55. Injuries
From Primary Surgery
55.1 Immediate treatment for a severely bleeding wound
Preventing a patient's blood from leaving his circulation is one of the most urgent surgical tasks. He can lose a litre or more internally into his peritoneal (66.1) or pleural cavities (64.5), or around broken bones (76.1, 78.4). External bleeding is much easier to diagnose and stop. The most useful methods are to raise the wound and to press on it. The least useful method is a tourniquet. So when you teach first aid workers, stress the value of local pressure from a firm pack in the wound, combined with pressing firmly on the pressure points when necessary. Many surgeons feel that a tourniquet is so dangerous that no first aid worker should ever use one-you will however find a pneumatic tourniquet invaluable in the theatre (3.8).
IMMEDIATE TREATMENT FOR A BLEEDING WOUND
ELEVATION If a patient's limb is bleeding, raise it. This will usually control venous bleeding. If his wound is in the upper part of his body, sitting him up may help, but be careful that he does not faint.
DIRECT PRESSURE Press a large dressing firmly over his
wound and wait five minutes. This is usually much more effective
than a haemostat. Don't do anything more until you have
waited for at least five minutes, unless a torrent of blood pours
from the dressing. If bleeding stops, be thankful and don't
meddle with the dressing.
PRESSURE POINTS These are much less effective than direct
pressure. Press: (1) the patient's carotid artery against the
transverse process of his 6th cervical vertebra. (2) His temporal
artery against his skull just in front of his ear. (3) His
subclavian artery against his first rib. (4) His brachial artery
against the middle of his humerus. (5) His femoral artery over
his mid-inguinal point.
HAEMOSTATS If bleeding continues after after five minutes,
a large vessel may have been injured, probably an artery, more
likely from a tear rather than complete transection. When an
artery is completely divided, bleeding usually stops. Secure
the bleeding vessel with a haemostat. This is hardly ever
necessary.
CAUTION ! (1) Get proximal control by pressing on a pressure point first. (2) The vessel must be clearly visible. Don't jab the haemostat blindly into a pool of blood. Be sensible about where you apply a haemostat. Some vessels accompany important nerves. For example, don't crush a patient's ulnar nerve in trying to clamp his ulnar artery.
When the haemostat is in place, incorporate it in the dressings. Don't remove it and try to tie the vessel until he is in the theatre.
PACKING Use this to control deep inaccessible bleeding when the above methods fail. Pack the wound with broad strips of folded gauze. If necessary, hold it in place with deep sutures taking a bite of the uninjured tissue well wide of the edges of the wound.
TEMPORARY SUTURES In some situations, such as the face,
temporary haemostatic sutures may be useful. Don't let them
strangle the tissues.
FIRST AID TOURNIQUETS The few first aid indications for
a tourniquet are: (1) When other methods of controlling
bleeding have failed, bleeding threatens the patient's life, and
the risk of losing his limb can be accepted. (2) A rapidly
increasing arterial haematoma in a closed injury. (3) Some
cases of snake bite.
CAUTION ! (1) A tourniquet is too often applied by first aid workers in a way which impedes the venous return, and so increases bleeding instead of stopping it. (2) Record the time at which 't was applied. (3) It must be supervised and released every 15 minutes.
If a patient arrives with an effective tourniquet that has been in place more than two hours (rare), he is in serious danger of the crush syndrome. The sudden release into his circulation of toxic metabolites, especially myoglobin from his injured muscles, may cause renal failure and kill him. So, if an effective tourniquet has been in place for many hours, and his limb is ischaemic, amputate it at or above the level of the tourniquet.
55.2 Definitive treatment for severe arterial bleeding
If you have temporarily controlled bleeding by the methods in the previous section, you will now have to explore a patient's wound and tie or try to repair his injured vessel, depending upon its collateral circulation. You can usually safely tie: (1) The smaller arteries below his elbow and his knee. (2) His profunda femoris artery. (3) His internal iliac artery. (4) His subclavian artery. But his limb may become gangrenous, especially if he is old, if you tie: (1) his axillary artery, (2) his brachial artery, (3) his femoral artery above the origin of its profunda branch, or (4) his popliteal artery. Try to repair these if you can, by the methods in Section 55.6.
You may have great difficulty finding his injured artery, because his wound may look just like so much meat, and his artery may be contracted and very thin. To find it you may have to release the tourniquet or the proximal clamp, and look for bleeding, or feel for pulsation.
