Plastic Surgery Emergencies Principles and Techniques Second Edition Jam al M. Bu llock s, MD, FACS Ch ief Plast ic Su rger y Dep ar t m en t Kelsey-Sybold Clin ic Clin ical Assistan t Professor Division of Plast ic Surger y Baylor College of Medicin e Hou ston , Texas, USA Pat r ick W. Hsu , MD, FACS Private Pract ice Mem orial Plast ic Su rger y Hou ston , Texas, USA Sh ayan A. Izad d oost , MD, Ph D, FACS Ch ief of Plast ic Su rger y Ben Taub Hospit al Associate Professor of Su rger y Baylor College of Medicin e Program Director In tegrated Residen cy in Plast ic an d Recon st ruct ive Su rger y Associate Professor of Molecu lar an d Cellular Biology Baylor College of Medicin e Hou ston , Texas, USA Lar r y H. Hollier, Jr., MD, FACS, FAAP Ch ief Plast ic Su rger y Ser vice Texas Ch ildren’s Hosp ital Ch ief of Plast ic Su rger y Baylor College of Medicin e Baron Hardy Ch air an d Professor Plast ic Su rger y an d Pediat rics an d Or th opedics Baylor College of Medicin e Hou ston , Texas, USA ERRNVPHGLFRVRUJ 150 illu st rat ion s Th iem e New York • St u t tgar t • Delh i • Rio de Jan eiro Execu t ive Editor: Tim othy Hiscock Man aging Ed itor: Elizabeth Palu m bo Director, Ed itorial Ser vices: Mar y Jo Casey Product ion Editor: Torsten Sch eihagen In tern at ion al Produ ct ion Director: An dreas Schaber t In tern at ion al Market ing Director: Fion a Hen derson In tern at ion al Sales Director: Lou isa Tu rrell Director of Sales, Nor th Am erica: Mike Rosem an Sen ior Vice Presiden t an d Ch ief Op erat ing Officer: Sarah Van derbilt Presiden t: Brian D. Scan lan Library o f Co ngress Catalo ging-in-Publicatio n Data Nam es: Bu llocks, Jam al M., au th or. Title: Plast ic su rger y em ergen cies / Jam al M. Bu llocks, MD, FACS, Ch ief, Plast ic Surger y Depar t m en t , Kelsey-Seybold Clin ic, Clin ical Assist an t Professor, Division of Plast ic Surger y, Baylor College of Medicin e, Houston , TX [and th ree oth ers]. Descript ion : Secon d ed it ion . | New York, NY : Th iem e Medical Pu blish ers, In c., [2016] | Revision of: Plast ic su rger y em ergencies / Jam al M. Bullocks ... [et al.]. c2008. Id en t ifiers: LCCN 2016016016 (p rin t) | LCCN 2016016879 (ebook) | ISBN 9781626231153 (prin t) | ISBN 9781626231160 (eISBN) | ISBN 9781626231160 (e-book) Su bject s: LCSH: Su rger y, Plast ic. | Surgical em ergencies. Classificat ion : LCC RD118 .P5363 2016 (p rin t) | LCC RD118 (ebook) | DDC 617.9/52--dc23 LC record available at h t t p s://lccn .loc.gov/2016016016 © 2017 Th iem e Medical Publish ers, In c. Im p or t an t n ote: Medicine is an ever-changing scien ce un dergoing con tin ual developm en t. Research an d clin ical exp erien ce are con t in u ally expan ding ou r kn ow ledge, in part icu lar ou r kn ow ledge of proper treatm ent and drug th erapy. Insofar as this book m ent ions any dosage or applicat ion, readers m ay rest assured that the authors, editors, and publishers h ave m ade ever y effor t to ensure that su ch referen ces are in accordan ce w ith t h e st ate of k n ow ledge at t h e t im e of p rod u ct ion of th e book. Neverth eless, this does n ot involve, im ply, or express any gu aran tee or respon sibilit y on th e par t of the publishers in respect to any dosage instruct ions and form s of applications stated in the book. Ever y u ser is requ ested to exam in e carefu lly the m anufact urers’ leaflets accom panying each drug an d to ch eck, if n ecessar y in con su ltat ion w ith a physician or specialist, w hether the dosage schedules m entioned therein or the cont raindications stated by the m anufact urers differ from the statem ents m ade in the present book. Such exam ination is par ticularly im portant w ith drugs that are either rarely used or h ave been n ew ly released on th e m arket. Ever y dosage sch edu le or ever y form of application used is ent irely at the user’s ow n risk an d respon sibilit y. Th e au th ors an d pu blish ers requ est ever y u ser to report to th e publishers any discrepan cies or in accu racies n ot iced. If errors in this w ork are fou n d after publication, errata w ill be posted at w w w.thiem e. com on the product descript ion p age. 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Nilo Peçan h a, 50 – Sala 2508 Rio de Jan eiro 20020-906, Brasil +55 21 3172-2297 / +55 21 3172-1896 Cover design : Thiem e Pu blish ing Group Typeset t ing by DiTech Process Solut ion s Prin ted in In dia by Replika Press Pvt . Ltd. ISBN 978-1-62623-115-3 Also available as an e-book: eISBN 978-1-62623-116-0 54321 This book, in clu ding all p ar t s th ereof, is legally protected by copyrigh t . Any use, exploit at ion, or com m ercializat ion ou t sid e th e n arrow lim it s set by copyrigh t legislat ion , w ith ou t th e pu blish er’s con sen t , is illegal an d liable to p rosecu t ion . Th is applies in par t icular to ph otostat reproduct ion , copying, m im eograp h ing, preparat ion of m icrofilm s, and elect ronic data processing an d storage. It is w ith great pleasure that I dedicate the new est edit ion of our text to our senior author, Dr. Sam uel Stal. Sam died several years ago after a lengthy illness. He w ould have been m ost pleased to see that this w ork has stood the test of t im e. Sam w as a surgeon w ho dedicated his life to the t reat m ent of children. He w as passionate about teaching and passing on all that he had learned through the years. He w as a m entor to all of us w ho w orked w ith him on this book and he w as inst rum ental in seeing the first edit ion through to publicat ion. I know that I can speak for all of m y coauthors, and thank Sam for being the person that he w as—an excellent teacher, but first and forem ost, a k indhearted and caring m an. —Larry H. Hollier, MD Contents 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Forew ord ........................................................................................................... Preface ............................................................................................................... Ack n ow ledgm en t s .......................................................................................... List of Ab b reviat ion s ...................................................................................... ix xi xi xiii Wou n d Man agem en t ..................................................................................... An est h esia an d Wou n d Closu re .................................................................. Pressu re Sores .................................................................................................. Bit e Wou n d s ..................................................................................................... Bu r n s an d Frost b ite ........................................................................................ Gen eral Assessm en t an d Man agem en t of Facial Trau m a .................... Facial Lacerat ion s ........................................................................................... Or b it an d Zygom a Fract u res ........................................................................ Nasal an d Naso -Or b it al-Et h m oid (NOE) Fract u res ................................ Fron t al Sin u s Fract u res ................................................................................. Man d ib u lar Fract u res .................................................................................... Exam in at ion of Han d In ju r ies ..................................................................... An est h esia an d Sp lin t in g of t h e Han d an d Wr ist ................................... Han d an d Wr ist Fract u res an d Dislocat ion s ............................................ Han d In fect ion s an d In ject ion In ju r ies ..................................................... Han d an d Forear m Ten d on In ju r ies ........................................................... Han d Vascu lar In ju r ies an d Digit Am p u t at ion s ...................................... Up p er Ext rem it y Per ip h eral Ner ve In ju r ies ............................................ Up p er Ext rem it y Com p ar t m en t Syn d rom e ............................................. Postop erat ive Evalu at ion of Free Flap Recon st r u ct ion s ....................... Th e Postop erat ive Aest h et ic Pat ien t .......................................................... Ster n al Wou n d s ............................................................................................... 1 8 16 20 32 63 76 88 99 109 114 126 138 148 174 196 207 217 222 229 238 252 In d ex .................................................................................................................. 256 ERRNVPHGLFRVRUJ vii ERRNVPHGLFRVRUJ Forew ord from the First Edition “Th e m an w h o gradu ates today an d stops learn ing tom orrow is un edu cated th e day after.” —New ton D. Baker Jr. W hen I w as asked to w rite a foreword for this book Plastic Surgery Em ergencies, I m ust confess, m y first thought was, “Is anoth er book truly necessary?” But after reading it , I am both h onored and flat tered by th e request . The brow ser m ight first question if th is relatively sm all book fulfills a need, an d second ask if it fulfills the need well. The answer to both questions is a resoun ding “Yes.” With the body of m edical know ledge doubling every 5 years or so, th e in form at ion that m ust eith er have been learned or be readily available and understandable to both the young as well as th e experienced plast ic surgeon continues to increase exponentially. This book distills presen t know ledge into an easily readable guide to alm ost any em ergency a plastic surgeon m ight face w ho is on call in the em ergency room , or responding to a late-night/early-m orning call from the hospital relating to a postoperative patien t. Th e au th ors, w h o are gen eral p last ic su rgeon s an d specialist s from th e Division of Plast ic Surger y h ere at t h e Baylor College of Medicin e, h ave cu lled in form at ion from th eir ow n su rgical exp erien ces, as w ell as a w id e variet y of ou t side sou rces. Th ey h ave con den sed th is kn ow ledge in to a sm all, h an dy volu m e, w h ich cou ld easily be read eit h er at on e’s leisu re or im m ediately prior to assu m ing th e care of a p at ien t . It w ou ld be difficult to fin d an injur y or com plicat ion from a plast ic su rger y operat ion w hose em ergen cy t reat m en t is n ot covered in th is book. Th e aut hors h ave det ailed th e specifics in term s of differen t ial diagn osis an d th e correct ive steps n ecessar y to fu lfill th e respon sibilit ies of a plast ic su rgeon an sw e- ring em ergen cy room call. Th ere are m any referen ces to th e gen eral prin ciples of t reat m ent s—th ose learn ed in residen cy t rain ing an d in th e early years of p ract ice th at h ave stood th e test of t im e. Th e abilit y of t h e surgeon to presen t an organ ized t reat m en t plan an d th en carr y it ou t exp ed it iou sly w ill in st ill con fiden ce in th e pat ien t an d th e h ealth care person n el involved in t h e t reat m en t of th ese p at ien t s. Th e form at of th e book is con du cive to allow ing readers to add both person al an d tech n ical notes, w h ich w ill ser ve th em w ell in th e t reat m en t of fut u re pat ien t s w ith sim ilar injuries. I w ou ld be rem iss if I did n’t call sp ecial at ten t ion to t he lead au th or, Dr. Jam al M. Bullocks, w h ose abilit y an d you t h fu l en th u siasm h as am algam ated th e th ough t s an d exp erien ce of th e oth er auth ors in to a volum e th at w ill fin d great valu e for all plast ic su rgeon s as w ell as gen eral su rgeon s an d em ergen cy room physician s. To those older plast ic surgeon s w h o m ay believe that they have already learned the an swers to m ost of the problem s presen ting to th e plastic surgeon on call, I respectfully suggest that although the problem s that presented a decade or t wo ago m ay be the sam e, the answers (i.e., treatm ent) today m ay be different. It is to that difference that we are indebted to the authors of this book for their effort and tim e in providing us w ith concise an d practical an swers. ERRNVPHGLFRVRUJ Melvin Spira, MD, DDS Division of Plast ic Surgery Depart m ent of Surgery Baylor College of Medicine ix ERRNVPHGLFRVRUJ Preface Th e goal in creat ing Plast ic Surgery Em ergencies is to provide a quick referen ce gu id e for h ealth care p roviders to rapid ly assess, t riage, an d t reat pat ient s w ith problem s th at are com m on ly referred to th e p last ic su rgeon . Th e first version t argeted acu te care scen arios com m on ly seen in th e em ergen cy dep ar tm en t of acutely injured facial and han d t raum a pat ien t s, as w ell as pat ien t s sust ain ing a variet y of soft-t issu e inju ries from var ying m ech anism s of t raum a, in cluding burn s. Th is n ew ed it ion provides th e reader w ith addit ion al con ten t , in cluding added chapters, p h otos, an d sect ion s w h ich w ill expan d th e book’s audience to out pat ien t an d h ospit albased physician s caring for ch ron ically ill p at ien t s w ith w ou n ds. Th e in form at ion presen ted w ill prove sign ificant ly ben eficial to p last ic su rgeon s, otolar yngologist s, derm atologist s, p ediat rician s, fam ily p ract ice, an d h ospit alist an d em ergen cy room p hysician s for t reat ing an d t riaging p at ien t s in th e acu te an d ch ron ic disease set t ing. Ult im ately, th e aim is to d em yst ify sim p le p roblem s th at p resen t to th ese providers an d elu cidate scen arios th at require a h igh er level of care or follow -u p w it h a p last ic su rgeon . Ou r in ten ded au dien ce addit ion ally exten ds to residen t s an d st u den t s t rain ing in th ese fields w h o exp erien ce th ese en cou n ters as con sult at ion s an d du ring on -call act ivit y. Th e out line form at w as preser ved w ith t run cated in t roductor y vern acular to con fer direct m ech an ism s for in st ruct ion s on h ow to w ork u p, categorize, an d in it iate th e first level of t reat m en t . We h ope th at th is focused an d sim p lified p resen t at ion w ith in st r u ct ive illust rat ion s, ch ar t s, an d diagram s w ill provid e a single-sou rce referen ce in a conven ient pocket-sized form at . Acknow ledgments Plast ic Surgery Em ergencies is a collection of the collaborative kn ow ledge and experien ce of all th e affiliated and full-tim e facult y of the Division of Plastic Surgery in the Mich ael E. Debakey Departm ent of Surger y at Baylor College of Medicine. The authors would also like to express th eir gratit ude to the residents, staff, and institut ions of the Texas Medical Center for th eir support in the com pletion of this work. Illustrato r: Mike d e la Flor Cover Illustrato r: Cara Ryan Dow n ey, MD ERRNVPHGLFRVRUJ xi ERRNVPHGLFRVRUJ List of Abbreviations 3D ABCs ABGs ACON ACS AFib AP APB APD APL APTT ASA BP BSA BSAB CBC Ch em -7 CK CMC CML CN COPD CRP CSF C-spin e CT CVP CXR D5 1/2NS DIC DIEAP DIP DISI DJD DRU DVT EBL ECRB ECRL ECU EDC EDM EIP EMG EMLA ENoG ENT EPB EPL ER ESR FCR FCU FDA FDM FDP FDS FFP FPB FPL th ree-dim en sion al air w ay, breathing, and circu lat ion ar terial blood gases acute com pressive opt ic n europ athy abdom inal com par t m en t syn drom e at rial fibrillat ion an teroposterior abdu ctor pollicis brevis afferen t p upillar y defect abdu ctor pollicis longu s act ivated PTT asp irin blood p ressure body surface area body surface area burn ed com p lete blood coun t a basic m et abolic pan el creat in e kin ase carpom et acarp al carpom et acarp al ligam ent cran ial ner ve ch ronic obst ruct ive pu lm onar y disease C-react ive protein cerebrospin al fluid cer vical spin e com p uted tom ography cen t ral venou s pressure ch est X-ray 5% dext rose in 0.45% n orm al saline dissem in ated in t ravascu lar coagu lat ion deep in fer ior ep igast ric ar ter y perforator flap dist al interp halangeal dorsal in tercalated segm ent in st abilit y degen erat ive join t disease dist al radiouln ar deep venous throm bosis est im ated blood loss exten sor carpi rad ialis brevis exten sor carpi rad ialis longus exten sor carpi ulnar is exten sor d igitor um com m u n is exten sor digit i m in im i exten sor in dicis p roprius elect rom yogram eu tect ic m ixt u re of local an esth et ics elect ron euron ography ear, n ose, an d th roat extensor pollicis brevis exten sor p ollicis longus em ergen cy room er yth rocyte sedim ent at ion rate (or sed rate) flexor carpi radialis flexor carpi uln aris Food an d Drug Adm inist rat ion flexor digit i m inim i flexor d igitor um profu ndus flexor d igitor um sup erficialis fresh frozen plasm a flexor pollicis brevis flexor pollicis longu s ERRNVPHGLFRVRUJ xiii GCS Hct HDCV Hgb I&D ICU IM INR I/Os IP IRV IV IVF JP JVD LDH LET LFT LR MAP MCP MMF MRI MRSA MVA NCS NOE NPO NS NSAID OOB OR ORIF OTC PA PDS PEEP PIP PL PNM POD PRBCs PT PTT RBBB RBC RIG ROM RR SBP SC SCM SSEP SMAS SOF STAT TBSA Tc 99m MDP Td TFCC TIG TMJ TON TPA xiv Glasgow Com a Scale hem atocrit hu m an diploid cell rabies vaccin e hem oglobin incision an d d rain age in ten sive care unit int ram uscu lar or in t ram u scularly in tern at ion al nor m alized rat io in t akes/ou t p u ts in ter ph alangeal inverse rat io ven t ilat ion int ravenou s or in t raven ou sly int ravenou s fluid Jackson -Prat t jugu lar ven ous distent ion L-lactate d ehydrogen ase lidocain e-epin eph rin e-tet racain e liver fun ct ion test lactated Ringer's m ean ar terial pressure m et acarp op h alangeal m axillom an dibu lar fixat ion m agn et ic reson an ce im aging m eth icillin -resistan t Staphylococcus aureus m otor vehicle accid en t n er ve con du ct ion st udies n aso-orbit al-eth m oid noth ing by m outh norm al salin e n on steroidal an t i-in flam m ator y drug ou t of bed operat ing room op en red uct ion and inter nal fixat ion over-the-counter posteroan terior polyd ioxan on e sut ure posit ive en d-exp irator y pressure proxim al in terph alangeal palm aris longu s polyn uclear m on ocyte postop erat ive day packed red blood cells proth rom bin t im e p ar t ial throm boplast in t im e righ t bun dle bran ch block red blood cell rabies im m un oglobulin range of m ot ion respirator y rate systolic blood pressu re su bcut an eous or su bcu tan eou sly stern ocleidom astoid som atosen sor y evoked poten t ial su perficial m uscu loaponeu rot ic system su perior orbit al fissure at on ce, im m ediately total body su rface area tech n et ium 99m m ethylen e d isph osph on ate tetanus toxoid t riangular fibrocart ilage com plex tetanus im m unoglobulin tem porom an dibular joint t rau m at ic opt ic n europ athy t issue plasm in ogen act ivator ERRNVPHGLFRVRUJ TPN TRAM TSST-1 UC VDR VISI W BC ZMC tot al paren teral nu t rit ion t ran sverse rect u s abdom inis m yocut an eou s flap toxic sh ock syn drom e toxin -1 ulcerat ive colit is volu m e diffusive respirator volar in tercalated segm en t in st abilit y w h ite blood cell zygom at icom axillar y com plex ERRNVPHGLFRVRUJ xv ERRNVPHGLFRVRUJ 1 Wound Management Evaluation Accurate assessm ent of the ch aracteristics of an d circum stan ces surroun ding th e presentation of w oun ds is critical to guiding treatm en t strategies. Th erefore, before w ound m an agem ent is plan ned, a full evaluation of th e w oun d m ust be undertaken w ith the follow ing con siderations. Acute Wounds • Assess size, sh ape, an d locat ion . • Determ in e th e t im ing of th e w ou n d—acu te (t im e elap sed sin ce injur y) versu s ch ron ic (persisten t > 3 m on th s). • Est ablish lacerat ion , avu lsion , or ch ron ic open w ou n d. • Evaluate th e w ou n d for odor, exu date, p u ru len t drain age, bleeding, an d debris. • Determ in e if th ere is exp osu re of vessels, ten don s, n er ves, join t , m uscle, or bon e. • Evaluate for foreign bodies in th e w ou n d; con sider X-ray evaluat ion —if th e h istor y is in con sisten t w ith clin ical evaluat ion . Chronic Wounds Ch ron ic w oun ds require invest igat ion in to reason s w hy proper w oun d h ealing is n ot accom plish ed (Table 1.1). Th erefore, ch ron ic w ou n ds w arran t serologic evalu at ion to in clu de • • • • • • • • • • W h ite blood cou n t . Hct/Hgb. Albu m in . Prealbu m in . ESR, or sed rate. C-react ive p rotein . LFTs, h ep at it is p an el. Blood glu cose. Biopsy of w ou n d. Cult u re of w oun d. 1 ERRNVPHGLFRVRUJ 2 Wound Managem ent Table 1.1 Contributors to poor wound healing Local factors that contribute to poor w ound healing Patient comorbid conditions that contribute to poor w ound healing Tissue ischem ia Venous hypertension Edem a Infection Microbial contam ination Bacterial > 10 5 or 10 4 group B Streptococcus species Fungus At ypical mycobacteria Anem ia Hypoxia Advanced age Malignancy Poor nutrition Vitam in de ciencies History of radiation Severe system ic disease (e.g., diabetes, hepatic disease) Collagen vascular diseases Wound tension or pressure > 30 m m Hg Presence of foreign bodies Im m unosuppression Smoking Obesit y Treatment Irrigation Acute Wounds Irrigat ion in th e acu te w ou n d set t ing is design ed to rem ove blood, foreign bodies, debris, an d bacteria from a w oun d. Th is can easily be accom plish ed w ith a 1-L bot tle of n orm al salin e w ith t w o or th ree h oles pu n ch ed in to th e cap w ith an 18-gauge n eedle. W h en squ eezed forcefully, it ser ves as an e ect ive pressu rized irrigator. Th e w oun d sh ould be irrigated u n t il all visible debris is w ash ed aw ay. An esth et izing th e w ou n d p rior to irrigat ion an d débridem en t p rovides for greater p at ien t com for t an d allow s for aggressive decon tam in at ion of th e w ou n d. Chronic Wounds Sim ple surface irrigation of a chronic w oun d is usually only m arginal and m inim ally e ective. It can be useful at the bedside if there is debris grossly evident in the wound. Studies have show n that pressure irrigation at approxim ately 70 psi is needed to reduce bacteria count and particulate ERRNVPHGLFRVRUJ Wound Managem ent 3 m at ter. This is best done in the operating room w ith a pulse lavage or a jet lavage system . If needed, a thorough débridem ent of devitalized tissue can also be done in the operating room . Tangential hydrotherapy via the Versajet (Sm ith & Nephew ) device is often useful for irrigation and m echanical débridem ent. A chronic w ound m ay bene t from biopsy and tissue culture as clinically indicated. Débridement and Hemostasis Adequate débridem ent of devitalized tissue and skin edges is im portant in preparing the contam inated wound for closure. The skin is highly vascular and excessive skin rem oval is usually not necessary. Jagged skin edges should be trim m ed to facilitate an easier closure. Hem ostasis can be achieved w ith pressure, silver nitrate, topical brin, Surgicel (Johnson & Johnson), topical throm bin or epinephrine (1:100,000), suture ligature (absorbable for sm all vessels and nonabsorbable for larger vessels), or cautery (Fig. 1.1). If th ere is any qu est ion as to th e viabilit y of th e t issue, it is bet ter to allow the t issu e to dem arcate rath er th an to débride it init ially. Tissue of qu est ion able viabilit y can often u n dergo n ecrosis after débridem en t du e to ret rograde throm bosis. On ce dem arcated, th e t issue can be débrided to h ealthy bleeding t issue. Th is approach allow s conser vat ive preser vation of th e tissu es w ith out cau sing addit ion al t issu e loss an d dis guration. Fig. 1.1 Useful tools for establishing hemostasis in acute wound m anagem ent: (a) topical epinephrine diluted to 1:100,000, applied with gauze, (b) topical thrombin spray, (c) oxidized m ethylcellulose (Surgicel), (d) coagulation with silver nitrate, or (e) disposable portable cautery device. ERRNVPHGLFRVRUJ 4 Wound Managem ent Closure and Antibiotics Prior to closu re, irrigat ion , d ébridem en t , h em ost asis, an d t rim m ing of th e skin’s jagged edges sh ou ld be perform ed. A ten sion -free closure w ill h elp to en su re h ealing w ith an opt im al scar. Most clean lacerat ion s, if ad dressed in < 8 h ou rs, h ave m in im al con tam in at ion an d can be closed prim arily w ith out th e n eed for an t ibiot ics. Clean w ou n ds presen t ing after 8 h ou rs can be closed after débridem en t of th e en t ire w oun d an d sh arp débridem en t of edges. Th is w ould in clude st ab w ou n ds, lacerat ion s by w in dow or glass, an d clean avu lsion s. In e ect , sh arp débridem en t an d decon t am in at ion of th ese late presen t ing w ou n ds convert s th em in to fresh w ou n d s th at are m ore app rop riate for closu re. On th e oth er h an d, con t am in ated w ou n d s, su ch as w ou n ds w ith dir t an d debris, sh ou ld be t reated w ith system ic an t ibiot ics w ith ad dit ion al con siderat ion for tetan u s p rop hylaxis. Ch oice of an t ibiot ics sh ou ld u su ally cover gram -p osit ive organ ism s (cefazolin 1 g IV). Due to th e in crease in m eth icillin -resistan t Staphylococcus aureus (MRSA), cer tain w oun ds m ay require oth er an t ibiot ics for coverage (clin dam ycin 600 m g IV or van com ycin 1 g IV). Th e ast u te caregiver sh ou ld t ake advan t age of adm in ist rat ion of a single IV dose of an t ibiot ics to w oun ds at risk for con t am in at ion w h ile th e pat ien t is in a h ealth care set t ing un dergoing evalu at ion . If th e w ou n d is grossly con t am in ated w it h debris or if th e p at ien t is diabet ic, broader-sp ect ru m an t ibiot ics sh ou ld be con sidered, for exam ple, Avelox (Bristol-Myers Squ ibb) 400 m g IV or by m outh daily, Zosyn (Wyeth Ph arm aceu t icals) 3.375 g IV ever y 6 h ours, im ipen em 1 g IV ever y 8 h ou rs, or com bin at ion th erapy. Con tam in ated w ou n ds sh ou ld be left op en except for th ose on th e face. Wet to dr y dressing ch anges sh ou ld be don e at least t w ice a day. In addit ion , th e p at ien t sh ou ld sh ow er frequ en tly an d w ash th e w ou n d w ith soap an d w ater. A 5- to 7-day cou rse of ou t p at ien t an t ibiot ics m ay also be w arran ted. Coverage sh ou ld in clude gram -p osit ive an d MRSA coverage (oral clin dam ycin 450 m g by m outh fou r t im es a day, or oral t rim eth oprim / su lfam eth oxazole t w ice a day). Cep h alexin is n ot e ect ive in t reat ing a con tam in ated w ou n d. Rarely, acu te w ou n ds w ill requ ire inpat ien t t reat m en t w ith IV an t ibiot ics. Usu ally débridem en t an d prophylact ic oral an t ibiot ics sh ould su ce. In th e case of m ore subacu te or ch ron ic w ou n ds w ith gross con t am in at ion or p u ru len ce, con siderat ion sh ou ld be given to adm ission , IV an t ibiot ics, an d form al débridem en t . ERRNVPHGLFRVRUJ Wound Managem ent 5 Skin-Flap Wound Closure If th e p at ien t h as an avu lsed skin ap, th e ap sh ould be tacked dow n w h ere it lies (Fig. 1.2). Do not put tensio n o n the skin ap fo r co m plete clo sure . Ten sion w ill lead to tot al ap loss. First , débride all devit alized t issu e an d th en in set th e ap so th at n o ten sion is presen t . Dist al m argin s of th e ap w ill usually un dergo n ecrosis. Plan on addit ion al débridem en t as th e ap dem arcates. Tetanus Prophylaxis Tetan u s-p ron e w ou n ds are th ose th at are old (> 6 h ou rs), d eep (> 1 cm ), an d/or con tam in ated, especially th ose th at involve ru st y m et al, feces, or soil. Depen ding on t h e degree of con tam in at ion , tet an us toxoid, tet an u s im m un oglobulin , or com plete im m un izat ion m ay be required. Speci c recom m en dat ion s for tet an us prophylaxis are in cluded in Table 1.2 th rough Table 1.4. Fig. 1.2 (a) Avulsed skin ap. (b) Avulsed skin ap tacked down without tension. ERRNVPHGLFRVRUJ 6 Wound Managem ent Table 1.2 Tetanus-prone wounds Clean (low risk) Tetanus prone (high risk) Clean incised wound Any wound or burn > 6 h old Super cial graze Contact with soil, feces, compost, or saliva Scalded skin Puncture-t ype wound Avulsion wounds Crush open wounds Infected wound Compound fracture Large am ount of devitalized tissue Anim al or hum an bite Burns and frostbite Table 1.3 Im munization status and tetanus risk Immunization status Low risk Moderate risk High risk Fully im m unized, < 5 y since booster None None None Fully im m unized, 5–10 y since booster None Td Td Fully im m unized, > 10 y since booster Td Td Td + TIG Incompletely imm unized or uncertain Full tetanus vaccine Full tetanus vaccine + TIG Full tetanus vaccine + TIG Abbreviations: Td, tetanus toxoid; TIG, tetanus im m unoglobulin. ERRNVPHGLFRVRUJ Wound Managem ent 7 Table 1.4 Recom m endations for vaccination with tetanus im m unoglobulin Patient Dosage Treatment Adult 250–500 U For both patient groups, the vaccine should be given IM in the opposite upper extrem it y (arm ) to the tetanus toxoid Pediatric 250 U Follow -up Carefu l an d frequ en t follow -u p is im perat ive for all w oun ds. Pat ien ts sh ould be asked to ret u rn to th e clin ic or gen eral p ract it ion er w it h in 3 days if p ossible an d edu cated on all th e sign s an d sym ptom s of an in fect ion . Speci c in st ru ct ion s on w oun d care an d an t ibiot ic th erapy are cru cial to gu aran teeing pat ien t com p lian ce an d u lt im ately a favorable progn osis. ERRNVPHGLFRVRUJ 2 Anesthesia and Wound Closure All wounds should be clean of foreign bodies and adequately irrigated (see Chapter 1). Hem ostasis is achieved w ith pressure, silver nitrate, brin, Surgicel, throm bin, or suture ligature (absorbable for sm all vessels and nonabsorbable for larger vessels) to prevent hem atom a form ation. Any devitalized tissue, as well as jagged edges, should be trim m ed for optim al cosm esis. Wounds can be closed w ith sut ures, staples, skin tapes, or w ound adhesives. Generally, w ounds should be closed in layers using appropriate sut ures an d the epiderm is reapproxim ated so that it is relatively tension free and everted if possible. Everted skin edges event ually atten out and produce a level w ound surface, w hereas inverted skin edges have a tendency to produce a depressed scar. To guaran tee a successfu l w oun d closure, a com for table environ m en t sh ou ld be created for both th e p ract it ion er an d th e p at ien t . Th e u se of an algesics, local an esth esia, an d even sedat ion are h elpfu l adjun ct s in redu cing p at ien t an xiet y. Th is w ill u lt im ately in crease th e likelih ood of m ore precise closu re. Anesthesia Local Anesthetics Local an esth et ics w ork by a ect ing th e sodium (Na +) ch an n els on a eren t sen sor y n er ves. Local an esth et ic en ters th e cell m em bran es an d reversibly bin ds to Na + ch an n els. Th is reversible bin ding in cap acit ates th e cells so th at th ey are th en u n able to d ep olarize. Lid ocain e is t h e m ost com m on ly u sed an d easily accessible local an esth et ic agen t in t h e em ergen cy room (ER). Epin eph rin e sh ould rout in ely be u sed w ith any local an esth et ic to assist in h em ost asis an d to prolong durat ion . Th e vasocon st rict ive p roper t ies lead to decreased absorpt ion so th at larger doses of an esth et ic can also be used w ith ou t system ic toxicit ies. Th e m a xim u m safe dose for lidocain e is 4 m g/kg. With th e ad dit ion of epin eph rin e (usually at 1:100,000 con cen t rat ion ), th e m axim um dose in creases to 7 m g/kg. A 1% solu t ion of lidocain e is de n ed as 8 1 g/100 m L = 10 g/1,000 m L = 10,000 m g/1,000 m L = 10 m g/1 m L Exam ple Maxim um dose of lidocaine w ith epinephrine in a 70-kg (154-lb) m an ERRNVPHGLFRVRUJ Anesthesia and Wound Closure 9 70 kg × m a x dose (7 m g/kg) = 490 m g of lidocain e 490 m g × 1 m L/10 m g (con cen t rat ion of 1% lidocain e) = 49 m L of 1% lidocain e w ith epin eph rin e Alth ough m any textbooks h ave cited th e con t rain dicat ion for u sing epin eph rine in en d ar teries such as th ose in digit s an d th e n ose, recen t st udies h ave exon erated epin eph rin e as th e culprit in causing t issue n ecrosis. Therefore, it is safe to use lidocain e w ith epin eph rin e virt ually anyw h ere on th e body. For th e m axim u m e ect s of epin eph rin e to take place, th e pract it ion er sh ould w ait 10 to 15 m in utes. Table 2.1 provides oth er local an esth et ics th at m ay be used, w ith th eir m a xim u m dosages an d durat ion of act ion . Once you have chosen your local anesthetic, it is useful to add bicarbonate to the solution, particularly w hen the patient is awake. The pH of local anesthetic solutions is generally bu ered to bet ween 4 and 5 to prolong shelf life. This acidit y routinely leads to a burning pain upon injection. Adding a base such as bicarbonate to the local anesthetic not only alleviates the pain but also accelerates the action because the higher pH favors the nonionized form of the anesthetic, w hich crosses the cell m em brane m ore easily. The addition of 1 m L of a 1-m Eq/m L solution of bicarbonate for every 9 m L of local anesthetic can alleviate the burning and im prove patient com fort. Warm ing the anesthetic, using a sm aller-caliber needle (25 gauge or higher), and injecting by inserting the needle w ithin the wound (instead of through the skin) all help in reducing pain felt by the patient. Table 2.1 Local anesthetics for wound closure Drug Onset Maximum dose mg/kg (w ith epinephrine mg/kg) Duration (w ith epinephrine) Lidocaine Rapid 4.5 (7) 120 m in (240 min) Mepivacaine Rapid 5 (7) 180 m in (360 m in) Bupivacaine Slow 2.5 (3) 4 h (8 h) Procaine Slow 8 (10) 45 min (90 m in) Chloroprocaine Rapid 10 (15) 30 m in (90 m in) Etidocaine Rapid 2.5 (4) 4 h (8 h) Prilocaine Medium 5 (7.5) 90 m in (360 min) Tetracaine Slow 1.5 (2.5) 3 h (10 h) ERRNVPHGLFRVRUJ 10 Anesthesia and Wound Closure Topical Anesthetics • Eutect ic m ixt ure of local anesthet ics (EMLA): 2.5% prilocain e an d 2.5% lidocain e cream . • Lidocaine-epinephrine-tetracaine (LET) gel: 4% lidocain e, 1:2,000 ep in eph rin e, 1% tet racain e. Top ical an esth et ics are m ore com m on ly u sed in th e p ediat ric pat ien t to alleviate th e pain associated w it h local inject ion s. Alth ough e ect ive, th ey are n ot n early as e ect ive as local an esth et ic in lt rat ion in providing an esth esia. Th e du rat ion an d depth of th e blockade is dep en den t on th e am ou n t of t im e th e cream is in con t act w ith th e skin . App ly to th e w oun d an d th en cover w ith a Tegaderm (3M) or oth er occlusive dressing. Th e cream or gel w ill u su ally n eed to be in place for at least 45 m in utes before any an esth et ic e ect is ach ieved. Digital and Facial Nerve Blocks Please see respective chapters: Upper Extrem it y Injuries (Chapter 18) and Facial Traum a (Chapter 8). Conscious Sedation Most sim ple and even m oderately com plex laceration s can be repaired w ith relative ease w ith local anesthetics alone in the adult patient. How ever, fear and anxiet y are com m on in the pediatric patien t. Th erefore, it m ay be di cult to repair a laceration in th e understandably un coop erative pediatric patient. Conscious sedation m ay be used if conditions are appropriate and the necessar y precautions follow ed. A w ell-trained pediatrician or anesthesiologist should be consulted for adm inistration of conscious sedation, especially if the surgeon’s experience is lim ited in this eld. Full m onitoring by a nurse is required throughout the procedure. Prior to adm in istering con sciou s sedat ion , a com p lete h istor y an d physical exam in at ion sh ou ld be obtain ed , in clu ding • • • • • • • Age. Weigh t (m easu red, n ot est im ated, w h en ever possible). Vit al sign s. Oxygen sat urat ion . Absen ce of h ead injur y (docu m en t). Hear t , lu ng, n eu rologic, an d m en t al stat u s. Com p lexit y an d locat ion of injur y. ERRNVPHGLFRVRUJ Anesthesia and Wound Closure 11 Prior to sedat ion , th ere sh ould be • No oral liqu ids for 2 h ou rs p rior to p rocedure in ch ildren < 2 years of age—3 h ou rs if > 3 years. • No m ilk or solid food for 8 h ou rs p rior to th e procedu re. Du ring th e p rocedu re, • Main tain con t in uou s oxygen sat u rat ion an d h eart rate m on itoring. • Record vit al sign s an d blood p ressure ever y 15 m in u tes for con sciou s sedat ion an d ever y 5 m in u tes for deep sedat ion . • Record dr ug dose an d t im e adm in istered. • Record state of con sciou sn ess an d resp on se to st im u lat ion . As p recau t ion ar y m easures, en su re th at • Nasal can n ula an d in t u bat ion t ray are available du ring th e procedu re. • Reversal agen t s are ready, prep ared in syringe (Narcan [Du Pon t Ph arm a] 0.4 m g IV pu sh ever y 2 to 3 m in utes as n eeded, u m azen il 0.2 m g IV p u sh given over 30 secon ds, th en 0.3 m g IV push given over 30 secon ds as n eeded, m axim u m total d ose 3 m g). • Suct ion ing apparat u s an d can ister are available. • Nursing sta is in th e room du ring th e procedu re to assist . • Dr ug com bin at ion s th at in clu de am n est ic an d an algesic e ects are u sed. The drugs co m m o nly used are as fo llow s (Table 2.2): • For ad u lts. – Sh or t procedure: Versed (Ho m an LaRoch e) + fen tanyl. – Moderate in ter val p rocedu re: Morph in e + At ivan (Biovail Ph arm aceu t icals, In c.). • For pediat ric pat ien ts. – Ketam in e + Versed. For all pat ien t s, st art w ith a subth erapeu t ic dose, th en rebolu s in sm all in ter vals to t it rate sedat ive e ect . ERRNVPHGLFRVRUJ e e l l n n y i o 2 i f . n d h n o 2 m a e p g a t s p a r v e u r t n i l o o r t e e r e b M D F V A K P a T o C n s c , , , o o o r n n n o f p p p n y y y n o h h h o i c - - - c c i c c c c i t i i t i i i i e e e e e s s s t t t t p a v v v v v i e e e s s s s i i i i i d r t t t t t g e e e e g g e l l l c a a a a a n n n n s s a a a d d d d d e n s n n e e e m m m m e e u s A S A S A s a a a a S D o i t t t u , , , o c c c i i i w n / 8 5 M 3 – I 1 – 3 – n 4 i 2 V r 5 I 4 . r o m n 0 2 e e i . ) s v V r 5 0 I V o m I o o – r ( d g 4 0 o / V k M I h r e 6 l I / g / s e a – k g g g g v t V M o / 0 I I e o o g m m d r m 3 m t g g / u t V 1 2 5 y l k k I s 0 g . g r / / – – u o 2 n 4 e l g i g g 5 5 m m d – . . – v c 5 m 0 e 0 m 2 m 1 m 3 A d / / e / c – g n r n 5 e m e o 0 n r . i v y 2 d 0 o r l M m – i I r e y 5 h l 0 o v . g c e 3 k w 0 r / , M o r I l o g e M / f o I s c / , m O d n V e V P I e I o r 7 d u – g g e O n k k s d g e 3 P e s k e o r / g g V c o d g o I m g / o k d m m r e / g g m m c c p k k 6 g 5 1 i o / . . / n n r 2 i 1 c o . 0 g 0 t g m o t r e 0 a – – h m r r i e 0 0 m V – 5 5 I t o 1 2 5 1 d d i 1 2 1 0 o . r – – . . . – – n e g 0 N 2 1 0 0 0 2 6 p k u P n i ) m V I ) ( 0 V I 1 n ( i – n s 5 m o , 0 i ) 5 t ) 3 . a , M 2 V I I ) d ) , ( ( ) e V M n I I n s i i M ( ( I f , ( ) m n m n ) o i i V n I t 0 0 i M ( I m m e 3 2 ( m s s ) – 3 – 4 h n V 5 – 5 5 – 0 I 1 ( 1 1 1 1 3 4 O 12 Anesthesia and Wound Closure ERRNVPHGLFRVRUJ Anesthesia and Wound Closure 13 Sutures A variet y of su t u re m aterials are available, an d, in gen eral, th ey can be di eren t iated based on th e follow ing categories (Table 2.3): • • • • Absorbable versus n on absorbable. Braided versu s n on braided. Ten sile st rength . Half-life. A variet y of n eedles are also available an d can gen erally be classi ed as t aper or cut t ing. • Taper/rou n d n eedle: Use in m u scle, car t ilage, an d m ucosa. • Cut t ing n eedle: For skin . – Use a h alf-circle cu t t ing n eedle for subcu tan eous t issue. – Use a 3/8-circle cu t t ing n eedle for skin . Suture Techniques (Fig. 2.1) • Sim ple interrupte d: Gen eral t issu e ap proxim at ion . • Co ntinuo us running o r running baseball: An e ect ive an d fast con t in u ou s su t u re for long lacerat ion s. • Ve rtical m attress: Most e ect ive st itch for ever t ing skin edges. Be careful to n ot set ten sion too t igh t to preven t t issu e n ecrosis. • Ho rizontal m attress: E ect ive in evert ing skin edges. Be carefu l to n ot set ten sion too t igh t to p reven t t issu e n ecrosis. • Running subcuticular: A buried derm al sut u re for closing skin in clean w ou n d s w ith ou t jagged edges. • Staples: Sim ple an d fast closu re com m on ly u sed in th e scalp or dir t y w oun d s to be closed loosely to allow drain age. Staples sh ould be rem oved in 5 days to avoid ep ith elializat ion an d a p oor cosm et ic result . • Adhesive skin tape: Used to reapp roxim ate sm all lacerat ion s w ith ver y lit tle ten sion . • Derm abo nd (Ethico n): Skin adh esive th at can be u sed for clean lacerat ion s w ith ou t jagged edges. After th e w ou n d is adequ ately prepared, reapp roxim ate skin edges w ith a nger an d apply th e rst coat , let it dr y for 20 secon ds, an d th en ap ply a secon d coat . • In con clu sion , th e ast ute p ract it ion er w ill rep air lacerat ion s an d w ou n ds in th e follow ing order: ERRNVPHGLFRVRUJ o m p ) l e , n r a ) S i o u n r ) D c t i e o P n u t h c : i S o t a c n h l E i ) ( t t o y m c i h E r n i u t 3 t e ( . c e o a E g l n i r m 2 c ( n o i y v e o u n l o n r i e S e h r l t k k l r o c o t a l l y i h l D r u i i b E b S P C V P M ( S S N P b a T A r o l s . c u e s d r u e n e e e e l t e l l l l u v b u b b b b o s a a a a a e l w e e e e e b e b b b b l l l l l r r r r r b r n b b b b b o o o o o a o o a a a a a f s s s s s b n b b b b b b b b b b s r r r r r r a l a a a a a o x o o o o o a i n n n n s n s s s s s o r i o o o o b b b b b b o e d t A A A n A A A N N N N y a l s u t t t t t t e n n n n n n n e d i e e e e e e a m m m m m m m r a a a a a a a l b l l l l l l d d d s e e e o o o o o o o u d d d n s i i i n n n n n n r a a o a o o o o o o r r r e e M v M M M B B M M M B r t d e e e e e n n n n f k k d i a a a a l w w - 0 k k f m m m m l 1 2 3 r r r r w w a – – – e e e e P P P P 2 4 1 7 H 2 n n n n t t t t o r k k k k k d p k w w d w w w 4 h w 1 1 3 7 6 2 2 t 4 t t t t t t t g a a a a a a a t n a e % % % % % % % r 0 2 0 5 % 5 0 5 t S - - 5 - 1 7 - 7 8 2 2 6 e l - - - - 3 2 s 8 4 o m m m b r – – A p 2 6 3 t o o p e r l m m o o o o o i n t , , e u l l a a n s s i i r n i a a c o c s s u a k o l i i l s s s m m c s s d u r r a n a l f a a c f n c e e i s s o t t i a r e r r n e t e d d s s e s t t l l r e e m o u o o c o a , c t t p p u i c d s c s s s s n n e e m l l m m d i i b n u u u o e e o o o e e e k k l u e B B S S P M D D C c m s h h M r e s 14 Anesthesia and Wound Closure ERRNVPHGLFRVRUJ Anesthesia and Wound Closure 15 1. An esth et ize th e pat ien t’s w ou n d. 2. Débride it m et iculou sly w ith rem oval of jagged edges, devit alized t issue, an d any foreign bodies. 3. Properly irrigate th e w ou n d in prep arat ion for closu re. 4. Obtain h em ostasis. 5. Rep air th e w ou n d in layers w ith care to reapproxim ate th e derm al an d epiderm al layers of th e skin to p rovide th e pat ien t w ith th e best cosm et ic resu lt . Fig. 2.1 Suture techniques. ERRNVPHGLFRVRUJ 3 Pressure Sores Th e t reat m en t of pressu re sores can be a long an d di cu lt ch allenge. Pressu re sores are frequ en tly a secon dar y sequ ela to th e sed en t ar y pat ien t w ith a m ore com plicated p rim ar y issu e. Com m on ly, pat ien ts w ith pressure sores presen t w ith m ult iple com orbidit ies. It is essen t ial to keep in m in d th at th e likely source of fever an d in fect ion is often t im es n ot th e sore it self, sin ce m ost sores are open to drain . Each case w arran ts a com plete evaluat ion by th e exam in er to rule ou t th e pressure sore as th e likely cau se of an in fect ion . Pressure Sore Staging System (Fig. 3.1) • Stage 1: In t act skin w ith n on blan ch able er yth em a. • Stage 2: Su p er cial u lcer involving p ar t ial t h ickn ess of t h e ep id er m is an d d er m is; u su ally p resen t s as an abrasion , blister, or ver y sh allow u lcer. Fig. 3.1 Pressure sore staging system . 16 ERRNVPHGLFRVRUJ Pressure Sores 17 • Stage 3: Fu ll-th ickn ess skin loss dow n to th e su bcu tan eous t issue, w h ich does n ot exten d beyon d u n derlying fascia. • Stage 4: Full-thickness skin loss dow n th rough subcutan eous tissue w ith involvem ent of m uscle, bone, tendon, ligam en t, or joint capsule. Evaluation Position the patient in a w ell-lit area to facilitate visualization of th e ulcer. Gen tly p robe th e w ou n d an d assess for u id collect ion or pu rulen t drain age. If pu s is p resen t , in cision an d drain age (I&D) sh ou ld be p erform ed an d th e w ou n d irrigated cop iou sly an d packed w et to dr y (see below ). Obt ain a cu lt u re an d sam ples of th e pu ru len t m aterial. Necrot ic soft t issu e is com m on . If it is devoid of pu ru len t d rain age, it is un likely to be t h e sou rce of sep sis. Cop iou s drain age m ay be in dicat ive of a m u ch larger w ou n d ben eath th e skin . Subcu tan eous fat an d m uscle are m ore pron e to isch em ia th an skin . Th erefore, in t act skin (possibly w ith sm all esch ar) m ay h arbor a large area of n ecrot ic t issu e below, m aking th e w ou n d u n st ageable. Often , an esch ar at or above th e adjacen t skin layer is in dicat ive of par t ial skin th ickn ess loss. An esch ar th at is depressed m ay rep resen t fu ll-th ickn ess skin loss. Larger sores m ay w arran t radiograph ic evaluat ion to assess th e exten t of soft t issue involvem en t an d possible bony involvem en t . CT scan or MRI w ill provide m ore in form at ion versu s t radit ion al X-ray. An MRI sh ou ld be p erform ed to ru le ou t osteom yelit is if bon e cu lt u res are n ot available. Ch eck rout in e st udies—CBC, blood cult ures, CXR, blood sugar, albu m in an d p realbu m in , ESR, CRP, an d u rin alysis. Rule out oth er possible system ic causes of fever—pn eu m on ia, cen t ral lin es, an d u rin ar y t ract in fect ion s. Ch eck for in con t in en ce. Treatment General Treatment for All Ulcers • Alleviat ion of pressu re—place pat ien t on an air- uid m at t ress; u se pillow s, egg car ton s, don u ts. • Avoidan ce of sh earing forces. • Frequ en t t u rn ing of th e pat ien t , h ou rly if p ossible. • Clean ing or d iver t ing aw ay in con t in en ce—use of Foley an d suprap u bic cath eter, rectal t u be, or colostom y. • Ma xim izing n ut rit ion (albu m in > 3.0, p realbu m in > 18). ERRNVPHGLFRVRUJ 18 Pressure Sores For Staged Ulcers • Stage 1: Use m oist u rizers to p reven t dr yn ess. • Stage 2: No débridem en t is n ecessar y; u se occlusive d ressings such as polyu reth an e lm (Du oderm [Convatec In c.]) or hydrocolloids. • Stages 3 and 4: Sh arp débridem en t is often n ecessar y w ith th e addition of pulse lavage irrigat ion . Woun ds are p acked w et to dr y w ith Kerlix (Ken dall Co.). Con sider bon e biopsy to assess for osteom yelit is an d to obtain bon e cult u res to gu ide an tibiotic th erapy. Th e in it ial t reat m en t an d m an agem en t of a pressu re sore sh ou ld include t r ying to alleviate th e pressu re th at in it ially cau sed th e w ou n d. Even a clean w ou n d w ill h ave t rou ble h ealing if th e in cit ing even t is st ill presen t . Proper débridem en t an d w ash out is param oun t . A m in im al to m oderate am ou n t of n ecrot ic t issu e can often be débrided at bedside w ith local an esth esia, scissors, an d a scalpel. Larger areas sh ou ld be don e in th e operat ing room becau se of pain an d th e poten t ial for un con t rolled bleeding. Sh arp débridem en t sh ou ld be perform ed d ow n to h ealthy vitalized t issu e th at bleeds. Properly an esth et izing th e p at ien t w ill h elp w ith p ain con t rol an d h em ost asis. Refer to Ch apter 2 for a list of local an esth et ics to u se. Wet to dr y d ressings can be don e w ith n orm al salin e, 0.25% Dakin’s solut ion , 0.25% acet ic acid, an d gau ze. Kerlix gauze is com m on ly u sed becau se of th e large su rface area it can cover. Kerlix gau ze is soaked in on e of th e p referred solut ion s an d th en squeezed dr y. Th e m oist gauze is th en in ser ted an d p acked directly in to th e w ou n d to cover th e en t ire surface of th e w oun d. Do n ot place m oist Kerlix directly on th e skin , sin ce th is can lead to skin m acerat ion . Th e dressing sh ould be ch anged t w o to th ree t im es p er day dep en ding on h ow dirt y th e w oun d is. Wet to dr y dressings keep th e w oun d m oist an d allow for m ech an ical débridem en t of devit alized t issu e on ce th e gau ze dries, h en ce th e n am e “w et to dr y.” Dakin’s 0.25% or acet ic acid 0.25% solu t ion sh ou ld be u sed in th e infected pu r ulen t w ou n d; h ow ever, it sh ould be discon t in ued on ce th e w ou n d is clean , sin ce both solu t ion s can in h ibit t issu e grow th an d h ealing. Most h osp it als h ave a w ou n d care team t h at can assist w ith bedside pu lse lavage an d a sm all am oun t of sh arp débridem en t by th e w oun d ostom y n u rse. Con su lt th e w ou n d care team for assist an ce w ith dressing ch anges, bedside pulse lavage, an d m in or débridem en ts. Duoderm m ay be p laced on eith er side of th e w ou n d, th ereby avoiding frequ en t t ape con tact directly w ith th e skin . En zym at ic débridem en t is a com m on adju n ct to th e m an agem en t of pressu re ulcers. Agen t s such as San t yl (Sm ith an d Neph ew ) are frequen tly ap plied to th e w ou n d to p rovide con st an t p roteolyt ic débridem en t . ERRNVPHGLFRVRUJ Pressure Sores 19 Alth ough frequ en tly u sed, th ey are by n o m ean s a su bst it u te for sh arp m ech an ical débridem en t of n ecrot ic t issu e. Th ese agen ts h ave low m orbidit y an d assist in clean ing u p th e sm all am ou n t s of n ecrot ic t issu e th at are often h ard to com p letely rem ove du ring bedside débrid em en ts. If th e pat ien t is seen in th e em ergen cy room an d th ere is n o cellu lit is, n o elevat ion in w h ite blood cell cou n t , an d n o pu ru len t drain age, th en th e w ou n d can be débrided as n ecessar y an d th e pat ien t can be seen as an ou t p at ien t . In th ese cases, in st r u ct th e fam ily on (1) dressing ch anges ever y 8 h ou rs, (2) th e im por tan ce of keeping th e w oun d clean , an d (3) th e n eed for frequ en t t u rn ing of th e pat ien t . If th e p at ien t presen t s w ith cellulit is an d purulen t drain age of th e w oun d, th en adm ission to th e h osp it al sh ou ld be con sidered, especially if th e p at ien t h as oth er com orbidit ies. Silvaden e (San o -Aven t is Ph arm aceu t icals), Mafen ide Acetate Cream , or Bet adin e (Pu rdue Products LP) can be used in selected cases of w oun ds w ith super cial esch ars. Th ese are usu ally sm all sores th at involve on ly th e derm is. Th ese an t im icrobial agen t s can h elp decrease th e ch an ce of an in fect ion w h ile th e w ou n d h eals by secon dar y in ten t ion . Cu lt u re sw abs are of lit tle u se becau se all w ou n ds are colon ized, even in th e clean gran u lat ing w ou n d. A qu an t it at ive t issu e biopsy can be obtain ed to evaluate t issue bacterial coun t s (> 10 5 p er gram of t issu e), an d bon e biop sy to r ule ou t related osteom yelit is. ERRNVPHGLFRVRUJ 4 Bite Wounds Bite w ou n ds from an im als, in sect s, an d h u m an s are com m on ly presen t in th e em ergen cy set t ing. More severe an d violen t bites can be associated w ith com p lex com posite t issu e d efects w ith devitalized t issue. General m anagem ent includes: 1. In lt rate local an esth esia to an esth et ize th e w oun d to allow th orough evalu at ion an d d ébridem en t . 