Category Archive Fracture of Bone A-Z

Traumatic injuries

• Soft tissue injuries range from mild, superficial soft tissue injuries (e.g., simple contusions, strains, or sprains) to traumatic arthrotomies following gunshot wounds or penetrating lacerations

• The osseoligamentous spectrum of injury encompasses fractures, fracture-dislocations, ligamentous injuries, and simple versus complex dislocation patterns

  • “Simple” referring to no associated fracture accompanying the dislocation
  • “Complex” refers to an associated fracture accompanying the dislocation

Supracondylar fractures

• Most common in children peak ages 5 to 10 years, rarely occurs at greater than 15 years
• Extension type (98%) –  fall on an outstretched hand with fully extended or hyperextended armType 1: minimal or no displacement type 2: slightly displaced fracture, posterior cortex intact type 3: totally displaced fracture, the posterior cortex is broken.
• Flexion type – blow directly to a flexed elbowType 1: minimal or no displacement type 2: slightly displaced fracture, anterior cortex intact type 3: totally displaced fracture, the anterior cortex is broken
• Lateral condyle fractures
• Medial epicondyle fractures
• Radial head and neck fractures – Usually indirect mechanism (such as fall on an outstretched hand), and the radial head being driven into capitellum
• Olecranon fractures

Uncomplicated posterolateral dislocation usually treated with closed reduction. If there is evidence of entrapped medial epicondylar fragment, open reduction may be needed.[rx][rx]

• Orthopedic consultation is the standard for all but nondisplaced, stable fractures, which as a rule, can be splinted 24 to 48 hours orthopedic follow-up

• Fractures generally requiring orthopedic consultation:

  • Transcondylar, intercondylar, condylar, epicondylar fractures
  • Fractures involving articular surfaces such as capitellum or trochlea

• Supracondylar fractures:

  • ED physician can handle type 1 with 24 to 48 hours orthopedic follow-up
  • The elbow may be flexed and splinted with a posterior splint
  • Types 2 and 3 require an immediate orthopedic consult
  • Reduce these in ED when the fracture is associated with vascular compromise

• Anterior dislocation:

  • Reduce immediately if vascular structures compromised
  • Then flexed to 90º and place the posterior splint

• Posterior dislocation:

  • Reduce immediately if vascular structures compromised
  • Then flexed 90º and place posterior splint.

• Radial head fracture:

  • Minimally displaced fractures may need aspiration to remove hemarthrosis: instill bupivacaine and immobilize.
  • Other types should have an orthopedic consult.

• Radial head subluxation

  • In one continuous motion, supinate and flex elbow while placing slight pressure on the radial head.
  • Hyper pronation technique is possibly more effective – while grasping the patient’s elbow, the wrist is hyper-pronated until feeling a palpable click.
  • A palpable click will often accompany the reduction
  • If the exam suggests fracture, but radiograph is negative, splint and have the patient follow up in 24 to 48 hours for re-evaluation

Medication

• Conscious sedation is often necessary to achieve reductions
• Painkillers – especially non-steroidal anti-inflammatory drugs (NSAIDs).
• Injections – Steroid injections.
• Ibuprofen – 600 to 800 mg (pediatric: 5 to 10 mg/kg) PO TID
• Naprosyn – 250 to 500 mg (pediatric: 10 to 20 mg/kg) PO BID
• Tylenol with codeine – 1 or 2 tabs (pediatric 0.5 to 1 mg/kg codeine) PO: do not exceed acetaminophen 4g/24 hours
• Morphine sulfate – 0.1 mg/kg IV
• Hydromorphone 5 mg/acetaminophen 300mg
• Hydrocodone/acetaminophen – 1 to 2 tabs PO

Attritional injuries management modalities

Most of these injections contain one of the following active ingredients. These include but are not limited to[rx][rx][rx]:

• Corticosteroid injection – when applicable
• Platelet-rich plasma (PRP) considerations – 2016 study noted efficacy in managing UCL insufficiency
• Steroids: reduce inflammation. Studies show that steroid injections can temporarily relieve pain. But there is also evidence that they can disrupt the healing process: People who were first given several steroid injections had more pain after a few months than people who didn’t receive any steroid injections. Frequent steroid injections carry the risk of tissue dying (atrophy), for instance, leaving a visible mark on the elbow.
• Hyaluronic acid – A substance made by the body, found in tissue and joints. It is typically used to treat osteoarthritis. One study suggests that hyaluronic acid might be effective in the treatment of tennis elbow. But further research is needed to assess its pros and cons.
• Botox – inhibits the sending of signals between the nerve cells. This has a paralyzing effect on the muscles. According to studies done on this so far, Botox can relieve the pain just a little at most. Also, Botox injections can have side effects like partial paralysis in the fingers that can last several weeks.
• Autologous blood injections – Blood is taken from a vein in the arm and then injected into the elbow. This blood may be treated in different ways before it is injected. One common form of treatment with autologous blood is called platelet-rich plasma (PRP) therapy. It involves separating the blood into its various elements in a centrifuge. Then a concentrated solution of blood platelets is injected into the elbow. There is no evidence that treatment using autologous blood is effective.

Disposition

• Admission Criteria

  • Vascular injuries, open fracture
  • Fractures requiring operative reduction or internal fixation.
  • Admit all patients with extensive swelling or ecchymosis for overnight observation and elevation to monitor for and decrease the risk for compartment syndrome.

• Discharge Criteria

  • Stable fractures or reduced dislocations with none of the above features.
  • Splint and arrange orthopedic follow-up in 24 to 48 hours
  • Uncomplicated soft tissue injuries.

It is crucial to recall that prolonged elbow immobilization can cause stiffness to the patient, so the main goal is to get the elbow’s range of movement back as soon as possible.

Surgery

• Different surgical approaches are used. Most of them involve detaching parts of the forearm muscles or separating and destroying the nerves that carry the pain signals.

Complications of Elbow Fractures

Complications of lateral epicondylitis can include recurrence of the injury when normal activity is resumed, rupture of the tendons with repeated steroid injections, and failure to improve conservative treatment.

Neuropraxia – This occurs because of nerve injury. It resolves in three to four months. Nerve injury occurs in 11% of supracondylar fractures. Most commonly injured is the interosseous nerve, followed by the radial, median, and ulnar nerves.[rx][rx]

• The anterior interosseous nerve (arising from the median nerve) and may be involved either due to traction or contusion.
• The radial nerve may be involved with posteromedial displacement
• Median nerve involvement may occur with posterolateral displacement
• Ulnar nerve involvement may occur with a flexion type supracondylar fracture. The ulnar nerve is most commonly involved due to posterior displacement of the proximal fragment.
• Beware that motor testing can only identify anterior interosseous nerve injury. This testing can be done by flexing at the index finger distal interphalangeal and thumb interphalangeal joints and making the “okay” sign. Inability to do so represents a lack of sensory component in the anterior interosseous nerve.

Vascular injury – Brachial artery injury should always be suspected, particularly if the radial pulse is absent. However, vascular injury may occur even if the hand is pink and well perfused. This may be due to partial transection of a vessel.

Compartment syndrome –  this may occur after a supracondylar fracture. Evaluate for the early or impending signs by determining if a radial pulse is absent. This injury results from prolonged ischemia of the forearm. It should be suspected if the following are present:

• Inability to open the hand in children
• Pain on passive extension of the fingers
• Tenderness over the forearm
• Absence of a radial pulse
• A careful neurovascular examination is therefore important to promptly recognize this serious complication.

Malunion – Fracture malunion can lead to cubitus valgus or cubitus varus deformity (common in supracondylar fracture). A common complication is a loss of the carrying angle, which results in a cubitus varus, or “Gunstock,” deformity.

Nonunion – Lateral condylar fractures are more prone to nonunion. These, therefore, require revision surgery.

