy of the flexor tendons in the hand
• Flexor tendon lacerations should always be repaired in the operating room because the synovial sheaths predispose to serious infections
TENDON INJURIES
Table 1 - Classification of Flexor Tendon Injury
Zone Description
I Flexor digitorum superficialis inserts into the profundus tendon and the base of the distal phalanx
II
From the MCP to the DIP joint of the fingers
III
Extends from the exit of the carpal tunnel to the MCP joint
IV
Includes the wrist and carpal tunnel
V
Forearm
• Any flexor tendon lacerations should be repaired by a hand surgeon within 12 hours
• But they can be splinted with the fingers flexed for delayed repair within four weeks. This is not as favorable, however, as having the tendon repaired within the first 12 hours.
Discussion
• Medical therapy: -IV antibiotics when indicated-tetanus immunization
• Surgical therapy: All flexor tendons should be repaired in the OR • Hemostasis• Irrigation• Debridement are of vital importance. Debris and nonviable tissue left within the wound are niduses for infection,
which can severely compromise the final range of motion.
Injuries to Nerves
• Nerve injury has always been the most challenging aspect of managing trauma to the extremities
• It is the principal factor that accounts for limb loss and permanent disability
• Some nerve injuries, such as brachial plexus injuries and nerve root injuries, preclude repair
Table 1 - Sunderland's Classification of Injuries to Nerves
Degree of Injury
Anatomic Disruption
First Conduction loss only, without anatomic disruption
Second Axonal disruption, without loss of the neurilemmal sheath
Third Loss of axons and nerve sheaths
Fourth Fascicular disruption
Fifth Nerve transection
REFERENCES1. Neumeister, M. Flexor Tendon Laceration. Southern illinois School of
Medicine, 2003.2. Bukata WR, Orban D, Newmeyer WL, Karkal S. Reducing pain and disability from common wrist injuries. Emerg
Med Reports 1986; 7(18):138. 3. Chaudhry,N. MD, Hand, Upper Extremity Vascular Injury.4. Cooper MA. Upper-extremity injuries: Shoulder, arm, and wrist. In:
Chipman C, ed. Emergency Department Orthopedics. Rockville, Aspen 1982:13-25.
5. Mattox KL, ed. Trauma, 5th ed. 2004 McGraw-Hill6. Owings, J et al: Extremity Trauma. American College of
Surgeons.20027. Schwartz, Seymour. Principles of Surgery. 7th edition, Vol II: 11827. Strickland JW: The Hand, Lippincott-Raven Publishers, 1998.
MCQ
1. The initial examination for extremity trauma should first be directed toward
a. Neurologic Evaluation
b. Circulatory Evaluation
c. Motor Function Evaluation
d. Gross Deformity Evaluation
e. Complete Systemic Evaluation
MCQ
2. Presence of the following manifestation in peripheral vascular injury warrants surgical exploration except?
a. Large expanding or pulsatile hematomab. Ischemiac. Stable hematomad. Absent distal pulsese. Palpable Thrill over the wound
MCQ
3. What is the critical time interval for restoration of the limb perfusion and optimal limb salvage following extremity vascular trauma?
a. 1-2 hoursb. 6-8 hoursc. 10-12 hoursd. 16 hourse. 24 hours
MCR
4. The following statements is/are true regarding vascular injuries to upper extremity.
1. Arterial injuries in an upper extremity are generally a less demanding problem than corresponding injuries in a lower extremity
2. Upper extremity vessels have much better collateral flow
3. Remain viable except when extensive soft tissue damage is present
4. Upper extremity blood vessels are protected by bulk musculatures
MCR
5. Flexor Tendon Muscle bellies have a superficial, an intermediate and a deep layer. The following includes the superficial muscle group.
1. Pronator Teres
2. Flexor Pollicis Longus
3. Flexor Carpi Ulnaris
4. Flexor digitorum profundus
Thank You!