A CASE PRESENTATION AND DISCUSSION ON TRAUMA OF THE UPPER EXTREMITIES

DR. OLIVER S LEYSON

GENERAL DATA: A.L, 24 YEARS OLD, MALE, FROM PASAY CITY

CHIEF COMPLAINT: GAPING WOUND ARM RIGHT

HPI: 1 HRS PTA - PATIENT HAD AN ARGUMENTWITH HIS GIRLFRIEND

SUDDENLY HIT A MIRROR WITH HIS RIGHT FIST SUSTAINING INJURY IN THE

UPPER ARM RIGHT (+) NUMBNESS OF ARM RIGHT

(+) COOLNESS  (+) PAIN ON MOTION (+) BRISK BLEEDING CONSULT

PHYSICAL EXAMINATION:

GEN SURVEY: CONSCIOUS,COHERENT

BP:120/80 CR:104 RR:21

HEENT: ANICTERIC SCLERAE PINK PALPEBRAL CONJUNCTIVAE

CHEST: SYMMETRICAL CHEST EXPANSION NO RETRACTION CLEAR BREATH

SOUND

CARDIAC: TACHYCARDIC, REGULAR RATERHYTHM

ABDOMEN: FLAT, NORMO-ACTIVE BOWEL SOUND, NO GUARDING NO TENDERNESS

EXTREMITIES: (+) GAPING WOUND UPPER EXTREMITIES, NO PULSE, WITH CYANOSIS OF THE NAILBEDS ON THE AFFECTED EXTREMITIES. LIMITED MOTION ( LIMITED FLEXION OF THE ELBOW, (+)PAIN, BRISK

BLEEDING Incised wound

SALIENT FEATURES:

• INCISED WOUND ANTERIOR ASPECT DISTAL 3RDUPPER ARM RIGHT

• SIGNIFICANT ARTERIAL BLOOD LOSS

• NO PULSE,

• WITH CYANOSIS OF THE NAILBEDS ON THEAFFECTED EXTREMITIES

• LIMITED MOTION

• NUMBNESS (PARESTHESIA)

• COOLNESS OF LIMB ( POIKILOTHERMIA)

• BRISK BLEEDING ( RED)

• PARALYSIS

Algorithm Of Penetrating Trauma of the Upper Extremities

Trauma of the Upper Extremities

Closed Injury Open Injury

Splinting

Active Bleeding No active Bleeding

Wound dressing

N Neuro Vascular

compromised

Neuro

compromised

Suspected

Compartment

radiographs History and PE

Vascular Compromised

(-) (+)

Observe

Angiogram

Emergent Wound

Exploration

Clinical: Patients presenting to the emergency department with upper extremity

vascular injuries are fully assessed forspecific signs that suggest arterial injury, as

follows:

Hard signs

o Diminished or absent pulses

o Ischemia

o Pulsatile or expanding hematoma

o Arterial bleeding

o Bruit

Equivocal or soft signs

o Wound proximity to a major vessel

o Small, stable hematoma

o Nearby nerve injury

o Shock that is not the result of other injuries

PRIMARY IMPRESSION:

PARACLINICAL DIAGNOSTIC PROCEDURE

• NO, WE DO NOT NEED ONE BECAUSE OF THE HIGH DEGREE OF CERTAINTY OF MY PRIMARY CLINICAL IMPRESSION  PRESENCE OF HARD SIGNS

• I WILL PROCEED WITH MY TREATMENT

Pre-treatment Diagnosis

GOALS OF TREATMENT

1. CONTROL OF BLEEDING

2. MAINTAIN FUNCTION

PREOP. PREPARATION

• LARGE BORE IV LINE

• BLOOD EXTRATED FOR HGB, HCT, BLOOD TYPING AND CROSSMATCHING

• IV ANTIBIOTICS STARTED FOR PROPHYLAXIS (PEN. G 5M UNITS )

• ATS 4,500 “U” INTRAMUSCULAR ANST

• TETANUS TOXOID INTRAMUSCULAR

• INFORMED CONSENT FOR OPERATION

Intra-operative Management

• PATIENT WAS THEN “ DIRECT “ TO OR

• PROXIMAL AND DISTAL CONTROL OF BLEEDERS BY DIRECT PRESSURE

• ASSESSMENT OF THE SOURCE OF BLEEDING

• INTRAOPERATIVE FINDINGS NOTED

INTRA-OPERATIVE FINDINGS

• Complete transection of

1. Brachial artery

2. Basilic vein

3. Median nerve

4. Musculocutaneous nerve

Partial transection of bicep brachii muscle.

1ST GOAL

• CONTROL BLEEDING FROM BRACHIAL

ARTERY TRANSECTION

TREATMENT OPTIONS

+++ 3000 LEAKS

THROMBOSIS

++ GSV

graft

+++ 500 Ischemia ++ Ligation

+++ 1000 LEAKS

THROMBOSIS

++++ Primary

Repair

AVAILABILITY COST RISK BENEFIT

Treatment done on Vascular Injury

• Primary repair on brachial artery

• Ligation on basilic vein

- with presence of collaterals, venous

injury can be safely ligated

Bowley D, Penetrating vascular trauma in Johannesburg, .

