COMPLICATIONS OF TREATMENT
Common complications of the treatment of hand injuries
The most common complication of any hand injury is stiffness, due to the collaborative effects of inflammation, swelling and immobility. Attempts at prevention of stiffness are much more effective and worthwhile than later attempts to correct established stiffness. This and other complications are less likely when the treatment follows priority based guidelines.
Priorities: Management priorities are the same for severe and minor injuries: establish the extent of injury; remove the bad; reconstruct the good; involve the patient and tailor the surgery to the patient (CO). Severe upper extremity injuries with soft tissue loss have shorter hospitalization and more rapid recovery with primary reconstruction, even if this requires primary microvascular free flap surgery (DC). One conceptual approach to organizing the initial management of severe head injuries is to break down priorities as they relate to either healing or function:
Healing priorities: circulation, skeleton, closure: Inadequate blood supply is the single most likely explanation for complications of delayed healing, fibrosis and infection. Adequate blood supply is achieved by aggressive debridement, revascularization, and use of vascularized flaps. Edema represents inadequate lymphatic circulation, and has the same ultimate effects as inadequate blood supply. Edema is best treated with elevation and active range of motion, when permitted. Optimum bone and joint reconstruction goals are prompt, anatomic reduction of injury and stable skeletal fixation with the least amount of additional soft tissue disruption. Wound closure with mobile, well vascularized soft tissue cover should be achieved as quickly as possible. In the hand, stiffness, difficulty with use and ultimate disability is directly related to the length of time required for wound healing.
Function priorities: nerve, joint, muscle: Nerve injuries should be approached aggressively, as there is never a better time to evaluate and to perform repairs, and the only satisfactory time to repair partial nerve lacerations is in the acute setting (prtnerve2.htm, foreign.htm). Passive range of motion has two components: The first is preservation of the gliding function of the surfaces of the joints and tendons. This is achieved by early protected motion: all moving parts in which are safe to move are moved frequently, against no resistance and at the earliest opportunity. The second is maintenance of physiological length of capsuloligamentous and muscular tissues. This is achieved by splinting the hand in between exercises in the "protective position": interphalangeal joint extension, metacarpophalangeal joint flexion, and preservation of the thumb-index web space span (safepose.htm). Active range of motion additionally reduces edema, builds strength, promotes bone healing, prevents dysfunctional patterns of disuse, and probably reduces the incidence of complex regional pain syndrome.
Complications of bandaging
Tight dressings: Finger dressings made from tubular gauze may produce ischemic pressure complications. Technical errors in application predisposing to tubular gauze pressure complications include excessive longitudinal traction during application, using more than a 90 degree twist during application, and rolled proximal dressing edges (AX). Even minimally tight elastic dressings applied as part of a circumferential bandage may lead to progressive swelling, aggravating all of the ill effects of swelling on the injured hand, as described above (tightwrap.htm). Swelling may hinder assessment and may delay surgery until reduced by elevation and change to a noncompressive dressing. Complications of elastic dressings are less when applied with care, and when applied over a bulky soft non circumferential bandage. The technical trick is to place a multiple linear circumferential gauze bandage as the deepest portion of the bandage, then split it longitudinally before completing the bandage. This ensures that at least the deepest layer of bandage cannot provide circumferential pressure. Tight casts may result in local pressure sores, discomfort, and in the worst scenario, vascular compromise and compartment syndrome. The situation at greatest risk is circumferential casts applied after closed reduction of an elbow or forearm fracture on the day of injury. In this situation, the risk may be reduced by primarily splitting the cast immediately after application.
Inadequate positioning: Splints and other supportive dressings maintain a posture which may be helpful or detrimental. Often, splints fabricated in the emergency room for comfort maintain joints in positions which promote stiffness. Even splints intended to maintain the generic "protective position" may actually do just the opposite, a problem which may only be confirmed by x-ray (safepose2.htm).
Complications of wound care: The goal of wound care is to maintain an environment which discourages excessive bacterial growth and encourages normal healing. Excessive bacterial growth occurs on moist undisturbed services, and is a common problem in the interdigital web spaces of the immobilized hand, and beneath occlusive bandages. Eventually, unchecked surface growth produces such high concentrations of organisms that the skin is invaded directly, producing maceration dermatitis. This may progress to cellulitis, but in the early stages can be stopped by increasing frequency addressing changes, and when possible, allowing be affected skin to dry. Allergic contact dermatitis may develop over the course of treatment using topical antibiotics or skin preparation formulas such as Mastisol (dermatitis.htm). This can produce a confusing picture, for inflammation associated with the reaction may be confused with infection. The early hallmarks of contact dermatitis are itching and blistering accompanying the reaction.
