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Главная > № 4 (2017) > Егиазарян

TREATMENT OF INJURIES TO THE HAND IN PATIENTS WITH MULTIPLE AND ASSOCIATED INJURY

Egiazaryan K.A., Skoroglyadov A.V., Germanova I.A.

Pirogov Russian National Research Medical University, Moscow, Russia  

The problem of treatment of hand injury in patients with multiple and associated injuries is not described well in literature. We have found only few articles dedicated to this topic. Nothing is known about epidemiology, characteristics and outcomes of such injuries. The available literature data are contradictory [1]. The features of such complex anatomic and functional entity require for a specific approach to diagnosis, treatment and following rehabilitation [2-5].
At the same time, more rapid and powerful vehicles appear, extreme types of sports develop, resulting in increasing amount of patients with high energy multiple and associated injuries, which often include hand damages [2]. These damages have some features:
- they are characterized by severe damages of soft tissues and multiple bone fractures [6, 7];
- in most cases, they are associated with high energy trauma (HET);
- diagnosis of such injuries is difficult owing to presence of life-threatening injuries, need for resuscitation measures, unconsciousness, prolonged sedation in ICU;
- they do not make significant influence on life-relating outcome and do not play the significant role in the cascade of the pathophysiological processes of traumatic disease [8];
- they are characterized by complexity of treatment and need for specialists in hand surgery, as well as by long term stay of the patient in the surgery room;
- long term functional disorders of the hand play the leading role in decreasing quality  of life and ability to work and self-care.
In some cases, unsatisfactory results of treatment are associated with errors in diagnosis of injuries, management or surgical technique [9]. Even after successful primary and delayed reconstructive operations, the patients with hand injuries demonstrate the quite high rate (up to 90 %) of unsatisfactory outcomes owing to insufficient or inadequate postsurgical rehabilitation [1, 9, 12].
Objective – to summarize the data on the prevalence of hand injuries in patients with polytrauma.
During the literature analysis we had the following tasks: generalization of data on rates of hand injuries in patients with polytrauma, identification of the features and the patterns of hand injuries in this group of patients, estimation of diagnostic difficulties and available approaches to treatment, investigation of long term outcomes of the injuries.

EPIDEMIOLOGY

According to the data by some authors, hand injuries are identified in 3.5-25 % of patients with multiple and associated injuries [1, 6]. Such high scatter can be explained by the fact that the studies are retrospective and limited by a single medical facility or a data base. Moreover, fractures of the distal part of the forearm bones are often considered as a hand injury.
S. Ferree et al. conducted the retrospective analysis of 2,046 cases of polytrauma in Dutch National Trauma Database (DNTD). 3.5 % of the patients had the fractures and dislocations of the hand. The following features were identified after comparing those patients with the patients without hand injuries: the mean age of the patients with hand injury was lower (44 years); hospital stay was higher by 4 days; 90 % of the patients suffered from high energy trauma (52 % in the main group) as result of road traffic accident with cars or motorcycles [1].
S. Adrian et al. analyzed the data from their hospital and found that 386 patients had hand injuries in 26-67 %. A half of the injuries were the fractures of the distal radial bone. Therefore, these two studies showed the similar findings of the rates of hand injuries without consideration of the distal part of the forearm. Other values were similar: the mean age was 36.4 years, high average ISS (28.3) indicating the prevalence of high energy trauma [13].
According to M. Schaedel-Hoepfner [7], the patients with polytrauma have hand fractures in 2-16 %, soft tissue damages – in 2-11 %, amputations and severe damages of soft tissues are rare (0.2-3 %). Wrist fractures are 29 %, metacarpal bones – 48 %, phalanges – 24 % among hand fractures [1]. Such injuries are often underestimated during urgent care. It is determined by diagnostic difficulties (small injuries are disguised by organ ruptures and fractures of big bones), as well as by complexity of treatment (reconstructive surgical interventions require for hand surgery specialists and long term stay in the surgery room).