A LIMB ARTERY BLEEDS SEVERELY
IMMEDIATE TREATMENT Take the patient to the theatre, and make sure you have good light. Place a pneumatic tourniquet (3.8) loosely round his injured limb high above his wound so that you can inflate it in a hurry later if you need to. Anaesthetize and drape him. Drape any site you may need to take a graft from. Gently remove the dressings, and explore his wound.
If most bleeding has stopped, you will be able to explore the wound without further trouble.
If his wound bleeds profusely, blow up the tourniquet while you explore it. Try to find the torn artery. Try to apply an arterial clamp above the tear.
If you cannot find the tear, enlarge the wound if necessary, or release the proximal clamp, and feel for pulsation.
If his wound is so high up his limb that you cannot apply a tourniquet or a clamp, be prepared to expose and temporarily clamp his subclavian (3.4) or external iliac artery (3.5).
When you have controlled the bleeding and explored the patient's wound, you will have to decide whether to tie his injured artery or to try to repair it. Below his elbow and knee tie it. Above them try to repair it (55.6).
ALTERNATIVELY, blow up the tourniquet from the start. If you
don't find the vessel (unusual), complete the wound toilet and
any other repairs, then deflate the tourniquet and look for
bleeding from the injured artery.
55.3 The cold blue injured limb
If a patient's limb is cold and blue (if he is Caucasian), its circulation is impaired and he is in danger of gangrene or the compartment syndrome followed by Volkmann's ischaemic contracture (70.4). The commonest causes of these disasters are: ~1) An unsplit cast on a forearm fracture. (2) A supracondylar racture in a child. (3) A fractured tibia causing obstruction to the anterior compartment of the leg (81.14). (4) Any badly treated fracture, a crush injury, or a bullet wound.
The compartment syndrome is the easiest cause to treat. The vessels of a patient's limb may be so tightly compressed by exudate, blood, or swollen muscle that blood cannot pass through them. Toileting his wound, incising the fascia, and exposing his artery is often all that is necessary to restore his circulation. Or, a local injury may be causing an artery to contract down so tightly that no blood can pass through it. A tightly contracted artery like this looks like a piece of solid cord. The distal part of the brachial artery, the femoral, the popliteal, and the posterior tibial arteries can all contract like this.
THE COLD BLUE INJURED LIMB See elsewhere for ischaemia following a supracondylar fracture (72.8), or the compartment syndrome in a patient's forearm (73.7) or lower leg (81.14). If his injury is elsewhere, expose his injured vessel through an adequate incision. This alone may be enough to make it start pulsating again.
If it does not start pulsating, and part of it looks like a
piece of whipcord, expose the healthy artery above and below
the cord-like section. Expose it on all sides, so that there is
no tissue surrounding it.
If it fails to dilate, open an ampoule of 2% papaverine, or
less satisfactorily, pethidine, or 2% lignocaine (without
adrenaline), and flood this onto its contracted segment. Then
lay a warm moist pack on it, and wait 10 minutes. When you
return, you will probably find that the artery will have
increased in size and will have started to pulsate.
If it is still not pulsating, apply an arterial clamp above
the constriction, and inject 2% lignocaine with a little heparin,
between the clamp and the constriction. This may distend
it enough to make it start pulsating. Wait 10 minutes while
the heparin acts.
If it is torn, repair it (55.6). Only if these measures fail consider
tying it, or if possible, resetting and anastomosing it.
CAUTION ! When you close the wound make sure that the injured vessel is not exposed to the air; cover it with adjacent tissue, or if necessary with split skin.
| WHEN IN DOUBT EXPOSE AND DECOMPRESS WIDELY |
55.4 A stab wound close to a major artery
The common danger site for this emergency is the groin. Open and explore the wound early, so as to examine the artery and repair it if necessary. This will be easier than trying to deal with the arterial haematoma or aneurysm that may result from leaving it.
