So, the topic this morning is the urban mangled hand, and everyone here has an appreciation for mangled hands and know how complicated they are and how complex they are. The mechanisms we typically see are farm, industrial, recreational, motor vehicle, motorcycle crash injuries. But in the urban environment, the mechanisms are different that we see. And we know that mechanism is very important. Mechanism drives the zone of injury and the degree and the type of the tissue structures that are injured. The debridement is critical, but how much debridement you may do varies depending on the mechanism because it's difficult to identify the zone of injury. And we'll talk about that as well. How is the zone of injury determined? How is it measured? And also, the expectations that you have with the different mechanisms are very different. And how does that affect your decision making going forward with surgical planning and counseling the patient and also discussing salvage versus amputation? Another very important concept to remember is that the zone of injury is dynamic. We oftentimes think of the zone of injury as static. The patient has the injury and that's the zone of injury. But as we know, over time, the zone of injury can actually decrease with good debridement and rest of the tissues. But very importantly also, the zone of injury can actually increase. If you have a chronic wound, if you don't adequately debride, the zone of injury will increase and become larger over time. And that's something that people really underappreciate. So the mechanisms that we'll be talking today are electrocution, something that we don't see that often in the US. But when we do see them, they're severe. And they're also very unique in how they're handled. Ballistic injuries, high versus low. The difference between those two, and unfortunately we see a lot of those, especially in some of our urban centers and in some areas we're seeing increasing rates of those. And then also fireworks injuries that can be very devastating. So our speakers today, first one is Dr. Hadi Venkatramani from Ganga Hospital. And I don't know if you've ever visited or are familiar with Ganga Hospital, but if you ever get a chance to go there, I highly recommend it. It is an epicenter for the management of severely injured limbs. He'll be speaking on electrocution. And Dr. Jason Strelzo from University of Chicago speaking on ballistic injuries. And that's an area of the city that sees a lot of those injuries, especially on the south side of Chicago as a level one trauma center. And then Dr. Patrick Revy will be speaking on the fireworks injuries. He's from the University of Rochester. So these are all three excellent speakers. And we'll have some cases at the end of the presentations today. All right, so the first speaker is Dr. Venkatramani. burns are never isolated so they are a part of multi-organ or multi-system problem and they can happen with very simple things like this lady was trying to pluck a mango from the terrace of her house and the electric pole just went and accidentally not even touched it was very close to the high-tension wire that itself caused such a significant and devastating injury. So you need to examine completely so have a full clinical examination head to toe and all the what we do in ATLS ABCDE is very important and first of all in electrical burns you need to concentrate on the urine output and the resuscitation and always take a CT abdomen and CT brain because many times though it may not look apparent on day one but they may have fallen down or they may have an SAH as seen in this lady she had otherwise she was conscious fully oriented and always do a CT abdomen when there is abdominal involvement because the challenges here are we need to know the abdominal wall integrity when the perineum is involved we need to have an option of colostomy or some way to divert the the contamination concern about the upper limb morbidity and the plantar burns if they are bilateral then always makes ambulation difficult so we need to keep that in mind and of course taking care of infection and sepsis. So we debride so we debride on day one and this is at seventh day actually in this lady we were not able to do an acute debridement because she did not present to us on day one it was 48 hours later and then on the seventh day now you need to decide what are we going to do with the limb burns so here you have an option if they are systemically fit and it is only involving a single limb you can at this stage go for flap cover or some definitive form of cover but in this lady as you see it is involving from the abdomen and practically head to toe so WAC is a good option. WAC many times can reduce the area and also be a good preparation to definitive cover. On 15th today you will see here now she's ready so we just go for skin grafting and that's the outcome following WAC even if you see the forearm has granulated well this is not ideal I will come to that in the later part but then it can take care of the wound healing and the heel as you see has beautifully granulated and that's her close to a month after presentation. So what have we learned here you need to resuscitate them well even if they present at 48 hours they are usually under so good fluid resuscitation take care of the serum lactate and other just like any major polytrauma. Always suspect visceral injuries in a in a inconceivable it may not look as if they are involved but they can be involved. WAC is very useful early flap cover can restore function and good results if grafted early. Now we come to surgery and electrical burns can be divided into three acute situation which is amputation in many cases doing fasciotomy and decompression of the nerves wound cover and secondary reconstruction. So as I mentioned they are very devastating sometime we cannot do much so here if you see here this small kid we had to do amputation at the shoulder but the thing to remember here is always go higher up and do a subclavian artery ligation otherwise they can have blowout at the amputation stump so that is what you need to keep in mind. When there is major burns though the face and the other part may look very very severe but that's not what is going to cause long-term morbidity. The limbs have to be taken care first and better. So when do we or how do we do fasciotomy and estrotomy always just like we do compartment release in trauma have a low suspicion and always be on the or on the side of doing early fasciotomy and estrotomy. So if pulses are not felt and usually it is very difficult we use Doppler or pulse oximeter but still it is better to do fasciotomy and estrotomy. They do not need as such full anesthesia so under sedation we can do this use your monopolar cautery and then it is quite bloodless. So release the circumferential burns right from the axilla to the fingertip and on the chest so this can really decompress well and they can go on to heal well and very trivial burns can often be very devastating because it looks very trivial here but if you check the sensation in the fingertip there is blunting in the median nerve territory. So we do a carpal tunnel on day one so carpal tunnel release should be done as early as possible. Even after carpal tunnel and under nerve release you see here she had developed a claw but usually because we have done it early they go for full recovery. So this