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.
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
History of the Present Illness Few hrs. PTA Patient was advised operation but prompted to be transferred at OMMC. CONSULT
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
Initial Survey: Extremity Trauma Assessment of nerve, muscle and tendon Injury Splinting Exposed transected Flexor tendons Definitive Repair No Pulsatile bleeding
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
Past Medical History No known history of Allergy Vaccinations – unknown
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
Algorithm Injured Extremity SuperficialDeep Extent of Injury SkinSubcutaneousNeurovascularMuscle Tendon PE
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)
Paraclinical Diagnostic Procedure Do I need a paraclinical diagnostic procedure? NO
Pretreatment Diagnosis Deep Lacerated wound, with Tendon Injury, Palm, Medial Aspect, Left
Goals of Treatment Restore anatomy and function Prevent complication
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
Plan of Operation Wound Exploration Primary repair of tissue and tendon injury
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
Intra- Operative Patient placed supine with left arm extended Area prepared, Asepsis and antisepsis technique Sterile drapes placed Irrigation
Intra-Operative Findings Transected Tendons complete transection of flexor digitorum profundus and flexor digitorum superficialis of 5 th digit, hand, left
Intra-Operative Findings Repair of transected tendons using 3-0 prolene suture Debridement Hemostasis checked
Intra- Operative Washing with NSS Correct instrument, needle and sponge count Closure of the skin Dry sterile dressing Immobilization - splinting
Operation Done Wound Exploration Debribement; Tenorrhaphy FDS and FDP 4 th and 5 th Digit Zone 3
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
Post-operative Management Maintain dorsal splint at 30º wrist flexion Proper monitoring of limb perfusion Elevate affected extremity Wound checked
Follow Up care 2 weeks post Op - removal of sutures 6 weeks post op - refer to rehabilitation medicine for active range of motion exercise
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
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
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
Initial Assessment History PE Time of Injury if vessels are involved Mechanism of Injury Presence of major vascular injury
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
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
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
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
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
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).
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
Injuries to Blood Vessels Classic signs of tissue Ischemia Pain Pallor Paralysis Paresthesia Poikilothermia
Injuries to Blood Vessels Hard signs oDiminished or absent pulses oIschemia oPulsatile or expanding hematoma oBruit
Injuries to Blood Vessels Equivocal or soft signs oWound proximity to a major vessel oSmall, stable hematoma oNearby nerve injury
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
Complications Occlusion and bleeding -early complications -necessitate reoperation. Muscle edema Nerve injury Arteriovenous fistulas and false aneurysms -late complications
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
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
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.
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.
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
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
REFERENCES 1. Mattox KL, ed. Trauma, 5th ed. 2004 McGraw- Hill 2. Owings, J et al: Extremity Trauma. American College of Surgeons.2002 3. Schwartz, Seymour. Principles of Surgery. 8th edition, Vol II: 4. Strickland JW: The Hand, Lippincott-Raven Publishers, 1998.
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
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
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. 10-12 hours d. 16 hours e. 24 hours
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
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
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
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.
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.
Methods: This study was conducted at the department of Plastic Surgery, Pakistan Institute of Medical Sciences, Islamabad from 1st March 2002 to 31st August 2003. Only adult patients of either sex with an acute injury were included in whom primary or delayed primary tendon repair was undertaken.
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.
Passive movements of fingers were started from the first post operative day, and for controlled, active movements, a dynamic splint was applied.
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.
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.
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.