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Case Presentation and Discussion on Extremity Trauma


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Case Presentation and Discussion on Extremity Trauma

  1. 1. Case Presentation, Discussion and Sharing of Information on Skin and Soft Tissue Trauma JGGuerra, M.D. Level III Surgery Resident OMMC 092606
  2. 2. General Data <ul><li>P.C., 29M </li></ul><ul><li>Tondo, Manila. </li></ul>
  3. 3. Chief Complaint <ul><li> Lacerated wound, right wrist </li></ul>
  4. 4. History of the Present Illness <ul><li>Few minutes PTA accidentally slashed </li></ul><ul><li>by a mirror sustaining injury to his right wrist </li></ul><ul><li>noted brisk bleeding hence </li></ul><ul><li> CONSULT </li></ul>
  5. 5. Initial Survey: Extremity Trauma Injured Extremity Check Circulation Control Bleeding BP: 110/70 CR: 90 Diminished distal radial pulse Pulsatile bleeding Quick Neurologic Exam Motor function Sensory function Digital Pressure Proximal Torniquet application Assessment Intervention PNSS Pain control
  6. 6. Initial Survey: Extremity Trauma Assessment of nerve, muscle and tendon Injury Splinting Exposed transected Flexor tendons Definitive Repair Diminished distal Radial pulse Pulsatile bleeding ????????????????
  7. 7. 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
  8. 8. Secondary Survey <ul><li>Conscious, coherent, NICRD </li></ul><ul><li>BP 110/70mmHg CR: 90bpm RR: 22cpm Temp: 37.1 </li></ul><ul><li>Pink palpebral conjunctivae, anicteric sclerae </li></ul><ul><li>Supple neck, no cervical lymphadenopathy </li></ul>
  9. 9. Physical Examination <ul><li>Symmetrical chest expansion, no retractions, clear breath sounds </li></ul><ul><li>Adynamic precordium, no murmur </li></ul><ul><li>Flat abdomen, normoactive bowel sounds, soft, non-tender </li></ul>
  10. 10. Past Medical History <ul><ul><li>No known history of Allergy </li></ul></ul><ul><li> Vaccinations – unknown </li></ul>
  11. 11. Salient Features <ul><li>29M </li></ul><ul><li>(+) Laceration, wrist, right </li></ul><ul><li>(+) Pulsatile bleeding, ulnar side </li></ul><ul><li>(+) Diminished distal pulse, radial side </li></ul><ul><li>(+) Distal pallor </li></ul><ul><li>(+) Exposed transected flexor tendons </li></ul><ul><li>(+) Inability to Flex Hand </li></ul><ul><li>(+) Wrist extension </li></ul><ul><li>Intact sensory function </li></ul><ul><li>No structural deformity </li></ul>
  12. 12. Algorithm Injured Extremity Superficial Deep Extent of Injury Skin Subcutaneous Neurovascular Muscle Tendon PE
  13. 13. Clinical Diagnosis Surgical (suturing) 5% Superficial Lacerated wound Secondary Surgical (formal wound exploration) 95% Deep Lacerated wound with major vessel, and tendon Injury Primary Treatment Certainty Diagnosis
  14. 14. Paraclinical Diagnostic Procedure <ul><li>Do I need a paraclinical diagnostic procedure? </li></ul><ul><ul><ul><ul><ul><li>NO </li></ul></ul></ul></ul></ul>
  15. 15. Pretreatment Diagnosis <ul><li>Deep Lacerated wound, with Vascular and Tendon Injury, Wrist, Right </li></ul>
  16. 16. Goals of Treatment <ul><li>Control of bleeding </li></ul><ul><li>Restore anatomy and function </li></ul><ul><li>Prevent complication </li></ul>
  17. 17. TREATMENT OPTIONS ( Vascular Injury) / 1000 Thrombosis Rejection Infection /// /// Saphenous Vein graft / 300 Thrombosis /// /// Primary Repair / 200 Ischemia Thrombosis / /// Ligation Restore function/anatomy Control bleeding AVAILABILITY COST RISK BENEFIT
  18. 18. Treatment Options ( Tendon Injury) Available 500 Adhesion Scar tissue formation Re-operation Infection Less chance to restore function Delayed Repair Available 200 Edema Infection Early restoration of function Immediate repair AVAILABILITY COST RISK BENEFIT
  19. 19. Plan of Operation <ul><li>Wound Exploration </li></ul><ul><li>Primary repair of tissue, vascular and tendon injury </li></ul>
  20. 20. Pre-operative Preparation <ul><li>Informed consent </li></ul><ul><li>- Plan Carefully explained to relatives </li></ul><ul><li>Psychosocial support </li></ul><ul><li>Optimize patient’s health </li></ul><ul><li>- R esuscitation </li></ul><ul><li>- Tetanus Immunization </li></ul><ul><li>- Antibiotics </li></ul><ul><li>Screen for any condition that will interfere with treatment </li></ul><ul><li>Prepare materials for OR </li></ul>
