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Case Presentation, Management, Discussion and Sharing of Information on Skin and Soft Tissue Trauma Jonathan Malabanan, M.D. Surgery Resident OMMC.

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Presentation on theme: "Case Presentation, Management, Discussion and Sharing of Information on Skin and Soft Tissue Trauma Jonathan Malabanan, M.D. Surgery Resident OMMC."— Presentation transcript:

1 Case Presentation, Management, Discussion and Sharing of Information on Skin and Soft Tissue Trauma Jonathan Malabanan, M.D. Surgery Resident OMMC

2 General Data E.V., 16M Sampaloc, Manila.

3 Chief Complaint Lacerated wound, left palm

4 History of the Present Illness Few hrs. PTA accidentally fall sustaining injury to his left palm by a broken sink. No brisk bleeding was noted. Brought to a private hospital where packing, wound cleaning and dressing done.

5 History of the Present Illness Few hrs. PTA X-ray of left hand AP-O was done revealing no fracture. ATS and TT was given. Upon physical examination, lack of flexion at the area of 5 th digit was noted but with no sensory loss. Volar cast was applied. CONSULT

6 History of the Present Illness Few hrs. PTA Patient was advised operation but prompted to be transferred at OMMC. CONSULT

7 Initial Survey: Extremity Trauma Injured Extremity Check Circulation Control Bleeding BP: 110/70 CR: 90 No Pulsatile bleeding Quick Neurologic Exam Motor function Sensory function AssessmentIntervention Pain control

8 Initial Survey: Extremity Trauma Assessment of nerve, muscle and tendon Injury Splinting Exposed transected Flexor tendons Definitive Repair No Pulsatile bleeding

9 Physical Examination (+) Laceration, palm, medial aspect left (-) no active bleeding (-) Distal pallor (+) Exposed transected flexor tendons (+) Inability to Flex 4 th and 5 th digit (+) extension of all fingers Intact Sensory function No structural deformity

10 Secondary Survey Conscious, coherent, NICRD BP 110/70mmHg CR: 90bpm RR: 20cpm Temp: 37.1 Pink palpebral conjunctivae, anicteric sclerae Supple neck, no cervical lymphadenopathy

11 Physical Examination Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, no murmur Flat abdomen, normoactive bowel sounds, soft, non-tender

12 Past Medical History No known history of Allergy Vaccinations – unknown

13 Salient Features 16/ M (+) Laceration, palm, medial aspect, left No active bleeding (-) Distal pallor (+) Exposed transected flexor tendons (+) Inability to Flex 4 th and 5 th digit (+) extension of all fingers Intact sensory function No structural deformity

14 Algorithm Injured Extremity SuperficialDeep Extent of Injury SkinSubcutaneousNeurovascularMuscle Tendon PE

15 Clinical Diagnosis DiagnosisCertaintyTreatment Primary Deep Lacerated wound with major vessel, and tendon Injury 95% Surgical (formal wound exploration) Secondary Superficial Lacerated wound 5% Surgical (suturing)

16 Paraclinical Diagnostic Procedure Do I need a paraclinical diagnostic procedure? NO

17 Pretreatment Diagnosis Deep Lacerated wound, with Tendon Injury, Palm, Medial Aspect, Left

18 Goals of Treatment Restore anatomy and function Prevent complication

19 Treatment Options ( Tendon Injury) BENEFITRISKCOST AVAILABILITY Immediate repair Early restoration of function Edema Infection 2000Available Delayed Repair Less chance to restore function Adhesion Scar tissue formation Re-operation Infection 5000Available

20 Plan of Operation Wound Exploration Primary repair of tissue and tendon injury

21 Pre-operative Preparation Informed consent - Plan Carefully explained to relatives Psychosocial support Optimize patient’s health - R esuscitation - Tetanus Immunization - Antibiotics Screen for any condition that will interfere with treatment Prepare materials for OR

22 Intra- Operative Patient placed supine with left arm extended Area prepared, Asepsis and antisepsis technique Sterile drapes placed Irrigation

23 Intra-Operative Findings Transected Tendons complete transection of flexor digitorum profundus and flexor digitorum superficialis of 5 th digit, hand, left

24 Intra-Operative Findings complete transection flexor digitorum superficialis 4 th digit, hand, left partial transection flexor digitorum profundus 4 th digit, hand, left

25 Intra-Operative Findings Repair of transected tendons using 3-0 prolene suture Debridement Hemostasis checked

26 Intra- Operative Washing with NSS Correct instrument, needle and sponge count Closure of the skin Dry sterile dressing Immobilization - splinting

27 Operation Done Wound Exploration Debribement; Tenorrhaphy FDS and FDP 4 th and 5 th Digit Zone 3

28 Final Diagnosis Deep Lacerated wound palm, medial aspect, left with tendon injury, FDS and FDP, 4 th and 5 th Digit S/PWound Exploration Debribement; Tenorrhaphy FDS and FDP 4 th and 5 th Digit Zone 3

