A CLINICAL CASE OF POSTTRAUMATIC RECOVERY OF FUNCTIONAL CAPABILITY OF THE HAND IN A CHILD
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Long term compression of the hand is a severe injury of a segment of the upper extremity. It often results in amputation of a part of a segment or the whole hand, with further working incapability and disability. The main category of victims includes young, healthy men of working age who are involved in industry [1, 2]. Unfortunately, such injuries happen in children. In other words, capacity to work is lost in preschool and school age that is significant shock for a child, with depressing his/her mental and physical condition and disordered social adaptation [3]. Development of microsurgical technique and appearance of new specific types of surgical treatment of injuries to the hand allow solving this problem [4].
It is necessary to note that long term compressing the hand is a result of impaction of heavy weight objects. Moreover, a patient or bystanders sometimes cannot eliminate the crushing impaction to the hand. If compression involves some mechanic parts of a device, then termination of compression often requires specific tools and trained personnel.
Hand compression or injury from a working part of an electric mincing machine is an extremely rare, and severe injury to the hand common for children of preschool age.
The patient B., age of 2 years and 9 months, was admitted for urgent surgical treatment to the intensive care unit, Regional Clinical Center of Miners’ Health Protection, on May 30, 2015.
Upon the moment of admission the traumatologist on duty conducted the examination. During the primary examination the child’s mother presented some complaints about the multiple extensive injuries to the right hand and bleeding in the same region. Also she informed about intense pain syndrome as result of the injury to the hand.
From the history of the disease at the moment of the examination: On May 30, 2016 the girl accidently put her right hand into the hasher worm of the mincing machine, when she tried to put some meat into the working field of the device (Fig. 1).
Figure 1
The appearance of the right hand after the injury
The parents transported the child to Belovo City Hospital. The duty traumatologist examined the patient after admission. The examination showed the impossibility of removing the hand from the mincing machine, unless specific aid from Ministry of Emergency Situations was used. The Belovo team of Ministry of Emergency Situations performed successful removal of the hand by means of use of some specific devices. They did not iflict any additional damages (Fig. 2).
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Figure 2 The appearance of the hand after extraction from the working section of the mincing machine |
Figure 3 Absent signs of bleeding in the fingers 3, 4 during perforating the phalanges with the injection needle |
After extraction of the right hand from the mincing machine the duty team of the traumatologists confirmed the fact of absent blood flow in the fingers as result of their mechanical damage. The primary surgical preparation of the wounds was conducted. For restoration of blood flow and preservation of the functional capabilities of the hand the child was transported to Regional Clinical Center of Miners’ Health Protection for realization of specific urgent microsurgical treatment. The patient was admitted to the admission department at 7:35 p.m.
From the previous history of life: without specific features. The age characteristics were normal. There were no registered cases of quarantine according to the place of residence. The child had no previous specific diseases registered in medical specialists. Allergic history is absent.
The objective examination showed some signs of traumatic shock of degree 1.
The laboratory examination identified some signs of posthemorrhagic anemia of mild degree.
The local examination: the right upper extremity is immobilized with the metal ladder splint. Fixation is stable. The dressings of the right hand are moderately moistened with the blood. The dressings can be removed. The visual examination shows moderated edema in the right hand. Along the volar and dorsal surface of the fingers one can see some multiple tear-contused wounds with unsmooth edges (5-15 mm). The bleeding from the wounds is of capillary type. The fingers 2, 3 and 4 are in the position of flexion. Active flexions are impossible. Passive flexions are within the full range. The visual examination shows some signs of disordered blood circulation in the fingers 3 and 4. Capillary response is absent. Soft tissue turgor in the fingers 3 and 4 is absent. Local hypothermia. Skin color of the fingers 3 and 4 is white. The blood does not exude after perforating the distal phalanxes of the fingers 3 and 4 with the injection needle (Fig. 3). A drop of the blood of scarlet color actively discharges after perforating the phalanxes of the fingers 1, 2 and 5. During perforating the finger 1, the superficial surface of the finger 2 and the internal surface of the finger 5 the child demonstrates the response in view of cry and drawing the hand back. Sensitivity is absent in other fingers. There is a tear-contused wound with detachment of the skin along the dorsal surface of the finger 2 at the level of the proximal interphalangeal joint. The tongue-shaped flap is about 8 mm in diameter and it takes 2/3 of the finger circle (Fig. 2). The color of the flap is white with the signs of venous hyperemia at the bottom of the skin flap. There is a surgically prepared tear-contused wound along the anterior surface of the hand in the projection of the distal palmar line from 4th intermetacarpal space to 1st intermetacarpal space. The bleeding from the wounds is characterized by capillary type. The volume of active motions in the joints of the fingers 1 and 5 is observed. It is impossible to estimate the disarrangement of hand innervation because of the age of the patient.
The presented X-ray images of the right hand from another medical facility (May 30, 2016) showed a longitudinal fracture of the proximal phalanx of the finger 4 without displaced fragments. Epiphysiolysis of the proximal phalanx of the finger 3.