2. Rem oval of foreign bodies (teeth ) an d débridem en t of devitalized t issu e. 3. Copiou s irrigat ion w ith NS. 4. Determ in e if tetan us or rabies prop hylaxis is in d icated. 5. Repair of w oun d/lacerat ion —con sider loose closu re or leaving open if in fected or con tam in ated. 6. Postclosu re an t ibiot ics an d m on itoring. Human Bites Hu m an m ou th s con tain som e of th e m ost con cen t rated an d varied bacteria. Organ ism s in clude Eikenella, Staphylococcus, viridan s st reptococci, an d Bacteroides. Th e gen eral prin ciples of con t am in ated w ou n d m an agem en t , as m en t ion ed above, app ly to all h u m an bite w ou n ds. In th e acute bite, th e w ou n d m u st be assessed fu lly an d irrigated copiously. Th e pat ien t sh ou ld be p laced on ap propriate p rop hylact ic an t ibiot ics an d follow ed closely for any sign s of in fect ion . Th e in it ial inju r y often ap pears m in or to th e pat ien t; th u s n o care is sough t u n t il an in fect ion develops. It is im p ort an t to fu lly assess th e pat ien t in th e u rgen t care set t ing an d t riage for p ossible h ospit al adm ission , IV an t ibiot ics, an d operat ive m an agem en t . Bite inju ries requ ire carefu l evalu at ion for a deep in fect ion becau se of th e relat ively ben ign presen tat ion of th eir ap pearan ce. At t im es, du e to th e close proxim it y of th e skin an d u n derlying st ru ct u res, n er ve an d ten don inju ries m ay also be presen t . Also, due to th e in h eren t depth of pen et rat ion by th e teeth , m icroorgan ism s easily seed th e depth of w ou n ds, allow ing rapid dissem in at ion along th e deep p lan es of th e fascia an d su bcu tan eou s t issu e. Th erefore, r u le ou t a deep inju r y even w h en th e presen t at ion is a m in or w oun d su ch as an abrasion . 20 ERRNVPHGLFRVRUJ Bite Wounds 21 Assessment and Treatment 1. Evaluate w ou n d for depth , foreign body, drain age, an d cellu lit is. 2. Assess for crepit u s (su bcu tan eou s em physem a), w h ich w ou ld in d icate gas-form ing organ ism s along th e deep p lan es. 3. Débride devit alized t issu e an d copiou sly irrigate. 4. Loose closu re versus p ack w ou n d—facial bites sh ou ld be closed for th e best cosm et ic resu lts. 5. Treat w ith an t ibiot ics. Closed-Fist Injury (Fight Bite) W ith closed- st inju ries, th e force of th e blow to t h e m ou th w ill often pen et rate th e skin over th e m et acarpop h alangeal join t to lacerate or in fect th e exten sor ten don an d con tam in ate th e u n derlying join t , su ch as t h e m et acarpop h alangeal join t , w it h bacteria from th e m ou th . W h en th e h an d is placed back in to a n eu t ral p osit ion , th e bacteria can be displaced, resu lt ing in m ore proxim al con t am in at ion . Figh t bite w oun ds n ot on ly involve soft t issues but also can in fect join t s an d ten don s. Aggressive in cision an d drain age, irrigat ion , an d débridem en t in th e operat ing room sh ould be con sidered for grossly con t am in ated w oun ds an d th ose th at presen t late. 1. Evaluate w ou n d for depth , foreign body, drain age, an d cellu lit is. 2. Assess for crepit u s (su bcu tan eou s em physem a), w h ich w ou ld in d icate gas-form ing organ ism s along th e deep p lan es. 3. Evaluate th e in tegrit y of th e exten sor an d exor ten don s ( exor ten osyn ovit is). 4. Assess for loss of join t h eigh t , w h ich w ou ld in dicate m etacarpal h ead fract ure. 5. Obt ain h an d series (r u le ou t m etacarpal h ead fract ure, osteom yelit is, an d den tal foreign body). 6. Débride devit alized t issu e an d copiou sly irrigate. 7. Close th e w ou n d loosely or leave th e w ou n d op en an d p erform daily dressing ch anges w ith gau ze. 8. Treat w ith an t ibiot ics. Se e Ch apt e rs 1 4 an d 1 6 for m an age m e n t of fract u res of t h e m et acarp al h ead an d ext e n sor t e n d on inju r ies, resp e ct ively, associat e d w it h gh t bit es. ERRNVPHGLFRVRUJ 22 Bite Wounds Antibiotics All pat ien ts seen in th e em ergen cy set t ing sh ould receive a single dose of IV an t ibiot ics. IV an t ibiot ics sh ou ld be con t in ued in th ose w h o require adm ission for m ore com plicated in fect ion s. Th ose w h o can be disch arged h om e are released on th e appropriate oral regim en w ith close follow -u p w ith in 1 w eek. • First-line IV: Un asyn (P zer Ph arm aceut icals) 1.5 g IV ever y 6 hours or clindam ycin 600 m g IV ever y 6 hours + Levo oxacin 500 m g IV daily. • First-line oral: Augm en t in (Gla xoSm ith Klin e). – Adult: 875/125 m g t w ice a day × 10 days. – Pediat ric: 45 kg/day t w ice a day × 10 days. – Alternat ives: Moxi oxacin 400 m g daily × 10 days or clin dam ycin 450 m g fou r t im es a day + Bact rim DS t w ice a day × 10 days. Cat Cat bites are d eep ly p en et rat in g w ou n d s t h at are h eavily con t am in ated , an d ap p roxim ately 80% of t h ese w ou n d s becom e in fected . Organ ism s in clu d e Pasteurella m ultocida an d Staphylococcus sp ecies. Ir r igate h eavily, w ash daily, t reat w it h an t ibiot ics, an d see below for rabies vaccin at ion cr iter ia. Evalu ate for tet an u s p rop hyla xis. Do n ot close t h e w ou n d . Antibiotics • First-line oral: Augm en t in . – Adult: 875/125 m g t w ice a day × 10 days. – Pediat ric: 45 kg/day t w ice a day × 10 days. – Alternat ives: Doxycyclin e 100 m g t w ice a day × 10 days or cefu roxim e 0.5 g t w ice a day × 10 days. Dog Dog bites con st it ute 80 to 90% of all an im al bites. Organ ism s include P. m ultocida, Bacteroides, viridan s st reptococci, Fusobacterium , an d Capnocytophaga. Massive force can often cause sign i can t avu lsion inju ries; h ow ever, due to th e low er bacterial coun t , in fect ion is n ot seen as frequ en tly as in cat bites. Large avu lsion inju ries can be reapp roxim ated loosely as long as th e w ou n d can be p acked an d allow ed to drain sh ould an in fect ion en sue. Elevate an d t reat w ith an t ibiot ics. See below for rabies vaccin at ion criteria. Evalu ate for tetan u s p rophylaxis. ERRNVPHGLFRVRUJ Bite Wounds 23 Antibiotics • First-line oral: Augm en t in . – Adult: 875/125 m g t w ice a day × 10 days. – Pediat ric: 45 kg/day t w ice a day × 10 days. – Alternat ives: Un asyn 1.5 g IV ever y 6 h ou rs or clin dam ycin 450 m g four t im es a day + Bact rim DS t w ice a day × 10 days. Rabies Rabies is a viral infection of the central and peripheral nervous system that causes en cephalitis w ith or w ithout paralysis. If left untreated, it has close to 100% m ortalit y. In the United States, rabies is m ost com m on in bats, raccoon s, skun ks, foxes, coyotes, ferrets, cats, and dogs. Bats are th e m ost com m on w ild anim als to carr y rabies. Cats are the m ost com m on dom estic anim als to carry rabies because of the high num ber of unvaccinated strays an d their contact w ith raccoons, bats, an d oth er w ild an im als. Transm ission is through the m ucous m em branes and saliva through breaks in the skin. The virus then replicates locally in the m uscle and eventually travels through peripheral nerves to the spinal cord, then to the brain. Incubation tim es have ranged from as short as 5 days to as long as 7 years; however, the average incubation tim e is approxim ately 1 to 3 m onths. Com m on signs and sym ptom s of rabies are detailed in the box below. The most common signs and symptoms of rabies infection Paresth esias at th e site of th e bite Hyp ersalivat ion Hydrop h obia Altered m en tal stat us An xiet y Hyperact ivit y Bizarre beh aviors Hyper ten sion Hyp er th erm ia Hyper ven t ilat ion Spasm s an d con t ract ion s of th e n eck m u scles Ph ar yngeal an d respirator y m u scle paralysis Seizures ERRNVPHGLFRVRUJ 24 Bite Wounds Treatment Th e w ou n d sh ou ld be copiou sly irrigated w ith n orm al salin e. Devit alized t issu e sh ou ld be adequ ately débrided, w ith all w oun ds left open to h eal by secon dar y in ten t ion . Tetan us st at us sh ould be determ in ed an d vaccin e adm in istered if in dicated (see Ch apter 1). A broad-spect r um an t ibiot ic m ay be adm in istered for 10 days (Augm en t in 875/125 m g by m outh t w ice a day). Domestic Animals If th e rabies st at u s of th e dom est ic an im al (e.g., cat , dog, ferret) is un kn ow n , th e an im al sh ou ld be qu aran t in ed an d obser ved for 10 days; prophyla xis can be p ost p on ed if su sp icion is relat ively low. If th e an im al is rabid or if th e presen ce of rabies is h igh ly su spected, h u m an rabies im m u n oglobu lin (RIG) an d h u m an diploid cell rabies vaccin e (HDCV) sh ould be adm in istered. • RIG: 20 IU/kg, 50% in to th e w ou n d an d 50% given IM. • HDCV: Given on days 0, 3, 7, 14, an d 28. Wild Animals Regard all w ild an im als (e.g., bat s, foxes, coyotes, raccoon s, sku n ks) as rabid. Test th e an im al if capt u red an d adm in ister RIG an d HDCV to all pat ien ts as in dicated above. Snake Th e m ajorit y of sn akes are n onven om ou s; th erefore, sn akebite w ou n ds w ill likely h eal w ith out exten sive in ter ven t ion . Ven om ous sn akebites, h ow ever, can pose a severe th reat to th e local soft t issu es or cause life-th reaten ing system ic react ion s. Th e fam ily Viperidae is th e largest fam ily of ven om ous sn akes w orldw ide. Th e subfam ily Crotalin ae (pit vipers) in clu des rat tlesn akes, cot ton m ou th s, an d copp erh eads; pit vip ers are th e m ost com m on t yp e of ven om ou s sn ake in th e Un ited St ates. Th e fam ily Elapidae is th e n ext largest fam ily of ven om ous sn akes. Coral sn akes are com m on ly fou n d in th e sou th ern an d sou th w estern region s of th e Un ited States, w h ile cobras, m am bas, an d kraits are n ot in digen ous to th e Un ited States, but are exot ic sn akes th at can be foun d in zoos or are kept by private collectors. ERRNVPHGLFRVRUJ Bite Wounds 25 Th e iden t i cat ion of th e sn ake’s species is im portan t in determ in ing if enven om at ion is expected. Com m on ly p at ien t s w ill presen t w ith kn ow ledge of th e t ype of sn ake th at w as involved (see Table 4.1 for som e t ypes of ven om ous sn akes). Altern at ively, th e di eren t iat ion bet w een a ven om ous an d a n onven om ous sn akebite can be m ade using th e pat tern of the bite or physical feat ures of th e sn ake if brough t for presen t at ion (Fig. 4.1). Evaluation Obt ain th orough h istor y th at in clu d es • Tim e of th e bite. • Descript ion of th e sn ake. Assess th e t im ing of even ts an d on set of sym ptom s. (Early an d in ten se pain im p lies sign i can t enven om at ion .) Determ in e h istor y of prior exp osu re to an t iven in or sn akebite. Table 4.1 Venom ous snake species Family Geographic range Common names Viperidae Africa, Europe, Asia, North and South Am erica Subfam ily Crotalinae (pit vipers) includes rat tlesnakes (diam ondback, tim ber), cot tonm ouths, copperheads Pit vipers are the m ost com m on t ype of venom ous snake found in the U.S. Elapidae North Am erica, Europe, Africa, Asia, Australia Coral snakes, cobras, mam bas, kraits Coral snakes are com m only found in the U.S. in the southern and southwestern states ERRNVPHGLFRVRUJ 26 Bite Wounds Fig. 4.1 Characteristics of (a) venomous versus (b) nonvenomous snakes and their bite patterns. Assessm en t an d physical exam in at ion sh ould det ail th e follow ing: 1. Fang m arks. 2. Edem a. 3. Bu llae. 4. Er yth em a. 5. Necrosis. 6. Crepit us. 7. Petech iae. 8. Paresth esia. 9. Hem opt ysis. 10.Presence of com partm ent syndrom e if the bite occurs on an extrem ity (Fig. 4.2). ERRNVPHGLFRVRUJ Bite Wounds 27 Fig. 4.2 (a) Fang marks characteristic of a venom ous snakebite. (b) Signs of severe local reaction and compartm ent syndrom e. (c,d) Forearm and hand fasciotomy required for the treatm ent of compartm ent syndrom e secondary to the reaction from a venomous snakebite. ERRNVPHGLFRVRUJ 28 Bite Wounds Treatment 1. Review th e ABCs an d evalu ate th e pat ien t for sign s of sh ock (e.g., t achyp n ea, t achycardia, d r y pale skin , m en t al st at u s ch anges, hypoten sion ). 2. Obtain baselin e laboratories (in clu ding PT, PTT, an d INR) an d CXR; t ype an d crossm atch pat ien t for FFP an d PRBCs. 3. Rule ou t com par t m en t syn d rom e an d assess ever y 4 h ours for sign s of com part m en t syn drom e (see Ch apter 19). 4. Tet an u s prophyla xis. 5. Prophylact ic an t ibiot ic u se is con t roversial; h ow ever, som e recom m en dat ion s in clu de th e follow ing: Roceph in (Roch e Ph arm aceu t icals) 1 g IV ever y 12 h ou rs or Tim en t in (GlaxoSm ith Klin e) 3.1 g IV ever y 6 h ours. 6. Im m obilizat ion , n eu t ral p osit ion ing (splin t) of ext rem it y, an d suppor t ive care. Su ct ion devices on th e bite can be e ect ive in th e rst 15 to 30 m in u tes. Do n ot at tem pt in cision over th e bite, m outh suct ion ing, tou rn iqu ets, or ice p acks. 7. Elevate the invo lve d extrem ity. Th is m ay requ ire th e aid of an IV p ole, w ith w h ich th e ext rem it y is h u ng u sing a stockin et te. Grading of Envenomation 1. Mild enven om at ion . a. Local pain an d ed em a. b. Sign s of system ic toxicit y are absen t . c. Laborator y valu es are n orm al. 2. Moderate enven om at ion . a. Local react ion —severe pain , edem a greater th an 12 in ch es surrou n ding th e w ou n d. b. Mild system ic toxicit y presen t , in clu d ing n au sea, vom it ing. c. Abn orm al laborator y valu es—decreased h em atocrit or platelet values. 3. Severe enven om at ion . a. Severe local react ion an d gen eralized p etech iae, ecchym osis. b. Severe system ic react ion —respirator y dist ress, air w ay edem a, blood-t inged spu t u m , hyp oten sion , ren al dysfun ct ion . c. Ch anges in coagulat ion p ro le—PT, APTT, an d DIC. Antivenin is give n for m oderate and severe cases of snake envenom ation. Serum sickness is possible w ith antivenins, w hich are m ade w ith horse or sheep serum venom . A test dose is recom m ended; watch for an anaphylactic reaction. CroFab (BTG International Inc.) is a puri ed pit viper antivenin ERRNVPHGLFRVRUJ Bite Wounds 29 that has few er hypersensitivit y reactions, so that serum sickness is less of an issue. CroFab is the preferred antivenin for pit viper envenom ation. An t iven in is given in am p u les. On e sh ou ld st ar t w ith 5 to 10 vials an d con t in u e th erapy for u p to 24 h ours from th e in it ial bite. If th e pat ien t respon ds (a decrease in both local an d system ic react ion ), th en a dosing regim en of an t iven in can be w ean ed. If th e pat ien t respon ds par t ially, plan to redose th e an t iven in . Pat ien t s sh ou ld be m on itored in an ICU set t ing du ring adm in ist rat ion of an t iven in for sign s of allergic react ion . Bites fro m co ral snakes (“red on yellow kills a fellow ”) are n ot t reated w ith an t iven in in th e Un ited States due to lack of produ ct ion of speci c coral sn ake an t iven in an d a h alt by th e FDA on th e product ion of Wyeth’s Nor th Am erican coral sn ake an t iven in . Because a speci c an t iven in for coral sn akes is n ot available, pat ien t s are curren tly t reated w ith m on itored sup por t ive care. Spider Th ere are over 20,000 species of spiders on Ear th . Dangerous species often en coun tered in Nor th Am erica in clu de th e brow n recluse, th e black w idow, th e h obo or aggressive h ou se spider, an d th e yellow sac sp ider. Of th ese, on ly t h e brow n reclu se an d t h e black w idow h ave ever been associated w ith sign i can t disease (Fig. 4.3). Fig. 4.3 The black widow and brown recluse spiders. ERRNVPHGLFRVRUJ 30 Bite Wounds The Brow n Recluse Spider Th e brow n reclu se sp ider h as six eyes an d a violin -sh ap ed p at tern on it s th orax an d is fou n d alm ost exclu sively in t h e Midw estern an d sou th eastern st ates. Alt h ough th e ven om is m ore toxic th an t h at of th e rat tlesn ake, m orbidit y is usu ally n ot as severe because of th e sm all am oun t of ven om th at can act u ally be injected by th e creat u re. On e of th e sp eci c en zym es in th e ven om cau ses dest ruct ion of skin , fat , an d blood vessels. Th is process even t u ally leads to soft t issue n ecrosis at th e site of th e bite. Th e ven om also h as a profou n d e ect on th e im m u n e respon se, t riggering th e release of various in am m ator y cytokin es, h ist am in es, an d in terleu kin s th at can th em selves cau se furth er injuries an d system ic respon ses. Alth ough rare, th ese in clude h em olysis, th rom bocytop en ia, coagulopathy, acu te ren al failu re, com a, or death . On e sh ould carefully assess th e pat ien t for any of th e above sym p tom s, an d adm ission is w arran ted for anyon e exh ibit ing system ic toxicit y. Apply ice to decrease pain an d sw elling, an d elevate th e site of injur y above th e h ear t . Wash th e area th orough ly w ith soap an d w ater, an d in st ruct th e pat ien t to avoid any st ren u ou s act ivit y, w h ich can facilitate th e sp read of th e ven om . Do n ot place h eat on t h e area; th is can accelerate t issu e dest ru ct ion . Do n ot at tem pt to su ct ion th e ven om ou t , an d th e use of steroid cream s is n ot advised. Brow n recluse sp ider bites are u su ally p ain less at rst , an d sym p tom s are slow to develop . Pain w ill u su ally p resen t aroun d 4 h ou rs after th e in it ial bite, w it h th e bite w ou n d p resen t ing w ith a bu ll’s-eye ap pearan ce. Blistering is th en com m on ly seen 12 to 24 h ours later, w ith soft t issu e n ecrosis to follow. Early débridem en t is n ot in d icated, an d n ecrot ic lesion s sh ou ld be kept clean an d carefully dressed u n t il spreading stops an d th e area of n ecrosis is w ell de n ed. A w ide area of t issu e aroun d th e n ecrot ic skin can th en be rem oved, w ith su bsequ en t skin graft ing as n eeded. 1. Baselin e laboratories sh ou ld in clu de CBC, Ch em -7, PT, PTT, an d INR. 2. Th ere is n o an t iven in available; h ow ever, dapson e 100 m g by m outh daily can be reser ved for peop le w ith severe system ic disease (an em ia, DIC, acute ren al failu re). 3. Acetam in oph en or op iates for pain . Avoid asp irin , ibup rofen (Mot rin [P zer Ph arm aceu t icals], Advil [Wyeth Ph arm aceu t icals]), an d n ap roxen (Aleve [Bayer Con su m er Care]). 4. Diph en hydram in e 25 to 50 m g by m ou th ever y 6 h ours as n eeded. 5. An t ibiot ics sh ou ld be adm in istered if sign i can t soft t issue n ecrosis en sues. Pat ien ts sh ou ld be w atch ed ver y closely, w ith follow -u p th e n ext day if possible. ERRNVPHGLFRVRUJ Bite Wounds 31 The Black Widow Spider Black w idow spiders are n oct urn al an d are foun d in th e south ern states. Th is spider h as a dist in ct ive red-colored h ourglass gu re on it s u n derbelly. It s in it ial bite is usu ally associated w ith local pain follow ed by system ic react ion s th at can carr y m ortalit y as h igh as 5%(u su ally in ch ildren or th e elderly). Gen eralized sym ptom s usu ally in clude • • • • • • • Nausea, vom it ing. Fain t n ess, dizzin ess. Ch est pain . Hyp oten sion . Tachycardia. Respirator y di cult ies. Abdom in al pain m im icking gallbladd er disease or app en dicit is. Th ere is m in im al t issue toxicit y, an d th e w ou n d sh ou ld be irrigated an d cared for in th e usu al m an n er. Treat m en t for system ic sym ptom s is su p por t ive, an d an an t iven in is available for severe cases. It sh ou ld on ly be used if th e pat ien t is u n stable. Cold com p resses h ave been u sed to ease th e p ain at th e site, as w ell as over-th e-cou n ter p ain m edicat ion s. Over-th e-cou n ter p ain m edicat ion s (e.g., acet am in op h en , n ap roxen , ibu profen , Advil) can be u sed, as w ell as Ben adr yl 25 to 50 m g by m ou th ever y 6 h ou rs for itch ing. In gen eral, an t ibiot ic prophyla xis an d exten sive m edical follow -up is n ot n eed ed. ERRNVPHGLFRVRUJ 5 Burns and Frostbite Evaluat ion an d m an agem en t of th e acutely burn ed pat ien t is a com m on requ irem en t of th e plast ic su rgeon on call. Rapid assessm en t , st abilizat ion , an d t riage are essen t ial for decreasing m orbid it y an d m or t alit y associated w ith burn injur y. Com m on ly, th e in it ial en cou n ter w ill be as a con sultan t subsequ en t to th e evalu at ion perform ed by th e em ergen cy room person n el. It is im perat ive, h ow ever, to rem em ber to in it iate m easu res to stop th e bu rn ing p rocess an d p ract ice u n iversal safet y precau t ion s to con fer in creased safet y for both th e pat ien t an d th e caregiver. Bu rn inju r y is often associated w ith t rau m a; th erefore, a com plete assessm en t of oth er inju ries sh ould be perform ed. If a ch ild is bu rn ed an d th e m ech an ism of inju r y does n ot t th e bu rn p at tern or if t h e pat ien t w as bu rn ed u n der u n likely circu m st an ces or con dit ion s, con sider abu se. Thermal Burns Initial Assessment—Starting w ith the ABCs Airw ay • Establish a paten t air w ay an d begin oxygen at ion . – Em ploy m an u al tech n iqu es—ch in lift , jaw th ru st . ▪ Ut ilize n asal t ru m p ets an d oral air w ays. ▪ Con sider creat ing a su rgical air w ay w h en th ere is upp er air w ay obst ru ct ion (cricoidectom y, t rach eostom y). • Assess for in h alat ion inju r y (Fig. 5.1). – Determ in e w h eth er th e bu rn s occu rred w h ile th e pat ien t w as in an en closed space. – Sign s an d sym ptom s of in h alat ion inju r y. ▪ Soot deposits in th e oroph ar yn x. ▪ Carbon aceou s sp u t u m . ▪ Singed n asal h air. ▪ Facial edem a, tongu e edem a, h oarsen ess. – Measure carboxyh em oglobin level. ▪ > 10% requ ires oxygen th erapy an d is h igh ly suggest ive of an in h alat ion inju r y th at requ ires in t u bat ion . 32 ERRNVPHGLFRVRUJ Burns and Frostbite 33 Fig. 5.1 Signs of potential airway burns and inhalation injury. • Gen eral criteria for in t u bat ion . – Glasgow Com a Scale score < 8 (Table 5.1). – In h alat ion injur y. – Deep facial an d n eck bu rn s. – Facial bu rn s w ith associated TBSA bu rn s > 40%. – Large TBSA bu rn s—to allow adequ ate resuscit at ion . – Oxygen at ion or ven t ilat ion com p rom ise. ▪ PaO2 < 60. ▪ PCO2 > 50. ▪ RR > 40. Pat ien t s w h o presen t w ith burn s of th e h ead an d n eck an d in h alat ion injur y m ay require early in t u bat ion to protect th e air w ay from late edem a an d edem a th at occu rs du ring resu scit at ion . ERRNVPHGLFRVRUJ 34 Burns and Frostbite Table 5.1 The Glasgow Com a Scale (score = E + M + V) Eye opening (E) Spontaneous 4 To speech 3 To pain 2 No response 1 Best m otor response (M) Obeys verbal com m and 6 Localizes painful stim ulus 5 Flexion: withdrawal 4 Flexion: abnorm al 3 Extension 2 No response 1 Best verbal response (V) Converses and oriented 5 Converses but disoriented 4 Inappropriate words 3 Incomprehensible sounds 2 No response 1 Breathing • Provide h u m idi ed oxygen by face m ask. • Expose th e ch est to assess ven t ilat ion , ch est excu rsion , degree of ch est w all injur y, an d presen ce of circu m feren t ial burn s to th e th orax. • Con sider th oracic esch arotom y for deep inju r y to th e ch est w ith associated ven t ilator y com prom ise. ERRNVPHGLFRVRUJ Burns and Frostbite 35 Circulation • Establish vascu lar access w ith large-bore, h igh - ow ven ou s can n ulat ion . Avoid th e inju red area if possible. • In it iate m on itoring: BP, p u lse, tem perat ure. • Con sider invasive ar terial lin es for m on itoring an d frequen t laborator y blood draw s. Disability • Gross assessm en t of n eurologic stat u s (m n em on ic tool = AVPU). – Aler t . – Respon ds to Vocal st im u li. – Respon ds on ly to Pain fu l st im uli. – Un resp on sive to all st im u li. • Glasgow Com a Scale (Table 5.1). Exposure • Rem ove all cloth ing an d debris to assess for gross inju ries an d for bu rn severit y. • Preven t hypoth erm ia by in creasing th e room tem p erat ure, covering th e p at ien t w ith clean w arm lin en s, an d in fu sing w arm IV u ids. Burn Severity Assessment For in it ial acu te resu scitat ion , th e follow ing in form at ion is n ecessar y: • Heigh t , w eigh t , an d age of th e p at ien t . • Depth of th e bu rn injur y. – Un iversal bu rn w oun d classi cat ion (Fig. 5.2). • Percen tage of th e total body su rface area bu rn ed th at is secon d or th ird degree. – Th e percen tage of total body su rface area (TBSA) can be est im ated by th e “r u le of n in es” (Fig. 5.3). – More accu rate calcu lat ion can be don e w ith bu rn ch ar ts (Table 5.2), w h ich is im por t an t in th e pediat ric p opu lat ion . – Gen erally, th e p at ien t’s h an d (p alm an d ngers) is est im ated as 1% of th eir total body surface area. ERRNVPHGLFRVRUJ 36 Burns and Frostbite Fig. 5.2 Burn wound classi cation. Epidermal Burns, First Degree (Fig. 5.4) • • • • • • Zon es of inju r y are con n ed to th e epiderm is. Sim ilar to su n bu rn . Non blan ch ing er yth em a. Ver y pain ful. Heals in 1 w eek. No sign i can t scarring. Partial-Thickness Burns, Super cial Second Degree (Fig. 5.5) • Con n ed to th e u pp er th ird of th e derm is. • Th e edem a layer bet w een th e inju red layer an d n orm al derm is causes blistering. • Com m on ly, th ese are th e resu lt of brief h ot-liquid exposu re. • Wou n ds are w et , p in k, an d blistering. • Wou n ds h eal in 10 to 14 days w ith m in im al scarring. ERRNVPHGLFRVRUJ Burns and Frostbite 37 Fig. 5.3 The rule of nines for adults and children. Fig. 5.4 First-degree epidermal burn. ERRNVPHGLFRVRUJ a m m d k r r k m k n n m a r a n r c u u k r a r a u r L o c e r d t r e t r t o t p n e r d e t w a r i u p a t p o n l 2 o i w o . b u l h u a p i r a o r t 5 t t t t b u l h e i d k a e t h h h h t t t t c n a e t s e f f f f l g g g g e e e r n i i i i o e e e e b A H N A P R L G R L R L R L a T n d r B o w d e r b u r n e s t t t – n i h e r 5 5 5 5 y i . . 9 . . 3 3 a 3 4 2 2 2 1 4 3 B 1 1 2 2 1 1 m i p e r c e n t a g e t 4 f 5 5 5 5 – 7 . . . . 3 3 o 2 1 2 1 y 1 2 2 2 3 4 1 4 3 1 o t a l b o d y a f 9 r 5 5 5 5 – 3 . . . . 3 3 u 2 2 1 5 y 1 2 2 2 3 4 4 3 1 1 s c e a r e a : a g 1 3 2 4 2 1 4 3 2 1 y 2 2 1 1 e e – 5 5 5 5 v 0 . . 1 . . 3 3 r u 4 s 1 s a r e a 2 3 4 9 2 1 2 4 3 1 y 2 2 1 1 5 5 5 5 5 . . . . 3 3 2 4 7 2 1 2 3 u 5 5 5 5 d . . . . 3 3 A 2 3 2 1 1 4 t l 38 Burns and Frostbite ERRNVPHGLFRVRUJ ( t ) g h i o d t g g h e o i e o g t l f u h o e t t t l t l f n i a h h h t t t t t f f f g g g n i i i o e e e o T R L R L R L C h 1 5 5 5 3 3 5 0 5 5 5 5 0 . . . . 1 5 5 6 3 3 6 0 5 5 5 5 0 . . . . 1 5 8 5 3 3 8 0 5 5 5 5 0 . . . . 1 8 8 6 3 6 3 0 5 5 5 5 0 . . . . 1 9 9 6 3 6 3 0 5 5 5 5 0 . . . . 1 9 7 3 7 3 9 0 5 5 5 5 0 . . . . Burns and Frostbite 39 ERRNVPHGLFRVRUJ 40 Burns and Frostbite Fig. 5.5 Super cial second-degree burn with blistering and epiderm olysis. Partial-Thickness Burns, Mid-dermal Second Degree (Fig. 5.6) • Result from longer h ot-liqu id exposu re, grease, an d ash am es. • Wou n ds are red w ith m in im al exudates an d m oderately pain ful. • Wou n ds h eal in 2 to 4 w eeks w ith m od erate scarring. Partial-Thickness Burns, Deep Dermal Third Degree (Fig. 5.7) • Result from exp osu re to am es, grease, ch em icals, an d elect ricit y. • Wou n ds are u su ally dr y, w h ite, an d m in im ally pain ful (due to dam age to n er ve en dings). • Gen erally, w ou n ds h eal in 3 to 8 w eeks w ith severe hyper t roph ic scarring. • Excision an d graft ing w ill accelerate closu re. ERRNVPHGLFRVRUJ Burns and Frostbite 41 Fig. 5.6 Mid-derm al second-degree burn. Full-Thickness Burns, Third Degree (Fig. 5.8) • Resu lt from h igh en ergy an d p rolonged th erm al exp osure (ch em icals, am es, elect ricit y, explosion s). • Wou n ds are dr y an d w h ite, or exh ibit im m ediate esch ar form at ion . • Wou n ds are pain less an d in sen sate. • Th ese w ou n ds n eed débridem en t an d graft ing to prom ote h ealing. Burn Patient Resuscitation Pat ien t s w h o require in t raven ous cr ystalloid resu scitat ion an d possibly uid balan ce m on itoring w ith a Foley cath eter p lacem en t are • Adult s w ith secon d- an d th ird -d egree bu rn s > 20% TBSA. • Ch ildren (< 14 years of age) w ith bu rn s > 15% TBSA. • In fan t s (< 2 years of age) w ith bu rn s > 10% TBSA. ERRNVPHGLFRVRUJ 42 Burns and Frostbite Fig. 5.7 (a) Deep dermal third-degree burn. (b) Deep derm al burn with areas of full-thickness involvem ent. All oth er pat ien t s can be m an aged w ith oral hydrat ion . Urin e ou t pu t is used to gauge th e success of u id resu scitat ion . If th ere is any qu est ion as to th e p at ien t’s abilit y to pass u rin e, place a Foley cath eter. Lact ated Ringer’s solu t ion sh ou ld be st ar ted as soon as possible after th e t im e of th e bu rn . Th e volu m e of uid given in th e rst 24 h ours for adult vict im s is determ in ed by th e Parklan d form ula: 4 × w eigh t (kg) × % BSAB = volu m e of uid for 24 h ours Th ese est im ates are based on secon d- an d th ird-degree bu rn inju ries on ly. Pediat ric p at ien t s h ave in creased u id requirem en ts secon dar y to di eren ces in BSA-to-w eigh t rat io an d require larger volum es of urin e for excret ion of w aste product s. Th e volum e required in th e rst 24 h ou rs for th e burn ed pediat ric pat ien t is est im ated using th e Galveston form ula (est ablish ed at th e Sh rin ers In st it ute for Bu rn ed Ch ildren , Galveston , TX): u id volu m e for rst 24 h ou rs of resuscitat ion (m L) = [2,000 m L × TBSA] + [5,000 m L × BSA (m 2 )] Tot al Body Su rface Area (TBSA) TBSA (m 2 ) = 0.007184 × (h eigh t in cm ) 0.725 × (w eigh t in kg) 0.425 Bu rn Su rface Area (BSA) BSAB (m 2 ) = TBSA × % su rface area bu rn ed (u sing ru le of n in es or calcu lated from bu rn % ch ar t) The rate o f infusio n w h en u sing t h e Parklan d an d Galveston form u las is as follow s: • Half of th e determ in ed volu m e is given w ith in th e rst 8 h ou rs of th e tim e of the burn. • Th e rem ain ing volu m e is given du ring th e su cceed ing 16 h ou rs. ERRNVPHGLFRVRUJ Burns and Frostbite 43 Fig. 5.8 Full-thickness burn injury. Fluid requirem en ts beyond the rst 24 hours are determ ined based on the patient’s w eight and evaporative losses, and adjusted according to the patient’s response (i.e., urine output). Maintenance vo lum e of uid is calculated in L/d as • 100 m L/kg for rst 10 kg. • 50 m L/kg for secon d 10 kg. • 20 m L/kg for each addit ion al kg of body w eigh t . In ad dit ion : evaporated losses related to th e burn w ou n ds per day = 3,750 m L × BSAB (m 2 ) Th is volu m e is th en added to th e m ain ten an ce volu m e an d divided over 24 h ou rs. Altern at ively, th e m ain ten an ce volu m e per day in th e postacu te resu scitat ion period is calcu lated as [1,500 m L × TBSA (m 2 )] + [3,750 m L × BSAB (m 2 )] Ult im ately, th is calculat ion sh ou ld be adjusted to en sure adequate en d-organ perfusion as m on itored by th e pat ien t’s u rin e out put , w h ich sh ould be > 0.5 m L/kg/h for ad u lt s or 1 m L/kg/h for ch ildren . Bolu s addit ion al IV u id to m ain tain adequ ate u rin e out pu t . ERRNVPHGLFRVRUJ 44 Burns and Frostbite Escharotomy Late t issu e edem a m ay lead to vascular com prom ise secon dar y to decreased elast icit y of a bu rn scar. Th is is p ar t icu larly h azardou s in deep burn s of th e ext rem it ies an d circum feren t ial burn s of th e ch est w all. An esch arotom y is perform ed early for circu m feren t ial deep derm al an d full-th ickn ess bu rn s to th e ext rem it ies an d ch est . Gen erally, esch arotom ies sh ould be perform ed by a surgeon or a physician experien ced in th e procedu re to d ecrease m orbidit y. Procedure (Fig. 5.9, Fig. 5.10) • Use elect rocauter y or a scalpel to in cise th e bu rn ed skin . • Exten d dow n th rough esch ar in to th e su bcu t an eou s fat . • Cu t m idm edially or m idlaterally. Fig. 5.9 Incision locations for escharotomy. ERRNVPHGLFRVRUJ Burns and Frostbite 45 Fig. 5.10 Lateral and dorsal escharotomy of the upper extrem it y. • Exten d th e in cision th e length of th e con st rict ing burn esch ar an d across involved join ts. • Avoid m ajor vessels, n er ves, ten d on s, an d p ressu re su rfaces. Associated Conditions Inhalation Injury Th e leading cause of death in res is sm oke in h alat ion , n ot burn s. In h alat ion inju r y is presen t in on e-th ird of bu rn p at ien t s an d dou bles th e m or t alit y rate from bu rn s. Signs and Symptoms of Inhalation Injury • • • • • • An atom ical distort ion of th e face an d n eck edem a. In abilit y of th e p at ien t to clear secret ion s. Altered m en t al st at us. Decreased oxygen at ion . In creased carboxyh em oglobin . Lact ic acidosis. Management of Inhalation Injury • Evaluate pat ien t for in t ubat ion . • Perform a beropt ic lar yngoscopy an d bron ch oscopy for diagn osis an d soot/secret ion rem oval. • 100% oxygen su pp lem en tat ion . • Assess for carbon m on oxide poison ing. • Elevate ch est/h ead to 20 to 30 degrees at all t im es. ERRNVPHGLFRVRUJ 46 Burns and Frostbite • Liberal use of bron ch odilators su ch as albu terol. • Tran sfer pat ien t to a bu rn cen ter or crit ical care set t ing. For advan ced m an agem en t of severely burn ed air w ay: • In t ubate; apply p osit ive pressu re ven t ilat ion . • Posit ive en d-exp irator y pressu re (PEEP); m ain tain paten cy of sm aller air w ays. • Give th e p at ien t N-acet ylcystein e. • Adm in ister n ebulized h eparin . • Tran sfer pat ien t to a bu rn cen ter or crit ical care set t ing. Carbon Monoxide Toxicity Carbon m on oxide toxicit y is on e of th e leading cau ses of death associated w ith res an d is p rodu ced in th e p rocess of O2 com bust ion . Carbon m on oxide preferen t ially bin ds to h em oglobin in place of oxygen an d form s carboxyh em oglobin (COHb), w h ich sh ifts th e oxyh em oglobin dissociat ion cu r ve to th e left , redu cing oxygen deliver y. Sign s an d sym p tom s of carbon m on oxide poison ing are ou tlin ed in Table 5.3. Management of Carbon Monoxide Toxicity • Adm in ister h igh - ow oxygen by m ask (FiO2 100%) u n t il carboxyh em oglobin is < 10%. • For obt u n ded pat ien t s. – In t u bate. – 90 to 100% oxygen via p osit ive pressu re ven t ilat ion . If th e pat ien t is n ot respon ding to 100% oxygen: • Con sider advan ced m odes of ven t ilat ing. – Volu m e Di u sive Respirator (VDR; Percu ssion aire), h igh frequ en cy percu ssive ven t ilat ion – Bi-level inverse rat io ven t ilat ion (IRV). ▪ Hyperbaric th erapy. ERRNVPHGLFRVRUJ Burns and Frostbite 47 Table 5.3 Symptom s of carbon m onoxide poisoning COHb (%) Symptoms 0–10 Norm al value 10–20 Headache, confusion 20–40 Disorientation, fatigue, nausea, visual changes 40–60 Hallucination, com bativeness, com a, shock state > 60 Mortalit y > 50% Burn Patient Triage On ce th e burn ed p at ien t is stabilized, th e app ropriate facilit y to care for th e p at ien t is determ in ed. Triage of t h e bu rn pat ien t in clu des ou t p at ien t m an agem en t , inpat ien t m an agem en t , m an agem en t by a t raum a ser vice, or referral to a specialized burn cen ter. Th e criteria for referral to a burn cen ter are ou tlin ed in Table 5.4. Th e criteria for th e m an agem en t of burn vict im s as outpatients in clu de th e follow ing: • Burn s are < 10% par t ial-th ickn ess bu rn s w ith ou t in h alat ion inju r y. • Pat ien t s are resp on sive to oral an algesics. • Vict im s are com p lian t p at ien t s w h o w ill care for th eir w oun ds an d presen t for follow -u p evalu at ion w ith in 3 to 5 days. • Th ere is n o im m ediate or delayed risk to sp ecialized areas (i.e., circu m feren t ial bu rn s). All oth er bu rn vict im s requ ire h osp it al adm ission for m ore exten sive t reat m en t or m on itoring. At t im es, pat ien ts w ith m in or bu rn s m u st be adm it ted for p ain con t rol or person al safet y/cau t ion , as in th e case of abuse or pat ien ts w ith m u lt ip le preexist ing com orbidit ies or t rau m a. ERRNVPHGLFRVRUJ 48 Burns and Frostbite Table 5.4 Burn Center Referral Criteria A burn center may treat adults, children, or both. Burn injuries that should be referred to a burn center include the following: • Partial-thickness burns of greater than 10 percent of the total body surface area. • Burns that involve the face, hands, feet, genitalia, perineum , or m ajor joints. • Third-degree burns in any age group. • Electrical burns, including lightning injury. • Chem ical burns. • Inhalation injury. • Burn injury in patients with preexisting m edical disorders that could complicate managem ent, prolong recovery, or a ect m ortalit y. • Burns and concom itant trauma (such as fractures) when the burn injury poses the greatest risk of morbidit y or m ortalit y. If the trauma poses the greater im m ediate risk, the patient’s condition m ay be stabilized initially in a trauma center before transfer to a burn center. Physician judgm ent will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols. • Burns in children; children with burns should be transferred to a burn center veri ed to treat children. In the absence of a regional pediatric burn center, an adult burn center m ay serve as a second option for the m anagement of pediatric burns. • Burn injury in patients who will require special social, emotional, or longterm rehabilitative intervention. Source: From Com m it tee on Traum a: Am erican College of Surgeons. Reproduced with permission. Burn Wound Management Th e p at ien t sh ou ld be prem ed icated w ith an algesics prior to w ou n d t reat m en t to decrease discom for t an d in crease p at ien t cooperat ion . General Principles • • • • • Clean se th e w ou n ds of p ar t icles an d débride devitalized t issue. In it iate tetan us prophylaxis. Daily or t w ice-daily w oun d clean sing an d dressing. An t ibiot ics on ly for gross soft t issu e in fect ion . Aggressive pain con t rol. Use ch lorh exidin e, 0.5% silver n it rate com bin ed w ith ch lorh exidin e glu con ate, n orm al salin e, or soap an d w ater to clean se th e burn w oun d. To preven t w oun d in fect ion an d deeper w oun d conversion , topical an t im i- ERRNVPHGLFRVRUJ Burns and Frostbite 49 crobials are u sed u n t il epith elializat ion of t h e w ou n d is com p lete. Th e topical an t im icrobials are p rovided via gau ze ap plicat ion s, oin t m en t s, cream s, or solu t ion s; dressings are ch anged at least t w ice a day. Com m on ly used topical an t im icrobials are outlin ed in Table 5.5 an d an t im icrobial dressings in Table 5.6. Outpatient Wound Dressings Epidermal First-Degree Burns • Heal spon tan eou sly w ith lit tle in ter ven t ion requ ired. • Moist urize th e w oun d to alleviate p ain . Partial-Thickness Burns, Super cial Second-Degree Burns • Treat blisters. – Min or blisters over a sm all su rface area require n o in ter ven t ion . – Large, ten se, t u rbid, p ain fu l blisters. ▪ Using asept ic tech n iqu e, asp irate w ith a large-bore n eedle, leaving ep iderm is as a biologic dressing. ▪ Débride epiderm is if w ou n ds are con tam in ated. ▪ Clean w ou n d th orough ly an d dress. ▫ An t ibiot ic im pregn ated pet roleum gau ze. ▫ Biobran e (UDL Laboratories, In c.) for clean scald bu rn s. ▫ Aquacel Ag (ConvaTec) for w ou n ds w ith excessive exu date. • Ap ply soft bulky gau ze d ressing. • Adm in ister an algesics as n eeded. • Follow u p in 2 to 3 days. If th e p at ien t is free of pain an d w oun ds are h ealing, th en in st r u ct th e p at ien t or caregiver on h ow to con t in u e dressing ch anges at h om e. Mid- to Deep Dermal Burns, Second- and Third-Degree Burns • Clean w oun ds th orough ly w ith ch lorh exidin e. • Débride su per cial devitalized t issu e. • Dress w ou n ds w ith an t im icrobial m aterial. – Silvaden e. – Su lfam ylon for bu rn s w ith esch ar form at ion . – Act icoat (Sm ith & Neph ew ) an d Mepilex Ag (Möln lycke Health Care) are great altern at ives to cream s th at o er a m ore organ ized an d easier app licat ion w ith a greater an t im icrobial sp ect r um . • Ap ply soft bulky gau ze d ressing. ERRNVPHGLFRVRUJ t r s t i n e e t e g e c n a a i a r l z t a a a e i i h e c d b t C a a a o f r r l e t i c u d 5 i i . s n n 5 r r m e i e e f t e v v l a l l n i i b A S M S a T t c i r s e n s n a r o u n s i r h u t c o y i u c l t b c t s b l n l e s s s e s f i a a o s d h n n r n n e r r e t i n r t m i m e t m t u u r r a t u o a e a w e e b b c r r m r n b v e i t t s d a d a o s s p p g e - - p e r n c h e a e e a r n e d d a n c f i i v e e o s e e u e s h o n M D U c D D p B i P e d M s d t m i e t l n n n n b o o o a s a i i i m m m l l t t t i a a a a m u u u a l l l e e e r c i v r r r o o o o p A f C s C s C s o c i e l o v t a i e t r g i s s n a t t n s i l n l e i i s s z n u l o a v a f n s s u a i e o i i p c i i m t c i a a i t - c a b d c a s b m n n n l g a a a o t o m m g i o o a s f s e a r a c i l n a s u e h l a i o i c r g l s o m m u a c i u y l l y n a s y s i d n o e a g s - t o o i e i e d y t r c e i u l i i r i r r i b A m d d r m t g h e a s v t e i i a v d e m c u i s S i o i e u u t s u c p h t b t n n v a r t r a e v e o e c R i o b o a e r l n c l l a e c e s r s . o s t i p o A c S E K P a P C A m s C M M a E s S P G a r n t i y g y c a n t o h r a n i i t s t g o c n a i i i - n d h r t x a ” o n w a t r r o 2 c a s c t s t o a a i l l y t l s l c h o d h k r u t t t n p e e c c i n e s c p e y s i p a i v u l w e a e t a h e s e o b p s a o n t s s g y l e w o s e s s p d l o n l l i n u e l e e f i u p e n u t f l l l s m a o v e c c p a n n n r o u c i i i s e a a a e a a l o r % a a a o p e e L P C H “ P m 5 P C r C r p a i e e s s r m i a e e s s r n t v a n o d i i c e o y i d y a b s e i i t r m h a o c i a o l o e e l n m a l t r t i e g a a e m t i a b o c r e o l i c s e n n a c t l t r i l i h r n e e a a a m o o c n e v r e t m p k n e r b i r v o e p e o e o o a h b e o t b d i t t k p p p r c s p m e o e h u y y y a e y y o e n S R l H M C i M c h H H M 50 Burns and Frostbite ERRNVPHGLFRVRUJ ( n i x ) e y ] t e a m f n l y i l l u o K s p h n t i / n i ) n c a n i i i d m b c c e S m o o a u r o r a r i t t n t x i i c p a n t c l a u e n a B G o G M ( [ B C s s g n n a l r r h i d t u u t i e r b b t s s s s a w l l a n n n n c r a a r r r r s i i e u u u u n d c c l r b b e b b o u r r s t l l d d l e e b a a o l i i n n p p r p c c e a a x a u u a a E e S S F H F H W e - e l r m m m b e a a % t a u l e e a 1 e r r . r o 0 W s c C C s s d u s o e r r m u s e s i a v s s u i s n . t c a a a u n S c a n c n g o o s i c g r o o t c e e o o a s o m c m n l z c a - o o o i y i c i t e r d d n h A r r p m e u u S e p o c e t a l t e e r R a r e n s s t t n o G E P D S S E P M c r s b h o d t e n 2 f n i u 7 l o - o r i f t l e w t a a f t s h i a e r g s i a n e l i e l a u r a s c c s e o i n I h L t o y f 2 s d u e Burns and Frostbite 51 ERRNVPHGLFRVRUJ t a i n b A o r e g m t c r 6 i n a n . i o a o f 5 s r m c i s i o b t e r t e l o n c r e i b A d B X A a T m i l c i r o s s h s x c n i s i i 8 r e t o e a t l t 4 t o e n s a i a r s – o r n b t n i e u 4 i m u l t l e s t a n 2 d o i a a n h n t r o r e d t e w a p e n s o d n d t g l f o y o e a n c n y a a r c t l v t o a l c i m e t c h i d c i l t y b s b o o n c o e e p b i a r d c e r s e n r x o o s b o , a e a g t t i o e o c m m t e n r b i a t n l l t p s t e u o t s o e l a e a t e t l o n c s i g h e r i g n t h i b v y a y t e z n b l l t i e r e n r a i s e l s n l i m u o o o u e z e e n w s , b i y r s m r a e t p l l s m r s h t t e o c a h m / c g r m s i i d o e s t o e d e s n r a n r e r o i e r y r e l a h d p f t r e o m t o s d B e i s m y e n n c o a n n a l p y t r a i l i v v e l l e o o l o o o h a o % e a a i n i i i m n R 3 S C I C P i m N C D p C s S a P N b t r s s n d s e - n n a n r r e p d e i a s l u u u C b S H M b U ( r l s e a n i r d c u ) p r b d s e l l e n e a a r p i c d u u c s s o b m a l m e e s i t v c s s u i i a t c t a r s i c t a a n i t o g o e n s c m e g r o s o m u i l n a e e r r - o y r t v b A e d h l e e c i t m S o u p n v s e c a r e R a o r o a p e s t o N B S t S P G a M C a l i r t t 8 n s s 4 h a t t r h h i n n y r t t r i i e e a w p e w w a w m m v n r t t e t d d o g i n n e e e i i t y e n i n n o o g a a g r i i r l l a n o b b o m a a s t i i l a i u m m e o b b h n c o o n o o C n o s n r r c c a i t o r c c o m i i d e e i c b s t a b b e k e m m c t i i s m c t n n e t t n o e a f o a l a l n n o n M C i C C a a B c N e h d 52 Burns and Frostbite ERRNVPHGLFRVRUJ ( ) g g A A d l x e e e u c l i n a i p t u e n q o M A C n i m a a d t o 7 s f u – e s r 5 n e r d o b o n r c f r i a e l t i e o v l s d r c v i l e i e d t s s f s y e a o h e e s e n l l i n n l i a i l e n l i i l r a b d a t s d t s e o n s e r y d y o c r d i i d r c d c e r o m e e i o b n b t v n l a m i n a m N e S a e N s r f w m e o r t s e s a n d n d u g u p i x b s e l e e a w i e d n c o v i o o i h s t r t s s s - c e n t e r e d p c a i f u x u h n M b t i S e h l t a i m m e e e e s s i i t t v v s s s u s u i i a a t c t c a a r r s s i c i c t a t a n n i i o o g g o o n n c c m m e e r s o r s o m m u l u n l n e e e e r - r o - o y y t v t v b A b d A d h l h l c i c i m m S S o u o u p p s s e e a r a r e e R R a a r r p e s p t e s t o o S t S P G a M S t S P G a M a a l l i i r r t e g v t n i i a t s h p a , t r e e s t o r g e s a c n g b h d i e s d a u i d s e e x s y t w e d l e e r d a n h d g d e d n a g e i n h u u t e t g a x h o v a i i n h e r g i s w c c e k n e d o i e b a g s t h n h s e n n d u l t i a o e a s o r s - v s l n f m d w i l a e e o y r a r f e e r S s p f p d H o Burns and Frostbite 53 ERRNVPHGLFRVRUJ 54 Burns and Frostbite • Adm in ister an algesic. • Adm in ister an t ibiot ic (Bact rim DS by m ou th t w ice a day) for sign s of in fect ion (i.e., cellu lit is). • Follow u p in 3 to 5 days. • Refer for p ossible excision an d graft ing if h ealing is delayed beyon d 3 w eeks. Management of Burns to Speci c Anatomical Regions Hand Burns • • • • • • • Assess for n eu rovascular com prom ise. Perform esch arotom ies for deep circum feren t ial inju r y. St abilize op en join t d eform it ies w ith K-w ires. Elevate. Sp lin t in a p osit ion of safet y. Refer pat ien t for occu p at ion al th erapy. Wou n d care. – Apply Xeroform gau ze. – Use Biobran e glove for su per cial bu rn s. – Silver-im pregn ated dressings for deeper inju r y. • Full-th ickn ess bu rn s are referred for early excision an d graft ing to preven t scarring an d con t ract u re leading to dysfu n ct ion . Facial Burns • • • • Evalu ate for in h alat ion inju r y. Assess for inju r y to eyes an d ears. Keep h ead elevated. For su per cial an d deep bu rn s. – Daily clean sing. – Ap ply bacit racin oin t m en t . • For full-th ickn ess burn s. – Allow 5 to 7 days of h ealing before com m it t ing to graft ing. – Cover tem p orarily w ith am n ion or bacit racin . ERRNVPHGLFRVRUJ Burns and Frostbite 55 Ear Burns • Assess extern al can al an d dru m for ot it is m edia or extern a an d t ym pan ic m em bran e perforat ion . • Ap ply topical Su lfam ylon or gen tam icin oin t m en t to exposed cart ilage. – Bew are of ch on drit is. – Avoid p lacing pillow s u n der th e h ead. Eyelid Burns • Irrigate th e a ected eye w ith bu ered salin e solu t ion . • Perform u orescein exam in at ion to iden t ify corn eal injur y; con sult an oph th alm ologist . • Su p er cial burn s. – Th in layer of bacit racin oin t m en t—do n ot con tam in ate eye. • Fu ll-th ickn ess bu rn s. – Excise an d graft w ith fu ll-th ickn ess skin early to preven t ect ropion an d corn eal exposu re. Burns to the Genitalia • In ser t Foley cath eter to m ain t ain p aten cy of u reth ra. • Pen ile esch arotom y for circu m feren t ial injur y. • Par t ial-th ickn ess bu rn s h eal spon t an eou sly w ith con ser vat ive m an agem en t—am n ion , Polysp orin (P zer Ph arm aceut icals), bacit racin . • Refer fu ll-th ickn ess bu rn s for graft ing; dress w ith Silvaden e. Electrical Burns Electrical burn inju r y resu lts from a sp ect ru m of low - to h igh -voltage elect rical exposure from ligh t n ing, direct elect rical con tact (elect ric sh ock), an d elect rical arch ing. Th e passage of th e elect ric cu rren t th rough t h e body cau ses th erm oelect ric bu rn s. Flash burns are th erm al burn s cau sed by th e h eat gen erated by an arc of elect ricit y. Flam e burns m ay resu lt from ign it ion of cloth ing. Th e system ic m an ifestat ion s of elect rical injur y are gen erally greater th an th e local t issue injur y an d are p oten t ially fat al. Th e system ic com p licat ion s of elect rical inju r y are ou tlin ed in Table 5.7. ERRNVPHGLFRVRUJ 56 Burns and Frostbite Table 5.7 • • • Cardiovascular – Changes in the perm eabilit y of myocyte m em branes – Cardiac arrest and ventricular brillation – Conduction defects – Creation of arrhythm ogenic foci due to myocardial necrosis Neurologic – Loss of consciousness – Confusion – Am nesia – Seizures – Visual disturbances – Delayed onset paralysis Respiratory – • • System ic E ects of Electrical Exposure Apnea from dam age to cerebral respiratory center Renal – Acute tubular necrosis – Myoglobinuria Musculoskeletal – Myonecrosis – Rhabdomyolysis – Compartm ent syndrom e – Fractures and dislocations from tetany Management of Electrical Burns • Acu te air w ay m an agem en t an d resu scitat ion . • Adm it for obser vat ion or refer to burn u n it . • 24-Hou r con t in u ou s card iac m on itoring an d serial assessm en t of m yocardial dam age (creat in e kin ase [CK], t rop on in , L-lact ate dehydrogen ase [LDH]). • Evalu at ion for rh abdom yolysis an d m yoglobin u ria. – Diagn osis: ▪ In creased urin e pigm en t—red. ▪ Urin e dipst ick is h em e posit ive, bu t n o RBCs are seen on m icroscopic evalu at ion . ▪ In creased urin e m yoglobin . – Treat m en t: ▪ In crease ren al perfu sion . ▪ Aggressive resuscitat ion w ith in t raven ou s uids. ERRNVPHGLFRVRUJ Burns and Frostbite 57 • • • • • • ▫ To m ain tain adequ ate u rin ar y ou t p u t , at least 0.5 m L/kg/h of urin e (35 m L/h for a 70-kg pat ien t), bu t preferably 50 to 100 m L/h . ▫ Man n itol 0.25 to 1 g/kg over 20 m in u tes ever y 4 to 6 h ours. ▪ Alkalin ize urin e. ▫ Add sod iu m bicarbon ate—1 to 2 m Eq/kg/d to IV u ids; adjust dose according to seru m an d u rin ar y pH. Evalu ation of th e lim bs for com p ar t m en t syn drom e an d n eed for esch arotom y. MRI o r CT evaluatio n fo r dee per injuries. Oph th alm