Particularities of hand and wrist complex injuries in polytrauma management

Hand and wrist lesions are relatively common in polytraumatised patients. These subjects sustain a wide range of potential life-threatening conditions and hand and wrist injuries incurred are often not diagnosed or are insufficiently treated. Closed lesions are the most frequently missed diagnosis, but even severe open lesions may be incorrectly treated. Most of these hand and wrist injuries can have a strong negative impact on long-term quality of life, particularly when treatment of these injuries is poor or delayed. Orthopaedic and hand surgeons should be vigilant in their assessment and treatment of patients with multiple injuries and a global approach, based on the advanced trauma life support (ATLS)-protocol, must be applied. The very common association of head, chest, abdomen, bone and soft-tissue lesions in the polytraumatised patient requires a multidisciplinary team approach from the beginning. The energy of trauma in these patients often causes complex injuries to the wrist and hand; these require correct treatment in terms of both timing and techniques. It is not possible to create a practical, useful guideline with a “one lesion-one solution” approach, because every case is different; therefore, this paper describes a spectrum of indications and techniques that may be useful in managing hand and wrist injuries, particularly in polytraumatised patients.     

Assessment of the severity of hand injuries using "hand injury severity score", and its correlation with the functional outcome

INTRODUCTION: Objective assessment of hand injuries is a complex subject. However, an objective assessment, leading to a score, can help in predicting outcome and can be used as a research tool. Campbell and Kay have devised one such score known as "hand injury severity score" or HISS [J. Hand. Surg. [Br.] 21 (3) (1996) 295]. A study on this score has been carried out in our institute. The idea was to see if the hand injury severity score, correlates with the functional outcome as measured by disability arm shoulder and hand score (DASH), after a period of minimum 2 years. METHOD: All the hand injury patients admitted in the hospital were assessed at the time of admission, and objective information was documented on a hand injury documentation form. The form captured all the data required to calculate "hand injury severity score" . A sample of 70 patients admitted during the first 6 months of 1999 was taken and their scores were calculated. The sample was selected such, that it had a reasonable representation of hand injuries of all severities. After obtaining a due approval from ethics committee, all these 70 patients were sent a DASH questionnaire. A total of 23 patients replied. Spearman's rank correlation test was used to analyse the correlation between the severity of hand injury as assessed using HISS, and functional outcome as measured using DASH. Correlations between the outcome and skeletal component score, outcome and motor component scores, and outcome and Integument component scores, were assessed separately. RESULTS: The study shows a statistically significant association ( r = 0.7182, P = 0.000165) between the severities of injury and the functional outcome. The functional outcome also shows a statistically significant association with the severity of injury to skeletal component (r = 0.5151, P = 0.014083) and motor component (r = 0.6797, P = 0.000507). However, the severity of injury to integument component, as measured by HISS, does not show any association with the outcome (r = 0.3571, P = 0.102736). This study supports the overall structure of the HISS. However an improvement in the integument component scoring is required to improve overall accuracy.     

手部压砸伤的急诊处理及功能恢复

目的：探讨急诊处理手部压砸伤的方法和疗效。方法：对132例患者，用无创技术彻底清创，骨折内固定后修复断伤的各种组织，用游离皮瓣，岛状皮瓣或带蒂皮瓣修复手部软组织的缺损，伤口愈合后辅以理疗及活血化瘀的中药泡手，术后尽早进行康复训练，结果：90例在术后随访2－18个月，42例失访，按肌腱评定标准（TAM）评定，手功能恢复优28例，良30例，中21例，差11例，优良率为64．4％。结论：急诊手部压砸伤的正确处理，创面的覆盖和术后早期功能锻炼对手功能恢复的优劣有一定的影响。     

Evolving trends in the care of polytrauma patients

Management of polytrauma patients has changed considerably in recent years. This is in keeping with the developments that have occurred in the fields of fracture fixation techniques and intensive care. Prior to the 1970s, patients with multiple injuries were treated non-operatively, as it was believed that they were too ill to withstand surgery. Around this time, literature appeared to suggest that these patients had high rates of complications as a result of prolonged recumbency. Fracture fixation techniques were also developing rapidly, and these events led to the advent of early fracture stabilisation of multiply injured patients, known as early total care. In the following decade, the surgical world came to recognise that early stabilisation of skeletal injuries produced poor results in certain patients. The concept of 'damage control' surgery was introduced for multiply injured patients. The current era may give way to new methods as our understanding of the pathophysiology of polytrauma improves.     