STAB WOUNDS NEAR MAJOR VESSELS Have blood for the
patient cross matched. Take him to the theatre and explore
his wound under general anaesthesia. Try to get proximal control
of the vessel. If the artery and vein are injured, you may
be able to close the hole by lateral suture as in Fig. 55-3. If
necessary sew a patch of long saphenous vein over the hole,
or do an end-to-end suture or graft.
| ALWAYS EXPLORE STAB WOUNDS CLOSE TO ARTERIES |
55.5 A pulsating (arterial) haematoma
Several things can happen if the blood from an injured artery cannot escape to the surface: (1) It may track widely in the patient's tissues. (2) It may form a tense local arterial haematoma, which may press on the collateral vessels, obstruct them, and cause gangrene. (3) The outer layers of the haematoma may later become organized and form a traumatic (false) arterial aneurysm. (4) If this aneurysm communicates with a vein, it will form an arteriovenous aneurysm. Initially, this may be difficult to diagnose. Suspect that such an an aneurysm is forming whenever a pulsating haematoma overlies a major artery and vein, particulary in the groin.
An arterial haematoma can form when an artery is injured by a penetrating wound or by a fracture. If it is rapidly expanding, it must be explored before it becomes an arterial aneurysm or an arteriovenous aneurysm, both of which are even more difficult to treat.
A PULSATING HAEMATOMA The patient has a pulsating swelling after an injury, perhaps only a minor one. If you cannot refer him, proceed as follows.
Where possible, apply a tourniquet proximally, to control bleeding. Then make an adequate incision to explore his wound. Expose the artery proximal to the injury, and control the flow of blood through it with an arterial clamp, or one of the other methods described below. Explore the haematoma, remove the clots, and tie his bleeding vessel. Finally, release the clamp or tourniquet cautiously to see if you have been successful.
If the haematoma is below his elbow or knee, tie the injured artery.
If the haematoma is above his elbow or knee, try to repair his injured artery (55.6). If you feel you cannot do this, or you don't have the necessary equipment, tie it as close to the injury as you can, and hope for the best. He may be lucky.
55.6 Repairing blood vessels
Vascular surgery is normally considered to be strictly the work of a specialist. But the patient must reach the specialist within 4 hours of his injury; if this is impossible, you will have to do as best you can yourself. If you operate carefully, and handle the patient's injured artery gently, you may succeed in repairing it. In doing so you may save his life, or his limb, so that you and he enjoy one of the most rewarding forms of fine surgical craftsmanship. The penalty for failure will certainly not be worse than that of not trying. You don't need any special equipment, but it will take you a long time. Use the finest instruments you have; eye instruments are suitable if you treat them carefully, and so are eye sutures. But successful repairs have been done with quite coarse ones. You will also need good aseptic technique, a strong light, adequate anaesthesia, good eyesight, or magnifying spectacles, and a blood transfusion. Your repair may thrombose later, but it may stay open long enough to let an effective collateral circulation develop.
Arteries have to be clamped or tied proximally before you can repair them, either in the wound itself, or at one of the sites of election using either a tape, or an arterial clamp.
Never clamp an artery with a haemostat. Even rubber tubes over the jaws of a haemostat will not prevent them from injuring it. Instead: (1) use the special arterial clamps, or (2) the Rummel tourniquet shown in Fig. 55-4. This is merely a length of stout linen or cotton tape passed round the artery and then threaded through a rubber or plastic tube. If you pull the tape and push the tube down on the artery you will occlude it. (3) Pass a fine rubber tube or catheter round the vessel, and hold it against your finger.
If the flow of blood in an artery stops, the blood in it is liable to clot, so stop it doing this by injecting dilute heparin into it proximal and distal to the clamp. Be careful never to inject more than one fifth of the anticoagulant dose of heparin for the whole patient (15,000 units in an adult).
Veins. In the limbs you can tie most veins without causing any disability. Veins bigger than the femoral should ideally be sutured. This is more difficult than suturing an artery. Torn veins are difficult to see because blood wells up into the wound, instead of spurting like an artery.
e CLAMP, bulldog for arteries, Blalock cross action, assorted sizes, four only. If you want to clamp an artery temporarily, apply one of these, not a haemostat.
REPAIRING BLOOD VESSELS
EQUIPMENT Arterial clamps. A very fine needle holder, and
fine dissecting forceps such as Adson's or finer. Half circle
round-bodied atraumatic needles (or better, a micropoint needle).
4/0 monofilament sutures or finer. Magnifying spectacles,
such as the Bishop Harman loupe. Heparin (50 mg or 5000
units in 100 ml of saline), or use the citrate solution from a
blood transfusion bottle or bag.
WOUND TOILET Do this carefully, and remove all dead or
dying tissue from the patient's wound. If he has a fracture,
allow its fragments to overlap while you repair his artery.
