paediatric soft tissue and envenomation inuries

1. SOFT TISSUE AND
ENVENOMATION INJURIES
Dr Arka Banerjee
M.Ch. Resident
Pediatric surgery
MAMC
Moderator: Dr. C. K. Gupta

2. INTRODUCTION
• Triage
• ABCDE of trauma
• Primary survey
• History
• Baseline function (compared witrh pre-injury status)
• Previous injuries
• Right- or left-hand dominance
• Mechanism and timing of injury
• Physical examination
• Vascularity and perfusion
• Secondary survey

3. EVALUATION
• Vascularity
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue

4. EVALUATION
• Vascularity
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue

5. EVALUATION: VASCULARITY
• Signs of ischemia (5 P’s)
• Pallor
• Pain
• Paresthesia
• Paralysis
• Pulselessness
• CFT (N < 3s) – Most accurately tested by compressing the lateral aspect of the distal
phalanx adjacent to the nail plate
• Delayed – impaired arterial inflow
• Rapid – venous hypertension/insufficiency

6. EVALUATION: VASCULARITY
• Tests
• Allen test
• Percutaneous Doppler
• Initial management
• Firm manual compression
• Proximal tourniquet application
* A hemostat or clamp should not be placed blindly into the wound because lack of
blood flow may injure adjacent neural structures
* Obvious foreign objects are removed, although projectiles impaled through an
extremity or retained foreign objects should be left in situ until definitive management
is possible because they may staunch the flow of blood from a vascular injury

7. EVALUATION
• Vascularity
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue

8. EVALUATION: PERIPHERAL NERVES
• Should be evaluated only after vascular inflow has been assessed
• Isolated nerve injuries cause predictable neurological deficits
• Vascular injuries can also cause neurological deficits
• Anhidrosis – indicates underlying neural damage (can be assessed even in the
uncooperative child)
• Neurologic findings associated with compartment syndrome evolve over time and
may not be obvious during the initial examination

9. EVALUATION
• Vascularity
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue

10. EVALUATION: SKELETON, TENDONS AND
LIGAMENTS
• Findings s/o #
• Pain
• Ecchymosis
• Instability
• Swelling
• Deformity
• Crepitus
• Describing a #
• Open or closed? – # hematoma
• Simple or comminuted? – bone fragments
• Length – shortened/elongated/normal
• Angulation – volar/dorsal/radial/ulnar
• Rotation – present/absent
• Displacement

12. EVALUATION: SKELETON, TENDONS AND
LIGAMENTS
• Difficult to diagnose
• Posture of the hand at rest gives
information regarding tendon integrity
• In a relaxed position, the hand forms a
gentle cascade – this position results
from passive tension of the tendons
• A digit that remains extended out of
the cascade suggests disruption of the
flexor mechanism

13. EVALUATION: SKELETON, TENDONS AND
LIGAMENTS
• Difficult to diagnose, particularly in the presence of associated soft tissue/skeletal
injuries
• Abnormal joint stability indicates disruption of the ligaments
• Joint stability should be compared with the opposite uninjured side as an indicator
of preinjury status
• Confirmation by plain and stress radiographs of an avulsion fracture at the site of
ligament insertion

14. EVALUATION
• Vascularity
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue

15. EVALUATION: SOFT TISSUE
• Important for evaluation of
• Wound healing
• Long-term function
• Outcome of primary or secondary reconstructive surgery
• The amount of soft tissue present in the area of a wound determines the feasibility of
primary repair of vascular, neural, and osteoligamentous injuries
• Description
• Size (measured objectively)
• Shape
• Location
• General configuration
• Exposed vital structures
• Associated fractures and tendon injuries

16. EARLY TREATMENT
• Vascular structures
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue
• Amputations

17. EARLY TREATMENT
• Vascular structures
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue
• Amputations

18. EARLY TREATMENT: VASCULAR STRUCTURES
• Revascularization is a top priority after the correction of life-threatening injuries
• Irreversible changes start to occur after 4 hours of ischemia
• Primary vascular repair – the most effective procedure and is ideally accomplished
by
• Debridement
• Mobilization
• Primary anastomosis/Reversed vein graft (foot/forearm/saphenous/cephalic)
• All arteries and veins proximal to the elbow should be repaired
• Repair of arterial injuries below the elbow
• Should be considered to prevent cold intolerance
• Success rate – 50%

19. EARLY TREATMENT: VASCULAR STRUCTURES
• Once repairs are complete, fasciotomy should be considered if
• Ischemia has been prolonged
• Soft tissue damage is significant
• Adequate postoperative monitoring is not available
• Then, serial examination to make an early diagnosis of
• Recurrent ischemia
• Postsurgical thrombosis/bleeding
• Role of anticoagulation therapy is controversial

20. EARLY TREATMENT
• Vascular structures
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue
• Amputations

21. EARLY TREATMENT: PERIPHERAL NERVES
• Not an emergency – Can be addressed when an adjacent vascular injury is being
repaired
• Primary repair with end-to-end anastomosis
• When wound is clean, uninfected and well vascularized
• Other options (when mobilization of the injured segments cannot adequately repair the
defect)
• Interpositional nerve grafts
• Nerve conduits
• Vein grafts
• Early secondary repair in the first 10 days after injury
• To ensure that the injured area remains intact, the involved limb should be splinted to
minimize further proximal migration of the transected nerve before surgery and to relieve
anastomotic tension