ologic an d otoscop ic evalu at ion . CT scan of th e h ead is in dicated in all h igh -volt age injuries. Evalu ation for h idden injuries—sp in al cord inju r y, blu n t th oracic or abdom in al t rau m a. Support ive care. Chemical Burns Ap proxim ately 3% of all bu rn s are secon dar y to ch em ical exp osu re, an d 30%of bu rn death s are d u e to ch em ical inju ries. More t h an 25,000 h om e or in dust rial product s are available th at can cause ch em ical inju r y. Th e resu ltan t injur y from ch em ical solu t ion s cau ses t issue protein coagulat ion an d n ecrosis. Th e o en ding agen t con t in u es to dest roy th e t issu es un t il th e agen t is n eu t ralized or com p letely rem oved. Deeper pen et rat ion of th e ch em ical com p ou n d can result in severe system ic toxicit y. Com m on h ou seh old agen t s an d n eu t ralizing su bstan ces are ou tlin ed in Table 5.8. Characteristics of Chemical Burns • Acid burn s. – Tissue dam age leads to co agulatio n necro sis. – Cause exoth erm ic react ion s w ith exposu re. – Associated w ith hyp ocalcem ia an d hypom agn esem ia. – Exposure m ay lead to in h alat ion inju r y. – System ic toxicit y m ay lead to h ep at ic or ren al failu re. • Alkali bu rn s. – Con st it u en t of lye exposure. – Tissue dam age leads to liquefactio n necro sis an d sapon i cat ion of fats. – Tissue inju r y app ears less severe th an th e act u al depth of inju r y. – Alkali bu rn s are associated w ith a h igh er in ciden ce of system ic toxicit y. ERRNVPHGLFRVRUJ 58 Burns and Frostbite Table 5.8 Com m on household agents associated with chem ical injury Agent Common use Treatment Phenol Deodorant Sanitizer Plastics Dyes Fertilizers Explosives Disinfectants Polyethylene glycol Vegetable oil Bacitracin ointm ent Phosphorus Explosives ( reworks) Poisons Insecticides Fertilizers Lavage with 1% copper sulfate Castor oil Sodium hypochlorite Bleach Milk Potassium perm anganate Deodorizer Egg white Disinfectant Paste Starch Lye Drain cleaner Water lavage Mafenide acetate Chrom ic acid Metal cleansing Water lavage Management of Chemical Burns • • • • Obtain a th orough h istor y to iden t ify o en ding agen t . Carefu lly in spect h an d s, face, an d eyes. Rem ove all cloth ing an d sou rces of ch em ical con tact . Im m ediately irrigate w ith w ater (except p h en ol). If th e pat ien t presen ts w ith a severe ch em ical exposu re, plan on irrigat ion for h ours in a sh ow er (esp ecially lye exposu res). Sm all exposures can be t reated w ith sm aller volu m es of u id. Alw ays err on th e side of m ore u id irrigat ion th an n eeded. • Resuscit ate based on am ou n t of su rface exposed an d m on itor urin e out put . • Con sider an t idote—refer to toxicologist , p oison con t rol cen ter, or local burn cen ter for assistan ce w ith m an agem en t . • Mon itor elect rolytes an d obtain blood gas to assess for system ic toxicit y. ERRNVPHGLFRVRUJ Burns and Frostbite 59 • Provide sup por t ive th erapy in a m on itored environ m en t for large bu rn s. • On ce irrigated, dress w ounds w ith Silvaden e or silver-im pregn ated dressing. • Refer p at ien t s to bu rn cen ters an d specialized facilit ies for excision an d graft of m id-derm al to fu ll-th ickn ess ch em ical burn s. Treatments for Speci c Chemical Burns • Sodiu m or lith iu m m et al, m u stard gas. – Cover w ith oil, san d, or Class D re ext inguish er; excise im m ediately. – Do n ot irrigate w ith w ater. • Ph en ol. – Wip e w ith polyethylen e glycol. – Do n ot irrigate w ith w ater. • Ph osp h oru s. – Cop per su lfate irrigat ion . • Hyd ro u oric acid. – Irrigate w ith 5% calciu m glu con ate or m assage w ith 2.5% calcium glucon ate gel. If pain persists, inject 5% calciu m glu con ate su bcu t an eously u n t il pain is relieved. – Magn esiu m sulfate su bcu tan eous inject ion m ay also be used. Chemical Burn Triage Du e to th e un iqu e m ech an ism of ch em ical bu rn injur y, sp ecialt y assist an ce sh ou ld be sough t from th e Am erican Associat ion of Poison Con t rol Cen ters’ h elp lin e (800–222–1222) or a local bu rn un it . Pat ien t s w ith th e follow ing ch aracterist ics sh ou ld be adm it ted an d p ossibly referred to a bu rn u n it: • Ch em ical inju r y > 15% TBSA. • Fu ll-th ickn ess bu rn s. • Burn s to th e perin eu m , eye, foot , h an d. • Mu lt iple com orbidit ies. • Pat ien t s at ext rem es of age. Intravenous Injection Injuries (IV In ltrates) Injection injuries are a form of chem ical burn that results from extravisation of an irritating chem ical during intravenous injection. The result is an interstitial in am m ator y process that w ill lead to local tissue necrosis and possibly system ic toxicit y. The degree of injury is dependent on the tox- ERRNVPHGLFRVRUJ 60 Burns and Frostbite icit y, am ount, and concentration of the m aterial injected. The m echanism of injury is by either induced ischem ia, osm otic derangem ent w ithin the tissue, or direct cytotoxicit y (Table 5.9). The reaction is progressive an d w orsens in the acute phase that can last days (Fig. 5.11). The local reaction is painful and begins as er ythem a that can progress to full-th ickness necrosis of the skin and even deeper penetration th rough the fascia to th e m uscle. Table 5.9 • • • Com m on agents associated with injection injuries Ischem ia-inducing agents – Dobutam ine – Dopam ine – Epinephrine – Norepinephrine – Vasopressin Hypertonic solutions – Calcium chloride – Calcium gluconate – Intravenous contrast agents – Potassium – TPN – 30% urea – 10% dextrose Cytotoxic agents – Chem otherapy drugs – Digoxin – Doxorubicin – Nafcillin – Tetracycline – Sodium bicarbonate Treatment of Injection Injuries Th e m ajorit y of inject ion inju ries involving dangerou s agen t s occu r in a m on itored environ m en t . Th erefore, th e am ou n t of exp osu re is lim ited an d th e m an agem en t is con ser vat ive due to th e relat ively sm all bu rden of injur y. Th e basic p rin ciples of con ser vat ive m an agem en t are as follow s: • Rem ove th e IV lin e. • Obtain a h istor y of th e agen t s being in fu sed. • Elevate th e a ected area. ERRNVPHGLFRVRUJ Burns and Frostbite 61 Fig. 5.11 IV in ltrate injury to the lower extrem it y demonstrating the progression from super cial to full-thickness injury. • Ap ply a cold com p ress. • If th e h an d is involved, u t ilize a sp lin t in th e safe p osit ion (w rist in dorsi exion , MCPs exed). • Diligen t obser vat ion . – Th e soft t issu e react ion m ay p rogress for 4 to 5 days. • An t ibiot ics for sign s of cellu lit is. In rare sit u at ion s w h ere th ere is m ore severe progressive t issu e dam age, con sid er a m ore aggressive ap p roach . Th is w ou ld in clu de th e in st illat ion of an an t idote in to th e a ected soft t issu e. Possible an t idotes in clude: • Hyaluro nidase: Hype ro sm o lar and cytotoxic age nts. • Phe nto lam ine: Vaso co nstricting agents. • Co rtico ste ro ids: Che m otherapy drugs. Early surgery is rarely indicated and is reserved for cases of m assive soft tissue injury associated w ith injection, com partm ent syndrom e, or vascular com prom ise. The patient is referred for excision and reconstruction of areas that have failed after 2 to 3 weeks to heal w ith conservative m anagem ent. Frostbite Cold inju r y resu lts from both t issu e freezing (frostbite) an d n on freezing injur y (t ren ch foot). Frostbite is th e resu lt of t issue freezing after exposure to tem p erat u res < 28°F (–2°C). At su ch tem p erat u res, ice cr ystals form in t racellu larly th at cau se t issu e dest ru ct ion , an d in t ravascu lar cr yst als con t ribu te to m icrovascu lar occlu sion . Th e p ath ogen esis of t ren ch foot is secon dar y to exp osu re, u su ally of an ext rem it y to a m oist environ m en t at tem p erat u res of 32 to 50°F (1 to 10°C) for long periods. Th is creates a scen ario of excessive h eat loss in th e involved region . Th ere is also isch em ic perfu sion secon dar y to vasocon st rict ion . Pat ien t s w ith cold th erm al injur y w ill com m on ly experien ce severe pain , pr urit us, n u m bn ess, p aresth esias, an d hyperem ia, w h ich m ay last u p to 6 w eeks. ERRNVPHGLFRVRUJ 62 Burns and Frostbite Management of Cold Thermal Injury • Rap id rew arm ing of th e involved area. – Water im m ersion —h eated to 104°F (40°C). • Adm in ister. – Paren teral an algesics. – Tet an u s prophyla xis. – System ic prost aglan din in h ibitors—ibu p rofen . – Topical th rom boxan e in h ibitors, e.g., aloe vera. • Débride n ecrot ic t issu e. – W h irlpool (hydroth erapy débridem en t). – Allow com plete w ou n d dem arcat ion before com m it t ing to radical surgical débridem en t . • Elevate a ected areas. • Begin early p assive range of m ot ion to all involved ext rem it ies. • Dress w oun d t w ice a day an d protect from fu r th er inju r y. ERRNVPHGLFRVRUJ 6 General Assessment and Management of Facial Trauma Facial t raum a varies in severit y from a sim ple lacerat ion to life-th reaten ing inju r y (Fig. 6.1). All p at ien t s requ ire an ap prop riate t rau m a evaluat ion begin n ing w ith th e ABCs (air w ay, breath ing, circu lat ion ). Th e pat ien t m u st also be evalu ated for oth er seriou s inju ries before focu sing on t reat ing th e facial injur y. Usu ally, t reat m en t of any in t ra-abdom in al, th oracic, or n eu rologic inju r y t akes p receden ce. Evalu at ion an d t reatm en t sh ould be coordin ated bet w een th e t rau m a, th oracic, vascular, ENT, or th op aedic, oph th alm ic, an d n eu rosu rgical ser vices. Th e exam sh ould star t w ith a detailed m edical, surgical, social, an d previou s cran iofacial inju r y h istor y. Th e m ech an ism of inju r y sh ou ld be ascert ain ed to gauge t h e force of con t act an d to determ in e th e locat ion of poten t ial fract ures or soft t issu e injuries. Addit ion al con siderat ion s in clude loss of con sciou sn ess, breath ing di cult ies, vision an d h earing de cit s. Fig. 6.1 Severe (a) penetrating and (b) blunt traum a to the face. 63 ERRNVPHGLFRVRUJ 64 General Assessm ent and Managem ent of Facial Traum a Airw ay Establishment Avoid n asal in t u bat ion in pat ien t s su sp ected of h aving a sku ll base fract u re or excessive m idface t rau m a to p reven t th e possibilit y of in t racran ial disru pt ion . Elect ive oral en dot rach eal in t u bat ion sh ou ld be con sidered in pat ien ts w ith severe pan facial t rau m a, esp ecially in th e m idface an d m an dible. Pat ien ts w ith large posterior base of tongue inju ries (in cluding lacerat ion s) sh ould be elect ively in t u bated . Any in t ubat ion sh ou ld be don e w ith cer vical spin e (C-spin e) precaut ion s: 10%of facial t rau m as h arbor a C-spin e inju r y. Trach eostom y sh ou ld be con sidered in com plex cases, p ar t icu larly w h en n asal or oral t rau m a preclu des u p per air w ay can n u lat ion s. Patient Evaluation Examination Rem ove all ar t icles of cloth ing an d jew elr y. Irrigate dir t , debris, foreign bodies, an d dr y cr usted blood to avoid obscu rat ion of th e injur y. Note all lacerat ion s, asym m et ries, bleeding, bruising, or foreign bodies. An organ ized, system at ic approach is recom m en ded to avoid any m issed inju ries. A carefu l exam in at ion sh ou ld in clude assessm en t for • Raccoon eyes (p eriorbital ecchym osis)—sku ll base fract ure. • Bat tle’s sign (post auricu lar ecchym osis)—sku ll base fract u re. • Otorrh ea—sku ll base fract u re, con dylar fract u re. • Hem ot ym pan u m —sku ll base fract u re. • Perforated t ym p an ic m em bran e. • Ep ist axis—n asal fract u re. • CSF rh in orrh ea—cribriform p late fract u re, NOE fract ure. • In t raoral inju r y. – Edem a. – Bleeding. – Gingival bleeding. – Fract u red /loose/disp laced teeth . – Den tal caries. • Nasal septal h em atom a. • Assess th e pat ien t’s den tal occlu sion an d h ave th e p at ien t com p are th is w ith th e p reinju r y occlusion . Abn orm al occlu sion is h igh ly suggest ive of m an dibu lar, m axillar y, an d Le Fort fract u res. • Test for m otor an d sen sor y d e cits (Table 6.1). Test all m uscles of facial exp ression an d follow w ith a detailed sen sor y exam . ERRNVPHGLFRVRUJ e l N I b I I V C I I I I V a T 6 . ERRNVPHGLFRVRUJ 2 m l a a l l a h i x t n i h a p m o e — g — i 1 r T V n r y m l r o i o l t t a a r y o n r a u i l e o m l a t e m o v c h c l i e E c t a m u g f o i p c l a r r O T N V O O T 1 c i o f c r a n e S e S n n s s a a t t o i o i n n t t o o m o f e d i r d e a c e a f h ; e i i t e , s t l r c e a c l ; o e i s c p s r r r s u l e n o u i a t p i m e c n m u d i e a s r e o r e i u t t e b s u q m i c h e l n q t n i n d p l b o l ; o u n c b o i s a f a i t o r y p r , e a r r r o o r v i v i a o o r r l l o r r i i l l t t i e e r r e e e h a e e p n p p n f f v g l u u m i u n e n n a S S l s i i P I S i n t s h C e s e n n d o a i e t k a h s e e r n o e F s s a t o i n , m e t u s g m a e n r u t i y t , f n t l l t r i w e o a a e n i u e i s i t n c e y p c o v c r l a o , i a i n r m a s f r l o e l t t a f l e a h l e i c w h s v o u t u o p o n n i o s l c c i l p o u l u o i w A V a O m p c t F C a n A n A e e s s t t h h e e s s a i a i e n v , , i o s i a t i i s c s i d p e g a v o e v o n t i e l i n t r d p r p k c i l e n u t r a a d t o r u e , n w u r o d ) l , r n a h n b i n a l t o l i e , n p o w n e s i h o o w t r s i , r i i w t m s u t a a v i s s c t o o a p i e f s n x d , o p n o s e e u l l i n r ( r i i f o d t s k l r s p p w n e c o o u p i y u l u i o l t y x a D B L p P e b p E d d r F a c t u r e o e i r r u e t t c s a o r P f s o f t h t e l n i a v i l b o r v o n i r m a , a l l i x F t l O u S a v g e e F F t t t l l l h m O O t u u u o S S a f a a r s v v v o g g d , e l l l i n n a n e a a i i a r t y t t t v v i e i i m u s l l a l j b n b b e o o x r p r r n o v v d i e a o o o e b n n l p i i r m r r , m a a r d i o o o e e e i o i l i i t o r r r t r r r f o a i n u u u a e t e e r t t t i t e t t m b c c c t s s s m b i h r a a a r o o e o o t r r r C e O p f h P f P f P General Assessm ent and Managem ent of Facial Traum a 65 ( t I I I n I I I X o V V V I C N C n i u l r a , a l e e r a l g a r l h n o c u , y r p , r o b i a c c a l s i l m d o a h t u n l e n l a p t , e b n i u a a l i , c o l b c m a d s i i u e m m a c o t s i n v d c s r — g c o a ) l 3 b e u y e a d G z b m c F A V e e m g i a r N T V e , x h s ; f n t s e n - y o l i f u r f c o t h o n a s c o c r r w o h u d e i t s e a r r d p t l i e r m l e l w a n u h e o l a c v u a o t i b r l h r a s i r , i g r t t e e u e k c o t n s o t n n i t d e a a e o r n m f n l o n n t e v i i n s e o i a / a t o f h o o t o t n y t t t i a g c s o o e r a o t t c r , r r i n o i s u i o a t o t h o o r p v r e s s d g t c t t t s t a r n e n i e n o a e n s o o e e e a h h e o u S S t m m M t t f t t n M H n I , s e t i r s u s a f e o r p l v e o c t — o e s e d , l n l y x r k i s a n i o e e e e i o t h w i i g n m s t e t t s s o e c n b o i h l r r i a r , e , u t c r a s r e s b i e a d c g t n p e e c c w e a b n u x e y y a a o S l f F e e e o H G A u F e x r n n r d e e h i t y o t o i , i r o e w a t b s g a i h o o i w s l t t n h s k p e i a f n y e a p y o l n d l e o e m h e a o n e p t v i r i w d e n h t d e f a n r d t , a i p o e o s p o , e s e i h n n s d ) l k c a t r n s d i r o a i a n o i a i l i e r u s f v o t a e t s c p f e o f g i c v a f e d i o h h r d f o g n n r t t e o i u r c e l t n r r s u c t a d i g n s a r f o a e r e s t s i n l n a s w s u e n l r o o o e h u o e n I L H A t ( b T s b t p t y D s ) s n F t n e l o i e O h r u s c l S a a m y n r u v e a s g r y a v o l r n r n r u a ( e l a i j o b u f t a v r e i r h j n i e l i t n o n d d v b u j o i r i f r r e s v N e r o o t e o t n n t n i C a a i n s e r x i s l o l e t i e c e a o e n t b i r a i u r i i e o r s a l u o t m s a u d r e t u n d t s o t e n s e l c c m a e d l s r c a i y t a a r u o e a r t o r F m P f L t s o R v m o P 66 General Assessm ent and Managem ent of Facial Traum a ERRNVPHGLFRVRUJ r I n I I t a u i n v i e N b o X C X X b C A ( s r a c s y s , r o N l o C g s e s : o u s e m p g c n ) y a c a o d i H N A V e t a l n a i l n e r , t e s r a h o t t m c o o o i o t t t d m s e i n n , u h e i o o y l t i i z r c t t a e o o a a p s p v v n r n r r a n m r n e e e e y o t t i s o s n n i t s , a d t n n l a , r i i a n e a v a r r v r a M u r r p o o e g C e t t e c M d S n n o s o n i C n ; o n n t M V M a i S I e v o , r s t o r e s t r e v k e r n l o d c t i o l , e a e r t e l s r r , u g n e r n n s a x e e o l n p t , u e o i n e c a i h a c u n n o n s l s e e w s i e e o n e a a u u g t r o i s y r g r t l r F o t c l g r n r t i s t u h i a g a a O y n n x r u n t o t s j i r a S r o e o h u o w e o a n ; T p G s h w l i S c r r F d i b t i e e a d l d l u l e u a g r u v r n u o e u j t o h , n t a i s x l i l n e e s a o h r p t i n e n e r f n t o k o e i o o a t g a t l i d i a i e t c n s n . s c g n o w p o e i i i f n d r u , t t f o u e a u k g a i f r i s a s u v s e s M v u s r e j e y d e C o i h n l D i D L d s W s S a t r o s k l e c i a r t e u n n j e l n a i s s r m l n n e b a t o o i u i i a t t s t l a n a p r p r e e e e e t c c e e o a a D l D l P General Assessm ent and Managem ent of Facial Traum a 67 ERRNVPHGLFRVRUJ 68 General Assessm ent and Managem ent of Facial Traum a Facial Palpation • • • • • • • • • • • • Ten dern ess. Crepit u s/subcu tan eou s em physem a. Bony step -o s. Scalp—gen tly palpate to u n cover dep ression s/crep it us. Foreh ead —fron t al sin u s fract u re. Orbit al rim . NOE (n aso-orbit al-eth m oid)—palp ate in t ran asally an d inw ard from m edial can th u s; bony m ovem en t to diagn ose NOE fract ure. Nasal bridge. Zygom a. Maxilla—gen tly dep ress th e m a xilla w ith both th u m bs to ru le out Le For t fract u res. If m obile, grab th e cen t ral in cisors bet w een th u m b an d in dex nger w ith on e h an d an d h old th e n asal spin e w ith oth er h an d. Movem en t of th e en t ire den tal alveolu s in dicates a Le For t I fract u re; m ovem en t of th e n asal bridge in dicates Le For t II or III. Man dible—preauricular p ain on p alp at ion can be in dicat ive of a con dylar fract ure. Neck exam —perform ed w ith cau t ion in relat ion to th e C-spin e. Ophthalmic Assessment • In sp ect ion . – Correct ive len s (con tact s or eyeglasses). – En op h th alm os/exop h th alm os. – Ret robulbar h em atom a. – In terpu pillar y distan ce—n orm ally 30 to 32 m m ; greater th an n orm al m ay in dicate an NOE fract u re. – Hyp h em a—blood layering in th e in ferior asp ect of th e an terior ch am ber. An oph th alm ologist sh ou ld be con sulted im m ed iately based u p on th e p oten t ial in crease in in t raocular pressu re. – Corn eal abrasion . – Su bconju n ct ival h em orrh age. – Ch em osis—scleral edem a. – Upp er eyelid ptosis m ay in dicate superior ssure syn drom e. – Fat prot ru sion . • Visual acuit y. – Test each eye sep arately by m easuring pat ien t’s abilit y to read legible n e prin t (ID card). – Diplop ia. ERRNVPHGLFRVRUJ General Assessm ent and Managem ent of Facial Traum a 69 – Red color sat u rat ion — rst color a ected in im p en ding opt ic n er ve inju r y. – Com pare an d con t rast red color percept ion in each eye in dividu ally. – Variat ion in exam m ay in dicate opt ic n er ve injur y. • Ext raocular m u scle fun ct ion —m u scle en t rap m en t; p erform forced duct ion test (Ch apter 9). • Pupillar y respon se—react ivit y, dilated, con st ricted. – Con sen su al ligh t respon se. ▪ If on e eye is exposed to ligh t , th ere sh ou ld be ipsilateral an d con t ralateral con st rict ion of th e p u p ils. ▪ An injured eye m ay be xed an d dilated secon dar y to in t rin sic dam age to th at eye, bu t m ain tain n orm al a eren t opt ic n er ve fu n ct ion . In th is scen ario, th ere w ill be loss of ipsilateral p u pillar y con st rict ion ; h ow ever, con t ralateral con st rict ion is m ain tain ed. – W h en con t ralateral pu p illar y con st rict ion is lost , th is in dicates an a eren t pu pillar y defect (APD) in th e a ected eye. ▪ In a p at ien t su spected of an a eren t p u pillar y defect , exposing th e u n a ected eye to ligh t w ill cau se both p u pils to con st rict . ▪ W h en th e ligh t is brough t back to th e a ected pu pil, th is p u pil w ill dilate (du e to con sen su al relaxat ion ), in stead of con st rict ing, con rm ing an a eren t pu p illar y defect in th is eye. – Medial/lateral can th al ten don stabilit y—t ract ion test: pull laterally on m edial aspect of low er eyelid; laxit y is in dicat ive of m edial can th al ten don disru pt ion . Im m ediate at ten t ion sh ou ld be paid to any sign s of acu te opt ic com p ressive n europ athy, pen et rat ing globe inju ries, or vision loss. Any qu est ion able inju r y or con dit ion w arran t s an op h th alm ologic con su lt/evalu at ion . Radiographic Evaluation If facial fract u res are su sp ected, a CT scan of th e face is w arran ted (Fig. 6.2). High -resolu t ion (axial, sagit t al, an d coron al) view s sh ou ld be obtain ed, an d 3D recon st r u ct ion s obtain ed if possible (Fig. 6.3). In t h e case of a m an dible fract u re, a Pan orex radiograp h is t h e on ly plain lm t h at sh ould st ill be rou t in ely obt ain ed even if a CT scan of th e face is also obtain ed (Fig. 6.2). Pan orex radiograph lm s are excellen t for evalu at ing fract u res an d con dyles, an d t h ey p rovide a single p lain lm view of th e en t ire m an dible. Th ey are also useful in evaluat ing den t it ion such as im p acted m olars. Pan orex lm s are n ot good for evalu at ing fract ures of th e sym p hyseal region . ERRNVPHGLFRVRUJ 70 General Assessm ent and Managem ent of Facial Traum a Fig. 6.2 (a) Panorex radiograph of a m andible with fractures of the parasymphysis and angle. CT scan of the mandible dem onstrating the same fractures of (b) angle and (c) parasymphysis. Fig. 6.3 3D reconstruction of the facial bones. ERRNVPHGLFRVRUJ General Assessm ent and Managem ent of Facial Traum a 71 Addit ion al plain lm s (rarely u sed) in clu de: • W aters view : PA view th at requ ires n eck exten sion . Occipit al-m en t al project ion th at opt im izes su p erior an d in ferior orbit al rim s, n asal bon es, zygom a, an d m axillar y sin u ses. • Caldw ell view : PA view th at requ ires n eck exion . Occipital-orbital project ion th at opt im izes fron t al bon es an d sin u s, lateral w alls of th e m axillar y sin u s, orbital rim s, an d zygom at icofron t al sut u res. • Lateral view : Opt im izes an terior fron t al sin u s w all, an terior an d posterior m axillar y sin u s w alls. • Subm ental view : Opt im izes view of zygom at ic arch es. Urgent Interventions Hemorrhage Control Large, deep lacerations can rst be treated w ith irrigation, follow ed by application of pressure to con trol bleeding. Active arterial bleeders can be tied o or sut ure ligated w ith 4–0 Vicr yl suture. Wounds can be extended w ith a scalpel to gain exposure. Because of the extensive collateral vascular supply of the face and scalp, even lacerations to the facial artery can be ligated if necessary to control bleeding. To avoid injury to nerves and other vital structures, do n ot blindly clam p any vessels. If direct visualization is not possible due to excessive bleeding, place 4x4 gauze on the w oun d, place pressure on the wound, and take the patient to the operating room . Epistaxis can be con t rolled w ith an teroposterior n asal packing. Obt ain a n asal speculum an d bayon et forceps, along w ith a Cot ton oid (Codm an & Sh u r tle ) soaked in epin eph rin e (1:200,000) (Fig. 6.4a). Four percen t cocain e m ay also be u sed, bu t w ith great cau t ion (Afrin in an altern at ive). If a Cot ton oid is n ot available, cu t Xeroform gau ze in to st rips an d layer th ose in to th e n asal cavit y. Un der direct visualizat ion using a n asal specu lu m , layer (d o n ot st u or pack) th e gau ze or Cot ton oid in to th e posterior n asal ph ar yn x (Fig. 6.4). W h en n asal p acking is used , star t th e pat ien t on p rop hylact ic an t ibiot ics to p reven t st reptococcal toxic sh ock syn drom e. Occasionally, m idface and m andibular fractures can result in severe bleeding. Com m on vascular structures include the m axillar y artery, alveolar artery, retrom andibular vein, facial arter y/vein, or buccal branches of the facial arter y. Access to these structures is di cult, and attem pts should be m ade to obtain som e crude reduction to tam ponade the bleeding. A Barton bandage can be applied using Kerlix reinforced w ith an Ace bandage to apply com pression to the face. The Kerlix is w rapped coronally m ultiple tim es to hold the m andible in occlusion, then w rapped around the forehead. Reinforce w ith an Ace w rap (Fig. 6.4c). ERRNVPHGLFRVRUJ 72 General Assessm ent and Managem ent of Facial Traum a Fig. 6.4 Techniques for achieving hem ostasis. (a) Anterior nasal packing. (b) Posterior nasal packing. (c) Barton bandage head wrap. (d) Selective arterial ligation or em bolization. Mandibular Stabilization Com m in u ted or com p lex fract u res of th e m an dible can be acu tely st abilized to redu ce oral air w ay edem a an d redu ce p ain . A bridle w ire (25-gauge w ire passed aroun d t w o teeth an king a fract ure) can be used to h elp st abilize a fract u re. St abilizat ion w ill also h elp to o set th e pat ien t’s p ain . A m ore e ect ive tech n ique m ay be Essig w iring. Th is involves passing a 25-gauge w ire arou n d t w o teeth on eith er side of th e fract ure an d th en placing in terden t al w ires above an d below th e rst w ire. ERRNVPHGLFRVRUJ General Assessm ent and Managem ent of Facial Traum a 73 Nasal Septal Hematomas Nasal septal h em atom as sh ould be drain ed in th e em ergen cy room to preven t sept al n ecrosis. Using an 18-gauge n eedle or 11-blade scalpel, m ake a sm all perforat ion in th e m ucosa w ith a n asal speculum un der direct visu alizat ion . Evacu ate th e h em atom a an d ap p ly a com pressive dressing (Xeroform layered packing w ith bacit racin oin t m en t) to p reven t reaccu m u lat ion (Fig. 6.4a). Note th at if th ere w as n o epistaxis at th e t im e of th e inju r y, th e p resen ce of a n asal bon e fract ure is less likely. Auricular Hematomas Auricular hem atom as sh ou ld be t reated like sept al h em atom as. Drain w ith a scalpel or an 18-gauge n eedle (aspirate) an d apply pressure dressing. Bolster th e ear w ith rolled-u p Xeroform gau ze sut ured in place w ith th rough -an d-th rough 2–0/3–0 nylon or Prolen e (Fig. 6.5). Fig. 6.5 Ear bolster dressing technique. ERRNVPHGLFRVRUJ 74 General Assessm ent and Managem ent of Facial Traum a Acute Optic Compressive Neuropathy Acute opt ic com pressive neuropathy requ ires em ergen t lateral can th otom y (Fig. 6.6) along w ith m an n itol, acet azolam id e, an d m ethylpredn isolon e to decrease in t raocular pressure an d to con t rol orbit al n er ve edem a (see Ch apter 8). • Man n itol: 50 to 100 g (1.5 g/kg) of 5% solut ion IV over 2 h ou rs; rep eat dose to m ain t ain u rin e ou t p ut (> 30 to 50 m L/h ou r), w ith a m axim u m of 200 g/d. Test d ose w ith 200 m g/kg. • Acetazolam ide: 250 m g by m outh ever y m orn ing or 5 m g/kg IV ever y 24 h ours. • Methylp redn isolon e: Loading dose of 30 m g/kg; th en , after 2 h ou rs, 15 m g/kg ever y 6 h ou rs. Fig. 6.6 (a) Lateral canthotomy. (b) Release of the lateral canthal tendon. ERRNVPHGLFRVRUJ General Assessm ent and Managem ent of Facial Traum a 75 Treatment Sequence and Timing Polyt raum a pat ien t s w ill be adm it ted to th e t raum a ser vice. Bony repair is delayed u n t il th e pat ien t is st able. If p ossible, repair sh ou ld be perform ed im m ediately to avoid excessive edem a or delayed from 10 days to 2 w eeks after inju r y to allow th e edem a to su bside. Soft t issu e inju ries sh ould be irrigated an d repaired w ith in 8 h ours. Do n ot leave open w ou n ds on th e face to gran u late; at tem pt closu re by any m ean s. Rem em ber th at closu re does n ot n eed to be de n it ive because revision s can be m ad e later during bony rep air. ERRNVPHGLFRVRUJ 7 Facial Lacerations Facial soft t issu e inju ries range from sim p le lacerat ion s to com p lex avu lsion s of th e facial skin an d ap pen dages (Fig. 7.1). Th ese injuries con t rib ute to a large n u m ber of visit s to em ergen cy room s in th e Un ited States each year. Th e m ech an ism of injur y varies from pen et rat ing to blun t t rau m a an d also in clu des sh earing m odalit ies. Motor veh icle accid en t s (MVAs) com prised th e m ajorit y of th ese inju ries. Advan ced autom obile safet y equ ip m en t h as redu ced th e prevalen ce of th ese inju ries. How ever, th e overall in ciden ce of facial inju ries d u e to sp or t s- an d job -related inju ries, an im al bites, an d factors related to dom est ic an d in terperson al violen ce h as rem ain ed con stan t . Treat m en t ranges from sim p le lacerat ion repair to rep air of sp ecialized an atom ical st r u ct u res an d m icrovascu lar rep lan t at ion . Fig. 7.1 Complex facial laceration (a) before and (b) after repair. 76 ERRNVPHGLFRVRUJ Facial Lacerations 77 Assessment Th e im m ediate priorit y for pat ien t s w ith facial injuries is to r ule out a life-th reaten ing air w ay or in t racran ial inju r y an d to con t rol th e air w ay an d stop any bleeding. Det ailed evalu at ion of th e facial t rau m a p at ien t is ou tlin ed in Ch apter 6. Th e physical exam in at ion proceeds w ith in spect ion an d palpat ion of th e pat ien t . Using a system at ic approach from th e scalp to th e base of th e clavicles, in spect for lacerat ion s, localized areas of edem a, an d ecchym osis th at m ay in dicate u n derlying inju r y. Care m u st be t aken to adequ ately rem ove any debris an d dried blood in th is region , w h ich can easily cam ou age lacerat ion s an d lead to m issed inju ries. Diligen tly assess cran ial n er ve fun ct ion by speci c provocat ive m an euvers. Facial injuries associated w ith lacerat ion s are grossly iden t i ed by in spect ion of facial asym m et r y at rest an d du ring an im at ion an d by assessing sen sor y fu n ct ion (see Table 6.1 in Ch apter 6). How ever, be cogn izan t t h at soft t issu e edem a m ay lim it n orm al facial m ovem en t , leading to false readings of facial n er ve fu n ct ion . Ut ilizing palpat ion , appreciate focal areas of ten dern ess, depression s, crep it u s, an d edem a th at m ay in dicate h em atom a or a bony fract u re. Pat ien t s w h o h ave injuries suspiciou s for facial fract ures sh ould h ave th eir w ou n ds th orough ly irrigated, débrided, an d closed, an d sh ou ld be referred for radiograp h ic evalu at ion (see Ch apter 6, Rad iograp h ic Evaluat ion ). Treatment General Procedures • Follow basic lacerat ion closu re p rocedu res (see Ch apter 3). • Measure th e lacerat ion an d assess for an atom ical distor t ion of specialized st r uct u res. • Irrigate an d perform con ser vat ive débrid em en t . Be m in dfu l th at overly aggressive débridem en t arou n d th e n ose, eyelids, an d brow m ay lead to severe d is gu rem en t . • For pat ien ts w ith severe “road rash ” or a blast inju r y, clean th e w ou n d m et icu lou sly u n der lou p e m agn i cat ion . Th is proced ure is t im e-con su m ing, but you w ill h ave bet ter resu lts. • Tetan u s prophylaxis. ERRNVPHGLFRVRUJ 78 Facial Lacerations • Local an esth esia prior to d ébridem en t an d lacerat ion repair w ill h elp facilitate th e p rocedu re. – Field blocks w ith 1% lidocain e/1:100,000 epin eph rin e th rough a 25- or 27-gauge n eedle. – Con sider region al blocks for large lacerat ion s isolated to a single n er ve d ist ribu t ion . – Region al blocks of th e t rigem in al n er ve are p erform ed by in st illat ion of 2 to 4 m L of local an esth esia (1% lidocain e or 0.25% Marcain e [Abbot t Laboratories]) above th e p eriosteum in th e region of th e n er ve (Fig. 7.2). • Man age su per cial lacerat ion s w ith m in im al dis gu rem en t con ser vat ively. – Clean se abrasion s daily an d ap p ly an t ibiot ic oin t m en t (bacit racin t w ice a day). – Close sm all w ou n ds w ith Steri-St rips (3M) or Derm abon d or Derm abon d Prin eo (Eth icon ). • Close larger lacerat ion s as soon as p ossible; w ait ing 2 or 3 days w ill com p rom ise th e resu lts. Lacerat ion s th at p resen t 6 to 8 h ours after inju r y n eed to be th orough ly irrigated an d th e w ou n d edges fresh en ed prior to closu re. Fig. 7.2 Placement procedures for regional blocks of the trigem inal nerve for the repair of facial soft tissue trauma. ERRNVPHGLFRVRUJ Facial Lacerations 79 • To avoid d ep ressed scarring, close deep t issu e w ith th e app ropriate sut ures. – Mu scle—Mon ocr yl 4–0, Vicr yl 4–0. – Skin . ▪ Deep layer—Mon ocr yl 5–0, 6–0. ▪ Super cial layer—nylon /Prolen e 6–0, 7–0. – Mu cosa—ch rom ic 3–0, 4–0. Pediat ric p at ien t con siderat ion s: • Pursu e radiograph ic evaluat ion to ru le ou t any associated fract u res. • Use con sciou s sedat ion (Ch apter 2) to red u ce em ot ion al t rau m a for th e p at ien t an d to rep air di cu lt lacerat ion s in sp ecialized areas safely (e.g., p eriorbital region ). • Use absorbable sut ures. – Skin . ▪ Deep layer—Mon ocr yl 5–0, 6–0. ▪ Super cial layer—fast-absorbing p lain gu t 5–0, 6–0. – Mu cosa—ch rom ic 5–0. – Mu scle—Vicr yl 4–0. Lip Lacerations • Ap proxim ate each layer of a fu ll-th ickn ess lacerat ion (Fig. 7.3). – Mu scle—Mon ocr yl 3–0, 4–0; Vicr yl 3–0, 4–0. – Skin —nylon /Prolen e 6–0, 7–0. – Mu cosa (all surfaces of lip )—ch rom ic 3–0, 4–0. • In st ruct th e pat ien t to m in im ize oral m ovem en t as m u ch as possible for 5 days after rep air. • Recom m en d a liquid diet for large in t raoral lacerat ion s, an d clean sing w ou n ds 5 t im es a day w ith Peridex m ou th w ash —sw ish an d discard. Lacerat ions through the w hite roll (skin–verm ilion border): • Align th e w h ite roll (skin –verm ilion ju n ct ion ), p h ilt ral colum n s, an d cup id’s bow before inject ion w ith local an esth esia. Th ese an atom ical lan dm arks w ill be distor ted by th e ed em a th at occurs after inject ion . • Ap proxim ate th e w h ite roll exactly to obt ain th e best cosm et ic ou tcom e. • Ap proxim ate th e orbicularis oris at th e ap propriate h eigh t to avoid a depressed scar. • Th e skin is approxim ated w ith a n on absorbable su t u re (nylon , Prolen e 6–0) at th e w h ite roll. • Sut ure th e verm ilion w ith 5–0 ch rom ic gu t su t ures. ERRNVPHGLFRVRUJ 80 Facial Lacerations Fig. 7.3 Layered closure of lip lacerations. Ear Lacerations • Irrigate ear lacerat ion s th orough ly, but débride con ser vat ively to preven t car t ilage exposu re. • En sure skin closu re over car t ilage to avoid ch on d rit is. • Approxim ate skin an d p erich on drium in a single bite u sing n on absorbable sut u res (Prolen e, 5–0 or 6–0). • Prescribe oral p rophylact ic an t ibiot ics (Bact rim DS by m ou th t w ice a day) for 5 to 7 days. • Clean an d cover in cision s t w ice a day w ith an t ibiot ic oin t m en t (Sulfam ylon or gen tam icin oin t m en t). • Prepare dressings to avoid h em atom a form at ion (Fig. 6.5). • Apply Xeroform w ith u ed gauze in a p ressu re dressing w ith circu m feren t ial h ead w rap. • Assess for p erich on drial h em atom as (Ch apter 6). ERRNVPHGLFRVRUJ Facial Lacerations 81 Large Ear Defects Large defects w ith eith er com posite or excessive skin loss m ay require secon dar y recon st ru ct ive p rocedu res for closu re (i.e., skin graft , part ial com posite resect ion ). • Cover ear w ith Xeroform an d em ploy frequ en t dressing ch anges un t il recon st ruct ion to avoid desiccat ion of th e car t ilage. Avulsion Injuries (Fig. 7.4) • Treat im m ediately to avoid vascu lar com p rom ise. • Assess for perfusion of th e avu lsed fragm en t . – Laser p h otograp hy w ith in docyan in e green p erfu sion test (Spy, Novadaq) is u sefu l to determ in e if th ere is perfu sion to th e par t ially am pu tated p ar t . • Débride, t rim , an d at tach sm all avu lsion fragm en t s as a com posite graft (< 1.5 cm ). Am putat ion an d large avulsion s m ay require m icrovascular at tach m en t depen ding on th e site of avu lsion an d residu al vascu lat ure. Altern at ively, th e car t ilage arch itect u re m ay be preser ved by derm abrasion of th e avulsed part w ith storage un der a postauricu lar ap or in th e abdom in al su bcu t an eou s t issu e (“pocket prin cip le”). Th is w ill allow u se of th is fragm en t for delayed recon st r u ct ion . How ever, th is p rocedu re is n ot as opt im al as reat t ach m en t of th e ear, if reat t ach m en t is possible. Microsu rgical Fig. 7.4 (a) Ear avulsion injury with preservation of the posterior circulation (b) allowing at tachm ent with complex repair. ERRNVPHGLFRVRUJ 82 Facial Lacerations rep lan t at ion can be perform ed to th e su per cial tem p oral ar ter y or th e posterior au ricular ar ter y. Ven ous out ow is provided by drain age to th e extern al jugular vein . Ut ilize vein graft s w h en n ecessar y. Ven ous congest ion is a com m on problem after repair of avulsion s. Large avulsed fragm en t s an d am put ated ears w ill require leech th erapy for sur vival. Scalp Lacerations • Ru le ou t in t racran ial inju r y. • Prom ote h em ostasis w ith a p ressu re dressing u n t il th e environ m en t is appropriate for exp lorat ion . • Iden t ify all lacerat ion s by carefu lly rem oving debris an d blood w ith hydrogen peroxide an d w ater. Sh aving is rarely n ecessar y. • Irrigate w ou n ds w ith am ple am ou n t s of n orm al salin e an d rem ove any m issed foreign bodies. • Layered closure. – Galea—Vicr yl or Mon ocr yl 2–0. – Skin —fu ll-th ickn ess bites, con t in u ou s su t ure for h em ost asis; Prolen e (blu e) 3–0, 4– 0, or st ap les. • Use sm ooth picku ps to pu ll h air ou t from th e w ou n d an d from un dern eath th e su t u res. • Use a Pen rose drain cu t longit u din ally un der scalp ap for w oun d drain age for 1 to 2 days, closed su ct ion drain s for large scalp avulsion s. • Large scalp avu lsion s (Fig. 7.5 ). – Determ in e adequ acy of perfusion . ▪ Look for bleed ing at th e skin edges. ▪ Ut ilize in d ocyan in e green angiograp hy. – Th orough irrigat ion an d layered closu re over drain s. • Scalp am pu tat ion s. – A sh arp cu t t ing am p u t at ion m ay p rovide vital t arget s for m icrosu rgical at t ach m en t . Leech es can be ap plied for ven ous congest ion if vein s are w eak or u n available. – Sh earing an d sh redding inju ries m ay n ot h ave reliable vessels in th e am pu tated por t ion for su ccessfu l m icrosu rger y. ▪ Con sider defat t ing th e am pu tated p ar t an d graft ing to th e galea if in tact . ERRNVPHGLFRVRUJ Facial Lacerations 83 Fig. 7.5 (a) Large scalp avulsion perfused by lateral circulation. (b) Closure after irrigation and débridement over Penrose drains. Eyelid and Eyebrow Lacerations • • • • Ru le ou t ocu lar inju ries (see Ch apters 9 an d 10). Bew are of lacrim al duct inju r y. Cop ious irrigat ion to rem ove ocu lar foreign bodies. Layer-by-layer closu re of conju n ct iva, tarsu s, an d skin u sing 6–0 fast-absorbing gu t w ith inver ted kn ot aw ay from th e corn ea. Conjun ct ival closu re is n ot alw ays n eeded w h en th ere is good in tegrit y of th e oth er layers. – Orbicu laris—6–0 Vicr yl su t u re. – Skin —6–0 fast-absorbing gu t or 6–0 nylon . For eyebrow lacerat ion s: • Do n ot sh ave. • Layered closure. – Deep layer an d m u scle—Mon ocr yl, Vicr yl 5–0. – Skin —exactly align brow elem en ts u sing Prolen e 5–0, 6–0. Eyelid Margin Lacerations (Fig. 7.6) • Ap proxim ate lid m argin . • Ever t th e lid m argin to p reven t lid n otch ing w ith ver t ical m at t ress sut ure. • An tem argin al tarsu s. – Tw o or th ree 6–0 Vicr yl su t u res. – On e-h alf to th ree-qu ar ters of th e th ickn ess of th e tarsus. – Kn ot en ds directed aw ay from th e corn ea. – Skin Prolen e 7–0. ERRNVPHGLFRVRUJ 84 Facial Lacerations Fig. 7.6 Repair of full-thickness eyelid laceration with repair of tarsus. Nasal Lacerations • Ach ieve n asal h em ost asis (see Ch apter 6). • In spect n asal cavit y to ru le ou t n asal septal h em atom a. – Drain h em atom a u n der direct vision w ith an 11-blade scalp el. • Layered closure of fu ll-th ickn ess lacerat ion s. – Mucosal layer—p lain gu t 4–0. – Align skin an d car t ilage togeth er w ith Prolen e 6–0. • Sp lin t n ose w ith Steri-St rips. Facial Hematomas • Evalu ate for in t racran ial inju ries an d C-spin e inju r y. • Adm in ister p ain m edicat ion . • Apply cold com presses for 48 h ou rs, an d th en ap p ly w arm com presses u n t il resolu t ion . • Drain h em atom as th at com p rom ise th e air w ay or visual axis. • Explore h em atom as th at are expan ding desp ite adequ ate pressure th erapy. • Evacu ate h em atom as th at p redisp ose th e overlying skin to p ressu re n ecrosis. • W h en a h em atom a is cou pled w ith a lacerat ion , u se th e lacerat ion as an access poin t for evacuat ion . • Aspirate h em atom as th at occu r in th e m alar region u sing an in t raoral in cision to avoid in ict ing addit ion al facial scars. ERRNVPHGLFRVRUJ Facial Lacerations 85 Facial Nerve Injuries • Lacerat ion s th rough th e su p er cial m usculoapon eurot ic system (SMAS) an d facial m u scu lat u re p u t th e n er ve at risk at any poin t along it s rou te (Fig. 7.7). • Injur y to th e tem poral or zygom at ic bran ch cau ses an in abilit y to elevate th e brow or close th e eye, respect ively. • Dam age to th e bu ccal bran ch cau ses loss of th e n asolabial crease an d an in abilit y to elevate th e lip. • Margin al m an dibular n er ve inju r y cau ses w eakn ess of th e low er lip depressors (frow n ing). Fig. 7.7 The course of the facial nerve: (a) frontotemporal branch, (b) zygomatic branch, (c) buccal branch, (d) marginal m andibular branch, and (e) cervical branch. ERRNVPHGLFRVRUJ 86 Facial Lacerations Facial Nerve Lacerations • On ce th e lacerat ion is iden t i ed , n er ve repair sh ou ld be perform ed w ith in 72 h ou rs. Repair w ith in th is t im e fram e allow s for th e iden t i cat ion of severed n er ve en ds u sing a n er ve st im u lator before th e m otor en d p lates are dep leted of n eurot ran sm it ters. • At tem pted repair after 72 h ours is ext raordin arily di cu lt secon dar y to con t ract ion of th e cut segm en t an d th e in abilit y to st im ulate th e distal en d for exact m atch ing to th e proxim al en d. • Repair th e n er ve in th e op erat ing room u n der lou pe m agn i cat ion or w ith th e m icroscop e. • Iden t ify an d t rim th e p roxim al an d distal n er ve en ds prior to an astom osis. • An astom ose th e fresh n er ve en ds u sing ten sion -free 9–0 or 10–0 n on absorbable (nylon ) su t u res in an epin eu ral fash ion . Fibrin glu e is also usefu l. • Sign i can t n er ve loss or ten sion m ay requ ire n er ve graft ing or th e use of ar t i cial n er ve con du its. For blun t injuries to th e face th at cau se n eu ropraxia to th e facial n er ve: • Th ese do n ot requ ire im m ediate op erat ive m easu res. • Mon itor for sign s of im p rovem en t over th e cou rse of 3 w eeks. • If th ere is n o eviden ce of h ealing, refer th e pat ien t for elect rodiagn ost ic test ing (ENoG, EMG). – Id en t i cat ion of advan ced arch itect u ral inju r y to th e n er ve at th is poin t w arran t s explorat ion an d rep air. Parotid Duct Injuries Th e p arot id du ct t raverses in a plan e from th e t ragu s to th e m iddle of th e upper lip . Th e du ct ori ce is in th e buccal m ucosa opposite th e secon d m axillar y m olar. Ext raoral or in t raoral lacerat ion s in th is locat ion place th ese st ru ct u res at risk for inju r y. Inju r y to th e bu ccal bran ch of th e facial n er ve sh ou ld also raise suspicion for p arot id du ct inju r y. A pat ien t w ith a su spected p arot id du ct lacerat ion can be tested easily by p lacing tooth paste in th e pat ien t’s oral cavit y. Excessive saliva w ill be expressed from th e lacerat ion . • Evalu ate a p arot id du ct inju r y by can n u lat ing th e in t raoral segm en t w ith a 22-gauge Angiocath (BD Medical). • Inject 1 m L of m ilk or m ethylen e blu e to assess paten cy. • Repair lacerated du ct over a sten t in th e op erat ing room u sing 7–0 m on o lam en t nylon su t u res (Fig. 7.8). ERRNVPHGLFRVRUJ Facial Lacerations 87 • Keep th e sten t in p lace for 5 days to allow paten cy an d p reven t st ula form at ion . • Give th e pat ien t prop hylact ic an t ibiot ics d u ring th is period—clin dam ycin . • Recon st ru ct ost ia for th e p roxim al segm en t or du ct ligat ion if th ere is severe irreparable dam age of th e p arot id du ct . • Oversew parot id glan d inju ries w ith out du ct injuries w ith absorbable su t u re—Mon ocr yl 3.0, 4.0, or Vicr yl. Fig. 7.8 Repair of parotid duct injury over Silastic (Dow Corning) stent. ERRNVPHGLFRVRUJ 8 Orbit and Zygoma Fractures The Orbit Anatomy Th e orbit is com p osed of seven bon es: • Zygom a. • Greater an d lesser w ing of th e sp h en oid. • Eth m oid. • Fron tal. • Palat in e. • Maxilla. • Lacrim al. Th ese seven bon es create a bony pyram id w ith th e opt ic can al at t h e ap ex. Th e orbit is com posed of th e follow ing st ru ct u res: • Floor: Roof of th e m axillar y sin us. • Med ial w all: Lam in a p apyracea of th e eth m oid bon e an d th e lacrim al bon e. • Lateral w all: Zygom a an d greater w ing of th e sp h en oid bon e. • Roof: Fron t al bon e, oor of th e fron tal sin u s. Th e m edial w all is th e w eakest st ru ct u re, follow ed by th e oor. Th e roof an d th e lateral w all are gen erally th e st rongest . Th e opt ic n er ve exit s th e opt ic can al sit u ated su perom edially an d app roxim ately 40 to 45 m m from th e in ferior orbit al rim . Th e su p erior orbit al ssure separates th e greater an d lesser w ings of th e sp h en oid. • St r u ct ures th at p ass th rough th e su perior orbit al ssu re. – Oculom otor n er ve (CN III). – Troch lear n er ve (CN IV). – Abducen s n er ve (CN VI). – Oph th alm ic division of th e t rigem in al n er ve (CN V1 ). • St r uct ures th at pass th rough th e in ferior orbital ssu re. – Maxillar y division of t rigem in al n er ve (CN V2 ). – Bran ch es of sph en opalat in e ganglion . – Bran ch es of th e in ferior op h th alm ic vein . 88 ERRNVPHGLFRVRUJ Orbit and Zygom a Fract ures 89 Physical Examination Orbital fract ures are usually associated w ith blun t t raum a. Nearly 30% of orbital fract u res w ill h ave injuries to th e globe. It is im por t an t to perform a det ailed oph th alm ic exam th at in cludes visu al acu it y, pu pillar y react ion , ret in al exam , an d red color sat u rat ion , as d escribed in Ch ap ter 6. Any deviat ion from n orm al w arran t s an em ergen t oph th alm ic con su lt at ion . • Path ologic physical n dings. – Orbit al ecchym osis. – Periorbital edem a. – Su bconju n ct ival h em orrh age. – Ep ist axis. – Orbital rim /zygom a bony step -o s. – Dip lopia. – Ext raocu lar m uscle en t rapm en t . ▪ Exam in e th e act ive range of m ot ion of th e ext raocular m u scles to ru le out m ech an ical en t rapm en t . ▪ In u n con sciou s pat ien ts, perform th e fo rced ductio n test: u sing Adson forceps, grasp th e in ferior cap su lop alpebral fascia of th e in ferior rect u s m u scle an d gen tly rotate th e globe, w h ile feeling for any rest rict ion s. – In t raorbital edem a. – Opt ic n er ve n eu ropraxia. – Pu pillar y sh ape—oblong pu p il is suggest ive of ocu lar p erforat ion . – Pu pillar y respon se—a eren t p up illar y defect (see Ch apter 6) – Su praorbital, in fraorbit al, alveolar n er ve paresth esias. – Crepit u s/su bcu t an eou s em p hysem a—disru pt ion of m axillar y or eth m oid sin u s m u cosa. – En op h th alm os—n ot iceable w ith > 2-m m sh ift; h ow ever, rarely eviden t im m ediately after inju r y becau se of edem a. – Proptosis/exop h t h alm os. – Hyp h em a— uid in th e an terior ch am ber of th e eye. – Supe rio r o rbital ssure (SOF) syndro m e, resu lt ing from fract u res of th e SOF. ▪ Fixed dilated pup il (CN III). ▪ Up per lid ptosis (CN III). ▪ Loss of corn eal re ex (CN V1). ▪ Op h th alm oplegia (CN IV, CN VI). – Orbital apex syndro m e—SOF syn drom e p lu s im p airm en t of opt ic n er ve as it exit s th e opt ic can al; blin dn ess. – Nau sea, vom it ing, bradycardia—ocu locardiac respon se to ext raocu lar m uscle en t rap m en t (Fig. 8.1). ERRNVPHGLFRVRUJ 90 Orbit and Zygom a Fract ures Fig. 8.1 (a) Hypoglobus at rest. (b) Diplopia with upper gaze associated with entrapm ent of the inferior rectus m uscle lim iting ocular m obilit y. (c) Coronal CT scan; arrow indicates inferior rectus within the trapdoor of the fracture. Acute Compressive Optic Neuropathy (ACON) Orbital injuries sustain ed from h igh -velocit y t raum a can resu lt in a rapid in crease in orbit al pressu re du e to th e accu m u lat ion of edem a or blood (ret robulbar h em atom a) in th e orbital pyram id. Th is can cause vision -th reaten ing com pression of th e opt ic n er ve. • Sign s an d sym ptom s of acu te com pressive opt ic n eu ropathy. – Proptosis. – Severe eye pain . – Diplop ia. – Vision loss. – Reduced ocu lar m ot ilit y. – Ch em osis. Treatment of Acute Compressive Optic Neuropathy Pat ien t s su sp ected of h aving acute com p ressive opt ic n europathy sh ould un dergo em ergent de co m pressio n. • Decom p ression is p erform ed w ith a lateral can th otom y (Fig. 6.6) or by fract u ring th e m edial orbital oor. • St ar t m ethylp redn isolon e (load 30 m g/kg follow ed in 2 h ou rs by 15 m g/kg ever y 6 h ou rs), acet azolam ide (250 m g by m ou th t w ice a day), an d m an n itol (1 g/kg IV, rep eat ever y 6 h ours as n eeded). ERRNVPHGLFRVRUJ Orbit and Zygom a Fract ures 91 To perform a lateral can th otom y, ret ract th e u pp er an d low er lid su periorly an d in feriorly, resp ect ively, w ith you r in dex an d th ird nger. In cise th e lateral can th al skin 4 to 5 m m , th en palpate t h e lateral can th al ten don w ith n e scissors an d release overlying soft t issue lateral to th e con ju n ct iva all th e w ay dow n to th e lateral bony orbit . Disin ser t ion of th e can th al ten don w ill result in a m ore freely m obile eye, along w ith com plete m obilit y of th e low er lid. To fract u re th e m edial orbit al oor, rst m an u ally ret ract th e low er lid. With a pair of n e h em ostats, pu sh th rough th e oor m edially to allow drain age in to th e m axillar y sin us. Traumatic Optic Neuropathy (TON) A subset of patients w ith ocular injuries w ill present w ith vision loss secon dar y to opt ic n er ve t raum a (com pression or edem a) w ith ou t in creased ext raocular orbit al pressure. Th ese pat ien t s are suspected of h aving t raum atic optic n europathy. Th e et iology m ay be direct secon dar y to bony fragm en ts w ith in the optic canal. Indirect injur y is secon dar y to ischem ia and edem a of the optic ner ve. Em ergent high-resolution CT of th e orbit is perform ed to iden tify speci c an atom ical opt ic n er ve path ology. Pat ien t s w ith decreased ligh t percept ion sh ou ld be started on a m egadose of steroids for 48 h ours (m ethylpredn isolon e load 30 m g/kg follow ed in 2 hours by 15 m g/kg ever y 6 h ours). Patients w ho exhibit w orsening light percept ion or w h o presen t w ith n o ligh t perception sh ould be con sidered for operative opt ic ner ve decom pression. Types of Orbital Fractures Orbit al fract ures can occur anyw h ere along th e m edial or lateral w alls, oor, roof, an d apex. Most com m on ly, th ey w ill be localized to th e m ed ial w all an d oor, th e w eakest st ru ct ures. Medial w all fract ures are par t of a com plex of fract u res associated w ith th e n asal an d eth m oid bon es; th ey are discu ssed in Ch apter 10. Orbital Floor Orbital oor fractures (blow -out) m ost com m only occur at the m edial w all and oor of the orbit along the infraorbital groove (paresthesia). A fract ure defect m ay en trap periorbital fat an d possibly th e inferior rect us m uscle (Fig. 8.2). The pathom echanics of the injur y include t w o theories: ERRNVPHGLFRVRUJ 92 Orbit and Zygom a Fract ures Fig. 8.2 Schem atic of an orbital oor fracture with entrapment of inferior rectus. 