Postoperative complications can include the following:

• Failing to address concomitant pathology

  • patients report inferior outcomes and lack of improvement if the primary cause of symptoms is not addressed; patients should be educated regarding the risks and benefits of surgery — the former include but are not limited to infection, blood loss, neurovascular injury, continued pain, stiffness, or continued or worsening overall dysfunction
  • radial nerve entrapment can be missed or not addressed clinically in up to 5% of patients being managed for lateral epicondylitis

• Iatrogenic LUCL injury

  • occurs iatrogenically with increased risk if the surgical dissection extends beyond the radial head equator
  • postoperative iatrogenic posterolateral rotatory instability (PLRI) can develop if the extension or LUCL compromise is significant

• Iatrogenic neurovascular injury

  • radial nerve injury

• Heterotopic ossification

  • decrease risk with via copious saline irrigation following decortication and debridement
• Infection

References

Traumatic injuries

• Soft tissue injuries range from mild, superficial soft tissue injuries (e.g., simple contusions, strains, or sprains) to traumatic arthrotomies following gunshot wounds or penetrating lacerations

• The osseoligamentous spectrum of injury encompasses fractures, fracture-dislocations, ligamentous injuries, and simple versus complex dislocation patterns

  • “Simple” referring to no associated fracture accompanying the dislocation
  • “Complex” refers to an associated fracture accompanying the dislocation

Supracondylar fractures

• Most common in children peak ages 5 to 10 years, rarely occurs at greater than 15 years
• Extension type (98%) –  fall on an outstretched hand with fully extended or hyperextended armType 1: minimal or no displacement type 2: slightly displaced fracture, posterior cortex intact type 3: totally displaced fracture, the posterior cortex is broken.
• Flexion type – blow directly to a flexed elbowType 1: minimal or no displacement type 2: slightly displaced fracture, anterior cortex intact type 3: totally displaced fracture, the anterior cortex is broken
• Lateral condyle fractures
• Medial epicondyle fractures
• Radial head and neck fractures – Usually indirect mechanism (such as fall on an outstretched hand), and the radial head being driven into capitellum
• Olecranon fractures

Uncomplicated posterolateral dislocation usually treated with closed reduction. If there is evidence of entrapped medial epicondylar fragment, open reduction may be needed.[rx][rx]

• Orthopedic consultation is the standard for all but nondisplaced, stable fractures, which as a rule, can be splinted 24 to 48 hours orthopedic follow-up

• Fractures generally requiring orthopedic consultation:

  • Transcondylar, intercondylar, condylar, epicondylar fractures
  • Fractures involving articular surfaces such as capitellum or trochlea

• Supracondylar fractures:

  • ED physician can handle type 1 with 24 to 48 hours orthopedic follow-up
  • The elbow may be flexed and splinted with a posterior splint
  • Types 2 and 3 require an immediate orthopedic consult
  • Reduce these in ED when the fracture is associated with vascular compromise

• Anterior dislocation:

  • Reduce immediately if vascular structures compromised
  • Then flexed to 90º and place the posterior splint

• Posterior dislocation:

  • Reduce immediately if vascular structures compromised
  • Then flexed 90º and place posterior splint.

• Radial head fracture:

  • Minimally displaced fractures may need aspiration to remove hemarthrosis: instill bupivacaine and immobilize.
  • Other types should have an orthopedic consult.

• Radial head subluxation

  • In one continuous motion, supinate and flex elbow while placing slight pressure on the radial head.
  • Hyper pronation technique is possibly more effective – while grasping the patient’s elbow, the wrist is hyper-pronated until feeling a palpable click.
  • A palpable click will often accompany the reduction
  • If the exam suggests fracture, but radiograph is negative, splint and have the patient follow up in 24 to 48 hours for re-evaluation

Medication

• Conscious sedation is often necessary to achieve reductions
• Painkillers – especially non-steroidal anti-inflammatory drugs (NSAIDs).
• Injections – Steroid injections.
• Ibuprofen – 600 to 800 mg (pediatric: 5 to 10 mg/kg) PO TID
• Naprosyn – 250 to 500 mg (pediatric: 10 to 20 mg/kg) PO BID
• Tylenol with codeine – 1 or 2 tabs (pediatric 0.5 to 1 mg/kg codeine) PO: do not exceed acetaminophen 4g/24 hours
• Morphine sulfate – 0.1 mg/kg IV
• Hydromorphone 5 mg/acetaminophen 300mg
• Hydrocodone/acetaminophen – 1 to 2 tabs PO

Attritional injuries management modalities

Most of these injections contain one of the following active ingredients. These include but are not limited to[rx][rx][rx]:

• Corticosteroid injection – when applicable
• Platelet-rich plasma (PRP) considerations – 2016 study noted efficacy in managing UCL insufficiency
• Steroids: reduce inflammation. Studies show that steroid injections can temporarily relieve pain. But there is also evidence that they can disrupt the healing process: People who were first given several steroid injections had more pain after a few months than people who didn’t receive any steroid injections. Frequent steroid injections carry the risk of tissue dying (atrophy), for instance, leaving a visible mark on the elbow.
• Hyaluronic acid – A substance made by the body, found in tissue and joints. It is typically used to treat osteoarthritis. One study suggests that hyaluronic acid might be effective in the treatment of tennis elbow. But further research is needed to assess its pros and cons.
• Botox – inhibits the sending of signals between the nerve cells. This has a paralyzing effect on the muscles. According to studies done on this so far, Botox can relieve the pain just a little at most. Also, Botox injections can have side effects like partial paralysis in the fingers that can last several weeks.
• Autologous blood injections – Blood is taken from a vein in the arm and then injected into the elbow. This blood may be treated in different ways before it is injected. One common form of treatment with autologous blood is called platelet-rich plasma (PRP) therapy. It involves separating the blood into its various elements in a centrifuge. Then a concentrated solution of blood platelets is injected into the elbow. There is no evidence that treatment using autologous blood is effective.

Disposition

• Admission Criteria

  • Vascular injuries, open fracture
  • Fractures requiring operative reduction or internal fixation.
  • Admit all patients with extensive swelling or ecchymosis for overnight observation and elevation to monitor for and decrease the risk for compartment syndrome.

• Discharge Criteria

  • Stable fractures or reduced dislocations with none of the above features.
  • Splint and arrange orthopedic follow-up in 24 to 48 hours
  • Uncomplicated soft tissue injuries.

It is crucial to recall that prolonged elbow immobilization can cause stiffness to the patient, so the main goal is to get the elbow’s range of movement back as soon as possible.

Surgery

• Different surgical approaches are used. Most of them involve detaching parts of the forearm muscles or separating and destroying the nerves that carry the pain signals.

Complications of Elbow Dislocation

Complications of lateral epicondylitis can include recurrence of the injury when normal activity is resumed, rupture of the tendons with repeated steroid injections, and failure to improve conservative treatment.

Neuropraxia – This occurs because of nerve injury. It resolves in three to four months. Nerve injury occurs in 11% of supracondylar fractures. Most commonly injured is the interosseous nerve, followed by the radial, median, and ulnar nerves.[rx][rx]

• The anterior interosseous nerve (arising from the median nerve) and may be involved either due to traction or contusion.
• The radial nerve may be involved with posteromedial displacement
• Median nerve involvement may occur with posterolateral displacement
• Ulnar nerve involvement may occur with a flexion type supracondylar fracture. The ulnar nerve is most commonly involved due to posterior displacement of the proximal fragment.
• Beware that motor testing can only identify anterior interosseous nerve injury. This testing can be done by flexing at the index finger distal interphalangeal and thumb interphalangeal joints and making the “okay” sign. Inability to do so represents a lack of sensory component in the anterior interosseous nerve.

Vascular injury – Brachial artery injury should always be suspected, particularly if the radial pulse is absent. However, vascular injury may occur even if the hand is pink and well perfused. This may be due to partial transection of a vessel.

Compartment syndrome –  this may occur after a supracondylar fracture. Evaluate for the early or impending signs by determining if a radial pulse is absent. This injury results from prolonged ischemia of the forearm. It should be suspected if the following are present:

• Inability to open the hand in children
• Pain on passive extension of the fingers
• Tenderness over the forearm
• Absence of a radial pulse
• A careful neurovascular examination is therefore important to promptly recognize this serious complication.

Malunion – Fracture malunion can lead to cubitus valgus or cubitus varus deformity (common in supracondylar fracture). A common complication is a loss of the carrying angle, which results in a cubitus varus, or “Gunstock,” deformity.

Nonunion – Lateral condylar fractures are more prone to nonunion. These, therefore, require revision surgery.

