Istvan Frendl MD

Closed and open soft tissue injuries,Closed and open soft tissue injuries, wound treatment, vessel injuries wound treatment, vessel injuries

Istvan Frendl MD

Closed and open soft tissue injuries,Closed and open soft tissue injuries, wound treatment, vessel injuries wound treatment, vessel injuries

Department of Trauma and Hand SurgeryUniversity of Debrecen

Medical and Health Science CenterHungary

www: traumatologia.deoec.hulogin: traumatologykeyword: lectures

When somebody participate in sports and physical activities, can injure the soft tissues of the body. Even simple everyday activities can damage these ligaments, tendons, and muscles.

These closed soft-tissue injuries are:

• sprain• partial rupture• complete rupture• contusion• tendonitis• bursitis

Sprain:• The joints of the body are supported by ligaments. Ligaments are strong bands

of connective tissue that connect one bone to another. A sprain is a simple stretch or tear of the ligaments.

• The stability is maintained.

• A sprained ankle can occur when the foot turns inward. This can put extreme tension on the ligaments of the outer ankle and cause a sprain.

• A sprained knee can be the result of a sudden twist.

• A wrist sprain most often occurs when somebody fall on an outstretched hand.

• Most mild sprains heal with "R.I.C.E." (rest, ice, compression, and elevation) and exercise. Moderate sprains may also require a period of bracing. The most severe sprains may require surgery to repair torn ligaments.

Partial rupture:• Tendons connect muscles to bones.

• A partial rupture is the result of an injury to either a muscle or a tendon, usually in the foot or leg. It may be a simple stretch in the muscle or tendon, and in the muscle-and-tendon combination.

• There is some loss of stability.

• The recommended treatment for a partrial rupture is the same as for a sprain: rest, ice, compression, and elevation. This should be followed by simple exercises to relieve pain and restore mobility.

Complete rupture• For a serious tear (complete rupture), the

soft tissues may need to be repaired surgically.

• There is loss of stability.

Subcutaneous rupture of the Achilles tendon

Quadriceps muscle subcutaneous rupture

Pull-out suture and pinning

Stack splintaluminum or plastic splints, custom thermoplastic splints

Mallet fingerExtensor tendon injury at DIP

Rupture (tendon)

Avulsion (tendon –bone junction)

Dorsal fracture (abruptio)

Dorsal fracture with big fragment and DIP joint dislocation

Mallet finger

Boutonniere deformity

Swan neck deformity(Mallet finger with compensatory swan neck)

(no active DIP extension)

PIP flexion + DIP hyperextension)

Boutonniere deformitySubcutan extensor tendon rupture at PIP joint (PIP flexion + DIP hyperextension)

Bunnell splint

Flexor digitorum profundus tendon (FDP) avulsion

Leddy classification:I: avulsion with long proximal tendon retractionII: avulsion with short retraction (vinculum longum is intact)III: small fragment

Contusions:

• A contusion is a bruise caused by a blow to the muscle, tendon, or ligament. The bruise is caused when blood pools around the injury and discolors the skin.

• Most contusions are mild and respond well when you rest, apply ice and compression, and elevate the injured area (R.I.C.E.).

Tendonitis:• Inflammation is a healing response to injury. It is usually accompanied by

swelling, heat, redness, and pain. An inflammation in a tendon or in the covering of the tendon is called tendonitis.

• Tendonitis is caused by a series of small stresses that repeatedly aggravate the tendon.

• Baseball players, swimmers, tennis players, and golfers are susceptible to tendonitis in their shoulders and arms.

• Soccer and basketball players, runners, and aerobic dancers are prone to tendon inflammation in their legs and feet.

• Tendonitis may be treated by rest to eliminate stress, anti-inflammatory medication, steroid injections, splinting, and exercises to correct muscle imbalance and improve flexibility.

Bursitis:• A bursa is a sac filled with fluid that is located between a bone

and a tendon or muscle. A bursa allows the tendon to slide smoothly over the bone.

• Repeated small stresses and overuse can cause the bursa in the shoulder, elbow, hip, knee, or ankle to swell. This swelling and irritation is called bursitis.

• Most ofen the olecranon bursa and prepatellar bursa are diseased.• Bursitis can usually be relieved by rest and possibly with anti-

inflammatory medication.• Most severe bursitis may require surgery.

Degloving injury (Decollement):• If a limb pulled violently at the moment of impact, the skin may be

peeled back over the bones. The skin being stripped off the underlying tissues. There will be subcutaneous haematoma. It is common in fractures of the tibia and fibula.

• Treatment: Debridement, Haematoma removal,

• The degloved skin is dead and should be replaced as if it were a free skin graft.

Mesh split thickness skin graft

Compartment syndrome:• Group of muscles are contained within fascial compartments. The fascia

prevents the damaged tissue swelling and the pressure within the compartment will rise, the tissues become ischaemic and undergo necrosis.

• Ischaemic muscle is replaced by fibrous tissue, which contracts.

• Nerves also become damaged.

• The forarm has two compartments (ventral and dorsal) and the leg has four compartments (anterior tibial, superficial posterior, deep posterior, peroneal).

• Symptoms: big pain, pallor of the limb, the skin is cool, pulses are absent (not always!), movement, particularly passive extension is extremly painful.

• Tretment: fasciotomy, open wound treatment until swelling has subsided, than secundary skin closure or the defect should be skin grafted.