手部套脱伤的分型与程序化治疗临床应用研究

目的 探讨手部皮肤套脱伤的分型与治疗方式.方法 依据不同的伤情与手术治疗方法,将手部套脱伤分为六种类型.针对不同分型,提出程序化治疗的概念,采取点对点的应对措施,并使用了阶梯式修复血管、交替式切口清创、局限性缝合固定、区域性加压包扎及散在性切口引流等技术.结果 本组共144例,获得10年以上随访49例,5年42例,3年24例,1年20例,5个月9例.15例全手套脱伤中仅1例手背部分皮肤作了游离植皮治疗,小指部分坏死作了截指;其他类型的皮肤撕脱和手指套脱伤经治疗全部存活.皮肤外形美观,耐磨擦能力强,基本恢复了原来的手功能.结论 手部套脱伤六型分类法切合临床实际,程序化治疗采用点对点的应对措施,便于临床迅速展开救治.其中的关键技术解决了手部套脱伤手术中的技术难题,术中、术后相关辅助措施进一步提高了手部皮肤套脱伤治疗的成活率.程序化治疗为临床手部套脱伤的救治开辟了一条全新的途径.     

The use of external fixators in the definitive stabilisation of the pelvis in polytrauma patients: Safety,efficacy and clinical outcomes

ObjectivesTo analyse the complications and outcomes (functional/radiographic) of Pelvic External Fixators applied as part of the definitive fixation in polytrauma patients.DesignA single center retrospective chart review.SettingA level-1 trauma center.Patients and methodsWe reviewed all the polytrauma patients (ISS > 16) between 2007 and 2012 that had a PEF applied more than 30 days. Complications including infection, aseptic loosening, neurological injury, loss of reduction, non-union and mal-union were recorded. Pelvic asymmetry and Deformity Index (DI) were measured at the immediate postoperative radiographs and final follow-up. The functional outcome at final follow up was estimated using a scale previously reported by Chiou et al.Results59 patients with mean age of 38.4 (16 − 81) years and mean ISS score 28 (16- 66) were included. The PEFs were applied for mean duration of 56 (30–104) days. The average follow-up was 403 days. 22 injuries were type B and 37 type C (AO/OTA). The most common symptomatic complications were pin site infection in 11 (18.6%) and loosening in 5 (8.5%) cases. 44 (74.5%) patients had satisfactory functional outcome. The immediate post-operative and final asymmetry and DI were compared between the two pelvic injury groups (type B and C fractures). The difference in displacement progression was more for type C injuries (p = 0.034) but no correlation to the functional outcome was evident.ConclusionPEF can be used as definitive alternative stabilization method in specific situations at polytrauma setting. Radiological displacement occurred in both type B and C injuries but the clinical outcome was not correlated to this displacement. Complications related to PEF do not affect the final clinical outcome.Level of evidenceTherapeutic Level III.     