young girl went on for full recovery after release of carpal tunnel and gave on canal release. Carpal tunnel can also be done when there is a flap cover requirement. So this is a young small child and four-year-old kid so if you see here if you keep concentrating on the wound and not take care of the carpal tunnel release you can have later on morbidity. So we continue with the wound debridement same sitting we have done carpal tunnel release and we have done a pedicle abdominal flap and that's the long-term result and because we have done early release there is full function in the hand. Localized deep burns you can do it primarily so you just go in deep just like the same concepts of wound care excise them and do local flap cover. Many times it will be deep involving the bone and the common mistake is leaving behind dead bone so as we know in trauma you should not leave behind anything which is hypovascular or going to die in 48 hours. So day one remove it and then put a flap cover. Here again we have done a small abdominal flap we come back later and do iliac rush bone graft. Now the most devastating part in an electric burns especially around the elbow is loss of long segments of tendon, nerve, blood vessels and even bone. So practically all your reconstructive armamentarium and skill will come in use in major burns like this. You can have bilateral so this this young boy had bilateral if you see here on the right side we can salvage but left side though it is viable but there is no way we can salvage so the left side went for amputation. On the right side see unlike the previous example which I said don't go for back in such cases because you know that you may need to do secondary reconstruction. We always first choice is always doing an abdominal flap if the areas are well preserved so we have just done an abdominal flap the tendons and nerves were intact and that's a result we can get. So this highlights the the role of early flap cover the other side went for below elbow amputation. If the tendons are discolored the common hesitation is trying to do a wide debridement and we try to leave behind tendons and nerves which are hyper vascular and we do a sub optimal debridement because we are concerned that hand will be either go a vascular or there will be extensive loss of nerves and tendons but if they are dead and dry there's no point keeping them so excise them do a flap cover so you will reach a stage like this now the hand is saved there is a flap but the distal part is insensate with no nerves and no tendons so that will see how we reconstruct or you have a situation like this where you can preserve some of the tendons so if the tendons look okay they are not so bad you can give a benefit of doubt and leave them so here we have left the tendons behind and that's a flap we plan you can flap in any any orientation you want right from the umbilicus to the groin all the segment all the areas so this is a para umbilical flap you can take SIE a based or a straight forward groin flap so there's a para umbilical flap that's how it is now our important point to remember is take care of blowouts when you do pedicle flaps in a bed which is not very clean and there is always a risk of sloughing out under the flap so this boy had a blowout keep that in mind and know where you need to ligate it in case there is a blowout so this is very important they can be devastating you need to just compress them and straight bring in them to the OR and then give a block and then take care of it so this is at the end of the flap cover the arrow points out that even though there is a small gap in the palm subsequent reconstruction can be done only if because you have to tunnel the tendons and nerves if required so always have extra provision for the flap so don't make a flap which is straight and then there is a tight segment in the center so that's him he's awaiting flexor tendon but because the nerves have been preserved he is able to have an adduction of the thumb more extensive burns you need to stage them so take care which is the priority so here if you see this patient had back scar scalp and burns extending from the axilla to really nearing the wrist so here the upper limb is a priority so first we debride it well to this level and we have done a trunk flap so just place it where it sits and just raise big flap so you can take really big flap from here to here that's a flap taken from the abdominal lateral side and then we have put a vac in the immediate during this period we had put back for the scar scalp and then we came back and did a trapezius transfer for the scalp bilaterals are very challenging because you need to plan them well and you have positive donor sites so here is a bilateral abdominal flap done for bilateral upper limb burns so again if you see the flap really goes up to the palm so this is the key point when you design the flaps and this is at the end of the the flap division and awaiting tendon transfer tendon graft so the tendon and nerve graft now we come to that what do we do so long segments of tendon and nerve now grafts we use sural nerve grafts so bilateral sural nerve grafts have been taken and because most of these you you may we know that it is not going for motor recovery we are only aiming for sensation in the hand so we take long sural nerve grafts for both ulnar and median and we use facial autograft for the tendon so I'll just come to that in the next case how we harvest the facial autograft so this is the same patient gone back usually because the nerves have been recovered they will get adduction and they have some adduction power and flexor tendon reconstruction in this form the role of regional flaps we avoid regional flaps like ulnar artery perforator or radial perforator flaps because if you need to do any secondary tendon reconstruction if you see here the arrow points to the skin grafted area in the forearm this patient had other injuries so we were not able to do pedicle abdominal flaps but whenever possible either a pedicle abdominal flap or a free flap is a flap of choice if the area does not have soft tissue so this patient referred to us in this situation everything has healed insensate hand so first provide good soft tissue cover so you can design flaps like this one for the dorsal side the other one for the ulnar side and that's a donor side and then this is what I mentioned we take facial autografts facial autograft is an excellent donor site for long flexor tendons you just need two to three millimeter strip for each each tendon and that's a sural nerve graft so we tunnel them the nerve need not be in the straight direction the tendons have to be in a straight line of pull so nerves we go from the side and so that in case we need to do a tinolysis at a later date we don't disturb the nerve so that's the graft and that's the amount of power he can get of course this is nearly 10 year before now he's got married he's got a big job and that's the amount of power he can get and precision in the finger so when do we do micro surgery having seen pedicle flaps so micro surgery in burns is relatively less indicated in our in our experience but we do it for salvage for cover for function and for creating a foundation for future reconstruction so you need to be very proficient in the big five as I keep mentioning in our in our unit we use this big five which is an ALT lat dorsi