Case Management, Presentation, Discussion and Sharing of Information on Trauma of the Extremities
Robelle Joan A.
Peralta, M.D.
General Data
R.C.
66-year-old
male
Bacoor,
Cavite
Chief Complaint: Lacerated wound, palmar
aspect, hand, right
History Of Present Illness
NOI: Blast Injury without amputation
TOI: 10:45 P.M.
DOI: January 31, 2008
POI: Trece, Martires, Cavite
1 day PTC - the patient lighted
a fire cracker that suddenly exploded in his hand which lead him to consult.
Primary Survey
Secondary Survey
GEN
SURVEY: awake, conscious, coherent, ambulatory
VITAL
SIGNS: BP: 140/80 CR: 98 RR: 21
SHEENT: Warm, moist skin, pink palpebral conjuntiva, anicteric sclera, no NAD, no CLAD
CHEST: Symmetrical chest expansion, no retractions, clear breath sounds
CARDIAC: Adynamic precordium, normal rate, regular rhythm, no murmur
ABDOMEN: Flabby, normoactive bowel sounds, soft, nontender
EXTREMITIES: lacerated wound, palmar aspect, hand, right, soft tissue swelling, dorsal aspect,
hand, right, no cyanosis of the nail beds, no active bleeding, full and equal pulses, no motor and sensory deficits
Salient Features
Lacerated
wound, palmar aspect, hand, right
Soft
Tissue Swelling, dorsal aspect, hand, right
No
cyanosis of the nailbeds
Full
and equal pulses
No
active bleeding
No
motor and sensory deficits
Lacerated wound, palmar aspect, hand
Primary
Impression
Lacerated
Wound, palmar aspect, hand, right
T/c
fracture, hand, right
Do I need a paraclinical diagnostic
procedure?
Yes
Hand APL: Incomplete, non displaced fracture, 3rd
and 4th, proximal third, metacarpals, hand, right
Pre-treatment Diagnosis
Goals of Treatment
Decrease the incidence of infection
Maintain function
Treatment Options
Plan Of Operation
Debridement with external fixature
Pre operative Preparation
Informed consent - carefully plan and 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
Intraoperative
Patient placed supine with right arm extended
Area prepared, Asepsis and antisepsis technique
Sterile drapes placed
Irrigation
Intraoperative
Operation Done
Final Diagnosis
Lacerated
wound, Palmar aspect, Hand, right
Incomplete,
non displaced fracture, 3rd and 4th, proximal third, metacarpals, hand, right
Post – operative management
Maintain dorsal splint at 30º wrist flexion
Proper monitoring of limb perfusion
Elevate affected extremity
Wound checked
Continue medications at home
Continue daily wound care
For rehabilitation after the wound has completely healed
Follow up plan
6 weeks post op- refer to rehabilitation medicine for active range of motion
exercise
Discussion
Upper extremity injuries constitute 30-40% of peripheral vascular injuries.
Brachial artery injuries are the most common (20-30%).
Injuries to the ulnar and radial arteries comprise 15-20%.
Patients presenting to the emergency department with upper extremity vascular
injuries are fully assessed for specific signs that suggest arterial injury, as follows:
Hard signs
Diminished
or absent pulses
Ischemia
Pulsatile
or expanding hematoma
Arterial
bleeding
Bruit
Equivocal or soft signs
Wound
proximity to a major vessel
Small,
stable hematoma
Nearby
nerve injury
Shock
that is not the result of other injuries
The presence of hard signs is almost always indicative of an underlying arterial injury and requires
immediate operative exploration and repair.
Patients presenting with soft signs of arterial injury usually undergo further evaluation.
The history and physical examination are the basis for diagnosing vascular injury.
Questioning should be directed about the injury, its location, its mechanism, the symptoms of vascular
or nerve impairment, and the amount of blood loss.
Upper extremity vascular injuries require early surgical treatment to minimize the risk of developing
limb ischemia and to regain adequate extremity function.
Critical time for restoration of perfusion is 6-8 hours following extremity vascular trauma.
Complications
Occlusion and bleeding from thrombosis
Muscle edema
Nerve injury causing motor or sensory deficits
Tissue death and necrosis
Infection
Questions
1. The following are hard signs except
A. Diminished or absent pulses
B. Ischemia
C. Pulsatile or expanding hematoma
D. Arterial bleeding
E. Bruit
2. In patients presenting will soft signs the appropriate
management includes the following except
A. Operative Exploration and repair
B. Observation
C. Both
3. The critical time for restoration of perfusion following extremity vascular trauma is
A. 1-2 hours
B. 2-4 hours
C. 4-6 hours
D. 6-8 hours
References
1.
Schwartz, Seymour. Principles of Surgery. 7th edition, Vol II: 1182
2.
Nadeem Chaudhry, MD Hand, Upper Extremity Vascular Injury, November 23, 2003
3. Management of Complex Extremity Trauma; American College of Surgeons Committee on
Trauma; 2005
4. John T. Owings, M.D., F.A.C.S; Injuries to the Extremities: Assessment and Management
of Extremity Injuries; 2002
THANK YOU.
