COMPLICATIONS OF INJURY

Complications of complex wounds Complex wounds are wounds which require additional procedures, such as radical debridement, to achieve wound closure.

Complications of missed complex wounds

Severe contamination is a common theme in missed complex wounds of the hand because the hand is so often physically exposed to contaminated mechanisms of injury.

Bite injuries

Human bite injuries of the hand most often take the form of clenched fist bite injuries, sustained when the hand strikes the mouth of another person in an altercation. The most common constellation of injuries is a skin laceration at the metacarpal head level, accompanied by extensor tendon injury and metacarpal head injury.  The pitfall in managing this injury is the fact that the injury is usually sustained when the hand is in a clenched fist position, but the patient frequently does not present until the hand is swollen and the metacarpophalangeal joint is held in extension.  This change of position places the soft tissue and bone injuries at an offset, giving the appearance that the injury is more superficial than it is (1071401S.htm, boxer4.htm). Treatment requires a high level of suspicion and aggressive debridement and intravenous antibiotics appropriate for a bite injury.

Animal bite injuries of the hand are most often from dog and cat bites. They can lead to prolonged morbidity, particularly when there is a delay between injury and initial treatment (CR). Dog bites are associated with soft tissue crush injury and fractures. Cat bites are particularly dangerous in hand because the needle like teeth of the cat can easily penetrate into joint spaces, tendon sheaths and other deep compartments of the hand through a relatively innocuous appearing skin wound.

Insect bites of the hand such as brown recluse spider bites may cause painful, slow healing wounds with chronic functional deficits. The initial bite injury may be painless. When surgical excision is indicated, results appear to be better when surgery is delayed until after the acute inflammatory process has subsided (EF).

Rattlesnake bite injuries of the upper extremity have serious complications and at least one third of cases, including local soft tissue necrosis (most common complication), coagulopathy, stiffness, loss of sensibility, and Volkmann's contracture (BT). Antivenin and steroids reduce the degree of swelling and hemorrhage, but do not affect or prevent tissue necrosis (snakebite.htm), which may require operative treatment.

Chemical Burns

Industrial acid burns of the hand occur when the inexperienced or careless worker splashes even small amounts of acid on their fingers or hand.  This type of injury can go undetected on initial evaluation unless a careful history is obtained because visible signs of injury are often delayed (hfl.htm). Hydrochloric and hydrofluoric acids are used in industrial processing, and may cause severe burns which are not manifest for a day after exposure. Early recognition and treatment with topical, intravenous or intraarterial calcium gluconate reduce pain and extent of tissue loss.

White phosphorus burns are sustained in the handling of military munitions, fireworks, and other industrial and agricultural products. Deep progressive burns and systemic effects of multiple organ system failure may result. Although copper sulfate has been recommended as a specific antidote, the most safe and effective treatment is copious water irrigation (EH). Again, immediate recognition and treatment of the nature of injury is essential to reduce long term complications.

Injection injuries

High pressure injection injuries of paint, sand, lubricating fluid and other materials are uncommon, but important because they are also on the list of injuries missed in the accident ward. Typically, the patient has briefly placed their hand or fingertip over a pressure spray nozzle, sustaining an injection of material into the soft tissues. Under pressure, this material tracks up tissue planes next to flexor tendons, nerves, arteries and through the named bursae and compartments of the hand and arm. Debris may be driven from the fingertip to the chest wall. The examiner may be misled by a small visible wound and (depending on the material injected) relatively few physical findings, and the patient may be discharged only to return within 24 hours because of worsening symptoms. X-rays may show soft tissue air, particulate debris, or pigment in certain types of paint. Treatment is emergency radical debridement (CN). The pressure injected material tends to track through the loose areolar tissue along longitudinal structures, and only careful debridement may allow preservation of all vital structures (1491601x.htm). In contrast, late surgical treatment may require en bloc tumor like excision of contaminated zones or amputation. Late results are worst when the injected material is either a petroleum based solvent or particulate (sandblasting) material, when the tendon sheath is involved, and when there is wide proximal spread of the injected material (DH). The injected material is not sterile, and prophylactic antibiotic treatment is indicated. Pressure injection injuries presenting with poor perfusion should be treated with primary amputation (DH). Injection of pressurized aerosol flurocarbon liquids such as used in refrigerants may additionally result in deep frostbite injury.

Intentional injection injuries of household cleaners, solvents, mercury or illicit drugs may be difficult to sort out because of either delusional or drug seeking nature of the patient. X-rays may show particulate or metallic debris or evidence of gas forming infection (ivdagas.htm).

Factitious or intentional wounds of the hand are uncommon, but very difficult to treat successfully because of recurrence. Swelling, ulceration, and recurrent wound breakdown are common themes. Such wounds are most typical on the dorsum of the nondominant hand. Narcotic seeking behavior may be part of the overall picture. The most important aspect of treatment is recognition, so that unnecessary, unsuccessful, or mutilating procedures may be avoided.  Although the problem is psychiatric, psychiatric intervention may or may not be helpful, and confrontation is generally ineffective intervention.  Such patients may jump from doctor to doctor in a community, and it is wise to notify local colleagues when such a patient is identified.

