Cheyenne Kate P. Rebosura, MD Clinical Associate Orthopaedic Surgery KhooTeck PuatHospital

Size: px

Start display at page:

Download "Cheyenne Kate P. Rebosura, MD Clinical Associate Orthopaedic Surgery KhooTeck PuatHospital"

Ella Patrick
5 years ago
Views:

1 Cheyenne Kate P. Rebosura, MD Clinical Associate Orthopaedic Surgery KhooTeck PuatHospital

2 Outline I. Principles of Assessment II. Flexor Tenosynovitis III. Fight Bite IV. Animal Bite V. Compartment Syndrome VI. High pressure Injection Injury VII. Acute Carpal Tunnel Syndrome VIII.Vessel Laceration IX. Amputation X. Nailbed injury

3 Principles of Assessment HISTORY Mechanism of Injury Forces and its direction Previous Injury Clinical Context Handedness Occupation Sporting interests, hobbies

4 Examination A Appearance B Both hands C Circulation D Deficit ( Neurological Assessment ) E Extension F Flexion

6 FDP FDS

7 Median Ulnar Radial

8 Investigation Xray Ultrasound CT scan MRI

9 Flexor Tenosynovitis

10 Flexor Tenosynovitis Infection of the synovial sheath that surrounds the flexor tendon Risk factors diabetes IV drug users Immunocompromised patients Organisms Staph aureus(40-75%) MRSA(29%) other common skin flora

11 Flexor Tenosynovitis

12 Flexor Tenosynovitis Emergent Hand surgery Consult! Nonoperative Rare! Only if early presentation Hospital admission, IV ABx, hand immobilization, observation. No surgery needed if improvement within 24 hours Operative If late presentation or no improvement after 24 hours of nonoperative treatment I&D followed by culture-specific IV antibiotics

13 Fight Bite Injury

14 Fight bite injury Pathophyiology most often result of direct clenched-fist trauma (from tooth) after punching another individual in the mouth Microbiology polymicrobial most common organisms alpha-hemolyticstreptococcus (S. viridans) and staphylococcus aureus eikonella corrodens in 7-29%

15 Fight bite injury History often overlooked consider the injury a "fight-bite" until proven otherwise Symptoms small wound over dorsal aspect of MCP joint possible pain with passive ROM of MCP joint

16 Fight Bite Injury Imaging Obtain Xraysto exclude foreign bodies, fractures or dislocations Treatment Drainage, Debridement Culture Specific antibiotics Left untreated, these bites can quickly progress to osteomyelitis, tenosynovitis, or septic arthritis.

17 Animal Bite

18 Animal Bite Bites by domestic animals are common dog bites are most common cat bites are 2nd most common Pathophysiology dog bites cause crush, puncture, avulsion, tears and abrasions large dogs' jaws exert >450lbs/ square inch more likely to causestructural damageto nerves, vessels, joints

19 Animal Bite Pathophysiology catbites penetrate bones and joints, and cause septic arthritis and osteomyelitis small,sharpteeth cause puncture wounds that seal immediately penetrate joints and flexor tendons higher risk for infectionthan dog bites

20 Animal Bite most common isolate is Pasteurella sp. Treatment Non Operative copious irrigation, prophylactic antibiotics amoxicillin/clavulanic acid effective against Pasteurella tetanus toxoid, +/- rabies prophylaxis

21 Animal bite Treatment Operative crush or devitalized tissue foreign body bites to digital pulp space, nail bed, flexor tendon sheath, deep spaces of the palm, joint spaces tenosynovitis septic arthritis abscess formation

22 Compartment Syndrome Increased osseofascialcompartment pressure leads to decreased perfusion May lead to irreversible muscle and nerve damage Pathophysiology trauma and soft tissue destruction> bleeding and edema> increased interstitial pressure>vascular occlusion > myoneural ischemia Fractures most common cause