Enlarge his wound as necessary, so that you can really get
at his injured vessel easily, and inspect it.
TORN ARTERIES
If the patient's artery is only partly divided, or is cut longitudinally, you may be able to suture it directly.
If It has been nearly cut across, you may be able to anastomase its cut ends.
If a length of it is bruised or torn, you may have to cut out the ragged piece and bring clean cut ends together for anastomosis.
If its cut ends are ragged, excise them, so that you can bring two clean-cut ends together. You may be able to excise 2 cm or more and still bring the ends together. If they will not come together, you will have to insert a saphenous vein graft, as described in the next section.
If the adventitia (which looks like filmy cobwebs) projects beyond the other coats, trim it away. If you leave it, it will promote thrombosis in the suture line.
If there is a gap in one wall of the artery, you may be able to repair it with a saphenous vein patch graft, as in B, Fig. 55-3.
MOBILIZE THE ARTERY Arteries are elastic, so you will probably be able to free enough of the artery above and below the wound to let you work on it. Apply arterial clamps or Rummel tourniquets above and below the wound. In an emergency, ask your assistant to press the artery between his finger and thumb. Inject heparin into it on the far sides of each clamp or tourniquet.
Try to preserve any reasonably sized branches, because these will help to maintain the collateral circulation if the repair fails.
REPAIR Put something behind the injured vessel, such as a piece of gauze or half a glove, so that you can see what you are doing as in Fig. 55-4.
CAUTION ! Before you start the repair, allow the artery to bleed from both ends to remove any clot that may have formed. This will wash out the heparin, so inject more through fine catheters.
Squeeze any clot out of the cut ends of the artery and drip a few drops of heparin onto each of them. Bring the cut ends of the artery together with two stay sutures at opposite sides. Two more at the top and bottom may help. Use these to steady the artery and rotate it, where necessary.
Either use horizontal mattress sutures to evert its cut edges, or use continuous sutures. Place them about 1 mm apart or less and 1 mm from the cut edges. Place the knots on the outside. Drop some heparin solution onto the artery while you suture it.
CAUTION ! Place the sutures carefully and avoid dog ears or the anastomosis will leak.
When the suture is complete, release the distal clamp first. This low pressure retrograde flow will show up any leaks. If necessary, stitch them.
Then press the anastomosis lightly with gauze and gradually release the proximal clamp. The repair will bleed, but the bleeding will usually stop spontaneously in a few minutes. If necessary, put in more sutures.
If the repair leaks, press it with a gauze pack for a few minutes. Blood may clot in the leaks and block them.
If you are successful there will be a pulse in the artery distal to the repair.
CAUTION ! Cover the repair with living muscle or subcutaneous tissue. Don't leave it exposed while waiting for delayed primary closure (54.4). Rotate a flap over it, or partly close the wound.
TORN VEINS Sponge holding forceps are useful in grasping a torn vein because they take large bites and flatten it. If possible use lateral occluding clamps which will let you see the edges of the tear and insert an everting layer of fine continuous sutures.
Failing this, press firmly on the vein above and below the tear. This will empty it and show you the hole outlined against its posterior wall.
If all else fails, occlude the vein above and below the tear, and tie it.
POSTOPERATIVELY (all vascular injuries) Splint the patient's limb in the position of least tension on his injured vessel, and then gradually straighten it over several days. If there is a fracture, you have at least 10 days in which to align the bony fragments before they unite in the wrong position.
55.7 Saphenous vein grafts
if such a large section of a patient's artery is injured that you cannot bring its ends together, you will have to join them with a piece of his saphenous vein, or refer him for this to be done. Although you are only using a vein, it will withstand his arterial blood pressure adequately, and will resist infection better than an artificial vessel. If repairing an artery is only possible under tension, insert a vein graft. This is a procedure for the caring operator who cannot refer a patient.
GRAFTING WITH THE SAPHENOUS VEIN
INDICATIONS An arterial injury, which cannot be repaired in any other way, and cannot be tied for fear of causing gangrene-see Section 55.2.
REVERSED SAPHENOUS VEIN GRAFT Expose the patient's
saphenous vein through an adequate incision along its length.
Remove a suitable length of vein, and cut off all its side branches between 4/0 monofilament ligatures.
