Case Presentation, Discussion and Sharing of Information on Skin and Soft Tissue Trauma

JGGuerra, M.D.

Level III Surgery ResidentOMMC092606

General Data

P.C., 29M

Tondo, Manila.

Chief Complaint

Lacerated wound, right wrist

History of the Present Illness

Few minutes PTA accidentally slashed

by a mirror sustaining injury to his right wrist

noted brisk bleeding hence

CONSULT

Initial Survey: Extremity TraumaInjured Extremity

Check Circulation

Control BleedingBP: 110/70 CR: 90

Diminished distal radial pulsePulsatile bleeding

Quick Neurologic Exam

Motor functionSensory function

Digital PressureProximal Torniquetapplication

Assessment Intervention

PNSSPain control

Initial Survey: Extremity TraumaAssessment of

nerve, muscle and tendon Injury

Splinting

Exposed transectedFlexor tendons

Definitive Repair

Diminished distal Radial pulse

Pulsatile bleeding

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Physical Examination(+) Laceration, wrist, right

(+) Pulsatile Arterial bleeding, ulnar side

(+) Diminished distal radial pulses

(+) Distal pallor

(+) Exposed transected flexor tendons

(+) Inability to Flex wrist

(+) Wrist extension

Intact Sensory function

No structural deformity

\

Secondary Survey

• Conscious, coherent, NICRD

• BP 110/70mmHg CR: 90bpm RR: 22cpm Temp: 37.1

• Pink palpebral conjunctivae, anicteric sclerae

• Supple neck, no cervical lymphadenopathy

Physical Examination

• Symmetrical chest expansion, no retractions, clear breath sounds

• Adynamic precordium, no murmur

• Flat abdomen, normoactive bowel sounds, soft, non-tender

Past Medical History

No known history of Allergy

Vaccinations – unknown

Salient Features

• 29M• (+) Laceration, wrist, right• (+) Pulsatile bleeding, ulnar side• (+) Diminished distal pulse, radial side• (+) Distal pallor• (+) Exposed transected flexor tendons• (+) Inability to Flex Hand• (+) Wrist extension• Intact sensory function• No structural deformity

AlgorithmInjured Extremity

Superficial Deep

Extent of Injury

Skin Subcutaneous Neurovascular Muscle

Tendon

PE

Clinical Diagnosis

Diagnosis Certainty Treatment

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 Vascular and Tendon Injury, Wrist, Right

Goals of Treatment

• Control of bleeding

• Restore anatomy and function

• Prevent complication

TREATMENT OPTIONS( Vascular Injury)

BENEFIT RISK COST AVAILABILITY

Control bleeding

Restore function/anatomy

Primary Repair

/// /// Thrombosis 300 /

Ligation /// / Ischemia

Thrombosis

200 /

Saphenous Vein graft

/// /// Thrombosis

Rejection

Infection

1000 /

Treatment Options( Tendon Injury)

BENEFIT RISK COST AVAILABILITY

Immediate repair

Early restoration of function

Edema

Infection200 Available

Delayed Repair

Less chance to restore function

Adhesion

Scar tissue formation

Re-operation

Infection

500 Available

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

- Resuscitation- 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

Operation Done

Wound Exploration

Radial artery anastomosis

Repair of Ulnar Artery

Tenorrhapy

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

• Basic needs supplied– Nutrition– Antibiotics

– Analgesia

– Comfort

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 o Diminished or absent pulses o Ischemia o Pulsatile or expanding hematoma o Bruit

Injuries to Blood Vessels

Equivocal or soft signs o Wound proximity to a major vessel o Small, stable hematoma o Nearby 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 radialflexor carpi radialis palmaris longus flexor carpi ulnaris

• Intermediate layer FDS• Deep layer

FDPFPL

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

Zone Description

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

First Conduction loss only, without anatomic disruption

Second Axonal disruption, without loss of the neurilemmal sheath

Third Loss of axons and nerve sheaths

Fourth Fascicular disruption

Fifth Nerve transection

REFERENCES1. 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-Hill6. Owings, J et al: Extremity Trauma. American College of

Surgeons.20027. Schwartz, Seymour. Principles of Surgery. 7th edition, Vol II: 11827. 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 hematomab. Ischemiac. Stable hematomad. Absent distal pulsese. 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 hoursb. 6-8 hoursc. 10-12 hoursd. 16 hourse. 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

Thank You!