Tertiary survey in polytrauma patients should be an ongoing process

IntroductionDue to prioritisation in the initial trauma care, non-life threatening injuries can be overlooked or temporally neglected. Polytrauma patients in particular might be at risk for delayed diagnosed injuries (DDI). Studies that solely focus on DDI in polytrauma patients are not available. Therefore the aim of this study was to analyze DDI and determine risk factors associated with DDI in polytrauma patients.MethodsIn this single centre retrospective cohort study, patients were considered polytrauma when the Injury Severity Score was ≥16 as a result of injury in at least 2 body regions. Adult polytrauma patients admitted from 2007 until 2012 were identified. Hospital charts were reviewed to identify DDI.Results1416 polytrauma patients were analyzed of which 12% had DDI. Most DDI were found during initial hospital admission after tertiary survey (63%). Extremities were the most affected regions for all types of DDI (78%) with the highest intervention rate (35%). Most prevalent DDI were fractures of the hand (54%) and foot (38%). In 2% of all patients a DDI was found after discharge, consisting mainly of injuries other than a fracture. High energy trauma mechanism (OR 1.8, 95% CI 1.2–2.7), abdominal injury (OR 1.5, 95% CI 1.1–2.1) and extremity injuries found during initial assessment (OR 2.3, 95% CI 1.6–3.3) were independent risk factors for DDI.ConclusionIn polytrauma patients, most DDI were found during hospital admission but after tertiary survey. This demonstrates that the tertiary survey should be an ongoing process and thus repeated daily in polytrauma patients. Most frequent DDI were extremity injuries, especially injuries of the hand and foot.     

手部皮肤套脱伤的治疗

目的探讨手部皮肤套脱伤的治疗方法。方法2002年4月-2004年11月，治疗22例手部皮肤套脱伤患者，其中19例分别通过吻合血管、套脱皮肤修薄回植及多切口引流等方法进行修复。另有3例，因无法行套脱皮肤回植而采用腹部带蒂皮瓣修复。结果术后随访3个月-1年。19例套脱皮肤原位回植患者中，13例皮肤完全成活，4例有部分皮缘坏死，经中药换药后愈合，2例行切痂植皮术后治愈。手功能按ATN功能评分评定：优9例，良7例，中3例，优良率为84％，患者对手外形及功能满意。3例腹部皮瓣修复者，皮瓣全部成活。术后随访5个月-1年，手外形及功能明显差于皮肤原位回植者。结论尽可能地回植手部套脱皮肤，对手功能及外形的恢复具有重要意义。     

真皮下血管网皮瓣原位再植治疗手背皮肤逆行撕脱伤

目的探讨真皮下血管网皮瓣原位再植治疗手背皮肤逆行撕脱伤的临床效果.方法 1996年1月至2001年6月,应用真皮下血管网皮瓣原位再植治疗手背皮肤逆行撕脱伤56例.撕脱皮瓣面积为7 cm × 10 cm ～ 10 cm × 13 cm. 结果 56例移植皮瓣全部成活.术后随访3个月～ 5年,10例失访;46例的手背外形满意,再植皮瓣恢复了保护性痛觉,拇指对掌对指功能正常.2 ～ 5指的伸屈活动范围按 TAM评定标准评定,功能恢复优良者40例,占87.0%. 结论将无挫伤或轻度挫伤的手背逆行撕脱皮肤修成真皮下血管网皮瓣原位再植,是治疗手背皮肤逆行撕脱伤的有效方法之一.     

The impact of injuries below the knee joint on the long-term functional outcome following polytrauma

Previous studies have suggested that the lower-extremities are among the most frequently injured body regions in polytrauma patients and have a major impact on the functional recovery following polytrauma. In particular, injuries to the distal part of the lower-extremity appear to be associated with a poor functional outcome. Therefore, the goal of this study was to evaluate the impact of injuries below the knee joint on the long-term functional outcome following polytrauma. Three hundred eighty-nine polytrauma patients with associated lower-extremity fractures and a minimum follow-up of 10 years were included in this study. All patients were examined by a doctor, using a patient questionnaire and a standardised physical examination. Significantly, inferior outcomes were seen in patients with fractures below the knee joint as measured by the modified Karlstr?m-Olerud score, Lysholm score, range of motion, weight bearing status, Hannover score for polytrauma outcome (HASPOC), SF-12, Tegner activity score, and inability to work (P < 0.05). Fractures below the knee joint have a significant impact on the functional recovery following polytrauma. We suggest that delayed treatment, thin soft tissue envelope below the knee joint, high-energy trauma, unfavorable blood supply, and complex fracture patterns contribute to these unfavorable outcomes.     