Remove the isolated segment of vein, clamp its distal end with a haemostat, and irrigate it with heparinized saline (55.6) under pressure. This will show up the leaks from any small side branches you may have have missed. It will also distend the vein most usefully, but take care not to distend it too much.
Leave it distended with heparin and lying in some heparin or blood while you prepare the artery to receive it.
Trim the ends of the veins and anastomose them to the artery, using the method described above for anastomosing an artery. The piece you take may have a valve in it, so make sure you reverse the direction of the flow of blood in it.
Remove the distal arterial clamp just before the last stitch or two, so that any air caught inside the repair can escape through the hole between your last two sutures.
Leave the repair under a warm saline pack while you wait 10 minutes. Inspect it, and if it looks satisfactory, cover it with adjacent tissue and close the wound, preferably by delayed primary closure.
SAPHENOUS VEIN PATCH GRAFT Take a piece of saphenous vein, open it out, make quite sure the intima faces inwards, and patch it in place with fine sutures. If you fail, you will have to tie the patient's injured vessel. If his limb becomes gangrenous, amputate it.
55.8 Examining the peripheral nerves
Whenever a patient has injured a limb, especially if he has a penetrating wound, test the function of its nerves and tendons before you anaesthetize him or refer him elsewhere. Test the most distal point supplied by each nerve. The following tests are so quick that you can do them all in a few seconds. Always record your results. It will then be certain that paralysis is not the result of treatment.
QUICK TESTS FOR PERIPHERAL NERVES
Record both power and sensation when you first see a patient, and after each subsequent examination. For the nerves of the hand goto Section 75.1.
AXILLARY (CIRCUMFLEX) NERVE This arises from the posterior cord of the bachial plexus, and winds round the neck of a patient's humerus to supply his deltoid and the skin over the lower part of this muscle. It is injured in dislocations of the shoulder.
Ask the patient to abduct his arm. Put the palm of your hand over his deltoid as he does so, as in A, Fig. 55-6. Even a flicker of contraction shows that his deltoid is working.
Test sensation with a pin on the outer part of his shoulder, over the insertion of his deltoid. If his axillary nerve has been injured, there will be a small patch of anaesthesia.
MUSCULOCUTANEOUS NERVE If this nerve has been injured there will be anaesthesia along the outer side of his forearm, and he will be almost unable to flex his arm.
SCIATIC NERVE This is sometimes injured by pelvic fractures. Test its peroneal and tibial branches as described below. Test the sensation of the dorsum of his foot.
COMMON PFRONFAL BRANCH OF SCIATIC NERVE
Paralysis causes foot drop. Can he walk on his heels with his
forefoot raised? Test for anaesthesia in the distribution of his deep peroneal nerve in the web between his big and second toe. His common peroneal nerve can be injured by Thomas splints, badly applied skin traction, or blows to the neck of his fibula.
TIBIAL BRANCH OF SCIATIC NERVE Ask him to plantar flex his ankle, or stand on tip toe.
55.9 Primary nerve repair
A patient's digital nerves, and his median and ulnar nerves commonly need repairing, but you may occasionally need to repair almost any nerve. Whenever you toilet a wound, inspect any nerves that might be injured, but don't try to repair them, unless they have been cut completely. Closed injuries usually only bruise nerves, so that they are able to recover in a few weeks.
One of your first problems will be to distinguish a nerve from a tendon deep in a wound. Even supposedly expert surgeons have sutured a nerve to a tendon, especially at the wrist.
A nerve is yellowish and flexible. You can make it lie in various positions, and if you press it, it will flatten fairly easily from side to side and from back to front. Its cut edge bulges slightly. Look at it carefully, if possible with a lens, and you will see its fibres lying in bundles, like fine macaroni. If it has been cut, you can easily see these bundles surrounded by connective tissue. A nerve often has a small tortuous vessel running along its surface. This is a rare on a tendon.
A tendon is bluish white and glistening, straighter and firmer and more difficult to deform by compression than a nerve. It has a flat smooth cut surface like wood cut across the grain, and its bundles are more difficult to see.
Nerve injuries are best referred immediately to an expert. But, if there is no expert, make as good a primary repair as you possibly can yourself, and don't merely tack the cut ends of the patient's nerve together with black silk, which is now quite outmode. If a patient needs a secondary repair later, he will then be in a good position for it. In practice, an attempt at primary repair is likely to be more satisfactory than merely doing an approximate repair in the hope of being able to refer him later.