Traumatic amputations of the hand most often involve the fingers. The associated nerve injury always forms a neuroma, and the treating surgeon should trim the digital nerve ends away from the distal wound to lessen the chance of disabling scar tenderness. Dysesthesia is common and all patients should be provided with an early desensitization program that they can do at home. Complex regional pain syndrome may be triggered and then maintained by tender finger amputation stumps (tipsrsd.htm) and early on may be difficult to distinguish from swelling, stiffness, tenderness and avoidance always associated with the injury.  Cold sensitivity or intolerance is a problem for the majority of patients, but usually improves after the first year. When there is loss of more than the distal third of the distal phalanx, a hook nail deformity will result, with the fingernail curving toward the palm, covering the distal fingertip. This and other variations of retained nail remnant may be avoided by careful total excision of the entire germinal matrix of the time of amputation closure. Fingertip amputations are no less problematic than more proximal amputations, particularly when the critical contact areas used in pinching and fine manipulation are involved (1114301s.htm). Amputations through the proximal phalanx often result in extensor habitus, described above. Metacarpophalangeal joint disarticulation of the index or small finger results in an easily traumatized and visibly prominent metacarpal head. Metacarpophalangeal joint disarticulation of the middle or ring finger results in a "hole in the hand", through which small objects held in the cupped palm can fall. Treatment of either of these scenarios with removal of a metacarpal replaces the original problem with a narrowed palm and reduced  torque grip strength.

Fingertip injuries other than amputations still carry all of the painful and otherwise disabling complications of finger amputations. Nail deformities, tender scars and nonunion (1121100s.htm) are all difficult treatment issues. Pediatric fingertip crush injuries are common, and severe injuries involving a sterile matrix laceration with a tuft fracture are frequently missed in children (DF). These injuries require meticulous nailbed repair to avoid deformity.

Foreign bodies in the hand are most often symptomatic when they involve the distal phalanx (BK). Removal of foreign bodies which are lodged entirely beneath the surface should be performed with tourniquet control and surgical anesthesia.  Otherwise, a common result is that the area of a foreign body is incised, attempts at retrieval unsuccessful, and the problem is compounded by the inflammation and scarring from instrumentation. Foreign bodies are most likely to give rise to problems when they are composed either of organic (wood, plant thorn, etc.) or highly contaminated materials. Phoenix date palm thorns frequently produce a chronic sterile inflammatory reaction and require radical debridement and extensive synovectomy as the primary treatment (DV). Foreign body entry points at the dorsal surfaces of the metacarpophalangeal or interphalangeal joints, or at the palmar flexion increases of the fingers are at particular risk for contamination of tendons and deep space infections. Chronic symptomatic foreign body problems require tumor like excision and synovectomy, not incision and removal (foreign.htm).

Thermal burn injuries of the upper extremity result in stiffness of the hand, and the best prevention for this is early active motion within two weeks of injury (CQ). This goal is difficult to achieve reliably, because depth of burn may be difficult to assess, and areas which require skin grafting must be immobilized for at least one week after surgery.  When possible, the goal is early definitive wound closure with full thickness or tangential excision and skin grafts or flaps, followed by motion at the earliest possible opportunity. The ultimate disability in hand function is thought to relate to the time required to achieve wound closure, although this point is controversial (CY). Burn injuries can cause lifetime problems which can not be cured with any amount of surgery and therapy, and the surgeon must strive to promote realistic, achievable goals (CW). Compartment syndrome (AS, BB), contractures (CT) of web spaces, extensor and flexor services, hypertrophic scars and heterotopic ossification are common complications. Although rare, surface contact burns over the course of the brachial artery may lead to ischemic limb loss (AD). Pediatric burns of the hand more commonly involve an isolated contact burn of the palm, particularly in infants, sustained when a child grabs a hot object such as a curling iron, and then grips even more tightly in response to pain. As for burns in other areas, excision and grafting is indicated if the injury is expected to take longer than three weeks to heal, but in this instance, contractures requiring additional reconstructive procedures are common (CT). Pediatric hand burns have the most favorable outcome when managed in a specialty treatment program (DE).

Frostbite (EI) injuries of the hand have a wide variety early treatment recommendations, but rapid rewarming is standard. Traditional management is observation and delayed amputation (frost.htm). Bone scan may help distinguish between unsalvageable and potentially salvageable regions. Early operation may provide marginal tissue with a new blood supply and preserve both function and length in the upper extremity.

