Plastic Surgery for Trauma

The Essential Survival Guide

Dorian Hobday, Ted Welman, Maxim D. Horwitz, Gurjinderpal Singh Pahal, Dorian Hobday, Ted Welman, Maxim D. Horwitz, Gurjinderpal Singh Pahal

• Éditeur: CRC Press
• Année: 2022
• ISBN:
  9781000541229
• Édition: 1
• Sujet: Medizin
• Sous-sujet: Notfallmedizin & Intensivmedizin

Covers the immediate assessment and management of common plastic and reconstructive surgery emergencies and referrals. A companion for junior doctors starting within plastic surgery, the Plastic Surgery for \Trauma provides succinct and clear presentation together with up to date guidelines on the common plastic surgery emergencies. With cleardescriptions of difficult trauma scenarios, illustrated with numerous figures, and updated guidelines for each step of practice, this book will ensure that the reader can access all the information required to help gain confidence and experience.Be the readers passing through a plastic surgery rotation on their way to some other career goal or beginning within plastic surgery and keen to make a strong start with a view to progressing in the speciality, this book provides the support to allow rational and confident clinical decision making from the start. Essential reading for all non-specialists and trainees.

CHAPTER 1Hand Assessment

DOI: 10.1201/9781003163770-1

In acute hand trauma and hand infection, the combination of the three elements of history, examination and imaging (if required) will inform your management plan.

Do not forget to check for other injuries or medical issues as these may influence management. Around 7% of polytrauma patients have injuries to the upper limb [a], so bear in mind that your patient may require treatment for these other potentially more urgent injuries prior to the definitive management of the hand injury. Equally, a severe infection to the upper limb may be linked to other significant medical issues, so you may need to ensure your patient is admitted under the care of the medical team as well as plastics.

HISTORY

It is important to find out the timing of injuries as this can influence the urgency of operative management, both in bony and soft tissue injuries. You will need to take a focussed medical and social history (Table 1.1) as this may influence the management plan.

TABLE 1.1 Hand History

Question	Comments
Mechanism of injury	Lacerations: Was it a slicing or stabbing mechanism? Stabs are more likely to damage deep structures and may leave a deceptively small wound. What was the object that caused the injury? Glass or metal fragments can be seen on X-ray, whereas wood is less visible. Dirty objects have a higher chance of causing wound contamination requiring formal washout. What was position of the hand at time of injury? Clues to structures likely damaged, and that there may be a mismatch of laceration site to underlying structures damaged, especially in tendon injuries. Crush injuries: What was the object and speed? Severe crush can devitalise tissue and also cause compartment syndrome.
Time of injury	Delay to presentation may affect your management. An animal bite from 2 days prior will likely be infected and require formal washout, admission and IV antibiotics, whereas it may be sufficient to washout a same-day bite and discharge on oral antibiotics.
	A delay in the presentation of tendon/nerve injury may require you to expedite their operative management. Operative repairs in older fractures are more challenging due to callous formation as the bone heals. If there has been a delay, then why is this? There may be confounding factors that prevented immediate presentation. In paediatrics, never forget to consider non-accidental injury.
Initial management completed	Have tetanus/antibiotics already been given? Has imaging been performed? Has the wound been appropriately washed?
Medical history to include	Previous hand injuries? Diabetic?
Drug history + allergies	Anti-coagulants may affect surgical planning.
Social history to include	Smoking status? This – along with diabetic status – has significant effect on wound healing. Tetanus and COVID vaccination status? Socioeconomic situation? Need to return to work/inability to engage with hand therapy may influence management.
Hand history	Hand dominance? Line of work? Self-employed manual labourers may opt for the fastest return to work solution over other options, e.g. terminalisation of an amput...