1. Th e hydrau lic th eor y—direct t rau m a to th e globe leads to in creased in t raorbital p ressu re resu lt ing in a decom p ressing fract u re at th e w eakest poin t . 2. Th e bon e con duct ion th eor y—an in direct t ran sm ission of forces arou n d th e orbit al rim leading to fract ure of th e oor. Orbital Roof Fract u res of th e orbit al roof are rare du e to p rotect ion by th e su p raorbital rim an d st rong fron tal bon e. Th ese fract ures are m ore com m on in ch ildren secon dar y to th e di eren ces in th e arch itect u re of th e cran ium . W h en fract ures in th e roof occur, displacem en t can be eith er in to th e an terior cran ial fossa or, m ore com m on ly, in to th e orbit , causing a “blow -in ” fract ure. Evalu at ion of th ese p at ien t s by CT sh ould ru le out both in t racran ial an d in t raocular involvem en t . Blow -in fract ures are ch aracterized by a decreased orbital volu m e (i.e., exoph th alm os) an d com m on ly w arran t urgen t su rgical in ter ven t ion to decrease th e in creased in t raocular pressu re (Fig. 8.3). Addit ion ally, inju r y to th e supraorbital ar ter y can resu lt in a ret robu lbar h em atom a. ERRNVPHGLFRVRUJ Orbit and Zygom a Fract ures 93 Fig. 8.3 (a) Axial and (b) 3D reconstruction CT scans of a patient with an orbital roof fracture. Radiographic Evaluation CT scan s sh ou ld be obt ain ed w ith 1.5-m m th in cu t s th rough th e orbit w ith sagit tal an d coron al recon st ruct ion s. Evalu ate radiograph s for th e follow ing: • Disp laced fract u re fragm en t s. – Trapdoor fract ure. – Bony fragm en t im p ingem en t on th e opt ic can al. • Area of oor defect . • Soft t issu e en t rapm en t . • En op h th alm os. • Len s dislocat ion . • Ret robu lbar h em atom a. • Oth er associated fract u res (m edial w all fract u re). Management Pat ien ts w ith ou t eviden ce of en t rapm en t , TON, ret robu lbar h em atom a, ACON, or any sign s of globe inju r y can be disch arged h om e. Non displaced fract ures m ay be associated w ith diplop ia secon dar y to edem a an d blu n t t rau m a to th e globe. Dip lopia alon e is n ot an in dicat ion for surger y. Pat ien t s sh ou ld be follow ed closely for 2 w eeks to en sure resolu t ion of sym ptom s. Pain m edicat ion sh ou ld be prescribed as in dicated; an t ibiot ics are n ot in dicated . Pat ien t s sh ou ld be in st ru cted to u se ar t icial tears to keep th e eye lubricated, an d to m in im ize n ose blow ing to avoid orbital em physem a an d disp lacem en t of a fract u re. ERRNVPHGLFRVRUJ 94 Orbit and Zygom a Fract ures Pat ien t s w h o do requ ire delayed su rgical in ter ven t ion sh ould be seen by an op h th alm ologist p rior to su rger y to r u le ou t op en globe inju ries. Fract u res are opt im ally operated on after 2 to 4 w eeks on ce edem a resolves. Em ergen t su rger y is in dicated for th ose p at ien t s w h o h ave clear bony displacem en t in to th e opt ic can al or globe as con rm ed by CT, en t rap m ent , or sign s an d sym ptom s suggest ive of ocu locardiac resp on se. Surgical Indications—Orbital Floor Fractures Urgen t su rgical in dicat ion s are • Orbit al en t rapm en t . • Oculocardiac respon se—bradycardia, n au sea, syn cope. In dicat ion s for delayed su rgical in ter ven t ion are • Early en op h th alm os > 2 m m w ith in 6 w eeks. • En op h th alm os w ith sym ptom at ic diplopia last ing longer th an 2 w eeks (prim ar y eld). • Displaced fract ure w ith oor defect > 1 cm 2 . • Hypoglobu s—low -lying globe. Zygoma/Zygomaticomaxillary Complex Fractures Th e zygom a ar t icu lates w ith th e fron t al, sp h en oid, m axillar y, an d tem poral bon es com prising th e ch aracterist ic tet rap od (Fig. 8.4). It is com posed of t w o faces, th e m alar face, w h ich com p rises th e lateral orbit , an d th e body, w h ich gives project ion to th e ch eek. Th e zygom at ic p rocess of th e tem p oral bon e ar t icu lates w ith th e body of th e zygom a to create th e zygom at ic arch . Th e zygom a h as m u lt iple m u scular at tach m en t s; m ost im p ort an t is th e m asseter, w h ich prod uces a m ajor in ferior deform ing force on th e body an d arch w h en fract ured. Fract u res an d disar t icu lat ion s of th e zygom a u su ally resu lt in an in ferior disp lacem en t , leading to in creased in t raorbit al volum e produ cing en op h th alm os. Th ese fract u res are m ost com m on ly referred to as t ripod, tet rapod, or a zygom at icom axillar y com plex (ZMC) fract u re, so called becau se it involves separat ion of all of th e m ajor at tach m en ts of th e zygom a to th e rest of th e face (Fig. 8.5). Occasion ally, th ere can be an isolated fract ure of th e zygom at ic arch or lateral w all w ith ou t con com itan t ZMC fract u re (Fig. 8.6). ERRNVPHGLFRVRUJ Orbit and Zygom a Fract ures 95 Fig. 8.4 Zygom atic tetrapod bone articulations. Fig. 8.5 ZMC fracture illustrating disruption of the (a) lateral orbital wall, (b) nasomaxillary suture, and (c) orbital oor. ERRNVPHGLFRVRUJ 96 Orbit and Zygom a Fract ures Fig. 8.6 Displaced zygomatic arch fracture with impingement of the coronoid process of the m andible. Symptoms and Physical Findings • • • • • • • • • • • • En oph th alm os. Flat ten ing of th e m idface/m alar asym m et r y. Diplop ia. Trism u s. Im pingem en t on th e coron oid process. Periorbital an d su bconjun ct ival h em atom a (Fig. 8.7). – “Flam e sign .” Ep istaxis. In ferior displacem en t of globe. In ferior displacem en t of lateral can th u s. In fraorbit al n er ve injur y—p aresth esia of th e ch eek, u pp er lip, an terior in cisors, an d ala of th e n ose; V2 dist ribu t ion . Man dibu lar occlusion an d range-of-m ot ion dist u rban ces—t rism u s. In t raoral h em atom a. ERRNVPHGLFRVRUJ Orbit and Zygom a Fract ures 97 Fig. 8.7 Flame sign—suggestive of an orbitozygomatic fracture. Radiographic Evaluation • CT scan . – Axial. – 1.5 m m cu ts. – Coron al. – Orbital evalu at ion . – Recon st r u ct ion s. ▪ 3D recon st r u ct ion s. • Plain radiograph s (less com m on ly u sed). – Caldw ell view. – Su bm en tal ver tex. – Waters view. ▪ Most h elpfu l plain lm . ▪ 30 degrees of occipitom en t al project ion , exten sion . ▪ Visu alizat ion of zygom at ic bu t t resses. ERRNVPHGLFRVRUJ 98 Orbit and Zygom a Fract ures Management Pat ien t s w ith no ndisplaced ZMC fractures can be disch arged h om e, obser ved, an d t reated con ser vat ively. An t ibiot ics are n ot in dicated. Keep pat ien ts on a soft diet (n on ch ew ) for 6 w eeks w ith p rotect ion of th e m alar em in en ce. Follow -up sh ould be in 2 w eeks to assess for displacem en t an d en oph th alm os. Th is can occu r over th e long term w ith th e m asseter p u ll on th e fract u red zygom a. Pat ien t s w ith displaced ZMC fractures sh ou ld be prep ared for surger y to realign th e lateral orbital w all an d oor an d to correct con tour irregu larit ies of th e m alar em in en ce. An op h th alm ologist’s evaluat ion is w arran ted w ith orbit al involvem en t . Orbit al oor an d rim fract ures are com m on ly associated w ith ZMC fract u res. Im pacted ZMC fract u res m ay h ide orbit al defects on radiograph s. If th ere is an in dicat ion for urgen t in ter ven t ion due to orbit al involvem en t (i.e., en t rapm en t), th en th e pat ien t sh ou ld be adm it ted an d p repared for redu ct ion of th e ZMC an d orbital oor recon st r uct ion . Pat ien t s w ith nondisplace d iso late d zygo m atic arch fractures requ ire n o su rgical in ter ven t ion . Th ey can be disch arged h om e w ith m alar em in en ce protect ion . Pat ien t s w ith displaced iso lated zygo m atic fractures do n ot n eed adm ission an d can be disch arged h om e to h ave th eir fract u re repaired elect ively. Rep air can be don e w ith in 24 h ou rs or delayed un t il 2 w eeks after edem a resolves. Th ose pat ien t s w ith t rism u s secon dar y to im p ingem en t on th e coron oid or m asseter an d cosm et ic tem poral deform it ies also w arran t con siderat ion for operat ive redu ct ion . ERRNVPHGLFRVRUJ 9 Nasal and Naso -Orbital-Ethmoid (NOE) Fractures Inju ries to th e m idface involve th e com plex u n ion of th e n ose, th e orbit , an d t h e base of th e sku ll. Fract u res of th ese areas can occu r in isolat ion or in conju n ct ion at th e u n ion of th ese st ru ct u res (NOE). Anatomy Nasal an atom y (Fig. 9.1): • • • • • • • Nasal bon e. Fron t al processes of th e m axilla. Nasal car t ilage. Nasal sept u m . Quadrilateral car t ilage. Perp en dicu lar p late of th e eth m oid. Vom er. Blood su pply: • • • • • Oph th alm ic ar ter y is th e rst bran ch of th e in tern al carot id. An terior an d p osterior eth m oidal bran ch es of in tern al carot id. Facial ar ter y bran ch es. Superior labial bran ch . In tern al m axillar y bran ch es of extern al carot id (sph en op alat in e, greater p alat in e, an d in fraorbital). Extern al in n er vat ion : • Nasociliar y n er ve V1 . • Suprat roch lear n er ve V1 . • In fraorbital n er ve V2 . In tern al in n er vat ion : • An terior eth m oid n er ve V1 . • Greater palat in e n er ve—lateral w all. • Nasopalat in e n er ve V2 . 99 ERRNVPHGLFRVRUJ 100 Nasal and Naso-Orbit al-Ethm oid (NOE) Fractures Fig. 9.1 (a) Bony and cartilaginous vault anatomy. (b) Nasal septal anatomy. Nasal Fractures Physical Examination Evalu ate th e n ose in a w ell-lit area w ith th e p at ien t com for t ably seated an d reclin ed at a 45-degree angle to facilit ate in spect ion of both th e extern al an d in tern al n asal cavit y. Su ct ion , irrigat ion , n asal sp eculu m , h eadligh t/h an dh eld ligh t , an d cot ton -t ip applicators sh ould be readily available. ERRNVPHGLFRVRUJ Nasal and Naso-Orbit al-Et hm oid (NOE) Fractures 101 Com m on p hysical n dings in clu de • • • • • • • • • • Ten dern ess. Crepit u s. Nasal deviat ion . Mobilit y. Ep ist axis. Air w ay obst ru ct ion . Septal deviat ion . Septal h em atom a. Saddle deform it y. Mu cosal lacerat ion . Septal Hematomas Septal hem atom as are caused by bleeding bet w een the septum and m ucosa. Diagnosis is m ade by direct visualization of a hem atom a beneath the m ucosa (Fig. 9.2). Septal h em atom as require im m ediate drainage in the acute setting. If left undrained, the accum ulation of blood in the m ucoperichondrium can lead to septal ischem ia w ith potential septal necrosis. Com plications include perforation, loss of dorsal support, and saddle deform it y. Nasal septal hem atom as should be drained appropriately, w ith the proper pressure dressing applied (see Chapter 6, Fig. 6.4a). Packing should be rem oved on day 3 to prevent sin usitis or toxic shock. Place the patient on clindam ycin or Augm entin w hile packing is in place. Fig. 9.2 (a) Nasal septal hem atom a that requires imm ediate drainage. (b) CT scan conrm s diagnosis. ERRNVPHGLFRVRUJ 102 Nasal and Naso-Orbit al-Ethm oid (NOE) Fractures Radiographic Evaluation Plain lm s an d CT scan s (Fig. 9.3) are n ot absolu tely n ecessar y. Th ey becom e m ore relevan t if oth er injuries are suspected (e.g., n aso-orbital-eth m oid fract ures [NOE], orbital oor fract u re, in t racran ial bleeding). If on e h as a low clin ical su spicion of any oth er inju r y, n asal fract ures in gen eral do n ot requ ire any radiograp hy. In selected clin ical scen arios, a n asal series (an terior an d lateral view ) can be ordered to aid in diagn osis an d for docum en t at ion . Stranc-Robertson Nasal Fracture Classi cation (Fig. 9.4) • Type I. – An terior por t ion of th e n asal pyram id. – Sept u m . • Type II. – Com m in u t ion of th e n asal pyram id. – Dislocat ion of th e sept u m . • Type III. – Fron tal p rocesses of th e m a xilla. – NOE fract ures. Nasal Fracture Treatment Th e t im ing of th e repair is u su ally bim odal an d correlated w ith t h e am oun t of edem a. Any repair sh ou ld be perform ed w ith in th e rst 2 h ours, before th e on set of sign i can t edem a. A p at ien t rarely p resen t s w ith in th is t im e, an d t ypically, repairs are perform ed after 1 to 2 w eeks, w h en th e edem a su bsides. Fig. 9.3 CT scan of nasal bone and septal fracture with orbital component. ERRNVPHGLFRVRUJ Nasal and Naso-Orbit al-Et hm oid (NOE) Fractures 103 Fig. 9.4 Stranc-Robertson nasal fracture classi cation. Closed Reduction Adequ ate an esth esia can be ach ieved locally if a redu ct ion is at tem pted in th e em ergen cy care set t ing. Epin ep h rin e 1:100,000 or 4% cocain esoaked Cot ton oid/p ledgets or Afrin (Sch ering-Plough Corp.) spray on pledgets can be ap p lied in t ran asally for 5 m in utes. A region al block—1%lidocain e w ith 0.25%Marcain e m ixed 1:1—p rovides long-last ing pain relief w ith fast on set . Epin eph rin e can also be added at 1:100,000. • Region al block (see Ch apter 7, Fig. 7.1). – Nasociliar y n er ve. – In frat roch lear n er ve. – In fraorbital n er ves. – Tip—colu m ella. Asch or Walsh am forceps can be u sed to realign an d reduce th e fract u re (Fig. 9.5). Th e blun t en d of a scalpel h an dle can also be used. Redu ct ion sh ould be aim ed at reposit ion ing th e n ose to th e m idlin e. Resh aping th e n asal pyram id often involves “ou tfract u ring” of th e n asal sidew alls. Assess redu ct ion by visu alizat ion an d palp at ion . ERRNVPHGLFRVRUJ 104 Nasal and Naso-Orbit al-Ethm oid (NOE) Fractures Fig. 9.5 Closed reduction of nasal fracture using Walsham forceps. Postreduction Care • Packing—place p acking in dist in ct layers, if n ecessar y, to ach ieve h em ostasis (see Ch apter 6, Fig. 6.4). – Merocel (Merocel Su rgical Produ ct s), Xeroform gau ze, Vaselin e (Un ilever PLC)/bacit racin -im pregn ated gau ze, Cot ton oid soaked w ith epin eph rin e 1:100,000. – Rem ove packing w ith in 3 days to avoid sin usit is or toxic sh ock (see Ch apter 6, Fig. 6.4a). – Prescribe an t ibiot ics for pat ien ts w ith in t ran asal packing. ▪ Augm en t in 875 m g by m ou th t w ice a day × 3 days or clin dam ycin 450 m g by m ou th fou r t im es a day × 3 days. ▪ A silicon e in tern al n asal splin t can also be u sed if bleeding is con t rolled (Fig. 9.6). ▫ In tern al sp lin ts are su t u res th rough th e sept u m (2–0 Prolen e) to p reven t m igrat ion an d are rem oved in 2 w eeks. ERRNVPHGLFRVRUJ Nasal and Naso-Orbit al-Et hm oid (NOE) Fractures 105 • Splin t—ap ply an extern al n asal sp lin t to th e dorsu m (Fig. 9.6); keep sp lin t s in p lace for 7 to 10 days. – Fash ion a splin t ou t of a sm all piece of plaster over Steri-St rips if prefabricated th erm op last ic splin t s are n ot available. • Have th e pat ien t avoid n ose blow ing for several w eeks. • Have th e pat ien t avoid con tact to n ose. • Follow u p w ith in 1 w eek. Pat ien ts w ith n asal fract u res th at are sign i can t ly displaced or w ith sign i can t edem a h in dering redu ct ion in th e acute set t ing can be disch arged h om e w ith con t act precau t ion s. An t ibiot ics are n ot n eeded , an d pat ien t s sh ou ld follow u p in 2 w eeks for at tem pted closed or op en operat ive redu ct ion . Naso -orbital-ethmoid Fractures NOE fract u res resu lt from force directly over th e n asal pyram id. Th e n ose is depressed bet w een th e orbit s, resu lt ing in fract u res of th e n asal bon e an d m edial orbit al w all. Fract u res are com m on ly bilateral, bu t on e-th ird of th e t im e th ey are un ilateral. Th e h igh -velocit y im pact w ill often be accom p an ied by orbit al blow -ou t fract u res or can exten d in to t h e cran ial base (Fig. 9.7). Fig. 9.6 Postreduction intranasal and dorsal splints. ERRNVPHGLFRVRUJ 106 Nasal and Naso-Orbit al-Ethm oid (NOE) Fractures Fig. 9.7 Open complicated NOE fracture with disinsertion of the medial canthal tendon extending into the orbital oor and m axilla. Anatomy • Posterior. – Sph en oid bon e. • Roof. – An terior cran ial fossa. • Lateral exten sion of in terorbit al sp ace. – Medial orbit al w alls. • An terior st ru ct u res. – Maxilla, fron tal an d n asal bon es. Th e m edial can th al ligam en t is th e direct exten sion of th e orbicularis ocu li m u scle w ith in ser t ion on to th e m ed ial orbit al w all. Th e ligam en t is com posed of th ree lim bs, w h ich h elp provide m edial support to th e globe, along w ith keeping th e eyelids t angen t ial to th e globe. Th e su perior, an terior, an d posterior lim bs toget h er form a ten t t h at h ou ses t h e lacrim al sac. Th is ligam en t is im port an t in th e classi cat ion of NOE fract u res. ERRNVPHGLFRVRUJ Nasal and Naso-Orbit al-Et hm oid (NOE) Fractures 107 Physical Findings That May Indicate an NOE Fracture • • • • • Loss of dorsal-n asal prom in en ce (saddle deform it y). Glabellar, periorbital, n asal ecchym osis. Bony crep it u s over can th al region . Telecan th u s 35 m m (n orm al 30–32 m m ). Bow st ring test—lateral t ract ion of low er eyelid w ill result in telecan th u s if ligam en t is disr u pted. • Rh in orrh ea—in dicat ion of a cribriform plate fract u re. • Olfactor y dist u rban ce. Radiographic Evaluation • CT scan —1.5-m m cu t s axial an d coron al. Markow itz Classi cation (Fig. 9.8) • Type I: Single-segm ent central fracture w ith m edial canthal tendon attached. • Type II: Com m in uted fract u re w ith m edial can th al ten don at tach ed. • Type III: Com m in u ted fract u re w ith avu lsed m edial can th al ten don . Treatment and Management Pat ien t s w ith NOE fract ures n eed to be adm it ted an d m on itored, an d in t racran ial injur y sh ou ld be ru led ou t . Urgen t oph th alm ologic evalu at ion is w arran ted to ru le ou t inju r y to t h e globe. Th e p at ien t sh ould be assessed for leakage of cerebrosp in al u id (CSF), w h ich m ay in dicate dam age to th e cribriform plate, fron t al sin u s, or an terior cran ial fossa. CSF rh in orrh ea is evalu ated by perform ing th e h alo test (form at ion of a h alo w h en CSF is p laced on t issu e paper) or by laborator y an alysis of glu cose or -t ran sferrin in t h e n asal d rain age. If p oten t ial du ral con t am in at ion is su spected, a n eu rosu rgical con su lt is ap p ropriate. • Place pat ien t on IV an t ibiot ics (clin dam ycin 600 IV ever y 6 h ou rs, Rocep h in 1 g IV ever y 24 h ou rs). • Fract ures w ill likely be explored an d rep aired. • Elevate h ead of bed. • No n ose blow ing. • Follow appropriate preop erat ive procedu res (n oth ing by m ou th , IV u ids, etc.) if su rger y is plan n ed . ERRNVPHGLFRVRUJ 108 Nasal and Naso-Orbit al-Ethm oid (NOE) Fractures Fig. 9.8 Markowit z classi cation of naso-orbital-ethm oid fractures. ERRNVPHGLFRVRUJ 10 Frontal Sinus Fractures Th e fron tal bon e is th e st rongest bon e of th e face. Th e an terior table can w ith st an d 800 to 2,200 lb of force; th erefore, a direct isolated h igh -en ergy im pact is usually n eeded to fract ure th is bon e. Th e fron t al sin uses are absen t in 4% of in dividu als, ru dim en t arily develop ed in 5%, an d u n ilateral in 10%of in dividu als. Th e developm en t of th e fron t al sin u s begin s at age 2; it becom es radiograp h ically p resen t at age 8 an d con t in ues to develop u n t il th e age of 12. Fron t al sin u s fract u res are rare in th e p ed iatric p op ulat ion . In stead, th e forces applied to th is area are t ran sm it ted to th e orbit al rim (u pp er or th e w eaker low er) an d th e n asal eth m oid area in you nger p at ien ts. Anatomy Th e an atom y of th e fron tal sin u ses com prises (Fig. 10.1) • Tw o paired irregu lar cavit ies. – An terior w all = an terior table. – Posterior w all = p osterior table. Physical Examination Physical n dings th at suggest a fron tal sin u s fract u re: • • • • • Foreh ead con t usion . Foreh ead lacerat ion . Foreh ead or orbit al h em atom as. Ep ist axis. Otorrh ea or rh in orrh ea from dural tears—test for h alo sign on paper tow el; sen d uid for glu cose an d β-t ran sferrin an alysis. • Palpable step -o deform it y secon dar y to u n d erlying fract u re; m ay be obscured by overlying sw elling in th e acu te set t ing. • Paresth esias in th e su praorbit al n er ve d ist ribu t ion . • Exten sion in to th e sup raorbital rim an d su p erior orbital ssure can lead to su perior orbital ssu re syn drom e (see Ch apter 8). 109 ERRNVPHGLFRVRUJ 110 Front al Sinus Fract ures Fig. 10.1 The frontal sinuses. Radiographic Evaluation CT of the face w ith 3-m m axial cuts and coronal reconstructions is the m ost sensitive m odalit y for diagnosing frontal sinus fractures. Managem ent w ill often be dependent on w hether or not there is a nasofrontal duct injur y. Fract ures that are located inferiorly and m edially should raise a high level of suspicion for nasofrontal duct injury (Fig. 10.2, Fig. 10.3). ERRNVPHGLFRVRUJ Front al Sinus Fract ures 111 Fig. 10.2 Frontal sinus fracture pat terns. (a) Norm al relationship. (b) Anterior table. (c) Com minuted anterior and posterior table. Management All patients w ith fron tal sin us fractures sh ould be adm it ted and observed. • In it ial evalu at ion . – Subarach n oid h em orrh ages. – Subdural h em atom as. – Ep idu ral h em atom as. – Cerebral con t usion s. – Pn eu m ocep h alu s. • Elevate h ead of bed to m in im ize edem a. • Begin in t raven ou s an t ibiot ics. – Ceft riaxon e 1 to 2 g IV ever y 24 h ou rs. • Have th e p at ien t avoid act ivit ies th at could in crease in t racran ial con t am in at ion from th e sin u ses. – Avoid n ose blow ing. – Cough an d sn eeze w ith m ou th open an d n ot th rough n ose. ERRNVPHGLFRVRUJ 112 Front al Sinus Fract ures Fig. 10.3 CT of anterior table fracture. Operat ive m an agem en t is depen den t on degree of fract ure displacem en t , n asofron tal d uct involvem en t , an d du ral in tegrit y. An terior table fract u res in du ce a cosm et ic deform it y. Non displaced fract u res do n ot requ ire operat ive in ter ven t ion . Obliterat ion of th e n asofron tal du ct is in dicated w h en th e du ct is involved in th e fract u re. Oth er w ise, displaced fract u res m ay by reduced an d xed in a delayed fash ion . Posterior table fract u res occu r in com bin at ion w ith an terior table fract u res an d can produ ce th e sam e sequ elae, w ith th e add it ion of th e poten t ial for an terior cran ial fossa involvem en t an d du ral pen et rat ion . CSF leak is eviden t w h en th e p at ien t p resen t s w ith sign i can t rh in orrh ea th at is posit ive for β2-t ran sferrin or creates a yellow ring on t issue paper (h alo test). If th e p osterior table is n ot disp laced , th e p at ien t is obser ved for 4 to 7 days. Pat ien t s w ith persisten t leakage of CSF or displacem en t an d com m in u t ion of th e posterior table requ ire cran ializat ion . Sp eci c fract ure m an agem en t st rategies are outlin ed in Fig. 10.4. ERRNVPHGLFRVRUJ Front al Sinus Fract ures 113 Fig. 10.4 (a) Algorithm for anterior table fracture. (b) Algorithm for posterior table fracture. ERRNVPHGLFRVRUJ 11 Mandibular Fractures Anatomy • A U-sh ap ed bon e th at con t ain s t w o equal segm en t h em im an dibles. • St ru ct u res u n ite at m idlin e called sym physis. • Each h em im an dible con sist s of several st ruct u res (Fig. 11.1). – Body. – Angle. – Ram u s. – Coron oid process. – Con dyle. • Muscles of m ast icat ion . – Jaw prot ru sion . ▪ Lateral pter ygoid (lateral pter ygoid plate to con dylar n eck). – Jaw elevators. ▪ Tem p oralis (tem p oral fossa to coron oid). ▪ Masseter (zygom at ic arch to th e body). ▪ Medial pter ygoid (m edial pter ygoid plate to angle). – Jaw dep ressor-ret ractors. ▪ Lateral pter ygoid. ▪ Digast ric. ▪ Gen iohyoid. ▪ Mylohyoid. ▪ Gen ioglossus. • Con dyle ar t icu lates w ith cran iu m at th e glen oid fossa of th e tem p orom an dibu lar join t (TMJ). • Blood su p ply of m an dible. – In ferior alveolar ar ter y from th e in tern al m axillar y ar ter y en ters at m an dibu lar foram en an d exit s at m en t al foram en . – Bran ch es from th e m u scles of m ast icat ion . • Ner ve su pply. – In ferior alveolar n er ve from CN V3 en ters at m an d ibu lar foram en an d exits at m en tal foram en . • Men tal foram en . – Located bet w een rst an d secon d p rem olars. 114 ERRNVPHGLFRVRUJ Mandibular Fract ures 115 Fig. 11.1 Anatomy of the m andible. Dental Relationships Ch ild: • 20 decidu ous or prim ar y teeth labeled A th rough T. – Righ t—A B C D E F G H I J. – Left—T S R Q P O N M L K. Adu lt: • 32 perm an en t teeth labeled 1 th rough 32. – Nu m bering begin s w ith th e th ird righ t m axillar y m olar as tooth n o. 1 an d th e last m axillar y m olar as n o. 16. ▪ Nu m bering con t in u es w ith th e m an dibular left th ird m olar as n o. 17 an d en ds w ith th e m an dibu lar righ t th ird m olar as n o. 32. Each h em im an dible or h em im a xilla con sist s of • • • • On e cen t ral an d on e lateral in cisor. On e can in e (cu spid). First an d secon d prem olar (bicu sp id). First , secon d, an d th ird m olar. ERRNVPHGLFRVRUJ 116 Mandibular Fractures Angle Classi cation of Occlusion Based on t h e rst m axillar y m olar an d it s posit ion relat ive to th e m an dibular m olar (Fig. 11.2): • Class I—n orm al occlu sion . – Mesiobu ccal cu sp of th e m axillar y rst m olar occlu des w ith bu ccal groove of th e m an dibu lar rst m olar. • Class II—overbite. – Low er rst m olar is distal (p osterior) to th e u p per rst m olar. • Class III—u n derbite. – Low er rst m olar is m esial (an terior) to th e u pper rst m olar. Fig. 11.2 Angle classi cation of occlusion. ERRNVPHGLFRVRUJ rst Mandibular Fract ures 117 Mandibular Fractures Fract u res of t h e m an d ible are often t h e resu lt of p hysical altercat ion s an d h ave t h e h igh est frequ en cy in m en bet w een t h e ages of 25 an d 35. Fract u res com m on ly arise in t h e t h in n est p or t ion s of t h e bon e in t h e an gle an d con dylar region . Th e t h ick ram u s is fract u red t h e least (Fig. 11.3). Man d ibu lar fract u res often occu r at t w o sites on t h e m an d ible d u e to t h e cou p -con t recou p p h en om en on . Symptoms and Physical Findings • • • • • • • • • • • • Pain . Malocclusion —docum en t th e angle class of occlu sion . Trism u s—in abilit y to com p letely op en m ou th du e to p ain . Crep it u s/bony step -o s. Man dibular in stabilit y. Edem a an d ecchym oses over fract u re site. Con t u sion s, lacerat ion s, an d excoriat ion . In t raoral. – Den tal in fect ion /abscess. – Buccal or lingu al ecchym osis. – Avulsed teeth /loose teeth . ▪ Use th e n u m bering system to accou n t for avulsed, loose, fract u red , or m issing teeth . Open bite. Deviat ion of jaw on open ing—suggest ive of con dylar fract ure. Paresth esia/an esth esia—docu m en t fu n ct ion of in ferior alveolar, lingu al, an d m en t al n er ves. – Tran sect ion of th e in ferior alveolar n er ve can result in paresth esia/an esth esia at th e lips, teeth , an d gu m s. TMJ dislocat ion or derangem en t . – Assess TMJ w ith a nger in extern al au ditor y can al—con dylar h ead sh ou ld t ran slate an teriorly w ith out sign i can t pain if join t is n ot inju red. ERRNVPHGLFRVRUJ 118 Mandibular Fractures Fig. 11.3 Incidence of m andibular fractures by region. Radiographic Evaluation A Pan orex rad iograp h (Fig. 11.4) o ers t h e best d iagn ost ic tool in su sp ected m an d ible fract u res. It is a qu ick an d in exp en sive rad iograp h t h at o ers a com p lete view of t h e m an d ible. It p rovid es an easy m ean s of iden t i cat ion of sym p hyseal an d an gle fract u res, as w ell as sh ow in g t h e relat ion of th e fract u re lin e to teet h . Som e m in im ally d isp laced fract u res at t h e sym p hysis m ay be d i cu lt to visu alize on a Pan orex. Pat ien t s are requ ired , h ow ever, to h ave t h eir C-sp in es cleared becau se t h e Pan orex rad iograp h is t aken in t h e sit t in g p osit ion . Ot h er w ise, an in t u bated or obt u n d ed p at ien t can u n d ergo a p an oram ic zon ograp hy or Zon arc (a p an oram ic evalu at ion in t h e su p in e p osit ion ). CT evaluat ion is cost-e ect ive an d o ers n early 100% sen sit ivit y for diagn osing m an dibu lar fract u res (Figs. 11.5). A CT scan of th e face w it h coron al recon st ru ct ion s sh ou ld be ordered for pat ien t s w h o dem on st rate a h igh in dex of suspicion for a m an dible fract u re. Each CT scan sh ould be com plem en ted w ith a Pan orex radiograph to sh ow th e relat ion of th e fract u re lin e to th e teeth . Th is det ailed in form at ion on den t al occlu sion in relat ion to th e fract ure is n ot easily seen on CT im ages an d is im portan t w h en assessing w h ich teeth m ay n eed to be ext racted to allow for opt im al m an dibu lar u n ion . Coron al CT evalu at ion is also h elpful in diagn osing m an dibu lar coron oid an d con dyle fract u res (Fig. 11.5c). ERRNVPHGLFRVRUJ Mandibular Fract ures 119 Fig . 11.4 Mandibular fractures of the sym physis com m only occur in com bination with fractures of the contralateral condylar region. Panorex radiograph clearly illustrating the fracture of the parasym physis. Classi cation of Fracture Types of Fracture • • • • • • Closed versus open . Disp laced versu s n on disp laced. Com p lete versus in com p lete. Lin ear versu s com m in u ted. Favorable—w h en th e m u scles draw th e bony fragm en t s togeth er. Un favorable—w h en th e fragm en ts are disp laced by th e forces of th e m u scles. ERRNVPHGLFRVRUJ 120 Mandibular Fractures Fig. 11.5 (a) CT evaluation of a fracture of the symphysis. (b) Evaluation of the parasymphyseal fracture by coronal CT. (c) CT coronal scan of the same patient as in Fig. 11.4 demonstrating a subcondylar fracture not easily seen on the Panorex radiograph. (d) CT evaluation of a fracture of the angle. Location of Fracture (Fig. 11.1) • Sym physeal—bet w een cen t ral in cisors. • Parasym p hyseal—bet w een dist al border of can in e an d cen t ral in cisor. • Body—bet w een dist al edge of can in e an d dist al border of th ird m olar. • Angle. • Ram u s. • Coron oid. • Con dyle. – Con dylar h ead. – Con dylar n eck. ERRNVPHGLFRVRUJ Mandibular Fract ures 121 Nonoperative Management Th e a bsolu t e goa l in t h e t r ea t m en t of m a n dibu la r fr a ct u r es is r eest a blish m en t of pr ein ju r y occlu sion . Addit ion ally, at ten t ion sh ou ld be placed on reest ablish m en t of facial con tour, h eigh t , sym m et r y, an d p roject ion . Th ese goals are accom plish ed by ach ieving an atom ical reduct ion of th e fract ure fragm en ts w ith out in fect ion an d w ith n orm al m an dibular m ot ion . Im m obilizat ion tech n iqu es dep en d on th e degree of disp lacem en t an d t h e fract u re locat ion . Non operat ive m an agem en t is in st it u ted w h en th e fract u res are single an d n on d isp laced an d w h en p at ien t s exh ibit p reinjur y occlu sion (Table 11.1). These patients are counseled to com ply w ith a nonchew diet and to perform aggressive oral hygiene for 6 weeks. Nonoperative candidates treated conservatively should be m onitored closely at 1- or 2-week intervals until fracture healing. During this observation period, patients should be evaluated for m aintenance of occlusion and signs of infection. Deviation from a norm al prognosis m ay portend operative m anagem ent. • Non operat ive h om e disch arge regim en . – Non ch ew diet for 6 w eeks. – Good oral hygien e—tooth brush ing an d Peridex m outh w ash , sw ish an d sp it ever y 2 to 4 h ou rs. – Follow -u p in clin ic w ith in 2 w eeks—obtain addit ion al Pan orex radiograp h s an d assess occlu sion . Table 11.1 fractures Criteria for nonoperative and operative treatm ent of m andibular Indications for nonoperative treatment of mandibular fractures Indications for operative treatment of mandibular fractures Isolated to one region Fractures of m ultiple regions Nondisplaced Displaced Simple Com m inuted Patient exhibits preinjury occlusion Poor occlusion Failed nonoperative m anagement Associated infection ERRNVPHGLFRVRUJ 122 Mandibular Fractures Surgical Treatment Gen erally, surgical t reat m en t for m an dibu lar fract u res is recom m en ded for pat ien t s w ith com m in uted, displaced, in fected, or m u lt iple injuries. Treat m en t st rategies in t h e acu te set t ing in clu de bridle w iring an d closed redu ct ion in m axillom an dibu lar xat ion (MMF) w ith arch bars an d w ires or elast ics (Fig. 11.6). Th e sp eci c fract ure m an agem en t depen ds on th e region . On ce operat ive t reat m en t h as been decided , redu ct ion of th e fragm en ts sh ou ld be un der taken to redu ce t h e possibilit y of in fect ion , pain , an d m alun ion . Fig. 11.6 (a) Closed reduction of mandible fractures utilizing arch bars with elastics or wire xation. (b) Rapid placement of MMF can be accomplished using the Hybrid MMF system (Stryker). ERRNVPHGLFRVRUJ Mandibular Fract ures 123 If fract u re redu ct ion is to be d elayed m ore th an 5 days, th e fract u re fragm en t s sh ould be stabilized w ith a Barton ban dage (see Ch apter 6, Fig. 6.4), a cer vical collar extern ally, or altern at ively w ith MMF u n t il surger y. Fixat ion of open fract u res sh ou ld be at tem pted w ith in 72 h ou rs. Instructio ns fo r patie nts adm itted fo r o pe rative treatm ent: • Prophylact ic an t ibiot ics—clin dam ycin 600 m g IV ever y 8 h ou rs. • En su re p aten t air w ay. Pat ien ts w ith m an dibu lar fract ures m ay h ave tongu e-based air w ay obst ru ct ion (lacerat ion s, etc.) th at m ay require t rach eostom y. • Ru le ou t C-spin e inju ries. • Clear liquid or n on ch ew diet . • Oral hygien e—tooth bru sh ing an d Peridex m ou th w ash , sw ish an d sp it ever y 2 to 4 h ou rs. • IVFs to p reven t dehydrat ion secon dar y to poor oral in t ake. • Preoperat ive w ork-up . – Nu t rit ion con su lt Condylar Fractures Con dylar fract u res are t reated con ser vat ively w ith closed red u ct ion or open reduct ion depen ding on th e degree of displacem en t an d lateralit y. Treat m en t st rategies in th is region are em p loyed to decrease th e in ciden ce of an kylosis of th e TMJ. Closed redu ct ion is advocated in ch ildren or w h en th e fract ure pat tern is h igh an d con t ain ed w ith in th e capsu le. Open reduct ion an d in tern al xat ion (ORIF) is advocated w h en th ere is sign i can t disp lacem en t ou t sid e th e capsu le of th e TMJ or in to th e m iddle cran ial fossa (Fig. 11.7). Foreign bodies w ith in th e capsule an d failed closed reduct ion are addit ion al in dicat ion s for open reduct ion an d in tern al xat ion . Un ilateral n on displaced fract u res in p at ien t s w ith n orm al occlu sion can be t reated con ser vat ively. Pat ien ts are p laced on a n on ch ew diet an d en couraged to perform reh abilit at ion protocols to p reven t an kylosis. Displaced u n ilateral fract u res in pat ien t s w ith m alocclusion are t reated w ith closed redu ct ion for 7 to 10 days, after w h ich reh abilit at ion is begun . Bilateral n on displaced fract ures in a pat ien t w ith a stable m idface are t reated w ith closed redu ct ion . How ever, bilateral displaced fract u res or bilateral fract ures in a pat ien t w ith an un stable m idface sh ould be con sidered for ORIF of at least on e side to preser ve m an dibular h eigh t an d en su re occlu sion . ERRNVPHGLFRVRUJ 124 Mandibular Fractures Fig. 11.7 Subcondylar fracture with extracapsular displacement of the condylar head should be considered for ORIF. Coronoid and Ramus Fractures Coron oid fract u res, if isolated, are m an aged con ser vat ively provided th e pat ien t can op en an d close th e m ou th n orm ally. Th ose pat ien t s w h o are un able to range n orm ally or w h o h ave sign i can t p ain sh ou ld u n dergo ORIF. W h en coron oid fract ures occur in com bin at ion w ith oth er m an dible fract u res, ORIF of th e con com it an t fract u re is recom m en ded over closed redu ct ion to preven t an kylosis. Due to th e splin t ing m ech an ism of th e in ser t ion of th e m uscles of m ast icat ion on th e ram u s, ram us fract ures are stable un less severely displaced. Ram us fract u res in isolat ion are t reated w ith closed reduct ion . Angle Fractures Th e angle of th e m an dible is th e th in n est p or t ion of th e bon e an d is addit ion ally w eaken ed by th e presen ce of th e th ird m olar. Fract u res in th is region com m on ly occu r secon dar y to direct t rau m a an d in isolat ion . Th e angle lacks den t it ion an d in cu rs sign i can t d ist ract ing forces from ERRNVPHGLFRVRUJ Mandibular Fract ures 125 th e m asseter an d th e tem p oralis, w h ich n egates th e abilit y of closed reduct ion to est ablish occlu sion . Th erefore, angle fract ures are t reated w ith ORIF. Body and Symphyseal Fractures Du e to th e presen ce of den t it ion in th e body an d sym physis, fract ures in th is region are t reated w ith closed redu ct ion if th ey are single an d easily redu cible. If sign i can t den t it ion is m issing or th e fract u re pattern is com m in u ted or irredu cible, ORIF is con sidered. Fract u res in th is region of th e m an dible com m on ly occu r w ith con t ralateral fract ure to th e su bcon dylar area. Th erefore, carefu l exam in at ion of t h e con dyles is w arran ted in th ese pat ien t s. Severely Comminuted Fractures Severely com m in uted fract ures are associated w ith severe bony disp lacem en t , as w ell as p ossible soft t issu e loss. Th ese fract u res m ay requ ire extern al xat ion an d débridem en t in th e operat ing room . Estab lish m en t of an air w ay an d ru ling ou t C-sp in e inju r y are of p aram oun t im por tan ce. ERRNVPHGLFRVRUJ 12 Examination of Hand Injuries W h en evalu at ing a p at ien t w ith a h an d inju r y, begin w ith a detailed physical exam in at ion . History • • • • • • • • • Age. Sex. Han d dom in an ce. Occu pat ion . Oth er m edical problem s. Locat ion of th e inju r y. Cause of th e injur y. Tim e of th e inju r y. Durat ion of th e injur y p rocess. Physical Examination • • • • • Verify any p hysical h an d deform it ies. Establish if th ere is any bleeding, p ain , sw elling, or ecchym osis. Con rm open w ou n ds. Note old scars. Assess post u re of th e h an d. – Angulat ion of digit s sign als possible dislocat ion s an d fract ures. • Palp ate ngers, palm , an d w rist for ten dern ess. • Determ in e th e tem p erat u re of th e h an ds an d if th ey are dr y or m oist . After a h istor y is t aken an d a physical exam in at ion is perform ed, obt ain appropriate radiograph s (stan dard X-rays in th ree view s). All patie nts w ith hand injuries sho uld have radio graphs m ade to evaluate fo r fractures and fo reign bo dies. 126 ERRNVPHGLFRVRUJ Exam ination of Hand Injuries 127 Range of Motion Ch eck th e rest ing h an d posit ion ; th is m ay in dicate ten don injuries if th e n at ural arcade is disr upted. Exam in e th e m otor fun ct ion , st rength , an d m obilit y of all join ts of th e h an d. Obser ve m ovem en t globally an d each in dividu al join t’s m ovem en t . Star t w ith th e ngert ips an d m ove proxim ally. Table 12.1 lists th e n orm al ROM for each join t in th e h an d. Distal Interphalangeal Joint Evaluate for t uft fract u res dist al to th e DIP join t . Norm al ROM is 0 degrees of exten sion an d 65 degrees of exion . St abilize t h e m idd le p h alan x w it h th e PIP join t exten ded to test exion of th e exor digitor um profu n dus (FDP). Lack of exten sion of th is join t m ay in dicate m allet nger, w h ich is a resu lt of th e avu lsion of th e term in al exten sor ten don , leaving th e DIP join t in a exed p osit ion . Table 12.1 Norm al range of m otion for joints of the hand Joint Degrees of exion Finger DIP 65 Finger PIP 110 Finger MCP 85 Thum b IP 90 Thum b MCP 45–60 ERRNVPHGLFRVRUJ 128 Exam ination of Hand Injuries Proximal Interphalangeal Joint Full ROM is from 110 degrees of exion to 0 degrees of exten sion in th e PIP join t . In abilit y to ex th e PIP join t can resu lt from disr u pt ion of th e exor digitoru m su per cialis (FDS) ten don /m uscle, volar plate disrupt ion , or con t ract u re of th e in t rin sic m uscle of th e h an d. In abilit y to exten d th e join t m ay be a resu lt of exten sor m ech an ism injur y (bouton n ière deform it y) or con t ract u re of th e exor m ech an ism . Metacarpophalangeal Joint Th e digit MCP join t s p rogress th rough 85 d egrees of exion an d 0 degrees of exten sion . Often , ten don s or th e join t capsule m ay be exposed in cases of lacerat ion . In cases of assault , look for an open lacerat ion over th e join t along w ith decreased prom in en ce of th e fth m et acarp al h ead. Th is sign als th e possibilit y of fract u re of th e fth m et acarpal n eck (boxer’s fract u re). Join t dislocat ion s m ay also be p resen t . Th ese m ay be di cu lt to redu ce if ten don or volar plate en t rap m en t occu rs. The Thumb Norm al MCP join t ROM for th e th u m b is 45 to 60 d egrees of exion an d 0 degrees of exten sion . Exam in e for radial an d uln ar deviat ion an d pain in th e MCP an d CML join t s. Radial deviat ion at th e MCP join t is a sign of w eakn ess of th e u ln ar collateral ligam en t (gam ekeep er’s th um b). Common Hand Deformities Boutonnière Deformity • PIP exion w ith DIP exten sion cau sed by disru pt ion of th e exten sor in ser t ion of m iddle ph alan x an d volar m igrat ion of th e lateral ban ds. Sw an Neck Deformity • PIP hyperexten sion w ith DIP exion cau sed by lateral ban d t igh t n ess an d volar p late la xit y. ERRNVPHGLFRVRUJ Exam ination of Hand Injuries 129 Extrinsic Muscles of the Hand (Table 12.2) Flexors Each of th e ext rin sic exors is respon sible for exion across on e or m ore join t s. Care m u st be taken to isolate an d test each of th ese ten don s in dividually. Th e exors can be inju red at th eir m u scle bellies in t h e forearm or th eir ten din ou s p or t ion s in th e h an d. Th e ext rin sic exors of th e digit s in clu de th e FDP, th e FDS, an d th e exor p ollicis longu s (FPL). Th e w rist is exed by th e com bin at ion of th e exor carpi uln aris (FCU) an d exor carpi rad ialis (FCR) m u scles an d secon darily w it h exion of th e nger exors. Table 12.2 Intrinsic and extrinsic exors and extensors of the hand by joint Joint Flexion Extension Finger DIP FDP Lum bricales, interossei Finger PIP FDP, FDS, FDM EDC, lum bricales, interossei MCP Lum bricales, interossei EDC, EIP, EDM Thumb IP FPL EPL Thum b MCP FBP EPB Wrist FCR, FCU, PL ECU, ECRL, ECRB Abbreviations: FDP, exor digitorum profundus; FDS, exor digitorum super cialis; FDM, exor digiti m inimi; FPB, exor pollicis brevis; EDC, extensor digitorum com m unis; FPL, exor pollicis longus; EIP, extensor indicis proprius; EDM, extensor digiti m inim i; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; FCR, exor carpi radialis; FCU, exor carpi ulnaris; PL, palm aris longus; ECU, extensor carpi ulnaris; ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis. ERRNVPHGLFRVRUJ 130 Exam ination of Hand Injuries Testing FDP. Hold th e p at ien t’s PIP join t in exten sion an d ask th e p at ien t to ex th e DIP join t . Th e FDP can ex both join ts if on e is n ot im m obilized (Fig. 12.1). FDS. Hold all ngers in full (PIP an d DIP) exten sion except th e on e digit w h ose FDS ten d on you are test ing. Ask th e p at ien t to ex h is or h er nger. If th e FDS is un injured, th en th e PIP w ill ex. Th e m uscle bellies of th e FDS ten don can w ork in depen den tly of each oth er w h en th e FDP ten don s are pu lled togeth er. Th erefore, im m obilize all of th e digits in exten sion so th e FDS ten don can be tested for each digit (Fig. 12.2). Th e on ly except ion to th is rule is th e FDS of th e in dex nger. To determ in e if th e FDS is in t act in th e in dex nger, h ave th e pat ien t h old a sh eet of paper bet w een th e th u m b an d in dex nger. If th e PIP join t in th e in d ex nger is exed (du e to th e presen ce of th e FDS), th en th e FDS is in t act . If th e PIP join t is exten ded, th en th e FDS is n ot in t act . Fifteen p ercen t of th e gen eral popu lat ion do n ot h ave a sm all nger FDS; it is n ot fun ct ion al in an oth er 15%. FPL. Elicit exion of th e th u m b IP join t . Fig. 12.1 Physical exam ination of exor digitorum profundus (FDP). Isolate the FDP by im m obilizing the PIP joint, thereby m inimizing the contribution of the FDS tendon. ERRNVPHGLFRVRUJ Exam ination of Hand Injuries 131 Fig. 12.2 Physical examination of the exor digitorum supercialis (FDS). Imm obilize other digit s in extension to m inimize contribution of FDP to nger exion. Extensors Th e ext rin sic exten sors can be dam aged from th eir m u scle bellies in th e dorsal forearm all th e w ay to th e distal p h alan x. Th ey are grou p ed in to six com p ar t m en t s. Th e MCP join t is exten ded by th e ext rin sic exten sors on ly w h ile th e PIP an d DIP join ts are exten ded by th e com bin at ion of th e in t rin sic an d ext rin sic exten sors. Th e com par t m en t s an d test s of th e ext rin sic exten sors are as follow s: • Com pa r t m en t 1: Abdu ctor p ollicis longu s (APL; abdu cts th um b) an d exten sor p ollicis brevis (EPB; exten ds MCP join t). – APL: Abdu ct ion of th u m b on at surface (Fig. 12.3). – EPB: Exten sion of th u m b MCP join t . – Fin kelstein’s test: Test s for de Qu er vain ten osyn ovit is. Have th e pat ien t m ake a st over th u m b an d deviate h an d uln arly. Th is reprodu ces p at ien t’s p ain over th e rst com par t m en t (Fig. 12.4). • Com pa r t m en t 2: Exten sor carp i radialis longu s an d brevis, exten d w rist . – Make a st an d exten d w rist again st resist an ce. ERRNVPHGLFRVRUJ 132 Exam ination of Hand Injuries Fig. 12.3 Physical exam ination of abductor pollicis longus (APL) and extensor pollicis brevis. Fig. 12.4 Finkelstein’s test. See text for details. ERRNVPHGLFRVRUJ Exam ination of Hand Injuries 133 Fig. 12.5 Physical examination of extensor pollicis longus. • Com pa r t m en t 3: Exten sor p ollicis longu s. – Pu t h an d on a table an d raise th u m b o th e table (Fig. 12.5). • Com pa r t m en t 4: Exten sor digitoru m com m u n is (EDC) an d exten sor in dicis p ropriu s (EIP). – EDC: Exten d all ngers. – EIP: Ask pat ien t to h old th e in dex nger in exten sion w h ile exing oth er ngers. EDC ten don s are grou p ed an d th erefore can n ot act in dep en den tly of each oth er. • Com pa r t m en t 5: Exten sor digit i m in im i. – Hold sm all nger in exten sion w h ile m aking a st w ith oth er ngers. • Com pa r t m en t 6: Exten sor carpi u ln aris. – Exten d th e w rist u ln arly an d p alpate ten don over fth m etacarpal. Intrinsic Muscles of the Hand (Table 12.2) Th e m uscle bellies an d ten don s of th e in t rin sic m uscles of th e h an d are con t ain ed w ith in th e h an d. Togeth er th ese m uscles act to ex th e MCP join t w h ile exten ding th e IP join ts. Th e in t rin sic m uscles of th e h an d are listed below, togeth er w ith th e ap p rop riate test s. • Th en a r m u scles: Abductor pollicis brevis, op pon en s pollicis, exor pollicis brevis. – Palpate th en ar em in en ces. If hyp ot roph ic, con sid er m edian n er ve dam age. To test th ese m uscles, ask th e pat ien t to p erform th u m b pu lp -to-sm all- nger-pu lp op p osit ion . • Addu ct or pollicis: Involved in pin ch ing. ERRNVPHGLFRVRUJ 134 Exam ination of Hand Injuries • Hypot h en a r m u scles: Abdu ctor digit i m in im i, exor d igit i m in im i, an d oppon en s digit i m in im i. – Palp ate hypoth en ar em in en ce. Ask th e p at ien t to abduct sm all nger. • In t er osseou s m u scles: MCP exion an d IP exten sion . – Dorsal: Digit al abdu ct ion . – Palm ar: Digital ad du ct ion . ▪ Hold IP join ts in exten sion an d ask th e p at ien t to ex th e MCP join t . • Lu m br ica les m u scles: MCP exion an d IP exten sion . – Ho ld MCP in exion an d ask p at ien t to exten d IP join ts. Vascular Examination • Test to see if th e h an d is cold, congested, or edem atou s. • Ch eck capillar y re ll by pin ch ing nger t ips an d cou n t ing th e t im e it takes to re ll; 2 to 3 secon ds is n orm al. • Ch eck for blu e or n ecrot ic sp ot s on th e nger t ips. • Palpate radial an d u ln ar ar teries. If n ot palp able, th en use a h an dh eld Dopp ler p robe. • Perform Allen test to determ in e th e in tegrit y of th e palm ar arch . – First , ask th e pat ien t to m ake a st w h ile you occlu de th e radial an d u ln ar ar teries. – Th en h ave th e p at ien t op en th e exsanguin ated h an d. – Let go of th e radial vessel an d determ in e if th e h an d ret urn s to its n orm al p in k h u e. Rep eat th is p rocedu re an d let go of th e uln ar ar ter y. Take sp ecial n ote of ret urn of vascu larit y to th e th um b. – If th e p at ien t can n ot m ake a st , th en u se Dopp ler ult rasou n d to n d th e p alm ar arch . Occlu de th e radial or u ln ar ar ter y an d ch eck to see if th ere is a Dopp ler sign al in th e p alm ar arch . Perform test on both radial an d u ln ar ar ter y. – Make sure to exam in e th e arch th rough ou t its course in th e p alm . • Exam in e each of th e digital ar teries by assessing tem p erat ure, color, an d capillar y re ll. Neurologic Examination Th e rad ial, u ln ar, an d m edian n er ves su p ply th e h an d; Table 12.3 gives dist ribu t ion an d in n er vat ion . First determ in e if th e p at ien t h as sen sat ion over th e radial dist ribu t ion (th e back of th e h an d). ERRNVPHGLFRVRUJ Exam ination of Hand Injuries 135 Next , t urn th e h an d volar an d determ in e if th e pat ien t h as gen eral sen sat ion over th e radial th ree digit