Predictors of functional outcome after hanging injury

Purpose

Suicide becomes a serious problem in today's society and hanging is a common method of suicide. We want to find the factors which can predict the final functional outcomes of these cases.

Assessment of quality of life and functional outcome in patients sustaining moderate and major trauma: A multicentre,prospective cohort study

Background

Trauma care systems aim to reduce both death and disability, yet there is little data on post-trauma health status and functional outcome.

Objectives

To evaluate baseline, discharge, six month and 12 month post-trauma quality of life, functional outcome and predictors of quality of life in Hong Kong.

Methods

Multicentre, prospective cohort study using data from the trauma registries of three regional trauma centres in Hong Kong. Trauma patients with an ISS ≥ 9 and aged ≥ 18 years were included. The main outcome measures were the physical component summary (PCS) score and mental component summary (MCS) scores of the Short-Form 36 (SF36) for health status, and the extended Glasgow Outcome Scale (GOSE) for functional outcome.

Results

Between 1 January 2010 and 31 September 2010, 400 patients (mean age 53.3 years; range 18–106; 69.5% male) were recruited to the study. There were no statistically significant differences in baseline characteristics between responders (N = 177) and surviving non-responders (N = 163). However, there were significant differences between these groups and the group of patients who died (N = 60). Only 16/400 (4%) cases reported a GOSE ≥ 7. 62/400 (15.5%) responders reached the HK population norm for PCS. 125/400 (31%) responders reached the HK population norm for MCS. If non-responders had similar outcomes to responders, then the percentages for GOSE ≥ 7 would rise from 4% to 8%, for PCS from 15.5% to 30%, and for MCS from 31% to 60%. Univariate analysis showed that 12-month poor quality of life was significantly associated with age > 65 years (OR 4.77), male gender (OR 0.44), pre-injury health problems (OR 2.30), admission to ICU (OR 2.15), ISS score 26–40 (OR 3.72), baseline PCS (OR 0.89), one-month PCS (OR 0.89), one-month MCS (OR 0.97), 6-month PCS (OR 0.76) and 6-month MCS (OR 0.97).

Conclusion

For patients sustaining moderate or major trauma in Hong Kong at 12 months after injury < 1 in 10 patients had an excellent recovery, ≤3 in 10 reached a physical health status score ≥ Hong Kong norm, although as many as 6 in 10 patients had a mental health status score which is ≥ Hong Kong norm.     

三种修复手部创面皮瓣的临床疗效评价

目的 比较骨间背侧动脉皮瓣、股前外侧皮瓣和腓肠内侧动脉穿支皮瓣的临床疗效,为临床的皮瓣选用提供参考.方法 对应用骨间背侧动脉皮瓣、股前外侧皮瓣和腓肠内侧动脉穿支皮瓣修复手部创面的23例患者进行随访,比较分析DASH(disability of the arm,shoulder and hand)分数、损伤的部位、触觉压觉(Senunes-Weinstein单丝法)、两点分辨觉(动、静态,m2PD、s2PD)、温度觉、臃肿程度和供区瘢痕挛缩程度.结果 三种皮瓣的DASH评分、瘢痕挛缩程度、皮瓣的臃肿程度、触觉压觉、两点分辨觉和温度觉的结果 ,差异均没有统计学意义;股前外侧皮瓣的臃肿程度高于其他两种皮瓣,差异具有统计学意义.结论 三种皮瓣各有特点,临床选择应该根据各种客观要求,不要主观臆测.     

Timing of intervention for spinal injury in patients with polytrauma

ObjectiveThe optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores.MethodsA narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995–2020) based on the keywords – polytrauma OR multiple trauma AND spine fracture AND timing, present in “All the fields” of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed.ResultsSpine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, “damage control” internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay.ConclusionRecognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.     

