General Concepts: Indications for Surgery



General Concepts: Indications for Surgery


Ethan W. Dean

Robert C. Matthias Jr.



INTRODUCTION



  • Hand and wrist injuries are very common presenting complaints in the acute care setting.


  • Categories of injury



    • Fracture or dislocation


    • Tendon injury


    • Nerve injury


    • Infection


    • Soft tissue damage or amputation


    • Vascular injury


    • Any combination of the above


  • Selection of appropriate treatment strategy requires a thorough history, physical examination, and relevant imaging studies.


  • Optimum treatment requires individualized approach to the patient:



    • Age


    • Occupation


    • Functional status


    • Presence of comorbidities


    • Ability to cooperate in treatment strategy


  • Common questions posed to the treating provider:



    • Which conditions can be definitively managed in the acute care setting?


    • Which conditions warrant referral to a hand specialist?


    • Which conditions require emergent operative management?


  • Principles of surgical management:



    • Restore maximal function of the injured hand or wrist


    • Prevent further loss of function


    • Expectation that ultimate outcome will be equivalent or better than the nonoperative alternative


    • Restore normal anatomy when possible



  • Must consider risks of surgery including:



    • Soft tissue damage


    • Infection


    • Necessity for secondary procedures (eg, implant removal)


    • Iatrogenic injury or technical failure


    • Further decompensation in acutely ill patients


  • Although many acute hand and wrist injuries may ultimately require surgical intervention, relatively few are considered emergent.



    • Important to appropriately triage


    • Determine which injuries may be appropriate for management in the subacute setting


    • If in doubt, discuss with hand specialist to aid in decision-making


EMERGENT INDICATIONS FOR SURGERY



  • Surgical emergency



    • Medical emergency for which a delay in surgical management could result in permanent impairment or death


    • Few hand and wrist injuries are life-threatening; however, many can result in significant functional impairment if not treated in a timely fashion


  • In general, hand or wrist conditions that may require emergent operative intervention include, but are not limited to:



    • Compartment syndrome


    • Open fractures or dislocations


    • Acute compressive neuropathy


    • Traumatic amputation


    • Infection


    • High-pressure injection injury


    • Vascular injury


  • Compartment syndrome (see Chapter 51)



    • Increase in pressure within a limited space (usually a fascial compartment), which limits the perfusion and function of the tissues in that space


    • Mechanisms include, but are not limited to:



      • Fracture (most common)



        • Distal radius fractures in adults


        • Supracondylar humerus fractures in children



      • Crush injury or soft tissue contusion


      • Arterial injury


      • Limb compression (eg, tight cast or splint)


      • Burns


    • If missed, can result in rapid tissue necrosis, subsequent fibrosis, contracture (ie, Volkmann ischemic contracture), and loss of function


    • Diagnosis is primarily clinical:



      • Pain out of proportion to clinical situation


      • Pain with passive stretch of fingers



        • Most sensitive finding


      • Paresthesias


      • Paralysis


      • Swelling/tense compartments


      • Absence of peripheral pulses



        • Almost always a late finding


      • Hand may rest in the intrinsic minus position



        • Metacarpophalangeal (MCP) joints extended and proximal interphalangeal joints flexed


    • Direct measurement of compartment pressure may be indicated if examination equivocal or if patient unresponsive or unreliable



      • Performed with specialized instrument (eg, Stryker Intra-Compartmental Pressure Monitor or equivalent)


      • Surgical intervention generally indicated for:



        • Value within 30 mm Hg of diastolic blood pressure



          • ▲ Accounts for effects of systemic hypertension or hypotension


        • Absolute value of 30 to 45 mm Hg



          • ▲ Falling out of favor



            • image May lead to unnecessary fasciotomies


            • image May lead to failure to perform needed fasciotomies


      • Often technique dependent



        • Should be performed by experienced provider


    • Unequivocal diagnosis of compartment syndrome should prompt emergent decompressive fasciotomy



      • Increase in time to surgery has been shown to result in worse outcomes.


  • Open fracture or dislocation



    • Communication of a fracture or joint space with the external environment



      • Typically graded by Gustilo classification (see Chapter 41)



    • All open injuries should receive adequate infection prophylaxis as soon as possible:



      • Coverage for typical skin bacteria (Gram-positive cocci)



        • Usually a first-generation cephalosporin (eg, cefazolin)


      • Add Gram-negative coverage for higher grade injury



        • Often an aminoglycoside (eg, gentamicin)


      • Add high-dose penicillin for soil or barnyard contamination


      • Add fluoroquinolone for fresh water or salt water wounds


      • Antitetanus prophylaxis


    • Need for emergent operative intervention often depends on degree of contamination.



