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

1
Case Presentation, Discussion and Sharing of
Information on Skin and Soft Tissue Trauma

• JGGuerra, M.D.
• Level III Surgery Resident
• OMMC
• 092606

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General Data

• P.C., 29M
• Tondo, Manila.

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Chief Complaint

• Lacerated wound, right wrist

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History of the Present Illness

• Few minutes PTA accidentally slashed
• by a mirror sustaining injury to his
  right wrist
• noted brisk bleeding hence
• CONSULT

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Initial Survey Extremity Trauma
Assessment
Intervention
Injured Extremity
Check Circulation
PNSS Pain control
BP 110/70 CR 90 Diminished distal radial
pulse Pulsatile bleeding
Control Bleeding
Digital Pressure Proximal Torniquet application
Quick Neurologic Exam
Motor function Sensory function
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Initial Survey Extremity Trauma
Assessment of nerve, muscle and tendon Injury
Diminished distal Radial pulse Pulsatile
bleeding
Exposed transected Flexor tendons
????????????????
Splinting
Definitive Repair
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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
\
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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

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Physical Examination

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

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Past Medical History

• No known history of Allergy
• Vaccinations unknown

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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

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Algorithm
Injured Extremity
PE
Extent of Injury
Superficial
Deep
Skin
Subcutaneous
Neurovascular
Muscle Tendon
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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)
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Paraclinical Diagnostic Procedure

• Do I need a paraclinical diagnostic procedure?
• NO

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Pretreatment Diagnosis

• Deep Lacerated wound, with Vascular and Tendon
  Injury, Wrist, Right

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Goals of Treatment

• Control of bleeding
• Restore anatomy and function
• Prevent complication

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TREATMENT OPTIONS( Vascular Injury)
BENEFIT BENEFIT RISK COST AVAILABILITY
Control bleeding Restore function/anatomy
Primary Repair /// /// Thrombosis 300 /
Ligation /// / Ischemia Thrombosis 200 /
Saphenous Vein graft /// /// Thrombosis Rejection Infection 1000 /
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Treatment Options( Tendon Injury)
BENEFIT RISK COST AVAILABILITY
Immediate repair Early restoration of function Edema Infection 200 Available
Delayed Repair Less chance to restore function Adhesion Scar tissue formation Re-operation Infection 500 Available
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Plan of Operation

• Wound Exploration
• Primary repair of tissue, vascular and tendon
  injury

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Pre-operative Preparation

• Informed consent
• -Plan Carefully explained to relatives
• Psychosocial support
• Optimize patients health
• - Resuscitation
• - Tetanus Immunization
• - Antibiotics
• Screen for any condition that will interfere with
  treatment
• Prepare materials for OR

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Intra- Operative

• Patient placed supine with right arm extended
• Area prepared, Asepsis and antisepsis technique
• Sterile drapes placed
• Irrigation

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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

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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

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Intra- Operative

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

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Operation Done

• Wound Exploration
• Radial artery anastomosis
• Repair of Ulnar Artery
• Tenorrhapy

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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

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Post-operative Management

• Basic needs supplied
• Nutrition
• Antibiotics
• Analgesia
• Comfort

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Post-operative Management

• Maintain dorsal splint at 30º wrist flexion
• Proper monitoring of limb perfusion
• Elevate affected extremity
• Wound checked

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Follow Up care

• 2 weeks post Op
• - removal of sutures
• 6 weeks post op
• - refer to rehabilitation medicine for
  active range of motion exercise

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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

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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

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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

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Initial Assessment

• History
• PE
• Time of Injury if vessels are involved
• Mechanism of Injury
• Presence of major vascular injury

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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

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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

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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

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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

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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

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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).

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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

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Injuries to Blood Vessels

• Classic signs of tissue Ischemia
• Pain
• Pallor
• Paralysis
• Paresthesia
• Poikilothermia

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Injuries to Blood Vessels

• Hard signs
• Diminished or absent pulses
• Ischemia
• Pulsatile or expanding hematoma
• Bruit

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Injuries to Blood Vessels

• Equivocal or soft signs
• Wound proximity to a major vessel
• Small, stable hematoma
• Nearby nerve injury

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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

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Complications

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

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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

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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

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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
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• 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.

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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.

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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

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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
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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
  198213-25.
• 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.

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MCQ

• 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

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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

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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

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MCR

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

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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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• Thank You!