میحرلا نمحرلا الله مسب

Management of the mangled hand هدش هل تسد اب دروخرب یگنوگچ

• • H.Saremi MD Orthopaedic hand&shoulder surgeon • Hamedan University of medical sciences Hamedan,IRAN

•

Do you Really know the importance of Hands???

•

Look at the following pictures and Think again

بیطلا ملکلا دعصی هیلا

هعفری حلاصلا لمعلاو

Management of the mangled hand

• • Needs a multi-speciality team approach No two cases are alike - No preferred approach - A set of principles

History

When?

- delay>6-12h precluding primary closure or coverage -Where?

-How?

History

• • • Health and co morbidities Smoking or other vaso active drugs Functional needs and goals

Examination

• • • • • Difficult in emergency department Vascular status Sensibility Muscle tendon unit function Radiography -standard -additional views -amputated part

Evolution in the treatment

• • • • Primary method : Amputation 1950s : Minimal debridement and preserving length (antibiotics-anesthesia) 1970s Delayed closure to reduce infection 1980s Thorough debridement,early ORIF,early vascularized soft tissue coverage

Recomended approach to treatment

• • Emergent treatment Operative treatment -Debridement/wound excision -Skeletal/joint reconstruction -Soft tissue reconstruction

Emergent treatment

-evaluate and treat other life threatening injuries -control hemorrhage by direct pressure.dont

blindly clamp -

reduce gross skeletal deformity

-administer tetanus prophylaxis and antibiotics -if a major limb is ischemic,place temporary vascular shunt -cool devascularized tissue,,leave skin bridges intact

Debridement

• • The initial debridement is perhaps the single most important step that determines the functional outcome Performing it properly requires experience and judgment

Debridement

• Pasteur : It is the environment not the bacteria that determines whether a wound becomes infected

Debridement Conservative debridement

Debridement

• Marginally viable tissues -further toxic insult of adjacent tissues -systemic complications

debridement

• • Aggressive debridement of minimally vascularized tissue specially muscle Two exceptions - revascularization - pure skin flaps critical for coverage of vital structures

Debridement

• • • Tourniquet Loupe magnification Bone fragments - attached and potentially viable - non viable structural non structural

Debridement

• • • • Irrigation - pulse-lavage -bulb-syringe -mechanical debridement Release tourniquet Culture?

Repeat debridement in 24-36h - heavily contaminated - critical areas viability not certain

Debridemrnt Decisions must be made

(replantation , amputation , partial amputation , reconstrucition) - Save “spare parts” for later use in primary reconstruction

Skeletal/Joint Reconstruction GOAL

Restore - length - alignment - stability - anatomically smooth and stable articulation

Skeletal/Joint Reconstruction TIME Initial operation At the very least within the first week

Fixation

The only chance Adequate stable fixation to allow early motion is the only chance to overcome the inevitable scar formation

Fixation

When?

With the exception of severe contamination ,fixation is best performed

at the initial operation

(excellent vascularity in compare to lower extremity)

Fixation

Approach for fixation -open injury----------------wound often dictate the approach -intra operative x ray control even with good exposure

Fixation

Important decision Restore anatomic length --------or-------- -shorten the bones (bone,nerve,arteries,graft )

fixation

-1---1.5 cm shortening in phalanges and metacarpals -up to 4 cm in the forearm Without significant loss of function

Fixation Intra articular fractures

-reconstructable----------or--------- primary or secondary fusion?

Intra articular fractures Reconstruction 50% to75% of the articular surface remains

-depressed articular fragments should be elevated if fragments are large SCREWS provide excellent skeletal fixation -minicondilar plates are very useful

Intra articular fractures Test the stability of the joint

-ligament repair or reconstruction ,preferably with adjacent tissues -some times “spare parts “ tendon or Palmaris langus graft -trans articular k wire

fixation

Shaft of radius and/or ulna fx Best treated with 3.5 dcp plates

fixation

Distal ulna or ulnar styloid fx -K wire and tension band wire reconstruction

Distal radius fx

-anatomic reconstruction of the articular surface -dorsal or volar buttress plate -When metaphysical comminution multiple carpal fx/dx,risk over time is great-------- external or internal spanning fixation or of shortening

Distal radius fx Internal spanning fixation

-2.4 mm mandibular reconstruction plate -tunnel between 2th and4thdorsal compartment -locking screws -left for 3-4 months -rigid splint is required -provides stability and maintains than an external fixator length , better

fixation Carpal,metacarpal,phalangeal fx

-focus to provide sufficientely allow early motion stable fixation to

fixation Metacarpal and phalanges

-Mini plate and screw fixation

Carpus

Cannulated compression

screw

fixation -

ligaments

reattached with bone anchores

K wire Still has role

-in reconstructing

articular fragments

fx around a joint and -if remains beyond 4w cut them below the skin

K wire

Even crossed is

unable

to rotational or horizontal stability unless numerous -is internal splint rather than rigid fixation

K wire

As provisional fixation drill for screw exchange -0/045-----------1.1mm-----------core diameter--------1.5mm

-0/062-----------1.5mm----------core diameter ---------2mm

External fixation

if not possible to achieve rigid internal fixation(comminution or internal fx anatomy) -maintaining the first web space to prevent adduction contraction

Bone defect

Because of good vascularity,

primary bone graft

unless: -significant contamination -poor soft tissue coverage -compromised adjacent tissue vascularity

Bone defect

If wound or coverage unsuitable for primary bone graft, -antibiotic impregnated PMM beads or spacers -after wound stabilization and maturation,the spacers are replaced with bone graft