1. A man with multiple chop wounds
HKCEM College Tutorial
A man with multiple chop wounds
Author
Dr. tw wong
Revised by
Dr. clarence CHU Kwok Keung
Nov 2013

2. Triage Triage Category I M 24 chopped by several gangsters
Multiple wounds
BP 130/80
P 100/min
Triage Category I
Usual story in gang fight.

3. Primary Survey
ABCD normal
ATLS principles apply.

4. AMPLE History Allergy nil Medication nil
Past health good, tetanus status not sure
Last meal 2 hours ago
Event chopped by a gang outside a restaurant, able to run away

5. Now proceed with secondary survey
Head and neck normal Chest and abdomen normal
Main injuries in limbs and back.

6. What underlying structure may be injured? Please assess...
R arm wound
What underlying structure may be injured? Please assess...
Deep chop wound. Radial N injury should be considered.

7. Radial Nerve injury
Look for drop wrist, fingers Where is the area of sensory loss?
Typical sensory loss over first web dorsum.

8. Radial N
In such high lesion, weakness is expected in elbow supination, wrist and finger extension.

9. Left forearm What structures may be injured? How to test?
Median N or the anterior interosseous branch is at risk.

10. Median Nerve injury Opposition test
Opposition of thumb to finger tips tests pollicis opponens M.

11. Other tests Oschner Prayer sign Oschner tests long finger flexor.
Prayer sign tests thumb extension.

12. R hand is dressed Without looking at the wound, what
structure may have
been injured?
Should do neurovascular tests before looking at the wound.
The hand posture is abnormal. Ask tutees to rest hand on table and compare with the patient.

13. The hand posture suggests...
Cut tendons to Ring Finger and Little Finger

14. How to test finger flexors ?
Ask tutees to demonstrate.

15. Flexor tendon tests
Profundus
Sublimis

16. What other underlying structures may be injured?
How to assess?
Since the ulnar tendons are cut, ulnar N is also at risk.

17. Ulnar nerve injury Froment cone
The cone tests intrinsic muscles. Failure to form a cone indicate ulna N lesion.

18. Ulnar Nerve tests
Intrinsic muscle
Abduction test

19. Ulnar nerve tests Palm sweep Froment sign
Froment sign tests adductor of thumb.
Palm sweep keeping IP jt extended tests adductor.
Froment sign

20. Palm wound What is the best way to test finger sensation?
This is quite typical of defense wound when the patient tried to grab the weapon.
This is quite a deep wound. Digital N cut is likely. Median N may also be injured. The tutee should test abduction of thumb as well.

21. 2 point discrimination
This is the most sensitive test. Use normal side as bench mark.

22. Left thumb wound Part of the thumb is chopped off.
How do you deal with
the amputated part ?
The thumb is chopped.
Discuss with tutees along two lines:
If skin bridge is still present, what should we do.
If amputation is complete, what should be done.
Prophylactic antibiotics probably not needed.

23. Keeping Amputated Part
Wrap with gauze
Put in a plastic bag
Put in a container with ice + water.
NB: not ice alone
Direct contact with ice will cause frost bite
Gauze dry or wet? Local preference.
For finger tip, if replantation is done a short time, it is not terribly important to put on ice-water.

24. What underlying injuries may be present?
Back injury
As the patient ran away, chop wound over back is typical.
The direction is likely from head to leg.
Judging from the picture, penetration to abd is unlikely.
Kidney injury should be considered.
What underlying injuries may be present?

25. Torso injuries Penetration to retroperitoneum Kidney injury
Let surgeon explore this wound.

26. Right leg wound What underlying structure is at risk ? Tibial Nerve
Leg wound is caused by chopping from behind when the patient was running for his life.
There are several wounds over popliteal fossa and upper calf. Tibial N and axillary vv are at risk.

27. You have seen all the wounds
How would you manage the patient?

28. Patient management Activate trauma team (per local protocol)
orthopedic surgeon for limb and hand wounds
general surgeon for loin wound
IV line
Analgesics
Dress wound to control bleeding
Tetanus
Consider prophylactic antibiotics
For the point of prophylatic antibiotics , evidence suggested that its effectiveness is dependent on needle-time.
Thus , once you decide to give , you should give it as soon as possible. Drugs of choice ? Per local protocol.
It seems there is still no very solid evidence about the most effective drugs. ( penicillin group Vs cephalosporin )

29. Summary
We have covered: 1. Evaluation of limb wounds 2. Neurovascular examination in limbs 3. Management of amputated finger

30. The end