Postoperative complications can include the following:

• Failing to address concomitant pathology

  • patients report inferior outcomes and lack of improvement if the primary cause of symptoms is not addressed; patients should be educated regarding the risks and benefits of surgery — the former include but are not limited to infection, blood loss, neurovascular injury, continued pain, stiffness, or continued or worsening overall dysfunction
  • radial nerve entrapment can be missed or not addressed clinically in up to 5% of patients being managed for lateral epicondylitis

• Iatrogenic LUCL injury

  • occurs iatrogenically with increased risk if the surgical dissection extends beyond the radial head equator
  • postoperative iatrogenic posterolateral rotatory instability (PLRI) can develop if the extension or LUCL compromise is significant

• Iatrogenic neurovascular injury

  • radial nerve injury

• Heterotopic ossification

  • decrease risk with via copious saline irrigation following decortication and debridement
• Infection

References

Traumatic injuries

• Soft tissue injuries range from mild, superficial soft tissue injuries (e.g., simple contusions, strains, or sprains) to traumatic arthrotomies following gunshot wounds or penetrating lacerations

• The osseoligamentous spectrum of injury encompasses fractures, fracture-dislocations, ligamentous injuries, and simple versus complex dislocation patterns

  • “Simple” referring to no associated fracture accompanying the dislocation
  • “Complex” refers to an associated fracture accompanying the dislocation

Supracondylar fractures

• Most common in children peak ages 5 to 10 years, rarely occurs at greater than 15 years
• Extension type (98%) –  fall on an outstretched hand with fully extended or hyperextended armType 1: minimal or no displacement type 2: slightly displaced fracture, posterior cortex intact type 3: totally displaced fracture, the posterior cortex is broken.
• Flexion type – blow directly to a flexed elbowType 1: minimal or no displacement type 2: slightly displaced fracture, anterior cortex intact type 3: totally displaced fracture, the anterior cortex is broken
• Lateral condyle fractures
• Medial epicondyle fractures
• Radial head and neck fractures – Usually indirect mechanism (such as fall on an outstretched hand), and the radial head being driven into capitellum
• Olecranon fractures

Uncomplicated posterolateral dislocation usually treated with closed reduction. If there is evidence of entrapped medial epicondylar fragment, open reduction may be needed.[rx][rx]

• Orthopedic consultation is the standard for all but nondisplaced, stable fractures, which as a rule, can be splinted 24 to 48 hours orthopedic follow-up

• Fractures generally requiring orthopedic consultation:

  • Transcondylar, intercondylar, condylar, epicondylar fractures
  • Fractures involving articular surfaces such as capitellum or trochlea

• Supracondylar fractures:

  • ED physician can handle type 1 with 24 to 48 hours orthopedic follow-up
  • The elbow may be flexed and splinted with a posterior splint
  • Types 2 and 3 require an immediate orthopedic consult
  • Reduce these in ED when the fracture is associated with vascular compromise

• Anterior dislocation:

  • Reduce immediately if vascular structures compromised
  • Then flexed to 90º and place the posterior splint

• Posterior dislocation:

  • Reduce immediately if vascular structures compromised
  • Then flexed 90º and place posterior splint.

• Radial head fracture:

  • Minimally displaced fractures may need aspiration to remove hemarthrosis: instill bupivacaine and immobilize.
  • Other types should have an orthopedic consult.

• Radial head subluxation

  • In one continuous motion, supinate and flex elbow while placing slight pressure on the radial head.
  • Hyper pronation technique is possibly more effective – while grasping the patient’s elbow, the wrist is hyper-pronated until feeling a palpable click.
  • A palpable click will often accompany the reduction
  • If the exam suggests fracture, but radiograph is negative, splint and have the patient follow up in 24 to 48 hours for re-evaluation

Medication

• Conscious sedation is often necessary to achieve reductions
• Painkillers – especially non-steroidal anti-inflammatory drugs (NSAIDs).
• Injections – Steroid injections.
• Ibuprofen – 600 to 800 mg (pediatric: 5 to 10 mg/kg) PO TID
• Naprosyn – 250 to 500 mg (pediatric: 10 to 20 mg/kg) PO BID
• Tylenol with codeine – 1 or 2 tabs (pediatric 0.5 to 1 mg/kg codeine) PO: do not exceed acetaminophen 4g/24 hours
• Morphine sulfate – 0.1 mg/kg IV
• Hydromorphone 5 mg/acetaminophen 300mg
• Hydrocodone/acetaminophen – 1 to 2 tabs PO

Attritional injuries management modalities

Most of these injections contain one of the following active ingredients. These include but are not limited to[rx][rx][rx]:

• Corticosteroid injection – when applicable
• Platelet-rich plasma (PRP) considerations – 2016 study noted efficacy in managing UCL insufficiency
• Steroids: reduce inflammation. Studies show that steroid injections can temporarily relieve pain. But there is also evidence that they can disrupt the healing process: People who were first given several steroid injections had more pain after a few months than people who didn’t receive any steroid injections. Frequent steroid injections carry the risk of tissue dying (atrophy), for instance, leaving a visible mark on the elbow.
• Hyaluronic acid – A substance made by the body, found in tissue and joints. It is typically used to treat osteoarthritis. One study suggests that hyaluronic acid might be effective in the treatment of tennis elbow. But further research is needed to assess its pros and cons.
• Botox – inhibits the sending of signals between the nerve cells. This has a paralyzing effect on the muscles. According to studies done on this so far, Botox can relieve the pain just a little at most. Also, Botox injections can have side effects like partial paralysis in the fingers that can last several weeks.
• Autologous blood injections – Blood is taken from a vein in the arm and then injected into the elbow. This blood may be treated in different ways before it is injected. One common form of treatment with autologous blood is called platelet-rich plasma (PRP) therapy. It involves separating the blood into its various elements in a centrifuge. Then a concentrated solution of blood platelets is injected into the elbow. There is no evidence that treatment using autologous blood is effective.

Disposition

• Admission Criteria

  • Vascular injuries, open fracture
  • Fractures requiring operative reduction or internal fixation.
  • Admit all patients with extensive swelling or ecchymosis for overnight observation and elevation to monitor for and decrease the risk for compartment syndrome.

• Discharge Criteria

  • Stable fractures or reduced dislocations with none of the above features.
  • Splint and arrange orthopedic follow-up in 24 to 48 hours
  • Uncomplicated soft tissue injuries.

It is crucial to recall that prolonged elbow immobilization can cause stiffness to the patient, so the main goal is to get the elbow’s range of movement back as soon as possible.

Surgery

• Different surgical approaches are used. Most of them involve detaching parts of the forearm muscles or separating and destroying the nerves that carry the pain signals.

Complications

Complications of lateral epicondylitis can include recurrence of the injury when normal activity is resumed, rupture of the tendons with repeated steroid injections, and failure to improve conservative treatment.

Neuropraxia – This occurs because of nerve injury. It resolves in three to four months. Nerve injury occurs in 11% of supracondylar fractures. Most commonly injured is the interosseous nerve, followed by the radial, median, and ulnar nerves.[rx][rx]

• The anterior interosseous nerve (arising from the median nerve) and may be involved either due to traction or contusion.
• The radial nerve may be involved with posteromedial displacement
• Median nerve involvement may occur with posterolateral displacement
• Ulnar nerve involvement may occur with a flexion type supracondylar fracture. The ulnar nerve is most commonly involved due to posterior displacement of the proximal fragment.
• Beware that motor testing can only identify anterior interosseous nerve injury. This testing can be done by flexing at the index finger distal interphalangeal and thumb interphalangeal joints and making the “okay” sign. Inability to do so represents a lack of sensory component in the anterior interosseous nerve.

Vascular injury – Brachial artery injury should always be suspected, particularly if the radial pulse is absent. However, vascular injury may occur even if the hand is pink and well perfused. This may be due to partial transection of a vessel.

Compartment syndrome –  this may occur after a supracondylar fracture. Evaluate for the early or impending signs by determining if a radial pulse is absent. This injury results from prolonged ischemia of the forearm. It should be suspected if the following are present:

• Inability to open the hand in children
• Pain on passive extension of the fingers
• Tenderness over the forearm
• Absence of a radial pulse
• A careful neurovascular examination is therefore important to promptly recognize this serious complication.

Malunion – Fracture malunion can lead to cubitus valgus or cubitus varus deformity (common in supracondylar fracture). A common complication is a loss of the carrying angle, which results in a cubitus varus, or “Gunstock,” deformity.

Nonunion – Lateral condylar fractures are more prone to nonunion. These, therefore, require revision surgery.

Postoperative complications can include the following:

• Failing to address concomitant pathology

  • patients report inferior outcomes and lack of improvement if the primary cause of symptoms is not addressed; patients should be educated regarding the risks and benefits of surgery — the former include but are not limited to infection, blood loss, neurovascular injury, continued pain, stiffness, or continued or worsening overall dysfunction
  • radial nerve entrapment can be missed or not addressed clinically in up to 5% of patients being managed for lateral epicondylitis

• Iatrogenic LUCL injury

  • occurs iatrogenically with increased risk if the surgical dissection extends beyond the radial head equator
  • postoperative iatrogenic posterolateral rotatory instability (PLRI) can develop if the extension or LUCL compromise is significant

• Iatrogenic neurovascular injury

  • radial nerve injury

• Heterotopic ossification

  • decrease risk with via copious saline irrigation following decortication and debridement
• Infection

References

• https://www.ncbi.nlm.nih.gov/books/NBK482281/
• https://www.ncbi.nlm.nih.gov/books/NBK507841/
• https://www.ncbi.nlm.nih.gov/books/NBK545260/
• https://www.ncbi.nlm.nih.gov/books/NBK536933/

History

Hand dominance, occupation, time of injury, mechanism of injury, other associated injuries, comorbidities and NPO status.

