Hand and Wrist Surgery - part 4 pptx

V A S C U L A R D I S O R D E R S 162 Host factors also influence the prognosis of extravasation injuries. Advanced age, immune compromise, nutritional deficits, steroid dependency, and preexisting pe- ripheral vascular disease are all common host factors that can greatly amplify the damage caused by any given extravasation event. Remember that the mainstay of conservative management is elevation, use of a cool compress, and a loosely wrapped splint to protect and rest the injured part. Al- though it may seem obvious, make sure that the offending intravenous catheter is removed so that no more agent can extravasate, and make sure that the affected ex- tremity is not further compromised by tight circumferential items such as jewelry, hospital identification bracelets, or tight bandages. Application of heat to the af- fected area often makes the local swelling much worse and should be avoided. Mark the affected area of the limb with an ink marker so that improvement or worsening can be easily noted as time passes. Save whatever intravenous equipment and drug bags are present initially so that the offending agent and circumstances of extravasa- tion can be clearly and thoughtfully assessed. Injection of antidote material into the affected area may be occasionally indicated for specific cases (i.e., hydrofluoric acid or powerful vasoconstrictor extravasations), but in most cases such injections should be avoided because they will only increase local tissue pressures, increase the likelihood of tissue death or vascular compromise, and inconsistently reach the of- fending agent. Surgical intervention is an immediate requirement if compartment syndrome or compromise of a major vessel is present. Surgical drainage and decompression of an extravasation injury is also helpful if large volumes of agent are involved, or if the offending agent is a vesicant and the necrosis interval has not yet expired. Once this interval has passed, surgical intervention may be better delayed until clear demar- cation of dead tissue has occurred. After thorough debridement of dead tissue, flap coverage or other complex reconstructive procedures may be warranted based on the size of the remaining soft tissue defect. Nonsurgical Management This patient presented with a severe, acute left forearm compartment syndrome. All circumferential appliances and intravenous lines were removed from the affected extremity, including the blood pressure cuff, hospital identification bracelet, and 20-gauge angiocatheter. This situation represented a surgical emergency, and all other immediate care required operative intervention. Surgical Management The patient was taken to the operating room immediately for emergency fas- ciotomies. A dorsal, longitudinal incision was made from the lateral epicondyle to the mid-carpus, and the dorsal forearm fascia was completely released. A palmar incision was then performed, from the antecubital region to the mid-palm in the hand. The lacertus fibrosus was released, as well as the entire volar forearm fascia. The deep volar compartment was also explored and the fascia overlying the deep volar muscle layer was released. Distally, a carpal tunnel release was also performed (Figs. 26–4 and 26–5). Upon release of these compartments, ~250 cc of clear fluid was drained from the wounds. Laboratory analysis of this fluid suggested it was a mixture of plasma and E X T R A V A S A T I O N I N J U R I E S 163 Figure 26–4. The palmar surface of the left forearm immediately following fasciotomy. electrolyte solution. Neither the dorsal nor palmar forearm and wrist incisions could be closed primarily and no attempt was made to do so. Postoperative Care The patient returned to the operating room multiple times over the next 3 weeks for wound debridements. After the swelling subsided and the wounds were stable, meshed full-thickness skin grafts were applied for soft tissue coverage. Analysis of Case In the case history presented, the patient suffered a major extravasation injury from electrolyte solution intended to replace lost volume from bleeding. Several factors made this extravasation injury particularly severe. First, the patient had epinephrine infused with the electrolyte solution, which as an extravasant acted as a local vaso- constrictor and greatly worsened local ischemia. Second, because the patient was obtunded, recognition of the injury was significantly delayed and the patient de- veloped a compartment syndrome, probably due both to the amount of fluid ex- travasated as well as to the vasoconstrictive nature of the