22. EARLY TREATMENT
• Vascular structures
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue
• Amputations

23. EARLY TREATMENT: SKELETONS, TENDONS
AND LIGAMENTS
• Restoration of normal or acceptable anatomy followed by appropriate immobilization
• Immobilization of the potentially injured area despite equivocal physical
examination or radiographic findings
• Allows protection from further injury
• Improves pain control
• Maintains local anatomy
• A splint (instead of a cast) is ideal because it allows swelling into a nonfixed space
and limits the possibility of vascular compromise during the acute injury and post-
reduction periods
• Anatomic reduction of fractures and dislocations can be done at the time of injury or
in the following week with good functional results

24. EARLY TREATMENT: SKELETONS, TENDONS
AND LIGAMENTS
• Specific position of immobilization is less critical for children than for adults
• Children are less prone to stiffening and tightening of the ligaments
• “Position of safety”
• Wrist in 30 - 45° extension
• Metacarpophalangeal joints in 70° flexion
• Interphalangeal joints left straight
• Serial physical and radiographic examinations tailored to the specific injury and
clinical course

25. EARLY TREATMENT
• Vascular structures
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue
• Amputations

26. EARLY TREATMENT: SOFT TISSUE
• Irrigation of all significant wounds with NS
• Removal of all foreign objects
• Debridement of devitalized tissue
• Simple lacerations and small surface area avulsions can be closed primarily
• Suture material depends on the location, size and cause of the wound as well as the
patient’s age

27. EARLY TREATMENT: SOFT TISSUE
• Open wounds that cannot be closed primarily
• NS wet-to-wet dressings
• Provide limited debridement
• Allow the initiation of granulation
• Prevent desiccation
• Povidone-iodine dressings for short-term use in infected wounds
• 0.25% acetic acid solution for wounds infected with Pseudomonas
• Subatmospheric pressure dressings
• Temporary cover of a contaminated or extensive wound
• Bridge to more extensive soft tissue reconstruction
• For definitive closure of extremity wounds
• Quantitative wound biopsies for nonthermal burns

28. EARLY TREATMENT: SOFT TISSUE
• Split-thickness skin grafts (STSG/Thiersch graft)
• Larger wounds (if the skin defect is partial thickness only and no vital
structures are exposed)
• Less cosmetically significant wounds
• Suboptimal wound bed because of infection/inflammation/ischemia
• Full-thickness skin grafts (FTSG/Wolfe graft)
• Contract less after revascularization
• Ideal for cosmetically significant areas/where wound contraction is undesirable.

29. EARLY TREATMENT: SOFT TISSUE
• Local skin flaps – Cosmetically favorable replacement of like tissue
• Random – no specific blood supply
• Axial – the blood is supplied by a specific vessel
• Regional muscle flaps
• When highly vascularized tissue of significant bulk is required to cover exposed critical
structures and fill dead space
• Used on the basis of a known blood supply
• Microvascular free tissue transfer
• when local tissue is not available/ is inadequate to provide wound closure

30. EARLY TREATMENT
• Vascular structures
• Peripheral nerves
• Skeleton, tendons and ligaments
• Soft tissue
• Amputations

31. EARLY TREATMENT: AMPUTATIONS
• Replantation by a qualified microsurgical team
** To optimize the chance of success, the amputated part should be
wrapped in a saline-moistened gauze, sealed in a plastic bag and placed
in a bag of ice and saline solution; the part must not be in contact with
the ice directly

32. ENVENOMATION INJURIES
• Snake bites
• Other bite injuries

33. ENVENOMATION INJURIES
• Snake bites
• Other bite injuries

34. ENVENOMATION INJURIES: SNAKE BITES
• Poisonous snakes belong to 3 families
• Elapidae: Neurotoxic
• Cobra (Naja)
• Krait (Bungarus)
• Viperidae: Vasculotoxic
• Russell’s viper
• Saw-scaled viper
• Hydrophidae: Myotoxic
• Sea snakes

35. ENVENOMATION INJURIES: SNAKE BITES
• Neglected tropical disease [WHO, 2009]
• 3% of all deaths in children aged 5-14 yrs
• All bites are not a/w envenomation
• Signs of envenomation
• Pain
• Edema
• Local tissue necrosis
• Ecchymosis
• Nausea/vomiting
• Hypotension
• DIC
• Hemolysis
• Mental status changes
• Seizures
• Neuroparalytic symptoms – Ptosis, Flaccid paralysis
• Death
• Severity of signs is proportional to the degree of envenomation

36. ENVENOMATION INJURIES: SNAKE BITES
• Early intervention
• Reassurance and support
• Immobilization
• Limb elevation
• Venous tourniquet application
• Tetanus immune globulin and toxoid
• Fasciotomy
* Cryotherapy and wound incision and suction
are no longer recommended because of
potential damage to vital structures

37. ENVENOMATION INJURIES: SNAKE BITES
• Antivenin Fab AV
• Sheep immunoglobulin immunized with antigen from 4 snakes
• Administered iv after a skin test (immediate allergic reaction in ~5% pts)
• 4-6 vials (4-6 g) is given immediately
• Followed by aggressive iv hydration
• Close monitoring
• Crotalid envenomation – at least 12 hrs
• Coral snake bites – 24 hours (possible delayed-onset neurotoxicity)
• Redosing in 1 hour if the patient does not respond

38. ENVENOMATION INJURIES: OTHER BITES
• Scorpion sting
• Local signs of envenomation are minimal
• Systemic neuromuscular findings
• Autonomic symptoms
• Severe cardiorespiratory and neuromuscular dysfunction associated with envenomation
• Treatment
• Local wound care
• Topical ice
• Specific antivenin
• Systemic support, including ventilation, control of tachyarrhythmias, and sedation
• Human bite
• Eikenella corrodens
• Aggressive primary intervention is mandatory
• Thorough irrigation of penetrating bite wounds
• Broad-spectrum antibiotic coverage
• Frequent wound checks