Physical Exam

Level of amputation, structures involved, neurovascular status, function, and degree of contamination (if relevant).  It is vital to assess the amputated part and ultimately determine its suitability for replanting respective to the mechanism of injury (e.g., crush, guillotine-style, avulsion).

The assessment is likely to include:

• a thorough medical examination – assessing your physical condition, nutritional status, bowel and bladder function, your cardiovascular system (heart, blood and blood vessels) and your respiratory system (lungs and airways)
• an assessment of the condition and function of your healthy limb – removing one limb can place extra strain on the remaining limb, so it’s important to look after the healthy limb
• a psychological assessment – to determine how well you’ll cope with the psychological and emotional impact of amputation, and whether you’ll need additional support
• an assessment of your home, work and social environments – to determine whether any additional provisions will need to be made to help you cope

You’ll also be introduced to a physiotherapist, who will be involved in your post-operative care. A prosthetist (a specialist in prosthetic limbs) will advise you about the type and function of prosthetic limbs or other devices available.

Finger amputations classification is generally according to the level of amputation.  The Sebastian and Chung classification is outlined below[rx]:

Evaluation

Laboratory:(optional depending on clinical scenario)

• CBC (complete blood count) to assess for blood loss
• Coagulation studies (only if the patient is known to be on anticoagulants)

Imaging

• Plain radiograph of the affected finger/hand and amputated part; this allows assessment of bony injuries, bone quality and guide decisions regarding bony fixation methods. Angiograms are normally not requested unless it forms part of investigations for other injuries.

How Do I Get Ready For an Amputation

Ask your surgeon to tell you what you should do before your amputation. Below is a list of common steps that you may be asked to do:

• Your surgeon will explain the procedure and ask if you have any questions.
• You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask
• questions if something is not clear.
• Along with a complete medical history, your surgeon may do a physical exam to ensure you are in otherwise good health. You may have blood or other tests.
• You will be asked to fast for 8 hours, generally after midnight.
• If you are pregnant or think you may be, tell your surgeon.
• Tell your surgeon if you are sensitive to or are allergic to any medicines, latex, tape, or local and general anesthesia.
• Tell your surgeon of all medicines (prescription and OTC) and herbal supplements that you are taking.
• Tell your surgeon if you have a history of bleeding disorders or if you are taking any blood-thinning (anticoagulant) medicines, aspirin, or other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.
• You may be measured for an artificial limb.
• You may receive a sedative to help you relax.
• Based on your medical condition, your surgeon may request other specific preparation.

What Happens During an Amputation

Talk with your surgeon about what to expect during your procedure. An amputation requires a stay in a hospital. Procedures may vary depending on the type of amputation, your condition, and your surgeon’s practices.  An amputation may be done while you are asleep under general anesthesia, or while you are awake under spinal anesthesia. If spinal anesthesia is used, you will have no feeling from your waist down. Your surgeon will discuss this with you in advance.

Generally, an amputation follows this process

• You will be asked to remove any jewelry or other objects that may interfere with the procedure.
• You will be asked to remove your clothing and put on a gown.
• An IV line may be started in your arm or hand.
• You will be positioned on the operating table.
• The anesthesiologist will monitor your heart rate, blood pressure, breathing, and blood oxygen level during the procedure.
• A thin, narrow tube (catheter) may be inserted into your bladder to drain urine.
• he skin over the surgical site will be cleansed with an antiseptic solution.
• To determine how much tissue to remove, the surgeon will check for a pulse at a joint close to the site. Skin temperatures, color, and the presence of pain in the diseased limb will be compared with those in a healthy limb.
• After the incision, your surgeon may decide that more of the limb needs to be removed. The surgeon will keep as much of the functional stump length as possible. He or she will also leave as much healthy skin as possible to cover the stump area.
• If the amputation is due to injury, the crushed bone will be removed and smoothed out to help with the use of an artificial limb. If needed, temporary drains that will drain blood and other fluids may be inserted.
• After completely removing the dead tissue, the surgeon may decide to close the flaps. This is called a closed amputation. Or the surgeon may decide to leave the site open. This is called open flap amputation. In a closed amputation, the wound will be sutured shut right away. This is usually done if there is little risk of infection. In an open flap amputation, the skin will remain drawn back from the amputation site for several days so any infected tissue can be cleaned off. At a later time, once the stump tissue is clean and free of infection, the skin flaps will be sutured together to close the wound.
• A sterile bandage or dressing will be applied. The type of dressing used will depend on the type of surgery done.
• The surgeon may place a stocking over the amputation site to hold drainage tubes and wound dressings, or the limb may be placed in traction or a splint.

What Happens After an Amputation

In the hospital

• After the procedure, you will be taken to the recovery room. Your recovery will vary depending on the type of procedure done and anesthesia used. The blood flow and feeling of the affected extremity will be checked. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room.
• You will get pain medicines and antibiotics as needed. The dressing will be changed and watched closely.
• You will start physical therapy soon after your surgery. Rehabilitation is designed for your specific needs. It may include gentle stretching, special exercises, and help getting in and out of bed or a wheelchair. If you had a leg amputation, you will learn how to bear weight on your remaining limb.
• There are specialists who make and fit prosthetic devices. They will visit you soon after surgery and will instruct you how to use the prosthesis. You may begin to practice with your artificial limb as early as 10 to 14 days after your surgery, depending on your comfort and wound healing process.
• After amputation, you will stay in the hospital for several days. You will get instructions as to how to change your dressing. You will be discharged home when the healing process is going well and you are able to take care of yourself with assistance.
• After surgery, you may have emotional concerns. You may have grief over the lost limb or a physical condition known as phantom pain. This is pain or other feeling in your amputated limb. If this is the case, you may receive medicines or other types of nonsurgical treatments.

Treatment

The development of the science of microsurgery over last 40 years has provided several treatment options for a traumatic amputation, depending on the patient’s specific trauma and clinical situation:

• 1st choice – Surgical amputation – break – prosthesis
• 2nd choice – Surgical amputation – transplantation of other tissue – plastic reconstruction.
• 3rd choice – Replantation – reconnection – revascularisation of amputated limb, by microscope (after 1969)
• 4th choice –Transplantation of cadaveric hand (after 2000),^[rrx][rx]

Medications

Medications that may be used to help relieve pain include:

• Non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen
• Anticonvulsants – such as carbamazepine or gabapentin
• Antidepressants – such as amitriptyline or nortriptyline (these medications work directly on the nerves in your leg)
• Opioids – such as codeine or morphine
• Corticosteroid – or local anaesthetic injections

Self-help measures and complementary therapy

There are several non-invasive techniques that may help relieve pain in some people. They include:

• Checking – the fit of your prosthesis and making adjustments to make it feel more comfortable
• Applying heat or cold to your limb – such as using heat or ice packs, rubs and creams
• Massage – to increase circulation and stimulate muscles
• Acupuncture – thought to stimulate the nervous system and relieve pain
• Transcutaneous electrical nerve stimulation (TENS) – where a small, battery-operated device is used to deliver electrical impulses to the affected area of your body, to block or reduce pain signals

Research has shown that people who spend 40 minutes a day imagining using their phantom limb, such as stretching out their “fingers” or bunching up their “toes”, experience a reduction in pain symptoms. This may be related to the central theory of phantom limb pain (that the brain is looking to receive feedback from the amputated limb), and these mental exercises may provide an effective substitution for this missing feedback.

Another technique, known as mirror visual feedback, involves using a mirror to create a reflection of the other limb. Some people find that exercising and moving their other limb can help relieve the pain from a phantom limb.