29 Post-operative Management Basic needs supplied –Nutrition –Antibiotics –Analgesia –Comfort

30 Post-operative Management Maintain dorsal splint at 30º wrist flexion Proper monitoring of limb perfusion Elevate affected extremity Wound checked

31 Follow Up care 2 weeks post Op - removal of sutures 6 weeks post op - refer to rehabilitation medicine for active range of motion exercise

32 Sharing of Information Upper extremity injuries 30-40% of peripheral vascular injuries 15-20% of peripheral vascular traumas -ulnar and radial arteries Penetrating trauma -most common cause

33 Assessment and Management of Extremity Injuries Trauma to the extremities falls into two basic categories –penetrating (vascular or neurologic injury) –blunt (fractures and the soft tissue injuries) Unless active bleeding is present, injuries to the extremities are less urgent than injuries to the trunk, the head, or the neck

34 Assessment and Management of Extremity Injuries most extremity injuries are not immediately life-threatening and thus can be treated more deliberately Massive Hemorrhage: goal is to control bleeding and transport to the OR

35 Initial Assessment History PE Time of Injury if vessels are involved Mechanism of Injury Presence of major vascular injury

36 Initial Assessment The initial examination should first be directed toward the circulation Blood pressure and temperature in both the injured limb and its contralateral counterpart should be determined

37 Initial Assessment The circulatory examination should be followed first by a quick neurologic examination aimed at assessing motor function in the hands and feet Ascertain the presence or absence of sensation and later by a proximal examination of sensory and motor function

38 Initial Assessment Gross deformity is pathognomonic of fracture or dislocation Soft tissue defects should be noted If oozing is present, particularly in the hand, proximal application of a tourniquet –may facilitate examination –permit definitive control of the bleeding point –determine nerve, muscle, or tendon

39 Injuries to Blood Vessels Arterial injuries in an upper extremity are generally a less demanding problem than corresponding injuries in a lower extremity main reasons: –that upper extremity vessels have much better collateral flow –remain viable except when extensive soft tissue damage is present

40 Injuries to Blood Vessels Injuries from blunt trauma usually result in thrombosis of a vessel Penetrating injuries that completely divide the vessel may be manifested by thrombosis rather than hemorrhage If the vessel is only partially divided, it contracts and will continue to bleed. Partial transections are more dangerous than complete ones

41 Injuries to Blood Vessels If the location of the penetrating injury is obscure or if multiple injuries may exist, angiographic or ultrasonographic evaluation may be appropriate 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).

42 Injuries to Blood Vessels 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

43 Injuries to Blood Vessels Classic signs of tissue Ischemia Pain Pallor Paralysis Paresthesia Poikilothermia

44 Injuries to Blood Vessels Hard signs oDiminished or absent pulses oIschemia oPulsatile or expanding hematoma oBruit

45 Injuries to Blood Vessels Equivocal or soft signs oWound proximity to a major vessel oSmall, stable hematoma oNearby nerve injury

46 Injuries to Blood Vessels Hard signs -indicative of an underlying arterial injury -requires immediate operative exploration and repair. Soft signs -further evaluation Critical time for restoration of perfusion is 6-8 hours following extremity vascular trauma

47 Complications Occlusion and bleeding -early complications -necessitate reoperation. Muscle edema Nerve injury Arteriovenous fistulas and false aneurysms -late complications

48 TENDON INJURIES Flexor tendon injuries cause less impairment of hand function than extensor tendon injuries This is mainly due to the redundancy of the flexor tendons in the hand Flexor tendon lacerations should always be repaired in the operating room because the synovial sheaths predispose to serious infections

49 TENDON INJURIES Table 1 - Classification of Flexor Tendon Injury ZoneDescription I Flexor digitorum superficialis inserts into the profundus tendon and the base of the distal phalanx II From the MCP to the DIP joint of the fingers III Extends from the exit of the carpal tunnel to the MCP joint IV Includes the wrist and carpal tunnel V Forearm

50 Any flexor tendon lacerations should be repaired by a hand surgeon within 12 hours 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.

51 Medical therapy: -IV antibiotics when indicated -tetanus immunization Surgical therapy: All flexor tendons should be repaired in the OR Hemostasis Irrigation Debridement are of vital importance. Debris and nonviable tissue left within the wound are niduses for infection, which can severely compromise the final range of motion.

