4 AMPLE 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
5 Now proceed with secondary survey Head and neck normal Chest and abdomen normalMain injuries in limbs and back.
6 What 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.
7 Radial Nerve injuryLook for drop wrist, fingers Where is the area of sensory loss?Typical sensory loss over first web dorsum.
8 Radial NIn 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 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.
13 The hand posture suggests... Cut tendons to Ring Finger and Little Finger
14 How to test finger flexors ? Ask tutees to demonstrate.
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 testsIntrinsic muscleAbduction 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 discriminationThis 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 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.
23 Keeping 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.
24 What 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?
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 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 )
29 SummaryWe have covered: 1. Evaluation of limb wounds 2. Neurovascular examination in limbs 3. Management of amputated finger