Mangled upper extremity.pptx

Upper limb trauma

1. MANAGLED UPPER EXTREMITY Dr. Moeez Fatima R1 Plastic Surgery

2. D evastating injuries that involve multiple critical structures of the fingers, hand, arm, or any combination of the three and nearly always lead to significant disability, both directly and through their psychosocial impact. Definition

3. Preserve life Preserve tissue Preserve function Reconstruct and restore function of both the extremity and the patient CRITICAL POINTS Goals in Treating Upper Extremity Mangling Injuries

4. Careful and complete evaluation Reconstructive plan tailored to the patient’sneeds wound debridement Meticulous operative reconstruction Restoration of good vascularity Rigid skeletal Stable , vascularized soft tissue coverage Rehabilitation of the extremity and the patient Priniples

5. M ultispecialty team approach. Judgement T imings

6. Mangled Extremity Severity Score (MESS ). Hand Injury Severity Score (HISS) CLASSIFICATION

7. MECHANISMS AND PATHOPHYSIOLOGY OF INJURY

8. One wound - One scar concept. Mechanism of ischemia Tissue susceptibility of ischemia. Ischemia- Reperfusion Injury. Super-oxide radical accumulation. Accumulation of neutrophils. Extent of zone of injury.

9. ATLS Protocol. INITIAL EVALUATION

10. When ?? Where?? How?? Patient’s comorbidities. Fators affecting reconstructive plan. History

11. Vascular status: Clinical Doppler MRA/ Angiography. Examination

12. Compartment Syndrome

13. Skeletal Injury

14. Muscle–Tendon unit Injury

15. Sensory Motor 3main nerves: Median Ulnar Radial Nerve Injury

16. Motor: Resistance to palmar abduction of the thumb reflects median nerve-innervated abductor pollicis brevis function. Sensory: volar aspect of the index or middle finger. Median Nerve

17. Motor: Resistance to flexion of the metacarpophalangeal (MP) joint of the small finger reflects ulnar nerve–innervated flexor digiti quinti function. Sensory: the volar aspect of the small finger Ulnar Nerve

18. R esistance to extension of the MP joint of the index finger reflects radial nerve–innervated extensor digitorum communis and extensor indicis proprius function . T he dorsum of the first web space. Radial Nerve

19. CBC Electrolytes ABGs Toxicology screen Amylase Blood typing & Cross match Labortaory Investigations

20. GOALS OF TREATMENT: BIOMECHANICS OF THE INJURED HAND

21. 7 basic Functions of Hand

22. P recision pinch

23. Opposition pinch

24. key pinch

25. Chuck grip

26. Hook grip

27. Span grasp

28. Power grasp

29. 1 . An opposable thumb 2. The index and long 3 . The ring and small fingers. 4 . The wrist Basic units

30. Amputation/Skeletal Contribution

31. RECONSTRUCTION

32. HAND

33. JOINTS

34. DIP Joints of fingers / IP Joint of Thumb PIP Joints of Fingers. MP Joints Wrist Joint

35. Tendons

36. Lumbrical Plus Finger

37. Quadrigia

38. Soft Tissue Coverage & Nerves

39. Emergency Management

40. The trauma “ABCs”). Control hemorrhage by direct pressure—do not blindly clamp. Reduce gross skeletal deformity. Administer tetanus prophylaxis and antibiotics. For a ischemic major limb, place a temporary vascular shunt. Cool devascularized tissue. Leave any skin bridges intact.

41. Excise the wound. Marginally vascularized tissue, especially muscle. Save critical structures : Begin with a tourniquet; release and reinflate for further debridement. Tag nerves and arteries. gravity-assisted lavage Decide about replantation, amputation, partial amputation, or reconstruction Perform amputations as part of debridement. Save “spare parts” for later use in primary reconstruction. Debridement

42. Visualize the fracture. Restore length for optimal Accurate anatomic Minimally invasive fixation and begin early motion with fracture healing. • Radius/ulna: 3.5-mm limited-contact dynamic compression (LCDC) plate. panning plate to the second or third metacarpal with locking screws if severe comminution is present. Fixation of fractures of the wrist, use compression screws or Kirschner wires, repair or reconstruct ligaments, and stabilize with Kirschner wires. Metacarpals: miniplate fixation Maintain the first web space with an external fixator or thumb CMC pinning. For the phalanges, use a miniplate , Kirschner wires, or tension band wiring . For skeletal defects, decide between shortening, primary bone grafting, and placement of an antibiotic spacer with delayed bone BONE RECONSTRUCTION

43. Debride crushed intrinsic muscles to prevent contracture. Use four-core locking sutures plus a fine epitendinous suture if zone 2 is involved. Repair both the flexor digitorum superficialis and flexor digitorum profundus . Repair the A2 and A4 pulleys. For tendon rods use two-stage reconstruction if primary repair is not possible. Consider primary tenodesis /tendon transfer. For late reconstruction, tendon grafting, tendon transfer, tenolysis , and functional free muscle transfer may be needed Tendon Repair/Reconstruction