gracilis radial artery is relatively less so you can substitute with any other small skin flap and fibula when you need for bone so when the limb is at risk as seen here so it is little risky to keep them in the abdomen so because it dependent position the pulse oximeter is showing 80 90 saturation but the hand is viable so here it is better to go higher up and do a big ALT flap we always take with lot of muscle with the practically the entire vastus that is the size of the skin and the vastus is same because the skin goes to one side and the vastus goes to the other side difficult areas around the elbow again free flap is preferable so it's a small area so gracilis bigger area you can do a ALT but when you do it for the elbow you need to do end to side so you need to be very proficient and take an extra length of pedicle so that's the cover with the gracilis when the donor sites are not available so this patient as you see you refer to us in this situation is already have a below elbow amputation on one side and donor sites are not there so first stage we do a thorough debridement and ALT flap so this is what I mentioned see the amount of vastus we have taken along with it is very useful because the skin comes on the front that is the area we want to do secondary reconstruction and the muscle goes to the side so on table it may look very bulky but if you see them at six months so this is at three to four months at this stage before we do the flexor tendon reconstruction always first separate the first web space because unless you separate the first web space the the finger will not meet the thumb so we do the pedicle flap for first web space so at this stage and this is a small trick we find very useful just mark three lines going on the forearm and the abdominal wall so anytime the hand moves the patient and the caregivers will know that the position has changed and they will just put it back and this is now is ready for the flexor tendon and now reconstruct and if you see the amount of the muscle has totally wasted and the skin flap looks nice now and then we tunnel the nerve and the facial autographs so how do we tunnel it so this is also very this we learn from Simon K from UK and we just take a suction cannula put the sural nerve graphs and just apply gentle suction so it just comfortably comes on the other side and then you just release the suction so this is very nice way of tunneling the long nerve graphs so this is a result at six months so he had a processes on the other hand but he didn't use that much so this is his function so he has good precision good pinch and he's able to and he's quite happy with the though it is not a normal function but for from where we started and where we end it is a good function for him when do we do secondary reconstruction you saw in skin flaps the difficulty comes when you have a muscle flap so we don't do muscle flap but this lady was referred to us from another center and that's a lat dorsi sitting there so when you have a muscle flap it becomes very difficult so you need to have India when the induration settles down you go to the ends and then tunnel it so the lessons we have learned better to do it early and then go for secondary reconstruction later on finally for functional tissue restoration so this is a young boy who has a loss of thumb so when you have a loss of thumb what do you do so toe transfer as we know is the best option so you need to be prepared for toe transfer the thing to be taken care of is that the vessel so you need to take a long length of the dorsal spirits and this stiffness vein so that you go quite proximal in the forearm in children this is at one year follow-up and if you see him at 11 year or 10 year follow-up the thumb really shrinks and this we are just written up this paper that you don't need to really reduce the size of toe when you do primarily over a period of time this toe in the hand is longer than the toe in the foot on the opposite side so it really becomes long and thin so that's that 11 year follow-up finally electrical burns will always need other microsurgical reconstruction so you need to be prepared to cover the scalp because this patient is under your care so you need to use all your other reconstructive armamentarium so here this is a scalp so we have done a lat dorsi for the scalp reconstruction and that's the heel part if you have and many of them have ankle burns because that's an exit wound so you need to be prepared to cover these areas also so here one side we have done a gracilis other side we have done a reverse surer so you need to be prepared to doing these kinds of flaps also along with the upper limb so the learning points research state well always suspect visceral injuries avoid sepsis so early excision is very important if you are anyway going to be the definitive plan is to be delayed then put back so that is it keeps it preserved and does not allow the the hospital flora to get into early flap cover can restore better function and microsurgical techniques can extend our reconstructive capability thank you very much So, we'll change gears a little bit. I'm Jason Schlesinger from the University of Chicago. For those of you who don't read the news or have news available, we obviously have a little bit of a gun issue in Chicago, and so we'll talk a little bit about our experience and some of the things we've learned over the years. None of these are really relevant to what we're going to talk about today. So hopefully at the end, you'll have an idea of some tools for how to manage gunshot wounds to the upper extremity. They're definitely different than lower extremity gunshot wounds, and if you want, I'm happy to talk about that at the end. Is it safe to manage them? Is it safe to manage them acutely? Do you have to wait? Do you have to debride? Hopefully, you'll have some answers to that. And then last but not least, maybe some tricks to keep you out of trouble. Number one, who has managed someone with a gunshot, just so I know who's... Okay, perfect. Good. All right. So I know that you guys probably know at least some of this early stuff, so hopefully this will be a little bit of a review. Obviously, the tools we have to manage from a bony perspective is really non-operative management. Don't forget non-operative management. Everyone looks at a gunshot wound and thinks, I need to do something to it. Most of the literature, although it's relatively poor literature, would suggest that that's actually not the case. X-Fix. X-Fix is your friend. Whether that's a conventional one, i.e. a commercial one or something that you make, and I'll show you a couple of tricks for that. K-Wires. K-Wires are great. They can be pulled at any time, particularly if you're worried about infection or soft tissue bed. And then plates. And for the most part, you'll notice I did not put anatomic reduction on there, because that is not the goal most of the time. So why should you care? Sadly, this is obviously a civil and an urban health crisis, particularly here in the U.S. and won't go into all the details about that, but certainly is climbing the list, particularly in the youth population, where it is now number two cause of death. So what's important about gunshots? So you'll hear this a lot, but low energy versus high energy. What does that actually mean? And often, people confuse high and low energy with rifle versus