DIAGNOSIS

In cases of opened fractures, extensive wounds and traumatic amputations of the hand and the fingers, the injuries are evident, and their treatment is initiated as early as possible. As for closed injuries, their timely and early diagnostics is often associated with some difficulties resulting in untimely initiation of treatment. The risk of untimely diagnostics of hand injury reaches 50 % in patients with polytrauma [14]. The risk of late diagnosis of hand injuries is two times higher in patients with severe damages as compared to patients with less severe injuries [14].
Treatment of life-threatening injuries takes the first priority in patients with polytrauma [15-19], whereas hand injuries are often missed. Diagnostics of hand injuries is initiated with proper examination. The examination is initiated from estimation of viability of the whole hand and each finger individually. The viability of the tissue is estimated according to skin color, intensity of bleeding in injured regions and temperature. The hand has the quite extensive network of the vessels and the nerves. Therefore, hand wounds cause the significant pain and intense bleeding. As result, the arresting bleeding tourniquet is often applied to the injured extremity. In this regard, one should remember that application of the tourniquet to the forearm can make significant influence on sensitive and motion functions of the hand (even after removal of the tourniquet) [3].
The trauma energy should be always considered – victims of road traffic accidents may have serious hand injuries (hand dislocations, multi-fragmentary fractures of the distal metaepiphysis of the radial bone and others), even in minimal changes in clinical examination [7, 20]. Unconscious patients should be examined more carefully, since the reliable signs of hand fractures are in 20-25 %, whereas the possible signs are 70-75 % [4]. Therefore, one should consider any bare signs of edema, asymmetry and deformation as compared to the healthy side. Conscious patients are examined for motion functions of the hand and the fingers, condition of palmar and digital branches of radial, median and ulnar nerves. Unconscious patients often receive late diagnostics of injuries to nerves and tendons, and hand fractures. Also two-plane (frontal and lateral, or ¾ of hand pronation) X-ray examination is necessary.
If hand treatment is initiated in appropriate time, it can lead to loss of hand function. To make an objective decision in each individual case, it is necessary to correctly estimate the injury and the patient’s condition. Many scales were developed for this purpose. The most common used scales are GCS (Glasgow Coma Scale), ISS (Injury Severity Score), APACHE (acute physiology and chronic health evaluation) and others.
J.M. Adkinson [14] conducted the analysis of treatment of 36,568 patients: 21.7 % of them had incomplete diagnosis. But the diagnosis was updated on the other day after admission in 91.3 %. The risk of untimely diagnosis of injuries increases in patients with higher ISS and lower GCS. However the results of multiple studies show that late diagnosis rarely causes the life threatening consequences – it decreases the economic efficiency of treatment (admission time and period of work incapacity increase). The question of late diagnosis influence on treatment outcomes is still disputable [1]. For decreasing rate of missed injuries, it is necessary to conduct recurrent examinations 24 hours later, with special attention to identification of “small” injuries (Trauma tertiary survey) [1, 6, 13, 14].