Compartment pressure measuring fasciotomy

Wound treatment(open soft tissue injuries)

Type of skin injury:Type of skin injury:

mechanical

thermical

chemical

irradiation

The wound healing process:The wound healing process: Acut inflammation phase

Cellproliferation phase

Epithelisation phase

Development of extracellular matrix (fibroblasts

produce collagens)

Collagen remodellation

inspection

palpation

functional examination (Moberg test on hand)

active and passive range of motion

of the joints (Neutral-O-Methode)

innervation

blood supply (Allen test)

Patient examination:Patient examination:

Examination of the hand, Moberg test

Examination of the FDP (flexor digitorum profundus) tendon function

Examination of the FDS (flexor digitorum superficialis) tendon function

Type of mechanical skin injuries (in latin):Type of mechanical skin injuries (in latin):

vulnus caesum (cut) vulnus scissum (section) vulnus punctum (punture) vulnus contusum (contuse) vulnus morsum (animal bite) vulnus lacerum (destruction) vulnus sclopetarium (gunshoot)

Wound treatment:Wound treatment:

Tetanus profilaxis Time factor:

- in 6 hours, new, fresh, „clean” wound:

primary closure: excision, debridement,

haemostatis, drainage,

- after 6 hours: delayed wound treatment,

open wound treatment (anaerob bacteria)

Open wound treatment, delayed wound tretment:Open wound treatment, delayed wound tretment:

infected wound gunshoot, explosion injury butcher’s wound sewage/canal worker’s wound puncture wound animal bite high pressure spray-gun injury

Proper skin incisions on the handProper skin incisions on the hand

DrainageDrainage

intracutan suture of skin angleintracutan suture of skin angle

Vessel injuries

Wound treatment on the site:Wound treatment on the site:

Bleeding:

Compresson bandage or pneumatic cuff

(max. 2 hours)

Wound:

steril bandage

AnatomyAnatomy

Blood supply to the hand: radial and ulnar artries

The ulnar artery forms the superficial palmar arterial

arch and the radial artery forms the deep palmar

arterial arch.

Variations

The superficial palmar arterial arch is more important.

Blood supply to the hand: radial and ulnar artries

The ulnar artery forms the superficial palmar arterial

arch and the radial artery forms the deep palmar

arterial arch.

Variations

The superficial palmar arterial arch is more important.

The superficial and deep palmar arterial arches

Types of vessel injuriesTypes of vessel injuries

Arterial and venous bleeding

Open and closed vessel injuries

Cutting and puncture arterial injuries (knife, glass)

Crush - Destruction injuries

(the adventitia is intact but the intima injured)

Explosion (vessel defect !)

Displaced fracture (i.e. closed supracondylar humeral

fracture)

Arterial and venous bleeding

Open and closed vessel injuries

Cutting and puncture arterial injuries (knife, glass)

Crush - Destruction injuries

(the adventitia is intact but the intima injured)

Explosion (vessel defect !)

Displaced fracture (i.e. closed supracondylar humeral

fracture)

Symptoms, Diagnosis:Symptoms, Diagnosis:

Open vessel injury

arterial: pulsative, shoot out type bleeding,

venous: darker colour, slowly flowing bleeding

Weak or no peripheral pulse

No capillar refill

Open vessel injury

arterial: pulsative, shoot out type bleeding,

venous: darker colour, slowly flowing bleeding

Weak or no peripheral pulse

No capillar refill

Diagnosis:Diagnosis:

Allen-test

Angiography

Doppler - ultrasound

Operative exploration

Allen-test

Angiography

Doppler - ultrasound

Operative exploration

Allen test

Allen test

Treatment of bleeding: Treatment of bleeding:

Compresson bandage or pneumatic cuff

(max. 2 hours) + elevation of the extremity

Never use vessel clamp on the site

(only in operation room)

Compresson bandage or pneumatic cuff

(max. 2 hours) + elevation of the extremity

Never use vessel clamp on the site

(only in operation room)

On the site, first responder

Types of vessel injury:Types of vessel injury:

Macrovessel injury: proximal from wrist

Microvessel injury: distal from wrist

Macrovessel injury: proximal from wrist

Microvessel injury: distal from wrist

Treatment of vessel injury:Treatment of vessel injury:

Operative techniques for macrovessel anastomosis:

Preparation of vessel stumps, removal of adventicia,

vessel clips, heparin Anastomosis: after sharp injury, with 5/0-8/0

atraumatical suture material, running suture Vena graft: after destructive injury or defect

(vena saphena magna, cephalica, basilica)

Preparation of vessel stumps, removal of adventicia,

vessel clips, heparin Anastomosis: after sharp injury, with 5/0-8/0

atraumatical suture material, running suture Vena graft: after destructive injury or defect

(vena saphena magna, cephalica, basilica)

Treatment of vessel injury:Treatment of vessel injury:

Operative techniques for microvessel anastomosis:

Microvessel: vessel with 2-0,3 mm lumen.

Magnification: Operation microscope or glasses

Microsurgical suture materials and instrumets. Preparation of vessel stumps, removal of adventicia, vessel clips, heparin. Simple interrupted sutures with (8/0-11/0) suture materials.

Microvessel: vessel with 2-0,3 mm lumen.

Magnification: Operation microscope or glasses

Microsurgical suture materials and instrumets. Preparation of vessel stumps, removal of adventicia, vessel clips, heparin. Simple interrupted sutures with (8/0-11/0) suture materials.

End-to-end arterial anastomosis(removal of the adventicia, stay stitches)

End-to-end arterial anastomosis(removal of the adventicia, stay stitches)

End-to-end arterial anastomosisEnd-to-end arterial anastomosis

(back wall sutures)(back wall sutures)

End-to-end anastomosis(front wall sutures)

End-to-end anastomosis(front wall sutures)

End-to-end arterial anastomosisEnd-to-end arterial anastomosis

(the completed anastomosis)(the completed anastomosis)

Interpositional vein graftInterpositional vein graft

Thank you for your attention!