agent. Third, the presence of constrictive devices around the extremity also contributed in some fashion to the severity of injury. Not only did the patient have a hospital identification band wrapped tightly around her wrist, the frequent blood pressures that were taken with an automatic cuff situated at the upper left arm may also have restricted venous out- flow and added to congestion in the extremity. It is also noteworthy that an infusion pump was used, which can produce dramatic extravasation effects by forcing fluid into the extremity. All of these factors can add up and produce a more severe injury than would have otherwise occurred with intravenous fluid extravasation. This case also illustrates that the presence of peripheral pulses does not exclude a compartment syndrome or suggest that severe local soft tissue injury is not present. Furthermore, although it may seem obvious, the infusion should be turned off and the intravenous catheter removed immediately once a potential extravasation prob- lem has been identified. Of note in this case presentation is that the patient may have received a significant additional amount of electrolyte and epinephrine solution for Figure 26–5. The dorsal surface of the left forearm immediately following fasciotomy. V A S C U L A R D I S O R D E R S 164 some period of time after abnormality first presented in the left forearm because no one bothered to turn off the intravenous line and move it to another location. Suggested Readings Benson LS, Sathy MJ, Port RB. Forearm compartment syndrome due to automated injection of computed tomography contrast material. J Orthop Trauma 1996;10: 433–436. Bowers DG, Lynch JB. Adriamycin extravasation. Plast Reconstr Surg 1978;61: 86–92. Brown AS, Hoelzer DJ, Piercy SA. Skin necrosis from extravasation of intravenous fluids in children. Plast Reconstr Surg 1979;64:145–150. Gault DT. Extravasation injuries. Br J Plast Surg 1993;46:91–96. Larson DL. What is the appropriate management of tissue extravasation by anti- tumor agents? Plast Reconstr Surg 1985;75:397–402. Linder RM, Upton J, Osteen R. Management of extensive doxorubicin hydro- chloride extravasation injuries. J Hand Surg 1983;8:32–38. Loth TS, Eversmann WW. Extravasation injuries in the upper extremity. Clin Orthop 1991;272:248–254. Loth TS, Eversmann WW. Treatment methods for extravasations of chemothera- peutic agents: a comparative study. J Hand Surg 1986;11A:388–396. Loth TS, Jones DEC. Extravasations of radiographic contrast material in the upper extremity. J Hand Surg 1998;13A:407–410. Luedke DW, Kennedy PS, Rietschel RL. Histopathogenesis of skin and subcuta- neous injury induced by Adriamycin. Plast Reconstr Surg 1979;63:463–465. Mabee JR, Bostwick TL, Burke MK. Iatrogenic compartment syndrome from hyper- tonic saline injection in Bier block. J Emerg Med 1993;12:473–476. Scuderi N, Onesti MG. Antitumor agents: extravasation, management, and surgical treatment. Ann Plast Surg 1994;32:39–44. Seyfer AE. Injection and extravasation injuries. In: Hand Surgery Update. Rose- mont, IL: American Academy of Orthopaedic Surgeons; 1996:405–411. Seyfer AE. Upper extremity injuries due to medications. J Hand Surg 1987;12A: 744–750. Seyfer AE, Solimando DA. Toxic lesions of the hand associated with chemotherapy. J Hand Surg 1983;8:39–42. Stanley D, Conolly WB. Iatrogenic injection injuries of the hand and upper limb. J Hand Surg 1992;17B:442–446. Section VI Contractures Dupuytren’s Contracture Jack Abboudi and David S. Zelouf Stiff Joints Shelly M. Sailer D U P U Y T R E N ’ S C O N T R A C T U R E 167 PEARLS • The tabletop test is positive when the patient cannot place his or her open hand flap onto a table surface due to flexion contractures. This finding may prompt considera- tion for surgical treatment. • Counsel patients with early dis- ease as to your indications for operative treatment. This may help the patient seek reevalu- ation at an appropriate point for surgery before severe con- tractures form. • MP contracture correction tends to produce more satisfy- ing results than PIP correction. • Cleland’s ligaments, the deep transverse metacarpal liga- ment, and the flexor tendon sheath are not involved in the disease. PITFALLS • Procedures performed by “limited exposure” still require adequate visualization of the neurovascular structures that may be displaced from their normal location. • Neurovascular structures may be displaced superficially and toward the midline of the digit by the spiral cord and should not be assumed to be in their anatomic position. Generally, tracing the neurovascular structures is easier in a proxi- mal to distal direction starting just distal to the transverse carpal ligament. • Neurovascular structures are displaced more toward the midline and more superficial with increasing PIP contracture. 