TREATMENT

Treatment of hand injuries requires for special attention and accuracy of reposition of fractures at any level of injury [4]. From the moment of hospital admission of the patient with multiple or associated injury, the first priority is salvage of the patient’s life, maximal accurate and early diagnostics of TBI, damages of bones, the extremities, the pelvis and the abdominal cavity. Lots of specialists are involved in arrangement of care for patients with polytrauma [6, 15]. At this stage, the main tasks of the team of specialists are inspection and interpretation of data of clinical and instrumental examinations, estimation of severity of polytrauma, condition and compensatory abilities of the patient, choice of time and admissible traumatic potential of a surgical intervention, estimation of possibility for simultaneous operations or need for control of injuries severity, compliance with phases of traumatic disease and with features of wound process of wound closure time, terms and methods of final stabilization of fractures.
After interpretation of the results of clinical and radiologic examinations, the traumatologist and the hand surgeon, with use of the team approach to treatment of patients with polytrauma, should quickly choose the best time and a technique of medical care with use of the principles: life saving, preservation of tissues, preservation and restoration of the function.
Arrangement of care for patients with polytrauma is scheduled by ATLS-protocol [21, 22]. ATLS was developed by Dr. Jim Styner in 1978. Since 1980, it has been implemented by American Surgical Colleague for training of physicians of all specialties. ATLS (Advanced trauma life support) is based on the gradual transition in diagnostics and treatment from most dangerous, life-threatening injuries to less dangerous [21]. According to ATLS, the basic rule of medical care is “golden hour”, i.e. gradual arrangement of treatment with the uniform protocol beginning from first aid at the scene of the accident to specialized surgical care in the hospital [21]. As result, the chance of death decreases, when the physician treats less severe injuries without identification of most dangerous ones.
The impact of various high energy forces causes the so called first hit, when different injuries to the organs and fractures appear. Therefore, the injury can be considered as a trigger for the cascade of posttraumatic responses and events resulting in the range of the pathophysiological processes in the organs and tissues [7, 18, 23]. The “first hit” is inevitably followed by the “second hit”. The term “second hit” includes not only surgical invasion, but also ischemia, reperfusion injuries and infectious complications which can worsen the course of SIRS, causing the multiple organ dysfunction syndrome (MODS), multiple organ failure (MOF) and death [7].
The experience in treating multiple and associated injuries resulted in development of early total care (ETC) in 80s of the 20th century. ETC means the earliest and complete treatment of all available injuries in stable patients. Its objective is to disrupt the pathologic chain of mutual burdening and to promote the fast initiation of restorative treatment [24, 25]. One should mention that hand injuries, along with injuries to other organs, may play the specific role in development of mutual burdening syndrome, but their role in prediction of death is extremely low [8]. ETC was used universally for all groups of patients regardless of severity of injuries. In the end of 80s, with advancement in surgery, it became inefficient for patients with critical injuries.
Owing to the high mortality in patients in unstable, borderline or extremely severe condition, damage control orthopedics (DCO) was developed in 1993. Its main point is the staged treatment of injuries, beginning with life-saving and minimally traumatic operations in the first hours after trauma and completing with low invasive osteosynthesis after complete stabilization of hemodynamic and other values of homeostasis [26, 27, 28]. Realization of this concept allows reducing the surgical “second hit” and facilitating SIRS, MODS and MOF. The significant decrease in time of surgical intervention, blood loss minimization and use of external fixing devices promote the decrease in early and late lethality after associated injuries and their consequences [6]. DCO includes three stages. The first stage includes early temporary stabilization of unstable fractures and control of blood loss. The second stage includes the resuscitation measures for stabilization of the patients’ condition in the intensive care unit (circulating blood volume replacement, coagulopathy correction, stable hemodynamics maintenance, acidosis correction). The third stage includes the delayed final surgical treatment of all injuries [5, 6, 7, 15, 16, 24].
Implementation of ETC and DCO inevitably resulted in appearance of various classifications of surgical interventions depending on severity of condition and severity of injuries.
There are not any uniform classifications of surgical interventions according to time of their conduction for patients with polytrauma. The same terms correspond to different time intervals relating to different stages of traumatic disease.