The diagnosis was made on the basis of the subjective, objective and paraclinical data: “Long term compression of the right hand. Multiple tear-contused wounds of the hand and the fingers with detachment of soft tissues. Decompensated ischemia of the fingers 3 and 4. The injury to the flexor tendons of the fingers 2, 3 and 4 and to the digital arteries of the fingers 3 and 4. An opened longitudinal fracture of the proximal phalanx of the finger 4 without displaced fragments. Epiphysiolysis of the proximal phalanx of the finger 3. The condition after primary surgical preparation of the wounds of the right hand (May 30, 2016). Traumatic shock of degree 1”.
An urgent surgical operation was conducted after presurgical preparation and the clinical discussion. The operation was conducted: secondary surgical preparation of the wounds of the right hand. Microsurgical suture of the digital artery of the finger 3, angiolysis of the common digital arteries of the fingers 2-3, 3-4 and 4-5. Microsurgical suture of the digital nerve of the finger 5, the common digital nerves 2-3, 3-4 and 4-5. Suturing the flexor tendons of the fingers 2, 3 and 4 of the right hand according to Rozov. The operation lasted for 5 hours and 20 minutes.
It is necessary to note that after secondary surgical preparation of the hand of the right hand we found the significant wound contamination with small metal chips after extracting the hand from the mincing machine by means of special tools performed by the employees of Ministry of Emergency Situations. Proper secondary surgical preparation of the hand wounds from metal parts was performed for prevention of productive inflammation after surgery.
Also the revision procedure showed the contusion of the common arteries of the fingers 2-3, 3-4, 4-5. During angiolysis of the common arteries 2-3, 3-4 and 4-5 we noted the restoration of arterial perfusion in the finger 4. During the revision procedure for the wounds of the finger 3 at the level of the proximal phalanx we noted the injury to the digital arteries. The precise technique was used for microsurgical suturing of the digital artery of the finger 3 with use of prolene 10/0, because the diameter of the vessel is significantly lower than in adults. The finger 3 was revasculated. Microsurgical suturing with prolene 10/0 was conducted for the common digital nerves of the fingers 2-3, 3-4 and 4-5 and the digital nerve.
The revision showed the injury to the flexor tendons of the fingers 2 and 3 with the crushing injury to the tissues of the tendons within the length of 1.5 cm. The injury to the flexor tendons of the finger 4 without defects of tendon tissue. The injured part was resected. The flexor tendons were sutured according to Rozov.
The skin wounds were sutured with prolene 5/0 after completion of the main stage of the surgical intervention. In the regions of detached cellulocutaneous flaps, the wounds were sutured with minimal tension, with incomplete convergence of the wound boundaries in some regions for prevention of boundary necrosis of cellulocutaneous flaps. After completion of the intervention the wounds were drained with multiple rubber discharges between the stitches. Aseptic dressings were applied. Plaster immobilization was conducted with the splint in the functional position of the hand.
The postsurgical period lasted for 4 bed-days in conditions of the intensive care unit and included elimination of postanesthesia depression, posthemorrhagic anemia, pain syndrome and realization of conservative prevention of disordered perfusion in the microcirculatory bed of the hand and for daily dressings with general analgesia.
After stabilizing state the patient received inhospital treatment in the department of traumatology and orthopedics No.3, Regional Clinical Center of Miners’ Health Protection. Here the child received antibacterial therapy, daily dressings, anti-edema therapy, symptomatic analgesia.
The wounds healed with primary intention. The sutures were removed from the right hand on 21st day. Healing was with primary intention (Fig. 4).
Figure 4
The appearance of the hand after removal of sutures on 21st day after surgery
On 24th day after the surgical treatment the child was discharged. Her child was satisfactory and she received further outpatient treatment in Regional Clinical Center of Miners’ Health Protection (Fig. 5).
Figure 5
The appearance of the hand at the moment of hospital discharge after 24 days from the moment of the hand injury
CONCLUSION
1. During realization of surgical assistance in treatment of severe injuries to the hand in children the necessary condition is restoration of maximal amount of injured anatomic structures, despite of presence of detached soft tissues of the segment, signs of disordered blood flow of microcirculatory bed in tissues, wound contamination. Subsequently it allows preventing recurrent interventions and receiving good functional capabilities of the hand.
2. In early postsurgical period the children with severe hand injury should receive treatment in the ICU, which includes capabilities for correcting the vital functions of the internal organs and making necessary amount of dressings with use of general analgesia that makes positive influence on prevention of pain spasm in restored arteries of the child’s hand.
3. Extraction of the crushed segment of an extremity from mechanical equipment, particularly from the mincing machine, should be performed with participation of trained specialists of disaster medicine and with use of special tools. Adherence to these conditions allows maximal prevention of secondary injury to tissues of an extremity during its extraction.
4. Arrangement of aid for children with severe hand injuries is impossible without presence of special medical equipment and specialists dealing with microsurgical techniques.