Management of chemical injuries to the upper extremity

Chemical burns are interesting and challenging to treat. When the practitioner is comfortable with the pathophysiology of chemical injury and treatment based on these principles, most patients can be treated effectively with good outcome (Fig. 2). Early treatment with water irrigation, followed by diligent wound care, will allow our patients to benefit to the maximum from our medical skills.     

Management of upper extremity injuries in obese patients

Upper extremity injuries are more prevalent in obese people than in nonobese people after low-energy falls. Because splinting and casting are inefficient methods of stabilization in the setting of obesity, internal fixation provides stability for mobilization and realignment. Morbid obesity adversely affects positioning, surgical exposures, and complications associated with operative fixation. Avoiding short cuts and complications, morbidly obese patients should be able to return to normal functioning.     

Golf injuries of the upper extremity

Golf has demonstrated increasing popularity and with this heightened enthusiasm has come an increased awareness of the significant number of injuries associated with playing golf. While back injuries represent the most commonly injured specific body part, upper extremity injuries are most frequent overall and the most likely to result in loss of play. Patterns of injury differ based on level of play and time spent playing or practicing golf. Among golf professionals, the hand/wrist is the most commonly injured upper extremity structure. Among amateurs, the elbow is most commonly injured. The vast majority of upper extremity injuries are due to overuse. Age, ability, equipment, and swing mechanics also play contributing roles. Most upper extremity golf injuries can be successfully treated with appropriate cessation or modification of play, anti-inflammatory modalities, and rehabilitation. Surgical treatment is rarely required, but if needed can prove successful in a high percentage of patients.     

Rollover injuries of the upper extremity

Eleven patients were treated for rollover injuries of the upper extremities from 1971 to 1976 resulting from the rollover accidents of off-road vehicles in rough terrain. Injuries to the volar surfaces of the extremity were most common, but injury to the extensor surfaces seemed to be more severe. Soft-tissue injuries predominated as did injury to the nondominant hand. The majority of patients returned to their original jobs after sometimes prolonged recovery and rehabilitation. A redesign of the rollover cage with interior hand holds could reduce the frequency and severity of these novel injuries.     

Extravasation injuries in the upper extremity

Fourteen patients with intravenous extravasations of chemotherapeutic medications, radiographic contrast agents, vasopressors, fluorescein, or albumin/potassium phosphate were evaluated with regard to function and cosmesis. The average follow-up period was 8.4 months (range, one-24 months). Five patients initially were managed conservatively and, after demarcation of the necrotic area, had surgical procedures for skin coverage. Four of these patients had poor functional and cosmetic results. The remaining patient had an excellent final result. Because of the generally poor results observed in the aforementioned patients, a program of early recognition and surgical intervention in selected extravasation cases was instituted. Following this change, eight of nine patients had good or excellent results. Early surgical involvement in the evaluation of extravasations, with and early surgical drainage and irrigation in selected severe cases, appears to improve the outcome of these iatrogenic injuries.     

Drug injection injuries of the upper extremity

The increasing incidence of illicit intravenous drug abuse has reached epidemic proportions in western society. Although the accompanying infectious complications such as hepatitis and acquired immunodeficiency syndrome receive the most notoriety, injection injuries are causing an increasing number of problems. A retrospective review of patients requiring admission for acute or chronic drug injection injuries of the upper extremities was made at the Detroit Receiving Hospital from 1980 through 1985. The demographical, historical, physical, microbiological, and follow-up data were analyzed. The majority of the injuries involved subcutaneous injections into the hand with accompanying inflammatory or infectious complications. The bacteriological data revealed unique characteristics and did not reflect patterns expected from inoculation of normal skin flora. A treatment regimen based on the data is proposed.     

Management of acute burn injuries of the upper extremity in the pediatric population

Burns of the upper extremity occur frequently in children. Because of differences in development and anatomy, patterns of burn injury are different in children compared to adults. Immediate goals after these injuries are to prevent compartment syndromes and minimize progressive damage. The second decision is whether the burn requires conservative care or grafting. If the injury heals within 2 weeks, then scarring is minimized. If the wound has not healed in that time period, then grafting should be considered. Grafting techniques that optimize function and cosmetic appearance are outlined.     

Meat grinder injuries to the upper extremity

Three cases of hand injury caused by meat grinders are presented. All 3 injuries involved the dominant hand and resulted in varying degrees of deformity. Two of the 3 patients arrived in the emergency room with the injured hand still firmly wedged in the meat grinder. Although these injuries continue to prove very mutilating, maximum restoration of the injured hand can be accomplished by careful extrication, followed by preservation and reconstruction of all viable tissues. Perioperative antibiotics and wound irrigation with antibiotic solution are recommended. Microsurgical technique can be of value in treating selected patients.     

High-energy roller injuries to the upper extremity

Eleven cases of high-energy industrial roller injuries treated between 1980 and 1984 were retrospectively reviewed. The dominant extremity was affected in nine. Six patients sustained fractures and/or dislocations, and three of these patients required fasciotomies for clinical signs of impending compartment syndromes. All fracture/dislocations, with the exception of a scapula fracture, anterior dislocation of a thumb interphalangeal joint, and a fractured coronoid process of the ulna, required open reduction with internal fixation. Three patients required split-thickness skin grafting for extensive skin degloving. Two patients required immediate amputation. Late sequelae included prolonged edema, nutritional depletion, neuroma formation of the superficial branch of the radial nerve, late carpal tunnel syndrome, and partial brachial plexus palsy. Industrial roller injuries continue to be an occupational hazard associated with more severe crushing trauma than the low-energy wringer washer injuries first described by MacCollum (11). Attention must be paid to the treatment of crushed skin, muscle, and nerves, fracture stabilization, nutritional support, and occupational therapy. Concurrent monitoring for signs of a developing compartment syndrome and complications of rhabdomyolysis is essential.     