27 Dupuytren’s Contracture Jack Abboudi and David S. Zelouf History and Clinical Presentation A 51 year-old right hand dominant construction supervisor presented with a 2- to 3-year history of a progressive right ring finger contracture. He denies a history of trauma. He is of Scottish descent, and his father has undergone bilateral Dupuytren’s contracture releases. The patient denies a history of diabetes or other medical ill- nesses, and he is taking no medications. Physical Examination A prominent cord is noted in the palm in line with the ring finger extending to the level of the proximal interphalangeal (PIP) flexion crease. There was a prominent nodule present over the palmar aspect of the proximal phalanx, with a 60-degree metacarpophalangeal (MP) contracture and a 10-degree PIP contracture (Fig. 27–1). The left hand exhibited early palmar disease with no contracture. No knuckle pads were noted, and there was no involvement of the plantar surfaces of the feet. Radiographic Findings Plain x-rays of the right hand were unremarkable. Differential Diagnosis Dupuytren’s contracture Joint flexion contracture Scar contracture Flexor tendon bowstring Tendon adhesions Tumor (i.e., fibrosarcoma) Figure 27–1. Preoperative clinical photo. C O N T R A C T U R E S 168 Diagnosis Dupuy tren’s Cont rac ture Dupuytren’s disease has been attributed to genetic lines of Viking heritage and northern European lineage with an autosomal-dominant pattern of inheritance. The condition presents most frequently in males and after the age of 40. Clinical features include painless palmar pitting, cords, and nodules frequently in line with the small and ring finger. Many structures, described as “ligaments” and “bands” in their normal state, are referred to as “cords” in the diseased state (Fig. 27–2). The spiral cord is a continuum of the diseased spiral band, lateral digital sheet, and Grayson’s ligament. The spiral cord is pulled to the midline with contracture, caus- ing the neurovascular bundle to wrap around the straightening and tightening cord. The natatory cord can be palpated in the web space, and its contracture deviates the digit from the midline at the MP joint. See the suggested readings, later, for more comprehensive descriptions of the pathoanatomy. Disease progression generally leads to characteristic flexion deformities of the MP and the PIP joint. Associated findings include dorsal knuckle pads (Garrod’s nodules), thickening of plantar tis- sue in the foot (Lederhose’s disease), and penile fascia (Peyronie’s disease). Indications for surgical correction of Dupuytren’s contracture depend greatly on the impact of the deformity on the patient’s ability to perform activities of daily liv- ing and the ability and willingness of the patient to participate in the postoperative rehabilitation. Hard-and-fast, objective surgical indications are difficult to define. The “tabletop test” provides the earliest sign of significant flexion contracture, al- though this test alone is not always an indication for surgery. The test is positive when the patient cannot fully flatten his or her hand against a table surface. Gener- ally, flexion deformities of the MP joints are better tolerated by the patient and are relatively easier to correct, as MP flexion is a relatively “safe” position that maintains A B Figure 27–2. Anatomy of normal (A) and contractured (B) digits. D U P U Y T R E N ’ S C O N T R A C T U R E 169 collateral ligament length. On the other hand, PIP deformities interfere more with hand function and are more difficult to correct, as PIP flexion is a relatively “unsafe” position that allows for volar plate contracture. Therefore, PIP flexion deformities are stronger indications for surgery at earlier stages than are MP deformities. At the microscopic level, Dupuytren tissue demonstrates an abundance of normal fibroblastic and myofibroblastic cells. The local abundance of these cells explains some of the other molecular findings attributed to Dupuytren tissue such as in- creased amount of type III collagen. The fibroblastic and myofibroblastic prolifera- tion has been localized around occluded microvessels, and seems to be a cellular response to local tissue ischemia. This may explain the association of Dupuytren’s contracture with conditions that predispose to tissue ischemia, such as alcohol use, smoking, and age. The myofibroblasts