handgun, right? You'll hear that. Or shotgun versus handgun. I hope to dispel that myth. Really what matters is the size of the projectile, the distance from the projectile, and the velocity at which it exited the muzzle, okay? So what that means is a handgun shot at someone from a very close distance can be a high energy injury, okay? So don't forget that, because everyone wants to say, what did you get shot with? And that actually doesn't matter. So what to remember about these? Really, obviously, we focus a lot on the things we see on X-ray, because that's often the first thing that you hear about. If you're getting called from someone, they say, it looks really bad on the X-ray, right? Forget about that for a moment. Forget about the fracture, because usually that's actually the simplest thing to deal with. Think about the skin, the nerves, the vascularity to the area. And then, do they have any other injuries, right? So we frequently see people that have been shot 10, 15, 20 times, and you really don't care about their extremity if they've got abdominal injuries and if they have through and throughs. So patients that have been shot, hit in the elbow, they have a blunt injury to their lungs that's going to totally change your initial management. You're going to forget about the extremity. You're going to have them managed from a general surgery perspective. So you heard me kind of go off on the high versus low energy myth. Really, this is sort of what you want to remember. There's a whole host of different ways people can be injured by guns. And this is the traditional teaching, right? Everyone likes to think about that. But I want you to focus really on that bottom point, the kinetic energy, right? So we're talking mass and velocity. So big slug, big projectile from a short distance fired from something with a lot of velocity is going to cause a lot more damage. Again, this is the thing if you go on ortho bullets or you go on most teaching around gunshots, this is what you'll see. And then finally, I take out the handgun and rifle segregation there and really focus on low energy, again, mass times velocity. And if they are low energy, they're really equivalent probably to like a Castillo 0.5. And then as you get higher energy, you're really starting to talk about Castillo type 2 or type 3. And that's certainly been our experience in Chicago. Something to think about when you're thinking about how a projectile injures the tissues. We think a lot about what the projectile is actually doing. But around the projectile is actually where all the bad stuff happens, right? And so the compression and the crush that causes the fracture and the hole in the tissues, that's important. But really what you want to be thinking about is all of that temporary and permanent cavity, okay? So the temporary cavity is really the zone of injury. And it's a heck of a lot bigger than what you see. And hopefully I'll be able to demonstrate that through some cases here. The shockwave, the shockwave is important because when you see many of these patients, they'll have, let's say, a mid-shaft forearm through and through. And you'll see that they have numbness throughout their hand and you think, well, that's weird. The injury probably should have only taken off maybe the radial sensory. And the reality is that the cavitation and the shockwave is really, really quite traumatic to the nervous tissue around and the vascular tissue. And so many of the patients that initially present with a pulseless limb or a numb hand, if you give them enough time and you watch them, many of those things will recover. So some examples from things we've seen in the last couple of days before I flew out. So here's a through and through. Actually no bony injury. The quote unquote entry wound. Point for you from a legal perspective, never use gunshot, never use entry, and never use exit wound. If you ever get deposed, those things will hose you. So what you want to say is wound. There's a wound here. There's a wound there. There's a projectile. It's a foreign metallic retained body. And the reason for that is because you're not a firearm expert. And if you get deposed, they will ask you, well, how do you know that's the entry wound? How do you know that's the exit wound? And you can actually hurt whoever it is, either the defense or the prosecution, depending on which side they've deposed you on. Just a tidbit. So here, no fracture at all. This is an entirely soft tissue based injury. Basically traveled from what looks like the base of the thumb. I don't have an arrow. Can you see that? Okay. Entry wound likely here, although that's debatable, right? But there was definitely a wound here all the way through and took basically everything off that radial side of the finger. What you'll obviously appreciate very quickly is took out the neurovascular bundle on that side. The blast wound actually had, this patient had no pulse and no Doppler signal to any of the fingers when they initially presented. And we thought that's kind of strange, right? There's a wound that goes only on the radial side. You suddenly look for other injuries because sometimes there are and they're pretty small and everyone's focused on the mangled finger when it comes in. But actually nothing else. And so when you actually resuscitated the patient, you sat down for a few minutes and chatted with them slowly. You started to see that they got vascularity in all their fingers shy of the index. And so all we had to deal with was that digit. But everyone is focused on the fact that they can't get a pulse in any of the fingers. One thing that's very, very helpful in these patients because of the zone of injury and something I learned from the speaker who will talk after us is just take graft. Don't mess around. Even if it looks like, oh, I could just sew that artery back together. There's just a small little nick in it. The zone of injury, that cavitation injury and the shock wave traumatizes and gives the tissues such a hard time that it definitely helps to take some grafts. So I just take something from the dorsal hand usually or forearm to graft in and seems to work well. One question we get a lot about is antibiotics and debridement. Do you have to do it? How quickly do you have to do it? If you read the literature, most of the historic literature is military based and will tell you you need to get to the OR, you need to debride the wounds very carefully, maybe multiple debridements, maybe you should put an X fix on and do some bony stabilization. Realistically most of the current evidence from low energy mechanisms is that you treat them maybe like a gastilla one if the tissues are not terrible. If it is a higher energy injury, you may need to do an acute debridement. But realistically most of these patients can be treated with a single dose of antibiotics either at the time of the operation if you're going to do some bony fixation or the time of their ED visit. So our current protocol, if you have a gunshot wound to your hand, you get a dose while you're in the emergency room, we send you out, we bring you back and we fix you whenever we get around to getting you on the slate. For patients that are admitted, we often don't give them a dose of antibiotics in the emergency department and they get a pre-op as a standard protocol for our institution. That would show you the infection rates are almost