s an d palm (m edian n er ve). Be sure to exam in e th e proxim al p or t ion of th e palm for sen sat ion . Fin ally, exam in e th e volar an d dorsal u ln ar p or t ion (u ln ar n er ve dist ribu t ion ). To d eterm in e if digit al n er ves are in t act , perform th e Weber test . Using a caliper or ben t paper clip, m easure th e m in im um dist an ce of t w o-poin t discrim in at ion . Norm al is 2 to 3 m m in th e nger pu lp . Pat ien t s involved in occu pat ion s w h ere h eavy labor is requ ired m ay h ave a t w o-p oin t discrim in at ion of 5 to 6 m m . Pat ien t s w h o are blin d m ay h ave a discrim in at ion of 1 to 2 m m . Th e pat ien t n eeds to be correct in 7 test s out of 10 for good t w o-p oin t discrim in at ion . Test ing of m otor n er ve fu n ct ion of th e u pp er ext rem it y is perform ed by elicit ing con t ract ion of sp eci c m otor un its. • Musculocutaneous nerve: Flexes th e elbow. • Radial nerve: Elbow exten sion . • Median nerve: Wrist , nger (in d ex, long) exion , an d th um b exion . • Ulnar nerve: Wrist , nger (ring, sm all), an d in t rin sic h an d m ot ilit y, inclu ding abdu ct ion an d addu ct ion of th e ngers. • Radial nerve: Wrist , nger (MCP join t), an d th u m b exten sion . Speci c n er ve–m uscle associat ion s are listed in Table 12.3. In assessing m otor fun ct ion , th e Medical Research Coun cil m uscle scale is u seful for qu an t ifying st rength (Table 12.4). Table 12.3 Nerve and m otor innervations of the hand Nerves Motor Sensory Radial Triceps Dorsal wrist capsule Anconeus Dorsal radial hand Brachioradialis Dorsal thum b, index nger, m iddle nger, and radial half of ring nger to PIP joint Supinator Extensor carpi radialis brevis Extensor carpi radialis longus Extensor carpi ulnaris Extensor digitorum com m unis Extensor indicis proprius Extensor digiti m inim i Abductor pollicis longus Extensor pollicis longus ERRNVPHGLFRVRUJ 136 Exam ination of Hand Injuries (Continued) Extensor pollicis brevis Ulnar Flexor carpi ulnaris Ulnar half of the dorsum of hand Flexor digitorum profundus (sm all and ring ngers) Palm aris brevis Volar and dorsal aspect of small nger, ulnar side of ring nger Dorsal interosseous muscles Palm ar interosseous m uscles Ring and sm all nger lum bricales Adductor pollicis Flexor pollicis brevis deep belly Hypothenar m uscles: Abductor digiti m inim i Flexor digiti m inim i Opponens digiti m inim i Median Pronator teres Pronator quadratus Palm aris longus Volar wrist, thum b, index nger, m iddle nger, and radial half of ring nger extending to the DIP joint Flexor carpi radialis Flexor digitorum super cialis Flexor digitorum profundus (index and m iddle ngers) Flexor pollicis longus Index and m iddle nger lum bricales Thenar m uscles Abductor pollicis brevis Opponens pollicis Super cial belly of exor pollicis brevis ERRNVPHGLFRVRUJ Exam ination of Hand Injuries 137 Table 12.4 The Medical Research Council muscle grading system Observation Muscle grade No contraction 0 Flicker or trace of contraction 1 Active m ovem ent, with gravit y elim inated 2 Active movem ent against gravit y 3 Active m ovem ent against gravit y and resistance 4 Norm al power 5 ERRNVPHGLFRVRUJ 13 Anesthesia and Splinting of the Hand and Wrist Anesthesia Th e ap p licat ion of n er ve blocks n ot on ly p rovides com for t to p at ien t s but also assists th e physician in exposing an d repairing injuries to th e upper ext rem it y. Com m on local an esth et ics available in th e em ergen cy set t ing are: • Lidocain e 1 to 2%. – Toxic dose > 4 m g/kg. • Lido cain e 1% w ith epin ep h rin e 1:100,000. – Toxic dose > 7 m g/kg. • Marcain e 0.25%. – Toxic dose > 2.5 m g/kg. • 1:1 m ixt ure of lidocain e/Marcain e. – Toxicit y is th e sam e for both agen ts. – Toxicit y is n ot addit ive. Injection of Local Anesthetics Th ere are several tech n iqu es to con sider w h en adm in istering local an esth esia to in crease pat ien t com for t an d to reduce com plicat ion s: • Dilute th e con cen t rat ion . – Dilu te w ith sterile injectable salin e. ▪ Provides addit ion al volu m e for inject ion over a larger area w ith ou t in creasing th e total dose adm in istered. ▪ Aids in decreasing th e total dose required. • Adm in ister th e local an esth et ic agen t slow ly. – Toxicit y develops du e to peak ser u m con cen t rat ion . – Inject each site sequ en t ially rath er th at all at on ce. – Sp read th e total dose of local an esth et ic over a longer p eriod; th is leads to low er peak seru m levels. • Add epin eph rin e. – E ect ive con cen t rat ion s 1:1,000,000. – Im proves safet y an d allow s adm in ist rat ion of low er doses. – Im proves h em ostasis, th us decreasing du rat ion of procedu res. 138 ERRNVPHGLFRVRUJ Anest hesia and Splinting of the Hand and Wrist 139 – Helps preven t th e n eed for su bsequ en t inject ion . – Bew are of epin ep h rin e u se in p at ien ts w ith cardiac h istor y. – Avoid adm in istering epin ep h rin e in th e digits an d to p ediat ric pat ien t s. • Add bicarbon ate. – Decreases bu rn ing on adm in ist rat ion . – Add 1 m L of a 1-m Eq/m L bicarbon ate for ever y 9 m L of local an esth esia. • Con sider m ixing agen t s. – Use m ore th an on e local an esth et ic to t ake advan tage of th e u n iqu e proper t ies of each local an esth et ic. – Use a sh or t-act ing local an esth et ic (lidocain e) w ith a long-act ing agen t (Marcain e). – Provides prolonged an esth esia w ith ou t cau sing toxicit y from eith er agen t . – Th e toxicit y of th e m ixt ure does n ot exceed th e in divid ual toxicit y of each agen t . – Toxicit y of m u lt ip le agen ts in a solu t ion is n ot addit ive. • Draw back prio r to inje ctio n to e nsure no anesthetic is given intravascularly. Digital Nerve Block Tw o volar an d t w o dorsal n er ves in n er vate th e digit . Th e com m on digit al n er ve an d dorsal sen sor y n er ves are blocked via a dorsal approach w ith on e n eedlest ick. Using a 25-gauge n eedle, a 1-m L w h eal is m ade over th e exten sor m ech an ism at th e level of th e MCP join t to block t h e dorsal sen sor y n er ve. Th e n eedle is th en advan ced volarly on eith er side of th e join t in th e w eb space un t il it is palpated in th e palm . An addit ion al 1 m L of local an esth et ic is p laced on each side to block th e digit al n er ve. Altern at ively, a digital n er ve block m ay be perform ed w ith direct in st illat ion of th e 1 to 3 m L of an esth et ic agen t in th e adjacen t w eb spaces dorsally an d dorsal over th e MCP join t (Fig. 13.1). Care m ust be t aken n ot to p erform circu m feren t ial in st illat ion arou n d th e digit th at m ay su bsequ en tly im p air p erfu sion . Wrist Block Wrist blockade in cludes an esth esia of th e m edian , uln ar, an d radial n er ves. Th e e cacy of a w rist block is in creased by ap p licat ion of a tou rn iqu et at th e m idforearm . Wrist blocks are ap p lied as follow s. ERRNVPHGLFRVRUJ 140 Anest hesia and Splinting of the Hand and Wrist Fig. 13.1 Digital nerve block. Media n n er ve. Inject 5 m L of agen t bet w een th e p alm aris longu s an d exor carpi radialis ten don s at th e proxim al w rist crease using a 25-gauge n eedle. Avo id inje ctio n directly into the m e dian nerve. If th e pat ien t feels t ingling du ring inject ion , w ith draw th e n eedle 1 to 2 m m an d reinject . Uln a r n er ve. Inject 5 m L of agent radial to the exor carpi ulnaris tendon at the w rist crease w ith the w rist in exion. Take care not to inject into the ulnar artery. Rem em ber to draw back on the syringe rst. Ra dia l ner ve—super cia l br a nch. Inject 5 m Lof agent from the m idpoint of the dorsum of the w rist to the radial border of the anatom ical snu box (Fig. 13.2). Draw back on the syringe so as not to inject into the radial artery. ERRNVPHGLFRVRUJ Anest hesia and Splinting of the Hand and Wrist 141 Fig. 13.2 Wrist blocks. (a) Radial sensory nerve block. (b) Median nerve block. (c) Ulnar nerve block. Splinting Th e proper splin t ing of fract ures an d dislocat ion s is of param oun t im portan ce. Th e use of a splin t in ten don , n er ve, an d arter y repair p rotect s again st t ract ion an d disru pt ion of t h e repair. Sp lin t s of th e h an d for in fect ion s an d soft t issu e t rau m a p reven t dysfun ct ion al bon e an d soft t issu e con t ract u res. Th e u se of a sp lin t also h elp s to decrease a p at ien t’s p ain an d discom for t . ERRNVPHGLFRVRUJ 142 Anest hesia and Splinting of the Hand and Wrist General Procedures (Fig. 13.3a) • Use local an d region al blocks to allow p ain less m an ipu lat ion of th e ext rem it y w h ile splin t ing. • Sp lin t ing m aterials used. – Kerlix gau ze. – 4-in ch (10-cm ) Webril roll. – 4-in ch plaster m aterial. – 4-in ch Ace ban dage. – 4-in ch Coban (3M). • After inju r y rep air, clean an d dr y th e ext rem it y. • Place a single layer of Webril (Ken dall Com p any) arou n d th e h an d an d forearm loosely (Fig. 13.3b). • Measure th e length of th e area to be splin ted; cu t a 10-ply p iece of plaster m aterial at th at length . Altern at ively, p rem ade p laster/ gauze of berglass com posites (e.g., OCL [Or th opedic Cast ing Lab m an ufact u rers] splin t roll) can be cut to length an d used (Fig. 13.3c). • Place p laster in Webril w rap (Fig. 13.3d). • Wet th e plaster m aterial an d p lace it on th e h an d/forearm in th e desired p osit ion (Fig. 13.3e). • Hold th e plaster m aterial in p osit ion by w rapp ing w ith a single layer of Kerlix (Fig. 13.3f). • Hold th e h an d in th e desired p osit ion (Fig. 13.3 g). • Apply eith er Ace or Coban in a single loose layer over th e splin t (Fig. 13.3h). • Apply circu m feren t ial w raps loosely to avoid con st rict ion . • Elevate th e ext rem it y to preven t dep en den t edem a w h ile in th e splin t . • Prescribe a sh or t-term follow -u p p rotocol, esp ecially in ou t pat ien t t reat m en t , to allow assessm en t for edem a, digital p erfusion , an d splin t displacem en t . Splint Types Volar Splin t (Fig. 13.3) • • • • • • Most versat ile sp lin t for rad ial-sided inju ries. In dex an d long nger fract u res. In dex an d long nger in fect ion s. Wrist n eurovascular inju ries. Forearm in fect ion s. Metacarp al fract u res. ERRNVPHGLFRVRUJ Anest hesia and Splinting of the Hand and Wrist 143 Fig. 13.3 (a) Volar splint. The gray shading denotes plaster position. (b–g ) Placement of a plaster, step-by-step. ERRNVPHGLFRVRUJ 144 Anest hesia and Splinting of the Hand and Wrist Fig. 13.3 (Continued) (b–g ) Placement of a plaster, step-by-step. (h) Plaster in place. ERRNVPHGLFRVRUJ Anest hesia and Splinting of the Hand and Wrist 145 Posit ion In t rin sic Plu s Posit ion - “Safe Posit ion ” • • • • • • • • Proxim al forearm to DIP join t . Ap ply on volar su rface of th e forearm /w rist an d h an d. In clu de in d ex th rough sm all nger. Keep th u m b free. Exten d w rist 35 degrees. Flex MCP join t 90 degrees. Flex PIP/DIP join ts 0 to 10 degrees. For exten sor ten don inju ries, place MCP join t in exten sion . Uln ar Gut ter Sp lin t (Fig. 13.4) • • • • • Uln ar-sided inju ries. Ring an d sm all nger fract u res. Ring an d sm all nger in fect ion s. Exten sor ten d on injuries. Uln ar-sided m et acarpal fract u res. Posit ion • Proxim al forearm to DIP join t . • Ap ply on u ln ar volar surface of th e forearm /w rist an d on th e h an d to th e m id-dorsu m . • In clu de ring an d sm all ngers. • Keep th u m b an d in dex an d long ngers free. • Wrist exten ded 35 degrees. • Flex MCP join t 90 degrees. • Flex PIP/DIP join ts 0 to 10 degrees. Fig. 13.4 Ulnar gutter splint. The gray shading denotes plaster position. ERRNVPHGLFRVRUJ 146 Anest hesia and Splinting of the Hand and Wrist Th u m b Spica Sp lin t (Fig. 13.5) • • • • • • Most versat ile sp lin t for th u m b inju ries. Th u m b fract ures an d dislocat ion s. Th u m b an d th en ar in fect ion s. Th u m b ten don injuries. Scaph oid inju ries. First m etacarpal fract ures. Posit ion • Proxim al forearm to IP join t . • Apply t w o plaster splin t s. – On e on volar su rface of th e forearm /w rist an d th u m b. – On e radially to th e m id-dorsu m . • Keep in dex th rough sm all nger free. • Exten d w rist 35 degrees. • Flex MCP join t 10 to 15 degrees. • Flex IP join t 0 to 10 degrees. Fig. 13.5 (a,b) Thum b spica splint. The gray shading denotes plaster position. ERRNVPHGLFRVRUJ Anest hesia and Splinting of the Hand and Wrist 147 Exten sion Block Sp lin t (Fig. 13.6) • Flexor ten don injuries. • Proxim al an d m id dle p h alangeal fract u res. Posit ion • • • • • • • Splin t from proxim al forearm to DIP join t . Ap ply on dorsal su rface of th e forearm /w rist an d h an d. In clu de in d ex th rough sm all nger. Flex w rist 45 degrees. Flex MCP join t 90 degrees. Flex PIP join t 45 degrees. Flex DIP join t 20 degrees. – Sp lin t from proxim al forearm to DIP join t . – Ap ply on dorsal su rface of forearm . Fig. 13.6 Extension block splint. The gray shading denotes plaster position. Proximal and middle phalangeal fractures • Con sider in t rin sic plu s p osit ion w ith plaster d orsal to block exten sion . – In clude adjacen t digits. ▪ Wrist in n eu t ral posit ion or sligh t exten sion . ▪ MCP join t in 70 to 90 degrees of exion . ▪ IP join t exten ded. ERRNVPHGLFRVRUJ 14 Hand and Wrist Fractures and Dislocations Hand Fractures Physical Examination Pat ien t s w ith su spected h an d fract ures requ ire a th orough physical exam in at ion (Ch apter 12). • Perform a com plete physical exam in at ion to determ in e th e in tegrit y of th e n er ves, th e ar teries (p erfu sion ), th e ten don s, join t m obilit y, an d th e soft t issu es. • Radiograph s are p aram ou n t for establish ing an d con rm ing th e correct diagn osis. – Plain radiograp h s—a h an d series sh ould in clu de AP, t ru e lateral, an d oblique view s. – In selected cases of carp al fract u res an d m ore com plex w rist inju ries, a CT scan m ay be in dicated. – Con sider radiograph s of th e join t proxim al to th e injur y so as n ot to m iss associated inju ries. Fracture Classi cation • Open versus closed . • Displaced versu s n on displaced. • Tran sverse versu s obliqu e versu s spiral versu s com m in u ted or avulsion . • Trau m at ic versus path ologic. • Adu lt versus pediat ric – In pediat ric pat ien ts—green st ick versus ep iphyseal plate. – Ep iphyseal plate fract u res—Salter-Harris classi cat ion (Fig. 14.1). 148 ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 149 Fig. 14.1 Salter-Harris classi cation of epiphyseal fractures. Fracture Treatment In gen eral, h an d fract u res can be t reated in th e em ergen cy room w ith closed reduct ion an d splin t ing. How ever, if th e fract ure is open , displaced, or u n st able, or if t h e angu lat ion is n ot acceptable, th en operat ive t reat m en t m ay becom e n ecessar y. Open Fractures • Perform a digit or w rist block. • Cult u re an d irrigate open fract u res p rofu sely. • Adm in ister IV an t ibiot ics (ER t reat m en t or inp at ien t). ERRNVPHGLFRVRUJ 150 Hand and Wrist Fract ures and Dislocations – Am picillin 500 g IV ever y 8 h ou rs + gen t am icin 3 to 5 m g/kg daily divided ever y 8 h ou rs (ch eck peak an d t rough serologic levels). – Van com ycin 1 g IV ever y 12 h ou rs + ceft ria xon e 1 to 2 g IV ever y 24 h ours. – Ou t p at ien t p rop hylact ic an t ibiot ics for p at ien t s w ith a plan for later su rger y in clu des Bact rim DS by m ou th t w ice a day. • Irrigate th e w ou n d an d sp lin t th e p at ien t in prep arat ion for operat ive redu ct ion . Phalangeal and Metacarpal Fractures Indications for Operative Treatment • • • • • • • • In t ra-ar t icu lar fract ures. Irredu cible fract u res. Malrotat ion . Su bcapit al ph alangeal fract u res. Open fract u res if disp laced or angled. Bon e loss. Mult ip le fract u res. Fract u res w ith soft t issu e injur y. Phalangeal Fractures Distal Phalanx Fractures Dist al ph alan x fract u res are th e m ost com m on fract u res in th e h an d. Th e th u m b an d m iddle nger are m ost likely involved. Pat ien t s p resen t w ith t u ft fract u res, sh aft fract u res, an d in t ra-ar t icu lar inju ries du e to crush . Tuft Fractures Open Fractures • • • • Perform nger or w rist block. Rem ove n ail. Irrigate. Repair n ail bed w ith 6–0 to 7–0 ch rom ic sut u re an d sten t th e n ail m at rix (see Ch apter 17, Fig. 17.2). • Im m obilize DIP join t in exten sion w ith tongu e blade or alum in u m splin t for 3 to 4 w eeks w ith PIP free. ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 151 • In cases of severe com m in u t ion , soft t issu e repair is adequ ate for sp lin t ing fract u res. • Treat w ith Bact rim DS by m outh t w ice a day ×5 days. Closed Fractures • Perform nger or w rist block. • If a h em atom a is p resen t u n der th e n ail, drain it using a pun ct u re tech n iqu e. – Sterile 18-gauge n eed le t ip , h eated p aper clip , or elect rocau ter y. – If th e h em atom a > 50% of n ail bed, likely n ail bed inju r y ▪ Rem ove an d rep air n ail bed an d sp lin t w ith p iece of foil from ch rom ic package or u se th e n ail itself (see Ch apter 17, Fig. 17.2). ▫ Splin t nger for 2 w eeks. ▫ Treat w ith ou t p at ien t an t ibiot ics ×5 days. Shaft Fractures - Distal Phalanx • Non displaced. – Rep air soft t issue. – Sp lin t for 3 w eeks. – Bact rim DS by m ou th t w ice a day. • Disp laced . – Likely n ail bed lacerat ion . – Rep air n ail m at rix (see Ch apter 17, Fig. 17.2). – Stabilize fract ure w ith K-w ire or 18-gauge n eedle. – Sp lin t nger w ith PIP free for 3 w eeks. – Ou t pat ien t an t ibiot ics ×5 days. Intra-articular Fractures - DIP • Open fract u re. – Rep air n ail bed. – Sp lin t DIP join t in exten sion for 6 to 8 w eeks. – Ou t pat ien t an t ibiot ics. • Closed fract ure. – Sp lin t DIP join t in exten sion . ERRNVPHGLFRVRUJ 152 Hand and Wrist Fract ures and Dislocations Dorsal Base An in t ra-ar t icular fract ure of th e dorsal base (m allet fract ure) is a hyperexion injur y in w h ich a por t ion of th e dorsal bon e breaks o w ith exten sor m ech an ism . It cau ses exten sor lag w ith a m allet nger deform it y. Treatm en t requires st rict pat ien t com p lian ce. In th e p ediat ric p opu lat ion th is m ay require a K-w ire th rough th e DIP join t . • Treat w ith splin t in exten sion for 6 to 8 w eeks. Volar Base (FDP Avulsion) An in t ra-ar t icular fract ure of th e volar base is a hyperexten sion injur y in w h ich th e exor digitoru m p rofu n du s (FDP) p u lls o th e dist al ph alan x. • Treat w ith ORIF because FDP m ay ret ract in to palm . • Sp lin t h an d in em ergen cy room w ith tongu e blade or alu m in u m splin t . • If open , w ash out , rep air n ail bed, star t an t ibiot ics, an d splin t . Middle and Proximal Phalanx Fractures Middle an d p roxim al ph alan x fract u res are cau sed by cr u sh ing forces rath er th an direct blow, t w ist ing, or angu lar forces. If th ese fract ures are n on displaced or stable, sim ply buddy tape or splin t w ith IP exten ded for 3 to 4 w eeks. A com m in u ted, displaced fract u re of th e m iddle or proxim al ph alan x to th e ar t icu lar su rface is called a pilon fract ure. Articular Fractures - PIP • In ER set t ing. – Fract u re of single digit—en su re involved join t is in exten sion . ▪ Alum in u m or tongue blade sp lin t . – Mult ip le fract u res—splin t h an d in in t rin sic p lu s. – Follow u p in clin ic for operat ive m an agem en t . • Non displaced—in h eren tly u n stable. – Operat ive m an agem en t u sing eith er closed or open reduct ion or xat ion by m u lt iple K-w ires or screw s or a com bin at ion . – If n on operat ive m an agem en t ch osen , th en close follow -up requ ired. • Disp laced. – Dorsal base fract ures of m iddle p h alan x. ▪ ORIF to avoid bou ton n ière deform it y. ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 153 – Dorsal base fract u res of p roxim al ph alan x. ▪ Require ORIF. • Un icon dylar (displaced). – In h eren tly un stable—eith er closed or op en reduct ion an d xat ion w ith m ult iple K-w ires or screw s. – Exten sion splin t 2 to 3 w eeks. • Bicon dylar. – Requ ires ORIF. – Non com m in uted. ▪ Fix con dyle to con dyle rst , th en to th e sh aft w ith K-w ires or screw s. – Com m in uted. ▪ Di cu lt to t reat . ▪ DIP join t . ▫ Min im al disp lacem en t—closed redu ct ion . * Sp lin t 2 w eeks in exten sion . * Physical th erapy in 2 w eeks. ▫ Displaced. * ORIF w ith K-w ire/screw xat ion . * Early m ot ion at 2 w eeks. ▪ PIP join t . ▫ Skeletal t ract ion of th e m iddle ph alan x for 3 to 4 w eeks w ith forearm sp lin t . ▫ Act ive exion of PIP join t im m ediately. Fig. 14.2 Transverse fracture of the proximal phalanx. ERRNVPHGLFRVRUJ 154 Hand and Wrist Fract ures and Dislocations Nonarticular Fractures • Sh aft . – No ndisplaced and stable—not r ot a t ed, a n gu la t ed, or com m in u t ed. ▪ Splin t th e nger in exten sion w ith an alu m in u m splin t . ▫ Mu st cover p roxim al an d distal join t . ▫ Durat ion of 1 w eek. ▫ On ce pain an d sw elling resolve, bu ddy t ap e to adjacen t nger an d begin range of m ot ion . – Disp laced bu t am en able to st able closed reduct ion . ▪ Usually tran sverse fract u res (Fig. 14.2), n ot oblique or spiral. ▪ At tem pt red uct ion an d stabilizat ion . ▫ Perform digit block (See Ch apter 13, Fig. 13.1). ▫ Flex MCP join t m a xim ally. ▫ Flex distal fragm en t to correct volar angu lat ion . ▫ Dorsal sp lin t in in t rin sic p lu s posit ion . * Plaster sh ou ld be placed dorsally for exten sion blocking—MCP 90 degrees, IP exten ded, in clu de adjacen t digits in sp lin t for stabilizat ion . ▫ Sp lin t for 3 w eeks, th en bu ddy tape for addit ion al 2 w eeks. – Un st able—if poten t ial for rot at ion or angu lat ion exists. ▪ Open , obliqu e, spiral, com m in u ted fract u res. ▪ Radiograp h ically angu lated. ▪ Assess by h aving pat ien t ex nger. ▫ Fingers overlap . Fig. 14.3 Com m inuted fracture of the proxim al phalanx. ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 155 ▫ Plan closed redu ct ion w ith p ercu t an eou s p in n ing w ith in 3 to 4 days. ▫ Use 0.035- to 0.045-in ch K-w ire. ▪ Un stable t ran sverse fract u res. ▫ In t ram edu llar y longit u din al xat ion th rough m etacarpal h ead w ith K-w ire. ▫ Exten sion block splin t in in t rin sic plu s posit ion w ith IP join ts free for 3 to 4 w eeks. ▪ Com m in uted fract u res (Fig. 14.3). ▫ Require operat ive m an agem en t . ▫ At tem pt closed K-w ire xat ion . ▫ Extern al xat ion device often in dicated for com plex com m in u t ion an d sh or ten ing. * Preser ves length . * Assist s w ith m an agem en t of soft t issu e inju ries. ▪ For u n su ccessfu l p ercutan eou s p in n ing, p erform ORIF w ith plates or in terosseous w iring. Base Fractures of Proximal Phalanx • Ext ra-ar t icu lar. – Angu lat ion of 25 degrees in adu lt s an d 30 degrees in ch ildren requires t reat m en t . – To redu ce. ▪ Flex MCP m axim ally. ▪ Flex distal fragm en t to correct volar angulat ion . – Sp lin t in in t rin sic plu s (dorsal p laster) for 3 w eeks. – Failed closed redu ct ion . ▪ K-w ire xat ion . Metacarpal Fractures Head Fractures • Open fract u res secon dar y to closed- st inju r y, or gh t bite (also see Ch apter 15, Fig. 15.9). – Wrist or local block. – High -pressu re irrigat ion an d débridem en t . – Leave w ou n d open . ERRNVPHGLFRVRUJ 156 Hand and Wrist Fract ures and Dislocations • • • • – Delay xat ion un t il sign s th at in am m at ion or in fect ion h as su bsided . – Sp lin t in in t rin sic plus volar splin t (see Ch apter 13, Fig. 13.3). – Augm en t in 875 m g by m ou th t w ice a day × 10 days or Bact rim DS by m outh t w ice a day. – Sh or t-term follow -u p. In dex nger m ost com m on ly involved due to axial loading, an d often int ra-ar t icular. AP, lateral, an d obliqu e X-rays; if n ot clear, th en Brew erton view. Non displaced—splin t in volar splin t for 4 w eeks (see Ch apter 13, Fig. 13.3). – If > 25% of ar t icular su rface or > 1 m m step -o , splin t in safe posit ion , p lan ORIF. – Min iplate xat ion p referred, to allow early m obilizat ion (Fig. 13.3). If com m in uted, p erform w rist block an d w ash ou t w ou n ds. – Sp lin t acu tely in safe p osit ion . – Plan for im m obilizat ion for 2 w eeks w ith skeletal t ract ion , extern al xat ion , or ar th roplast y. Neck Fractures • In dicat ion s for reduct ion . – Pseu doclaw ing (claw ing of ngers w ith u ln ar n er ve in t act). – MCP hyperexten sion /PIP exion . – Rot at ion al deform it y. – Scissoring of ngers. – Un accept able angu lat ion . Apex do rsal angulatio n o ccurs fro m intrinsic m uscle co ntractio n. Treat m en t is based on angu lat ion : • Sm all digit (boxer’s fract u re)—50 degrees angu lat ion accept able. • Ring nger—30 to 40 degrees angu lat ion acceptable. • Middle an d in dex nger—10 to 15 d egrees acceptable. If angu lat ion is u n accept able, an d p seu doclaw ing or rot at ion d eform it y is presen t: • In a fresh fract u re, at tem pt closed redu ct ion . • Fract u re > 7 days old m ay requ ire op erat ive red u ct ion . • Closed reduct ion by Jah ss m an euver (Fig. 14.4)— rst perform a w rist block (w rist block for boxer’s fract u re). • Next , ex MCP join t to 90 degrees an d PIP join t to 90 degrees. ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 157 Fig. 14.4 Jahss maneuver for reduction of m etacarpal fractures. • Ap ply u pw ard pressu re on th e proxim al p h alan x w h ile pressing dow n on th e m et acarp al sh aft . – If redu ced, splin t in safe p osit ion for 3 to 4 w eeks an d m on itor redu ct ion regu larly (Fig. 13.3) for secon d an d th ird m etacarp al. – For fou r th an d fth m etacarpal fract u re, u se u ln ar gut ter splin t (see Ch apter 13, Fig. 13.4). – If n ot red u cible, use in tern al xat ion w ith K-w ires, plates, or dorsal ten sion ban d w ires. ▪ Splin t in a safe posit ion acu tely. – After reduct ion , take radiograph to con rm redu ct ion . – Also con sider splin t ing w ith MCP join ts exten ded – PIP join ts are left free of im m obilizat ion ERRNVPHGLFRVRUJ 158 Hand and Wrist Fract ures and Dislocations Shaft Th e t ypes are: • Spiral: Torsion al forces w ith 5 degrees of m alrotat ion causing a 1.5-cm digit al overlap . • Oblique: Lateral ben ding forces w ith axial load . • Transverse: Lateral ben ding force versu s axial load. • Com m inuted: Direct im p act on th e m et acarp al, w h ich m ay cau se sh or ten ing. If angulat ion is accept able (see Neck Fract ures above), th en close redu ce th e fract u re u sing t ract ion an d a w rist block. • Flex MCP join t . • Press on th e fract u re ap ex d orsally w ith a palm ar-directed force. • Place in volar in t rin sic plu s splin t . If th ere are m ult iple fract ures (Fig. 14.5), t h e fract u re is u n st able/op en , or th ere is scissoring an d severe angu lat ion , th en perform ORIF w ith K-w ires, in terosseou s w ires, p lates, lag screw s, or extern al xat ion . In th e em ergen cy room , place th e pat ien t in a safe-posit ion splin t . Fig. 14.5 Fractures of m ultiple metacarpals. ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 159 Base Fractures/CMC Joint Fracture -Dislocation Base fract u res an d CMC join t fract ure-dislocat ion are in h eren tly un stable fract u res cau sed by axial load versu s direct blow. In dex ngers an d m iddle ngers are less likely to u n dergo th is t yp e of fract u re becau se th ese join t s are less m obile. A h am ate– fth m et acarpal in t ra-art icular fract ure is a baby (reverse) Bennett fracture. • Because th e exten sor carpi u ln aris pu lls on th e fth m etacarpal, in th e X-rays you w ill see th at th e uln ar por t ion su blu xates proxim ally an d dorsally. • Closed redu ct ion w ith K-w ires versu s ORIF. In th e em ergen cy room , place th e pat ien t in a volar splin t in safe posit ion (see Ch apter 13, Fig. 13.3). Thumb Fractures Inju ries occu r from direct t rau m a an d angu lar or rot ar y forces. Thumb Phalangeal Fractures Ext ra-ar t icular: • Proxim al ph alan x fract u re w ith > 20 to 30 degrees apex volar angu lat ion is un acceptable an d requ ires redu ct ion . • Com m in u ted fract ures requ ire redu ct ion an d eith er open or closed xat ion (K-w ire) (Fig. 14.6). – Severe com m in u t ion m ay requ ire extern al xat ion to preser ve length . • In th e em ergen cy room , splin t in a th u m b spica sp lin t an d plan operat ive t reat m en t (Fig. 13.5). • Distal t u ft—associated w ith su bu ngu al h em atom a, n ail bed inju ries, an d com m in u ted fract u res. – Finger block. – Rem ove n ail. – Irrigate th orough ly. – Rep air n ail bed. – Sp lin t 3 to 4 w eeks in exten sion w ith tongu e blade or alum in u m sp lin t . • Tran sverse sh aft . – Finger or w rist block. – Close redu ce. – Sp lin t in exten sion ; if u n st able, th en ORIF. ERRNVPHGLFRVRUJ 160 Hand and Wrist Fract ures and Dislocations Fig. 14.6 Fracture of the thum b proximal phalanx that requires xation. Intra-articular—(occurs w hen axial load is placed on partially exed thum b): • Dorsal base avu lsion = m allet th um b. – Treat w ith 6 to 8 w eeks of exten sion splin t . – Con sider ORIF if su blu xat ion p resen t . • Volar base fract u re. – Con sider avu lsion of exor p ollicis longu s. • Fract ures of th e ulnar base represent avulsion of the ulnar collateral ligam ent and are also called skier’s thum b or gam ekeeper’s thum b. • If th e fragm en t is disp laced > 2 m m or > 25% of ar t icular su rface, th en K-w ire xat ion versu s ORIF. • In th e em ergency room , place in a th um b spica splint (see Chapter 13, Fig. 13.5). Thumb Metacarpal Fractures Head an d sh aft fract ures resu lt from torsion al, direct im pact , angulator y, or rot ar y forces. Ext ra-ar t icu lar: • Fract u res u p to 30 degrees angu lat ion are acceptable du e to com pen sat ion by CMC m obilit y. • Head—rare fract u re th at requires redu ct ion an d K-w ire xat ion versu s ORIF if disp laced. Can at tem pt closed redu ct ion by Jah ss m an euver (Fig. 14.4). ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 161 • Shaft—after radial an d m edian n er ve block at th e w rist , close reduce an d splin t in th u m b sp ica splin t (Fig. 13.5). In t ra-ar t icu lar: • Bennett fracture—occu rs w h en par t ially exed th um b is a xially loaded. – It is de ned as intra-articular fracture-subluxation of the base of the rst m etacarpal. On X-rays, the volar ulnar aspect of the m etacarpal base rem ains stable due to the anterior oblique ligam ent. However, the rest of the m etacarpal m oves dorsally, proxim ally, and radially due to the pull from the abductor pollicis longus. – If th e bon e fragm en t is > 20% of CMC join t su rface, th en reduce closed an d stabilize w ith a K-w ire. – If th e fract u re can n ot be redu ced in a closed fash ion , th en ORIF. – In th e em ergen cy room , splin t in a th u m b spica splin t an d plan operat ive t reat m en t (Fig. 13.5). • Ro lando fracture —any com m in u ted in t ra-ar t icu lar fract u re of th e base of th e rst m et acarp al, bu t t rad it ion ally referred to as Y- or T-sh ap ed in t ra-ar t icu lar fract u res. – If severely com m in u ted, u se skelet al t ract ion an d perform percu t an eous xat ion . – If fract u re con t ain s large fragm en t s, on ly ORIF. – In em ergen cy room , p lace in th um b spica splin t (Fig. 13.5) an d plan op erat ive t reat m en t . Pediatric Phalangeal and Metacarpal Fractures Children rarely present w ith fractures of the hand. When they do, the chance of displacem ent is less than in adults. This is due to the m alleabilit y of the child’s bones, as well as the tougher periosteum . Fractures are classied into either nonepiphyseal fractures (66%) or fractures that involve the epiphysis. Epiphysis fractures are categorized by Salter-Harris classi cation (Fig. 14.1). Fractures in children heal tw ice as fast as those in adults, and the epiphyseal plate com pensates for angular deform it y of the fractures. How ever, accurate reduction is crucial in intra-articular fractures. Extra-articular Fractures Fract ures com m on ly occur in th e m iddle an d proxim al ph alan x in ch ildren . • If th e fract u re is n ot displaced (t ype I), splin t in a safe posit ion . • If decreased (t ype II) or n o (t yp e III) bon e con t act bet w een th e fragm en t an d rem ain der of th e bon e, th en u se K-w ire xat ion . ERRNVPHGLFRVRUJ 162 Hand and Wrist Fract ures and Dislocations • In th e em ergen cy room , splin t th e h an d in a safe posit ion (see Ch apter 13, Fig. 13.2). – In in fan t s, con sider in clu d ing th e elbow in exion along w ith dorsally placed plaster in th e sp lin t . Intra-articular Fractures • In cases of displaced fract ures, ORIF w ith m in iat urized w ires (0.028–0.039 in ches) and screw s—especially in children > 2 years old. Epiphyseal Fractures (Fig. 14.1) Sa lt er -Ha r r is I. Th is is a fract ure th rough th e epiphyseal plate w ith sep arat ion of epiphysis from th e m et aphysis (sh ear injur y). Th is usually occurs in early ch ildh ood w h en th e plate is th ick w ith a zon e of hypert rop hying ch on drocytes an d sp arse calci cat ion . Th e progn osis is good w ith a w rist block, reduct ion , an d splin t ing th e h an d in a safe posit ion (see Ch apter 13, Fig. 13.2). May require dorsal plaster in young ch ildren . Sa lt er -Ha r r is II. Th is fract u re involves a m et ap hyseal fragm en t associated w ith an epiphyseal fract ure. Th is is th e m ost com m on Salter-Harris fract u re. Th e progn osis is good w ith adequate redu ct ion an d splin t ing. Sa lt er -Ha r r is III. Th is fract ure occurs in ch ildren > 10 years of age du e to avu lsion force. It is an in t ra-ar t icu lar fract u re th rough th e epiph ysis an d th e epiphyseal plate. Un less accurate reduct ion is perform ed, th e progn osis is poor. Sa lt er -Ha r r is IV. Th is is a rare fract u re th at occu rs at any age. Th e fract u re exten ds from th e ar t icu lar su rface th rough th e ep ip hysis an d th rough th e ep iphyseal p late, an d it also involves a p or t ion of th e m et ap h ysis. It h as a p oor progn osis u n less an accu rate red u ct ion is p erform ed. Sa lt er -Ha r r is V. Th is is an ext rem ely rare fract u re th at occu rs at any age. It is cau sed by cru sh ing of th e ep iphyseal plate by axial load. It h as a poor progn osis du e to grow th arrest . Dislocations Phalanx and Metacarpal Dislocations Proximal Interphalangeal Joint Th e PIP join t is st abilized by a com bin at ion of th ick collateral ligam en ts, accessor y collateral ligam en ts, an d th e volar plate. Th is is a h inge join t w ith an arc of rotat ion of 100 to 110 degrees an d is th e m ost com m on ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 163 site of ligam en tou s injur y. Th e direct ion of dislocat ion is dep en den t on th e posit ion of th e m iddle ph alan x at th e m om en t of join t dislocat ion . Types of Dislocation • Vo lar: Rare, cau sed by rotar y longit udin al com pression force on a sem i exed m iddle ph alan x. • Do rsal: Resu lt of longit u din al com pression an d hyperexten sion . Stability • Active : Ask pat ien t to m ove th rough fu ll ROM. If su blu xat ion occurs, th e p at ien t h as severe ligam en tous injur y. If th e pat ien t h as full ROM w ith ou t sublu xat ion , th en adequ ate stabilit y exists. • Passive : Hold nger in fu ll exten sion an d th en at 30 degrees of exion . Test lateral st ress on th e collateral ligam en t s. Com pare stabilit y to u n a ected PIP join t . Grades • Mild: Join t st able w ith m icroscopic tears. • Moderate: Join t w ith abn orm al laxit y w ith m oderate degree of tear. • Com plete: Collateral ligam en ts are com p letely torn . Treatment Sprain s: • Splin t join t in exten sion for 2 to 3 days (w ith alum in um splin t). • If it rem ain s stable, st ar t early m ot ion . Dislocat ion s: • Vo lar: Exam in e nger for th e in tegrit y of th e cen t ral slip . After giving nger block, th en redu ce u sing t ract ion an d splin t 2 to 3 days in exten sion (alu m in u m sp lin t or tongue blade). If stable, st ar t early m ot ion . • Do rsal: If dislocat ion is stable after reduct ion , th en sp lin t in exten sion for 3 w eeks. If d islocat ion is un st able after reduct ion , th en surger y is requ ired. Th ese dislocat ion s often involve > 40% of th e volar ar t icu lar su rface. Plan ORIF or volar p late ar th roplast y. • Lateral: Use a com bin at ion of bu ddy taping an d exten sion splin t ing for 3 w eeks. In n early all cases, th e ligam en ts ret u rn to th eir n orm al posit ion even th ough th ey m ay h ave been com p letely disru pted. ERRNVPHGLFRVRUJ 164 Hand and Wrist Fract ures and Dislocations Distal Interphalangeal Joint and Thumb Interphalangeal Joint Because both exors an d exten sors in ser t on th e distal ph alan x an d h elp st abilize th e join t , dist al in terp h alangeal join t an d th u m b in terp h alan geal join t dislocat ion is rare. Dorsal an d lateral dislocat ion s w ith open w oun ds are m ost com m on . • Perform a digital block (see Ch apter 13, Fig. 13.1). • Alth ough th ese dislocat ion s are rarely reducible, t r y to reduce it by using longit u din al t ract ion an d direct p ressu re on th e dorsum of th e dist al p h alan x; m an ipu late th e distal ph alan x in to exion . • Im m obilize in a dorsal sp lin t for 2 to 3 days w ith PIP join t free. • Th en bu ddy tape an d star t con ser vat ive act ive m ot ion . Finger Metacarpophalangeal Joint Th e con dyloid join t is u su ally dislocated in a dorsal or uln ar direct ion . Dorsal dislocat ion m ost com m on ly occurs in th e in dex or sm all n ger, caused by forced hyperexten sion . In a sim ple sublu xat ion th e volar plate u su ally stays w ith th e p roxim al ph alan x. Treatment Flex th e w rist to relax exor ten don s. Th en ex th e MCP join t by applying distal an d volarly directed p ressu re to th e proxim al ph alan x. Do n ot apply t ract ion or hyperexten d because th is w ill conver t th e inju r y to a com plex dislocat ion . • Com p lex dislocat ion : Volar plate is u su ally jam m ed in to th e join t; th erefore, exion an d redu ct ion are im possible. – ORIF an d im m obilize for 2 w eeks. • Lateral: Radial collateral ligam en t is ru pt u red by th e forced u ln ar deviat ion w h ile th e MCP join t is exed. – Reduce an d im m obilize in 30 degrees of exion for 3 w eeks. – Bu ddy t ape w ith m ot ion for 2 to 3 w eeks. • Volar: Th is is ext rem ely rare. – At tem pt closed redu ct ion . – If redu ct ion n ot stable, th en ORIF. ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 165 Thumb Metacarpophalangeal Joint Gamekeeper’s Thumb Gam ekeeper’s th um b is th e m ost com m on th u m b MCP join t injur y, w h ich occu rs w h en th e p ar t ially exed th u m b is a xially loaded. Th is is de n ed as an avulsion fract u re from th e uln ar base of th e proxim al ph alan x du e to disru pt ion of th e u ln ar collateral ligam en t . Treatment Im m obilize th e join t for 6 w eeks in a th u m b sp ica sp lin t . Su rgical exp lorat ion is in dicated if th e join t con t in ues to be un stable or if th e uln ar collateral ligam en t is blocked by in terposit ion of th e addu ctor pollicis m uscle (Sten er lesion ). Wrist Injuries Th e w rist is an an atom ically com plex st ruct ure th at plays a vit al role in all aspects of h u m an life. Th e dist al radiou ln ar (DRU) join t is a site at w h ich h an d su p in at ion an d pron at ion occu r as th e radiu s rot ates arou n d th e u ln a. Dist al to t h e DRU join t is th e p roxim al carpal row, w h ich is com posed of th e scaph oid, lun ate, t riquet rum , an d pisiform . Th ese bon es ar t icu late w ith th e dist al p or t ion of th e radiu s an d u ln a an d allow for exion an d exten sion of th e h an d, as w ell as u ln ar an d radial deviat ion . Distal to th e p roxim al row of carp al bon es is th e distal carpal row, w h ich is com p osed of th e t rap eziu m , t rapezoid , cap it ate, an d h am ate. Th e dist al carpal row an d th e secon d an d th ird m et acarpals form th e “ xed un it” of th e h an d. A d et ailed h istor y th at in clu des pat ien t’s occu p at ion , h an d dom in an ce, an d detailed ch aracterizat ion of th e m ech an ism of injur y, as w ell as th e locat ion an d level of p ain , sh ou ld be th e rst step of evalu at ion . Th ree pat tern s of w rist injur y exist: th e perilun ate pat tern , th e axial pattern , an d inju r y from localized force con cen t rat ion . Perilunate Injuries Perilun ate injuries occur in an arc em an at ing from th e lun ate. Th e bon es involved in clu de t h e scaph oid, t riqu et ru m , an d cap it ate. If any of th ese bon es are fract ured , th en th e oth ers sh ou ld be ch ecked for a fract u re. ERRNVPHGLFRVRUJ 166 Hand and Wrist Fract ures and Dislocations Axial Pattern Injuries Axial pat tern injuries result from an teroposterior com pression forces. Th ese forces, gen erally occu rring from an explosion or crush injur y, propagate on eith er th e u ln ar or th e radial side of th e capit ate. Carpal Bone Fractures Single-bon e fract u res of th e carp u s u su ally are th e resu lt of a con cen t rated localized force. Scaphoid Most carp al bon e fract u res occu r in th e w rist . By ar t icu lat ing w ith th e lu n ate p roxim ally an d th e capit ate distally, th e scap h oid st abilizes th e w rist . Upon disr u pt ion , th e w rist becom es m ore su scept ible to collapse. Th e su p er cial palm ar bran ch an d th e dorsal carpal bran ch of th e radial arter y en ter at th e dist al aspect of th e scap h oid. A loss of blood su p ply du e to fract u res at th e w aist or th e p roxim al p or t ion of th e scaph oid leads to avascu lar n ecrosis of th e scap h oid (Preiser’s disease) an d fu t u re p ain /in st abilit y. Mechanism Scaph oid fract ures resu lt from a fall on an ou tst retch ed h an d. Diagnosis The patient has tenderness in the anatom ical snu box and radial w rist pain. Order X-rays in AP, pronation oblique, supination oblique, and lateral view s. Additionally, CT scans are useful in establishing the vascularit y and degree of displacem ent. A clen ch ed- st position m ay im prove view. Look for a radiolucent line radial to the scaphoid on an AP view. If the line is preserved, then the scaphoid is intact. If the scaphoid is fractured, the line is displaced or obliterated (navicular fat stripe sign) (Fig. 14.7). ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 167 Fig. 14.7 Scaphoid fracture. Types of Fracture • Ho rizo ntal o blique: Fract u re of th e scap h oid oblique to th e longit udin al a xis of scaph oid bu t p erp en dicu lar to th e long axis of th e lim b (m ost com m on fract u re of th e scaph oid). Stable an d usu ally t reated w ith closed t reat m en t in th u m b spica for 6 to 8 w eeks (see Ch apter 13, Fig. 13.5). • Transverse: Scaphoid fractures that are perpendicular to the longitudinal axis of the scaphoid, but oblique to the lim b. Less stable and less com m on th an horizontal oblique fract ures, these usually heal w ith 6 to 12 w eeks of closed treat m ent (th um b spica) (Fig. 13.5). • Ve rtical o blique: Rare an d less st able; requ ires longer cast ing. Treatment • Closed t reat m en t—reser ved for su spected fract u res an d stable fract u res w ith < 1 m m d isp lacem en t or a scap h olu n ate angle < 60 degrees or radiolu n ate fract u res < 15 degrees. • Place pat ien t in th u m b sp ica cast (Fig. 13.5) for 12 w eeks (long arm th u m b sp ica cast for th e rst 6 w eeks an d th en 6 w eeks in sh or t arm th um b sp ica cast). ERRNVPHGLFRVRUJ 168 Hand and Wrist Fract ures and Dislocations Suspected Fractures • Place th e p at ien t in th u m b sp ica. • Tech n et iu m 99m m ethylen e dip h osph on ate (Tc 99m MDP) bon e scan in 2 w eeks (t im e for bon e at fract u re site to resorb). – If n egat ive, th en n o fract u re exists. – If posit ive, order a CT scan for determ in at ion of fract u re site an d fu r th er t reat m en t . Nondisplaced Fractures • Th u m b sp ica cast un t il fract u re h eals. • Ch eck for u n ion . • Im m obilize in a long arm cast for 6 w eeks, th en a sh or t arm cast for an addit ion al 6 w eeks. Pediatric • Rarely displaced; ORIF on ly in severe displacem en t . – Oth er w ise, im m obilize u n t il skeletal m at u rit y. • Su rgical t reat m en t . – For op en fract u res of th e w rist . – Failed closed t reat m en t (n o h ealing in 12 w eeks or n on u n ion after 6 m on th s of cast ing). – Disp lacem en t > 1 m m or scap h olu n ate angle > 60 degrees or radiolu n ate fract u re > 15 degrees. – Ver y proxim al fract u res th at are p ron e to avascu lar n ecrosis. – If a pat ien t h as a n on displaced fract u re th at can n ot be im m obilized, an ar th roscop ic app roach can be t aken . ▪ Com p licat ion s. ▫ Malu n ion . ▫ Avascu lar n ecrosis. ▫ Non u n ion . ▫ Ar th rit is. ▫ Carp al in st abilit y. ▫ Scaph oid advan ce collap se. Other Carpal Bone Fractures Mechanism Oth er carpal bon e fract ures can result from a fall on an outst retch ed h an d. ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 169 Diagnosis Th e pat ien t h as pain in th e w rist; X-rays dem on st rate fract ures of carpal bon es. If a fract u re is su spected, th en th e Tc 99m MDP w ill be posit ive in 2 w eeks. A CT scan can also be p erform ed for d iagn osis of fract ures, especially in th e distal row. Triquet ral fract ures are caused by w rist hyperexten sion . Trapezial fract u res are seen using th e Bet ts view an d often occu r in cyclists. Treatment • Closed t reat m en t . – Non displaced carp al bon e fract u res sh ou ld be im m obilized for 6 w eeks. – Use a th u m b sp ica for lu n ate fract u res. – Sp lin t th e h an d in a safe posit ion for cap itate fract ures. • Surgical t reat m en t . – Use for all open fract u res an d disp laced fract u res. Lunate Fracture Lun ate fract u res m ay cau se Kien böck’s disease by a ect ing th e lun ate blood su p ply an d cau sing avascular n ecrosis. Hook of Hamate Fracture Hook of h am ate fract u res are associated w ith racqu et sp orts an d golf; pat ien t s p resen t w it h u ln ar an d volar w rist p ain . Th e fract u re occu rs on im pact w it h th e ball. Non u n ion is diagn osed w ith a CT scan . Rem oval of th e h ook relieves th e pain . Pisiform Fracture Non un ion is a com m on com plicat ion of pisiform fract u res. Supin ated oblique an d carpal t un n el X-rays are m ost useful in diagn osing th e fract ure. Pain on n on u n ion resolves w ith rem oval of th e p isiform s. ERRNVPHGLFRVRUJ 170 Hand and Wrist Fract ures and Dislocations Scaphocapitate Syndrome Scaph ocap it ate syn d rom e resu lt s from fract u res in both th e scaph oid an d capitate, along w ith rotat ion of th e capit ate fragm en t 90 to 180 degrees. Treat w ith ORIF early. If m issed , th en t reat expectan tly. If sym p tom s persist , perform a w rist ar th rodesis. Dislocations of the Wrist Dislocat ion s of th e w rist range from perilun ate ligam en tous injuries to lesser arc inju ries (dislocat ion s on ly) to greater arc inju ries (dislocat ion + fract u re). Th e p at ien t m ay p resen t w ith acu te on set carpal t u n n el syn drom e du e to p ressu re from dislocated carpal bon e, sp eci cally th e lu n ate. Em ergen t reduct ion an d decom p ression are in dicated. Scapholunate Ligamentous Injuries As t h e force cau sing perilu n ate ligam en tou s inju r y in creases, th ere is a predictable pat tern of inju r y. Th e progression proceeds from scap h olun ate sp rain s to scap h olu n ate dislocat ion , p erilu n ate dislocat ion , an d n ally dislocat ion of th e lun ate. In severe cases, pat ien ts presen t w ith ext rem e d orsi exion of th e w rist . Diagnosis • Watson sh ift test—pu t th u m b on distal p ole of scaph oid. Next , m ove join t radially, u ln arly, in to exten sion an d exion . – Assess for p ain or sublu xat ion , w h ich m ay h erald in st abilit y. • St ress radiograph s. – Scaph olun ate d isru pt ion . On the AP X-ray, a scapholunate disruption can be seen bet w een the scaphoid and lun ate > 3 to 4 m m (Terr y Thom as/Let term an/gap sign), or as a w edge-shaped lunate (piece of pie sign). If the lunate is rotated dorsally, th en th e pat ient h as a dorsal in tercalated segm ent instabilit y (DISI) deform it y. A volar dislocation of the lunate w ill be apparent as the spilled teacup sign on lateral view (not associated w ith scapholunate disruption). ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 171 Reduction Techniques If th e pat ien t presen ts w ith in 3 to 4 days of inju r y, th en at tem pt closed reduct ion , w h ich u su ally requ ires K-w ire for xat ion . If th e pat ien t can n ot be taken to su rger y, th en on e can at tem pt closed red uct ion in th e em ergen cy room . Th is m u st be preceded by a th orough n eurovascular exam in at ion . A h em atom a block or brach ial block can be p erform ed. Perilunate Dislocation In it ially, dorsi ex th e w rist , an d th en slow ly ex th e w rist volarly w h ile h olding th e posit ion of th e lun ate w ith th e th um b of your oth er h an d. Rear t iculate th e capit ate an d th e lu n ate using pron at ion . Use uoroscopy if n eeded. If pat ien t presen ts w ith acute carpal t un n el syn drom e, redu ce fract u re an d release carp al t u n n el if sym ptom s persist . Lunate Dislocation (Fig. 14.8) Star t w ith th e procedure for p erilun ate redu ct ion , th en stabilize th e lu n ate w ith you r th u m b an d bring th e capitate in to p alm ar exion . Em ergen cy reduct ion an d decom pression of carpal t un n el are in dicated if acu te carp al t un n el syn drom e sym ptom s exist . Scapholunate Dislocation First dorsi ex th e w rist an d th en radially deviate th e w rist . If reduct ion is perform ed in th e operat ing room (p referred), th en K-w ire th e reduct ion . If redu ct ion is p erform ed in th e em ergen cy room , th en at tem pt to place th e pat ien t in a splin t in a th u m b spica. If redu ct ion does n ot h old, th en you m u st perform ORIF. Fig. 14.8 (a–c) Reduction of a dislocated lunate. ERRNVPHGLFRVRUJ 172 Hand and Wrist Fract ures and Dislocations Fig. 14.8 (Continued) (a–c) Reduction of a dislocated lunate. ERRNVPHGLFRVRUJ Hand and Wrist Fractures and Dislocations 173 Fracture-Dislocations of the Wrist (Major Arc Injury) Th e m ost com m on t ype of fract u re-dislocat ion of th e w rist is th e t ran sscaph oid p erilu n ate fract u re-dislocat ion . Use X-rays t aken in t ract ion for diagn osis. Th ese usually requ ire ORIF. Ulnar-Sided Ligamentous Injuries The patient presents w ith tenderness on the ulnar side of the w rist (over lunotriquetral ligam ent) w ith possible avulsion fractures of the triquetrolunate ligam ent. Diagnosis • Ballot tem en t test (Reagan test)—displacem en t of th e t riquet r um dorsally an d volarly on th e lu n ate w ith p ain fu l crepit us. • Lich t m an test—su blu xat ion an d pain w ith axial loading an d deviat ion of w rist u ln arly. • X-ray—AP view dem onstrates volar intercalated segm ent instability (VISI) w ith volar- exed scaphoid. Lunate is volar- exed and triangular. Treatment Im m obilize for 6 w eeks in sh or t arm cast . Triangular Fibrocartilage Complex (TFCC) Tears The TFCC is a ligam entous and cartilaginous structure, w hich stabilizes the distal radioulnar joint and is the articulating surface for the ulnar carpus. Diagnosis • W h en pat ien t grasp s an object , w rist pain w orsen s. • X-ray. – Uln ar posit ive varian ce on X-ray. – Ar th roscopy versu s MRI. Treatment • Sh or t arm cast for 6 w eeks. • Con sider ar th roscopy an d débridem en t of tears. ERRNVPHGLFRVRUJ 15 Hand Infections and Injection Injuries Hand Infections Han d in fect ion s are classi ed as su per cial, deep, acu te, subacute, or ch ron ic. Han d in fect ion s range from su p er cial cellu lit is to osteom yelit is. Cellu lit is is a su p er cial in am m at ion of th e derm al/epiderm al com pon en t s of th e skin secon dar y to bacterial con t am in at ion . Deep to th e derm is, in fect ion in t h e su bcu t an eou s t issu e m an ifest s as an abscess. Con t in u ou s deep in fect iou s p en et rat ion w ill a ect th e fascia or th e syn ovial sh eath s of th e exor an d exten sor ten don s, par t icularly in th e h an d an d forearm . Th ese deeper in fect ion s w arran t rapid evaluat ion an d t reat m en t to preven t n ecrot izing in am m at ion w ith in th e deep t issu e plan es an d erosive exten sion in to th e h an d an d forearm . History and Physical Examination • Ascer t ain th e cause of th e in fect ion , an atom ical locat ion , an d length of durat ion . • In spect ion an d palp at ion to determ in e locat ion an d to assess th e depth of th e in fect ion . – Rem ove all jew elr y (w atch es, rings, etc.) to p reven t secon dar y vascu lar con st rict ion from a tou rn iqu et e ect w h en edem a develops. • Assessm en t of n eurovascu lar st at u s. • Passive ROM assessm en t of all join ts. • Obtain radiograph s of th e involved h an d/digit—th ree view s. Management Th e an t im icrobial t reat m en t s for com m on h an d in fect ion s are p resen ted in Table 15.1. Th e an t im icrobial th erapies d elin eated in Table 15.1 rep resen t em pirical recom m en dat ion s u n t il de n it ive cu lt ure resu lt s are available for sp eci c th erapy. 