General Data: Chief Complaint: History of the Present Illness: Case Presentation and Discussion on Extremity Trauma

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Myrtle Gardner
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1 Case Presentation and on Extremity Trauma General Data: By: Roderick S. Mujer MD. 2 nd year Resident Department of Surgery Ospital ng Maynila Medical Center M. P., 25- year- old, male from Tondo Manila. Chief Complaint: History of the Present Illness: Lacerated wound, right wrist Few minutes PTA accidentally slashed by a mirror thus sustained injury to his right wrist CONSULT

Past Medical History: No known history of Allergy Vaccinations unknown Physical Examination: Conscious, coherent, NICRD BP 100/70mmHg CR: 90bpm RR: 22cpm Temp: 37.

2 Past Medical History: No known history of Allergy Vaccinations unknown Physical Examination: Conscious, coherent, NICRD BP 100/70mmHg 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 Physical Examination: (+) Laceration (+) Exposed transected tendons (+) Arterial bleeding (+) Diminished distal pulses (+) Distal pallor (+) Inability to Flex wrist (+) Wrist extension Intact Sensory function No structural deformity

3 Salient Features 25-year-old, male (+) Laceration wrist, right (+) Exposed transected tendons (+) Arterial bleeding (+) Diminished distal pulses (+) Distal pallor (+) Inability to Flex Hand (+) Wrist extension Intact sensory function No structural deformity Algorithm Injured Extremity PE Extent of Injury Superficial Deep Skin Subcutaneous Neurovascular Muscle Tendon Clinical Diagnosis Paraclinical Diagnostic Procedure Do I need a paraclinical diagnostic Primary Secondary Diagnosis Lacerated wound with major vessel, and tendon Injury Lacerated wound with major vessel, tendon and nerve Injury Certainty 90% 10% Treatment Surgical Surgical procedure? NO

4 Goals of Treatment TREATMENT OPTIONS ( Vascular Injury) Control of bleeding Restore Function Repair tissue Integrity with strenght Primary Repair BENEFIT Restore function RISK THROMBOSIS COST 300 AVAILABILITY +++ Ligation SV graft Easy to perform Less tension Ischemia Thrombosis Gangrene THROMBOSIS rejection Infection Treatment Options ( Tendon Injury) BENEFIT RISK COST AVAILABILITY Plan of Operation Immediate repair Delayed Repair Early restoration of function Less chance to restore function Edema Infection Adhesion Scar tissue formation Re-operation Infection Available Available Wound Exploration Primary repair of tissues

5 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 Flexor carpi ulnaris 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 tansected tendons using 3-0 prolene suture Debridement Hemostasis checked

Intra- Operative Operation Done Washing with NSS Correct instrument, needle and sponge count Closure of the skin Dry sterile dressing Immobilization - splinting Wound Exploration Radial artery

6 Intra- Operative Operation Done Washing with NSS Correct instrument, needle and sponge count Closure of the skin Dry sterile dressing Immobilization - splinting Wound Exploration Radial artery anastomosis Repair of Ulnar Artery Tenorrhapy Final Diagnosis Lacerated wound wrist, right Complete transection radial artery Partial transection of ulnar artery Complete Transection of Flexor carpi radialis Fexor carpi ulnaris Palmaris Longus Post-operative Management Basic needs supplied Nutrition Antibiotics Analgesia Comfort

7 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 4 weeks post op - refer to rehabilitation medicine for active range of motion exercise Upper extremity injuries 30-40% of peripheral vascular injuries 15-20% of peripheral vascular traumas -ulnar and radial arteries Penetrating trauma -most common cause The greatest prevalence in urban areas, where aggressive acts of violence are the usual cause Upper extremity vascular injuries should be fully assessed for specific signs that suggest arterial injury (Allen Test)

8 3 layers of vessel wall Adventitia -Outer layer -connective tissue Media Central - smooth muscle and elastic fibers Intima inner layer - endothelial cell Classification of laceration Mild- less than 25% of vessel wall Moderate 25-50% Severe more than 50% 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 Arterial bleeding o Bruit

9 Equivocal or soft signs o Wound proximity to a major vessel o Small, stable hematoma o Nearby nerve injury o Shock that is not the result of other injuries 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 Relevant Anatomy: Superficial layer pronator teres- most radial flexor carpi radialis palmaris longus flexor carpi ulnaris Intermediate layer FDS Deep layer FDP FPL

10 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. 4 stages of healing mechanism: Hemostasis Inflammation Proliferation Remodeling REFERENCES 1. Neumeister, M. Flexor Tendon Laceration. Southern illinois School of Medicine, Bukata WR, Orban D, Newmeyer WL, Karkal S. Reducing pain and disability from common wrist injuries. Emerg Med Reports 1986; 7(18): 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: Mattox KL, ed. Trauma, 5th ed McGraw-Hill 6. Schwartz, Seymour. Principles of Surgery. 7th edition, Vol II: 1182 MCQ 1. A test used to evaluate arterial supply to the hand in patient with suspected Arterial Injury? a. Phalens Test b. Finklestein Maneuver c. Allen Test d. Tinel s Sign e. Two-Point Discrimination Test

11 MCQ 2. Presence of the following manifestation in peripheral vascular injury warrants surgical exploration except? a. Large expanding or pulsatile hematoma b. Ischemia c. Unexplained Hypotension 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 hours d. 16 hours e. 24 hours MCR 4. The following are involve in the healing mechanism of Flexor Tendon System 1. Hemostasis 2. Inflammation 3. Proliferation 4. Remodelling 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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General Data: Chief Complaint: History of the Present Illness: Case Presentation and Discussion on Extremity Trauma

General Data: Chief Complaint: History of the Present Illness: Case Presentation and Discussion on Extremity Trauma Case Presentation and Discussion on Extremity Trauma General Data: By: Roderick S. Mujer MD. 3 rd year Resident Department of Surgery Ospital ng Maynila Medical Center P.N., 48-year- old, male from Malacanang