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Degloving and Severe Upper Extremity Injuries in Motor Vehicle Crashes Involving Partial Ejection"

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"Degloving and Severe Upper Extremity Injuries in Motor Vehicle Crashes Involving Partial Ejection" Seattle CIREN University of Washington, Harborview Medical Center, Seattle WA Kaufman R., Blanar L., Bulger E. –Seattle CIREN, UW, HMC Lipira A., Friedrickson J. – Harborview Medical Center Mastrioanni S., Nelson M. –Seattle CIREN Upper Extremity (UE) Partial Ejection in Motor Vehicle Crashes (MVC) • Noted as an ‘arm‐ or hand‐out‐ window’ phenomenon • Upper extremity partial ejection in MVCs can result in contact to exterior objects, including the ground in rollovers, which can result in severe degloving type injuries • These severe injuries result in devastating and long‐lasting consequences J Trauma Acute Care Surg. 2013 Feb;74(2):687‐91. Vehicle factors and outcomes associated with hand‐out‐window motor vehicle collisions. Bakker A1, Moseley J, Friedrich J. Partial Ejection Mitigation • Seatbelts are 99.8% effective at preventing complete ejections, but only 38% effective in preventing partial ejections in rollover crashes • Side‐curtain airbags (SABs) can reduced and mitigated risk of partial ejection • BUT, most partial ejection research focuses on head or thoracic injuries • Partial ejection of the upper extremity (UE) remains a highly morbid mechanism of upper extremity injury in motor vehicle collisions References: 1. Bakker, A., Moseley, J. & Friedrich, J. Vehicle factors and outcomes associated with hand‐out‐window motor vehicle collisions. Journal of Trauma and Acute Care Surgery 74, 687–691 (2013). 2. Ball, C. G., Rozycki, G. S. & Feliciano, D. V. Upper Extremity Amputations After Motor Vehicle Rollovers. The Journal of Trauma: Injury, Infection, and Critical Care 67, 410–412 (2009). 3. Nikitins, M. D., Ibrahim, S. & Cooter, R. D. Injury to arms protruding through vehicle windows. Hand Surg 8, 75–79 (2003). 4. Harris, C. N. & Wood, V. E. Rollover injuries of the upper extremity. The Journal of Trauma: Injury, Infection, and Critical Care 18, 605–607 (1978). 5. Funk, JR, Cormier JM, Bain CE, Wirth JL, Bonugli EB, Watson RA –Factors affecting ejection risk in rollover crashes. AAAM 2012;56:203‐11 Severe Upper Extremity Injury due to Partial Ejection • Research has been limited to small studies from single centers – No national‐level studies • Research has generally been limited in evaluating injury and crash details of partial ejection. • Research objectives: – to evaluate severe UE injuries in relation to partial ejection – examine role of side curtain bags in prevention of UE severe injuries (and in turn, evaluate overall partial ejection prevention). Treatment of Severe Soft Tissue Degloving Injuries Contents • Definition • Causes • Classifications • Treatments/Procedures • Case Studies Definition (Severe degloving soft tissue injury) • Result of shearing force applied to skin surfaces • Separation of skin and subcutaneous tissues from underlying muscle and fascia leads to the creation of a space allowing for accumulation of fluid • Shearing forces disrupt and perforate vessels at the fascial level which may lead to skin necrosis(death) • Frequently associated with fractures and other life and limb threatening injuries. Mechanism of Severe Soft Tissue Injuries • Injury occurs during ejection in a motor vehicle crash, or when a patient is thrown across a fixed surface • Entrapment between a fixed surface and a moving object – arm exiting vehicle contacting ground or trapped between vehicle exterior and ground Classifications for Severe Soft Tissue Injury • Pattern 1 ‐Abrasion/Avulsion – Loss of tissue as a result of abrasive force; little undermining of remaining skin edges • Pattern 2 ‐Non‐circumferential degloving – Majority of skin is still present either as a flap or as an area of extensive undermining • Pattern 3 ‐Circumferential single plane – Either open or closed‐confined to a single plane(between deep fascia, subcutaneous fat and skin) • Pattern 4 ‐ Circumferential multi‐plane degloving – Pattern # 3 plus breach of muscle groups or muscle and periosteum Arnez, Z.M. & Khan, U. (2010). Classification of soft tissue degloving in limb trauma. Journal of plastic and reconstructive surgery, 63,1865‐1869. Treatments and Procedures • Conservative – Subcutaneous hematoma and dead fat is removed followed by drainage and pressure dressings – Injured muscle not directly inspected – May hide compartment or crush syndrome • Surgical – Serial excisions prior to reconstruction – Potential for bone desiccation and infection • Negative Pressure Wound Therapy – Wound VAC Negative Pressure Wound Therapy • Wound VAC – Treatment of acute and chronic wounds – Contaminated wounds, burns, infiltrations, envenomations, grafts, failed operations