Upper limb trauma

1. Dr. Moeez Fatima
R1
Plastic Surgery

2. 

3. 
 Devastating injuries that involve multiple critical
structures of the fingers, hand, arm, or any
combination of the three and nearly always lead to
significant disability, both directly and
 through their psychosocial impact.
Definition

4. 
 Preserve life
 Preserve tissue
 Preserve function
 Reconstruct and restore function of both the
extremity and the patient
CRITICAL POINTS Goals in Treating Upper
Extremity Mangling Injuries

5. 
 Careful and complete evaluation
 Reconstructive plan tailored to the patient’sneeds
 wound debridement
 Meticulous operative reconstruction
 Restoration of good vascularity
 Rigid skeletal
 Stable, vascularized soft tissue coverage
 Rehabilitation of the extremity and the patient
Priniples

6. 
 Multispecialty team approach.
 Judgement
 Timings

7. 
 Mangled Extremity Severity Score (MESS).
 Hand Injury Severity Score (HISS)
CLASSIFICATION

8. 
MECHANISMS AND PATHOPHYSIOLOGY
OF INJURY

9. 
 One wound - One scar concept.
 Mechanism of ischemia
 Tissue susceptibility of ischemia.
 Ischemia- Reperfusion Injury.
 Super-oxide radical accumulation.
 Accumulation of neutrophils.
 Extent of zone of injury.

10. 
 ATLS Protocol.
INITIAL EVALUATION

11. 
1. When??
2. Where??
3. How??
Patient’s comorbidities.
Fators affecting reconstructive plan.
History

12. 
 Vascular status:
• Clinical
• Doppler
• MRA/ Angiography.
Examination

13. 

14. 
Compartment Syndrome

15. 
Skeletal Injury

16. 
Muscle–Tendon unit Injury

17. 
 Sensory
 Motor
 3main nerves: Median
 Ulnar
 Radial
Nerve Injury

18. 
 Motor: Resistance to palmar abduction of the thumb
reflects median nerve-innervated abductor pollicis
brevis function.
 Sensory: volar aspect of the index or middle finger.
Median Nerve

19. 
 Motor: Resistance to flexion of the
metacarpophalangeal (MP) joint of the small finger
reflects ulnar nerve–innervated flexor digiti quinti
function.
 Sensory: the volar aspect of the small finger
Ulnar Nerve

20. 
 Resistance to extension of the MP joint of the index
finger reflects radial nerve–innervated extensor
digitorum communis and extensor indicis proprius
function.
 The dorsum of the first web space.
Radial Nerve

21. 
 CBC
 Electrolytes
 ABGs
 Toxicology screen
 Amylase
 Blood typing & Cross match
Labortaory Investigations

22. 
GOALS OF TREATMENT:
BIOMECHANICS OF THE
INJURED HAND

23. 
7 basic Functions of
Hand

24. 
Precision pinch

25. 
Opposition pinch

26. 
key pinch

27. 
Chuck grip

28. 
Hook grip

29. 
Span grasp

30. 
Power grasp

31. 
1. An opposable thumb
 2. The index and long
 3. The ring and small fingers.
 4. The wrist
Basic units

32. 

33. 
Amputation/Skeletal Contribution

34. 

35. 

36. 
RECONSTRUCTION

37. 
HAND

38. 
JOINTS

39. 
 DIP Joints of fingers / IP Joint of Thumb
 PIP Joints of Fingers.
 MP Joints
 Wrist Joint

40. 
Tendons

41. 
Lumbrical Plus Finger

42. 

43. 
Quadrigia

44. 
Soft Tissue Coverage &
Nerves

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46. 

47. 
Emergency Management

48. 
 The trauma “ABCs”).
 Control hemorrhage by direct pressure—do not
blindly clamp.
 Reduce gross skeletal deformity.
 Administer tetanus prophylaxis and antibiotics.
 For a ischemic major limb, place a temporary
vascular shunt.
 Cool devascularized tissue.
 Leave any skin bridges intact.

49. 
 Excise the wound.
 Marginally vascularized tissue, especially
 muscle.
 Save critical structures: Begin with a tourniquet; release
and reinflate for further debridement.
 Tag nerves and arteries.
 gravity-assisted lavage
 Decide about replantation, amputation, partial
amputation, or reconstruction
 Perform amputations as part of debridement.
 Save “spare parts” for later use in primary
reconstruction.
Debridement

50. 
 Visualize the fracture.
 Restore length for optimal
 Accurate anatomic
 Minimally invasive fixation and begin early motion
 with fracture healing.
 • Radius/ulna: 3.5-mm limited-contact dynamic compression
 (LCDC) plate.
 panning plate to the second or third metacarpal with
 locking screws if severe comminution is present.
 Fixation of fractures of the wrist, use compression screws or Kirschner
 wires, repair or reconstruct ligaments, and stabilize with Kirschner wires.
 Metacarpals: miniplate fixation
 Maintain the first web space with an external fixator or thumb CMC pinning.
 For the phalanges, use a miniplate, Kirschner wires, or tension band wiring.
 For skeletal defects, decide between shortening, primary bone grafting, and
 placement of an antibiotic spacer with delayed bone
BONE RECONSTRUCTION

51. 

52. 
 Debride crushed intrinsic muscles to prevent contracture.
 Use four-core locking sutures plus a fine epitendinous suture if
zone 2 is
 involved.
 Repair both the flexor digitorum superficialis and flexor
digitorum profundus.
 Repair the A2 and A4 pulleys.
 For tendon rods use two-stage reconstruction if primary repair
is not
 possible.
 Consider primary tenodesis/tendon transfer.
For late reconstruction, tendon grafting, tendon transfer,
tenolysis, and functional free muscle transfer may be needed
Tendon Repair/Reconstruction

53. 