identical to closed injuries. We're about to publish I think it's 500 patients with upper extremity injuries and our infection rates actually substantially lower than the gastilla ones. So again, it seems to be that you can manage most of these patients with low energy, like a standard fracture. Through joints, people ask a lot about joints. You have a through and through shoulder, you have a through and through elbow, wrist, etc. Arthrotomy alone, there's nothing we do, we don't even give them antibiotics. If there is a retained metallic foreign body, those patients we will go in and take the foreign body out. So for shoulders, arthroscopic removal of a retained foreign body, they get an antibiotic dose because they're going to the OR and we're doing a procedure, but no specific sustained antibiotics. We do not treat these like a standard traumatic arthrotomy the way we historically have been taught. And then nerves. So what happens to those nerves? The vast majority of these nerves are shockwave injuries, they're neuropraxic. We published our data from our center and it seems to be reflected in most of the other data out there that lower energy injuries predominantly produce a neuropraxia. They're very slow to recover. Most of these patients do get most of their function back. However, there is a small group, 15% in the upper extremity, it's a little higher in the lower extremity, that don't seem to be able to get their function back and we're trying to figure out how we can predict who those patients are because you'd be surprised. Some of the patients you think there's no way a nerve's injured and you get in there and you see a huge gap and you're wondering how did we miss this? But it happens. So a couple of examples here. So here's a patient that was referred to us, index metacarpal was actually sent as a trauma transfer, they were worried about the finger. He was a heavy smoker, had a pretty poor soft tissue bed when he was initially brought in. Largely just because of the way it was managed by the patient after the gunshot. He presented a little bit later on than we would traditionally have worried about initial infection, et cetera. So he presented to this outside hospital almost a week and a half after the injury and then was transferred over because they were concerned. We did this, this is just a cheap, very effective external fixator if you're worried about anything. He had a lot of finger malrotation which is the only reason we actually offered him an operation and so we used this to derotate him. Didn't do anything fancy with the soft tissues other than sort of clean up the edges but really allowing this to granulate in and our focus here was getting a finger that he could make a fist with because the finger was pointed almost 90 degrees in the wrong direction. They get stiff as you can imagine with these external fixators and a lot of soft tissue trauma. But taking them to the OR we did a nice little contracture release and we're able to get him into a substantially better position. You notice I did not show you an x-ray of the metacarpal. Why did I not show you an x-ray of the metacarpal? Because clinically he'd healed and we don't routinely re-x-ray them. Why? In our series I think we have 150 metacarpal fractures. The vast majority of them go on a fibrous union. They're clinically as stable as you would imagine a nicely healed fracture. They're using their hands. They go back to doing all the things they wanted to do and so we don't traditionally chase up a bony fibrous union in the hand. A little different case. Here's an 18-year-old shot through the hand, had multiple other injuries. But these were the ones that we were most concerned about from a hand perspective. Obviously a large soft tissue defect, a bony defect, and you can see the tendon kind of just in the breeze there. Again, just thinking through what else to do for this patient. Very sensate fingers, surprisingly. Here's the radiographs of just the bony destruction that was apparent. So again, here you're focused on doing a couple things. Number one, pinning them out to length, not doing anything too fancy. We covered it with Integra, never to be seen again, which is unfortunately a recurring theme. But this is a very similar patient that we managed. Not as bad a soft tissue mechanism, but certainly the same kind of bony injury. Usually we're pulling the pins around the six-week mark. Again, not guided by the x-ray, but clinically how they're feeling and how they're doing. This patient, again, different, was closed primarily. Again, we traditionally leave the bullet wounds open, but if there is a soft tissue flap we'll lightly tack it over. And then if there are secondary wounds or larger wound defects, we'll come back at a later date. And then the vast majority of these patients where you're pinning them, they will require something for adhesions, just because they do get quite stiff as you try and stabilize them for longer than I would typically leave my pins in. I'm usually a four-week pin person for non-ballistic injuries. One to just illustrate how the size of the wound is not important. So this is a 34-year-old referred in to us for a hand at risk. He shot himself while cleaning his handgun. So a close-range injury from a handgun through and through the carpus there. Wound itself looks relatively benign, quite a small little wound, but he described complete numbness throughout the hand. So, you know, if you look at this and you think, well, that has to have hurt something important, right? Do I know that for a fact? No. Do I want to wait on it? I don't know. I would love to know how to find if this nerve is truly, truly transected or if it's just a neuropraxia. Currently our practice is really provider-dependent and we're working on some different modalities to make that diagnosis. The biggest problem we have is obviously some of the tools we traditionally use, MRI, ultrasound. With retained metallic fragments, you can't use many of them or you can't see anything. So they can be challenging. They can be challenging. With this one, just with the proximity of the wound, we elected to explore. So because of some carpal instability, we debrided him just to be able to get the plate in position. We were there anyways. And then a large, large nerve laceration. So here, the transection, I should say, the metallic fragment had largely basically eaten everything out of the carpal tunnel, which was unfortunate for him. So I think, you know, to summarize what to remember, remember it's really a fracture around soft tissue injury. The fracture is not something that we traditionally focus on, at least in ballistics. They're very common for the most part. And really you're looking for techniques to just hold them stable. The vast majority of them heal. Our non-union rates for our upper extremity fractures treated with either bridging or non-operative management techniques is on par with traditional non-ballistic mechanisms. So again, don't chase the fracture. We're really thinking about soft tissue management more than anything else. Formal IND of these wounds, removal of the fragments, not necessary. We typically leave them in place and do not chase them. And don't typically take patients for a formal IND. If there's a wound there that we happen to need to go through, we'll do an IND. But if the wound is separate and you're not planning to