174 ERRNVPHGLFRVRUJ r o n s c s o i c i i e n t t c m a c s i o i s o n i t s e r h t b f o e e n c u c t a n c p y A t i e e r s f y n u n a e b t n s o b o i c a s r 1 m p r a n l . r a e e l s a a i p o a a c c 5 l p a i t l s b s i a p s n t 1 l e o r u b e p n d c p t u i e S s C a o l h e e o l l u l f e D T M c e b e n a I C A F D T t s e e e p t s s v v v e i i i n r u u t t t t e i i i c c s s S s s s c c e e m m o o s s s o o o t s b b c c i u u u p p p a o o - - - o o e e e n r r e t t r r r r a e e p p m m m u u u t a a g e e a a a a a a l r r r r r r n n . . . t t a i O S G S S A G S S A G b c c c r o c o o o o f o c c c s m u o i i i c c c c c c m o n h a n r r y u u h a g r o o f f d 6 ) o m V s V a I y y O O I e y r 0 a P P s e g p e 5 g t d c o v i a g g 4 m n r d e m a w e n e m m t 0 t s i l 1 O h 0 c e m 0 0 u t P n y t O 9 i 5 5 d l m a P h g c i 4 4 a m n a y y t e i ( y i S a h 2 r a a m n n c r b s i i t d 1 D m y d d 8 u c c n o 0 n t o y i r y y o a a y o 0 m l c f r n m i c r i c a s s 5 i t e n m m e r e i d e e c r O v t a a a x v A t m e n c o P v e d d i e e i S f a m m l t a i i n n n R p t t i i i B C n l l e n A K M C C I d r y s o a e s y y d + a e a a m r i a e h d d t m o r c i e i a a r 2 t o c h h i u 1 w y r e e h t o a c c 2 6 u w y i i f t r d 1 6 o y O f w w e r O a y y P t t O v e r r P O e P e v g e e O O P c g e v v i g V P P m I e e y g m w V g g m I 0 p t g V V m s 0 I I a 0 0 g m m y 1 r 5 n O 5 0 0 g g g e 5 P 4 5 5 o 5 n r 1 i n i h 1 7 1 i 7 7 4 t S e n . c t e c i l 3 8 8 c e l y . 3 D y n c n r e i e i a n n 3 y l f i i m n o v c m r r m i i i c t t m n y n n o t i m t o o y o i i p y n n r y c l r a n a a c e l t m y e e y s e n i f h e d y d n c a a a r t o c a e r x n m m a i d y d d e a i Z v c m e l o i r g g B n n v t a i C e d T l l u u e e A P C A A S Hand Infections and Injection Injuries 175 ERRNVPHGLFRVRUJ ) d e n p u y o t w n d e c o t e i e i i t t u i t b e n c b i b g t e t a f i o n a n o I D C D C ( t m i s a c t d c n o o r o c c e e l v i v a a i t i a a s a d d b i i i o s g o c c m n r o e i o o s c i t t p n g i l l - - n u u ru m a m m e y m m g l a a a r . . r r o . P P P G G P O n i a t o i n r e h u y c l i i 6 o f a h w y t d r 6 O y O e g g P y p v t P r a e m g m n e g r e m v 0 V 0 e m s I m e u 0 — 0 h m n r 0 t g t 5 e t 4 5 V o 5 I l i a c n 7 1 n n 4 t a . i e e i o 8 g i + l c r c c 3 p n r t b y i e o n y a s 5 a i f o . - n c a o x a n t x t i r i n y r 1 d d t o d o n n i n o u c i e n l i e e n a m a l i q i e y d i e o y a t x r o s a e r m c m s n r i d i a o e c e m d p a e g i t i i o n n v p t i n u c a m T n l m e u w e x n i A t I U C t S E p A 2 y 6 O w r e O 1 t y P e P n r y v o g O e r g l e v P e o y m e v m V S n I p i e 0 s 0 V a D u I y g 0 r 8 n V q I 5 g e g 4 o 1 m r o i i h g n r t r e 5 n n i t i l i t o c l 1 c 7 c c c e e u a a 3 y y f e a . v x i B n n 3 o m t m i m i + h i r l a a t o l n i e p y o i d c o n y r a r c e r w s n n y i f e i d p e l a o a i e n v t V c Z C a c d l e e S P A e y a a m i + d e t c h a r i u 2 e w o h h c t 1 f i s 176 Hand Infect ions and Injection Injuries ERRNVPHGLFRVRUJ t , i A v S s o i e R n n s p y o o i M s y c t e : g t o t y a i n r n ) n i n n b o e i m d n i e z t i o t e t o o n i t a i m a u r t h a i t o a n c w c v o r c t i y m e x t e c e n a r f f n e u e n e l o b n n o I H O S c N i F b C A ( s m i e t h i s s p c m u d a s c u c t o r n o c r S b e c o s t e u d c n e e l r n m v o o s i o v a a b r t i u i t i n u i r t t t p o r a c i b o s s o r a e i s t e c s g c o r e t e s n y n o r t o i e m c b a e a h c s m a c s l p n r i a n o l c i p o o m u - - - i r b t t e a o a n n n m b i e p p o i l t n l m m h a l r y c a e e l e l a a a a n c i a g y i r P P r r k n . o o i r c r i E O T C M m P c G A G O h o l y o c e h c + i a 8 + X r h w e y o h t y r c l 2 i i e h h 6 1 O a v w 6 y 2 P t d e y r r 1 y y g e V O O e r I y p v v t P P e r m a e e g v n e r g g 0 e v e V e V m I 5 I e m m h V m 2 I 0 t g g t V 5 0 I l 0 n a g 7 5 i m 1 a 9 e g i c 8 2 5 r 5 n . y n b i t . 1 i n e 7 1 i s c o c t m n t 3 e r y u y . n o n n c e r i y 3 m a r e m e m i s i h n u o a n t t p a m i y m i c i a k y d a e n r b a t g s f n y s r n p a w d i U n u l e a a o e u l n c A A d I T 6 C a V Z C c c s y e y a a a m d d i y r e t l a i a c o r i y a e l e r u y i d w l c y c i o i o y a l i t f i + a a d O y w a w d d O t y P a t O l d / O i P d a P O O a P V O O I g a P e g P d P P g c g e i y m g g m g O c g m p i w 0 m P m 0 m t a m m 0 y 0 w r 8 0 g 0 t 0 2 5 g 0 e O 0 4 0 0 r 0 1 0 m P h 0 4 n O 2 e l n 1 i t 1 i l 1 P S 0 l c o n e c e i e t e l 0 a e a D S y l c n v u x n o 6 i i i r a D l o n z l o b m t i m + z x c o n a c l i a i a l y a o r y m m n y i y d o p i n t c n c a a r c a o r r i n c i o y o t i c h d m p d x e l a i x n t c n c a t a i o C a c B l r e f o e r r a u i t P I M o d o B r M A Hand Infections and Injection Injuries 177 ERRNVPHGLFRVRUJ 178 Hand Infect ions and Injection Injuries Types of Hand Infections Acute Paronychia Acute paronych ia is an in fect ion th at involves th e eponych ial or paronych ial fold or th e n ail m at rix. Th is process u su ally begin s u n der th e skin of th e lateral n ail fold, causing er yth em a an d edem a (paronych ia). Persisten t disease m ay cau se exten sion in to th e eponych ium (eponych ia) or un der th e n ail sulcus to th e con t ralateral fold (run aroun d in fect ion or h orsesh oe in fect ion ). Etiology • • • • • • • Poor ngern ail hygien e. Min or t rau m a. Nail bit ing. Finger su cking. Man icu res. Ar t i cial n ails. Hangn ails. Treatment An early in fect ion w ith out eviden ce of con ser vat ively: u ct u an ce can be t reated • Warm soaks th ree t im es a day w ith a 1:1 solu t ion of 3% hydrogen peroxide an d n orm al salin e. • Oral an t ibiot ics for 1 w eek; con sider an aerobic coverage (clin dam ycin 450 m g by m ou th fou r t im es a day) for associated n ail bit ing or nger su cking et iologies (h u m an bite). • Elevat ion . • Sh or t-term follow -up. A paronychia that has developed a collection of purulence requires drainage: • Perform a digital block (see Ch apter 13, Fig. 13.1). • Use th e in cision tech n iqu e (Fig. 15.1a). – In cise along th e lateral n ail fold w ith a scalpel. – Elevate th e n ail fold u sing sm all elevator from th e paronych ial/ eponych ial ju n ct ion to th e p roxim al n ail edge. – Drain th e pu r ulen t m aterial. – Excise th e dist al th ird of th e n ail to evacu ate p u ru len t m aterial an d, if n eeded, for addit ion al exp osu re. • Excision tech n iqu e (Fig. 15.1b). – Begin w ith a longit u din al in cision along th e lateral n ail fold w ith a 15-blade scalpel beveled aw ay from th e n ail. ERRNVPHGLFRVRUJ Hand Infections and Injection Injuries 179 Fig. 15.1 (a) Incision and drainage of a paronychial infection. (b) Partial nail excision technique. – Repeat bilaterally if both sides are involved. – Drain p ur u len t m aterial at th e base of th e n ail by elevat ing th e eponych ial fold. – Excise a longit u din al st rip of th e n ail adjacen t to th e fold w ith an edge of th e eponych iu m for drain age. – Exten sive eponych ial an d subu ngu al in fect ion s require rem oval of th e n ail plate an d sten t ing of th e fold w ith iodoform gauze. Postoperative Care • Warm soaks th ree t im es a day w ith a 1:1 solu t ion of 3% hydrogen peroxide an d n orm al salin e. • Oral an t ibiot ics for 1 w eek. • Elevat ion . • Sh or t-term follow -u p . • Avoid n ail bit ing an d t rim m ing n ails too closely. Chronic Paronychia Chronic paronychia is de ned as an infection that involves the eponychial or paronychial fold or th e nail m atrix lasting longer than 6 w eeks. Fungi are m ost com m on ly associated w ith these infect ion s. C. albicans is the prim ar y infectious organism . How ever, at ypical m ycobacteria are im plicated in hand infection s of persons ch ron ically exposed to w ater. Generally, these infections are found in sw im m ers, dishw ashers, and housekeepers w ho h ave prolonged exposure to m oist environm ents and repeated exposure to chem ical irritants. ERRNVPHGLFRVRUJ 180 Hand Infect ions and Injection Injuries Treatment • Topical m icon azole t w ice a day or terbin a n t w ice a day. • Oral ketocon azole 200 m g by m ou th daily or u con azole 100 m g by m outh daily for 4 w eeks. • Con sider biopsy to ru le ou t squ am ou s cell carcin om a for recalcit ran t disease. • Marsu pializat ion . – Perform a digital block. – Ap p ly nger tou rn iqu et . – Using a 15-blade scalpel, in cise along th e p roxim al an d distal edge of th e eponych ium in a crescen t fash ion . – Excise th e ep onych ial skin an d in fected t issu e, leaving th e germ in al m at rix in t act . – Irrigate th e exteriorized germ in al m at rix, th en pack th e region w ith iodoform gau ze. – Rem ove th e n ail plate if grossly deform ed. • Ch ange th e d ressing ever y day un t il com p lete epith elializat ion h as occurred. Felon Th e volar pad of th e dist al p h alan x is divided in to 15 to 20 brous fascial com par t m en t s by ver t ical brous septa exten ding from th e derm is to th e distal ph alan x. In fect ion s in th is area are com par t m en t alized, cau sing th e form at ion of sm all abscesses. S. aureus, st reptococci, an d an aerobes cau se m ost felon s. Evalu at ion sh ou ld ru le out th e presen ce of a foreign body, w h ich occasion ally can be detected radiograph ically. Persisten t disease w ill resu lt in exten sion to th e distal p h alan x an d p ossibly th e ten don sh eath of th e exor digitoru m su p er cialis (FDS), cau sing osteom yelit is or exor ten osyn ovit is, resp ect ively. Treatment Th e volar p ad sept a m u st be com p letely obliterated, w h ile m in im izing dam age to th e n eu rovascu lar bu n dle: • Perform a digital block. • Apply a nger tou rn iqu et . • Mark th e n on dom in an t side of th e nger for th e in cision . Th is is usually th e u ln ar side of th e in d ex nger, long nger, or ring nger. For th e th um b an d lit tle nger, release via an in cision on th e radial side of th e digit . ERRNVPHGLFRVRUJ Hand Infections and Injection Injuries 181 • In cision s. – High lateral in cision (Fig. 15.2). – Fish m outh in cision . – Palm ar longit u din al in cision . • Obt ain cult ure. • Spread th rough septa-disr u pt ing all of th e com p ar t m en ts. • Irrigate th orough ly. • Pack w ith iodoform gau ze. Fig. 15.2 Incision and drainage of a felon. (a) High lateral incision avoiding neurovascular bundle. (b) Disruption of the ventral brous septa. (c) Packing of the space with iodoform gauze after thorough irrigation. (d) Complicated felon dem onstrating epidermolysis extending to the ulnar position of the index nger. (e) Débridement of the detached epidermis and ulna-based incisions and drainage of felon. (f) Follow-up 1 m onth after surgery. The arrow indicates site of felon. ERRNVPHGLFRVRUJ 182 Hand Infect ions and Injection Injuries Postoperative Care • Warm soaks th ree t im es a day w ith a 1:1 solu t ion of 3% hydrogen peroxide an d n orm al salin e. • Oral an t ibiot ics for 1 w eek. • Elevat ion . • Sh or t-term follow -up. Herpetic Whitlow Herp es sim p lex is th e cau sat ive organ ism associated w ith vesicu lar er u pt ion of th e dist al digit s. Th e viral con t am in at ion is u su ally secon dar y to exposure to oral secret ion s. Health care w orkers, par t icularly den t ist s an d an esth esiologist s, are at in creased risk. Physical exam in at ion reveals clear vesicles th at p rogress to u lcerat ion w ith in 14 days. Th e volar pad is edem atous, but soft an d pain ful to palpat ion . Diagn osis can be con rm ed by viral cult ures an d a Tzan ck sm ear th at dem on st rates m ult in ucleated gian t cells. Th e abilit y of th e virus to live in th e dorsal root ganglion prom otes th e recu rren ce of th is disease. Treatment • Do not a t tem pt in cision a n d dr a in a ge. – Th is a self-lim ited disease th at resolves in 10 to 14 days. • Clean se w oun d t w ice a day to p reven t a bacterial su perin fect ion . • Cover w oun d w ith loose dressing. • Oral an t iviral dr ugs decrease th e clin ical cou rse an d recurren ce. – Acyclovir 200 m g by m ou th ever y 4 h ours × 10 days (recu rren ce × 5 days), su pp ression 400 m g by m outh t w ice a day. – Valacyclovir 1 g by m ou th t w ice a day × 10 days (recu rren ce 500 g by m outh t w ice a day), su p p ression 500 g by m ou th daily. Flexor Tenosynovitis Syn ovit is of th e exor ten don sh eath occurs from in am m ator y an d in fect iou s et iologies. In th e acute set t ing, su pp u rat ive sten osing in fect ion of th e exor ten don sh eath requ ires rap id evalu at ion an d t reat m en t to preven t exten sion to th e forearm . In fect ion s of th e exor ten d on sh eath resu lt from eith er d irect exten sion from a su bcu tan eou s abscess (e.g., felon , m idpalm ar space abscess) or direct in oculat ion from pen et rat ing t rau m a. A p at ien t w h o presen ts w ith exor ten osyn ovit is w ill exh ibit th e fou r Kan avel sign s (Fig. 15.3). ERRNVPHGLFRVRUJ Hand Infections and Injection Injuries 183 Fig. 15.3 Presentation of exor tenosynovitis of the thum b illustrating Kanaval signs. Hallmark of Flexor Tenosynovitis is Pain—on passive extension Pat ien t com plain ts of severe pain , paresth esia, an d sw elling of th e h an d m ay in dicate exor ten osyn ovit is. Th ese sym ptom s can be explain ed by Kan avel sign s. Kanavel Signs Pain over ten don sh eath Fusiform sw elling of digit Finger h eld in exion Pain on passive exten sion (h allm ark sign ) The tendon sheath is a closed space from the DIP to the A1 pulley. The thum b and sm all nger tendon sh eaths com m unicate w ith the radial and ulnar bursae, respectively, an d con tinue into the w rist. The radial and ulnar bursae com m unicate via the Parona space. Th e intricate architecture and proxim it y of the tendon sheaths and bursae allow extension of the infection to the hand proxim ally. Additional potential com plications include carpal tun nel syndrom e, tendon n ecrosis, and tendon adhesions. Treatment Pat ien ts w ith exor ten osyn ovit is requ ire h osp it al adm ission , broad-sp ect ru m an t ibiot ics, an d u rgen t operat ive exp lorat ion . ERRNVPHGLFRVRUJ 184 Hand Infect ions and Injection Injuries • Bring th e pat ien t to th e operat ing room . • Place tou rn iquet an d exsangu in ate arm by elevat ing arm for 2 m in u tes an d occlu ding th e brach ial ar ter y. Raise tourn iqu et to 100 m m Hg greater th an th e SBP. Do n ot exsangu in ate using m ech an ical exsangu in at ion tech n iqu es. • Lim ited in cision an d cath eter drain age (Fig. 15.4d). – In cise th e m idaxial border of th e involved distal p h alan x. (Avoid con tact an d pressu re surfaces of th e digit). – Make a sep arate t ran sverse in cision at th e level of th e A1 pu lley. – Th rough th ese in cision s, expose th e exor ten don sh eath . ▪ Evacu ate pu rulen ce. ▪ Obt ain cu lt ure. ▪ Th orough ly irrigate both w ou n ds. – In ser t a sm all cath eter for irrigat ion in to th e ten don sh eath —6 Fren ch pediat ric feeding t u be. ▪ Irrigate. – Keep cath eter in place for con t in u ou s irrigat ion . ▪ 500 m L n orm al salin e + 1 g van com ycin . ▪ In fu se at 20 to 50 m L/h ou r, dep en ding on pat ien t toleran ce. – Rem ove cath eter in 48 h ou rs. • Exten sive explorat ion an d débridem en t—requ ired for delayed diagn osis an d exten sive soft t issu e n ecrosis. – Mark th e n on dom in an t side of th e nger for th e in cision . Th is is u sually th e uln ar side of th e in dex nger, long nger, an d ring nger. For th e th u m b an d lit tle nger, release via an in cision on th e radial side of th e digit . – Make Brun n er (Fig. 15.4b) zigzag in cision s from th e distal p h alan x to th e palm . ▪ Take care n ot to dam age th e n eurovascu lar bu n dles or cross th e exion creases volarly at righ t angles. – Evacuate pu rulen ce. – Obt ain cu lt u re. – Rem ove n ecrot ic debris. – Th orough ly irrigate both w oun ds. • Close skin loosely over a sm all cath eter for con t in uou s cath eter irrigat ion using a 6 Fren ch pediat ric feeding t u be. – 500 m L n orm al salin e + 1 g van com ycin . – In fu se at 20 to 50 m L/h , depen ding on p at ien t toleran ce. – Rem ove cath eter in 48 h ou rs. • Splin t in safe p osit ion . • Begin ROM protocols after cath eter is rem oved to decrease adh esion s. ERRNVPHGLFRVRUJ Hand Infections and Injection Injuries 185 Fig. 15.4 (a–d) Incision techniques for drainage of the exor tendon sheath. • If th ere is sign i can t soft t issue dest ru ct ion , w h irlp ool th erapy as an adjun ct is u sefu l for débridem en t of th e devitalized soft t issu es after operat ive drain age. Deep Fascial Space Infections Deep space in fect ion s begin from pen et rat ing w oun ds of th e h an d or by exten sion of a su per cial in fect ion (Fig. 15.5). Th e com p lex an atom ical relat ion sh ip of th e d eep fascial sp aces in th e h an d is illust rated in Fig. 15.6; Fig. 15.7 sh ow s th e in cision s for deep palm ar abscesses. ERRNVPHGLFRVRUJ 186 Hand Infect ions and Injection Injuries Fig. 15.5 (a,b) Presentation of a m idpalm ar space infection with dorsal cellulitis. Fig. 15.6 Deep fascial spaces of the hand. ERRNVPHGLFRVRUJ Hand Infections and Injection Injuries 187 Treatment • Place tou rn iqu et an d exsangu in ate arm by elevat ing arm for 2 m in u tes an d occluding th e brach ial ar ter y. Raise tou rn iqu et to 100 m m Hg greater th an th e SBP. • In cision an d drain age. – Th e w ou n d is left open . – Wou n d packed w ith iodoform or a Pen rose drain is p laced. – Daily dressing ch anges are p erform ed. • Sm all dorsal abscesses can be safely drain ed in th e em ergen cy room . Make in cision s in bet w een exten sor ten don s to avoid injur y to th e ten don s. • Volar abscesses are exp lored in th e operat ing room . • An t ibiot ics. • W h irlpool th erapy t w ice a day. – Aids w ith débridem en t of devit alized t issu e. – Edem a m ay be in creased th rough ou t th e du rat ion of th erapy. Fig . 15.7 (a–d) Incision techniques for drainage of deep hand abscesses. Avoid dam age to neurovascular structures. ERRNVPHGLFRVRUJ 188 Hand Infect ions and Injection Injuries Fig. 15.8 Presentation of a collar but ton abscess of the second web space with abduction of the digit s and dorsal cellulitis. Collar Button Abscess A purulen t in fect ion of th e w eb space is referred to as a collar but ton abscess (Fig. 15.8). Fissures an d blisters are com m on ly im plicated as et iologies. Pat ien ts presen t w ith an h ourglass con gurat ion at th e base of th e digit in an abdu cted p osit ion . Collar bu t ton in fect ion s are drain ed th rough t w o longit u din al in cision s on th e dorsal an d volar su rfaces of th e w eb space (Fig. 15.7a). Dorsal Subaponeurotic and Subcutaneous Abscesses Ben eath th e exten sor ten don s on th e d orsu m of th e h an d, an in fect ion m ay reside in th e su bap on eu rot ic sp ace, w h ich is di eren t iated from an in fect ion above th e exten sor ten don s (su bcu t an eou s space). Drain age is perform ed th rough longit u din al in cision s. A su spected su bap on eu rot ic in fect ion is ap proach ed th rough longit udin al in cision s over th e in dex an d sm all nger m etacarp als (avoid dam age to exten sor ten don s). ERRNVPHGLFRVRUJ Hand Infections and Injection Injuries 189 Fig. 15.9 Presentation of a ght bite injury with associated abscess and MCP joint contam ination. A fracture of the m etacarpal head is often associated with these injuries. Fight Bite Closed st injuries occurring during st icu s m ay resu lt in in ocu lat ion of th e MCP join t w ith oral an aerobes from th e assaulted. W h en th is occurs th ere sh ould be th e con siderat ion of a con com itan t fract ure to th e m et acarpal h ead. Pat ien t s often n eglect th ese inju ries du e to th e in cit ing circu m st an ce an d presen t in a delayed fash ion (Fig. 15.9). All pat ien t s w ith th is m ech an ism of inju r y sh ou ld h ave t h orough irrigat ion of th e join t sp ace an d an t ibiot ic th erapy. Pat ien ts w ith m ore advan ced presen t at ion s (cellu lit is an d abscess form at ion ) sh ou ld be adm it ted, irrigated in t h e op erat ing room , an d p laced on IV an t ibiot ics (see Ch apter 14 for a detailed m an agem en t st rategy for gh t bite inju ries). Thenar and Midpalmar Space Abscess Th en ar space in fect ion s occur in th e volar soft t issues of th e th um b an d rst dorsal in terossei. Th e th u m b is h eld in abduct ion an d pain is elicited w ith adduct ion . Drain age is perform ed w ith an in cision th at is parallel to th e th en ar crease. ERRNVPHGLFRVRUJ 190 Hand Infect ions and Injection Injuries Fig. 15.10 (a–d) Incision techniques for drainage of thenar abscesses. ERRNVPHGLFRVRUJ Hand Infections and Injection Injuries 191 Th e m idpalm ar space com prises an area deep to th e exor ten don s. Pat ien t s presen t w ith u ct u an ce, er yth em a, an d p alp able ten dern ess in th e m id palm . Tran sverse or obliqu e volar in cision s are u t ilized to exp lore th e exor ten don s an d m idpalm ar space (Fig. 15.10). After drain age, t h e w ou n ds are closed loosely over a con t in u ou s irrigat ion cath eter. Pat ien t s are adm it ted an d IV an t ibiot ics are adm in istered . Osteomyelitis and Septic Arthritis In fect ion s of t h e join t an d bon e are u su ally t h e resu lt of open fract u res, an exten sion of ch ron ic soft t issu e in fect ion s, or secon dar y to direct in ocu lat ion from a pen et rat ing object (e.g., a toot h ). Sept ic arth rit is an d osteom yelit is are less com m on ly th e result of h em atogen ou s con tam in at ion from a d ist an t focu s. Th is m ech an ism is part icu larly com m on in im m un osu ppressed an d p ediat ric p at ien t s secon dar y to th e in t rin sic vascular arch itect u re at th e p hysis/ep ip hysis. Diagn osis is based on h istor y an d radiograph ic evalu at ion . Pat ien t s h ave a h istor y of ch ron ic in fect ion , n on h ealing w ou n ds, or n on u n ion s. Elevated CRP an d ESR are n on speci c w h en acute in am m ator y con dit ion s occur sim ult an eou sly. Plain radiograph s w ill reveal bony erosion an d periosteal elevat ion . MRI is m ore speci c th an plain lm s. Osteom yelit is is t reated w ith débridem en t of th e in fected bon e an d rem oval of th e sequ est ra an d sin u s t ract s. Bon e sp ecim en is sen t for path ology an d cu lt u re. An t im icrobial t reat m en t is in st it u ted for 6 w eeks. Pat ien t s w ith pyogen ic ar th rit is presen t w ith th e involved join t h eld in a dist racted posit ion to m axim ize volum e. Ten dern ess an d er yth em a is localized over th e join t . Pain is elicited w ith p assive ROM. A subset of pat ien t s w it h in am m ator y ar th rit ides (e.g., gou t , rh eu m atoid art h rit is) m ay presen t w ith join t sign s an d sym ptom s sim ilar to th ose of sept ic arth rit is. In th ese cases, a careful h istor y w ith serology w ill assist in m aking th e diagn osis. Join t asp irat ion is in dicated for diagn osis (Table 15.2) an d for purposes of cult u re iden t i cat ion (Table 15.1). In cision an d drain age of th e MCP join t is p erform ed th rough dorsal in cision s proxim al to th e sagit tal ban d. Th e th u m b MCP join t is approach ed th rough a m idaxial u ln ar in cision . Th e IP join t s are also app roach ed th rough a m idaxial in cision an d irrigated w ith a bu t ter y n eedle. Hand Injection Injuries Th ese injuries occur m ost com m on ly secon dar y to in dust rial gun s loaded w ith p ain t s, grease, or fuels. Pressu re of app roxim ately 100 p si (7 kg/cm 2 ) is requ ired to p en et rate t h e ep iderm is, bu t in du st rial gu n s ERRNVPHGLFRVRUJ s r t a n s e e l v a e m a i p t u 0 % s r a u l m 5 s . 0 5 n e r g y a n a v S 3 2 2 o e r a h N < T < < N c i = t c t a s e p o s o i y r n r d h g o t s t i r t a i a r ) c a i D m d i c n c h ) m ( t o a ) a % 2 L h e e ( e . L a p µ c s y r d / s n o t 5 m o o i / m u i r C c e u t r u n 1 M g u l l t B D u a a s o e J l o l u N r e l m V C W P C G ( N D T O b N a T n d d i e r e n t s t i n i u s i i l o o j t i y y g r r r d o h o e n t o f d t r o y u a m a s p r e o s s e m r t o s d i t p g d n o m o a e n n t d i a 0 r e y a s n m n v a 0 s g m i o a p t 3 m l u r n m i % a i s r t a y – u e 5 a . 5 n e t n u g d k e 0 i a S 3 2 o e o l n h 0 e r n A = R N G N T > 2 < I a i R t t a s p r i a t e c y 0 r e 0 f m o t 0 n t u i , n r a 0 e c e e i c 5 m S v n i u – c l t e < i m 0 % s a t 5 g a 0 0 5 . n g p o 0 a 5 2 3 e y , e r n > N I T S P > 3 t o i n s r t a l a u p d o o h n t o r l l a c i i v c g i a i d a h l i t e h s t 0 h a r i e e a r n t 0 m p p i u v c e o 0 u i o o i v % , m r q r t t 5 i o 5 m 5 . 0 u a e m m u s p n a 7 S 2 g 3 5 p e e e i o e r y T P H H S < O < P s > > N h r y 192 Hand Infect ions and Injection Injuries ERRNVPHGLFRVRUJ t r o s j i n y t i e o h i v v t t i o a t a n p a y m o s e r m r n h a a e l r g u a n e i d o d e o y , t l n r s D o a J o l l e i D c i r v : h s o d n p ) e g o o d t i n r t i e n t a u d r e i i n e v s i m e t p b r g y n i u b o S H P b C A ( n i t d s i e a s e ; n s r i a o t i i e s t r l i c t h c i a s t e i r u f r s e m n a n t r o i y l l e n c i u c o e i d t c t p r r o a i o r , e o r c e b l o y M C s c u N U S T M P P s m o n o c t y e ; , C U u c l e r a t e v i c o t i l s i ; , C B W w h t i . l m l a e o i c m g o d s n i r o a v o o o l m n m b e y u e S H t a a n d o t h e r Hand Infections and Injection Injuries 193 ERRNVPHGLFRVRUJ 194 Hand Infect ions and Injection Injuries can inject w ith a p ow er of 10 to 100 t im es greater th an th is pressu re. Th e n on dom in an t in dex nger is th e m ost a ected site. Alth ough th e site of inject ion an d pen et rat ion of uids un der pressu re m ay seem sm all in it ially, m ost su ch inju ries requ ire w ide surgical in cision of th e h an d, m et icu lou s lavage, an d débridem en t . Sym ptom s are in it ially subtle, at t im es on ly a sm all pinpoin t pun ct u re in th e skin . After several h ou rs, h ow ever, pat ien t s com plain of in creasing edem a, p ain , dysesth esia, an d discolorat ion . If left u n t reated, th is w ill progress to n ecrosis, gangren e, lym p h angit is, an d bacterial in fect ion s. Examination • Determ in e th e precise locat ion of injur y, th e t im e of injur y, t ype of u id injected, an d tetan u s vaccin at ion stat u s. • Exam in e th e en t ire u pp er ext rem it y because th e su per cial appearan ce of th e inju r y often belies th e exten t of t issu e dam age. • Neurovascu lar evaluat ion an d docu m en tat ion are essen t ial. • Ch eck X-rays to ru le ou t fract u res an d visu alize radiograph ically opaqu e m aterial. Treatment • Tet an u s vaccin e. • Broad-sp ect rum an t ibiot ic coverage (van com ycin 1 g IV ever y 12 h ou rs + cefepim e 1 g IV ever y 12 h ou rs or Zosyn 3.375 m g IV ever y 6 h ou rs). • Elevate lim b. • Im m ediate su rgical explorat ion . • Evalu ate th e n eed for fasciotom y if injur y p resen ts late. Operative Treatment Use an upper ext rem it y tourn iquet w ith out u sing m ech an ical exsan guin at ion . In stead, raise th e arm for 3 m in utes w h ile com pressing th e brach ial ar ter y prior to in at ion of th e tou rn iqu et . Use an a xillar y block for an esth esia. Perform Bru n n er (Fig. 15.4b) or m idlateral (Fig. 15.4a) in cision s in th e ngers. Brun n er in cision s are m ade by rst cu t t ing along a d iagon al lin e from th e lateral n ail bed site to th e exion crease on th e op posite ERRNVPHGLFRVRUJ Hand Infections and Injection Injuries 195 side. Th e in cision is th en zigzagged back diagon ally to t h e n ext exion crease on th e opp osite side. It can be carried proxim ally across th e p alm . A m idlateral in cision is rst m arked by exing th e nger. Next , a lin e is draw n th at in tercon n ect s th e m ost dorsal asp ect of th e exion creases to each oth er an d to a poin t lateral to th e n ail p late. Th e n on dom in an t side of th e nger is u su ally th e u ln ar side of th e in dex nger, long nger, an d ring nger. For th e th um b an d lit tle nger, release via an in cision on th e radial side of th e digit . Cult ure any pur ulen t m aterial th at m ay be presen t . Th e m ost com m on in fect ing agen t in th ese w oun ds is Staphylococcus epiderm idis, an d polym icrobial in fect ion s are com m on . It is im p ortan t to débride all n on viable t issues w h ile preser ving n eurovascular st ruct ures th at are n ot a ected. Depen ding on th e spread of th e m aterial, a carpal t u n n el release m ay be required. In addit ion , open all involved ten don sh eath s an d th e radial an d u ln ar bu rsae. Irrigate all involved st ru ct u res th orough ly. Do n ot at tem pt to n eut ralize any ch em icals becau se th e n eut ralizing ch em icals often cau se dam age. Pack th e w ou n d w ith w et (salin e-soaked) gau ze, an d be prep ared for fu r th er débrid em en t in th e operat ing room if n ecessar y 24 to 48 h ou rs later. Splin t th e involved ext rem it y in a safe posit ion (see Ch apter 13). If th e injected m aterial w as radiopaque, th en a p ostop erat ive X-ray m ay h elp to determ in e if all m aterial w as rem oved. Postoperative Care En sure th e w oun d is clean an d clear of devit alized t issu e th rough as m uch débridem en t as is n ecessar y. W h irlp ool th erapy m ay be u sed postoperat ively to p rovide addit ion al débridem en t . Elevate th e involved ext rem it y w h en th e pat ien t is in a splin t . At tem pt to st ar t act ivit y in th e ext rem it y as soon as p ossible to decrease th e am ou n t of con t ract ures. In subsequen t surgeries, at tem pt to close parts of th e w oun d th at are clean an d gran u lat ing. Use a skin graft or syn th et ic/acellu lar derm al m at rix an d a skin graft to close w ou n ds. Altern at ively, severely con t am in ated w ou n ds can be closed by secon dar y in ten t ion . Begin th e pat ien t on h an d/occupat ion al th erapy as soon as possible, because th erapy is a m ajor determ in an t of th e p at ien t’s u lt im ate level of fu n ct ion . ERRNVPHGLFRVRUJ 16 Hand and Forearm Tendon Injuries Inju ries of th e dist al u p per ext rem it y range from sim p le lacerat ion s to com plex op en blast inju ries involving dest ru ct ion of vit al soft t issu e, n er ve, an d vascular st ru ct ures (Fig. 16.1). E ect ive evaluat ion an d t reatm en t requires detailed at ten t ion to th e m ech an ism , t im e, an d level of injur y. Th e in it ial evaluat ion of an inju red h an d or forearm con sists of a com plete assessm en t for bony, vascular, an d soft t issue injuries. Com plex inju ries m an date p riorit izing recon st ru ct ion . First , th e osseou s st r u ct u res are st abilized w ith in tern al or extern al xat ion m eth ods. Follow ing rigid stabilizat ion of th e ext rem it y, soft t issue repair is un dertaken to protect an d provide m in im al ten sion over delicate vascular an d n er ve recon st r uct ion s. W h en loss of soft t issu e is exten sive, priorit y is placed on bony st abilizat ion an d revascu larizat ion . Soft t issu e coverage is th en em ployed, an d th e soft t issu e is allow ed to stabilize an d h eal for 3 w eeks. Ten don an d n er ve recon st ru ct ion is delayed un t il soft t issue coverage h as stabilized . Fig. 16.1 Complex forearm injury involving tendons, neurovascular structures, m uscle, and bone. 196 ERRNVPHGLFRVRUJ Hand and Forearm Tendon Injuries 197 Tendon injuries of th e forearm an d hand range from a sim ple incom plete laceration of a single tendon to laceration and structural loss of m ultiple m usculotendinous units. The m echanism of injur y dictates the m ethod of repair. Sim ple tendon lacerations are repaired directly w ith any fam iliar tendon repair techniques (Fig. 16.2). The repair of tendon lacerations that are the result of blast and avulsion injuries is usually delayed because the exten t of tendon dam age is n ot im m ediately kn ow n . A delay of 3 to 4 w eeks allow s the determ in at ion of viable ten don, at w hich poin t, tendon reconstruction w ith ten don grafts is perform ed. Over the course of the delay, the tendon path and m uscle length can be preser ved utilizing Silastic tendon rods sutured to the injured tendon ends. Extensor Tendon Injuries Pat ien t s w ith exten sor ten don injuries presen t w ith obvious lacerat ion s over th e involved ten don or p alpable pain in th e region of a closed inju r y. Th e rest ing h an d posit ion w ill display th e involved digit in exion secon dar y to th e loss of th e cou n terbalan cing exten sor. Th e pat ien t w ill also be u n able to exten d th e involved digit act ively w h ile t h e p alm of th e h an d is face dow n on a at su rface (tableto p test). Extensor tendon injuries are com m only the result of open lacerations, but they also occur secondar y to a variet y of closed etiologies. Closed traum atic rupture of the extensor tendon includes but isn’t lim ited to rupture of the exten sor tendon at distal insert ion of th e distal ph alan x (m allet nger), cen tral slip from th e dorsum of the m iddle ph alanx (boutonnière deform ity), and rupture of the extensor pollicis longus associated w ith radius fractures. Patients w ith rheum atoid arthritis develop attrition rup tures at m ultiple levels that can also present in a sim ilar fashion. Fig. 16.2 Tendon injury repairs. (a) Modi ed Kessler stitch. (b) Bunnell stitch. (c) Massachuset ts General Hospital repair. (d) Epitendinous suture. ERRNVPHGLFRVRUJ 198 Hand and Forearm Tendon Injuries Anatomy Th e exten sor com p ar t m en t s of th e h an d are sep arated in to six dorsal com par t m en t s: 1. Abdu ctor p ollicis longu s an d exten sor p ollicis brevis. 2. Exten sor carpi radialis longus an d brevis. 3. Exten sor pollicis longu s. 4. Exten sor in d icis an d exten sor digitoru m com m u n is. 5. Exten sor digit i m in im i (qu in t i). 6. Exten sor carpi u ln aris. Longit udin ally th e exten sor ten don is divided in to n in e zon es from its course from th e m u scle to in ser t ion in to th e dist al ph alan x (Fig. 16.3): • • • • • • • • • Zone I: Distal in terph alangeal join t . Zone II: Middle ph alan x. Zone III: Proxim al in terph alangeal join t . Zone IV: Proxim al p h alan x. Zone V: Met acarpop h alangeal join t . Zone VI: Metacarpal. Zone VII: Carp u s. Zone VIII: Distal forearm . Zone IX: Muscu loten din ou s ju n ct ion proxim al forearm m uscle. Th e th um b h as on ly ve zon es (Fig. 16.3): • • • • • Zone I: In terph alangeal join t . Zone II: Proxim al p h alan x. Zone III: Metacarp oph alangeal join t . Zone IV: Metacarpal join t . Zone V: Carpu s. Th e exten sor ten don zon es are a u sefu l tool for describing th e level of inju r y; th ey also correlate to fu n ct ion al p rogn osis. For ease of referen ce, th e odd-n um bered zon es are located over th e join ts an d th e even -n u m bered zon es are located over th e bon e. In th e proxim al forearm , th e exten sor digitor um com m un is ten don s arise from a com m on m u scle belly an d disallow in depen den t exten sion of th e m iddle an d ring ngers. Th e except ion s are th e in dex an d sm all ngers, w h ich h ave th eir respect ive in depen den t exten sors (exten sor in dicis prop riu s, exten sor digit i qu in t i). In zon e VI, th e jun ct u rae ten din um con n ect th e long, ring, an d sm all nger ten don s, allow ing app roxim ately 30 degrees of exten sion of th e MCP join t even if th e sp eci c exten sor digit to th at ten don is cu t . Th is an atom ical con gurat ion m ay con fu se p hysical exam in at ion n dings w h en obvious lacerat ion s suggest proxim al inju r y. ERRNVPHGLFRVRUJ Hand and Forearm Tendon Injuries 199 Fig. 16.3 Extensor tendon zones. Timing of Repair Th e t im ing of a repair depen ds p rim arily on th e exten t of th e injur y. Sim ple exten sor ten don lacerat ion s m ay be rep aired easily in th e em ergen cy room w ith adequate local an esth esia. How ever, com plex inju ries of m ult iple ten don s at m any levels or w ith gross con tam in at ion require rep air in th e op erat ing room , w h ich allow s th e p at ien t th e ben e t of su st ain ed an esth esia in a tou rn iqu et-con t rolled environ m en t . Ten don inju ries th at are n ot associated w ith isch em ia-related inju r y to th e h an d or digit are rep aired w ith in 1 w eek. If it is n ot feasible to rep air th e ten d on at th e in it ial evalu at ion , th e w oun d is irrigated an d tem p orarily closed an d th e p at ien t is placed in a volar splin t w ith w rist , MCP, an d IP join t s in sligh t exten sion . Treatment Du e to th e com plex arch itect ure of th e exten sor ten don , th e t reatm en t regim en an d aftercare are dep en d en t on area of inju r y. Gen erally, com plete op en lacerat ion s are rep aired acu tely, w h ile closed an d part ial (< 50%) inju ries can be t reated w ith app ropriate splin t ing to allow h ealing. ERRNVPHGLFRVRUJ 200 Hand and Forearm Tendon Injuries Zone I Mallet deform it ies are classi ed in to four t ypes: • Type I: Closed lacerat ion w ith or w ith out fract u re of th e dist al ph alan x (less th an on e-th ird of th e ar t icu lar su rface). • Type II: Op en inju r y w ith ou t fract u re of th e d ist al ph alan x. • Type III: Op en injur y w ith loss of skin an d su bcu t an eous cover. • Type IV: Fract u re of th e d ist al ph alan x involving on e th ird or m ore of th e ar t icular su rface. Closed m allet deform it ies (t ype I) are t reated by splin t ing th e DIP join t in exten sion for 6 w eeks. Th e splin t is isolated to th e DIP join t an d spares th e PIP join t . Open injuries are repaired by derm atoten odesis. Th e skin an d ten don are repaired in a com posite fash ion w ith m at t ress or con t in uou s 4–0 m on o lam en t n on absorbable su t ures. Th e addit ion of K-w ire xat ion of th e DIP join t in exten sion for 6 w eeks is advocated in t ype III/IV injuries. K-w ire xat ion of th e DIP join t sh ou ld also be con sidered in all pediat ric zon e I exten sor ten don injuries becau se of th e h igh in ciden ce of n on com p lian ce w ith splin t ing. Zone II Derm atoten odesis is also recom m en ded in zon e II, w ith m at t ress or con t in uous 4–0 m on o lam en t n on absorbable su t u res for open inju ries. Zone III Inju ries at th e PIP join t level involve th e cen t ral slip an d lateral ban d s. Disru pt ion of th e cen t ral slip causes volar displacem en t of th e lateral ban ds. Th is results in a con gu rat ion in w h ich th e PIP join t is xed in exion an d th e DIP join t is xed in exten sion —the bo uto nnière defo rm ity. Closed inju ries at th is level m ay n ot be clin ically ap paren t in t h e in it ial period after injur y an d u su ally develop 2 to 3 w eeks after cen t ral slip r upt u re secon dar y to p rogressive m igrat ion of th e lateral ban ds. Closed acu te bou ton n ière deform it y is t reated w ith eith er splin t ing of th e PIP join t in full exten sion or K-w ire xat ion of th e PIP join t in exten sion . Splin t age places th e PIP join t in m axim u m exten sion w ith th e MCP an d DIP join t s free for 6 w eeks. Act ive an d p assive ROM is en cou raged in th e DIP join t , w h ile th e PIP join t is h eld stat ic in exten sion . Op en injuries of th e cen t ral slip or lateral ban ds are rep aired directly. Th e lateral ban ds are repaired w ith 5–0 or 6–0 m on o lam en t n on absorbable ERRNVPHGLFRVRUJ Hand and Forearm Tendon Injuries 201 m at t ress sut ures. Com plete lacerat ion of th e cen t ral slip is repaired w ith 4–0 m on o lam en t n on absorbable m odi ed Kessler or Bu n n ell sut u res. Th e pat ien t is th en splin ted w ith th e w rist in 15 to 30 degrees exten sion an d th e MCP an d PIP join t s in fu ll exten sion . Placing K-w ires obliquely across the PIP joint is a reliable way to hold the joint in rm extension for closed injuries or in com plex cases of soft tissue loss. K-w ires are utilized for 3 weeks, after w hich they are rem oved and the patient is placed in a PIP join t extension splint w ith the MCP an d DIP joints free, sim ilar to th at described above, for an addition al 3 w eeks. Zones IV and V Th e exten sor ten don over th e MCP join t an d th e proxim al ph alan x is com posed of th e cen t ral slip an d th e sagit tal ban ds. At th is level, injuries of th e exten sor ten don are associated n ot on ly w ith open injuries, bu t also w ith closed inju ries secon dar y to forcefu l exion or exten sion . Th is is m ost com m on in th e m id dle nger an d is usually secon dar y to a tear of th e radial sagit tal ban d. Rupt ure of th e radial or uln ar sagit t al ban ds causes con t ralateral su blu xat ion of th e cen t ral slip. Physical exam in at ion reveals in com p lete nger exten sion w ith u n ilateral displacem en t of th e ten don . Th e cen t ral slip is repaired prim arily w ith 4–0 m on o lam en t n on absorbable m odi ed Kessler or Bu n n ell sut ures. Th e sagit t al ban ds are rep aired w ith 5–0 m on o lam en t n on absorbable h orizon tal m at t ress sut u res. In cases in w h ich th ere is loss of su bst an ce of th e sagit t al ban d m ech an ism , th e ten don sh ould be cen tered on th e MCP join t by eith er sut uring th e t ran sverse bers to th e join t capsule or teth ering th e ten don w ith th e jun ct urae ten din um or a ret rograde slip of th e ten don . Splin ting in th ese zon es after repair is w ith th e w rist in 45 degrees exten sion , th e MCP join t in 15 degrees exion , an d th e PIP join ts in fu ll exten sion . Op en inju r ies in zon e V are also associated w it h h u m an bites, t h e so-called gh t bite w ou n d . In t h is case, t h e con t am in ated w ou n d sh ou ld be exp lored an d t h e join t in sp ected if t h e cap su le is violated . Th e w ou n d is t h en cu lt u red , t h orough ly irr igated, an d left op en . Th e associated ten d on lacerat ion is rep aired secon dar ily in 5 to 7 days, d ep en d ing on t h e st at u s of t h e su r rou n d ing soft t issu e. Th e p at ien t is t reated w it h Augm en t in 875 m g t w ice a day (clin dam ycin for p en icillin -allergic p at ien t s) for 10 days. Pat ien t s t h at p resen t w it h an obviou s in fect ion after a h u m an bite inju r y are ad m it ted an d p laced on Un asyn . Refer to Ch apters 14 an d 15 regard in g m an agem en t of t h ese inju r ies. ERRNVPHGLFRVRUJ 202 Hand and Forearm Tendon Injuries Zones VI and VII Ten don injuries in zon es VI an d VII are usually secon dar y to open lacerat ing inju ries. For t u n ately, th ese inju ries h ave th e best progn osis du e to th e w ell-de n ed ten don substan ce an d n ourish ing paraten on . Ten don s are repaired in th ese region s w ith four-st ran d core sut ures w ith th e kn ots buried an d an epiten din ous sut ure. A m odi ed Kessler sut ure w ith a 3–0 looped Supram id (S. Jackson , In c.) sut ure w ill facilitate fou r-st ran d core su t u res w ith on e kn ot . Th e ep iten din ou s rep air is perform ed w ith a 6–0 con t in uous nylon sut ure. In zon e VII, th e exten sor ret in aculum is par t ially excised longit u din ally over th e rep air to p rovide adequ ate excu rsion an d to p reven t form at ion of adh esion s. Repairs in th is zon e are splin ted w ith th e w rist in 45 degrees exten sion , th e MCP join t in 15 degrees exion , an d th e PIP join t s in fu ll exten sion . Zones VIII and IX Proxim al an d dist al forearm inju ries to exten sor com par t m en t s of th e forearm occu r from th e exten sor origin at th e lateral epicon dyle to th e w rist . In th e proxim al forearm , lacerat ion s involve th e m uscle belly of th e involved digit exten sor. Th ese inju ries com m on ly in clu de lacerat ion of th e radial sen sor y n er ve an d sign i can t h em atom a. Pen et rating w oun ds in th is region are explored u n der tou rn iquet an d irrigated, an d all h em atom a is evacuated. Repair of th e m uscle belly is don e w ith 3–0 PDS gu re-eigh t su t u res. In th e distal forearm , lacerat ion s occu r in th e distal m u scle belly, in th e m u scu loten din ou s ju n ct ion , or ju st proxim al to th e w rist . At th e ju n ct ion of th e ten d on an d m u scle, th e fascial m argin s are iden t i ed w ith in th e m uscle an d sut ured to th e dist al ten don en d u sing a 3–0 looped Supram id-m odi ed Kessler sut ure. Th e fascial m argin s are rep aired arou n d th e jun ct ion w ith a 4–0 PDS sut u re. Inju ries m ore dist al to th is region are repaired sim ilarly to zon e VI an d VII lacerat ion s. Th e ext rem it y is sp lin ted in an elbow -im m obilizing fash ion after rep air for 4 w eeks. Th e elbow is p laced in 90 degrees exion , th e w rist in 45 degrees exten sion , MCP join ts in 15 degrees exion , an d IP join t s in full exten sion . ERRNVPHGLFRVRUJ Hand and Forearm Tendon Injuries 203 Flexor Tendon Injuries Pat ien t s w h o presen t w ith exor ten don dam age w ill h ave disru pt ion of th e n orm al rest ing arcade. Th e loss of on e or both exor ten d on s w ill resu lt in u n balan ced exten sion of th e involved digit . Usu ally lacerat ion s w ill give clu es to th e level of inju r y. Deep lacerat ion s of th e volar surface of th e nger an d h an d n ot on ly p lace th e su p er cialis an d profun dus ten don s at risk, bu t also in d icate th at n eu rovascu lar inju r y sh ou ld be suspected. A th orough exam in at ion of th ese p at ien t s in cludes radiograph s, sen sor y evalu at ion , an d isolated m otor test ing of th e super cialis an d p rofu n du s ten don s (see Ch apter 12, Fig. 12.1 an d Fig. 12.2.). Isolated inju r y to on e exor ten don m ay st ill allow exion of th e digits at th e PIP join t . Th erefore, to test th e in tegrit y of th e profu n dus ten don , th e PIP join t is h eld in exten sion w h ile exion of th e DIP join t is in it iated. Flexor Tendon Injury Zones Th e volar h an d area is divided in to ve zon es th at describe exor ten don injuries (Fig. 16.4): • Zone I: Distal to th e in ser t ion of th e exor digitoru m super cialis (FDS). • Zone II: No m an’s land; distal p alm ar crease to zon e I. • Zone III: Distal edge of th e t ran sverse carpal ligam en t to th e dist al palm ar crease. • Zone IV: Th e carp al t u n n el. • Zone V: Distal por t ion of th e forearm . Fig. 16.4 Flexor tendon zones. TI, TII, and TIII are the exor tendon zones of the thum b. ERRNVPHGLFRVRUJ 204 Hand and Forearm Tendon Injuries Fle xor Tendon Repair (Fig. 16.1) • Perform rep air w ith in 48 to 72 h ou rs. • Acu tely p lace pat ien t in exten sion block sp lin t (see Ch apter 13, Fig. 13.6). • Delay ten don rep air u n t il bony st abilizat ion an d soft t issu e decon t am in at ion . • Delay ten don repair w h en in fect ion is presen t . • Perform ten don rep air in th e operat ing room to allow greater exposu re for ten don ret rieval. • Repair both th e FDS an d th e exor digitoru m p rofu n dus (FDP) w h en inju red. • Exten sion block splin t after repair. Tech n iqu es for ten don ret rieval: • Flex w rist an d MCP join t to advan ce ten don . • Mobilize proxim al en d w ith a suct ion cath eter. • Massage proxim al en d in to w ou n d using an Esm arch ban dage or m an ually. • Grab en d w ith 18-gauge n eedle or skin h ook. • Su t ure ten don en d to ru bber cath eter to p ass u n der p ulleys or in to ten don sh eath . Zone I Repair Rep air of th e FDP ten don distal to th e in ser t ion of th e FDS takes in to con siderat ion th e stat u s of th e in ser t ion of th e ten don on to th e base of th e dist al p h alan x. If an avu lsion fragm en t is presen t w ith th e FDP at t ach ed, th e repair is p erform ed w ith com p osite p in xat ion of th e ten don to th e dist al p h alan x. W h en th e FDP is detach ed , th e distal p or t ion is secu red to th e dist al ph alan x w ith a bon e su t u re an ch or (3–0 or 4–0) or pulled th rough th e dist al p h alan x u sing a dou ble-arm ed 3–0 Su p ram id su t u re an d t ied over a bu t ton . In t h e rep air of m ore p roxim al zon e I inju ries, th e p roxim al ten don is ret racted in to th e region of th e m iddle ph alan x. Th e distal st um p th at is at tach ed to th e distal ph alan x is exp osed by dissect ion of th e A5 p ulley. Care sh ou ld be taken n ot to disru pt th e A4 pu lley. A core su t ure is placed in th e proxim al ten don en d (3–0 Su pram id), an d t h e n eedle is passed un der th e A4, pu lled, an d su t u red in to th e distal ten don st u m p. ERRNVPHGLFRVRUJ Hand and Forearm Tendon Injuries 205 Zone II Repair Du e to th e tech n ical di cu lt y of rep air an d p oorer fu n ct ion al ou tcom es, zon e II is colloquially kn ow n as “no m an’s land.” Exp osu re for rep air of zon e II exor ten don injuries requires w ide exposure w ith proxim al an d dist al Bru n n er in cision s, as w ell as dissect ion of th e exor ten don sh eath an d p u lley system . Th e A2 an d A4 p u lleys sh ou ld be p reser ved d u ring dissect ion . On ce th e proxim al ten d on en d is iden t i ed, a core sut u re (3–0 Su pram id) is p laced an d p u lled u n d er th e p u lleys so th at repair can be p erform ed bet w een a pu lley sh eath w in dow. Th e p roxim al en d can be h eld ten sion free by p lacing an 18-gauge n eedle in th e en d th rough th e p u lley an d th e sh eat h . Repair is th en perform ed w ith fou r-st ran d core sut ures an d an epiten din ous 6–0 run n ing Prolen e. Ext rem e care is t aken in zon e II to p rovide a rep air th at is at w ith out fraying to avoid teth ering d u ring ten don excu rsion . Par t ial resect ion of th e adjacen t p u lley is accept able to allow excu rsion of th e repair. Zones III, IV, and V Injuries proxim al to zone II have an im proved prognosis w ith good functional recovery. However, in these zones there is a higher propensit y to injure tendons of m ultiple digits and m ajor nerve and vascular structures of the hand. Repair in these zones is aided by extending palm ar and forearm in cisions for exposure and tendon ret rieval. Place a tourniquet on the patient’s upper extrem it y to achieve hem ostasis. The tourniquet should be raised to 100 m m Hg above th e systolic blood pressure. It can be left on for 2 hours, but needs to be de ated for 20 m inutes prior to rein ation for 2 m ore hours (5 m inutes of de ation for every 30 m inutes of in ation). Alw ays ex t h e in terp h alangeal join t s, t h e MCP join t , an d t h e w r ist to d eliver t h e d ist al en d s of t h e lacerated ten d on s in to t h e op erat ive eld . Th e lacerated en d s of th e w ou n d can be exten ded p roxim ally an d dist ally to allow for exposu re of th e ten don s, n er ves, an d vessels. Any bon e xat ion sh ou ld p reced e any rep air of soft t issu es, as d escr ibed in Ch apter 17. Id en t ify all t h e exor ten don en ds. Often t im es, ten don s are h idden in a sm all h em atom a in th e ten don sh eath . Dissect ou t all t h e ten d on s an d id en t ify t h eir fu n ct ion by p u lling on th e en ds an d n ot ing th eir act ion . Next , t ag th em by p er for m ing ten don repair on th e dist al en d of th e ten don , w ith loop ed Su pram id su t u res (Fig. 16.1; w e u se th e m odi ed Kessler tech n iqu e). On ce all th e en ds are accou n ted for, m atch t h em to t h e p roxim al en d s of t h e ten d on s, based on t h e p osit ion of t h e ten d on en d s in t h e p roxim al forearm . Having accou n ted for all t h e d ist al ten d on s an d h aving m atch ed t h em to t h eir ERRNVPHGLFRVRUJ 206 Hand and Forearm Tendon Injuries cou n terp ar t s in th e forearm , begin repair ing th e ten don by com p let ing th e repair from th e deep est ten don to th e m ost su p er cial. Rem em ber to p er for m ep iten d in ou s rep air w it h 6.0 Prolen e su t u re (Fig. 16.1) after t h e core su t u re rep air. If requ ired , p er form revascu larizat ion of t h e h an d by an astom oses of t h e severed en d s of t h e u ln ar or rad ial ar ter y alon g w it h t h e cep h alic vein or t h e ven ae com it an tes. Fin ally, rep air t h e m edian or u ln ar n er ve inju ries. Th ese rep airs sh ou ld involve lin ing u p th e fascicles an d vason eu riu m in th e n er ve an d p er for m ing epin eu ral rep air u sing 9–0 nylon su t u re. Th e rep air can be w rapp ed w ith 3- to 4-m m n eu rot u be t u bing, if desired . All at tem pt s sh ou ld be m ad e at p rim ar y rep air, sin ce th is tech n iqu e h eralds th e best p rogn osis. Mobilize th e n er ve to allow ten sion -free rep air. ERRNVPHGLFRVRUJ 17 Hand Vascular Injuries and Digit Amputations Vascular injuries of th e h an d an d digit al am put at ion s require im m ediate at ten t ion by a specialist to en su re proper revascularizat ion an d opt im um fu n ct ion al resu lt s for th e p at ien t . Vascular System of the Hand Th e h an d is supplied w ith blood by th e uln ar ar ter y an d th e radial arter y. Th e rad ial ar ter y is dom in an t 57% of th e t im e, w h ereas th e u ln ar arter y is dom in an t 21.5% of th e t im e (th e t w o ar teries are codom in an t th e rem ain ing 21.5% of th e t im e). Th e radial arter y divid es in to a sm all super cial palm ar ar ter y an d large dorsal radial bran ch . Th e uln ar ar ter y divides in to su per cial an d deep bran ch es. Next , th e dorsal radial bran ch gives o t h e p rin cep s p ollicis an d radial digit al in dex bran ch an d th en an astom oses to th e deep bran ch of t h e u ln ar ar ter y to form th e deep p alm ar arch . Th e super cial bran ch of th e radial ar ter y an astom oses to th e super cial u ln ar arter y to m ake th e super cial palm ar arch . Th e com m on digit al arteries arise from th e super cial arch . Th e digit al bran ch es arise from th e com m on digit al ar teries. Th e vascular su pply is regulated by m et abolic dem an ds, sym p ath et ic ton e, h orm on al factors, an d environ m en tal factors. Physical Examination Basic ten ets of th e vascu lar exam in at ion of th e h an d in clu de th e follow ing: • Test each digit for cap illar y re ll, sen sat ion , edem a, color, gangren e, an d petech iae. – If you are h aving di cu lt y perform ing a cap illar y re ll test on th e digits du e to ecchym osis or avu lsion of skin , you m ay use Doppler ult rason ography to determ in e th e in tegrit y of th e d igit al vessels. – For con t in u ou s m on itoring of th e perfusion to a nger, a pu lse oxim eter m ay be u sed on th e involved nger. • Test th e p roxim al blood su p ply by taking th e blood pressure in both arm s for a di eren ce com parison . 