手掌部皮肤逆行撕脱伤两种治疗方法的对比研究

目的　探讨手掌部皮肤逆行撕脱伤的修复方式。方法　应用显微外科技术重建远端肢体血运。吻合静脉组 2 4例 ,通过吻合掌侧浅静脉 ,再建皮肤的血液循环。对照组 2 1例 ,应用传统的方法将撕脱皮肤原位游离植皮。结果　术后随访 5～ 7年 ,皮肤存活面积、外形及功能 ,试验组均优于对照组。两组患者皮肤存活面积百分比的平均值相比 ,差异有显著意义 (t =11.62 3 ,P <0 .0 1)。结论　吻合掌侧浅静脉修复手掌部皮肤逆行撕脱伤是一种较为理想的修复方法     

The use of an iPad to collect patient-reported functional outcome measures in hand surgery

Background

The purpose of this study was to evaluate (1) patient preferences regarding iPad and paper-based questionnaires, (2) the efficacy of iPad and paper questionnaires in a hand surgery practice, (3) the influence of questionnaire length on patient preferences and data collection, and (4) patient characteristics associated with a preference for iPad-based questionnaires.

Methods

Two hundred total patients in a single hand surgery practice were randomly assigned to one of four groups. Each group completed either the Michigan Hand Questionnaire (MHQ) or QuickDASH (QD) using either an iPad or pen and paper. Patient preferences, questionnaire completion and timing, and demographic data were analyzed.

Results

The use of an iPad was associated with a statistically stronger preference for the same delivery format in the future compared to paper for the MHQ (93.9 vs 52.1 %, p < 0.001) and QD (90.0 vs 41.7 %, p < 0.001). The MHQ iPad group found the survey “physically easy” more often compared to the MHQ paper group, while no difference was found among QD groups. Questionnaire timing between iPad and paper groups was similar for the MHQ but statistically longer with the iPad for QD. A significantly higher proportion of patients who preferred the iPad were under the age of 50 compared to those who preferred paper.

Conclusions

The addition of an iPad is an efficient and preferable questionnaire format for functional outcome assessment in a hand and upper extremity surgery practice setting. The iPad is particularly preferable for longer outcome questionnaires and for patients under the age of 50.     

伤害控制骨科学--多发伤治疗最新观点

挽救生命、减少伤残仍是多发伤救治的基本观点，治疗的形式和时机却在逐渐地变化、修正，伤害控制原则是一项新的多发伤治疗策略，其在创伤骨科的应用产生了伤害控制骨科学。伤害控制骨科学包括三步，第一步：早期临时固定不稳定性骨折、止血，如果需要，作颅内减压；第二步：在ICU内复苏病人使其各项生理指标达到理想状态；第三步：病人病情稳定后进行最终的正式手术固定骨折。伤害控制骨科学适应证：血液动力学不稳定及极度危重的多发伤病人应遵循伤害控制原则；对临界病人，仍可早期手术正式固定骨折，但如果手术过程中任何时间发生病情恶化，手术应该立即改为伤害控制。伤害控制骨科学是一项正在发展、完善的技术，将来研究需要进一步验证既有观点的有效性，以减少多发伤病人ARDS和MOF的发生。     

手部感染的康复治疗

目的：观察综合康复疗法对治疗急、慢性手部感染的作用。方法：对50例手部感染患者，早期采用超短波电疗和紫外线疗法进行抗炎治疗以促进伤口愈合，后期通过蜡疗，超声波疗法及运动疗法达到恢复手部功能的目的。结果：50例的感染均得到早期控制，总有效率达98％，伤口愈合手功能完全恢复者急性感染占82．93％，慢性感染占44．44％，结论：治疗手部感染时同时积极采用康复治疗，可有效地控制炎症，促进伤口愈合，恢复手功能。     