  21. 21. Intra- Operative <ul><li>Patient placed supine with right arm extended </li></ul><ul><li>Area prepared, Asepsis and antisepsis technique </li></ul><ul><li>Sterile drapes placed </li></ul><ul><li>Irrigation </li></ul>
  22. 22. Intra-Operative Findings <ul><li>Complete Transection of radial artery </li></ul><ul><li>Partial transection of ulnar artery </li></ul><ul><li>Transected Tendons </li></ul><ul><li>Flexor carpi radialis </li></ul><ul><li>Palmaris Longus </li></ul><ul><li>Intact median, ulnar and radial nerve </li></ul>
  23. 23. Intra-Operative Findings <ul><li>End to End anastomosis of radial artery using prolene 7-0 suture </li></ul><ul><li>Repair of ulnar artery </li></ul><ul><li>Repair of transected tendons using 3-0 prolene suture </li></ul><ul><li>Debridement </li></ul><ul><li>Hemostasis checked </li></ul>
  24. 24. Intra- Operative <ul><li>Washing with NSS </li></ul><ul><li>Correct instrument, needle and sponge count </li></ul><ul><li>Closure of the skin </li></ul><ul><li>Dry sterile dressing </li></ul><ul><li>Immobilization </li></ul><ul><li>- splinting </li></ul>
  25. 25. Operation Done <ul><li>Wound Exploration </li></ul><ul><li>Radial artery anastomosis </li></ul><ul><li>Repair of Ulnar Artery </li></ul><ul><li>Tenorrhapy </li></ul>
  26. 26. Final Diagnosis <ul><li>Deep Lacerated wound wrist, right </li></ul><ul><li>Complete transection of radial artery </li></ul><ul><li>Partial transection of ulnar artery </li></ul><ul><li>Complete Transection of </li></ul><ul><li>Flexor carpi radialis, Zone IV </li></ul><ul><li>Palmaris Longus, Zone IV </li></ul>
  27. 27. Post-operative Management <ul><li>Basic needs supplied </li></ul><ul><ul><li>Nutrition </li></ul></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><ul><li>Analgesia </li></ul></ul><ul><ul><li>Comfort </li></ul></ul>
  28. 28. Post-operative Management <ul><li>Maintain dorsal splint at 30 º wrist flexion </li></ul><ul><li>Proper monitoring of limb perfusion </li></ul><ul><li>Elevate affected extremity </li></ul><ul><li>Wound checked </li></ul>
  29. 29. Follow Up care <ul><li>2 weeks post Op </li></ul><ul><li>- removal of sutures </li></ul><ul><li>6 weeks post op </li></ul><ul><li>- refer to rehabilitation medicine for active range of motion exercise </li></ul>
  30. 30. Sharing of Information <ul><li>Upper extremity injuries 30-40% of peripheral vascular injuries </li></ul><ul><li>15-20% of peripheral vascular traumas </li></ul><ul><li>-ulnar and radial arteries </li></ul><ul><li>Penetrating trauma -most common cause </li></ul>
  31. 31. Assessment and Management of Extremity Injuries <ul><li>Trauma to the extremities falls into two basic categories </li></ul><ul><ul><li>penetrating (vascular or neurologic injury) </li></ul></ul><ul><ul><li>blunt (fractures and the soft tissue injuries) </li></ul></ul><ul><li>Unless active bleeding is present, injuries to the extremities are less urgent than injuries to the trunk, the head, or the neck </li></ul>
  32. 32. Assessment and Management of Extremity Injuries <ul><li>most extremity injuries are not immediately life-threatening and thus can be treated more deliberately </li></ul><ul><li>Massive Hemorrhage: goal is to control bleeding and transport to the OR </li></ul>
  33. 33. Initial Assessment <ul><li>History </li></ul><ul><li>PE </li></ul><ul><li>Time of Injury if vessels are involved </li></ul><ul><li>Mechanism of Injury </li></ul><ul><li>Presence of major vascular injury </li></ul>
  34. 34. Initial Assessment <ul><li>The initial examination should first be directed toward the circulation </li></ul><ul><li>Blood pressure and temperature in both the injured limb and its contralateral counterpart should be determined </li></ul>
  35. 35. Initial Assessment <ul><li>The circulatory examination should be followed first by a quick neurologic examination aimed at assessing motor function in the hands and feet </li></ul><ul><li>Ascertain the presence or absence of sensation and later by a proximal examination of sensory and motor function </li></ul>