Partial nerve injuries in the upper extremity

The level of injury of a peripheral nerve is a critical factor that has a great impact on the result of the repair. At the level of the wrist, the median and ulnar nerves have pure motor and sensory fascicular groups. Proximal to the wrist, the motor fascicular groups combine with sensory fascicles and become mixed nerves. Mapping the fascicular orientation with electrical stimulation is indicated for injuries located from the wrist to the distal third of the forearm. Successful application of this technique depends on the level of injury, anesthetic technique, and careful patient selection. Children and patients with other serious coexisting injuries are not candidates for this technique. The depth of anesthesia must provide adequate analgesia while allowing the patient to communicate and cooperate with the surgeon during the procedure. There are few reports in the literature about repair of partially injured nerves in the upper extremities and the comparison of functional outcomes with or without the use of nerve grafts is not easy. Even under ideal operative conditions and with ideal indications, the outcomes are not always satisfactory. Hurst et al reported very good results using end-to-end repair of fascicular groups in their series. Using the rating system of the British Medical Research Council, they reported motor values of 4.0 (normal 5.0), and sensory values of 3.8 (normal 4.0). Kato et al reported very good results in their series of 51 cases with group fascicular end-to-end suture using orientation with electrical stimulation. In this series, there were five patients with partial nerve laceration and end-to-end coaptation of the fascicular groups provided very satisfactory outcome. End-to-end repair of the fascicular groups seems to provide better results than repair of the nerve using nerve grafts. It is desired, however, that the nerve gap be less than 2 cm for the application of end-to-end repair of the nerve.     

Management of severe proximal vascular and neural injury of the upper extremity

Purpose: Early amputation has been suggested to be the optimal treatment for severe combined vascular and neural injuries of the proximal upper extremity. This retrospective study was done to evaluate the long-term clinical outcome of our policy of limb salvage by revascularization and delayed treatment of neural injuries. Methods: Forty-six patients with neural and vascular trauma to the upper extremity were treated at our institution. All of these patients had aggressive treatment directed at limb salvage with restoration of vascular supply and nerve function. Long-term vascular and neurologic outcomes were recorded. Neurologic deficits were validated by the American Medical Association's standardized disability impairment scale (0% to 100%). Results: The rate of preoperative disability was 83%, which improved to 52% (p < 0.01) after treatment (mean follow-up, 43 months). Overall, 87% showed improvement. Conclusions: These results suggest that early amputation should not be performed unless there is massive tissue loss or an attempt at limb salvage might endanger life. Final outcomes cannot be predicted on the basis of initial clinical presentation. As a group, the majority of these patients improved with aggressive intervention. (J Vasc Surg 1998;27:43-9.)     

Blunt trauma-induced upper extremity vascular injuries

Penetrating vascular injury which is associated with a satisfactory response to treatment occurs more commonly than blunt injury in the upper limb. Blunt trauma is a complex entity with associated soft tissue and skeletal injuries that may determine outcome irrespective of successful vascular repair. We reviewed 50 patients with upper limb vascular injury of which 43 were due to blunt trauma and seven to penetrating trauma. All patients with penetrating trauma had a good result without loss of limb function. Eight amputations and residual poor limb function in ten patients confirm the poor results of blunt injury. Associated nerve damage, responsible for nine of the ten poorly functioning limbs, is the most important determinant of outcome in limbs surviving the peri-traumatic period.     

External fixation of high-energy upper extremity injuries

Forty patients with high-energy upper extremity injuries involving the humerus and forearm bones were treated by primarye external fixation. Concomitant soft tissue or neurovascular injuries were rated by the Gustilo classification, and this rating correlated well with the final results: three fractures were Gustilo type I, two fractures were type II, and 35 were type III (IIIA, nine fractures; IIIB, eight; and IIIC, 18). Immediate external fixation, open wound treatment, delayed bone grafting, and late internal fixation led to good to excellent results in 73%. Complications were either minor (related to the external fixation and included pin loosening, 20%) or significant (osteomyelitis, 3%).     

Tire explosion injuries to the upper extremity.

Several articles have been published that bring attention to the destructive potential of tire explosions. Although the severity of tire explosion injuries to the head and neck region is well established, only one previous article has reported injuries to the upper extremity. Fourteen patients with upper extremity tire explosion injuries have been treated by us from 1980 to 1988. Each injury was caused by single-piece wheel assemblies, as opposed to multipiece wheel assemblies, which have traditionally been associated with the injury. Three representative patient reports are discussed. Prevention of this injury can be achieved by increased public awareness, formal industrial safety training, tire servicing with dedicated equipment including restraining devices or barriers, complete evaluation of wheel/tire serviceability before tire mounting, separation of servicing of single and multipiece wheels, and complete tire deflation before servicing.     

Electrical injuries to the upper extremity a review

Electrical injury of the upper extremity requires mature management because the extremity can usually be preserved if the point of entrance (or contact) is on the dorsum of the arm. The converse is usually true if the contact is on the palmar-volar aspect of the hand and wrist, for significant loss of nerves, blood vessels and tendons occurs. Early amputation must be considered in this situation. The pathophysiology of these injuries is discussed along with a plan of management for functional return of the upper extremity.