incorporate that in your approach, we leave it. We don't even curette the wound. Really what you're focusing on from a bony perspective is all the things that you're taught to do from a bone management length, alignment, rotation. Once you have those things, get out of the OR. And the thing that'll keep you out of trouble is trying to make it look perfect. So in none of those pictures that I show you, anatomic reduction. Don't go chasing the pieces. The x-rays will lie about how stable, strong, and non-common in those fractures are. You're going to get a fine cut CT and you'll think, oh, this is a really simple fracture pattern. It won't be. I guarantee you that. You'll get in there and the pieces will be substantially more fragmented than you'd ever imagined. That's all I got. All right. Moving on to fireworks, the 4th of July special was the topic, title I was given. So as you guys all probably know, there's a variety of different types of fireworks from the smaller to the more significant, the mortars. And they each, the key thing, similar to the, I would say, the gun bullet size, et cetera, they all can be quite devastating regardless of what size they are. It depends on the size of the hand and the position it was in when it explodes. There's been an explosion, no pun intended, in fireworks sales in the past few years and we've seen that mirror in terms of injuries associated with fireworks. Most of them are men, young men, who either in proper use or misadventure with fireworks. So you can have young, unfortunately often young children get in the wrong end of these. The vast, there's a variety of locations of injuries in both adults and children. It's about 50% as isolated to the upper extremity in the hand. In the United States, obviously most of these occur during July, around the 4th of July, but if you go to any other country outside Europe, that's probably shifted more around New Year's Day. And one thing to always keep in mind is not all fireworks are legal and or appropriately made. So if you go to homemade firework on Google, there's no shortage of videos of people showing you how to make your own. So remember, they don't always work and they are essentially a bomb. There's a nice slow motion video of a small, very small firecracker going off in water. That's about as small as you can buy. And usually the one that's chained together with multiple other. So not something we would consider usually a large firework. But they are extremely violent explosions. It is an immediate release of kinetic energy that usually occurs in less than two-tenths of a second. And so if you think about the damage that those explosions will cause to a hand, you obviously have the blast. You have the thermal component and then you have the potential shrapnel and debris. The thermal component, obviously you get concerned about potentially burns. It is an immediate release of kinetic energy and so you'll have really evulsions, fractures and dislocations. And shrapnel and debris will maybe cause lacerations, but in your most commercial fireworks, it's just cardboard and paper. So for the most part, that is a pretty small component. If you look at the burns, maybe counterintuitively, 97% of the hand burns are nonoperative. It's a very quick thermal reaction unless they get like their clothes caught on fire. It's mostly going to be second degree and most of those burns will heal. But overall, 67% of these injuries are operative and it's mostly the soft tissue and bony injuries. So in general, we're really going to focus on the blast component of the firework injury and how it affects. And that blast can be quite varied in terms of how devastating it is. Again, related to the size of the firework, how it was being held and the distance of the explosion from the hand at the time. There have been a number of attempts to sort of classify a typical explosive injury to the hand based on the position of the injury, the location of the injury, whether or not there's carpal bone involvement. In my experience, I would say there's generally like I would say three different classes potentially of injury. What I would call the phalangeal. So just injury at the tips of the digits. Maybe you'll have an MCP dislocation. Always look out for those that involve the first web space. And then finally, I would just call devastating or carpal injuries. And obviously, there can be a mix of any of these along the spectrum. But I would say these are the especially the first web space are the ones to watch out for. So in terms of bone, you get dislocations and fractures. And skin, soft tissue injury, it's a crush and a tear injury. So your zone of injury, as we've sort of discussed, is quite wide and difficult to discern. And then you have an avulsion, which affects tendons. They're not usually lacerated at the where you have your soft tissue injury. They're usually avulsed either off the insertion or the musculotendons junction. And obviously, your neurovascular structures are also avulsed. So if we just sort of look at how a phalangeal injury would occur, usually it's a small firework held at the tips of the fingers. When it explodes, you get amputations, dislocations, and usually isolated phalangeal fractures. Again, as a sort of schematic, you have your finger, an explosion, immediate release of kinetic energy, and you end up with the energy going through the path of least resistance. That may be a fracture. It may be a dislocation. You have your tendons. If they are injured, they're often intact, surprisingly. You have a finger that's sort of held in flexion with everything else around it destroyed. But your muscles, if their tendons are injured, they're usually in avulsion, and then long sanguine neurovascular injuries. Though these are similar to gunshots, these are similar to war injuries, I'd say these are much more similar in terms of the immediate violence. And so if we look at this review from 1983 from Buckhalter, who had a lot of experience dealing with war injuries in Korea and Vietnam, his recommended treatment for explosive or war injuries was, debridement of skin is minimal, fascial incisions are generous, the bone is preserved except for small free fragments, partially devitalized fingers should not be amputated primarily, no tendon or nerve repairs are carried out, no tissue shifting is done to cover vital structures, and await a second look procedure. If possible, skeletal stability should be achieved. So that's your first operation. This is my thought process for just a typical mangled hand, regardless of mechanism. And with firework injuries, just as we talked about, you're not going to be thinking about doing tendons your first day. You're not going to be thinking about doing nerves the first day. You're not going to be thinking really about doing arteries the first day, with some caveats to that. Vein's the same. And then coverage is the big question and the problem. For bone, the standard is you're just going to be thinking K wires. There's very little reason to be considering, you know, in quotes, rigid fixation for these patients. They are going to end up very stiff and need secondary procedures. Here's an example of another injury where the amputation of the index finger and avulsion and dislocation of the middle ring and small finger with all the fingers were obviously relatively devascularized, but the middle finger was worse