手掌压砸伤术后尺偏手畸形的病因及治疗

目的 探讨手掌压砸伤术后"尺偏手"畸形的形成原因和治疗方法.方法 对40具手标本通过测量各指指背腱膜相对于指骨的位置、手内在肌的重量及生理横切面积,为明确临床"尺偏手"畸形的病因提供解剖学研究基础.2007年3月至2010年2月,对6例严重手压砸伤造成术后"尺偏手"畸形的患者进行手内在肌功能重建术.结果 解剖学研究发现指背腱膜及伸肌腱有将掌指关节拉向尺侧的作用力,而手内在肌则与之对抗,形成向桡侧的作用力.在正常手中,这两种作用力是平衡的;而在压砸伤术后手内在肌缺损的情况下,就失去了向桡侧的作用力,导致了临床中常见的"尺偏手"畸形.6例"尺偏手"畸形手内在肌功能重建术后随访时间平均8.5个月,尺偏得到较好的纠正,拇对指功能得到明显改善.结论 严重手掌压砸伤术后因手内在肌缺损导致肌力失衡引起"尺偏手"畸形,应在急诊手术中尽量保留手内在肌的连续性并修复断裂的手内在肌;对已经形成的"尺偏手"畸形,需行手内在肌重建术.

Abstract：

Objective To investigate the cause and management of ulnar club-hand secondary to crush injury of the palm. Methods Forty eadaver hands were dissected to measure the relative position between extensor aponeurosis and phalanges, the weight and cross-sectional area of intrinsic muscles to provide anatomical basis of the causes of ulnar club-hand. From March 2007 to February 2010, six patients with ulnar club-hand secondary to severe crush injury underwent intrinsic muscle reconstruction. The causes of ulnar club-hand were investigated in these cases. Results Anatomical dissection revealed that the extensor aponeurosis and extensor tendon of the finger tend to deviate the metacarpophalangeal joint ulnarly, while the intrinsic muscles work antagonistically to pull the joint radially. In the normal hand, these two kinds of acting forces are balanced. In the absence of intrinsic muscles after severe crush injury of the hand, this balance is broken, and the hand tends to deviate ulnarly. Intrinsic muscle reconstruction in six patients with ulnar club-hand secondary to palm crush injury restored the balance and corrected the ulnar deviation deformity after 8.5 months follow-up. Thumb opposition was also improved. Conclusion The absence of hand intrinsic muscles was the main cause of ulnar club-hand in severe crush injury. In the emergency operation, ruptured intrinsic muscles should be repaired whenever possible to prevent ulnar club-hand. For established ulnar club-hand, intrinsic muscle reconstruction should be done to correct the deformity.     

Incidence and significance of injuries to the foot and ankle in polytrauma patients—An analysis of the Trauma Registry of DGU

Background

Injuries to the foot and ankle are often missed or underestimated during the initial care for polytraumatized patients. Nonetheless, injuries to the lower extremity exert significant influence on long-term outcome after discharge from the acute care facility. Since the mortality of trauma decreased in the last decades, these injuries gain more effect on the overall outcome. We analysed foot and ankle injury patterns, associated procedures and special characteristics of this population during early care.

Methods

Multiply injured patients of the Trauma Registry of DGU (TR-DGU; Injury Severity Score, ISS ≥ 16) with injuries to the foot and ankle (group F&A) were compared to the remaining TR-DGU population (group Non-F&A) for differences in injury characteristics, surgical treatment and early outcome. A detailed comparative statistic is provided.

Results

Demographic data and injury severity were comparable between the groups. The group F&A showed significantly more falls from a height above 3 m and suicidal injuries. Their overall injury severity to the extremities, especially to the regions different from the foot and ankle, was significantly higher compared to group Non-F&A. Group F&A patients had more surgeries and less intensive care complications. Mortality was 11.6% (F&A) and 16.2% (Non-F&A). Concerning initial outcome when discharged from the acute care facility, group F&A patients more commonly were moderately or severely disabled in everyday life.

Conclusions

Our data enhance the need for a meticulous search for injuries to the foot and ankle in patients with falls, comparably light injuries to the trunk and head and especially in patients with multiple and severe injuries to the skeletal system. Since 88.4% of patients with foot and ankle injuries are discharged alive, early appropriate care should be given to these injuries that significantly affect long-term outcome.