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Lu IV March2014 Combined Upper Ext and Hand trauma Cases

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Information about Lu IV March2014 Combined Upper Ext and Hand trauma Cases
Health & Medicine

Published on March 9, 2014

Author: docnats

Source: slideshare.net

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Sample Cases

The Good • Minimal intervention, Excellent Results

Pediatric Fractures • Elasticity – Incomplete fractures

Pediatric Fractures • Remodelling Potential

Pediatric Fractures

Clavicle Frctures

Clavicle Fractures

Clavicle Fractures • Indications o Open Injuries o Significant Articular dissociation o Displacement (?) o Impending Open (?) o Associated Injuries (?) o Academic Exercise (?!)

Humerus Fractures

Humerus Fractures

Humerus Fractures • Surgical Indications o Open fractures o Failed closed management o Pathologic fx o Vascular injury o Floating elbow o Head injuries o Multiple trauma o Proximity to joint/intra-articular fractures

Case • 17/M, R handed student, recently heart broken • allegedly tripped, landing on extended hand

(Not a)Boxer’s Fracture • Poor punch (usually to a hard object) • Volar angulation • Assess rotational deformity/pseudoclawing • Resting splint for comfort must move

Distal Radius Fractures • Fall on out-stretched hand (FOOSH) • One of the most common injuries seen in our clinics • Bi-modal distribution

Distal Radius Fractures • Proper evaluation o Associated injuries o Displacement o Stability • Lafontaine’s criteria o initial dorsal angulation > 20° o dorsal comminution o radiocarpal intraarticular involvement o associated ulna fractures o age > 60 years

Distal Radius Fractures • So many combinations of stabilization techniques • Determinant is initial stability of fracture and adequcy of reduction

Elderly • Low demand • Pre-existing arthritic pain • Poor bone quality for fixation (?)

The Bad • Outcome dependent on early and proper intervention

Case • 32F, R handed, housewife • Injured while cutting vegetables • Seen at ER o Wash o Shorten (if with exposed bone) o Suture

Fingertip Amputations • • • • Very common Very commonly mismanaged Bad complications (not just cosmesis) Common problem o Poor evaluation of injury

Fingertip Amputations • Plane • Tissue Involvement

Adequate Treatment • Reconstruct the tip • Repair/reconstruct the nailbed

Finger Injury • 16/M, R handed, student • Finger got caught in opponent’s shirt while playing basketball • Pull and Send Home?

Simple Dislocation? • Does direction matter?

Treat Soft Tissue • Allowable range/positions • Targeted immobilization Volar Dorsal

Simple Laceration? • 21/M, L Handed, Bartender • Bar fight

Fight Bite Injury • Dirty • Cover for E. corrodens • Treat as septic arthritis

Simple Fracture? • Obvious fracture, easy management?

Fractures + • …with radial head dislocation (Monteggia)

Fracture - Dislocation • 43/M, R handed, surgeon, fell from ~2 meters • Deformity • No open wound

Complex Fracture - Dislocation

Complex Fracture - Dislocation

Complex Fracture - Dislocation

Aftercare! • Fixation o Allow motion as early as possible Site Movement begun Complications Supracondylar 3 weeks Myositis ossificans, Volkmann’s ischaemic contracture T-& Y-shaped # of lower humerus As soft tissue recovery Mal-union permits Arthritis Condylar 2 weeks Non-union/mal-union Late ulnar palsy Radial head As soon as pain permits Stiffness Late OA Olecranon Immediately Stiff elbow

Functional Outcome

The Ugly • Even in the best hands, the results may be far from perfect

Thumb Amputation • 22M, R handed, IT specialist • Thumb of dominant hand caught in motorcycle chain

Replantation • Ischemia time o More muscles, less forgiving • Function is ALWAYS impaired • Down time may not be worth it

Replant: Indications • • • • • Pediatric Thumb Proximal Multiple digits Sharp mechanism

Preservation Principles o o o o Relative emergency Cool, don’t freeze Moisten, don’t soak Cold ischemia • 6 hours if with significant muscle • ~24 hours for fingers

Stable NO Limb Limb Stable? NO Threatened? YES Amputate! Reconstruct Revascularize NO YES Limb Function? YES NO Fix Bone/Muscle

Microvascular Surgery  Goal 1: Survival  Goal 2: Stability  Goal 3: Function

Thumb Amputation • 22M, R handed, IT specialist • Thumb of dominant hand caught in motorcycle chain

Shorten bone and close?  Goal 1: Limb Survival  Goal 2: Limb Stability • Goal 3: Function???

Thumb Reconstruction

Thumb • Unique mobility • 50 % of hand function • Difficult to replace even with the best prostheses

Open Injury • 53M, R handed, carpenter • Pinned between truck and motorcycle

Stable NO Limb Limb Stable? NO Threatened? YES Amputate! Reconstruct Revascularize NO YES Limb Function? YES NO Fix Bone/Muscle

Open Injury • Problem 1: Large open wound with injuries to blood vessels • Problem 2: Multiple fractures • Problem 3: Infected tendons and avulsed muscles

Initial Management  Goal 1: Survival!    o Anastomosis Prevent further damage Infection control Coverage  Goal 2: Stability • Goal 3: Function

Second look • Goal 1: Limb Survival!     Anastomosis Prevent further damage Infection control Coverage • Goal 2: Limb Stability • Goal 3: Function

Long-Term

Complex Trauma • 32/M, cop • Motorcycle crashed to a post • Came in ER with stable vital signs • Left upper extremity completely bruised and paralyzed

Complex Trauma • Problem 1: Vascular injury • Problem 2: Floating limb • Problem 3: Brachial Plexus Injury

Complex Trauma • Goal 1: Limb Survival • Goal 2: Limb Stability • Goal 3: Function

Complex Trauma  Survival Assured • Goal 2: Limb Stability • Goal 3: Function

Complex Trauma  Survival Assured  Limb Stable • Goal 3: Function

Reconstruction  Survival Assured  Limb Stable  Function o Not perfect but better than none

Really Bad Trauma • Goal 1: Survival?? • Goal 2: Stability • Goal 3: Function

Really Bad Complications  Survival Assured  Limb Stable • Goal 3: Function??

Management Algorithm Life Life NO NO Limb Limb Threatened? Threatened? YES YES Limb Limb Stable?? Stable NO NO Threatened? Threatened? Resucitate Resucitate YES YES Amputate! Reconstruct Revascularize Revascularize NO NO YES YES Limb Limb Function?? Function YES YES NO NO Fix Bone/Muscle Fix Bone/Muscle

Sometimes…

Prosthesis

What’s ahead? • Prosthesis

What’s ahead? • Medical Management o Medications to enhance, speed up tissue healing • Acute - Limb survival • Long-term - Nerve recovery o Studies on prolonging the lifespan of neuromuscular junction

Take Home UE injuries-significant effects on patients’ lives Proper and timely evaluation is important Treatment plans should have realistic expectations Treatment should focus not on what the patient needs (not the doctor wants) • Surgery is not always needed but those who will, should be treated appropriately • Aftercare modalities are just as important as the first part of treatment. • • • •

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