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Click on images to view larger radiographs and clinical pictures.
Introduction
This 24 year old woman was the belted
driver of a car travelling at 100km/h on the highway.
She had her left arm outside the driver's door window when
she lost control of her car. With her arm still
outside the car flipped onto its side and travelled 20-30
metres in this position. Paramedics found this
patient with her hand trapped between the car door and the
asphalt. She was evaluated according to ATLS
protocols and this was found to be an isolated injury.
Pictures From the Trauma Room:
Trauma Room Radiographs:
How would you manage this patient
now ?
Tetanus status was unknown, but the
patient recalled that she had her series of tetanus toxoid
when she was a child. She had no allergies, no
history of renal dysfunction, and did not take any
medication. A detailed hand examination was carried
out as part of the secondary survey. Sensation was
found to be intact in the Median, and Ulnar nerve
distribution. Motor function for all three nerves
was intact. There was no sensation to the radial
side of the thumb which (see picture) had a hemi-degloving
type injury. Radial and Ulnar pulses were present,
and there was no evidence of an acute Carpal Tunnel
syndrome. There were no injuries to the left upper
extremity proximal to the forearm.
What is the appropriate management
now ?
0.5cc of Tetanus Toxoid was given,
and the patient was also given 1g of Ancef, 40mg of
Gentamycin, and 1.5 milion units of Penicillin.
After informed consent was obtained, the operating room
was booked for an urgent irrigation & debridement of
this patient's hand. Limb salvage was considered to
be possible given the intact perfusion and neurological
function. A staged procedure was felt to be the best
option
What would the best management be
for the second stage ?
There was extensive degloving of the
distal thumb, with most of the distal phalanx missing (see
trauma room pictures). Clinical and radiographic
examination revealed that almost 1/2 of the total depth of
the carpus was missing (including articular cartilage) and
that there was massive bone loss from the distal
ulna. Finally, there was a large amount of soft
tissue loss.
Therefore, the second stage procedure
consisted of:
Repeat Irrigation and debridement
What would the postoperative plan
be ?
Postoperatively, the arm was placed
in a full-length splint. Perfusion to the free
flap was monitored for one week using continuous Laser
Doppler Flow (LDF) readings. The hand and elbow
were immobilized for four weeks at which time sutures
and the proximal radioulnar pin was removed. The
wrist remained splinted but active ROM was begun at the
MCP, PIP and DIP joints of the fingers and at the elbow.
At the six week mark the pin across
the MP joint of the thumb was removed, and a removable
thermoplastic splint was applied. Aggressive
physiotherapy of the elbow (flexion / extension /
pronation / supination) was begun, as was active and
passive ROM of the fingers.
Two months postoperatively, the
patient was doing well, had regained -15 to 90 degrees
of flexion at the MCP joints of her fingers, full ROM of
the PIP/DIP joints, and could pro/supinate 60 degrees
each direction.
The free flap remained viable and
this young woman is scheduled for debulking of the free
flap approiximately six months from her last surgery.
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