207 ERRNVPHGLFRVRUJ 208 Hand Vascular Injuries and Digit Am put ations • Perform an Allen test (see Ch apter 12). – If you can n ot feel a p u lse, th en ch eck th e w rist for radial an d u ln ar Doppler u lt rasou n d sign als an d u se Doppler u lt rason ography to perform an Allen test . Test th e in tegrit y of th e palm ar arch es. • Ut ilize angiograp hy w h en n eeded. If you are u n able to perform th e above exam or if th e zon e of inju r y to th e vessels is in quest ion , th en an angiogram m ay be h elpfu l. • Fin ally, m ake su re to p alp ate th e com par t m en t s of th e forearm / h an d as w ell as m easu re th e com p ar t m en t pressu res w ith a St r yker n eedle or ar terial lin e to ru le out com p ar t m en t syn drom e an d th e n eed for a fasciotom y (see Ch apter 19). Arterial Injuries • Presentat ion: Pallor, lack of capillar y re ll or pu lse distally, pu lsat ile bleeding. In t im al dam age m ay p resen t w ith late th rom bosis. • Mechanism : Cr ush , st ab, or avu lsion inju ries. Th e in dicat ion s for repair of radial o r ulnar arte ry inju ries are • Absolu te in dicat ion : Han d or digital isch em ia. • Relat ive in dicat ion s: To im p rove cold in toleran ce, to provide bet ter circu lat ion for w ou n d h ealing. • In dicat ion for digital vessel repair: Digit isch em ia. Treatment Forearm and Hand Injuries In cases of sh arp inju ries to th e ar ter y, direct rep air can be perform ed. W h en th ere h as been a cru sh inju r y to th e ar ter y or an avu lsion , resect ion of th e inju red por t ion an d th e u se of vein graft s for recon st ru ct ion are required. Sign s of vessel dam age in clu de telescoping of th e vessels, petech ial h em orrh ages on th e vessel w all, vessel th rom bosis, cobw ebs in th e vessels, or poor ow from th e p roxim al en d of th e injur y. In th ese cases, reversed vein graft s can be u sed. Th e dorsal h an d vein s can ser ve as a good don or site. If th e pat ien t requires exten sive forearm fract ure redu ct ion prior to rep air of th e ar ter y, Silast ic sh u n ts can be u sed as a tem porar y w ay to est ablish perfu sion to th e h an d un t il th e fract ure is st able in th e operat ing room . Th en ar terial recon st ru ct ion is p erform ed ERRNVPHGLFRVRUJ Hand Vascular Injuries and Digit Am put ations 209 at th at set t ing. A forearm fasciotom y sh ou ld be perform ed if th e pat ien t h as com p ar t m en t syn drom e or com part m en t syn drom e is an t icip ated. Digital Vessels On ly on e digit al ar ter y is required for adequate perfu sion . Th erefore, injuries to both ar teries requ ire repair of at least on e ar ter y. Ven ous outow is also crit ical; in t act skin bridges m ay m ain t ain capillar y ven ou s ou t ow. How ever, if rep air of th e digital vein s can n ot be p erform ed, th en ven ous ou t ow an d sign s of congest ion sh ou ld be follow ed , an d ou t ow sh ou ld be augm en ted w ith leech es if n ecessar y. Cannulation Injuries A vessel inju r y can often occu r from can n u lat ion of th e radial ar ter y w it h an ar terial lin e or ar terial blood gas sam p ling. Th is can resu lt in p seu doan eu r ysm form at ion , th rom bosis, or ar terioven ou s st u la form at ion . Th e rate of th rom bosis in th e vessel is directly correlated to th e durat ion of can n u lat ion . If th e p at ien t h as a loss of radial pu lse, bu t does n ot h ave any digital isch em ia, su rger y is n ot n eeded. Th is can be m an aged con ser vat ively. An t icoagu lat ion sh ou ld be con sidered in th ese cases. Th e t reat m en t of th ese injuries en t ails surgical explorat ion an d th rom bectom y w ith direct ar terial repair. Sign i can t vessel gaps are repaired via reversed vein grafts h ar vested from th e ceph alic or saph en ous vein s. An ar teriogram m ay be ben e cial preoperat ively or in t raoperat ively to iden t ify th e level an d ch aracter of occlu sion . Hypothenar Hammer Syndrome Hypoth en ar h am m er syn drom e, th e m ost com m on cau se of th rom bosis in th e up per ext rem it y, resu lt s from repet it ive t raum a to th e u ln ar arter y cau sed by t h e p at ien t u sing th e h an d as a h am m er. Th is syn drom e usu ally occu rs in laborers in th eir 50s w h o sm oke. Th ere is dam age to th e elast ic lam in a of th e uln ar ar ter y, an d a th rom bu s an d/or an eu r ysm can result . Th e th rom bu s m ay em bolize. Th e pat ien t sh ould refrain from th e act ivit y causing th e t raum a. Sm oking could exacerbate th e con dit ion ; th erefore, sm oking cessat ion is param ou n t . Hypot h en ar h am m er syn drom e m ay be t reated m edically w ith th rom bolyt ics (u rokin ase, st reptokin ase, TPA). Altern at ively, th rom - ERRNVPHGLFRVRUJ 210 Hand Vascular Injuries and Digit Am put ations bectom y or resect ion of th e involved por t ion of th e vessel is required w ith eith er prim ar y closure or recon st ruct ion using vein grafts from th e forearm vein s or dorsal foot . In som e cases, ligat ion of th e ar ter y allow s for vasodilat ion an d collateral ow. Keep a h igh in dex of suspicion for com par t m en t syn drom e. Digit Amputation Replantation W h ereas revascu larizat ion of a digit refers to restorat ion of blood su p p ly to an in com pletely severed digit , replan tat ion refers to reat tach m en t of an d restorat ion of blood su p ply to a com pletely severed digit . Indications for Replantation • • • • • • Am put at ion of th e th um b. Mult iple digit am pu tat ion . Par t ial h an d am pu t at ion . Wrist or distal forearm am pu tat ion . Above-th e-elbow am pu tat ion . Any am p u t at ion in a ch ild < 12 years old . Relat ive In dicat ion • Single-digit am pu tat ion distal to th e in ser t ion of th e exor digitorum su per cialis (FDS). Contraindications for Replantation • If th e severed digit h as u n dergon e w arm isch em ia for > 12 h ours or cold isch em ia for > 24 h ou rs. – In th e case of am pu t at ion s proxim al to th e w rist , on ly a w arm isch em ia t im e of 6 h ou rs an d a cold isch em ia t im e of 12 h ours can be tolerated. – If th e p at ien t is n ot m edically st able en ough to u n dergo a long operat ion . – Relat ive con t rain dicat ion s are m en t ally u n stable p at ien t s, sm okers, an d p at ien t s w ith diabetes m ellit u s. ERRNVPHGLFRVRUJ Hand Vascular Injuries and Digit Am put ations 211 Crush an d avulsion injuries can be expected to h ave a h igh er failure rate for replan t at ion . If a pat ien t presen ts w ith a severely m angled digit w ith m u lt iple levels of inju r y, replan t at ion w ill likely be un successful. An oth er p redictor of p oor ou tcom e is th e presen ce of a red lin e on th e skin an d on th e n eu rovascular bu n dles. Peri-Operative Considerations Th e am put ated digit or par t sh ould be t ran spor ted to th e em ergen cy room w rapped in a salin e-soaked sponge, placed in a plast ic bag, an d placed on top of ice. Do n ot let th e nger freeze or be su bm erged in ice becau se frostbite w ill resu lt . Take X-rays an d p h otograp h s of th e h an d along w ith th e am pu t ated digit to determ in e th e level of inju r y. Prior to rep lan tat ion , th e am pu tated p ar t sh ou ld be exam in ed u n der a lou pe or m icroscopic m agn i cat ion to est ablish th e in tegrit y of th e involved vessels. Use th is in form at ion to determ in e if replan t at ion is feasible. Provide good u id resu scit at ion for th e pat ien t an d discuss th e risks an d ben e t s of th e su rger y w ith th e pat ien t so h e or sh e can u n derstan d th e procedu re an d th e n eed for reh abilitat ion , an d h ave realist ic expectat ion s. In th e op erat ing room , rst , th e bon e is sh or ten ed an d xed w ith a K-w ire, an d th en th e repair is u n der taken in th e follow ing order: exten sor ten don s, dorsal vein s, dorsal skin , exors, ar teries, an d n er ves. Th e sequen ce of vein s, ar teries, an d exor ten don s is con t roversial. Vessel rep air an d an astom oses sh ou ld be perform ed ou t side of th e zon e of injur y. Th e liberal use of vein graft s an d ven ou s ow -th rough aps w ill allow m icrosu rgical repair in a region w ith m in im al in am m at ion . If m ult ip le digit s are replan ted at th e sam e t im e, replan tat ion sh ould proceed par t by par t in stead of nger by nger (i.e., sam e rep lan tat ion step for each nger at th e sam e t im e). Postop erat ively, splin t th e inju r y, place th e pat ien t in a com fort able w arm room , an d elevate th e ext rem it y. Leech es can be u sed to aid w ith ven ous congest ion by providing th e local an t icoagu lan t h irudin an d rem oving blood. Usu ally th e leech es are p laced on th e ngert ip an d th ey are engorged in 30 m in u tes. Th e t h erapy is p erform ed for 5 to 7 days. Prophylact ic an t ibiot ics such as th ird-gen erat ion ceph alosporin s or gen tam icin or Bact rim can be used to avoid in fect ion w ith Aerom onas hydrophila. Th e best results are ach ieved w ith th u m b, w rist , an d distal FDS replan ts. Overall viabilit y is rep or ted at 80 to 90%. ERRNVPHGLFRVRUJ 212 Hand Vascular Injuries and Digit Am put ations Complications • • • • • Cold in toleran ce. Non u n ion . Malu n ion . Join t con t ract u res. In fect ion . Fingertip Injuries Tip avulsion s an d am pu t at ion s are a su bset of injuries th at occu r distal to th e term in al arborizat ion of th e digital vessels. In th is region of th e dist al p h alan x, th e digital arteries an d vein s are u n able to be rep aired m icrosu rgically. Addit ion ally, th ese inju res com m on ly occu r w ith con com it an t n ail avu lsion an d dist al p h alangeal fract u res (t u ft fract u res). Repair of t ip inju ries requ ires at ten t ion to fract u re redu ct ion , n ail repair, an d soft t issue restorat ion . Nail Repair Nail an atom y is depicted in Fig. 17.1. Com m on ly after inju r y, p at ien t s w ill presen t w ith subungu al h em atom as th at in dicate disrupt ion of th e sterile m at rix. Sm all su bu ngu al h em atom as (< 40%of th e n ail) are t reated w ith aspirat ion of th e subungual space an d subsequ en t irrigat ion w ith an 18- or 20-gauge n eedle. W h en severe dam age to th e sterile m at rix is su spected or larger su bu ngu al h em atom as are p resen t , rem oval of th e n ail plate an d direct rep air of th e m at rix is ap propriate. Com p lete n ail p late avu lsion inju ries are repaired rst by direct closu re of th e sterile m at rix w ith 6–0 p lain gu t su t u re. Next , th e germ in al m at rix is sten ted w ith a piece of n e gau ze, foil, or th e n at ive n ail plate w ith t w o ver t ical m at t ress 5–0 ch rom ic sut ures. Preser vat ion of th e germ in al m at rix w ill preven t syn ech ia an d allow grow th of a n ew n ail plate (Fig. 17.2). Pat ien t s sh ould be coun seled th at w ith t im e th e sten t w ill be replaced by th e grow th of th e n ew n ail plate from ben eath . Fig. 17.1 anatomy. ERRNVPHGLFRVRUJ Normal ngertip Hand Vascular Injuries and Digit Am put ations 213 Fig. 17.2 Nail bed repair. (a,b) Suture repair of sterile m atrix laceration. (c,d) Germ inal m atrix stenting. (e –h) Repair of nail bed in a patient with distal tuft fracture. ERRNVPHGLFRVRUJ 214 Hand Vascular Injuries and Digit Am put ations Tuft Fractures Th e m an agem en t of dist al p h alan x fract u res is d iscu ssed exten sively in Ch apter 14. Tu ft fract u res occurring w ith t ip inju ries are sim ple an d un com plicated. Restorat ion of th e n orm al soft t issue arch itect ure by sut uring an d subsequen t im m obilizat ion w ith an alum in um nger splin t is adequate for stabilizat ion . Th e in sert ion of an axial K-w ire or 20-gauge n eedle is also u sefu l to redu ce th e fract ure fragm en ts. Soft Tissue Repair Repair of the ngertip soft tissues depends on the degree of injury (am putation versus avulsion) and the availability of the am putated part. When avulsion of the tip is apparent, assess the avulsed fragm ent to determ ine its viability. If the avulsed fragm ent is cyanotic or ischem ic, the fragm ent is am putated. If the avulsed fragm ent is viable, it is because the intact arterial capillary plexus bet ween the tip and the fragm ent is providing perfusion. In these cases, the avulsed fragm ent is repaired by a suture to the tip w ith 4–0 nylon (5–0 chrom ic in children). A prim arily or secon darily am pu t ated t ip can be salvaged by rem oving th e su bcu t an eou s t issue from th e overlying glabrous skin . Th e skin is th en su t u red to th e t ip as a fu ll-th ickn ess skin graft (Fig. 17.3). Th e injur y is sp lin ted an d p rotected w ith an alu m in u m splin t in place for 5 days. If th e am p u t ated t ip fragm en t is u n available, rep air is depen den t on th e size of th e defect an d exposure of th e u n derlying st ru ct ures. Sm all defect s of th e t ip (< 1 cm ) w ith ou t exposed dist al ph alan x h eal w ell by secon dar y in ten t ion . Th ese inju ries are dressed w ith Xeroform gauze, an d pat ien ts are coun seled to perform dressing ch anges t w ice a day. Large defects are closed w ith fu ll-th ickn ess skin graft s from eith er th e hyp oth en ar em in en ce or t h e forearm . W h en th e d ist al p h alan x is exposed, t h e w ou n d is th orough ly irrigated an d local aps can be em ployed for closu re if th e su rrou n ding soft t issu e is n ot sign i can tly devit alized (Fig. 17.4, Fig. 17.5). Oth er w ise, th e w ou n d is dressed w ith Xeroform gauze an d local w ou n d t reat m en t is follow ed u n t il declarat ion of th e viabilit y of th e su rrou n d ing soft t issu es. Sh or t-term follow -u p allow s for assessm en t of th e pat ien t’s w oun d for closu re w ith local or region al aps. ERRNVPHGLFRVRUJ Hand Vascular Injuries and Digit Am put ations 215 Fig. 17.3 (a–c) Composite repair of tip amputation with amputated portion placed as a full-thickness skin graft. (d) Presentation of distal amputation. (e) Amputated distal tuft. (f) Follow-up 1 m onth after repair. Fig. 17.4 (a–c) Volar V-Yadvancem ent coverage of transverse tip injury. ERRNVPHGLFRVRUJ 216 Hand Vascular Injuries and Digit Am put ations Fig. 17.5 (a–c) Kutler lateral V-Y advancem ent ap coverage of tip defect. ERRNVPHGLFRVRUJ 18 Upper Extremity Peripheral Nerve Injuries Nerve injuries in the upper extrem it y occur as the result of a blast, crush injury, a penetrating blow, or due to an injury caused by a sharp object. Managem ent is predicated on establishing nerve continuit y in an environm ent that w ill allow nerve grow th and regeneration. Wallerian degeneration of the axons occurs at the tim e of injury. Reinnervation of the m otor end plates before 18 m onths w ill prevent m uscular atrophy and subsequent deform ity. Therefore, appropriate initial m anagem ent of these injuries w ill confer successful results w ith m inim al functional m orbidity. Classi cation of Injury (Fig. 18.1) First Degree : Neuropraxia First-degree injuries occur secon dar y to cru sh ing, com pressing, or st retch ing of th e n er ve. In th ese scen arios, th e n er ve arch itect ure is n ot disru pted an d th ere is n er ve con t in uit y. Con ser vat ive m an agem en t in cluding splin t ing of th e involved ext rem it y an d physical th erapy is app rop riate. Th e n er ve sh ou ld recover in 3 m on th s; oth er w ise, a secon d-, th ird-, or four th -degree injur y sh ould be suspected, w h ich w ould require operat ive in ter ven t ion . Second-, Third-, and Fourth-Degree Injuries Inju ries th at disr u pt th e in tern al arch itect u re of th e n er ve m ay con sist of isolated axon al derangem en t of n er ve fascicles w ith subsequen t scar form at ion (axon ot m esis/secon d degree). How ever, th ere m ay exist a scar con duct ion block at th e fascicu lar level or across th e en t ire n er ve (th ird an d fou r th degree). An a xon ot m et ic lesion w ill h eal w it h ou t su rgical in ter ven t ion if it allow s n er ve grow th th rough th e in tact sh eath at 1 m m p er day or 1 in ch per m on th . Injuries t h at h eal w ith a scar block cau se in com p lete con du ct ion across th e n er ve. Th ese lesion s m ay requ ire in tern al n eurolysis or excision an d direct repair, d ep en ding on th e con du ct ion drop across th e scar. Di eren t iat ion of th e degrees of th ese lesion s is determ in ed by EMG an d n er ve con du ct ion st u dies don e at som e t im e in ter val after th e injur y, if n o n er ve fu n ct ion ret u rn s. 217 ERRNVPHGLFRVRUJ 218 Upper Extrem it y Peripheral Nerve Injuries Fig. 18.1 The Seddon-Sunderland-Mackinnon classi cation of nerve injury. Fifth- and Sixth-Degree Injuries A com plete disru pt ion of th e n er ve is referred to as n eu rot m esis. Neu rot m esis is repaired by direct coapt at ion or via n er ve con duit graft s. Th e sixth -degree inju r y is m u lt ip le lesion s along th e length of th e n er ve. Du e to th e poten t ial for longit udin al scar form at ion , th ese lesion s requ ire operat ive in ter ven t ion . Management The location of the injury is obvious in patients w ho present w ith peripheral nerve injuries. Com m only, the injury is open and associated w ith speci c traum a to an extrem it y. Nevertheless, a thorough physical exam ination is warranted to determ ine the degree of function loss. The m otor exam ination should include assessm ent of all involved m uscle groups w ith docum entation of their strength. Sensory exam ination includes the assessm ent of t wopoint discrim ination and response to light touch and vibratory stim ulus. The speci c m an agem ent of these injuries depen ds on the degree of injury and the m echanism . Generally, closed injuries—neuropraxic or axonotm etic—are m anaged conser vatively. Recover y of function is ERRNVPHGLFRVRUJ Upper Extrem it y Peripheral Nerve Injuries 219 expected w ithin 3 m onths. Open injuries are repaired prim arily if the nerve and surrounding soft tissue do n ot have th e potential for devitalization. Sharp lacerations of the ner ve should be explored and repaired at the tim e of injur y after the wound bed is decontam inated. Repair is delayed in blast, crush, and avulsion injuries. With these lesions the ner ve is considered “stunned,” w ith the potential for devitalization of ner ve and tissues in the subacute period. Often these injuries are open. Therefore, the ner ve should be explored and exam ined. If the nerve ends are in close proxim it y, the ner ve is repaired. Otherw ise, ner ve ends are tagged for delayed repair in 4 to 6 w eeks. Prim ary n erve grafting is not recom m ended in blast, crush, and avulsion injuries. In open injuries, ner ve repair is perform ed after repair of bony an d vascular dam aged structures. Brachial Plexus Injuries Injury to the brachial plexus is suspected in patients w ho present w ith high-velocit y wounds or direct penetration in the region of the cervical roots. These patients w ill present w ith gross loss of sensation and weakness of the involved upper extrem ity. Care m ust be taken to rule out associated injury to the cervical spine, thoracic outlet vessels, and shoulder girdle. Evaluation Physical exam in at ion is perform ed to determ in e th e locat ion of th e lesion based on kn ow ledge of th e brach ial p lexu s an atom y (Fig. 18.2). Exam in at ion in cludes assessm en t of sen sor y loss, m otor fu n ct ion , an d vascular in tegrit y. In addit ion to th e p hysical exam in at ion , radiograph ic evalu at ion of th e cer vical sp in e an d involved u p p er ext rem it y is perform ed. CT scan s of th e cer vical region w ou ld reveal a cer vical sp in e injur y an d assist in evalu at ion for root avulsion . Management Man agem en t of brach ial plexu s inju ries is d ep en den t on w h eth er th e lesion is an avulsion or a r u pt u re ou t side of th e sp in al cord. Avu lsion lesion s w ill require delayed recon st ru ct ion after a th orough assessm en t of th e fu n ct ion al an atom y of th e plexu s by EMG/NCS an d SSEP st u dies. In th e acu te set t ing, th ese p at ien t s are t reated con ser vat ively w it h sp lin t ing an d reh abilit at ion . Th e u pp er ext rem it y is p laced w ith th e elbow in exion an d th e h an d an d w rist in th e safe p osit ion . Lesion s ou t side of th e CNS (ru pt u res) are m an aged sim ilar to isolated perip h eral n er ve inju ries (Fig. 18.3). ERRNVPHGLFRVRUJ 220 Upper Extrem it y Peripheral Nerve Injuries Fig. 18.2 Anatomy of the brachial plexus. ERRNVPHGLFRVRUJ g i F . 1 8 . ERRNVPHGLFRVRUJ 3 e N g l o r t i h t o f g r m a n g e m e t t n n t e n m e l e a m s v n e h o o r t v i a t p n o r c m p n o M I u m o F I 3 o f e h ) d t u y i e r s t s w u i c j t s y n e n r e i s o i d e i u r t n e j t v s d u a r z a n j i r a i n r l e l t n a a i o n e b l t n r . i v p n r a a v e l . x e e o i e l i e ( u t N d c C a s e x t a N f a v i y d o n e n i T m n r o i m B a O i l / d y T p r n e S P s u e j o p l n I O C A e v r p m I e r b r a c h P G S E C M S N E S a i l p e l u x s n i u j r , s T h P t p h c l t h e r a p ; y , T O o c c s t r u i n x a t p f u o a t a g n n i o t T i n O l t h e r a p . y t t t h n n t n e e n T e m o m T t O m e e O s m v v / s o o d T e r r 8 s P p p s 1 a – m m i e I 2 r 1 o N n e a v i S n t C a o i r t N e / a r p P o o E l a S p r t S t x n e I e n h e t m n R s o i l / T s p S e m P s 2 s 1 a – e r 6 e e p n l m e e p l e r l a v m a n i o e y r y r ) o r v h i S p c a t o r C c a l m r m p n I i a N b r / u n m o P F i e y v r o e c g v e r o G o i N t M c c n i r t i l e a r n E ( n a u y r i e s s s v o o x N A a a r p g e r e y v r r a e y e o s c n m i r h s e r A P G t P i S E C M w S N E S n . o s m e i 6 s s i i s s s k e e a i g e m n x m t n t o T a i i o r t e W o s O r l n p 3 n / i u u o l o T r e v x p P u A A g N S n T i e N t O n / i l T p P S / t n T n e P e m m e e v v o r o r p p m i m I o N y r e l o c s y s g r n r u a n e e i f s d M n s / r i n T n n a o o O r a t o c t / r o e d T e T S n P M R e T Upper Extrem it y Peripheral Nerve Injuries 221 19 Upper Extremity Compartment Syndrome Blun t crush ing t raum a is th e m ost com m on cau se of upper ext rem it y com par t m en t syn drom e. Alth ough less com m on , com p ar t m en t syn drom e can also occu r in th e h an d an d ngers. W h en con fron t ing u pp er ext rem it y inju ries, it is im p or t an t to closely m on itor th e p at ien t s for t issu e isch em ia an d to correctly d iagn ose th ose w h o d evelop a t ru e com part m en t syn drom e. Delay in su rgical in ter ven t ion leads to devastat ing con sequ en ces. Com par t m en t syn drom e of th e u pper ext rem it y requ ires urgen t care du e to it s im m ediate sequ ela of m uscle isch em ia an d longterm sequela of Volkm an n isch em ic con t ract u re. Increased com partm ent content or decreased com partm ent size leads to increased com partm ent pressures that cause tissue ischem ia. Pay special attention to com partm ent pressures in cases of crush injury, severe soft tissue dam age, fractures, intravenous in ltration, injection injuries, arterial insu ciency, burns, snakebites, patients lying on the lim b, and tight casts or splints. Diagnosis Th e diagn osis of com p ar t m en t syn drom e is prim arily a clin ical on e. Th e pat ien t w ill h ave persisten t pain th at becom es w orse w ith p assive m u scle st retch ing (a h allm ark) or act ive exion . Th e pat ien t com plain s of dim in ish ed sen sat ion , m u scle w eakn ess, an d p ain on palpat ion of th e com par t m en t s. Th e p resen ce of p alp able p u lses or Dop p ler u lt rasou n d sign als does n ot exclu de in creased in t racom p ar t m en tal pressu res an d com par t m en t syn drom e. Cardinal Signs • Persisten t , progressive p ain u n relieved w ith im m obilizat ion an d elevat ion . • Pain w ith passive exten sion . – Passive m u scle st retch test . ▪ Forearm . ▫ Dorsal com par t m en t: Finger, th u m b, an d uln ar w rist exten sors—test w ith passive w rist exion . 222 ERRNVPHGLFRVRUJ Upper Ext rem it y Com part m ent Syndrom e 223 ▫ Mobile w ad: Exten sor carpi radialis longu s, exten sor carpi radialis brevis, brach ioradialis—test w ith p assive w rist exion . ▫ Volar com par t m en t: Flexors of th e ngers, th u m b, an d w rist—test by p assive exten sion of th e ngers, th um b, an d w rist . ▪ Han d. ▫ In t rin sic com par t m en ts: Keep MCP join t s in fu ll exten sion an d PIP join ts in exion . Pain w ith p assive abduct ion an d adduct ion of th e ngers is diagn ost ically sign i can t . ▫ Th um b addu ctor com part m en t: Pu ll an d abdu ct th e th um b. • Dim in ish ed sen sat ion . • Ten se, ten der forearm or h an d. Alth ough a cool, p ale, an d pu lseless ext rem it y is often described in com par t m en t syn drom e, th ese are con sid ered secon dar y sign s an d are often n ot presen t un t il late. Th eir absen ce sh ou ld n ot delay surger y if cardin al sign s are presen t . After 8 h ou rs, th e e ect s of m u scle/n er ve isch em ia are irreversible. Pressure Measurement Use a St r yker n eedle (Fig. 19.1) or ar terial lin e (Fig. 19.2) to m easu re com par t m en t pressure. Forearm com par t m en t pressures can be m easured in th e m obile w ad an d volar com par t m en t s w ith a St r yker n eedle: • Pressu re < 25 m m Hg: Norm al—clin ical obser vat ion ; if sit u at ion w orsen s, rep eat m easu rem en t s. • Pressu re 25 to 30 m m Hg: Su sp iciou s—obser vat ion w ith rep eat m easurem en t s ever y 2 h ou rs. • Norm otensive pat ients w ith posit ive clinical ndings and pressure >30 m m Hg for 8 hours: Diagn ost ic for com p ar t m en t syn drom e. • Altered m en tal stat u s an d p ressure > 30 m m Hg for ≤ 8 h ours: High ly su spiciou s for com p ar t m en t syn drom e. • Hypoten sive p at ien t s w ith com p ar t m en t p ressu re < 20 m m Hg below diastolic blood pressu re for ≤ 8 h ou rs: High ly su spiciou s for com par t m en t syn drom e. Fasciotomy Perform a fasciotom y w h en th e above sym ptom s are presen t or com part m en t p ressu res > 30 m m Hg or if com part m en t pressu res are w ith in 20 m m Hg of d iastolic p ressu res. Perform an im m ediate fasciotom y if (1) th e t im e of on set of sign s an d sym ptom s is u n kn ow n , or (2) t h e p at ien t is ERRNVPHGLFRVRUJ 224 Upper Extrem it y Com partm ent Syndrom e Fig. 19.1 Stryker m easurement of compartm ent pressure. Needle is placed in forearm compartm ent. Measure pressure of normal arm as control. Detailed instructions are on the back of the Stryker needle device. obt un ded or un con scious. A prophylact ic fasciotom y is perform ed if an ar terial inju r y w ith isch em ic t im e of 4 to 6 h ou rs exists. Han d com p ar t m en t pressu res are di cu lt to assess, an d m easu rem en t s of th ese pressures are often in accurate. Rely on a clin ical exam in at ion in m aking a d iagn osis of com part m en t syn drom e. Management Fasciotom y and release of the com partm ents is the only treatm ent for com partm ent syndrom e. Do not elevate an extrem it y that has not been decom pressed, because the decreased perfusion causes an increase in ischem ic dam age. Elevation of the extrem it y after decom pression is appropriate. • Num ber of com part m ents: 4 in forearm an d 10 in th e h an d. – Forearm : Volar super cial an d deep, d orsal, an d m obile w ad. – Hand: Dorsal in terossei × 4, volar in terossei × 3, hypoth en ar, th en ar, an d addu ctor pollicis. ERRNVPHGLFRVRUJ Upper Ext rem it y Com part m ent Syndrom e 225 Fig. 19.2 Measurem ent of compartment pressure with arterial line setup. Needle is placed into forearm compartm ent. Zero the pressure at the level where needle is placed prior to entering the compartm ent. Forearm Fasciotomy (Fig. 19.3, Fig. 19.4) Release the m edian nerve, the ulnar nerve, and all three volar com partm ents. Check m uscle bellies in super cial and deep volar com partm ents. Perform an epim ysiotom y if necessary. The incision is started bet ween the thenar and hypothenar em inences (sim ilar to a carpal tunnel incision). At the w rist crease, the incision is carried transversely in the exion crease directly to the Guyon canal, and the ulnar nerve is released. Avoid transecting the palm ar branch of the m edian nerve, and m ake straight incisions perpendicular to the w rist crease. Next, carry out the incision approxim ately 5 cm proxim al to the w rist crease on the ulnar side of the forearm to create a ap for m edian nerve coverage. Next, curve the incision radially. The incision should reach its radial apex approxim ately one-half to t wo-thirds of the way up the forearm . The incision is then m ade in the ulnar direction to ERRNVPHGLFRVRUJ 226 Upper Extrem it y Com partm ent Syndrom e a point just radial to the m edial epicondyle, w here it can be carried up to explore the brachial artery and avoids a straight incision across the antecubital fossa. The incision should be extended above the elbow w here the lacertus brosus is released. If m uscles appear necrotic, do not débride them , because the extent of the injuries cannot be determ ined at the tim e of initial fasciotom y. Cover the m edian nerve w ith the sm all w rist skin ap. The m obile wad is released at the apex of the radial portion of the incision. After release of the super cial volar com partm ent, the deep volar com partm ent m ust be released in an interval bet ween the sublim is tendons and the exor carpi radialis. This w ill prevent ischem ic contraction of the m uscles of the deep volar com partm ent. Release of the volar com partm ents signi cantly decreases the tension of the dorsal forearm . However, if signi cant tension in this area persists after com plete release of all volar com partm ents, an incision is m ade along the m idpoint of the dorsal com partm ent. Hand Fasciotomy Release the dorsal interossei, volar interossei, and adductor pollicis through incisions on the dorsum of the second and fourth m etacarpals (Fig. 19.3). On either side of the m etacarpal, release the interossei fascia and expose the m uscles. Next, release the rst volar interossei and the adductor pollicis, and Fig. 19.3 Rowland incision for forearm or hand fasciotomy. ERRNVPHGLFRVRUJ Upper Ext rem it y Com part m ent Syndrom e 227 Fig. 19.4 (a,b) Clinical evidence of compartm ent syndrome of the forearm and hand. (c,d) After release of the volar compartm ents of the forearm and the carpal tunnel, hypothenar, thenar, and dorsal compartments of the hand. spread w ith blunt tip scissors along the ulnar side of the second m etacarpal. In sim ilar fashion, release the second and third volar interosseous m uscles by spreading along the radial sides of the fourth and fth m etacarpal. Fin ally, release th e th en ar an d hypoth en ar com par t m en ts u sing longit udin al in cision s along th e radial side of th e rst an d th e u ln ar side of th e fth m etacarpal, respect ively. Digits In severe inju ries or bu rn s to th e digit s, on e p erform s a nger fasciotom y/esch arotom y. Use a m ida xial in cision along th e n on dom in an t side of th e nger. Th e m idaxial port ion of th e nger is m arked by rst exing th e nger. Next , a lin e is draw n th at in tercon n ects th e m ost dorsal ERRNVPHGLFRVRUJ 228 Upper Extrem it y Com partm ent Syndrom e aspect s of th e exion creases to each oth er an d to a poin t lateral to th e n ail plate. Th e n on dom in an t side of th e nger is usually th e uln ar side of th e in dex nger, long nger, an d ring nger. For th e th u m b an d lit tle nger, release via an in cision on th e radial side of th e digit . Th en , release th e exor ten don by dissect ing along th e volar side of th e exor ten don sh eath an d releasing all ver t ical con n ect ion s. Carr y ou t th e in cision across th e m idlin e at th e t ip of th e nger. Perioperative Medical Management Patients should be m onitored for crush syndrom e and the system ic sequela of m assive myonecrosis. This is done by analysis of serum potassium , creatine kinase, and m yoglobin. Additionally, renal protective strategies are warranted. These include bladder catheter drainage and aggressive hydration to ensure a urine output between 0.5 and 1 m L/kg/h. Additionally, assessm ent of the urine pH and myoglobin sho uld be done. In cases of signi cant myoglobinuria, the urine should be alkalized w ith acetazolam ide (250 m g by m outh every m orning or 5 m g/kg IV every 24 hours) and m annitol (50 to 100 g of 5% solution IV over 2 hours, repeat dose to m aintain urine output w ith a m axim um dose of 200 g/d). Serial assessm ent of serum K+, CK, and urine myoglobin param eters allow s one to follow the course of disease and dictates resolution of disease, as well as term ination of treatm ent. Postoperative Sp lin t th e w rist in exten sion , MCP join t s at 90 d egrees, th u m b in abd u ct ion , an d IP join t s at 180 degrees. Elevate th e ext rem it y after decom pression . No e or ts sh ould be m ade at skin closure; h ow ever, skin sh ould be loosely closed over exp osed n er ves an d ar teries. Dress op en areas w ith Xeroform or Adapt ic (Joh n son & Joh n son , In c.) gau ze follow ed w ith Kerlix an d a volar sp lin t . Elevate th e ext rem it y p ostoperat ively. Main t ain n eu rovascular ch ecks in a m on itored care un it to assess for adequate decom p ression . In severe cases, p lan for a secon d-look operat ion in 24 to 48 h ours to débride n ecrot ic t issu e. Close w ou n ds de n it ively by 10 days. If skin can n ot be closed, th en place sp lit-th ickn ess skin graft s or tem p orar y skin su bst it u tes on th e w ou n d. Prior to closu re, all n ecrot ic t issu e sh ou ld be débrided. Altern at ively, Silast ic vessel loops can be u sed to slow ly close th e w ou n d w ith t igh ten ing daily. ERRNVPHGLFRVRUJ 20 Postoperative Evaluation of Free Flap Reconstructions In addit ion to th e basic postop erat ive ap proach to any su rgical p at ien t , th e p at ien t w ith a free ap recon st ruct ion requires speci c at ten t ion to detect an d p reven t a p oten t ially com p rom ised ap. An im por t an t r u le of th u m b is to physically in spect a ap w h en th ere is any quest ion of a ch ange in st at u s. Un less you are ver y exp erien ced, a n y exa m in a t ion of a a p w it h a su spect ed ch a n ge in st a t u s sh ou ld be r epor t ed t o t h e a t t en din g su r geon r espon sible for t h e a p. Assessment Vital Signs Heart rate m on itoring is im por t an t for assessing p ain con t rol, in t ravascular volum e st at us, an d possible arrhyth m ias. In adequate pain con t rol is a frequ en t cause of t achycardia. Be su re to ask h ow com fortable th e pat ien t is an d assess w h eth er addit ion al pain m edicat ion is n eeded. Watch for bradycard ia, w h ich can resu lt from h ear t blocks or overu se of an t ihyp er ten sive m edicat ion s su ch as β-blockers an d an algesics. Most free ap pat ien t s w ill spen d th e rst n igh t in a m on itored care un it on telem et r y; th erefore, at ten t ion sh ou ld be paid to t h e t racing to r u le ou t at rial brillat ion , u t ter, or oth er arrhyth m ias. It is im port an t to con t rol th ese arrhyth m ias, n ot on ly for th e safet y of th e p at ien t , bu t to m ain t ain th e viabilit y of th e ap. Sudden u ct u at ion s in blood pressure can lead to t u rbu len t ow across th e m icrovascular an astom osis or w ith in th e ap, w h ich cou ld lead to com p rom ised perfu sion of th e ap. Blood pressure sh ould be m on itored ver y closely in th e postoperat ive period. Most free ap pat ien t s sh ould h ave a MAP > 90 an d SBP > 120. Of p aram ou n t im p ortan ce is keeping th e pat ien t from becom ing hyp oten sive. Hypote nsio n can result in recipient artery spasm s and veno us stasis that can lead to thro m bosis. Du e to th e p rolonged su rger y, in sen sible losses, an d postoperat ive th ird spacing, free ap pat ien ts are u su ally in t ravascu larly depleted an d often requ ire u id su pplem en tat ion in th e acute postoperat ive period. In t ravascular u id st at us is m ost accurately rep resen ted by th e p at ien t’s u rin e out pu t . Free ap patients sho uld pro duce at least 0.5 m L/kg/h o f urine (35 m L/h fo r a 70-kg patient), but preferably 50 to 100 m L/h. Pat ien t s suspected to 229 ERRNVPHGLFRVRUJ 230 Postoperative Evaluation of Free Flap Reconst ructions be in t ravascularly depleted sh ould receive LR or n orm al salin e boluses. After th e rst 24 h ours, D5 1/2NS at m ain ten an ce rate is used for th e st able pat ien t . Patients should n ever receive diuretics to induce urin e output unless there are clear sign s of renal com prom ise in a w ell-hydrated patien t. Likew ise, avoid use of pressors to treat hypotension. Pressors should be a last resort and only used w hen absolutely necessary (profound hypotension). Hyper ten sion (> 180/100) can lead to bleeding in a fresh postop erat ive p at ien t . Elevated blood p ressu re is m ost com m on ly a sign of in adequ ate p ain con t rol. Ext rem es in hyperten sion un respon sive to an algesics sh ould be m an aged w ith low -dose an t ihyper ten sives (hydralazin e 10 m g IV, or labet alol 5 to 10 m g IV as n eeded) to preven t rapid decreases in th e MAP th at can u lt im ately be det rim en tal to a ap. Oxygenation should also be assessed w ith a pulse oxim eter to keep the blood oxygen sat uration > 93%. In replan ts, th e oxim eter is a useful tool for m onitoring the replanted digit. W hen the sen sor is placed on th e reattached part, loss of the sign al indicates arterial com prom ise, w hereas progressively declining saturations are suggestive of venous congestion. Hypoth erm ia is avoided to preven t vasospasm . Th e pat ien t’s room sh ould be kept above 70°F (21°C), w ith h eat ing u n its, lam p s, or Bair Hugger w arm ers (Arizan t Health care) u sed liberally if th e room tem perat ure can n ot be adequ ately con t rolled. Drain out put sh ould be closely m on itored. Alth ough drain age m ay be h igh in th e im m ediate postoperat ive period due to expected oozing, a drop in out put follow ed by a sustain ed in crease m ay be in dicat ive of ven ou s th rom bosis. Exten sive drain age sh ould prom pt im m ediate evaluat ion of th e ap. Clinical Observation Alt h ough re n em en t of m icrovascu lar tech n iqu es h as brough t failu re rates dow n , it is th e early recognitio n o f ap co m pro m ise fo llow e d by im m ediate surge ry that prevents total ap lo ss. Always notify the attending surgeon of any potential ap com prom ise and keep the patient NPO in case there is any need for operative exploration. In assessing a ap, good clin ical obser vat ion tech n iques are essen t ial. To begin , alw ays turn o n all the lights in th e pat ien t’s room an d evaluate th e ap’s gen eral appearan ce. Healthy aps sh ould be pin k, w arm , an d soft w ith a capillar y re ll of ap proxim ately 2 secon ds (Fig. 20.1). Any oth er ap p earan ce is w orrisom e (Table 20.1). Fig. 20.2 dem on st rates a congested free ap. Note th at pedicled aps are often congested postoperat ively; th is usually resolves w ith t im e (Fig. 20.3). A sign of ar terial ERRNVPHGLFRVRUJ Postoperative Evaluation of Free Flap Reconstructions 231 Table 20.1 Important clinical signs that di erentiate arterial versus venous problem s while m onitoring a ap Arterial Venous Color Pale, white Blue, purple Capillary re ll Sluggish (> 2 s) Brisk (< 2 s) Tissue turgor Prunelike Tense, swollen Dermal bleeding Scant Rapid dark oozing Temperature Cool Cool Doppler Absent Can still be present com prom ise is a pale ap th at is cool, w ith poor t issue t urgor. Ch eck to see if th e ap blan ch es an d for capillar y re ll (2 secon ds). If an in ow problem is su spected, an 18- or 20-gauge n eedle can be u sed to prick or scratch th e ap to assess for bleeding. Ch eck dist ally an d proxim ally, bu t avoid th e p edicle. Alw ays ap p roach th e ap at a sh allow angle to avoid deeper vascu lar st r u ct u res. Sign s of poor ven ou s ou t ow are a ten se ap w ith in creased t urgor pressure an d purple color; th e ap can be w arm or cool (Fig. 20.4). Th e ap w ill usually be oozing aroun d th e edges w ith ven ous blood, an d if th e ap blan ch es, th e capillar y re ll is u su ally brisk. A pinprick to th e ap w ill also resu lt in ven ou s dark bleed ing. Doppler Signal Doppler is used to m easure th e velocit y an d rate of blood ow th rough a vessel. Norm al ow dyn am ics sh ould possess th ree dist in ct audible ph ases. Th e rst ph ase is h eard du ring systole w it h th e for w ard ow of blood disten ding th e vessels. Early diastole rep resen t s th e secon d ph ase, w h ere th e elast ic vessel rebou n ds an d th ere is a m om en t ar y reversal of ow. Th e last ph ase is associated w ith late diastole an d at rial con t ract ion , w h en th ere is on ce again a for w ard ow. Th erefore, any Doppler sign al can be described as being m on oph asic, biph asic, or t rip h asic. Sou n ds sh ou ld be clear an d dist in ct . Triph asic sign als are w h at on e exp ect s in a h ealthy ap. In th e early postoperat ive period, th e sign al is often in it ially bip h asic, rep resen t ing th e fact th at th e ap h as been cold an d isch em ic for a period of t im e. As th e ap w arm s an d p erfu ses, th e th ird ph ase w ill becom e au d ible. A m o no phasic o r “jackham m er” type o f so und is indicative o f veno us o cclusio n. Any ERRNVPHGLFRVRUJ 232 Postoperative Evaluation of Free Flap Reconst ructions Fig. 20.1 (a) A norm al m uscle ap with a skin graft. (b) A congested m uscle ap. Fig. 20.2 Fasciocutaneous ap congestion. (a) Early congestion. (b) Moderate congestion. (c) Late congestion. ERRNVPHGLFRVRUJ Postoperative Evaluation of Free Flap Reconstructions 233 Fig. 20.3 (a) A congested pedicle paramedian forehead ap. (b) A congested pedicle TRAM ap. Fig. 20.4 (a) An ischem ic DIEAP ap. (b) A congested DIEAP ap. ERRNVPHGLFRVRUJ 234 Postoperative Evaluation of Free Flap Reconst ructions ch ange in th e sign al sh ou ld p rom pt a ver y carefu l exam in at ion of th e ap stat us. Th e bat teries of th e Dop pler device sh ould also be ch ecked. Im plan t able Dop pler devices are u su ally used w ith bu ried free aps, w ith w h ich th ere is n o skin p addle to m on itor extern ally. Th e Doppler cu can be placed on th e ar terial or ven ou s p edicle, bu t is m ore frequ en tly placed on th e vein . Th is is becau se ven ou s com p rom ise is m ore com m on an d becau se an ar terial sign al can st ill be t ran sm it ted even in cases of com p lete th rom bosis. A loss of sign al is m ost frequ en tly du e to disp lacem en t of th e cu ; h ow ever, a clin ical exam sh ould st ill be un dertaken to assess th e t ru e stat u s of th e ap. Recent advances in free ap m onitoring have resulted in the venous ow coupler by Synovis (Fig. 20.5). The m onitoring device is incorporated into the already popular venous coupler and elim inates the need for w ire placem ent onto the vessels. The ow coupler allow s for easy m onitoring w ith a soft exible w ire, sim ilar to the Cook im plantable Doppler, and yields the sam e inform ation. The venous out ow can be continuously m onitored w ith less failure due to positional changes because of the integrated design. Ven ous oxygen t issu e sat urat ion m on itoring (ViOpt ix) is often em ployed on aps w ith skin paddles. A t ran scutan eou s m on itor is placed on th e ap skin , an d th rough ber opt ics, th e m on itoring device m easures th e t issue ven ou s sat u rat ion . • Th e m on itor h as t w o in dicators (Fig. 20.6): – Sign al qu alit y. – Ven ou s sat u rat ion . The signal quality m ust be above 80 to accurately assess the venous saturation. The signal qualit y is related to the contact the transcutaneous m onitor has w ith the skin. If there is poor contact or a barrier bet ween the skin and the sensor (blood, Doppler gel), then this m ay cause the signal qualit y to be low and lead to inaccurate readings of the oxygen saturation. The venous oxygen saturation curve of a healthy ap should be a constant ap line w ith m inim al uctuations. Venous oxygen saturation levels above 30% are acceptable. Levels that are below 30%indicate poor perfusion. Large uctuations in saturation over short periods of tim e m ay indicate arterial spasm or kinking of the pedicle. Dow nward-trending saturations w ith changes > 20%in an hour m ay represent im pending ap com prom ise due to venous congestion, caused by either throm bosis of the venous anastom osis or progressive throm bosis of the pedicle or arterial anastom osis. Th e ven ou s oxygen t issu e sat u rat ion is also a ected by system ic factors in clu ding blood pressu re, h em oglobin level, an d oxygen sat urat ion . Th erefore, in terpret at ion of th e ven ou s oxygen sat u rat ion of t h e ap m ust take in to a ccoun t th e overall con dit ion of th e pat ien t . ERRNVPHGLFRVRUJ Postoperative Evaluation of Free Flap Reconstructions 235 Fig. 20.5 Flow Coupler device. (a) a Doppler probe is integrated into the venous coupler that is used to create a venous anastom osis. (b) After completion of the venous anastomosis, the exible wire is directly at tached to an external monitoring device. Fig. 20.6 ViOptix ap monitoring. Venous oxygen saturation curves of t wo free aps (bilateral breast). Signal qualit y m ust be above 80 to ensure accurate reading. A healthy ap should have a venous oxygen saturation that is steady and above 30%. ERRNVPHGLFRVRUJ 236 Postoperative Evaluation of Free Flap Reconst ructions Preventive and Salvage Techniques Local factors possibly com prom ising th e ered in it ially. ap sh ould alw ays be con sid- • Loosen all con st rict ive dressings to avoid any u n n ecessar y pressu re or com pression on th e ap (rem ove su t u res im m ediately if th ey appear to p lace u n du e ten sion on th e ap). Su t u res can be rem oved to h elp evacuate a h em atom a, or to relieve p ostop erat ive edem a an d congest ion a ect ing ap perfu sion . • St rip all drain s to relieve clot s th at m ay preven t evacu at ion of a h em atom a. • Reposit ion th e pat ien t to correct any p oten t ial kin king or com pression of th e p edicle. Th is m ay som et im es lead to im m ediate ap viabilit y an d relief of com prom ised in ow or ou t ow. • Elevate ext rem it ies w h en possible to preven t in adequate ven ous drain age from th e lim b an d to redu ce postop erat ive edem a, both of w h ich can lead to tam pon ade (ext rem it y free ap s an d rep lan ts). Anticoagulation Leech th erapy is usually used in digital replan t s or w ith m ildly congested free aps (Fig. 20.7). Leech es secrete th e pept ide h irudin in th eir saliva, w h ich cau ses th e ap to bleed. Th ey can salvage a ap by relieving con gest ion . Leech es at t ach for approxim ately 30 m in utes an d act ively suck blood from th e ap. After th ey fall o , th e bite w ou n d con t in u es to ooze du e to th e h iru din , w h ich accou n ts for m ost of th e blood loss. W h en using leech es, th e w ou n d is m ore su scept ible to aerom onus hydrophila species an d prophylact ic an t ibiot ics (Bact rim DS by m outh t w ice a day or cipro oxacin 500 m g by m outh or IV t w ice a day) sh ou ld be ut ilized. If th e leech es d o n ot adh ere, a 20-gauge n eed le can be u sed to in it iate bleeding from th e ap. Th is sh ould facilitate leech feeding. After on e feeding, leech es are usually sacri ced. Leech es can be obt ain ed from th e ph arm acy or from oth er local h ospit als, or th ey can be em ergen cy delivered from Leech es USA Ltd. (teleph on e 800-645-3569). Alth ough leech es m ay relieve m ild congest ion tem porarily, a free ap th at is con gested sh ou ld ret urn to th e OR for evaluat ion of th e ven ous an astom osis. Heparin is usu ally n ot u sed p ostop erat ively, bu t it can be in dicated for som e replan t s an d an astom ot ic revision s. Full h eparin izat ion in th e im m ediate postoperat ive p eriod is associated w ith a fairly h igh rate of sign i can t bleeding. In com p rom ised aps, a h eparin bolu s of 3,000 to 5,000 U can be h elpful in preven t ing propagat ion of a clot w h ile a pat ien t w ith a com p rom ised ap is being p repared for th e operat ing room . Depen ding on surgeon preferen ce, 10%dext ran can be rout in ely used postoperat ively. It n ot on ly acts as a volu m e exp an der, bu t also h as an t i- ERRNVPHGLFRVRUJ Postoperative Evaluation of Free Flap Reconstructions 237 Fig. 20.7 (a) Leech therapy for a congested ap. (b) A medicinal leech (Hirudo medicinalis). (c) Use of a cut syringe for placement of the leech in the desired position. platelet prop er t ies. A 5-m L test dose is u su ally given , an d th en em p irical th erapy is st ar ted at 25 m L/p er h ou r per day for 3 to 5 days or 40 m L/h x 12 h ours for 3 to 5 days. Side e ect s in clu de congest ive h eart failu re, volum e overload, ren al toxicit y, an d allergic react ion s. Th e u se of th rom bolyt ics h as been e ect ive in laborator y protocols; h ow ever, th eir results in th e clin ical set t ing h ave been m ixed an d con t roversial. Th ey h ave been described as being e ect ive in aps w ith ven ous com prom ise in lysing th rom bus w ith in th e ap. St reptokin ase (500,000 to 750,000 U) or 2 to 4 m g of TPA is in fu sed in to th e ar terial p edicle on ce th e vein h as been cu t to preven t system ic adm in ist rat ion . Salvage rates can approach 50 to 75%if p roblem s are diagn osed early. Th e evaluator m ust be ast ute w h en assessing th e free ap an d keep in m in d all th e poten t ial causes of ap failu re (th rom bosis, in t im al ap, back w alled an astom osis, kin ked p edicle, t igh t skin closu re, edem a, h em atom a, extern al pressu re, vasosp asm , hypoth erm ia, hypovolem ia). On e sh ould n ot w ait u n t il th e ap is pu rplish blu e an d cold an d h as n o Doppler sign al. At th at t im e, th e ap is likely beyon d salvage. Alw ays con sult w ith th e at ten ding surgeon or a surgeon of sen ior experien ce after a t h orough exam in at ion of th e ap an d be p repared to ret u rn th e pat ien t to th e operat ing room if n ecessar y. ERRNVPHGLFRVRUJ 21 The Postoperative Aesthetic Patient Postoperat ive evaluat ion of th e cosm et ic su rger y p at ien t involves evalu at ion for early sign s of com plicat ion s, p at ien t’s com for t level, qu est ion s, an d desires. Alw ays ch eck th e pat ien t’s vital sign s. A h igh h ear t rate, low blood pressure, an d decreased u rin e out put can h erald an im pen ding com plicat ion . In addit ion , ign oring h igh blood p ressu re du e to p ain can resu lt in a h em atom a form at ion . Hem atom a form at ion n ot on ly m ay lead to life-th reaten ing an em ia, bu t also w ill com p rom ise skin aps an d m ay lead to fun ct ion al m orbidit y. Ask th e pat ien t if th ere is a di eren ce in th e p ain w ith resp ect to lateralit y. Th is can often in dicate a h em atom a or in fect ion . W h en th ere is an in dicat ion of ch ange, excessive pain , or any oth er con cern s, dressings sh ou ld be rem oved an d th e w oun ds ch ecked (alw ays rem ove dressings of pat ien t s w h o h ave h ad an otoplast y an d com plain of asym m et ric severe pain ). Assessin g t h e pa t ien t a ccu r a t ely a n d pr oposin g a con cise a n d a ppr opr ia t e pla n to t h e pr im a r y su r geon sh ou ld be don e pr ior to a n y in t er ven t ion . Abdominoplasty Considerations • Ch eck vital sign s for h igh or low blood p ressu re, p ulse oxim et r y, an d h ear t rate. • Jackson -Prat t (JP) drain’s ou t pu t . – If th e JP drain ou t p ut is h igh an d bloody an d does n ot t urn serou s, con sider a h em atom a. • Bew are of low drain ou t p u t an d en larging/p ain ful m asses u n der th e abdom in al skin ap s. Con sider a h em atom a. Th e drain m ay be clot ted. A clot in th e drain , low p ressu re, low u rin e out pu t an d tachycardia are con sisten t w ith a h em atom a an d p oten t ially ongoing bleeding. • Keep pat ien t in “law n ch air” or exed p osit ion . – Pu t a sign above th e p at ien t’s bed to aler t caregivers abou t th e desired p osit ion . – Unplug th e bed con t rols. • In cen t ive sp irom et r y. – Reduce atelectasis. 