Negative Pressure Wound Therapy • Wound VAC – Open degloving injuries • Primary treatment • Secondary treatment‐ Temporary wound cover; Serve as a bridge to reconstruction; improves graft success Length of Stay for Severe Soft Tissue injuries • Required hospitalization for long periods • Involved multiple and repeat surgeries • Graft procedures fail, repeated • In some severe cases an extremity may require amputation Severe Soft Tissue Upper Extremity CIREN Case Studies Case Study #1 • 45 year old male status post side impact of car versus light pole. Patient found to have right pneumothorax, pulseless right upper extremity with degloving injury to right shoulder, right 1‐5 rib fractures, open right humerus fracture and radio/ulnar fractures • Angiography revealed a right brachial artery transection versus a complete occlusion Case Study #1 ‐Scene Case Study #1 ‐ Vehicle Case Study #1 ‐ Injury Diagram Large lacerations and Right Rib fractures 1‐5 large avulsion/degloving (with pnuemothorax) of the shoulder /arm musculature with transection of the pectoralis major muscle, Open humerus transection of the shaft fracture brachial artery leading to tissue ischemia Displaced Right radius and ulna fractures Case # ‐ Operations/Procedures • Day 1‐OR #1 – Part 1:Repair of right brachial artery with interposition bypass graft using reverse left greater saphenous vein – Part 2: Open reduction and internal fixation of right both bone forearm fracture, irrigation and debridement(I&D) of open right forearm fracture – Part 3: Open reduction and internal fixation of right humerus fracture • Day 3‐OR #2 – I & D right humeral shaft fracture & right forearm fracture. Application of wound closure device, delayed primary closure Operations/Procedures cont. • Day 6‐OR #3 – I & D right humerus & right forearm, wound VAC change • Day 8‐OR #4 – I & D right humerus & right forearm, wound VAC change • Day 11‐OR #5 – I & D right humerus & right forearm, wound VAC change, Dressing change • Day 15‐OR #6 – I & D right humerus & right forearm, application of wound VAC to right upper extremity from wrist to axilla • Day 19‐OR #7 – I & D right humerus & right forearm, wound VAC change Operations/Procedures • Day 22‐OR #8 – I & D right humerus & right forearm, wound VAC change • Day 25‐OR #9 – Ligation of previous right axillo‐brachial bypass graft secondary to blowout of graft and subsequent hemorrhage • Day 26‐OR #10 – Open through elbow amputation • Day 28‐OR #11 – I & D right upper extremity • Day 30‐OR #12 – I & D right upper extremity including debridement, subcutaneous tissue, bone and muscle Operations/Procedures cont. • Day 32 OR # 13 – Extend right elbow amputation to right shoulder disarticulation, excision of residual and infected bypass graft of the right arm, resection of chest wall wounds and rotation of large fascio‐ cutaneous flap to the defect of the shoulder and chest wall • Discharged on Day 37 • ICU days: 1 • Ventilation days: 1 • LOS: 37 days • Acute Healthcare only costs: $264,769.90 – Does not include professional fees, radiology Case Study #2 • 36 year old belted female who was involved in a low speed motor vehicle collision and rollover. Patient reported that she had her left arm out of the window when she was hit on the passenger side and rolled to the driver side. • Patient found to have left ulnar styloid fracture and extensive left forearm/hand avulsion injury – No other injuries Case Study 2 ‐ Scene/Vehicle • Case vehicle – 2004 compact utility vehicle • Far‐side & Rollover (2 quarter turn to left • Objects struck – V2 (2006 Chrysler Sebring) & the ground • Daylight, Clear, Dry Case Study 2 ‐ Occupant/Impact • Driver • Female • 36yrs. • 5’2”, 220 lbs • Normal posture • Restraint Use = Manual lap/shoulder belt (seat belt retractor pretensioner did not actuate); no air bag deployments • PDOF = Non‐Horizontal (Event #2) • CDC – 00LDEO01 • Delta V – Damage Severity = Minor Arm ‐ partial ejection evidence External Injury Left degloving injury of the forearm and Left hand comminuted fracture of the distal ulna. Extensor tendon avulsion Left thumb abrasion Case # ‐ Operations/Procedures • Day 2‐OR #1 – Irrigation and debridement(I&D) of left forearm avulsion injury including skin, subcutaneous tissue, muscle, and bone‐approximately 400 sq. cm. – Exploration of median and ulnar nerves in forearm • Day 5‐OR #2 – I & D left forearm with application of wound VAC • Day 7‐OR #3 – I & D left forearm with wound VAC change • Day 10‐OR #4 – Left forearm and dorsal hand debridement including skin, subcutaneous tissue, and muscle; wound VAC change Operations/Procedures cont. • Day 14 – OR #5 • I & D left dorsal forearm including skin & subcutaneous tissue; wound VAC change • Day 21 – OR #6 • Preparation of wound bed for left dorsal forearm and hand, 400 sq. cm., in anticipation of a split thickness skin graft
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