52 Injuries to Nerves Nerve injury has always been the most challenging aspect of managing trauma to the extremities It is the principal factor that accounts for limb loss and permanent disability Some nerve injuries, such as brachial plexus injuries and nerve root injuries, preclude repair

53 Table 1 - Sunderland's Classification of Injuries to Nerves Degree of Injury Anatomic Disruption FirstConduction loss only, without anatomic disruption SecondAxonal disruption, without loss of the neurilemmal sheath ThirdLoss of axons and nerve sheaths FourthFascicular disruption FifthNerve transection

54 REFERENCES 1. Mattox KL, ed. Trauma, 5th ed McGraw- Hill 2. Owings, J et al: Extremity Trauma. American College of Surgeons Schwartz, Seymour. Principles of Surgery. 8th edition, Vol II: 4. Strickland JW: The Hand, Lippincott-Raven Publishers, 1998.

55 MCQ 1.The initial examination for extremity trauma should first be directed toward a. Neurologic Evaluation b. Circulatory Evaluation c. Motor Function Evaluation d. Gross Deformity Evaluation e. Complete Systemic Evaluation

56 MCQ 2. Presence of the following manifestation in peripheral vascular injury warrants surgical exploration except? a. Large expanding or pulsatile hematoma b. Ischemia c. Stable hematoma d. Absent distal pulses e. Palpable Thrill over the wound

57 MCQ 3. What is the critical time interval for restoration of the limb perfusion and optimal limb salvage following extremity vascular trauma? a. 1-2 hours b. 6-8 hours c hours d. 16 hours e. 24 hours

58 MCR 4. The following statements is/are true regarding vascular injuries to upper extremity. 1.Arterial injuries in an upper extremity are generally a less demanding problem than corresponding injuries in a lower extremity 2.Upper extremity vessels have much better collateral flow 3.Remain viable except when extensive soft tissue damage is present 4.Upper extremity blood vessels are protected by bulk musculatures

59 MCR 5. True statements regarding evaluation of extrinsic flexors of the hand include which of the ff. 1. FDP flexes the proximal interphalangeal joint 2. FDP flexes the distal interphalangeal joint 3. FDS flexes the proximal interphalangeal joint 4. FDP inserts on base of distal phalanx

60 MCR 5. True statements regarding evaluation of extrinsic flexors of the hand include which of the ff. 3. FDS flexes the proximal interphalangeal joint 4. FDP inserts on base of distal phalanx

61

62 Thank You!

63 Journal Appraisal FLEXOR TENDON INJURIES OF HAND: EXPERIENCE AT PAKISTAN INSTITUTE OF MEDICAL SCIENCES, ISLAMABAD, PAKISTAN Muhammad Ahmad, Syed Shahid Hussain, Farhan Tariq*, Zulqarnain Rafiq**, M. Ibrahim Khan***, Saleem A. Malik Department of Plastic Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, *District Head Quarter Hospital, Rawalpindi, **Department of Orthopaedic PIMS, Islamabad, ***Frontier Medical College, Abbottabad.

64 Objective To know the cause, mechanism and the effects of early controlled mobilization after flexor tendon repair and to assess the range of active motion after flexor tendon repair in hand.

65 Methods: This study was conducted at the department of Plastic Surgery, Pakistan Institute of Medical Sciences, Islamabad from 1st March 2002 to 31st August Only adult patients of either sex with an acute injury were included in whom primary or delayed primary tendon repair was undertaken.

66 In all the patients, modified Kessler’s technique was used for the repair using non-absorbable monofilament (Prolene 4- 0). The wound was closed with interrupted nonabsorbable, polyfilament (Silk 4-0) suture.

67 Passive movements of fingers were started from the first post operative day, and for controlled, active movements, a dynamic splint was applied.

68 Results Laceration with sharp object was the most frequent cause of injury. Finger tip to distal palmer crease distance (TPD) was < 2.0 cm in 71% cases (average 2.4cm) at the end of 2nd postoperative week.

69 Results TPD was < 2.0 cm in 55% patients and < 1.0 cm in 38% cases (average 1.5cm) at the end of 6th week. Total 9 patients were lost to the follow up at the end of 8th week. TPD was < 1.0 cm in 67% (average 0.9cm) at the end of 8 th postoperative week. No case of disruption of repair was noted during the study.

70 Conclusion Early active mobilization programme is essential after tendon repair. Majority of the patients (92%) had fair to good results at the end of 2nd week which increased to 97% at the end of 8th week to good to excellent.

71 Appraisal Guide

72 Are the results of the study valid? Primary Guides: 1. Was the assignment of patients to treatment randomized? No.

73 Are the results of the study valid? Primary Guides: 2. Were all patients who entered the trial properly accounted for and attributed at its conclusion? No.

74 Are the results of the study valid? Secondary Guides: Were patients, their clinicians, and study personnel "blind" to treatment? No.

75 Are the results of the study valid? Secondary Guides: 4. Were the groups similar at the start of the trial? No.

76 Are the results of the study valid? Secondary Guides: 5. Aside from the experimental intervention, were the groups treated equally? No.


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