Management of Mutilating Upper Extremity Injuries Flashcards
Criteria for considering amputation
- Open fractures with large soft-tissue defect
- Warm ischemia time longer than 6 hours with muscle involvement
■ Proximal major nerve injury (e.g., brachia] plexus involvement) - Unstable patient
- Older patient
- Associated major organ trauma
■ Comorbid medical problems with increased risk with prolonged
anesthesia (e.g., myocardial infarction, stroke)
Mangled Extremity Severity Score of seven or higher has been used as a cutoff to perform amputation
T but this has not
been validated in the upper extremity
should not place the amputated part directly on ice to avoid
freezing of the tissues and frostbite injury
T
6 hours for a warm extremity, 12 hours for a cold
extremity, 12 hours for a warm digit, and 24 hours for a cold digit
T
As compared with digits, upper extremities have shorter ischemia times why?
because of degradation of deoxygenized muscle
Debridement may be performed in the
immediate or delayed setting depending on the stability of the patient
and availability of a reconstructive surgeon
T
The first debridement removes necrotic tissue and infectious burden, permitting adequate time for demarcation of nonviable tissues. 1
T
Presence of a peripheral pulse may not exclude impending arterial compromise
T
. Ischemia reperfusion injury consequences
decreased viability of the extremity, multiple organ failure syndrome,
and acute respiratory distress syndrome
degree
of displacement and ability to maintain fracture reduction plays a
substantial role in surgical management
T
more extensive soft-tissue injuries were associated with higher
infection and amputation rates
T
Plating systems require
wide undermining of the periosteum for appropriate exposure and
placement, which may compromise the vascular supply to the bone
T
plates and screw provide rigid fixation for earlier mobilization.
T
the ultimate goals are initiation of range of motion
to provide improved function and minimization of soft tissue stripping to achieve bony healing and union of the fracture
T
there are multiple tendons lacerated in zone 5, the tedious epitendinous sutures are often
not performed to expedite the surgical sequence because of the relative lack of restrictive adhesion formation in this zone
T
Pulley reconstruction in mutilating upper extremity injuries should be performed always
F if multiple digits are involved
The ribbon
sign has been used to identify areas of arterial vessel wall avulsion and
intimal injury and confers a poor prognosis for replantation
T
Areas
with the ribbon sign should be debrided both proximallyand distally and the gap created should be bridged by a vein graft
T
more extensive vascular
reconstruction, such as the palmar arch what type of graft we need ?
a Y-vein graft from the volar forearm is used to perform endto-end anastomoses to reconstruct multiple common digital arteries
concurrently
preferable to perform the nerve
repair outside the zone of injury to ensure success.
T
Indications for the use of conduits
nerve
gaps of less than 3 cm, nerves that are of small diameter, and noncritical, typically sensory nerves
Nerve conduits have been shown to
provide sensory recovery but are inferior to autologous nerve grafting
for motor regeneration
T
equivalent sensory outcomes for processed nerve allografts when compared
with nerve autografts, and they had superior sensory outcomes when
compared with nerve conduits
T
For a successful reconstruction, soft-tissue coverage should be
taken from outside the zone of injury for adequate healing
T
Fasciocutaneous flaps are usually the work horse flaps for mutilating upper extremity injuries
T
1% of all upper extremity trauma patients will need a fasciotomy, especially in those patients who suffered an arterial and venous injury
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All compartments within the hand and forearm must be fully
released for adequate decompression
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in instances
with vascular compromise in the mangled upper extremity, preemptive compartment releases should be performed because of the reperfusion injury and muscle ischemia after the return ofblood flow.
T
children tend to have better outcomes when compared
with adults.
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in children, epiphyseal plates may still be intact, and bones
may continue to grow after the injury or replantation,
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Despite being immobilized for longer periods of time, children recover mobility of the operated extremity much easier than adults.
T
loss of wrist and finger motion, neurogenic
pain, andheterotopic ossification contribute to delayed upper extremity amputation
T
Even with the most meticulous technique, mutilating upper extremity injuries often result in
poor motor and sensory recovery
T