In addition to your primary care doctor and surgeon, other medical professionals involved in your treatment plan may include:

• An endocrinologist – who is a physician with special training in the treatment of diabetes and other hormone-related disorders
• A physical therapist – who will help you regain strength, balance and coordination and teach you how to use an artificial (prosthetic) limb, wheelchair or other devices to improve your mobility
• An occupational therapist – who specializes in therapy to improve everyday skills, including teaching you how to use adaptive products to help with everyday activities
• A mental health provider – such as a psychologist or psychiatrist, who can help you address your feelings or expectations related to the amputation or to cope with the reactions of other people
• A social worker – who can assist with accessing services and planning for changes in care

Complications

Complications classify according to the time of onset[rx]

Postoperative and Rehabilitation Care

Post-operative management:

• Maintain adequate hydration and circulation volume
• Analgesia
• Keep the affected limb elevated and warm
• Frequent monitoring of the replant capillary refill, color, and temperature
• Avoid dressings changes in the first 48 to 72 hours to minimize manipulation of the repair
• Consider anticoagulation
• In cases of artery-only replants, consider stab incision to the distal amputated tip and apply heparin soaked gauze to allow venous drainage or use leeches instead. This treatment can end once the finger becomes pink with normal capillary refill thus indicating adequate venous drainage

Some patients require further surgery to improve their function, such as tenolysis, bone grafting, tendon transfer, etc.[rx] On average, following upper limb amputations, patients return to work within 2 to 3 months after injury.[rx] Studies show that functional recovery is better in more distal injuries than proximal, both in terms of movement and power.[rx]

Deterrence and Patient Education

• Good health and safety regulations – to provide a safe working environment and reduce occupation-related injuries
• Public information leaflet/public awareness campaign – same objective as above, but to ensure a safe home environment for work and recreation, e.g., BBC News article in May 2018, warning the public of DIY and gardening accidents

Pearls and Other Issues

• Once a patient with an amputation injury arrives in hospital, a speedy but thorough assessment is essential to minimize the delay to definitive surgical management
• Often, amputated parts are brought to the emergency department (although sometimes forgotten at the scene or referring hospital) in inappropriate storage. As a specialist center, it is crucial to inform referring units of the best way to preserve the amputated part, to label it with the patient’s details and keep it with the patient to avoid loss
• Early involvement of specialists where possible

• Take account of patient factors, i.e., age, occupation, comorbidities, and also patient wishes – replantation requires long and complex surgery, hospital admission, the risk of complications, long rehabilitation, and risk of an incomplete return to normal function.

  • This may not be acceptable in some patients, especially in those who are self-employed and cannot take prolonged time off work
  • As such, terminalization of the affected finger may allow early return to work and normal function for the patient – if possible, the patient needs to understand their options and the potential outcome of each
• Good rehabilitation process – early involvement of hand therapists

Rehabilitation after amputation

Loss of a limb produces a permanent disability that can impact a patient’s self-image, self-care, and mobility (movement). Rehabilitation of the patient with an amputation begins after surgery during the acute treatment phase. As the patient’s condition improves, a more extensive rehabilitation program is often begun.

The success of rehabilitation depends on many variables, including the following:

• Level and type of amputation
• Type and degree of any resulting impairments and disabilities
• Overall health of the patient
  Family support

It is important to focus on maximizing the patient’s capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence. The rehabilitation program is designed to meet the needs of the individual patient. Active involvement of the patient and family is vital to the success of the program.

The goal of rehabilitation after an amputation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life — physically, emotionally, and socially.

In order to help reach these goals, amputation rehabilitation programs may include the following:

• Treatments to help improve wound healing and stump care
• Activities to help improve motor skills, restore activities of daily living (ADLs), and help the patient reach maximum independence
• Exercises that promote muscle strength, endurance, and control
• Fitting and use of artificial limbs (prostheses)
• Pain management for both postoperative and phantom pain (a sensation of pain that occurs below the level of the amputation)
• Emotional support to help during the grieving period and with readjustment to a new body image
• Use of assistive devices
• Nutritional counseling to promote healing and health
• Vocational counseling
• Adapting the home environment for ease of function, safety, accessibility, and mobility
• Patient and family education

The amputation rehabilitation team

Rehabilitation programs for patients with amputations can be conducted on an inpatient or outpatient basis. Many skilled professionals are part of the amputation rehabilitation team, including any or all of the following:

• Orthopedists/orthopedic surgeons
• Physiatrist
• Internist
• Other specialty doctors
• Rehabilitation specialists
• Physical therapist
• Occupational therapist
• Orthotist
• Prosthetist
• Social worker
• Psychologist/psychiatrist
• Recreational therapist
• Case manager
• Chaplain
• Vocational counselor

Types of Rehabilitation Programs for Amputations

There are a variety of treatment programs, including the following:

• Acute rehabilitation programs
• Outpatient rehabilitation programs
• Day-treatment programs
• Vocational rehabilitation programs

Preventing foot ulcers

The best strategy for preventing complications of diabetes — including foot ulcers — is proper diabetes management with a healthy diet, regular exercise, blood sugar monitoring and adherence to a prescribed medication regimen.

Proper foot care will help prevent problems with your feet and ensure prompt medical care when problems occur. Tips for proper foot care include the following:

• Inspect your feet daily – Check your feet once a day for blisters, cuts, cracks, sores, redness, tenderness or swelling. If you have trouble reaching your feet, use a hand mirror to see the bottoms of your feet. Place the mirror on the floor if it’s too difficult to hold, or ask someone to help you.
• Wash your feet daily – Wash your feet in lukewarm (not hot) water once a day. Dry them gently, especially between the toes. Use a pumice stone to gently rub the skin where calluses easily form. Sprinkle talcum powder or cornstarch between your toes to keep the skin dry. Use a moisturizing cream or lotion on the tops and bottoms of your feet to keep the skin soft. Preventing cracks in dry skin helps keep bacteria from getting in.
• Don’t remove calluses or other foot lesions yourself – To avoid injury to your skin, don’t use a nail file, nail clipper or scissors on calluses, corns, bunions or warts. Don’t use chemical wart removers. See your doctor or foot specialist (podiatrist) for removal of any of these lesions.
• Trim your toenails carefully – Trim your nails straight across. Carefully file sharp ends with an emery board. Ask for assistance from a caregiver if you are unable to trim your nails yourself.
• Don’t go barefoot – To prevent injury to your feet, don’t go barefoot, even around the house.
• Wear clean, dry socks –  Wear socks made of fibers that pull sweat away from your skin, such as cotton and special acrylic fibers — not nylon. Avoid socks with tight elastic bands that reduce circulation or socks with seams that could irritate your skin.
• Buy shoes that fit properly – Buy comfortable shoes that provide support and cushioning for the heel, arch and ball of the foot. Avoid tightfitting shoes and high heels or narrow shoes that crowd your toes.If one foot is bigger than the other, buy shoes in the larger size. Your doctor may recommend specially designed shoes (orthopedic shoes) that fit the exact shape of your feet, cushion your feet and evenly distribute weight on your feet.
• Don’t smok –  Smoking impairs circulation and reduces the amount of oxygen in your blood. These circulatory problems can result in more-severe wounds and poor healing. Talk to your doctor if you need help to quit smoking.
• Schedule regular foot checkups  Your doctor or podiatrist can inspect your feet for early signs of nerve damage, poor circulation or other foot problems. Schedule foot exams at least once a year or more often if recommended by your doctor.

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3961849/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2018851/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590129/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923303/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303528/
• https://www.ncbi.nlm.nih.gov/books/NBK534773/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151422/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3329303/
• https://www.ncbi.nlm.nih.gov/books/NBK65152/
• https://www.ncbi.nlm.nih.gov/books/NBK448188/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5248418/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5248418/
• https://www.ncbi.nlm.nih.gov/books/NBK538153/
• https://www.ncbi.nlm.nih.gov/books/NBK327444/
• https://en.wikipedia.org/wiki/Amputation
• https://www.urmc.rochester.edu/encyclopedia/content.aspx?
• https://www.uofmhealth.org/conditions-treatments/rehabilitation/amputation
• https://www.britannica.com/science/amputation
• https://www.diabetes.co.uk/diabetes-and-amputation.html
• https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/amputation
• https://www.medicinenet.com/foot_problems_diabetes/article.htm#diabetes_and_foot_problems_facts
• http://www.circulationfoundation.org.uk/help-advice/peripheral-arterial-disease/leg-amputation
• https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/amputation-and-diabetes/art-20048262
• https://www.nhs.uk/conditions/amputation/
• https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=92&contentid=P08292
• https://www.assh.org/handcare/procedures-and-treatment/Amputation-and-Prosthetics

Acute Wound/Wounds are defined as a disruption of the normal structure and function of skin and underlying soft tissue that is caused by trauma or chronic mechanical stress (e.g., decubitus ulcers). Wounds can be broken down into acute or chronic, and open or closed. Wound treatment is performed according to pathology, the extent, and circumstances of the lesions. To heal, the wound needs to have a vascular supply, be free of necrotic tissue, clear of infection, and moist. General wound treatment includes surgical wound closure, open wound treatment, and plastic reconstruction of skin defects. In addition, infectious or concomitant disease prevention should be considered (e.g., antibiotic therapy, vaccines for tetanus and rabies, diabetes control).