than the others. One thing I do like to use for this is, intraoperatively, I will get a sterile pulse ox and just place it on the digits, and you'll be surprised what fingers actually have a waveform, even if there is no, you know, you can clearly see the vessels are either non-pulsatile or transected. But the middle finger did not have a waveform, and we decided to try to save it. We thought we were pretty slick and, you know, brought extra soft tissue in to reconstruct some of the defect and did a long graft for the middle finger. And everything looked great. We pat ourselves on the back, and he gets through his hospital stay, and then he shows up and you can see just complete continued demarcation of all that skin we left behind. So resist the temptation to do your coverage after your first operation. You're going to probably be happier if you wait, do a second debridement, and then reconstruct all the tissue that you need. These patients are going to get stiff. They're going to require secondary procedures. Your tendons, you're going to have to do secondary tendon reconstruction once you have a stable soft tissue envelope. So you're really talking, these are salvage cases for the most part. If it's a distal phalangeal injury and there are just a few phalangeal fractures and lacerations and maybe a tip amputation, you can approach that and take care of it pretty quickly. But anything more proximal, you really need to think about where you're trying to get the patient. And you really need to think about the end, not the operation you're seeing right there in the ER or the case you're going to do right there the day they came in, but what you're going to do at the end. And I think Francisco Del Pineal has a great way of sort of thinking about this or organizing the chaos. Think about what you need to get an acceptable hand. And he says three fingers. If you can, that'd be great. Pre-EP motion, good sensibility, and most importantly, a thumb. So in general, you're taking a devastating firework injury. This isn't the same patient, but the patient on the right is a secondary firework injury. But you're trying to take this devastating hand, get to something stable, healed. And then you can go on and just approach this like any hand reconstruction in a delayed fashion. So if we move on from just phalangeal injuries to the first web space. So that is usually when the explosive is held in the palm of the hand. You have an immediate release of energy again. And the energy carries right down through the first web space. You'll get a tear of the tissue, disruption of your neuromusculature. And if you have either of those, I guarantee you, you will have some degree of dislocation of your TM joint. It can be isolated with no fractures, just bad soft tissue. One thing to keep in mind, if you do have that, they might be subtle. But you often will also, if there's no gross dislocation of your second or third metacarpals, you may also have a small fracture. So look out for that. And obviously there can be a combination of this injury with the distal phalangeal injuries. Here's an example of there's a fracture there through the base of the index, which is not readily apparent, but is there on x-ray. And then one thing to point in mind here, you can see the clear avulsive injury to the nerves of the thumb. Here's another example of the first web space and it carrying across all of the metacarpals. So just keep an eye out for that. If you have a laceration in the first web space, your TMG joint is dislocated. You're going to need to pin it. And one thing is to respect the first web space. So again, it's tempting, you debridge some of that tissue, and it's tempting just to pull the thumb back against and suture that wound closed, and you'll be all happy that you got things closed up. Like I made the mistake of doing to this hand where the thumb is well adducted and pinned and his wound is closed, but you're going to end up having to do a first web space reconstruction. So in some ways you're better off, I think, getting the thumb in a good position, coming back in the subacute period, the next three or five days, and do your first web space. At that point it's easier then than it is later. Then finally, there's another subset I would say of not necessarily the first web space but a central injury. It can be more ulnar and you'll have sort of CMC dislocation of the ulnar digits and it will spare the first web space. And that is somewhat easier because you'll have at least a pretty normal thumb. And finally there's the carpal injuries. Again, this is usually a very large higher explosive or a medium explosive in a small hand and it's obviously being grasped centrally and it's usually just a mess. And you can't even recognize sometimes that it is a hand. One thing I think we often love the idea of trying to salvage parts and do complex surgeries to try to restore some of this tissue, but the reality is that sometimes a good amputation is better than trying to do 10 operations to not have a functional hand. So keep that in the back of your mind. A good amputation is not a loss. It's a good surgery for some patients. And in the case of that, one thing I would suggest is that consider a targeted muscle re-innervation for your nerves. You can do it at the time of your final amputation. Usually you can find nerves right in the stump and then for the ulnar nerve I just go up to the elbow and do it right to one of the SCU branches. But in my experience it helps significantly, at least anecdotally, with their post-operative recovery and moving on to function. One thing to consider in these cases also is Jim Higgins talks about ectopic banking. So again, we're not thinking about doing these replantations or revascularizations of the digits in place because the zone of injury is too great and you're often going to end up failing in the first day. But if you do have some viable parts, you could consider banking them elsewhere where you actually have good vessels to then come back, get your stable soft tissue, and then use those parts later for your reconstruction. So a quick summary. Fireworks. Think of the blast. Don't think of the flame. Don't think of the sparks. It's the blast. It will be crush. It will be avulsion. It will be severe fractures with dislocation. K-wires will be your friend. Remember the different types of injuries. I think the big thing to remember is this first web space. If you have a laceration in the first web space, your TMG joint is disrupted and you're going to want to pin it. And then again, I think learn from those who've come before us in dealing with much worse injuries or similar injuries to this and resist the temptation to get too fancy. Thank you. Thank you very much for those excellent talks. As you can tell, all the speakers have a lot of experience in the topics that they discussed today. So we're pretty much out of time, but we're going to go just a little over and feel free to leave. But I thought maybe having some cases or questions, if you have any, please feel free to come up and ask while we wait for that. So a question that I have, especially for these ballistic and these blast injuries where the zone of injury is undefined and you have a hand that is dysvascular, what is your decision making tree for when to take the patient back for exploration, for possible vein grafting versus just observation? Because