بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم قالو سبحانك لا علم لنا الا ما علمتنا انك انت العليم الحكيم صدق الله العظيم

2. Open wounds of the wrist Hamed Ahmed Abulkhair lecturer Orthopaedic surgery Zagazig University 2012

3. wrist anatomy

4. 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.

6. 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

7. Deep when it involves one or more of the following structures Tendons Muscles Nerves Arteries. Bones Or all of the above in amputation

8. Treatment of deep wounnd • Urgent exploration • Debridment • Repair of any of the injured deep structures

9. Tendon injury Diagnosis of Flexor Injury • Posture of Hand/ Normal cascade • Passive tenodesis test • Forearm compression test • Independent testing of FDS & FDP • Partial damage

10. Normal Flexion Cascade

11. Flexor Tendon Testing

12. 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

13. Tendon repair techniques Core suture techniques

14. Superfascial suture techniques

16. 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.

17. 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

18. 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

19. Nerves - Sensory

20. 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

22. 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.

24. 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

25. 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.

26. 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)

27. Contraindications Severely crushed or mangled parts or avulsed hand beyond reconstruction

28. 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 leak-proof bag • Put the bag in ice container

29. OPERATIVE SEQUENCE • Bone shortening and fixation • Tendon repair • Arterial repair • Neurorrhaphies • Venous repairs • Skin coverage or closure

30. 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

31. Post operative medications • Antibiotics • Systemic heparinzation • Chlorpromazine • Antiplatelets eg, aspirin