238 ERRNVPHGLFRVRUJ The Postoperative Aesthetic Pat ient 239 • Get pat ien t ou t of bed (OOB) w ith w alker ± physical th erapy postop erat ive day (POD) 1. – Use sequ en t ial com pressive devices on th e low er ext rem it ies. – Con sider start ing ph arm acologic DVT prophyla xis—Loven ox (Aven t is Ph arm aceut icals) 40 m g SC daily or SC h ep arin 5,000 U t w ice a day. • Abdom in al bin der w ill assist w ith pat ien t com for t , as w ill par t icip at ing in act ivit y. – Caut ion —excessively t igh t bin ders an d garm en ts can cau se pressure n ecrosis an d isch em ia-related ch anges to th e abdom in al skin ap . Th erefore, con sider p eriods of garm en t relief, especially w h en th e pat ien t is rest ing. • Um bilicu s viabilit y. – Sm all areas of delayed w ou n d h ealing w ill even t u ally h eal th rough secon dar y in ten t ion . – Keep th e um bilicu s clean . Hematoma • Diagn osis. – Asym m et ric p ain or asym m et ric bu lging of in cision /abdom en . – In creasing h ear t rate, decreasing BP, decreasing u rin e ou t p ut , h igh drain ou t put , or clots in th e drain . – Dropp ing h em ogram . • Treat m en t . – St rip drain s and ch eck serial hem oglobin and hem atocrit (every 6 hours). – Bolu s uids (NS 500 m L) an d in crease u id rate app rop riately (bew are of p at ien t s w ith cardiac h istor y—overresuscit at ion could cause p ulm on ar y edem a an d h ear t failure). – Hold all an t icoagu lan t s. – Crossm atch blood t yp e an d h old PRBCs in p reparat ion for t ran sfu sion . – Prepare for exp lorat ion in th e operat ing room . Respiratory Distress Pulmonary Embolus • Diagn osis. • Clin ical sign s an d sym ptom s—dyspn ea, pleu rit ic pain , hypoxia, t achycardia, h em opt ysis, or th op n ea, JVD. ERRNVPHGLFRVRUJ 240 The Postoperative Aesthet ic Patient • • • • • – Ar terial blood gasses (ABGs). ▪ Look for hypoxem ia, hypercap n ia, an d respirator y alkalosis. ▪ High probabilit y w h en low PaO2 an d dyspn ea. Elevated D-dim er. ECG ch anges—AFib, RBBB, Q w aves in lead s II, III, an d aVF. Orde r a CT scan o f the chest, pulm o nary e m bo lism proto co l. Ch eck for calf pain an d sw elling—if DVT is su sp ected, th en request a duplex u lt rasou n d. Treat m en t . – If you h ave a ver y h igh su sp icion of pu lm on ar y em bolism , th en st ar t h eparin drip , – St ar t p at ien t on h ep arin or Loven ox, ▪ Heparin —load w ith 80 U/kg bolus an d th en 18 U/kg/h in fu sion ; ch eck PTT ever y 6 h ou rs an d keep PTT bet w een 60 an d 90. ▪ Loven ox 1 m g/kg ever y 12 h ou rs SC (Loven ox h as a longer h alflife th an h ep arin ). Hem odyn am ically u n st able p at ien ts sh ou ld be t ran sferred to th e ICU an d m ay requ ire su ppor t for circu lator y collapse. Pulmonary Edema • Diagn osis. • Dyspn ea, hypoxia, w h eezes an d crackles in au scu lt at ion , palpit at ion s, an xiet y. • Histor y of volum e overload, lar yngosp asm , or h ear t failu re. – CXR—bilateral in lt rates. – Ch eck CVP if available; if above ap proxim ately 12, p at ien t is volu m e overloaded. • Treat m en t . • Apply su pplem en tal oxygen . – St ar t Lasix (Aven t is Ph arm aceu t icals) 20 m g IV. – Ch eck u rin e ou t p u t to keep in t akes/ou t p u ts (I/Os) n egat ive. – Redose Lasix as n eed ed. – Mon itor elect rolytes. Flash pulm on ar y edem a or n egat ive pressure pu lm on ar y edem a m ay resu lt in acu te global pulm on ar y com p rom ise th at m ay requ ire pressu re sup port ven t ilat ion or in t u bat ion an d m ech an ical ven t ilat ion . ERRNVPHGLFRVRUJ The Postoperative Aesthetic Pat ient 241 Overaggressive Plication • Pulm on ar y dysfun ct ion —decreases in fu n ct ion al residual capacit y. – Sign i can t in pat ien t s w ith a h istor y of asth m a or COPD. – Treat m en t . ▪ First em ploy con ser vat ive m an agem en t by ch anging th e p at ien t’s posit ion an d by resp irator y care to in clu de in cen t ive sp irom et r y an d bron ch odilators. ▪ Explorat ion in th e op erat ing room . • Abdom in al com p ar t m en t syn drom e (ACS)—in creased in t raabdom in al pressure leading to organ dysfu n ct ion . Th is m ay be exacerbated by overresu scitat ion . – Diagn osis. ▪ Hypoxem ia, dysp n ea, low u rin e ou t p ut , in creased abdom in al disten t ion , an d p ain . ▪ Measu re in t ra-abdom in al p ressu re—a bladder pressu re > 20 m m Hg m ay in dicate ACS. – Treat m en t . ▪ Lim it uid adm in ist rat ion , u se colloid resu scit at ion if n ecessar y. ▪ Nasogast ric decom pression . ▪ Plan for the possibilit y of surgical decom pression in the operating room . Dehiscence Small area • Rein force th e n on deh isced areas w ith Steri-St rip s. • Su p er cial sm all areas can be acu tely repaired w ith sim ple su t ure tech n iqu es (3–0 or 4–0 nylon ). • Deeper areas of delayed w ou n d h ealing w ill require local w oun d care w ith w et to dr y dressing ch anges an d fut u re revision . Large Area • Operat ing room débridem en t an d closure or vacu u m -assisted closure th erapy an d tert iar y closu re. ERRNVPHGLFRVRUJ 242 The Postoperative Aesthet ic Patient Breast Augmentation Hematoma (Fig. 21.1) • Diagn osis. – Un ilateral p ain , sw elling, br u ising, an d occasion al fever. – Ult rasoun d m ay be h elp fu l in pat ien ts w h o are obese or h ave large n at ive p aren chym al volu m es. • Treat m en t . – St rip drain s if p resen t . – Discon t in u e an t icoagu lan ts an d an t iplatelet th erapy. – Sm all h em atom as—obser ve if th e p at ien t is asym ptom at ic. ▪ App ly circu m feren t ial com pressive w rap or garm en t . – Large h em atom as—evacu at ion in an operat ing room . Infection • Usual p resen t at ion is POD 5 to 10. • Assess pat ien t for eith er su per cial skin or deep im p lan t in fect ion . • Diagn osis. – Leu kocytosis. – Warm th , er yth em a, an d edem a of th e breast or in cision s. – Ru le ou t periprosth et ic in fect ion . • Order u lt rasoun d/CT. – Look for u id collect ion or st ran ding/in am m at ion aroun d im plan t . • Treat m en t . – Su per cial. ▪ Cellulit is can be t reated w ith an t ibiot ics. ▪ Mild cases can be t reated as an ou t p at ien t w ith oral an t ibiot ics. ▫ Min ocyclin e 100 m g by m ou th t w ice a day or clin dam ycin 300 m g by m ou th fou r t im es a day. ▪ More severe m an ifest at ion s or failure of ou t p at ien t th erapy w ill requ ire IV an t ibiot ics. ▫ Clin dam ycin 900 m g IV ever y 8 h ou rs or van com ycin 1 g IV ever y 12 h ou rs + cefep im e 1 g IV ever y 12 h ou rs for severe in fect ion s; also con sider an t ibiot ic th erapy w ith equ al oral or IV bioavailabilit y (e.g., lin ezolid, Levaqu in , an d m oxi oxacin ). ERRNVPHGLFRVRUJ The Postoperative Aesthetic Pat ient 243 Fig. 21.1 Right breast hem atom a after breast augmentation. ERRNVPHGLFRVRUJ 244 The Postoperative Aesthet ic Patient – Exp osed im p lan t . ▪ Min or con tam in at ion w ith ou t in fect ion . ▪ IV an t ibiot ics. ▪ Local w ou n d care—Bet adin e pain t . ▪ Plan for explan tat ion w ith device ch ange. ▪ Capsu lectom y an d pocket débridem en t . ▪ ± Site ch ange or ap coverage in recon st ru ct ion cases. – In fected im p lan t . ▪ With eviden ce of p erip rosth et ic u id collect ion an d react ion , st ar t IV an t ibiot ics. ▫ Plan for explan tat ion an d rem oval of con tam in ated prosth esis. ▫ Capsu lectom y an d irrigat ion . ▫ In t raoperat ive evalu at ion of th e pocket . * In m ild cases, th e n ew prosth esis can be placed w ith a drain . * In severe cases, close th e w ou n d over a drain an d delay im plan t placem en t for 3 to 6 m on th s. * In st it ute an exten ded cou rse of cu lt u re-sp eci c an t ibiot ics postop erat ively. Rhinoplasty Airw ay Obstruction • Nasal packing or in t ran asal splin t aspirat ion . – Evaluate th e n asal an d oral air w ays an d clear p oten t ial obstacles to air m ovem en t . • Assess for aspirat ion of blood cau sing lar yngosp asm s. – Prepare for air w ay p rotect ive m easu res, su ct ion , oxygen supplem en tat ion , an d p ossible in t u bat ion . Visual Impairment • Vasospasm from local an esth et ic vasocon st rict ion . • Th rom boem bolism cau sing oph th alm ic ar ter y isch em ia. • Treat m en t . – Urgen t oph th alm ology con su lt . ERRNVPHGLFRVRUJ The Postoperative Aesthetic Pat ient 245 Hemorrhage • Localize sou rce. • Treat m en t . – Packing. ▪ Gau ze. ▪ Surgicel. – En doscop ic cauterizat ion . – If all else fails: Posterior n asal p acking (see Ch apter 6, Fig. 6.4b). Septal Hematoma • Treat m en t . – Asp irat ion . – In cision , drain age, an d p acking. – An t ibiot ic coverage to preven t septal abscess, – Augm en t in 875 m g by m outh t w ice a day. Infection Local • Cellu lit is. • Abscess. • Treat m en t . – Augm en t in 875 m g by m outh t w ice a day. Toxic Shock from Nasal Packing • Postoperat ive fever, vom it ing, diarrh ea, hypoten sion w ith out obviou s blood loss, an d an er yth em atou s sun bu rn like rash . • Th e sup er toxin toxic sh ock syn drom e toxin -1 (TSST-1), produ ced by th e organ ism S. aureus, cau ses th is syn drom e. • Treat m en t . – Rem oval of n asal packing an d acquisit ion of n asal cult u res. – Ap propriate β-lactam ase-resistan t an t istaphylococcal IV an t ibiot ics. ▪ Un asyn 3 g IV ever y 6 h ou rs. – Aggressive h em odyn am ic resu scitat ion . ERRNVPHGLFRVRUJ 246 The Postoperative Aesthet ic Patient Intracranial Infections • • • • Men ingit is. Su bdural em pyem a. Cerebral abscess. Cavern ou s sin u s th rom bosis. – Diagn ose w ith CT an d t reat w ith broad-sp ect ru m an t ibiot ics. • Acu te an d/or ch ron ic sin usit is. – Treat w ith Augm en t in 875 m g by m ou th t w ice a day. Neurosu rger y Con sult Edema • Treat m en t . – Head elevat ion . – Cold com presses. – Blood p ressu re con t rol. Blepharoplasty Retrobulbar Hemorrhage • Pain , proptosis, oph th alm op legia, ± blin dn ess (see Ch apter 6, Fig. 6.6). • Treat m en t . – If pat ien t h as visu al ch anges. ▪ At bed side, open su t u res an d perform lateral can th otom y em ergen tly. ▪ Decadron (Merck & Co., In c.) 10 m g IV. ▪ Plan im m e diate explo ratio n in the o perating ro o m . – If pat ien t does n ot h ave visu al ch anges. ▪ Plan im m ediate explorat ion in an op erat ing room . ▪ Steroids con t roversial. – Con t rol hyper ten sion . – IV 20% m an n itol (1 g/kg) an d acetazolam ide (500 m g IV in it ially, th en 250 m g IV ever y 6 h ou rs) can be u sed to d ecrease th e in t raocu lar pressu re. – If access to th e operat ing room is delayed an d pat ien t star t s to lose visu al acuit y, th en lateral can th otom y an d can th olysis m ay be perform ed at bedsid e (Fig. 6.6). ERRNVPHGLFRVRUJ The Postoperative Aesthetic Pat ient 247 Corneal Abrasion • Diagn osis. – Pain , tearing, an d sen sat ion of foreign body in eye. – Diagn osis w ith slit lam p by oph th alm ologist . • Treat m en t . – Ru le ou t a foreign body. – Ma xit rol (Alcon Laboratories) eyedrops. – Lacri-Lu be (Allergan , In c.). – Op h th alm ic bacit racin oin t m en t . – Resolves in 24-48 h ou rs. – Pressure dressing w ith eye closed for 24 h ou rs. Edema • Treat m en t . – Elevat ion of h ead. – Sw iss Th erapy eye m ask (Invotec) (cold com p ress). Rhytidectomy Hematoma • Most com m on com p licat ion , usu ally resu lt ing from h igh systolic blood p ressu re, aspirin or n on steroidal an t i-in am m ator y dr ug (NSAID) in take, or n au sea an d vom it ing. • Sym ptom s. – Pain , agit at ion , hyper ten sion , n eck/facial sw elling, bu ccal m ucosa ecchym osis, an d skin ecchym osis. – Can lead to skin n ecrosis. – May p resen t w ith respiratory distress w h en th e n eck is involved from pressure on th e air w ay. • Treat m en t . – Large h em atom as. ▪ Require im m ediate su rgical drain age in th e OR to avoid ap n ecrosis an d extern al air w ay obst r u ct ion . – Sm all h em atom as. ▪ Evacuate at bedside by exp ression or serial n eedle aspirat ion s an d pressu re dressing. – Con t rol blood pressu re. ERRNVPHGLFRVRUJ 248 The Postoperative Aesthet ic Patient Nerve Injury • Assess th e pat ien t’s facial sym m et r y by asking h im or h er to raise eyebrow s, sm ile, an d pu cker lip s. • Most m otor n er ve p aralysis in th e acu te p ostop erat ive pat ien t is du e to local an esth et ic e ect , excessive t ract ion of th e su per cial m uscu loapon eurot ic system (SMAS), in fect ion , or h em atom a. • Th e m ost com m on n er ve injured is great au ricu lar n er ve—provides sen sat ion to th e in ferior ear an d ear lobu le. • Th e m ost com m on m otor n er ve inju r y is to th e bu ccal bran ch of th e facial n er ve. • Treat m en t . – Ner ve paralysis im m ed iately after surger y sh ou ld be t reated w ith obser vat ion . Not ify th e su rgeon of sp eci c p hysical n dings to h elp determ in e th e origin /t reat m en t of th e facial n er ve paralysis. Skin Flap Necrosis • May rst presen t as cyan osis or congest ion th at m ay be reversible. • Assess for h em atom as, serom as, or in fect ion an d t reat app rop riately. • Par t ial skin ap n ecrosis. – Ap ply m oist gau ze or an t ibiot ic oin t m en t . – Treat fu ll-th ickn ess inju r y w ith con ser vat ive débrid em en t an d h ealing by secon dar y in ten t ion . • If pat ien t presen ts w ith skin u lcers arou n d th e m ou th , th is m ay in dicate a h erp es ou tbreak an d th e p at ien t sh ou ld be star ted on Valt rex (GlaxoSm ith Klin e) 500 m g t w ice a day. Liposuction Fluid Balances • Large volu m e liposu ct ion (> 4 L) can h ave large u id sh ifts. – Mon itor urin e ou t p ut closely w ith Foley cath eter – Calcu late u id balan ce in term s of total in an d ou t du ring th e procedu re. ▪ Inp ut = IVF + w et t ing solu t ion . ▪ Ou t p u t = aspirate + u rin e ou t pu t . • Fluid replacem en t . – Sm all volum e < 2,500 m L aspirate. ▪ Main ten an ce IVFs on ly. ERRNVPHGLFRVRUJ The Postoperative Aesthetic Pat ient 249 – Larger volu m e > 2,500 m L aspirate. ▪ Flu id rep lacem en t gu idelin e below. • Gen eral gu idelin e for u id replacem en t . – Tot al IVF su pplem en t (m L). ▪ Perioperat ive IVFs + p ostop IVFs + w et t ing solu t ion = 2× aspirate (m L). ▪ Postop uid replacem en t = 2×aspirate – [p erioperat ive uid + w et t ing solu t ion ]. – Tit rate to urin e ou t p u t . – Aggressive hydrat ion w ill cau se a hyp er volem ic st ate an d su bsequen t cardiopu lm on ar y m orbid it y. Blood Loss • Blood loss is calcu lated based on th e w et t ing tech n iqu e (Table 21.1). Hematomas/Seromas • Treat w ith com p ression garm en ts. • Con sider fu rth er padding w ith foam or bu lky su rgical dressings. – Large u id collect ion s th at cau se excessive skin ten sion an d isch em ia requ iring op erat ive in ter ven t ion . • Serom as m ay be aspirated at th e bedside or u n der u lt rasou n d gu idan ce. – Con sider p ercu tan eou s placem en t of a cath eter for large or recurren t serom as. ▪ Ult rasou n d guided w ith assistan ce of in ter ven t ion al radiology. ▪ Seldinger placem en t of a serom a cath eter (Serom aCath [Greer Medical, In c.]) (Fig. 21.2). Table 21.1 Wet ting technique to calculate blood loss Technique In ltrate EBL Dry None 20–40% Wet 200–300 mL/area 8–20% Superwet 1 m L in ltrate: 1 m L aspirate 1% Tum escent 2–3 mL in ltrate: 1 m L aspirate 1% Abbreviation: EBL, estim ated blood loss. ERRNVPHGLFRVRUJ 250 The Postoperative Aesthet ic Patient Fig. 21.2 Serom a catheter. A serom a catheter can be placed, using the Seldinger technique, into the suspected cavit y and connected to an active suction device (bulb suction). Lidocaine Toxicity Recom m en ded dose w h en u sed at 0.05%= 35 m g/kg in w et t ing solu t ion . • Diagn osis. – Circu m oral n u m bn ess. – Metallic taste. – Tin n it u s. – Ligh th eadedn ess, dizzin ess. – Im paired con cen t rat ion . – Visu al dist u rban ce. – Headach e. – Sedat ion . – Trem ors. – Seizu res. – Greater levels of toxicit y m ay lead to com a or cardiopulm onary arrest. • Treat m en t . – Su pp or t ive care. – Oxygen /hydrat ion . – Main ten an ce of air w ay. – Intralipid in fusion : 1.5 m L/kg of 20%IV bolus, then 0.25 m L/kg/m in for 30 m inutes. May repeat 1 to 2 tim es if patient fails to im prove. ERRNVPHGLFRVRUJ The Postoperative Aesthetic Pat ient 251 – Ben zodiazep in es for seizu re p rop hylaxis. ▪ Diazepam 5 to 10 m g or th iopen t al 50 to 100 m g. Hypoesthesias • Com m on an d t ran sien t—sen sat ion ret u rn s to n orm al w ith in 6 m on th s. Respiratory Distress • Fat em bolism syn drom e. – In t raven ous fat dep osits th at cau se pulm on ar y com p rom ise an d m ay lead to acute resp irator y disease syn drom e. • Physical exam in at ion . – Tachycardia, t achyp n ea, dysp n ea. – Hypoxem ia d u e to ven t ilat ion -perfusion abn orm alit ies. – Bradycardia. – High sp iking fever. – Petech iae over th e t r un k. – Su bconju n ct ival an d oral h em orrh ages. – Agitated deliriu m . – St u p or, seizures, or com a. – Ret in al h em orrh ages. • Diagn ost ic st ud ies. – ABGs—hypoxem ia, in creased p u lm on ar y sh u n t fract ion . – Th rom bocytopen ia. – An em ia. – Hyp o brin ogen em ia. – Urin ar y fat stain s—fat globu les in th e u rin e. • Treat m en t . – Su ppor t ive th erapy. – Mon itored care environ m en t . – Con t in uou s oxygen an d pu lse oxim et r y. – Hyd rat ion . – DVT p rop hylaxis. – Gast roin test in al st ress prophyla xis. – Steroids. ▪ Decadron 4 m g IV ever y 8 h ou rs. • Pulm on ar y em bolism an d p u lm on ar y edem as sh ould also be con sidered in th e di eren t ial diagn osis. – See Abdom in oplast y. ERRNVPHGLFRVRUJ 22 Sternal Wounds Early an d aggressive in ter ven t ion an d t reat m en t of stern al w ou n d in fect ion s is requ ired to avoid catast rop h ic com plicat ion s su ch as severe m ediast in it is an d death . Th ese w ou n ds n d th eir gen esis in cardiac surger y, w h ich m ay leave th e stern u m w ith a su bopt im al vascular blood su pply, ult im ately leading to a ch ron ic con tam in ated w ou n d or stern al osteom yelit is. Stern al w oun ds can be divided in to th ree categories (Table 22.1). • Class I w ou n ds in clude w ou n d s w ith drain age, w ith or w ith out stern al in st abilit y, th at p resen t w ith in th e rst w eek postoperat ively. • Class II w ou n ds presen t w ith cellulit is, pu ru len t m ediast in it is, drain age, an d sepsis (fevers), usu ally in th e secon d or th ird w eek postoperat ively. • Class III w ou n ds p resen t w ith osteom yelit is an d serosanguin eou s or seropu ru len t drain age m on th s to years after cardiac su rger y (Fig. 22.1). Obtain a th orough histo ry th at con tain s th e follow ing: • Type of cardiac su rger y p erform ed. • Determ in e w h eth er th e in tern al m am m ar y ar teries h ad been h ar vested (an d on w h ich side). • Elucidate w h eth er th e cardiac su rgeon s engaged in un derm in ing of th e pectoralis m yocu t an eou s ap or h ar vest of th e om en t u m . • Determ in e if th ere is h istor y of in t ra-abdom in al su rger y. • Review con curren t an t icoagu lat ion th erapy an d coagulat ion pro le. Physical Examination • Clicking of th e stern u m in dicat ing loose w ires. • Presen ce of p uru len t drain age, locat ion of th e drain age. • Presen ce of cellu lit is sh ou ld be n oted. Work-up • Cu lt u res sh ou ld be taken from th e w oun d . 252 ERRNVPHGLFRVRUJ Sternal Wounds 253 • CT of th e ch est w ith con t rast for evalu at ion of u id collect ion s above or ben eath th e stern u m . • Ch eck W BCs, C-react ive p rotein , an d ESR. Table 22.1 Pairolero and Arnold classi cation system for sternal wounds. Class Presentation time postoperatively Location of infection I 1 wk II III Diagnosis Treatment Super cial Drainage +/stable sternum Débridement, tighten wires, pectoralis aps; single stage 2–3 wk Mediastinum Fluid collection and an unstable sternum , high WBC, purulent m ediastinitis, sepsis and positive cultures Débridem ent, rem ove wires, pectoralis aps, om ental ap, +/hardware; one or t wo stages Chronic Sternum / wires Osteomyelitis, draining stula, localized cellulitis, rare m ediastinitis Débridem ent, rem ove wires, pectoralis aps, om ental ap; single stage Abbreviation: WBC, white blood cell. Fig. 22.1 Clinical examples of sternal wounds. (a) Class I sternal wound. (b) Early class II sternal wound. (c) Late class II sternal wound. (d) Class III sternal wound. ERRNVPHGLFRVRUJ 254 Sternal Wounds • PT/PTT/INR. • If th e p at ien t is an t icoagulated on w arfarin , h e or sh e sh ou ld be conver ted to a h eparin drip prior to exten sive débridem en t . • Com m un icat ion w ith th e cardiovascu lar su rger y, cardiology, an d in fect ious disease team s is an absolu te requ irem en t . Treatment Paradigm Th e p at ien t w ill requ ire op erat ive débrid em en t to decon t am in ate th e w ou n ds an d rem ove n ecrot ic t issu e, an d th orough explorat ion of h ardw are w ith determ in at ion of stern al stabilit y. In th e perioperat ive set t ing an d in th e postoperat ive set t ing, cult u re-driven in t raven ous an t ibiotics are a requ irem en t . Based on th e t yp e of in fect ion th at th e pat ien t h as, t reat m en t m ay be urgen t or elect ive. In th e case of class II pur ulen t m ediast in it is, it is im perat ive for th e pat ien t to ret urn to th e operat ing room u rgen tly for d ébridem en t of th e w oun d an d clearing of th e in fect ion , sin ce graft ru pt u re or th rom bosis can occu r. Class I w ou n ds m ay be t reated by débridem en t an d drain age in th e suprastern al area w ith t igh ten ing of th e w ires or p lacem en t of stern al p lates or devices. Class II w ou n ds are t reated w ith m et icu lou s d ébridem en t of th e su bcu t an eous t issue, th e stern um , involved ribs, an d all n ecrot ic t issu e. Classically, class II w ou n ds are also t reated as a staged op erat ion , w ith ret urn to th e operat ing room as n ecessar y to rem ove all foreign bodies an d n ecrot ic bon e or t issue. Class III w oun ds are t reated w ith rem oval of in fected bony sequ est ra or w ires, follow ed by im m ediate ap coverage. If good bon e stock is available after a m et iculous, th orough débridem en t of all n ecrot ic t issu e, an d if th e w oun d is com pletely clear of in fect ion an d pu ru len t drain age, th e stern u m can be xated w ith n ew plates or stern al xat ion devices, eith er in on e st age or in t w o separate st ages. If staged, dressing ch anges can be p erform ed w ith Xeroform an d w et to dr y dressing ch anges on top of th e Xeroform . Altern at ively t h e Vac can be u sed on top of a layer of Xeroform w ith ver y low pressure set t ings (25 m m Hg). Care m u st be taken n ot to place th e VAC directly over any vascu lar st r uct u res; th ese m u st be p rotected. On ce th e w ou n d is clean , coverage can be provided w ith pectoralis advan cem en t aps (based on th e pectoral bran ch of th e th oracoacrom ial vessel), w h ich are excellen t for coverage of th e superior t w o-th irds of th e stern u m . In th e pediat ric p op u lat ion , pectoralis advan cem en t aps can cover th e en t ire stern u m . Th e low er p or t ion of th e stern u m can be covered eith er w ith a p ectoralis t u rn over ap (based on th e in tern al m am m ar y perforators) using th e w h ole pectoralis or a split pectoralis, or w ith th e om en t al ap h ar vested from th e abdom en (based on th e gast roep ip loic vessels). If th e pectoralis an d om en t u m are n ot available, ERRNVPHGLFRVRUJ Sternal Wounds 255 th e rect u s abdom in is m u scle (or m yocu t an eou s ap) can be used to cover th e low er port ion an d th e u pper port ion of th e stern um . It is of th e u t m ost im p or t an ce to determ in e th e h ar vest of th e in tern al m am m ar y arteries prior to perform ing a pectoralis t u rn over ap or a rect us abdom in is m uscle ap. Th e rect us abdom in us can be based on th e eigh th in t racostal ar ter y. If n on e of th ese aps are available, th e lat issim us dorsi ap can be u sed to cover th e stern u m . In pat ien t s w h o do n ot h ave en ough h ealthy stern u m or rib bon e to allow for xat ion of th e ch est w all, aps can be u sed by th em selves for coverage of t h e h ear t an d vessels. In m ost all p at ien t s w ith ou t p u lm on ar y com prom ise, th e in am m ator y react ion caused by th e in fect ion resu lt s in su cien t rigidit y for th e ch est w all. Radiat ion h as th e sam e e ect . On ce coverage of vit al st ru ct u res h as been p rovided, skin can be closed over th e m u scles by elevat ion of fasciocu t an eou s aps from th e ch est w all. Flaps can usually be raised up to th e an terior axillar y lin e; care m ust be taken in elevat ion of th e large ap in fem ale pat ien ts w ith m acro m astia becau se th e blood su pp ly of skin edges m ay becom e com prom ised. Postoperative Care • Drain th e su bcu tan eous an d su b ap region s w ith large closed suct ion drain s th at are sequ en t ially rem oved over 2 to 3 w eeks. • Mam m ar y su pp or t or bin d er can be u sed in fem ale pat ien ts. • An t icoagulat ion can u su ally be started w ith in th e rst 5 days postop erat ively depen ding on in dicat ion s for an t icoagulat ion . • Long-term an t ibiot ics, as determ in ed by th e in fect iou s disease team an d exten t of in fect ion , are required. • Physical th erapy an d reh abilit at ion . • Close follow -u p over th e rst m on th ; it is essen t ial to en sure th at th e p u ru len t m ediast in it is h as resolved. ERRNVPHGLFRVRUJ Index A abdom in al com par t m en t syn drom e, 241 abdom in oplast y, 238–239 abdu ctor pollicis longu s, 129t , 131, 132f abscesses collar but ton , 175t , 187–188f, 188 deep h an d, 175t , 185–187, 186–187f dorsal subapon eurot ic, 175t , 188 m idpalm ar, 175t , 189–191, 190f su bcut an eou s, 175t , 188 th en ar, 175t , 189–191, 190f accessor y n er ve fun ct ion evalu at ion , 67t Act icoat , 52t acute opt ic com pressive neuropathy, 74, 74f, 90–91 acute paronychia, 175t , 178–179, 179f acute w ou n ds, 1, 2, 4 acyclovir, 182 addu ctor pollicis, 129t , 133 afferen t pupillar y defect (APD), 69 Allen test , 134 am picillin , 150 an esth esia con sciou s sedat ion , 10–12, 12t dosage regim en s, 8–9, 9t local, 8–9, 9t topical, 10 angle fract u res, 124–125 an t ibiot ics acute w oun ds, 4 bite w oun ds, 22 free flap recon st ruct ion s, 236 fron t al sin u s fract ures, 112 h an d fract ures, 150 NOE fract u res, 107 sn ake bite, 28 w oun d m an agem en t , 4–7 an t im icrobial dressings, 52–53t an t iven in s, 28–29 Aqu acel Ag, 53t At ivan , 12 Augm en t in , 22, 23, 156, 176–177t , 201 au ricu lar h em atom as, 73, 73f Avelox, 4 avulsion injur y, 81–82, 81f ERRNVPHGLFRVRUJ Index 257 B bacit racin /p olym yxin , 51t Bact rim , 22, 150, 175t , 177t , 236 Ben ad r yl, 30 Bet adin e, 19 Biobran e, 52t bite w oun ds an t ibiot ics, 22 cat , 22, 23, 176t closed-fist inju ries (figh t bite), 21, 189, 189f, 201 dog, 22–23, 176t h um an , 20–21, 177t , 201 m an agem en t prin ciples, 20 rabies, 23–24 sn akes, 24–29, 25t , 26–27f spider, 29–31, 30f black w idow spider, 29f, 31 bleach burn s, 58t bleph aroplast y, 246–247 blood loss est im at ion , 249, 249t body, sym physeal fract ures, 125 Bouton n ière deform it y, 128, 200 brach ial plexus inju ries, 219, 220–221f breast augm en t at ion , 242–244, 243f brow n reclu se spider, 29f, 30 bu ccal n er ve fun ct ion evaluat ion , 66t bu pivacain e, 9, 9t bu rn s carbon m on oxide poison ing, 46–47 ch em ical, 57–59, 58t deep derm al, 36f, 49 ear, m an agem en t , 54 elect rical, 55–57 epiderm al, 36, 36f, 40f esch arotom y, 44–45, 44–45f, 227–228 eyelids, m an agem en t , 55 facial, m an agem en t , 54 flu id m ain ten an ce volum e, 43 full th ickn ess, 36f, 41, 42–43f gen it alia, m an agem en t , 55 h an d, m an agem en t , 54 in h alat ion injur y, 45–46 inject ion injuries, 44f, 60–61, 61f Lu n d & Brow der est im ate, 38–39t m an agem en t , 32, 47 p ar t ial th ickn ess, deep derm al 3rd d egree, 36, 41f p ar t ial th ickn ess, superficial 2n d degree, 36, 40f, 49 ERRNVPHGLFRVRUJ 258 Index p at ien t resu scit at ion , 41–43 p at ien t t riage, 47 p ediat ric pat ien t s, 42–43 referral criteria, 48 rule of n in es, 35, 37fr severit y assessm en t , 35–41, 36–37f, 38–39t , 40–41f su perficial, 36f th erm al, 32–35, 33f, 34t w oun d m an agem en t , 48–49, 50–53t C Caldw ell view radiograph s, 71 can n ulat ion injuries, 209 carbon m on oxide poison ing, 46–47 carpal bon e fract ures, 166–170, 167f cat bites, 22, 23, 176t cefazolin, 4 cefepim e, 176t , 194, 242 ceft riaxon e, 112, 150 cellulit is, 175t , 186f cer vical n er ve fun ct ion evalu at ion , 66t ch em ical bu rn s, 57–59, 58t ch loroprocain e, 9, 9t ch rom ic acid bu rn s, 58t ch ron ic w ou n d s, 1–3 ciprofloxacin , 176–177t , 236 clarith rom ycin , 177t clin dam ycin , 4, 22, 107, 175–177t , 242 closed-fist inju ries (figh t bite), 21, 189, 189f, 201 closed reduct ion (n asal fract ures), 72f, 78f, 103–105, 104–105f coagu lat ion n ecrosis, 57 collar but ton abscess, 175t , 187–188f, 188 com p art m en t syn drom e abdom in al, 241 enven om at ion , 26, 27f u pp er ext rem it y, 223–228, 224–227f con dylar fract u res, 123, 124f con sciou s sedat ion , 10–12, 12t coral sn akes, 24, 25t , 29 corn eal abrasion , 247 coron oid, ram us fract ures, 124 Cot ton oid, 71 cran ial n er ve fun ct ion evalu at ion , 65–67t CroFab, 28–29 Crot alin ae, 24 C-spin e injur y, 64 ERRNVPHGLFRVRUJ Index 259 D débrid em en t , 3, 18–19, 254 Derm abon d, 13 derm atoten odesis, 200 dext ran , 236–237 digit al n er ve block, 139, 140f digit replan t at ion , 210–212 DIP join t t reat m en t , 200 dislocat ion s. see also h an d/w rist inju ries dist al in terph alangeal join t , 164 finger m et acarpoph alangeal join t , 164 lun ate, 171, 171–172f perilun ate, 171 PIP join t , 162–163 scaph olun ate, 171 th u m b in terph alangeal join t , 164 th u m b MCP join t , 160, 165 w rist , 170–173, 171–172f dog bites, 22–23, 176t dorsal subapon eurot ic abscesses, 175t , 188 doxycyclin e, 22, 177t E ear lacerat ion s, 73f, 80 Elapidae, 24, 25t elect rical bu rn s, 55–57 em ergen t decom pression , 90–91 enven om at ion com p art m en t syn drom e, 26, 27f sn akes, 24–29, 25t , 26–27f spiders, 29–31, 30f epin eph rine, 8–9, 138 epist axis, 71, 72f esch arotom y, 44–45, 44–45f, 227–228 Essig w iring, 72 eth am bu tol, 177t et idocain e, 9, 9t exten sion block splin t ing, 147, 147f exten sor pollicis brevis, 129t , 131, 132f exten sor pollicis longu s, 129t , 133, 133f ext raocular m uscle en t rap m en t , 89, 90f eyelid, eyebrow lacerat ion s, 83, 84f F facial h em atom as, 84 facial lacerat ion s assessm en t , 77 avulsion inju r y, 81–82, 81f ERRNVPHGLFRVRUJ 260 Index cran ial n er ve fun ct ion evalu at ion , 65–67t ear, 73f, 80 eyelid, eyebrow, 83, 84f large defect s, 81 lip, 79, 80f n asal, 84 n er ve blocks, 78, 78f over view, 76, 76f p arot id duct injuries, 86–87, 87f p ediat ric p at ien t s, 79 scalp, 82, 83f t reat m en t , 77–79, 78f facial n er ve fu n ct ion evaluat ion , 66t injuries, 85, 85f lacerat ion s, 86 facial t raum a acute opt ic com pressive n europathy, 74, 74f, 90–91 air w ay est ablishm en t , 64 au ricu lar h em atom as, 73, 73f exam in at ion , 63–64, 63f, 65–67t facial palpat ion , 68 h em orrh age cont rol, 71, 72f m an dibu lar st abilizat ion , 72 n asal sept al h em atom as, 72f, 73 op hth alm ic assessm en t , 68–69 radiograp h ic evaluat ion , 69–71, 70f t reat m en t sequen ce, t im ing, 75 fasciotom y digit , 227–228 forearm , 225–226, 227f h an d, 226, 226–227f in dicat ion s, 223–224 p erioperat ive m edical m an agem en t , 228 p ostoperat ive care, 228 fat em bolism syn drom e, 251 felon , 175t , 180–182, 181f fen tanyl, 12 figh t bite (closed-fist injuries), 21, 189, 189f, 201 Fin kelstein’s test , 131, 132f flam e bu rn s, 55 flash bu rn s, 55 flexor ten don injuries, 203–206, 203f flexor ten osyn ovit is, 177t , 182–185, 183f, 185f flu con azole, 177t flu oroqu in olon e, 176t fract u res. see specific t ype by anatom ical locat ion ERRNVPHGLFRVRUJ Index 261 free flap recon st ru ct ion s an t icoagulat ion , 236–237, 237f clin ical obser vat ion , 230–231, 231t , 232–233f diu ret ics, 230 Dop pler sign al, 231–234, 231t , 235f leech th erapy, 236, 237f pedicled, 230, 233f postoperat ive ap proach to, 229 preven t ive, salvage tech n iques, 236–237, 237f urin e out p ut values, 229–230 ven ou s flow cou p ler, 234, 235f ven ou s occlusion , 231 ViOpt ix m on itoring, 234, 235f vit al sign s m onitoring, 229–230 fron t al sin us fract ures an atom y, 110f m an agem en t , 111–112, 113f over view, 109 physical exam in at ion , 109 radiograph ic evaluat ion , 110, 111–112f frostbite, 62 G Galveston form ula, 42–43 gam ekeeper’s th u m b, 160, 165 gen t am icin sulfate, 51t Glasgow Com a Scale, 34t glossoph ar yngeal n er ve fu n ct ion evalu at ion , 66t H h an d, forearm ten don injuries an atom y, 198, 199f ch aracterizat ion , 196–197, 196f digit am pu tat ion , 210–212 exten sor ten don , 197, 199f, 201 fasciotom y, 223–228, 226–227f fingert ip, 212, 215–216f flexor ten don , 203–206, 203f n ail repair, 212, 212–213f repair tech n iques, 197f repair t im ing, 199 soft t issue rep air, 214 t reat m en t , 199–202 h an d fract u res baby (reverse) Ben n et t , 159 base/CMC join t fract ure-dislocat ion , 159–162, 160f Ben n et t , 161 ERRNVPHGLFRVRUJ 262 Index classificat ion , 148, 149f com m in uted, 154f, 155 in t ra-art icu lar, t reat m en t , 151–152 m et acarpal, 155–158, 157–158f, 160–161 m iddle, proxim al ph alan x, 152–155, 153–154f op en , t reat m en t , 149–150 p ediat ric, 149f, 161–162, 168 p h alangeal/m et acarpal, t reat m en t , 150 p hysical exam in at ion , 126–128, 127t , 148 radiograp h s, 148 Rolan do, 161 sh aft/dist al ph alan x, t reat m en t , 151 th um b, 146f, 159–160, 160f t ran sverse, 154 t reat m en t , 149–150 t u ft , 150–151, 214 volar base, t reat m en t , 152 h an d in fect ion s acute paronychia, 175t , 178–179, 179f an t im icrobial th erapies, 174, 175–177t bite w oun ds, 176–177t cellulit is, 175t , 186f ch aracterizat ion , 174 ch ron ic paronych ia, 179–180 collar but ton abscess, 175t , 187–188f, 188 deep space, 175t , 185–187, 186–187f diabet ic w oun d, 176t dorsal subapon eurot ic abscesses, 175t , 188 felon , 175t , 180–182, 181f flexor ten osyn ovit is, 177t , 182–185, 183f, 185f h erpet ic w h itlow, 182 h istor y, physical exam , 174 inject ion injuries, 185f, 191–195, 192–193t m idpalm ar abscess, 175t , 189–191, 190f n ecrot izing, 177t onych om ycosis, 177t osteom yelit is, 190 seaw ater con tam in at ion , 177t sept ic arth rit is, 190 su bcut an eou s abscesses, 175t , 188 th en ar abscess, 175t , 189–191, 190f h an d injuries deform it ies, com m on , 128 DIP join t , 127, 129t exam in at ion , 126–128, 127t ext rin sic m uscles, test ing, 130–133, 130–133f ext rin sic m uscles of, 129, 129t in t rin sic m uscles of, 129t , 133–134 ERRNVPHGLFRVRUJ Index 263 MCP join t s, 128, 129t MRC m u scle grading system , 135, 137t n eurologic exam in at ion , 134–135, 135–136t PIP join t , 128, 129t , 130 range of m ot ion , 127, 127t st rength qu an t ificat ion , 135, 137t th u m b, 128, 129t , 131, 132f vascu lar, 134, 207–210 h an d/w rist inju ries. see also dislocat ion s an esth esia, 138–139 axial pat tern , 166 carpal bon e fract ures, 166–170, 167f ch aracterizat ion , 165 digit al n er ve block, 139, 140f perilu n ate, 165 scaph oid fract ures, 166–167, 167f splin t ing (see splin t ing) t riangular fibrocar t ilage com plex tears, 173 uln ar-sided ligam en tous, 173 w rist blocks, 139–140, 141f h em atom as auricu lar, 73, 73f facial, 84 n asal septal, 72f, 73, 101, 101f, 245 postop erat ive evaluat ion , 239, 245, 249–250, 250f rhyt idectom y, 247 h eparin , 236 h erpet ic w h itlow, 182 h ook of h am ate fract ures, 169 h um an bites, 20–21, 177t , 201 hydroflu oric acid bu rn s, 59 hyperten sion , 230 hypoglossal n er ve fu n ct ion evalu at ion , 67t hypoten sion , 229–230 hypoth en ar h am m er syn drom e, 209–210 hypoth en ar m uscles, 129t , 134 I im ipen em , 4 in h alat ion inju r y, 45–46 inject ion injuries bu rn s, 44f, 60–61, 61f h an d in fect ion s, 185f, 191–195, 192–193t in terosseou s m uscles, 129t , 134 it racon azole, 177t J Jah ss m an euver, 156, 157f ERRNVPHGLFRVRUJ 264 Index K Kan avel sign s, 183 Keflex, 175t Kerlix gauze, 18, 71, 72f ket am in e, 12 Kien böck’s disease, 169 L lateral view radiograph s, 71 Leech es USA Ltd., 236 leech th erapy, 236, 237f lidocain e, 8–9, 9t , 138 lidocain e toxicit y, 250–251 lip lacerat ion s, 79, 80f liposu ct ion , 248–249 liquefact ion n ecrosis, 57 lum bricales m uscles, 129t , 134 lun ate fract u res, 169 lye bu rn s, 58t M m afen ide acet ate, 50t m ajor arc injur y, 173 m allet deform it ies, 200 m an dibu lar fract ures an atom y, 114, 115f angle, 124–125 angle classificat ion of occlu sion , 116, 116f body, sym physeal, 125 classificat ion of, 119 con dylar, 123, 124f coron oid, ram us, 124 den tal relat ion sh ips, 115 h em orrh age cont rol, 71, 72f locat ion of, 115f, 120 m an dibu lar st abilizat ion , 72 n on operat ive m an agem en t , 121, 121t Pan orex radiograph s, 69, 70f, 118, 119–120f severely com m in uted, 125 su rgical t reat m en t , 121t , 122–123, 122f sym ptom s, physical fin dings, 117, 118f m an dibu lar n er ve fun ct ion evalu at ion , 66t Marcain e, 138 MCP join t dislocat ion s, 160, 165 injuries, 128, 129t t reat m en t , 201 m edian n er ve, 135, 136t , 140, 141f ERRNVPHGLFRVRUJ Index 265 Mep ilex Ag, 53t m epivacain e, 9, 9t m et acarpal fract u res, 155–158, 157–158f, 160–161 m idface fract u re h em orrh age con t rol, 71, 72f m idpalm ar abscess, 175t , 189–191, 190f m in ocyclin e, 177t m orph in e, 12 m otor n er ve fun ct ion test ing, 135, 135–136t m oxifloxacin , 22, 176t MRSA prophylaxis, 4, 175t m up irocin (Bact roban ), 51t m uscu locut an eou s n er ve, 135 N n ail repair, 212, 212–213f Narcan , 11 n asal fract ures an atom y, 99, 100f closed redu ct ion , 72f, 78f, 103–105, 104–105f physical exam in at ion , 100–101 radiograph ic evalu at ion , 102, 102f sept al h em atom as, 72f, 73, 101, 101f, 245 St ran c-Robert son classificat ion , 102, 103f n asal lacerat ion s, 84 n asal sept al h em atom as, 72f, 73, 101, 101f, 245 n aso-orbit al-eth m oid fract ures. see NOE fract ures n ecrot izing h an d in fect ion s, 177t n er ve blocks fun ct ion evaluat ion , 65–67t t rigem in al n er ve, 78, 78f w rist , 139–140, 141f n er ve injur y, 248 NOE fract ures an atom y, 106 clin ical p resen t at ion , 105, 106f Markow it z classificat ion , 107, 108f physical exam in at ion , 107 radiograph ic evalu at ion , 107 t reat m en t , m an agem en t , 107 O ocu lom otor n er ve fu n ct ion evalu at ion , 65t olfactor y n er ve fun ct ion evalu at ion , 65t onych om ycosis, 177t opt ic n er ve fu n ct ion evalu at ion , 65t orbital fract ures acute com pressive opt ic n eu rop athy, 74, 74f, 90–91 an atom y, 88 ERRNVPHGLFRVRUJ 266 Index floor, 91, 92f, 94 m an agem en t , 93–94 p hysical exam in at ion , 89, 90f radiograp h ic evaluat ion , 93 roof, 92, 93f su rgical in dicat ion s, 94 t raum at ic opt ic n europathy (TON), 91 t yp es of, 91–92, 92–93f osteom yelit is, 190 P Parklan d form u la, 42–43 parot id duct injuries, 86–87, 87f pen icillin , 176t ph en ol burn s, 58t , 59 ph osph orus burn s, 58t , 59 PIP join t dislocat ion , 162–163 injuries, 128, 129t , 130 t reat m en t , 200–201 pisiform fract ures, 169 pit vipers, 24 plaster splin t ing, 143–144f postoperat ive evaluat ion abdom in oplast y, 238–239 bleph aroplast y, 246–247 blood loss est im at ion , 249, 249t breast augm en tat ion , 242–244, 243f deh iscen ce, 241 h em atom a, 239, 245, 249–250, 250f lidocain e toxicit y, 250–251 liposu ct ion , 248–249 n er ve injur y, 248 overaggressive plicat ion , 241 p rin ciples, 238 p ulm on ar y em bolu s, edem a, 239–240 respirator y dist ress, 239–240, 251 rh in oplast y, 244–246 rhyt idectom y, 247 serom a, 249, 250f skin flap n ecrosis, 248 pot assium perm angan ate bu rn s, 58t pressu re m easurem en t , 223, 224f pressu re sores (ulcers), 16–19, 16f prilocain e, 9, 9t procain e, 9, 9t propofol, 12 pulm on ar y em bolus, edem a, 239–240 pup illar y respon se assessm en t , 69 ERRNVPHGLFRVRUJ Index 267 R rabies, 23–24 radial n er ve, 135, 135–136t , 140, 141f respirator y dist ress evaluat ion , 239–240, 251 ret robu lbar h em orrh age, 246 rh in oplast y, 244–246 rhyt idectom y, 247 rifam pin , 177t Roceph in , 28, 107 ru le of n in es, 35, 37fr S Salter-Harris classificat ion , 149f, 161–162 scalp lacerat ion s, 82, 83f scaph ocap it ate syn drom e, 170 scaph oid fract ures, 166–167, 167f scaph olun ate ligam en tous inju ries, 170–171, 171–172f seaw ater con t am in at ion , 177t sept al h em atom as, 72f, 73, 101, 101f, 245 sept ic arth rit is, 190 serom a, 249, 250f Silvaden e, 19 silver n it rate, 50t silver su lfadiazin e, 50t skier’s th u m b, 160 skin -flap n ecrosis, 248 skin -flap w oun d closu re, 3, 5, 5f sn akes, 24–29, 25t , 26–27f sodium hypoch lorite bu rn s, 58t spider bites, 29–31, 30f splin t ing exten sion block, 147, 147f gen eral procedures, 142, 143f plaster, 143–144f p rin ciples, 141 p roxim al, m iddle p h alangeal fract ures, 147 th u m b spica, 146, 146f t ypes, 142–147, 143–147f u ln ar gut ter, 145, 145f Volar sp lin t , 142, 143f stern al w ou n ds, 252–255, 253f, 253t St ranc-Robert son n asal fract u re classificat ion , 102, 103f su bcu t an eou s abscesses, 175t , 188 su bm en tal view rad iograph s, 71 Sulfam ylon , 19 su perior orbit al fissure syn drom e, 89 Surgicel, 3 su t u res, 13–15, 14t , 15f sw an n eck d eform it y, 128 ERRNVPHGLFRVRUJ 268 Index T tem poral n er ve fun ct ion evalu at ion , 66t terbin afin e, 177t tet an us prophylaxis, 5–7, 5f, 6–7t tet racain e, 9, 9t TFCC tears, 173 th en ar abscess, 175t , 189–191, 190f th en ar m u scles, 129t , 133 th erm al burn s, 32–35, 33f, 34t th um b an atom y, 198, 199f fract ures, 146f, 159–160, 160f injuries, 128, 129t , 131, 132f in terph alangeal join t dislocat ion s, 164 spica splin t ing, 146, 146f Tim en t in , 28, 176t TMJ dislocat ion , derangem en t , 117 toxic sh ock syn drom e toxin -1, 245 t raum at ic opt ic n europathy (TON), 91 t ren ch foot , 62 t rigem in al n er ve fu n ct ion evaluat ion , 65–66t region al blocks, 78, 78f t roch lear n er ve fun ct ion evalu at ion , 65t t u ft fract u res, 150–151, 214 U ulcers (p ressure sores), 16–19, 16f uln ar gut ter splin t ing, 145, 145f uln ar n er ve, 135, 136t , 140, 141f Un asyn , 22, 176–177t upp er ext rem it y periph eral n er ve injuries blast , crush , avu lsion , 219 brachial plexus, 219, 220–221f classificat ion , 217–218, 218f m an agem en t , 218–219 V vagu s n er ve fun ct ion evalu at ion , 67t valacyclovir, 182 van com ycin , 4, 150, 175–177t Versed, 12 vest ibulococh lear n er ve fun ct ion evalu at ion , 66t Vip eridae, 24, 25t Volar sp lin t , 142, 143f ERRNVPHGLFRVRUJ Index 269 W Waters view radiograph s, 71 Weber test , 135 w et t ing tech n ique, 249t w oun d m an agem en t an t ibiot ics, 4–7 closure, 4–5, 8 débrid em en t , 3, 18–19, 254 evaluat ion , 1–2 follow -up, 7 h em ost asis, 3, 3f, 8 irrigat ion , 2–3 poor h ealing, factors affect ing, 2t w rist inju ries. see also h an d/w rist inju ries blocks, 139–140, 141f dislocat ion s, 170–173, 171–172f fract u re-dislocat ion s, 173 n er ve blocks, 139–140, 141f X Xeroform , 52t Z ZMC fract ures an atom y, 94, 95f displaced, 98 flam e sign , 96, 97f m an agem en t , 98 n on displaced, 98 radiograph ic evalu at ion , 97 sym ptom s, physical fin d ings, 96, 97f zygom at ic arch , 94, 96f, 98 Zosyn , 4, 177t , 194 zygom at ic n er ve fu n ct ion evaluat ion , 66t zygom a/zygom at icom axillar y com plex fract ures. see ZMC fract u res ERRNVPHGLFRVRUJ ERRNVPHGLFRVRUJ