‫بسم هللا الرحمن الرحيم‬
‫قالو سبحانك ال علم لنا اال ما علمتنا انك‬
‫انت‬
‫العليم الحكيم‬
‫صدق هللا العظيم‬
Open wounds of the wrist
Hamed Ahmed Abulkhair
lecturer
Orthopaedic surgery
Zagazig University
2012
wrist anatomy
Open wrist wounds means that the skin is
broken, wound contamination with
potential injury of deeper structures is a
possibility.
Depending on the mechanism of injury,
the wounds can occur after sharp
lacerations from a knife or saw injuries, a
crushing injury, an avulsion injury or any
combination of the above type of injuries.
Wound also can be superfascial or deep
Superfacial when the injury stops at the level
of the deep fascia affecting only the the
skin, subcutaneous tissue (fat) and the
superficial vessels or nerves
Treatment of superficial wounds
• Urgent exploration
•
Debridment
•
Repair of any important sc nerve
&
•
Finally wound closure
Deep when it involves one or more of the
following structures
Tendons
Muscles
Nerves
Arteries.
Bones
Or all of the above in amputation
Treatment of deep wounnd
•
Urgent exploration
•
Debridment
•
Repair of any of the injured deep
structures
Tendon injury
Diagnosis of Flexor Injury
• Posture of Hand/ Normal cascade
• Passive tenodesis test
• Forearm compression test
• Independent testing of FDS & FDP
• Partial damage
Normal Flexion Cascade
Flexor Tendon Testing
Tendon repair
When a laceration involves more than 30 50% of the tendon diameter, there is
significant loss of tension resistance and a
risk of tendon triggering or a delayed
complete rupture.
Tendon repairs take approximately 6 weeks
to heal and regain about 80 % of their
original strength in approximately 10
weeks and up to 95 % of their original
strength at final healing
Tendon repair techniques
Core suture techniques
Superfascial suture techniques
Rehabilitation
Presents a serious dilemma :
Early mobilisation to prevent stiffness, with the
risk of further rupture; therefore, a new surgical
intervention,
Late mobilisation to avoid rupture, with the risk of
significant stiffness ; therefore further surgical
intervention due to tenolysis.
A second procedure is frequent in all cases, and
the patient should be warned as soon as possible
about this fact.
Rehabilitation involves awareness on the part of
the patient regarding patience and cautionness.
Nerve injuries types
Neuropraxia
A reversible physiological nerve conduction
bloc
Axontemesis
There is loss of conduction but the nerve is
in continuity and the neural tubes are intact.
Neurotemesis
Complete division of the nerve trunk
CLINICAL FEATURES
Ask the patient if there is numbness,
paraesthesia or muscle weakness in the
related area. Then examine the injured limb
systematically for signs of abnormal
posture (e.g. a wrist drop in radial nerve
palsy), weakness in specific muscle groups
and changes in sensibility
Nerves - Sensory
Repair
A clean cut nerve is sutured without further
preparation; a ragged cut may need paring
of the stumps with a sharp blade, but this
must be kept to a minimum.
The stumps are anatomically orientated and
fine (1010) sutures are inserted in the
epineurium. There should be no tension on
the suture line. Opinions are divided on the
value of fascicular repair with perineurial
sutures
Nerve graft
Free autogenous nerve grafts can be used to
bridge gaps too large for direct suture. The
sural nerve is most commonly used; up to
40cm can be obtained from each leg.
Because the nerve diameter is small, several
strips may be used (cable graft).
The graft should be long enough to lie without
any tension, and it should be routed through
a well-vascularized bed. The graft is
attached at each end either by fine sutures
or with fibrin glue.
After care
While recovery is awaited the skin must be
protected from friction damage and bums.
The joints should be moved through their
full range twice daily to prevent stiffness
and minimize the work required of muscles
when they recover. 'Dynamic' splints may
be helpful
Once a nerve is repaired, the axon must re-grow
from the point where the injury occurred to the
end organ it innervates. In addition, if the final
target organ is a muscle, there is only a certain
amount of time available for the nerve to reach the
target organ and allow the muscle to remain
viable. If this does not happen within that time
frame, the muscle dies and function will never
recover for those muscles. This time frame is
about six months after a nerve injury. Sensory
nerves can have a more prolonged time frame to
reinnervate their sensory end organs which is
believed to be as long as several years.
Amputation&replantation
INDICATIONS FOR REPLANTATION
• Thumb
• Multiple digits
• Hand amputation through palm
• Hand amputation (distal wrist)
• Any part in a child
• More proximal arm (sharp only)
• Finger distal to sublimis insertion (zone 1)
Contraindications
Severely crushed or mangled parts or avulsed
hand beyond reconstruction
First aids
Patient
• Stabilize general
condition
• Wash &clean the
stump with saline
• Dressing&covering
• Immediate transfere
Amputated part
• Warp in sterile guaze
moistened with saline
• Place in a sterile leakproof bag
• Put the bag in ice
container
OPERATIVE SEQUENCE
•
•
•
•
•
•
Bone shortening and fixation
Tendon repair
Arterial repair
Neurorrhaphies
Venous repairs
Skin coverage or closure
Postoperative Management
• The patient should be placed in a warm
room in the postoperative periodto prevent
arterial spasm
• An indwelling axillary sheath catheter,
through which a constant infusion of
bupivacaine hydrochloride (Marcaine) is
given to provide pain relief and a chemical
sympathectomy, should be placed in the
operating room
Post operative medications
•
•
•
•
Antibiotics
Systemic heparinzation
Chlorpromazine
Antiplatelets eg, aspirin