If, for any reason accurate primary repair has not been possible, the patient's wound should be re-explored and a secondary repair done between 3 weeks and 3 months later. At 3 weeks fibrosis will no longer be proceeding proximally up his injured nerve and its sheath will be thicker, and better able to hold stitches. If secondary repair is necessary, make this quite clear to the patient and to his relatives, and record it in his notes. Mark the nerve ends with a non-absorbable suture.
| DON'T SUTURE PALMARIS LONGUS TO THE MEDIAN NERVE! |
PRIMARY NERVE REPAIR
INDICATIONS Any nerve which has been completely transected. If the wound is clean, attempt repair immediately. If it is grossly contaminated, control infection first.
EQUIPMENT Use your finest monofilament sutures, needles, and needle holder. Use 8/0 sutures on 3 mm atraumatic needles. Any suture larger than 610 is too big. Use ophthalmic forceps and needle holders, and operating spectacles such as the Bishop Harman loupe.
Don't use silk, catgut, human hair, or dexon because these are irritant. Coarse sutures may cause so much fibrosis that the nerve will never function again.
METHOD Explore the patient's wound as described in Section
54.1. Find the cut ends of the nerve. Put his limb in the
position which will help to bring them together.
Trim back both the cut ends of the nerve with a new sterile razor blade as in A, Fig. 55-8. Usually about 2 mm is enough. Match the cut ends in their correct anatomical positions, without rotation. There are usually very fine blood vessels on one side of a nerve which will enable you to distinguish its two sides. Study the cross section of its fasciculi carefully, and get the two cut ends to match.
Try to put all sutures into the outer sheath of the nerve. Sutures deep inside it will interfere with its function seriously. For clarity, the sutures in Fig. 55-8 are shown much larger than they really are.
Pass two stay sutures through the outer sheath of the nerve on either side. Tie them and leave the ends long (B). Carefully hold the two ends of the nerve together, and ask an assistant to hold the ends in artery forceps. Put one or two sutures into the front of the nerve (C).
Pass one of your stay sutures behind the anastomosis (D), and cross the other one in front of it, so that you rotate the nerve as you pull them and expose its back (E).
Put one or two sutures into the back of the nerve. It may be easier to repair the back of the nerve first.
CAUTION ! (1) Try not to put more than 8 sutures into the nerve, or there will be unnecessary fibrosis. (2) Don't let any nerve fibres stick out of the suture line.
Manage the wound as in Section 54.1. If you are leaving the wound open for delayed closure, try to cover the sutured nerve with muscle or skin, and don't leave it naked in the wound. If necessary, make relieving incisions, so that you can move skin over to cover the nerve, or cover it with a transposition flap, as in Fig. 55-9. Or, least satisfactorily, cover it with a split skin graft.
Splint the patient's limb in the position which best relieves tension on the nerve. If it is under tension, release the position of the splint slowly over several weeks. If you fail to do this, the sutures may pull out.
When you have removed the stitches from the patient's wound, and are waiting for his nerve to recover, splint his limb to prevent contractures, and tell him how to prevent trophic ulcers forming. If he intends to pick up something which might be hot, ask him to feel its temperature with his normal hand.
HAVE YOU SUCCEEDED? TINELS SIGN Tap the course of the nerve, if the patient feels pins and needles over its distribution, it is regenerating.
Examine and record the power of all the muscles that his injured nerve supplies. The most proximally innervated ones will recover first.
55.10 Secondary nerve repair by trial section
If you see a patient with an injured nerve late, or decide not to repair it at the time of the injury, the only way to repair it is by trial section and resuture. If you cannot refer him, you may have to do this yourself.
To begin with there is a blood clot between the fascicles of a recently cut nerve, as in A, Fig. 55-10. This soon becomes organized and invaded by fibrous tissue to form a rounded neuroma (B). You will have to cut this back in a succession of s mall slices until you reach healthy nerve (C). Sometimes a nerve is incompletely divided and although its ends are joined it is deformed by bulbous neuromas (D). These too have to be cut back until you reach healthy nerve.
The best time for secondary repair is 3 weeks after the patient's initial injury. You may find that, when you have excised the retracted fibrosed cut ends of his nerve, it has to bridge quite a gap. Nerves are not very elastic, so this can be difficult. An expert may be able to bridge the gap with a graft. Your best hope is to explore the nerve through an enormous long incision, so that you can mobilize enough nerve to make it stretch the gap. For example, you may have to explore the ulnar nerve from the wrist to the elbow and down into the hand.