A wound is damaged or disruption to the skin and, before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate treatment.[rx][rx][rx] Each clinician will have widely differing and distinct opinions and understanding of wound care depending on their prior experience. The reason for this because of the widely differing and distinct types of wounds, each with their etiology. An ostomy nurse will have a completely different approach to wound care that will require an orthopedic surgeon who deals with trauma and both will be far different from a dermatologist who treats burn victims. Nevertheless, each of these healthcare providers is performing wound care. How do professionals then approach wound assessment when the causes are so diverse? Below are some basic questions to ask during a wound assessment to best classify and treat a wound presenting in a clinical setting.

Normal Healthy Skin of Acute Wound

As the interface between the environment and body, the skin has several distinct functions. It protects the underlying tissues from abrasions, the entry of microbes, unwanted water loss, and ultraviolet light damage. Tactile sensations of touch, pressure, and vibration, thermal sensations of heat and cold, and pain sensations all originate in the skin’s nervous system. The body’s thermoregulation relies on the skin’s ability to sweat and to control the flow of blood to the skin to increase or decrease heat loss. The skin’s functions are performed by three distinct tissue layers: a thin outer layer of cells called the epidermis, a thicker middle layer of connective tissue called the dermis, and an inner, subcutaneous layer. The outer layers of the epidermis are composed of flattened, cornified dead keratinocytes that form a barrier to water loss and microbe entry. These cells are derived from a basal layer of constantly dividing keratinocytes that lies next to the dermis. The epidermis does not contain nerves or blood vessels and obtains water and nutrients through diffusion from the dermis. The dermis is composed mostly of collagen fibers and some elastic fibers both produced by fibroblasts and, along with water and large proteoglycan molecules, makes up the extracellular matrix. This layer of the skin provides mechanical strength and a substrate for water and nutrient diffusion; it contains blood vessels, nerves, and cells involved in immune function, growth, and repair. The dermis also contains sweat glands, oil glands, and hair follicles. The subcutaneous layer is composed of adipocytes that form a thick layer of adipose tissue.^[rx]

Types of Acute Wound

 Each of the potential underlying causes must be addressed for the wound to heal. Before determining the underlying cause, it is important to determine what type of wound the patient has. These subclassifications can be acute or chronic.[rx][rx][rx]

Types of Wounds

1. According to the severity, a wound can be classified as

Acute

Clinicians assess acute wounds by the method of injury and damage to the soft tissues and bony structures. In crush or high impact injuries, there is an area of demarcation which is not fully recognized until sometimes as much as a week or 2 later. For this reason, it is important to determine the method of injury and to keep in mind that the wound seen is not necessarily the entirety of the wound which will be present in a week. In these cases, the patient and their family should be educated on this progression to prevent frustration and misunderstanding.

For all acute types of wounds, it is important to determine the length of time since injury (days or hours), the involvement of neurovascular supply, muscle, tendon, ligament, and bony involvement, and the likelihood of contaminants in the wound. Also of importance is when the patient had their last tetanus shot. CLinicians should start antibiotics if the wound is severely contaminated or if it is longer than 3 hours since the injury. All underlying tissue should be repaired if possible, and the wound should be irrigated to remove contaminants and bacteria.

In cases of open fracture the most used classification is Gustillo-Anderson

• Type 1 – Clean wound, less than one cm with minimal soft tissue damage, adequate soft tissue coverage of bone, and no periosteal stripping
• Type 2 – Wound with moderate contamination, greater than one cm with moderate soft tissue damage, adequate soft tissue coverage of bone, and no periosteal stripping
• Type 3A – Wound with significant contamination, with significant soft tissue damage, adequate soft tissue coverage of bone, and periosteal stripping is present
• Type 3B – Wound with significant contamination, with significant soft tissue damage, unable to cover bone with soft tissue (requiring graft), and periosteal stripping
• Type 3C – Similar to type A or B, however with Arterial damage requiring repair

Chronic

If a wound becomes arrested in progression through the normal stages of inflammation and wound healing and remains open, then this becomes a chronic wound. While there is no consensus as to when a wound becomes chronic, a study by Sheehan et. al determined that in diabetic wounds, the degree of healing at 4 weeks is a strong predictor of 12 week healing, suggesting that those wounds which have not healed approximately 50% in 4 weeks are likely to have an arrested healing process, and therefore are chronic.[rx][rx]

In the chronic setting, the main goal is to identify why the wound is not healing and to fix this obstacle or obstacles.

There are a limited number of reasons a wound becomes chronic; however, once these reasons are rectified, the wound resumes its natural course of healing.

• Arterial – Is there enough blood flow? Generally speaking, an ABI of less than 50 mm Hg, or an absolute toe pressure less than 30 mm Hg (or less than 50 mm Hg for persons with diabetes) indicates critical limb ischemia and predicts failure of wounds to heal.
• Venous – Pressure-induced changes in blood vessel wall permeability then lead to leakage of fibrin and other plasma components into the perivascular space. Accumulation of fibrin has direct and negative effects on wound healing as it down-regulates collagen synthesis.
• Infection – Underlying infectious processes including cellulitic and osteomyelitis processes will inhibit wound healing. Culturing for aerobic, anaerobic, and fungal pathogens is recommended.
• Pressure – Increased pressure to the area of concern will destroy new tissue growth and prevent proper perfusion of blood to the wound site. These areas need to be offloaded to avoid pressure in the area.
• Oncologic – Always biopsy areas of concern in nonhealing wounds, as this can be an atypical presentation of some types of malignancies.
• Systemic – There are multiple systemic diseases which inhibit wound healing, with diabetes being the most common culprit. It has been determined that uncontrolled blood glucose levels suppresses the body’s normal inflammatory response, as well as causing microvascular disease which limits healing.
• Nutrition – While serum albumin has not been found to be a good predictor of wound healing, there is some evidence that protein malnutrition, as well as insufficient levels of certain vitamins and minerals, will limit the body’s ability to heal chronic wounds.
• Pharmacological – Hydroxyurea has been reported in multiple instances to cause nonhealing ulcerations.
• Self-inflicted/psychosocial – There are instances where a patient is causing the ulceration, either on purpose or as a result of noncompliance. This is often the hardest factor to spot and overcome, but must always be a consideration.

2. According to level of contamination, a wound can be classified as

• Clean wound – made under sterile conditions where there are no organisms present, and the skin is likely to heal without complications.
• Contaminated wound – usually resulting from accidental injury; there are pathogenic organisms and foreign bodies in the wound.
• Infected wound – the wound has pathogenic organisms present and multiplying, exhibiting clinical signs of infection (yellow appearance, soreness, redness, oozing pus).
• Colonized wound – a chronic situation, containing pathogenic organisms, difficult to heal (i.e. bedsore).

Open

Open wounds can be classified according to the object that caused the wound

• Incisions or incised wounds – caused by a clean, sharp-edged object such as a knife, razor, or glass splinter.
• Lacerations – irregular tear-like wounds caused by some blunt trauma. Lacerations and incisions may appear linear (regular) or stellate (irregular). The term laceration is commonly misused in reference to incisions.^[rx]
• Abrasions (grazes) – superficial wounds in which the topmost layer of the skin (the epidermis) is scraped off. Abrasions are often caused by a sliding fall onto a rough surface such as asphalt, tree bark or concrete.
• Avulsions – injuries in which a body structure is forcibly detached from its normal point of insertion. A type of amputation where the extremity is pulled off rather than cut off. When used in reference to skin avulsions, the term ‘degloving’ is also sometimes used as a synonym.
• Puncture wounds – caused by an object puncturing the skin, such as a splinter, nail or needle.
• Penetration wounds – caused by an object such as a knife entering and coming out from the skin.
• Gunshot wounds – caused by a bullet or similar projectile driving into or through the body. There may be two wounds, one at the site of entry and one at the site of exit, generally referred to as a “through-and-through.”

Closed

Closed wounds have fewer categories, but are just as dangerous as open wounds:

• Hematomas (or blood tumor) – caused by damage to a blood vessel that in turn causes blood to collect under the skin.
  • Hematomas that originate from internal blood vessel pathology are petechiae, purpura, and ecchymosis. The different classifications are based on size.
  • Hematomas that originate from an external source of trauma are contusions, also commonly called bruises.
• Crush injury – caused by a great or extreme amount of force applied over a long period of time.

