JOURNAL READING HAND_MANGLED UPPER EXTREMITY.pptx

ppt on mangled hand

1. MANAGEMENT OF THE MANGLED UPPER EXTREMITY A CRITICAL ANALYSIS REVIEW HAND DIVISION PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY STUDY PROGRAM UDAYANA UNIVERSITY/ PROF DR I.G.N.G NGOERAH HOSPITAL JOURNAL READING

2. Combined injury involving 3 of the 4 tissues: vascular, nervous, soft tissue and bone Causes: falls from a height, MV collisions , industrial machinery, firearms, / explosions). Past 20 years, 30 scientific mangled upper extremity articles  decision for amputation. Despite advance modern prosthetic technology  salvage hand’s prehensile & sensory function  improve QoL  outperform prosthesis. This review  overview of limb salvage for mangled upper extremity & critical analysis review of key evidence & controversies.

3. INITIAL RESUSCITATION & VASCULAR INJURY Principle: “No single limb is worth a person’s life”. First priority  ABC (ATLS). C.ABC (C=catastrophic hemorrhage)  Battlefield ATLS (BATLS)  mangled upper extremity is top priority

4. INITIAL RESUSCITATION AND VASCULAR INJURY Bleeding control  direct pressure/ pressure dressing. Tourniquets  military combat & mass-casualty events (multiple sites, austere environment)  appropriate use & careful timing (avoid nerve injury & ischemic complications) Large retrospective studies  safe prehospital tourniquet, low rate tourniquet-associated complications. Overtightening is avoided & 2 hours ischemia times. Clamping of vessels should be avoided (poor visibility & damage adjacent nerves)

5. INITIAL RESUSCITATION AND VASCULAR INJURY Warm ischemia time > 4 - 6 hours  ↑ infection & muscle death. ↑ time without reversal of vascular compromise  compartment syndrome, progressive neurological impairment, & limb loss. Acute vascular compromise of the limb  quick operative exploration & intervention Revascularization  direct repair, vascular reconstruction/ temporary shunt. Ischemic limbs >4 hours  prophylactic fasciotomies

6. INFECTION PREVENTION AND DEBRIDEMENT mangled limb  irrigated, dressed, realigned, & splinted. Surgical debridement < 24 hours (well-perfused limb). “window of 8 hours”  no consistent superiority in human /animal studies. Weber et al. (prospective cohort, 736 patients)  same infection rate when initial debridement happened >8 hours after injury : 24 hours.

7. Eastern Association for the Surgery of Trauma (EAST)  Gram(+) systemic ASAP after injury + Gram(-) for Gustilo Anderson type-III open injuries. Piperacillin & tazobactam  similar ↓ infection , alternative for patients with allergies / contraindications to cefazolin plus gentamicin. Animal study  ↑ infection rates if antibiotics were delayed >2 hours. Retrospective clinical study (137 patients OF )  ↑ infection rates if >1 h. INFECTION PREVENTION & DEBRIDEMENT

8. Tourniquet  facilitate visualization of key structures & avoid iatrogenic injury Nonviable, nonfunctional, or grossly contaminated tissues should all be removed. Fingers with multilevel & multisystem injuries require amputation. Muscle viability may be tested via contractility. Excisional debridement should include removal of devitalized bone Preserve nerves & vessels INFECTION PREVENTION AND DEBRIDEMENT

9. Highpressure irrigation causes osseous & soft-tissue damage & drives contaminants & bacteria into tissues.

10. After a satisfactory initial debridement, antibiotics may be discontinued Dellinger et al. ( double-blind RCT 248 OF patients)  24 hours / 5 days of antibiotics  no significant difference in infection rates. (heterogeneity makes generalizations difficult). INFECTION PREVENTION AND DEBRIDEMENT

11. ACUTE AMPUTATION COMPARED WITH SALVAGE “the arm is progressively more valuable from shoulder to fingers; the leg, on the contrary, is progressively of less significance.” (Malt & McKhann - first successful arm replant) Often , salvage of a portion of the hand & upper extremity will be superior functionally to a prosthetic replacement alone.