  36. 36. Initial Assessment <ul><li>Gross deformity is pathognomonic of fracture or dislocation </li></ul><ul><li>Soft tissue defects should be noted </li></ul><ul><li>If oozing is present, particularly in the hand, proximal application of a tourniquet </li></ul><ul><ul><li>may facilitate examination </li></ul></ul><ul><ul><li>permit definitive control of the bleeding point </li></ul></ul><ul><ul><li>determine nerve, muscle, or tendon </li></ul></ul>
  37. 37. Injuries to Blood Vessels <ul><li>Arterial injuries in an upper extremity are generally a less demanding problem than corresponding injuries in a lower extremity </li></ul><ul><li>main reasons: </li></ul><ul><ul><li>that upper extremity vessels have much better collateral flow </li></ul></ul><ul><ul><li>remain viable except when extensive soft tissue damage is present </li></ul></ul>
  38. 38. Injuries to Blood Vessels <ul><li>Injuries from blunt trauma usually result in thrombosis of a vessel </li></ul><ul><li>Penetrating injuries that completely divide the vessel may be manifested by thrombosis rather than hemorrhage </li></ul><ul><li>If the vessel is only partially divided, it contracts and will continue to bleed. </li></ul><ul><li>Partial transections are more dangerous than complete ones </li></ul>
  39. 39. Injuries to Blood Vessels <ul><li>If the location of the penetrating injury is obscure or if multiple injuries may exist, angiographic or ultrasonographic evaluation may be appropriate </li></ul><ul><li>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). </li></ul>
  40. 40. Injuries to Blood Vessels <ul><li>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 </li></ul>
  41. 41. Injuries to Blood Vessels <ul><li>Classic signs of tissue Ischemia </li></ul><ul><li>Pain </li></ul><ul><li>Pallor </li></ul><ul><li>Paralysis </li></ul><ul><li>Paresthesia </li></ul><ul><li>Poikilothermia </li></ul>
  42. 42. Injuries to Blood Vessels <ul><li>Hard signs </li></ul><ul><li>Diminished or absent pulses </li></ul><ul><li>Ischemia </li></ul><ul><li>Pulsatile or expanding hematoma </li></ul><ul><li>Bruit </li></ul>
  43. 43. Injuries to Blood Vessels <ul><li>Equivocal or soft signs </li></ul><ul><li>Wound proximity to a major vessel </li></ul><ul><li>Small, stable hematoma </li></ul><ul><li>Nearby nerve injury </li></ul>
  44. 44. Injuries to Blood Vessels <ul><li>Hard signs </li></ul><ul><li>-indicative of an underlying arterial injury </li></ul><ul><li>-requires immediate operative exploration and repair. </li></ul><ul><li>Soft signs </li></ul><ul><li> -further evaluation </li></ul><ul><li>Critical time for restoration of perfusion is 6-8 hours following extremity vascular trauma </li></ul>
  45. 45. Complications <ul><li>Occlusion and bleeding </li></ul><ul><li>-early complications </li></ul><ul><li>-necessitate reoperation. </li></ul><ul><li>Muscle edema </li></ul><ul><li>Nerve injury </li></ul><ul><li>Arteriovenous fistulas and false aneurysms </li></ul><ul><li>-late complications </li></ul>
  46. 46. Muscle Layers <ul><li>Relevant Anatomy: </li></ul><ul><li>Superficial layer </li></ul><ul><li>pronator teres- most radial </li></ul><ul><li>flexor carpi radialis </li></ul><ul><li>palmaris longus </li></ul><ul><li>flexor carpi ulnaris </li></ul><ul><li>Intermediate layer </li></ul><ul><li>FDS </li></ul><ul><li>Deep layer </li></ul><ul><li>FDP </li></ul><ul><li>FPL </li></ul>
  47. 48. TENDON INJURIES <ul><li>Flexor tendon injuries cause less impairment of hand function than extensor tendon injuries </li></ul><ul><li>This is mainly due to the redundancy of the flexor tendons in the hand </li></ul><ul><li>Flexor tendon lacerations should always be repaired in the operating room because the synovial sheaths predispose to serious infections </li></ul>
  48. 49. TENDON INJURIES Table 1 - Classification of Flexor Tendon Injury Forearm V Includes the wrist and carpal tunnel IV Extends from the exit of the carpal tunnel to the MCP joint III From the MCP to the DIP joint of the fingers II Flexor digitorum superficialis inserts into the profundus tendon and the base of the distal phalanx I Description Zone
