4AMPLE History Allergy nil Medication nil Past health good, tetanus status not sureLast meal 2 hours agoEvent chopped by a gang outside a restaurant, able to run away
5Now proceed with secondary survey Head and neck normal Chest and abdomen normalMain injuries in limbs and back.
6What underlying structure may be injured? Please assess... R arm woundWhat underlying structure may be injured? Please assess...Deep chop wound. Radial N injury should be considered.
7Radial Nerve injuryLook for drop wrist, fingers Where is the area of sensory loss?Typical sensory loss over first web dorsum.
8Radial NIn such high lesion, weakness is expected in elbow supination, wrist and finger extension.
9Left forearm What structures may be injured? How to test? Median N or the anterior interosseous branch is at risk.
10Median Nerve injury Opposition test Opposition of thumb to finger tips tests pollicis opponens M.
11Other tests Oschner Prayer sign Oschner tests long finger flexor. Prayer sign tests thumb extension.
12R hand is dressed Without looking at the wound, what structure may havebeen 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.
13The hand posture suggests... Cut tendons to Ring Finger and Little Finger
14How to test finger flexors ? Ask tutees to demonstrate.
19Ulnar nerve tests Palm sweep Froment sign Froment sign tests adductor of thumb.Palm sweep keeping IP jt extended tests adductor.Froment sign
20Palm 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.
212 point discriminationThis is the most sensitive test. Use normal side as bench mark.
22Left thumb wound Part of the thumb is chopped off. How do you deal withthe 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.
23Keeping Amputated Part Wrap with gauzePut in a plastic bagPut in a container with ice + water.NB: not ice aloneDirect contact with ice will cause frost biteGauze 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.
24What underlying injuries may be present? Back injuryAs 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?
25Torso injuries Penetration to retroperitoneum Kidney injury Let surgeon explore this wound.
26Right 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.
27You have seen all the wounds How would you manage the patient?
28Patient management Activate trauma team (per local protocol) orthopedic surgeon for limb and hand woundsgeneral surgeon for loin woundIV lineAnalgesicsDress wound to control bleedingTetanusConsider prophylactic antibioticsFor 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 )
29SummaryWe have covered: 1. Evaluation of limb wounds 2. Neurovascular examination in limbs 3. Management of amputated finger