Complications of hand procedures
Tourniquet palsy after surgery occurs in an average of one in 5000 cases, more commonly associated with microsurgical than other procedures (AY). All nerves are usually affected to some degree, the radial nerve usually worst affected. Tourniquet palsy is more likely in patients with coagulation disorders, pre-existing neuropathy, thin malnourished patients, those with systemic lupus erythematosus (AY) and in instances of unintentionally high tourniquet pressures due to gauge failure (BM).
Toxic shock syndrome is a rare complication, but has been reported after elective reconstructive hand surgery (BI).
Needle stick / vascular cannulation injuries
Radial artery catheterization may result in acute hand ischemia if there is inadequate perfusion through the ulnar artery (BS). This problem is more likely when ulnar artery perfusion is not confirmed by Allen's test before catheterization, when relatively large diameter cannulas (18 gauge versus 20 gauge) are used (BV), during prolonged periods of cannulation, and in hypercoagulable states (BS). In the presence of ulnar artery occlusion, even a single radial artery needle stick for arterial blood gas determination can precipitate acute hand ischemia (vascular.htm). Although uncommon, ischemia resulting in finger amputation has been reported after arterial monitoring in infants (CL).
Cutaneous nerve injury. The cephalic vein is frequently cannulated for intravenous access. It is closely related to the antebrachial cutaneous nerve in the proximal forearm and branches of the superficial radial nerve in the distal forearm. Although uncommon, needle stick injuries of either of these nerves can occur (BJ) and lead to prolonged morbidity. Patients report feeling a strong electrical paresthesia at the time of injury, which should be taken as a sign of possible injury. Numbness or tingling lasting more than a day may represent partial nerve injury, and should lead to consideration of early exploration. Treatment options for chronic cases are the same as for any cutaneous neuroma, although more likely to be compounded by the effects of litigation.
Suppurative thrombophlebitis (see below).
Extravasation injuries (DY, DZ, EA, EB, EC, ED, EE) of the hand are common, because of the common use of the hand for intravenous access. Local tissue necrosis has been reported following subcutaneous extravasation of chemotherapy, osmotically active substances, and tissue toxic preparations such as injectable phenytoin. These injuries often have delayed presentation, delayed healing, and prolonged morbidity, requiring reconstructive surgery if treated late. Major limb growth disturbances may occur following extravasation or thrombosis in the neonatal period. Although not well described in the literature, tense hematomas associated with intravenous access of the wrist or dorsal hand may also result in tissue loss (hematoma.htm). Extravasation injuries have the best potential outcome when recognized and treated early. Unfortunately, delayed presentation is still common because of the typically slow development of visible signs of injury. Treatment recommendations have varied over the years, but early treatment with soft tissue infiltration/irrigation has the most consistent history of effectiveness. Local injection with hyaluronidase is helpful, but this drug is no longer available for use. Prevention appears to be the best approach, by avoiding of the dorsal hand, anterior wrist, and antecubital fossa, as these locations are most prone to complications from extravasation.
Prior axillary lymphadenectomy: Although it is common practice to instruct patients who have undergone mastectomy and axillary dissection to avoid manipulation or instrumentation of the hand, there is not a documented increased risk of complications in this context (DP). Hand surgery on the side of previous axillary dissection is probably safe.
Complications of anesthesia
Epinephrine in digital block: Although it is traditional teaching that epinephrine used in digital nerve blocks may result in digital gangrene, there are no actual reported cases of finger gangrene resulting specifically from the use of epinephrine with lidocaine for digital block, and its safe use has been reported (AN).
Postoperative ulnar nerve palsy due to ulnar neuropathy at the level of the elbow is a recognized but poorly understood complication of surgery involving general anesthesia (AR). The exact mechanism of this process remains unknown. Preventative measures, including protective positioning on the operative table, use of elbow pads, avoidance of arm abduction, pronation and elbow flexion may reduce that has not been shown to prevent the development of this problem. Final outcome is unpredictable, and both conservative and operative treatments have yielded mixed results.
Brachial plexus block
anesthesia has been reported to have an incidence of postoperative
dysesthesias ranging from less than two per cent (DT,
DU)
to as high as a twelve per cent (AT,
DQ).
Although rare, perineural fibrosis (DS)
and permanent neurologic injury (AU)
following axillary block anesthesia has also been reported. Complex regional
pain syndrome has been reported to be both more common and less common
after axillary brachial plexus block.
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