Transcript Case Presentation and Discussion on Extremity Trauma

Case Presentation, Discussion
and Sharing of Information on
Skin and Soft Tissue Trauma
JGGuerra, M.D.
Level III Surgery Resident
OMMC
092606
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 Trauma
Assessment
Intervention
Injured Extremity
Check Circulation
PNSS
Pain control
BP: 110/70 CR: 90
Diminished distal radial pulse
Pulsatile bleeding
Control Bleeding
Digital Pressure
Proximal Torniquet
application
Quick Neurologic
Exam
Motor function
Sensory function
Initial Survey: Extremity Trauma
Assessment of
nerve, muscle and
tendon Injury
Diminished distal
Radial pulse
Pulsatile bleeding
Exposed transected
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Flexor tendons
Splinting
Definitive Repair
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
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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
Algorithm
Injured Extremity
PE
Extent of Injury
Superficial
Skin
Subcutaneous
Deep
Neurovascular
Muscle
Tendon
Clinical Diagnosis
Diagnosis
Primary
Secondary
Deep
Lacerated
wound with
major vessel,
and tendon
Injury
Superficial
Lacerated
wound
Certainty
95%
5%
Treatment
Surgical
(formal
wound
exploration)
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
Primary
Repair
Ligation
Saphenous
Vein graft
RISK
COST
AVAILABI
LITY
Control
bleeding
Restore
function/anatomy
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Thrombosis
300
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Ischemia
Thrombosis
200
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Thrombosis
Rejection
Infection
1000
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Treatment Options
( Tendon Injury)
BENEFIT
RISK
COST
AVAILABILITY
Immediate
repair
Early
restoration
of function
Edema
Infection
200
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
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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
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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
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Pain
Pallor
Paralysis
Paresthesia
Poikilothermia
Injuries to Blood Vessels
Hard signs
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Diminished or absent pulses
Ischemia
Pulsatile or expanding hematoma
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 radial
flexor carpi radialis
palmaris longus
flexor carpi ulnaris
• Intermediate layer
FDS
• Deep layer
FDP
FPL
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
I
Description
II
III
IV
V
From the MCP to the DIP joint of the fingers
Flexor digitorum superficialis inserts into the profundus
tendon and the base of the distal phalanx
Extends from the exit of the carpal tunnel to the MCP joint
Includes the wrist and carpal tunnel
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
First
Anatomic Disruption
Second
Third
Axonal disruption, without loss of the
neurilemmal sheath
Loss of axons and nerve sheaths
Fourth
Fifth
Fascicular disruption
Nerve transection
Conduction loss only, without anatomic
disruption
REFERENCES
1. 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-Hill
6. Owings, J et al: Extremity Trauma. American College of
Surgeons.2002
7. Schwartz, Seymour. Principles of Surgery. 7th edition,
Vol II: 1182
7. 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
hematoma
b. Ischemia
c. Stable hematoma
d. Absent distal pulses
e. 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 hours
b. 6-8 hours
c. 10-12 hours
d. 16 hours
e. 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!