3. According to the Visuality, a wound can be classified as

Internal Wounds

Disturbance of the different regulating systems of the human body can lead to wound formation, and may include the following:

• Impaired circulation – This can be from either ischemia or stasis. Ischemia is the result of reduced blood supply caused by the narrowing or blockage of blood vessels, which leads to poor circulation. Stasis is caused by immobilization (or difficulty moving) for long periods or failure of the regulating valves in the veins, which leads to blood pooling and failing to flow normally to the heart.

• Neuropathy – This is seen mostly in cases of prolonged uncontrolled diabetes mellitus, where high blood sugars, derivative proteins and metabolites accumulate and damage the nervous system. The patients are usually unaware of any trauma or wounds, mainly due to loss of sensation in the affected area.

• Medical illness – When chronic and uncontrolled for long periods (such as hypertension, hyperlipidemia, arthrosclerosis, diabetes mellitus, AIDS, malignancy, morbid obesity, hepatitis C virus, etc.), medical illnesses can lead to impairment of the immune system functions, diminishing the circulation and damaging other organs and systems.

External Wounds

External wounds can either be open or closed. In cases of closed wounds, the skin is intact and the underlying tissue is affected but not directly exposed to the outside environment. The following are the most common types of closed wounds:

• Contusions – These are a common type of sports injury, where a direct blunt trauma can damage the small blood vessels and capillaries, muscles and underlying tissue, as well the internal organs or bone. Contusions present as a painful bruise with reddish to bluish discoloration that spreads over the injured area of skin.

• Hematomas – These include any injury that damages the small blood vessels and capillaries resulting in blood collecting and pooling in a limited space. Hematomas typically present as a painful, spongy rubbery lump-like lesion. Depending on the severity and site of the trauama, hematomas can be small or large, deep inside the body or just under the skin.

• Crush injuries – These are usually caused by an external high-pressure force that squeezes part of the body between two surfaces. The degree of injury can range from a minor bruise to a complete destruction of the crushed area of the body, depending on the site, size, duration and power of the trauma.

Causes of Acute Wound

• Sudden forceful  fall down
• Road traffic accident
• Burn and injured suddenly
• Falls – Falling onto an outstretched hand is one of the most common causes of wound.
• Sports injuries – Many sports injury occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wound. Sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones.
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Diagnosis of Acute Wound

Treatment of Acute Wound

Emergency Management

Pain control

• Intravenous opiates are often used as patients typically in severe pain
  • Highly effective for management of pain 
  • Lower side effect profile than systemic analgesia
  • Always calculate your toxic dose of local anesthetic to avoid local anesthetic systemic toxicity

• Closed the wounds should be placed in long leg splint and can also be placed in traction
• If open Fractures should receive antibiotics and should proceed to OR for irrigation/debridement.
• Cleaning to remove dirt and debris from a fresh wound. This is done very gently and often in the shower.
• Vaccinating for tetanus may be recommended in some cases of traumatic injury.
• Exploring a deep wound surgically may be necessary. Local anaesthetic will be given before the examination.
• Removing dead skin surgically. Local anaesthetic will be given.
• Closing large wounds with stitches or staples.
• Dressing the wound – The dressing chosen by your doctor depends on the type and severity of the wound. In most cases of chronic wounds, the doctor will recommend a moist dressing.
• Relieving pain with medications – Pain can cause the blood vessels to constrict, which slows healing. If your wound is causing discomfort, tell your doctor. The doctor may suggest that you take over-the-counter drugs such as paracetamol or may prescribe stronger pain-killing medication.
• Treating signs of infection including pain – pus and fever. The doctor will prescribe antibiotics and antimicrobial dressings if necessary. Take as directed.
• Skin Traction (Hare or Thomas) if needed
  • May improve wound alignment, blood flow, and pain
  • Skin traction splint can cause complications if a patient with a significant  injury (i.e. multi ligamentous knee injury)
  • Hare Splint Video(link)
  • Thomas Splint Video (link)

Medication

Here we review only the commonly used medications that have a significant impact on healing, including glucocorticoid steroids, non-steroidal anti-inflammatory drugs, and chemotherapeutic drugs.

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Glucocorticoid Steroids – Systemic glucocorticoids (GC), which are frequently used as anti-inflammatory agents, are well-known to inhibit wound repair via global anti-inflammatory effects and suppression of cellular wound responses, including fibroblast proliferation and collagen synthesis. Systemic steroids cause wounds to heal with incomplete granulation tissue and reduced wound contraction [rx]. Glucocorticoids also inhibit production of hypoxia-inducible factor-1 (HIF-1), a key transcriptional factor in healing wounds [rx].
• Non-steroidal Anti-inflammatory Drugs – Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are widely used for the treatment of inflammation and rheumatoid arthritis and for pain management. Low-dosage aspirin, due to its anti-platelet function, is commonly used as a preventive therapeutic for cardiovascular disease, but not as an anti-inflammatory drug [rx]. There are few data to suggest that short-term NSAIDs have a negative impact on healing.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms or injury
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – To improve bones health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
• Dietary supplement -to remove general weakness & improved health.
• Vitamin C – It help to cure the wounds
• Chemotherapeutic Drugs – Most chemotherapeutic drugs are designed to inhibit cellular metabolism, rapid cell division, and angiogenesis and thus inhibit many of the pathways that are critical to appropriate wound repair. These medications inhibit DNA, RNA, or protein synthesis, resulting in decreased fibroplasia and neovascularization of wounds [rx].
• Nutrition – For more than 100 years, nutrition has been recognized as a very important factor that affects wound healing. Most obvious is that malnutrition or specific nutrient deficiencies can have a profound impact on wound healing after trauma and surgery. Patients with chronic or non-healing wounds and experiencing nutrition deficiency often require special nutrients. Energy, carbohydrate, protein, fat, vitamin, and mineral metabolism all can affect the healing process [rx].
• Carbohydrates, Protein, and Amino Acids – Together with fats, carbohydrates are the primary source of energy in the wound-healing process. Glucose is the major source of fuel used to create the cellular ATP that provides energy for angiogenesis and deposition of the new tissues [rx]. The use of glucose as a source for ATP synthesis is essential in preventing the depletion of other amino acid and protein substrates [rx].
• Protein – is one of the most important nutrient factors affecting wound healing. A deficiency of protein can impair capillary formation, fibroblast proliferation, proteoglycan synthesis, collagen synthesis, and wound remodeling. A deficiency of protein also affects the immune system, with resultant decreased leukocyte phagocytosis and increased susceptibility to infection [rx]. Collagen is the major protein component of connective tissue and is composed primarily of glycine, proline, and hydroxyproline. Collagen synthesis requires hydroxylation of lysine and proline, and co-factors such as ferrous iron and vitamin C. Impaired wound healing results from deficiencies in any of these co-factors [rx].
• Arginine – is a semi-essential amino acid that is required during periods of maximal growth, severe stress, and injury. Arginine has many effects in the body, including modulation of immune function, wound healing, hormone secretion, vascular tone, and endothelial function. Arginine is also a precursor to proline, and, as such, sufficient arginine levels are needed to support collagen deposition, angiogenesis, and wound contraction [rx][rx]. Arginine improves immune function, and stimulates wound healing in healthy and ill individuals [rx]. Under psychological stress situations, the metabolic demand of arginine increases, and its supplementation has been shown to be an effective adjuvant therapy in wound healing [rx].
• Glutamine – is the most abundant amino acid in plasma and is a major source of metabolic energy for rapidly proliferating cells such as fibroblasts, lymphocytes, epithelial cells, and macrophages [rx]. The serum concentration of glutamine is reduced after major surgery, trauma, and sepsis, and supplementation of this amino acid improves nitrogen balance and diminishes immunosuppression [rx]. Glutamine has a crucial role in stimulating the inflammatory immune response occurring early in wound healing [rx]. Oral glutamine supplementation has been shown to improve wound breaking strength and to increase levels of mature collagen [rx].
• Fatty Acids – Lipids are used as nutritional support for surgical or critically ill patients to help meet energy demands and provide essential building blocks for wound healing and tissue repair. Polyunsaturated fatty acids (PUFAs), which cannot be synthesized de novo by mammals, consist mainly of two families, n-6 (omega-6, found in soybean oil) and n-3 (omega-3, found in fish oil). Fish oil has been widely touted for the health benefits of omega-3 fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The effects of omega-3 fatty acids on wound healing are not conclusive. They have been reported to affect pro-inflammatory cytokine production, cell metabolism, gene expression, and angiogenesis in wound sites [rx] . The true benefit of omega-3 fatty acids may be in their ability to improve the systemic immune function of the host, thus reducing infectious complications and improving survival [rx].
• Vitamins, Micronutrients, and Trace Elements – Vitamins C (L-ascorbic acid), A (retinol), and E (tocopherol) show potent anti-oxidant and anti-inflammatory effects. Vitamin C has many roles in wound healing, and a deficiency in this vitamin has multiple effects on tissue repair. Vitamin C deficiencies result in impaired healing, and have been linked to decreased collagen synthesis and fibroblast proliferation, decreased angiogenesis, and increased capillary fragility. Also, vitamin C deficiency leads to an impaired immune response and increased susceptibility to wound infection [rx;rx]. Similarly, vitamin A deficiency leads to impaired wound healing. The biological properties of vitamin A include anti-oxidant activity, increased fibroblast proliferation, modulation of cellular differentiation and proliferation, increased collagen and hyaluronate synthesis, and decreased MMP-mediated extracellular matrix degradation [rx].
• Vitamin E, an anti-oxidant – maintains and stabilizes cellular membrane integrity by providing protection against destruction by oxidation. Vitamin E also has anti-inflammatory properties and has been suggested to have a role in decreasing excess scar formation in chronic wounds. Animal experiments have indicated that vitamin E supplementation is beneficial to wound healing [rx, rx; rx] and topical vitamin E has been widely promoted as an anti-scarring agent. However, clinical studies have not yet proved a role for topical vitamin E treatment in improving healing outcomes [rx,rx].
• Several micronutrients – have been shown to be important for optimal repair. Magnesium functions as a co-factor for many enzymes involved in protein and collagen synthesis, while copper is a required co-factor for cytochrome oxidase, for cytosolic anti-oxidant superoxide dismutase, and for the optimal cross-linking of collagen. Zinc is a co-factor for both RNA and DNA polymerase, and a zinc deficiency causes a significant impairment in wound healing. Iron is required for the hydroxylation of proline and lysine, and, as a result, severe iron deficiency can result in impaired collagen production [rx,rx;rx, rx; rx].