12. The Mangled Extremity Severity Score (MESS )-(Johansen-1990) Used retrospective review to define 4 factors (skeletal & soft-tissue injury, ischemia, shock, & age). ≥7  amputation  generalized to the upper limb. ACUTE AMPUTATION COMPARED WITH SALVAGE

13. Management  individualized. Non salvageable injuries (bones , nerves, & vessels over a large zone of injury), unstable for prolonged procedures  amputation. Decide salvage  establish adequate vascularity, remove devitalized tissue & perform skeletal stabilization. ACUTE AMPUTATION COMPARED WITH SALVAGE

14. SKELETAL STABILIZATION If initial definitive fixation infeasible  external fixation. External fixation 50 % nonunion , used as a bridge to internal fixation. External fixation for large osseous defect of the forearm When severe comminution of distal part of the radius is present, dorsal spanning plate fixation outcomes = non-spanning

15. Grossly contaminated OF should avoid immediate fixation was refuted by multiple studies; Wei et al.  definitive fixation at the initial operation, did not ↑ risk of deep infection (adequate debridement ). Early fixation allows immediate reconstruction & use of nonreconstructible elements. (Tissue is scavenged from parts that will be discarded). Avoid grossly exposed implants  prevent colonization. When soft tissues are unable to be primarily closed over the implant  NPWT SKELETAL STABILIZATION

16. SOFT-TISSUE COVERAGE Soft-tissue coverage  major obstacle in the management of the mangled upper extremity  NPWT RCT in pigs  after 4 days NPWT  ↓ bacterial counts 2 weeks RCT in 54 patients  NPWT ↓ deep infection in OF (28 % - 5.4 % ( p=0.024)) Extended time until definitive closure > 7 days ↓ benefit therapy. NPWT does not change surface area requiring soft-tissue coverage, but ↓ tissue edema, ↑blood supply, ↑formation of granulation tissue

17. Gustilo et al.  leaving wound open 5-7 days, with serial debridements . Lister&Scheker  emergency free flaps within 24 hours of injury, (29 of 31 survive) Hou et al.  32 patients delay in coverage of > 7 days ↑infection rates Wei et al.  80 patients type-IIIA & IIIB tibial fr  no significant difference Godina  ↓ complications with early flap coverage Coverage between 6 & 21 days is the ideal timing Derderian et al. (133 retrospective patients)  ↑failure flap coverage within 6 days (9% : 3 %; p<0.05 ) & ↑infection ( p<0.05). Most authors suggested coverage 3 & 14 days after the injury; SOFT-TISSUE COVERAGE

18. No bone / tendon is exposed & soft tissue bed is amenable for a skin graft. F lap reconstruction  cover exposed implant, tendon, &/ nerve. Local muscle flaps, ( brachioradialis / flexor carpi ulnaris ) cover small defects, & local / regional perforator flaps  avoid sacrifice of a major artery in context of compromised vascularity of a mangled upper extremity. Local tissue not available  pedicled flaps from trunk require no microsurgical techniques & can cover defects up to 30 x 15 cm. However, period of immobilization between flap inset & division can mean delay in therapies. Free flaps, technically more demanding, offer advantage of being a single stage. Flap options  Patient preferences, body habitus, & other injuries, surgeon’s experience & comfort SOFT-TISSUE COVERAGE

19. RECONSTRUCTION OF NERVE, TENDON, AND BONE Nerve & tendon reconstruction is determined by the ability to achieve tension-free nerve coaptation &/ direct tendon repair at the time of the initial operation. Free innervated gracilis  finger flexion / extension when insufficient donor muscles for tendon transfer, bipolar latissimus flap may be used to restore elbow flexion. Finger pollicization / toe transfers  r ecreate a thumb. Bilateral upper-extremity amputations  hand transplantation

20. REHABILITATION AND PSYCHOLOGICAL SUPPORT Despite best salvage & reconstructive efforts, some patients will require amputation Maintaining passive ROM throughout reconstructive process ensures nerve / tendon transfers have best chance of success. Early active ROM should be initiated where possible to prevent tendon adhesions. PTSD & depression may require psychiatrist evaluation, CBT, focused rehabilitation & group therapy

21. CONCLUSIONS Highly individualized approach. Initial management, debridement, & provisional fixation have important impact on the final reconstruction. Prehospital tourniquets is safe as long as early deflation & control of hemorrhage surgically / with pressure dressings occur within 2 hours. Antibiotics initiation & timely surgical debridement within 24 hours. Strong evidence supporting lavage fluids without additives & no evidence high-pressure / pulsatile lavage improves outcomes. If debridement is adequate, early fixation of fractures is safe. Early soft-tissue coverage (24 hours & 1 month) Secondary reconstruction should be tailored to the patient’s injury and needs.

22. THANK YOU