Electrical injuries of the the upper extremity may produce extensive deep tissue injury, compartment syndrome,  as well as delayed tissue necrosis and delayed vascular thrombosis (EM) . Early exploration and decompression of deep compartments, vascular graft reconstruction of segmental defects and early free microvascular flap reconstruction reduce amputation rate and shorten recovery (EK, EL, DM, EO) . Even with optimum treatment, long term sensory loss is common and remains and unsolved problem (EJ).

Degloving injuries of the hand most often result from the hand being caught in moving machinery.  When possible, microvascular replantation of the degloved tissues probably gives the best final result, although sensory recovery is difficult to achieve even with this technique (CB).  If replantation is not possible, efforts to salvage a crushed avulsed flap are usually unrewarding, and primary excision and resurfacing with a graft or flap (crush.htm) is indicated to avoid a prolonged course of progressive flap loss, delayed healing, infection and stiffness.

Mangling hand injuries result in a wide zone of mechanical injury, usually involving all tissue components of the hand. Mechanisms include crush, blast, ballistic, traction and avulsion injuries. All complications are possible, and these are at particular risk for delayed healing, marginal wound necrosis (15050.htm), infection (1434502x.htm), delayed thrombosis, prolonged swelling, compartment syndrome (AS, BB), intrinsic muscle contractures (1505201.htm), nonunion (gsw.htm, percmeta.htm), stiffness, and lack of sensory recovery (CB). The initial management plan is critical, as outlined in the next section.

Failure to proceed with primary amputation:  It is a difficult decision to decide when to attempt replantation of amputated digit or hand.  It is even more difficult and emotionally stressful to decide when to amputate a severely injured hand or digit, particularly when the part in question has at least the appearance of an existing blood supply.  "Saving" a mangled hand may simply burden the patient with a painful useless extremity, a triumph of technique over judgment.  One guide to making this decision is to ask the question "If this extremity looked like this, but was a complete amputation, would replantation be indicated?". If the answer is clearly "no", primary amputation should be strongly considered  (grisly.htm).  The best time to proceed with primary amputation for a mangled extremity is the very first operation. If the surgeon realizes at the time of the first operation that the hand is unsalvageable, but does not amputate, it sets a precedent for false expectations and even greater disappointment than would otherwise be endured. The patient in the family see the bandage, conclude that the hand has been "saved", and will find it much more difficult to accept the fact later that it has not. Although some patients with a saved mangled extremity may decide later to have an elective hand amputation (CK), most will be unable to make this decision even if the hand is a burden and clearly inferior to a prosthesis.

Inadequate debridement: The single common denominator of wound healing complications such as infection, delayed healing, marginal necrosis, and wound breakdown is inadequate debridement.  If the zone of injury can be determined with reasonable certainty, severe wounds should be radically debrided, anticipating the possible need for complex flap closure.  Debridement should remove severely contaminated tissues and all ischemic tissues which cannot be vascularized. This includes crushed flaps, distally based flaps with a length to width ratio greater than one to two, and flaps which are obviously ischemic. Initial debridement should be performed under tourniquet control, and proper initial debridement of severe wounds involves en bloc tumor like excision using scalpel and saw, not curette or irrigation, although these may be used later. The skin of the palm has a primarily perpendicular rather than tangential vascular pattern, and traumatic palmar flaps should be considered for primary excision and alternate resurfacing, as their vascularity is quite unreliable (crush.htm).

Poor timing of wound closure: Traditionally, the timing of closure of severe hand wounds has been classified as primary (immediate), delayed primary (within two weeks), and secondary (after two weeks).  Historically, delayed primary closure was recommended for military and other severe hand injuries. This recommendation is still appropriate when the only available wound closure technique is direct closure or closure with local flaps.  However, the timing of wound closure using distant or microvascular free flaps follows different guidelines. The status of severe open wounds which are candidates for flap closure is classified as acute (prior to the appearance of granulation tissue - usually less than one week), subacute (after the appearance of granulation tissue, before dense scarring - usually one to four weeks), and chronic (usually after one month). Wounds which require flap closure have the lowest complication rate (fewer flap failures, fewer post-operative infections, shorter hospitalization, least number of operations, shorter overall period of disability) when closure is performed in the acute phase and the highest complication rate when performed during the subacute phase (DC, BD, DK, DL, DN, DO). Free flap reconstruction of burn injuries has the lowest complication rate when employed for the reexploration and reconstruction of healed, closed burn injuries (DM).

Technical failure of complex wound closure: Even with adequate debridement, avoidance of using local flaps from potential zone of injury, and careful planning, wound closure may fail.  Skin grafts in the hand may be lost because of inability to provide adequate immobilization, and flaps may be lost when the complex wound dimensions exceed the capability of the flap. Although free flaps tend to be successful or loss on an "all or none" basis, partial free flap loss may occur.  Pedicled flap loss usually occurs at the exact point of critical need for flap coverage (flaploss.htm). However, even a perfectly designed and executed flap cannot obviate the effects of inadequate debridement or poor timing of wound closure.
 

e-Hand

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