Surgical Clinics of North Am Vol 82 No 1,

Neurologic Compromised

Open Closed

Immediate Exploration

Irrigation

Splinting and Neuro exam

(+) (-) Nerve Injury

Observe

INTRA-OPERATIVE FINDINGS

• Complete transection of

1. Brachial artery

2. Basilic vein

3. Median nerve

4. Musculocutaneous nerve

Partial transection of bicep brachii muscle.

GOAL

• REPAIR OF NERVE TO PRESERVE

FUNCTION

TREATMENT OPTIONS

++ 3000 pseudoneur

oma

+++ Nerve

graft

+++ 500 neuroma +++ Ligation

+++ 700 pseudoneur

oma

++++ Primary

Repair

AVAILABILITY COST RISK BENEFIT

Treatment done for Nerve Injury

• Primary repair perineurium

• Type of primary repair

epineurium

group fascicular suturing

nerve grafting

TREATMENT OPTIONS

+ 3000 ++ ++ Nerve

grafting

+ 500 ++ ++ Group

fascicular

+++ 700 ++ ++++ Epineural

suturing

AVAILABILITY COST RISK BENEFIT

Incised wound

Operative Technique

1. patient on supine under SAB

2. Prep and draping of entire extremity including contralateral uninjured extremity

3. Proximal and distal control of vessel prior to opening. Flush vessels with heparin      

solution using gauge 18 abbocath needles

11. Primary repair using prolene 5.0 or 6.0 for clean lacerations

12. End to end anastomosis if adequate. Reversed saphenous vein graft interposition

if there is tension.

13. Extra-anatomic bypass graft with SVG if there is extensive soft tissue injury or

local tissue infection.

14. Vascular tissue is done first if with associated nerve or bone injury.

15. Prosthetic grafts can be used if hemodynamically unstable.

16. Fasciotomy of distal extremity is contemplated if:

a. extremity looks ischemic preop

b. injury more than 6 - 8 hours

c. if swelling occurs post op

17. Coverage of vessel with muscle and

skin.

18. Systemic heparinization

a. for popliteal and infrapopliteal

repair

b. major thrombus is noted

c. no contraindication to systemic

heparinization

19. Completion arteriography

a. For complex repair

b. Doubt with run off

c. Can be routinely done to check

patency

20. Avoid rubber drains

21. Consider reperfusion injury of distal

extremity

- possible systemic toxicity of

metabolites superoxide

dismutase, oxygen free

radicals, catalase high k+ load

- may use mannitol to protect

tissues

- has to be given before

reperfusion

22. Close monitoring of distal extremity

post op

- signs of good perfusion

- peripheral pulses noted

23. Re-operation is done if limb is still

ischemic post op.

- do not rely on heparin drip to

improve perfusion

- heparin prevents clotting; it

does not dissolve formed

clots.

24. For venous injury

- repair is done unless patient is

hemodynamically unstable

To lower the incidence of

amputation

1. Thorough physical exam and

identification of injury

2. Immediate surgery if with hard

signs

3. Knowledge of vascular anatomy

and meticulous attention to

surgical detail

4. Debridement of injury vessels

with tension free, thrombus free

repair.

5. Debridement and flushing of

wounds with antibiotic

prophylaxis.

6. Early fasciotomy if indicated.

7. Close post-op monitoring and repeat

surgery if needed.

8. Adequate resuscitation.

9. If indicated - outright amputation

OPERATION DONE:

WOUND EXPLORATION REPAIR OF

BRACHIAL ARTERY,

NEURRHORRAPHY

POST-OPERATIVE CARE

Immediately Post-op:

• Posterior Mold Applied

• Nutrition: Diet as tolerated when fully awake

• IV antibiotics:Pen G 5 million U initially

• Adequate analgesia

Ketorolac 30mg TIV q6 x 8 doses

Monitored for occurrence of cyanosis and ischemia

FOLLOW UP PLAN

• Continue medications at home

• Continue daily wound care

• Maintain posterior mold up to 2 weeks

• For rehabilitation after the wound has

completely healed

Aftermath of the patient

• Achieved the following:

– Improved patients condition

– Happy and contented with the outcome

– No medicolegal suit

FINAL DIAGNOSIS: COMPLETE LACERATION, RIGHT

1. BRACHIAL ARTERY

2. CEPHALIC VEIN

3. MEDIAN NERVE

4. MUSCULOCUTANEOUS NERVE

PARTIAL TRANSECTION BICEP

BRACHII RIGHT

THANK

YOU!!

REFERENCES

• 1. Schwartz, Seymour. Principles of Surgery. 7th

edition, Vol II: 1182

• 2. Chaudhry,N. MD, FACS, Hand, Upper

Extremity Vascular Injury.

• 3. Bowley D, Penetrating vascular trauma in

johannesburg, south africa. Surgical Clinics of

North Am Vol 82 No 1, Feb2002.

• 4. Mattox KL, ed. Trauma, 4th ed. 2000

McGraw-Hill

• 5. MD consult- Journal