Another difficulty is finding the cut ends of the nerve deep in the scar of the wound. Look for them proximally and distally, and then follow both ends into the fibrous tissue of the wound. Be careful not to cut theta as you look for them. Use blunt dissection, where you can. If you have to use a scalpel, cut in the length of the nerve, not across it.
TRIAL SECTION AND RESUTURE
INDICATIONS (1) A nerve which was completely transsected at the time of the patient's original injury and was not repaired. (2) An injured nerve which is not recovering. If Tinel's sign (55.9) shows that any recovery is taking place, don't consider exploring a closed wound for several months. It is probably only contused, and will recover.
If possible refer the patient. If this is impossible, you may be justified in proceeding as follows.
Explore his healed wound and mobilize his injured nerve. Feel carefully for the parts of it that are hard and fibrosed.
Use a sharp scalpel, or a razor blade held in forceps, to cut thin slices across its thickest place.
The first slice you cut from the neuroma (E, in Fig. 55-10) may show a uniform slab of fibrous tissue. In the second slice (F) a few little dots of nervous tissue have started to appear. In the third slice (G) there are more little dots. The fourth slice is mostly nerve tissue (H). The final one (I) has the normal fibrillary structure of a nerve. This is the point to stop cutting back and do ananstomosis (J and K) as for primary nerve suture (55.9). Try to bring the ends together without rotation, so that the motor areas in each end correspond. One such area has been shown hatched in the diagram (J).
Section the distal end in the same way, then join the two ends as above.
PARTICULAR NERVES FOR SECONDARY REPAIR
Ulnar nerve Move the nerve anteriorly from behind the patient's medial epicondyle. This will give you the extra length you need to make the anastomosis. Keep his elbow and wrist flexed and try not to injure its branches to flexor carpi ulnaris, and the medial half of his flexor digitorium profundus.
Median nerve at the wrist Approach this by incising his carpal tunnel.
DIFFICULTIES WITH SECONDARY NERVE REPAIR
If the patient's NERVE INJURY WAS NEVER DIAGNOSED and his wound is now healing, explore it as soon as the danger of infection is over. The longer you delay after 2 months, the worse the result. If you feel a neuroma, the nerve has been seriously injured.
55.11 Tendon injuries
Rupture of the belly of a muscle usually causes little disability, but rupture of its tendon or the junction of tendon with muscle is usually serious. The result depends greatly on whether or not the tendon is surrounded by a sheath. For example, if one of the flexor tendons of a patient's wrist is cut, its ends retract, become rounded, fail to heal and lie loose inside their sheath. Repair will be easier and the result is better if a tendon has no sheath, as with the extensors of the wrist. Tendon injuries most commonly involve the hand, so they are further discussed in Sections 75.20 and 75.21. Here we only discuss the general principles. The main one is the method for inserting sutures.
REPAIRING TENDONS
See elsewhere for injuries of a patient's Achilles tendon (82.10), and his hand-his flexor tendons need special methods (75.21).
MATERIALS Non-irritating sutures, such as fine stainless steel wire, preferably braided, or monofilament nylon, preferably 5/0. Don't use catgut.
Thread both ends of a length of the suture material onto two straight needles, and pass this through the patient's cut tendon, as in A, Fig. 55-11.
Hold the cut end of the tendon in a pair of artery forceps and suture 1 or 2 cm down the tendon. Pass both needles through it diagonally two or three times.
Bring both ends of the suture out onto the cut ends of the tendon. Then thread them in a similar way into the cut surface of the other end of the tendon. Finally, pull the sutures tight and tie them.
CAUTION ! Take care to identify the cut ends correctly. Don't join a profundus to a sublimis tendon, or a nerve to a tendon!
POSTOPERATIVE CARE Immobilize the patient's limb for 3
weeks in the position which will cause least tension on his
cut tendon. Encourage as much active movement as
immobilization will allow.
The critical period for rupture of the repair is immediately you remove the splints. So start movements gradually, and try to devise some form of check strap to prevent sudden movements which may rupture his newly repaired tendon. His limb will be stiff and painful, but it should improve steadily over many weeks.
Headline text
Injuries to Blood Vessels, Nerves and Tendons