All identified classification of surgical interventions according to time of their conduction (V.A. Sokolov and E.I Byalik, D.I. Fadeev, S.G. Girshin and I.S. Abdusalamov et al.) [8, 29, 30], the special attention is given to treatment of “big” fractures, whereas time of surgical interventions for “small” fractures in patients with polytrauma is still unknown. Therefore, this issue requires for further investigation. There is no doubt that estimation of injury and condition severity cannot be the reliable criterion for selecting the treatment techniques and determination of indications and contraindications for one or other type of surgical intervention. The time course of the patient’s condition is very important. It shows the individual feedback to the injury and to efficiency of intensive care. Clinical monitoring and the clear ideas of time course of the patient’s condition make the basis for determination of safe time, terms and the volume of surgical interventions [29, 30].
Treatment of injuries to different structures of the hand is characterized by the own features. Hand soft tissue injuries after compression, wound, as well as degloving injuries consist 3-11 % in patients with polytrauma [6]. At the first stage, after manual detersion, the radical primary surgical preparation of wounds is carried out: all non-viable tissues are removed, wounds are washed with antiseptic solutions and are vacuumized for prevention of local and generalized infectious complications [31]. Traumatologists and hand surgeons should strike a balance between radical removal of all unviable tissues and preservation of function. To prevent the surgical “second hit”, all subsequent reconstructive interventions should be delayed and conducted 4 days or later after admission moment [23].
This principle is also used for nerve injures in patients with multiple and associated injuries. Condition of nerves is tested by means of examination of pain sensitivity in concordance with regions of innervation of radial, ulnar and median nerves in the hand. The advantages of primary and primary delayed suture in comparison with secondary one were proved in a number of the animal studies [3, 31]. Nerve suture was considered as primary on the fourth day after injury. However patients with opened fractures, dislocations and severe soft tissue injuries as result of compression receive the secondary nerve suture after wound sanation and condition stabilization.
Fractures and dislocations of wrist and hand bones as a part of polytrauma are mostly diagnosed in appropriate time, resulting in late initiation of treatment [6, 13, 14]. One should note that one week after injury, hand tissues become dense and rigid. Closed reposition is difficult and unsuccessful mostly [3, 4]. Closed or opened reposition and internal fixation are recommended for presence of fractures and dislocations of distal metaepiphysis of the radial bone, wrist bones and metacarpal bones with great displacement of fragments. According DCO principles, it is preferable to use external fixing devices for patients with polytrauma [27, 28]. Treatment of such injuries should be delayed in patients in borderline or unstable condition. After their condition stabilization, they also receive the closed or opened reposition or internal fixation. According to the data by some authors, good application of the external fixation device gives the long term functional results, which are similar with results after anatomical reposition and internal fixation with pins or plates [32, 33, 34]. Therefore, the external fixation device can be (with good position of fragments) a primary or secondary surgical intervention for patients with fractures and dislocations of wrist and hand bones.
Talking about tendon damage in patients with polytrauma, one should give attention to diagnostics. For conscious patients, tendon injuries are diagnosed on the basis of loss of motion functions. The main joints of hand fingers are flexed as result of action of lumbrical and interosseous muscles, even in injury to both flexors. Therefore, each finger joint should be examined separately [3]. Diagnosis of tendon injuries is quite difficult in unconscious patients with significant soft tissue injuries, evident edema and fractures of hand bones. Restoration of tendons can be primary, delayed primary or secondary, in dependence on severity of injuries and the patient’s condition [31, 33].
Traumatic amputations and perfusion disorders consist 0.2-3 % in patients with polytrauma [5]. Changes in skin color, turgor, temperature and absence of blood filling are the sufficient clinical signs for determination of perfusion status. Its determination can be difficult in patients with evident hypotension. Replantation and revascularization are conducted only for stable patients.

REHABILITATION

According to some authors, the studies of the issue of rehabilitation for patients with hand injuries as a part of polytrauma showed that the worst results were observed in patients with ipsilateral injuries to the upper extremity, brachial plexus damage, severe brain injury and high ISS. The researchers have some doubts on a possibility of use of the common scales (DASH, QDASH, PRWHE) for patients with polytrauma, since the scales do not consider the influence of concurrent injuries on limitation of functional capability of the hand [1].

CONCLUSION

Patients with hand injuries as a part of multiple and associated injuries require for detailed and timely diagnostics of hand injuries, early initiation of treatment and subsequent rehabilitation. It will allow improving the treatment outcomes and reducing time of hospital stay and disability rate. Participation of hand surgery specialists at the moment of hospital admission can improve the quality of medical care.

Information about conflict of interests

The study was conducted without sponsorship. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.

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