share cellular characteristics between fibroblasts and smooth muscle cells and are concentrated within the palmar nodules. The contractile ele- ments of this cell type produce a progressive pull through the Dupuytren cords that leads to the characteristic flexion deformity. Residual myofibroblasts within the dermis and epidermis after surgical excision of diseased tissue have been impli- cated in the recurrence of the contracture. This notion is supported by the lower recurrence rate seen with palmar skin excision and full-thickness skin grafting after fasciectomy. Surgical Management The patient was treated with a subtotal palmar and digital fasciectomy. He was brought to the operating room where, under axillary anesthesia, Brunner incisions were utilized to expose the pretendinous cord (Fig. 27–3). An early spiral cord was encountered at the level of the PIP joint. After both neurovascular bundles were identified and protected, the involved palmar fascia was excised and sent to the pathology laboratory for gross and histologic analysis. At the conclusion of the pro- cedure, complete correction was obtained at both the MP and PIP joints. The tourniquet was deflated prior to closure, and brisk capillary refill was noted imme- diately. The wounds were closed with interrupted 5–0 nylon sutures, and a short arm plaster splint was placed, immobilizing the MP joints in 30 degrees of flexion, with the PIP joints comfortably extended. Figure 27–3. Intraopera- tive photo demonstrating pretendinous cord. C O N T R A C T U R E S 170 Postoperative Management A follow-up examination was done on the third postoperative day, at which time the patient’s dressing was removed. Inspection revealed minimal swelling, with well- vascularized flaps. A light dressing was applied and occupational therapy was insti- tuted with a certified hand therapist, consisting of active, active assisted, and passive range-of-motion exercises. A resting night splint was fashioned with the ring finger in full extension, to be worn for 3 months. A follow-up visit at 3 months revealed an excellent early result, with full correction, and full flexion (Fig. 27–4). Alternative Methods of Management There are no proven nonoperative modalities that can reverse or even halt the devel- opment of cords, nodules, and contractures. A significant number of patients develop progression of their flexion contractures and involvement of other digits, although the risk and the rate of progression are variable and difficult to predict. There are reports of rare cases of disease regression. Therefore, the unpredictable natural history of this disease may present a sense of “efficacy” to some patients who try nonoperative modalities, and they should at least be counseled accordingly. The future may hold promise for the treatment of Dupuytren’s contracture with collagenase injections into the diseased cords, and such protocols are currently under investigational study. Historically, radical palmar fasciectomy was performed as an attempt to rid the patient of all diseased tissue. However, recurrences were still noted, and this proce- dure has fallen out of favor due to associated wound complications and patient morbidity. Segmental fasciectomy has been described as a method of correcting the flexion contracture with segmental excision of diseased tissue through multiple incisions. Full-thickness skin grafting at these multiple incisions can theoretically prevent recur- rence at those sites and provide “fire breaks” against full-length cord recurrence. Skin grafting techniques can also be done in conjunction with standard partial fasciectomy. Fasciotomy can be performed through a limited exposure to release the cords and provide correction of the contracture. This procedure does not attempt removal of diseased tissue; however, it does provide a method for contracture correction in the debilitated patient. A B Figure 27–4. Three-month clinical follow-up demonstrating full extension (A) and flexion (B). . amputations of the index and small fingers and near amputa- tions of the long and ring fingers. 28 Stiff Joints Shelly M. Sailer His tory and Clinical Presentati on A 44 -year-old right hand dominant cabinet. injuries due to medications. J Hand Surg 1987;12A: 744 –750. Seyfer AE, Solimando DA. Toxic lesions of the hand associated with chemotherapy. J Hand Surg 1983;8:39 42 . Stanley D, Conolly WB. Iatrogenic. WB. Iatrogenic injection injuries of the hand and upper limb. J Hand Surg 1992;17B :44 2 44 6. Section VI Contractures Dupuytren’s Contracture Jack Abboudi and David S. Zelouf Stiff Joints Shelly