Nonoperative Management Of Injuries Research Articles

RSTN COVID Hand: Hand trauma in the United Kingdom and Europe during the COVID-19 pandemic

The COVID-19 pandemic rapidly impacted the delivery of hand surgery services throughout the UK and Europe; from triage to treatment. Our aim was to assess the impact on management of common hand trauma injuries to inform future service delivery and research. The Reconstructive Surgery Trials Network led a service evaluation during the first wave of COVID-19 in 2020. Data was collected on hand injury management during the COVID-19 pandemic and was compared to the management clinicians would have delivered prior. Across 35 hand surgery units, 2540 patients with hand trauma were included. There was an increase of between 3% and 7% in non-operative management of injuries, apart from flexor tendon injuries where management remained unchanged. Cases triaged by a consultant doubled, with a 22% increase in the see-and-treat model. There was a move to operating in low-resource settings; a 13% increase in the use of minor operating theatres and 10% in clinic rooms. Use of WALANT, absorbable sutures, and remote follow-up also increased by 16%, 24%, and between 11% and 25%, respectively. The reported 30-day complication rate was 3.2%, with a surgical site infection rate of 1.8%. The pandemic led to rapid change in many aspects of hand trauma care. It was the impetus for increased out-of-theatre operating, use of local anaesthetic, and more non-operative management of injuries, without an increase in complication rate. Further research needs to assess the clinical and cost-effectiveness of these changes to ensure that COVID-19 is a catalyst for a modern, evidence-based, and environmentally sustainable delivery of hand trauma services.

Thoracic Stab Wound With Impaled Knife

A 52 year old man was brought to the Bellevue Trauma Center after a single stab wound to the upper back. The patient arrived hemodynamically normal with a Glasgow Coma Scale score of 15. He denied any chest pain or shortness of breath. Physical examination revealed mildly decreased breath sounds on the left and a sharp kitchen knife impaled in his upper back (Fig. 1). Pulse exams were equal in both upper extremities. Secondary survey was otherwise normal. FAST examination revealed no pericardial effusion or free intraperitoneal fluid. A chest radiograph revealed the foreign object as well as an asymmetric lucency at the left costophrenic angle consistent with a small pneumothorax (Fig. 2). A left-sided thoracostomy tube was placed with air and minimal blood return. Given his hemodynamic stability, the patient was brought for a CT scan of the chest with IV contrast to better delineate the knife blade tract (Fig. 3). The computed tomography (CT) demonstrated the knife blade entering the left lower lobe and terminating 8 mm from the descending thoracic aorta with no evidence for aortic or esophageal injury. The knife was withdrawn under controlled conditions in the operating room with the patient prepped and draped. His vital signs remained normal after a period of observation. The chest tube was removed after 2 days. The patient was subsequently discharged and doing well on follow-up. Evaluation of patients with impaled foreign bodies has evolved with the expansion and accessibility of diagnostic modalities such as CT scanning. The anatomic information acquired by CT, in conjunction with reliable and repeated clinical examination, allows for non-operative management of injuries that once mandated a more aggressive surgical approach.

Patient Selection for Nonoperative Management of Popliteal Artery Injuries

A twenty-six-year-old man was involved in a farming accident, whereby a corn head from a combine fell on his legs. He was transported by air care to the emergency room approx imately seventy-five minutes after the accident. Upon examination the patient was alert with a pulse of 100/minute, blood pressure 116/80 mmHg, and respiratory rate 20/minute. There was an anterior dislocation of the left knee with a wound in the popliteal fossa measuring 8 x 6 cm. There was a normal palpable left femoral pulse, but distal pulses were detectable only by Doppler. There was no evidence of an expanding hematoma or bruit. He had a left-sided foot drop with a cold, pale foot with diminished sensation. Roentgenograms of the lower extremities revealed an anterior dislocation of the left knee without any associated fracture. The patient was taken urgently to the operating room, and under general anesthesia a reduction of the anterior dislocation of the left knee, with debridement and irrigation of the wound, was done followed by stabi lization of the knee with an external fixator. The patient had palpable left posterior tibial and dorsal pedis artery pulses following the reduction. Intraoperative arteriography under fluoroscopy was then performed via the left femoral route by the Seldinger technique. This revealed a 50% 5-cm-long smooth stenosis of the left popliteal artery with normal distal runoff. It was decided to manage the patient's popliteal artery injury nonoperatively with anticoagulation and in-hospital serial observations. Duplex examination of the left popliteal artery confirmed the arteriographic findings. The patient was given intravenous heparin therapy for three days followed by warfarin for three months and is currently taking aspirin (325 mg/day). A follow-up duplex examination at one week and at one, six, and fifteen months following the injury revealed a normal healed popliteal artery. Traumatic knee dislocations have a well-known association with popliteal artery injuries. Because of a high amputation rate associated with missed or delayed diagnosis of popliteal artery injuries, early diagnosis and repair of such injuries is the standard of care. The authors describe the nonoperative management of this injury and review the literature on this subject.