23 Compartment Syndrome

24 Compartment Syndrome Clinical Diagnosis pain out of proportionto clinical situation Other symptoms include 6 P s Pain - most sensitive finding Pressure- most consistent clinical finding Paresthesia nerve ischemia Pallor Paresis -late finding Pulselessness late finding, amputation inevitable

25 Compartment Syndrome Treatment Emergent Surgical Consult! Emergent hand fasciotomies Regional, digital nerve blocks and local infiltration are contraindicated

26 High pressure injection injuries

27 High pressure Injection Injuries Characterized by extensive soft tissue damage associated with a benign high-pressure entry woundoften caused by spray or paint guns Usually involve the nondominant index finger. Pathophysiology leads to dissection along planes of least resistance (along neurovascular bundles) vascular occlusion may lead to local soft tissue necrosis

28 High pressure injection injuries History document duration since event Physical exam inspection entry wound often benign looking local soft tissue necrosis Imaging Radiographs

29 High pressure injection injuries Treatment immediate surgical debridement broad-spectrum antibiotics Monitor for compartment syndrome Complication Amputation-50 % oil based paint injection Infection

30 High pressure injection injuries Prognosis Up to 50% amputation rate for organic solvents (paint, paint thinner, diesel fuel, jet fuel, oil) severity of the injury is dependent on time from injury to treatment force of injection volume injected composition of material

31 Acute Carpal Tunnel Syndrome

32 Acute Carpal Tunnel Syndrome rapid onset of median neuropathy leading to median nerve ischemia. decreasing blood flow to the median nerve Localized tissue anemia of the muscles, and median nerve dysfunctions begin to set in

33 Acute Carpal Tunnel Syndrome Causes Fracture or dislocation of the wrist uncontrollable hemorrhage in the wrist area even after minor injuries Gout, Giant cell tumor of any of the tendon sheath surrounding the median nerve

34 Acute Carpal Tunnel Syndrome Treatment Emergent Surgical decompression!

35 Vessel Laceration Emergent referral if these hard signs are present Bright red pulsatile bleeding Expanding hematoma Cold, pulseless extremity Palpable thrill or audible bruit

36 Vessel Laceration Lacerated vessels should not be clamped; instead, direct pressure or approximal limb tourniquet application to avoid further damage to vessels. Apply direct pressure to the wound for 10 to 15 minutes with sterile, semicompressible material. After hemorrhage is controlled, the limb is elevated and the wound is wrapped with an elastic bandage tight enough

37 Amputations Essential information before referral Time of injury to establish ischemic time Mechanism Level Radiography for the stump and amputate Co-exisiting injuries Hemodynamic status

38 Amputations Reattachment should never be guaranteed to patients! Manipulation must be minimum NO tissue should be discarded unless seen by replant surgeon Stump clean, don t debride, wrap in saline soaked gauze Tissue bridge leave intact, may contain nerves/arteries

39 Amputated part Wrap digits in gauze moistened with LR or NSS Place in plastic bag. Place part on ice. Never place amputated part directly on ice Never use dry ice

40 Amputation Approximate allowable ischemia times for the digits 12 hours warm ischemia 24 hours cold ischemia Success rates forreplantationdepend onischemiatime, degree of tissue damage, and mechanism of injury

41 Nail/Nailbed Injury Subungual Hematoma nail trephination alone for subungual hematoma of any size without nail plate disruption will suffice as treatment

42 Nail/Nailbedinjury Nail Bed Laceration Require nail plate removal and nail bed matrix repair

43 Summary Proper assessment and management of traumatic hand injuries is essential If not appropriately assessed and managed, traumatic hand injuries can have considerable long-term consequences for patients quality of life and function. Early recognition of injuries that require urgent or emergent referral to a hand surgeon is critical.

Exam of the Injured Hand and Wrist. Christina M. Ward, MD Regions Hospital TRIA Woodbury

Exam of the Injured Hand and Wrist Christina M. Ward, MD Regions Hospital TRIA Woodbury Disclosures We have no disclosures that are pertinent to this presentation Terminology Ring Long Index Small Thumb