I think those cases occur relatively commonly where a blast or a ballistic injury comes in and the hand is hypoperfused. It's dysvascular, but there's still maybe some cap refill. So should we take the patient back or should we admit the patient, bear hugger, elevation? How do you approach it? I mean, I really like the pull socks. It gives you a very objective, oftentimes the people are in trauma, they're in vasospasm, you can't actually get an audible signal with a handheld Doppler, but if you do a pull socks, you can still see a little bit of a waveform. And if there's a little bit of a waveform in a situation like a firework injury where I don't think that I'm going to have an adequate inflow or a distal target and or coverage of that graft, then I just watch it and you'd be amazed at how many of those fingers end up surviving. Yeah, I was going to say exactly the same thing. If the pull socks is good, I tend not to chase them and it's amazing with a pull socks and a hand that looks perfused, but you just can't get a signal, I usually watch. It's a tough call and I think one of the other things that is helpful is knowing where the wound is, because sometimes you'll see a wound and you're like, this doesn't make sense that it's vascular, why? And it's often spasm, in the GSWs it's often spasm. The thing to remember is very difficult to revascularize electrical burns, so you cannot do a vein graft distally also will be sloughed out. So the only thing to remember is if the radial artery is flowing, then quickly take the ulnar artery and do off a flap, so you will preserve the radial from getting exposed and so most of them on arrival are viable, but over a period of 2-3 debridements or waiting for it to slough out, they will either blow out or they will dry off. So before that happens, if you step in and do a ALT flap, so ALT is the best easiest flap to do to the artery which is already thrombosed higher up, so that way you preserve the existing vascular. You prevent it from drying off and you're preventing that. Sorry, you go end to side? No, ulnar artery is anyway gone, so the other artery, whichever is looking better, you preserve it and do to the other artery. I see, I see. Feel free to come up if you have any questions. I think another challenging problem, Jason, like you had mentioned, were the peripheral nerve injuries and knowing when to explore, like you mentioned, a large percentage of these patients are neuropractic injuries, which is great, which is very reassuring, but that means that there's not an insignificant percentage of these which are not, which should not be just watched. So this is just one case, a gentleman that comes in 10 months after the injury and as you can see, he's got multiple, he survived, thankfully, and his exam, if this plays, which it doesn't, but what it shows is that on the right side, he has median and ulnar sensory issues and he has ulnar motor that's out, and on the left, he has median motor that's out, that's 10 months out from the injury. So what would your approach to this be now with this patient? Imaging shows, we, ultrasound and MR neurogram show that the nerves are in continuity. I never chase the sensory, ever. For the motors, you know, it's a tough conversation with the patients because, especially when they're in continuity, I have seen, especially in the GSWs, that, like, oh, to 18 months, I had one whole slew of patients, I think it was like 10 or 15 in a row, who had radial nerves right at the mid-shaft humerus from a GSW and almost all of them had recovery between 10 and 18 months. Same things, all the workup's pretty much normal and you just sort of sit there and you watch the EMG and hope something changes, and the weird thing, at least it seems as the weird thing about GSWs is they click on one day. It's not easy to tell someone at 10 months, let's wait, and so that's a big... It also depends on the patient population. So Where where I work Follow up in therapy is a problem For various reasons and so Having that sort of heart-to-heart about their options surgically is like hey, are we gonna follow through? Are we if we're gonna follow through what's the easiest options and at 10 months? You're kind of losing nerve transfer as a viable option for them In tendon transfers just I've struggled you've worked for where where I work. It's very very difficult to have success and it's just It's tough, long conversation, that's what I would say. We have done a few, for median alone you can take the dorsal cutaneous nerve of ulnar to just provide sensation. Or if the radial is intact, use the radial for the molar side. For 10 months we will not go and do graft for the proximal side. We just do whatever is still available, just transfer it. And as you said, it's difficult to do transfers in a later stage. So wherever orthodontics is possible, if you use a CMC joint, and the thumb comes in good position, fingers can come in touch. So simpler things, 10 to 12 months, but make them function. Finger has to touch the thumb, that's it. All right, I'll just say one more case. Oh, this is an algorithm that I found useful, is to identify when to explore and when not to explore. And so Jason, I'd love for you to comment on this. But how I oftentimes, like you said, the high energy versus low energy, large zone of injury versus small zone of injury. If it's a suspected low, small zone of injury, your assumption is that it's a neuropraxia. You monitor it. And then for me at least, by three months, if it hasn't recovered, then I think you should refer it to a peripheral nerve surgeon, which all of us are. This was for orthopedic traumatologists. And at that time, I think the three-month mark, for me at least, if it's a low energy and you're suspecting it's a neuropractic injury, then you have to figure out, okay, is it truly a neuropractic injury or is it not? Very different from a high energy injury. Do you want to comment on that algorithm? Yeah. So in our institution, I ask all of our trainees. Again, it's not generalizable to everywhere, but certainly where I work, the earlier you can plug in with the patient, the more likely you are to see them follow up. So I don't love the waiting for three months, but I can see in a system where the system can capture patients a little easier, three months is a very reasonable timeframe, because hopefully you'll see something on the EMG at that three-month mark that is encouraging. I think one of the challenging parts is the small versus large area. I have yet to say I understand when someone gets shot that it's small versus medium versus large, because some of these injuries, the one wound's proximal forearm and the quote-unquote exit wound, or whatever you want to call it, is dorsal wrist, and you kind of say, that went through a lot of tissue. Yes. Yeah. But I like this. I mean, I think this is a reasonable algorithm because the vast majority, like I said, will come back. And by three months, the EMG's showing you something. I think we're over now. What is it, 10 after or so? So I don't want to keep people too much longer. Any questions from anyone? No, feel free to come up if you have any other questions. But thank you very much for joining us. Thank you.

hand injuries

urban mangled hands

electrocution

ballistic injuries

fireworks injuries

debridement

zone of injury

fracture management

soft tissue management

nerve injuries