Diagnostic in Hand Injury Before Operation, Does It Matter?
A. R. Muharram*, Lynda Hariani**
Plastic Surgery Department of Airlangga University School of Medicine
Dr. Soetomo Hospital Surabaya
ABSTRACT
Occupational hand injury is a common problem in formal and non-formal sector.
Unfortunately, in non-formal sector, hand injury is more often than in formal sector since there
is no safety standard. As a trauma, the management of hand trauma have to follow ATLS
Protocol. That is the reason, not all hand injury need diagnostic before the patient is taken to
operating theatre. We will present one case that show the importance of ATLS Protocol for
hand trauma. The patient was taken to operating room before diagnostic was established. This
report will be presented with pre-operative and post-operative result.
Keywords: hand injury, trauma, diagnostic, ATLS
INTRODUCTION
Hand injury is a common case in in our emergency room on daily basis. The injury can affect
to soft tissue, nerves, blood vessels, bones, and tendons. The causes can be Electric, Crush,
Amputation, Caught In, Struck By, Hot/ Cold Surfaces, Laceration, aand Chemical Exposure.
The absence apart or whole hand should affect functional, and aesthetic of the upper limb.
In USA more than 1.000.000 hand trauma occurred every year, lacerations 63%, crush 13%,
avulsion 8%, puncture 6%, fracture 5%. 20% of the disabling hand trauma is occupational
injury. The most common cause is the industry equipment not performing as expected.
PATIENTS & METHODS
This case carried out one case. Male, 47 years old, that the left hand got stuck by peanut grinder
machine at the market when cleaning the grinder machine with bare hand. The patient was
taken to the hospital 2 hours after accident with the part of the machine still on his left hand
and a small rubber tourniquet applied at the brachii. Before sent to the hospital, the relative
have to cut away most part of the machine. During the process at the market, the bleeding is
about one dust cloth (+ 200cc).
From primary survey, airway was clear, breathing 20x/minutes, circulation: cold and pale hand
palm, HR: 110x/minute with active bleeding from his left hand, consciousness level: alert, and
large grinder machine still on his left hand. Later, the patient was assessed with crushed injury
manus sinistra and hypovolemic shock.
Initial treatment at emergency department as follows:
1. Oxygenation with nasal canule 3 lpm,
2. Intravenous access,
3. Bleeding control with applying tourniquet cuff.
Immediately after the patient was stable, we took the patient to operating theater for anesthesia
and pull out the grinder machine. Diagnostic was performed by using C-Arm X-ray Systems.
We assessed as:
1. Crush injury regio manus sinistra et causa grinder machine
2. Total rupture superficial and profundus flexor tendon digiti II. III, IV, and V
3. Total rupture extensor digitorum digiti II and III, tendon extensor indicis manus sinistra,
extensor tendon carpi radialis brevis and extensor tendon carpi radialis longus
4. Partial rupture extensor tendon digiti IV dan V, extensor tendon carpi ulnaris and
extensor tendon digiti minimi
5. Traumatic amputation proximal inter-phalanx digiti II and IV
6. Open fracture shaft metacarpal digiti II, III, IV and V manus sinistra
After diagnosis was established, we underwent shaft metacarpal digiti II, III, IV and V manus
sinistra.
RESULTS
The patient underwent debridement and amputation of the shaft metacarpal digiti II, III, IV and
V manus sinistra. The defect of amputation can be closed with primary colusre. Digiti I manus
sinistra was remain intact.
DISCUSSION
For many cases we should done radiology diagnostic first, but in this case we will show the
importance of ATLS Protocol before performing surgery.
The reconstruction of the umbilicus remains challenging for plastic surgeons. Various
techniques are described in the literature, including the use of local flaps 4,5. Although these
techniques provide some reasonably aesthetic results, they remain unable to yield a natural-
looking new umbilicus. In order for the reconstruction to be as close to ideal as possible, the
anatomical units of the element to be treated must be suitably reconstructed.
This paper presents a double opposing semilunar flap technique proposed by Franco et al.6 that
involves rebuilding the anatomical units (i.e., base, groove, and impeller) in a stepwise manner.
The base is formed at the aponeurosis by 2 fixing flaps, compressed at the distal edge. Because
the dermal layer is included in the suture of the flap, the flaps fold, which gives the appearance
of a groove. The proximity of the adjacent fat tissue to the new umbilicus raises the edges
around it, thus providing the required depth. The sutures should not be too tight at those points
in order to avoid necrosis of the adjacent tissue and liponecrosis. Because the flaps are short,
there is a bend in the skin around the new umbilicus, which forms the impeller. Therefore, all
anatomical structures are rebuilt, giving a natural final appearance. Some ptosis is expected to
occur on the skin located in the upper portion of the umbilicus over time, forming a discreet
fold that gives a more natural look to the final reconstruction. Using flap sizes of 1.5 to 2.0 cm
ensures that a small and smooth umbilicus is obtained.
The major difficulty of the reconstruction of the umbilicus is making the new umbilicus
sufficiently deep, particularly when the patient presents a scarce adipose panniculus. By
ensuring the adjacent fatty tissue is included, the present technique resolves this issue.
Maintaining a curve in the base of the flap rather than a right angle to the approach avoids the
formation of edges, thereby achieving a more rounded umbilicus and avoiding one that is
elongated and closed.
CONCLUSIONS
The technique for reconstruction of the umbilicus presented here accounts for the anatomical
units, provides a very natural look, and generates slight excess of skin on the upper part over
time, giving a more graceful appearance. The resultant umbilicus exhibits appropriate features
of depth and size. This technique avoids the appearance of scarring and secondary stenosis by
hiding the circular scar incision and maintaining its position in the middle of the new form.
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3. Coetzee T. Clinical anatomy of the umbilicus. S Afr Med J. 1980;57(12):463-6.
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