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

Case Presentation, Management, Discussion and Sharing of

Information on Skin and Soft Tissue Trauma

Jonathan Malabanan, M.D.

Surgery ResidentOMMC

General Data

E.V., 16M

Sampaloc, Manila.

Chief Complaint

Lacerated wound, left palm

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.


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 5th

digit was noted but with no sensory loss. Volar cast was applied.

CONSULT

CONSULT


Few hrs. PTA Patient was advised operation but prompted to be transferred at OMMC.

CONSULT

Initial Survey: Extremity TraumaInjured Extremity

Check Circulation

Control BleedingBP: 110/70 CR: 90

No Pulsatile bleeding

Quick Neurologic Exam

Motor functionSensory function

Assessment Intervention

Pain control

Initial Survey: Extremity TraumaAssessment of

nerve, muscle and tendon Injury

Splinting

Exposed transectedFlexor 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 4th and 5th digit

(+) extension of all fingers

Intact Sensory function

No structural deformity

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

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

• 16/ M• (+) Laceration, palm, medial aspect, left• No active bleeding• (-) Distal pallor• (+) Exposed transected flexor tendons• (+) Inability to Flex 4th and 5th digit• (+) extension of all fingers• 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 Tendon Injury, Palm, Medial Aspect, Left

Goals of Treatment

• Restore anatomy and function

• Prevent complication

Treatment Options( Tendon Injury)

BENEFIT RISK COST AVAILABILITY

Immediate repair

Early restoration of function

Edema

Infection2000 Available

Delayed Repair

Less chance to restore function

Adhesion

Scar tissue formation

Re-operation

Infection

5000 Available

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

- Resuscitation- 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 5th digit, hand, left


• complete transection flexor digitorum superficialis 4th digit, hand, left

• partial transection flexor digitorum profundus 4th digit, hand, left


• 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 4th and 5th Digit Zone 3

Final Diagnosis

Deep Lacerated wound palm, medial aspect, left with tendon injury, FDS and FDP, 4th

and 5th Digit

S/PWound Exploration

Debribement; Tenorrhaphy FDS and FDP 4th and 5th Digit Zone 3

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 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


• 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).


• 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


Classic signs of tissue Ischemia• Pain

• Pallor

• Paralysis

• Paresthesia

• Poikilothermia


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


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


• 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

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.

• 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

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 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. 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

Thank You!

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 8th 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.

Appraisal Guide

Are the results of the study valid?

Primary Guides:

1. Was the assignment of patients to treatment randomized?

No.


Primary Guides:

2. Were all patients who entered the trial properly accounted for and attributed at its conclusion?

No.


Secondary Guides:

Were patients, their clinicians, and study personnel "blind" to treatment?

No.


Secondary Guides:

4. Were the groups similar at the start of the trial?

No.


Secondary Guides:

5. Aside from the experimental intervention, were the groups treated equally?

No.

Documents

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