  49. 50. <ul><li>Any flexor tendon lacerations should be repaired by a hand surgeon within 12 hours </li></ul><ul><li>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. </li></ul>
  50. 51. Discussion <ul><li>Medical therapy: </li></ul><ul><li>-IV antibiotics when indicated </li></ul><ul><li>-tetanus immunization </li></ul><ul><li>Surgical therapy: </li></ul><ul><li>All flexor tendons should be repaired in the OR </li></ul><ul><li>Hemostasis </li></ul><ul><li>Irrigation </li></ul><ul><li>Debridement are of vital importance. </li></ul><ul><li>Debris and nonviable tissue left within the wound are niduses for infection, which can severely compromise the final range of motion. </li></ul>
  51. 52. Injuries to Nerves <ul><li>Nerve injury has always been the most challenging aspect of managing trauma to the extremities </li></ul><ul><li>It is the principal factor that accounts for limb loss and permanent disability </li></ul><ul><li>Some nerve injuries, such as brachial plexus injuries and nerve root injuries, preclude repair </li></ul>
  52. 53. Table 1 - Sunderland's Classification of Injuries to Nerves Nerve transection Fifth Fascicular disruption Fourth Loss of axons and nerve sheaths Third Axonal disruption, without loss of the neurilemmal sheath Second Conduction loss only, without anatomic disruption First Anatomic Disruption Degree of Injury
  53. 54. REFERENCES <ul><li>1. Neumeister, M. Flexor Tendon Laceration. Southern illinois School of Medicine, 2003. </li></ul><ul><li>2. Bukata WR, Orban D, Newmeyer WL, Karkal S. </li></ul><ul><li>Reducing pain and disability from common wrist injuries. Emerg Med Reports 1986; 7(18):138. </li></ul><ul><li>3. Chaudhry,N. MD, Hand, Upper Extremity Vascular Injury. </li></ul><ul><li>4. Cooper MA. Upper-extremity injuries: Shoulder, arm, and wrist. In: Chipman C, ed. Emergency Department Orthopedics. Rockville, Aspen 1982:13-25. </li></ul><ul><li>5. Mattox KL, ed. Trauma, 5th ed. 2004 McGraw-Hill </li></ul><ul><li>6. Owings, J et al: Extremity Trauma. American College of Surgeons.2002 </li></ul><ul><li>7. Schwartz, Seymour. Principles of Surgery. 7th edition, </li></ul><ul><li>Vol II: 1182 </li></ul><ul><li>7. Strickland JW: The Hand , Lippincott-Raven Publishers, 1998. </li></ul>
  54. 55. MCQ <ul><li>The initial examination for extremity trauma should first be directed toward </li></ul><ul><li>a. Neurologic Evaluation </li></ul><ul><li>b. Circulatory Evaluation </li></ul><ul><li>c. Motor Function Evaluation </li></ul><ul><li>d. Gross Deformity Evaluation </li></ul><ul><li>e. Complete Systemic Evaluation </li></ul>
  55. 56. MCQ <ul><li>2. Presence of the following manifestation in peripheral vascular injury warrants surgical exploration except? </li></ul><ul><li>a. Large expanding or pulsatile hematoma </li></ul><ul><li>b. Ischemia </li></ul><ul><li>c. Stable hematoma </li></ul><ul><li>d. Absent distal pulses </li></ul><ul><li>e. Palpable Thrill over the wound </li></ul>
  56. 57. MCQ <ul><li>3. What is the critical time interval for restoration of the limb perfusion and optimal limb salvage following extremity vascular trauma? </li></ul><ul><li>a. 1-2 hours </li></ul><ul><li>b. 6-8 hours </li></ul><ul><li>c. 10-12 hours </li></ul><ul><li>d. 16 hours </li></ul><ul><li>e. 24 hours </li></ul>
  57. 58. MCR <ul><li>4. The following statements is/are true regarding vascular injuries to upper extremity. </li></ul><ul><li>Arterial injuries in an upper extremity are generally a less demanding problem than corresponding injuries in a lower extremity </li></ul><ul><li>Upper extremity vessels have much better collateral flow </li></ul><ul><li>Remain viable except when extensive soft tissue damage is present </li></ul><ul><li>Upper extremity blood vessels are protected by bulk musculatures </li></ul>
  58. 59. MCR <ul><li>5. Flexor Tendon Muscle bellies have a superficial, an intermediate and a deep layer. The following includes the superficial muscle group. </li></ul><ul><li>1. Pronator Teres </li></ul><ul><li>2. Flexor Pollicis Longus </li></ul><ul><li>3. Flexor Carpi Ulnaris </li></ul><ul><li>4. Flexor digitorum profundus </li></ul>
  59. 60. <ul><li>Thank You! </li></ul>