      • Risk of infection directly related to adequacy of debridement


      • Injuries with extensive gross contamination often cannot be adequately debrided at the bedside



        • Remove any large, easily visible foreign bodies


        • Irrigate copiously with sterile saline or water


        • Cover with moist sterile dressing until reassessment in the operating room (OR)


    • Select open hand fractures may be appropriate for irrigation and debridement in the acute care setting with definitive management as an outpatient



      • Absence of contamination


      • Small wounds



        • <1 cm in size or “poke hole” wound


      • Ability to obtain close outpatient follow-up


    • Any open hand fracture generally warrants discussion with hand specialist.


  • Acute compressive neuropathy



    • Direct or indirect pressure on a nerve as a result of acute trauma



      • Causes local nerve ischemia with resulting paresthesias, pain, and weakness


      • Risk of long-term or permanent deficits if neglected


    • Acute carpal tunnel syndrome



      • Acute compression of the median nerve as it traverses the carpal tunnel at the wrist


      • Presentation



        • Numbness and tingling in thumb, index, long, and radial half of ring fingers


        • Rapidly progressive pain and paresthesias in the median nerve distribution



          • ▲ Symptom onset occurs over a period of hours/days versus weeks/months with chronic carpal tunnel syndrome



      • Causes:



        • Hand/wrist fractures or dislocations



          • ▲ Lunate or perilunate dislocations (see Chapter 15)



            • image Lunate may dislocate into carpal tunnel and compress median nerve


          • ▲ Distal radius fractures (see Chapter 26)


        • Postoperative



          • ▲ Most commonly after fixation of distal radius fractures


        • Hemorrhage into the carpal tunnel secondary to:



          • ▲ Trauma


          • ▲ Coagulopathy


    • First-line treatment



      • If secondary to fracture/dislocation:



        • Reduce as soon as possible


        • Should be performed by an experienced provider



          • ▲ Reduction of lunate/perilunate dislocations often challenging


      • Neurologic symptoms generally improve with successful reduction.


    • Emergent carpal tunnel release or open fracture reduction may be indicated with:



      • Failure of closed reduction


      • Worsening of median nerve symptoms despite reduction


      • Progressive symptoms in the absence of fracture or dislocation


  • Traumatic amputation (see Chapter 53)



    • Mechanisms



      • Sharp transection



        • Most favorable replant profile


      • Blunt transection


      • Avulsion (eg, ring avulsion)


      • Crush



        • Least favorable replant profile


    • Preserve any potentially salvageable amputated tissue



      • Two primary methods:



        • Wrap in gauze moistened with sterile saline or Ringer lactate and place on ice


        • Immerse in sterile saline or Ringer lactate in a plastic bag and submerge bag in ice


    • Key question guiding treatment—Is replant indicated?



      • Complex and multifactorial decision


      • Replants performed by specialized team at limited number of facilities



      • Time-sensitive


      • Early assessment by hand surgeon recommended to help guide treatment


    • Relative indications for replant:



      • Thumb amputation at any level


      • Multiple amputated digits


      • Partial hand amputation (through palm)


      • Amputation at wrist or forearm level


      • Amputation of individual digit distal to flexor digitorum superficialis insertion


      • Almost any amputated part in a child


    • Unfavorable factors



      • Crush or mangling injury


      • Amputation at multiple levels (segmental amputation)


      • Presence of serious medical comorbidities


      • Vascular disease


      • Amputation of individual digit in an adult proximal to flexor digitorum superficialis insertion


      • Prolonged warm ischemia time


      • Severe tissue contamination


    • Permissible ischemia time for replant:



      • Proximal to carpus:



        • Warm ischemia time <6 hours


        • Cold ischemia time <12 hours


      • Distal to carpus (eg, digital amputation)



        • Warm ischemia time <12 hours


        • Cold ischemia time <24 hours


    • If replantation feasible, prepare patient for operating room or make arrangements for emergent transfer to replant center


  • Infection

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May 7, 2019 | Posted by in ORTHOPEDIC | Comments Off on General Concepts: Indications for Surgery

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