Treatment Options ( Tendon Injury) BENEFITRISKCOST AVAILABILITY Immediate repair Early restoration of function Edema Infection 200Available Delayed Repair Less chance to restore function Adhesion Scar tissue formation Re-operation Infection 500Available
Plan of Operation Wound Exploration Primary repair of tissue, vascular 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 right arm extended Area prepared, Asepsis and antisepsis technique Sterile drapes placed Irrigation
Intra-Operative Findings Complete Transection of radial artery Partial transection of ulnar artery Transected Tendons Flexor carpi radialis Palmaris Longus Intact median, ulnar and radial nerve
Intra-Operative Findings End to End anastomosis of radial artery using prolene 7-0 suture Repair of ulnar artery 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
Final Diagnosis Deep Lacerated wound wrist, right Complete transection of radial artery Partial transection of ulnar artery Complete Transection of Flexor carpi radialis, Zone IV Palmaris Longus, Zone IV
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
Muscle Layers Relevant Anatomy: Superficial layer pronator teres- most radial flexor carpi radialis palmaris longus flexor carpi ulnaris Intermediate layer FDS Deep layer FDP FPL
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.
Discussion 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. Neumeister, M. Flexor Tendon Laceration. Southern illinois School of Medicine, 2003. 2. Bukata WR, Orban D, Newmeyer WL, Karkal S. Reducing pain and disability from common wrist injuries. Emerg Med Reports 1986; 7(18):138. 3. Chaudhry,N. MD, Hand, Upper Extremity Vascular Injury. 4. Cooper MA. Upper-extremity injuries: Shoulder, arm, and wrist. In: Chipman C, ed. Emergency Department Orthopedics. Rockville, Aspen 1982:13-25. 5. Mattox KL, ed. Trauma, 5th ed. 2004 McGraw-Hill 6. Owings, J et al: Extremity Trauma. American College of Surgeons.2002 7. Schwartz, Seymour. Principles of Surgery. 7th edition, Vol II: 1182 7. 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. Flexor Tendon Muscle bellies have a superficial, an intermediate and a deep layer. The following includes the superficial muscle group. 1. Pronator Teres 2. Flexor Pollicis Longus 3. Flexor Carpi Ulnaris 4. Flexor digitorum profundus
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