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Some of the unique features of each are described below.

The following dressings may be used on chronic or acute wounds depending on the nature of the wound.

• Low or nonadherent dressings – are inexpensive and allow wound exudate to pass through into a secondary dressing while helping to maintain a moist wound environment. These dressings are specially designed to reduce adherence to the wound bed. Non adherent dressings are made from open weave cloth soaked in paraffin, textiles, or multilayered or perforated plastic films. This type of dressing is suitable for flat, shallow wounds with low exudate such as a venous leg ulcer.
• Hydrocolloid dressings – are composed of adhesive, absorbent, and elastomeric components. Carboxymethylcellulose is the most common absorptive ingredient. They are permeable to moisture vapor, but not to water. Additionally, they facilitate autolytic débridement, are self-adhesive, mold well, provide light-to-moderate exudate absorption, and can be left in place for several days, minimizing skin trauma and disruption of the healing process. They are intended for use on light-to-moderate exuding, acute or chronic partial- or full-thickness wounds but are not intended for use on infected wounds. Upon sustained contact with wound fluid, the hydrocolloid forms a gel.
• Foam dressings – vary widely in composition and construction. They consist of a polymer, often polyurethane, with small, open cells that are able to hold fluids. Some varieties of foam dressings have a waterproof film covering the top surface and may or may not have an adhesive coating on the wound contact side or border. Foams are permeable to water and gas, and are able to absorb light to heavy exudate. This type of dressing is frequently used under compression stockings in patients with venous leg ulcers.
• Film dressings consist of a single – thin transparent sheet of polyurethane coated on one side with an adhesive. The sheet is permeable to gases and water vapor but impermeable to wound fluids. Film dressings retain moisture, are impermeable to bacteria and other contaminants, allow wound observation, and do not require a secondary dressing. Excessive fluid buildup may break the adhesive seal and allow leakage. Film dressings are intended for superficial wounds with little exudate and are commonly used as a secondary dressing to attach a primary absorbent dressing. The dressing may remain in place for up to seven days if excessive fluid does not accumulate. Film dressings have been used extensively to treat split-thickness graft donor sites.
• Alginate dressings – are made from calcium or calcium-sodium salts of natural polysaccharides derived from brown seaweed. When the alginate material comes into contact with sodium-rich wound exudates, an ion exchange takes place and produces a hydrophilic gel. This hydrophilic gel is capable of absorbing up to 20 times its weight and does not adhere to the wound. This dressing can remain in place for about seven days if enough exudate is present to prevent drying. This category of dressing is best suited for moist, moderate-to-heavy exuding wounds. Alginate dressings require a secondary dressing, such as a film dressing, to hold them in place and to prevent the alginate from drying out.
• Hydrofiber dressing –  is composed of sodium carboxymethylcellulose fibers.^[rx] The fibers maintain a moist wound environment by absorbing large amounts of exudate and forming a gel. This dressing is not intended for lightly exuding wounds. A secondary dressing is required.
• Hydrogel sheets  – are three-dimensional networks of cross-linked hydrophilic polymers. Their high water content provides moisture to the wound, but these dressings can absorb small-to-large amounts of fluid, depending on their composition. Depending on wound exudate levels, hydrogels may require more frequent dressing changes, every 1–3 days, compared with other synthetic dressings. Hydrogel sheets can be used on most wound types but may not be effective on heavily exuding wounds. The gel may also contain additional ingredients such as collagens, alginate, or complex carbohydrates. Amorphous hydrogels can donate moisture to a dry wound with eschar and facilitate autolytic débridement in necrotic wounds. A second dressing may be used to retain the gel in shallow wounds.
• Polymer-based dressing – Transforming methacrylate (TMD) was compared to carboxymethylcellulose (CMC-Ag) in one study of 34 patients. The study showed that TMD, compared to CMC-Ag, was associated with lower pain scores and better patient satisfaction, but the two dressings did not differ in terms of number of dressing changes and the time to complete healing.^[rx] Suprathel (a polymer-based dressing) was evaluated in a study of 72 patients, and it was compared to a polyurethane dressings (Biatain-Ibu) and a silicone dressing (Mepitel). The three dressings had similar time to re-epithelialization, but Suprathel had a significantly lower number of dressing changes compared to the two other dressings.^[rx]
• Crystalline cellulose dressings – Results for the comparison between CMC-Ag and TMD are presented above.^[rx] Veloderm was compared to Vaseline gauze in 96 patients.^[rx] The study showed that Veloderm was associated with lower time to complete healing and number of dressing changes. The two dressings did not differ in terms of incidence of exudate, peri-lesional erythema or pain intensity.^[rx]Rayon dressing was compared to Veloderm in a study of 14 patients and 28 skin graft donor sites.^[rx] Rayon dressing showed lower dressing adherence to wound and lower 1st day pain score; the two dressings did not differ in terms of pain beyond day 14, hyperemia, edema and pruritus.^[rx]
• Alginate dressings – The study evaluated the dressing materials in terms of time to healing, pain scores, clinical infections and hypergranulation. Results showed that the six types of dressings did not differ with statistical significance except in the following cases: first, the semi-permeable films (Tegaderm or Opsite) were associated with lower pain scores than any other dressing type; second, the hydrocolloid dressing (DuoDerm E) required lower time (seven days difference) to healing than all other dressings; finally, the gauze dressings (Adaptic or Jelonet) were associated with the highest incidence of clinical infections.^[rx]

Complication of  Wound Healing

Factors that can slow the wound healing process include

• Dead skin (necrosis) – dead skin and foreign materials interfere with the healing process.
• Infection – an open wound may develop a bacterial infection. The body fights the infection rather than healing the wound.
• Haemorrhage – persistent bleeding will keep the wound margins apart.
• Mechanical damage – for example, a person who is immobile is at risk of bedsores because of constant pressure and friction.
• Diet – poor food choices may deprive the body of the nutrients it needs to heal the wound, such as vitamin C, zinc and protein.
• Medical conditions – such as diabetes, anaemia and some vascular diseases that restrict blood flow to the area, or any disorder that hinders the immune system.
• Age – wounds tend to take longer to heal in elderly people.
• Medicines – certain drugs or treatments used in the management of some medical conditions may interfere with the body’s healing process.
• Smoking – cigarette smoking impairs healing and increases the risk of complications.
• Varicose veins – restricted blood flow and swelling can lead to skin break down and persistent ulceration.
• Dryness – wounds (such as leg ulcers) that are exposed to the air are less likely to heal. The various cells involved in healing, such as skin cells and immune cells, need a moist environment.

References