Файловый архив студентов. Файловый архив студентов.
1327 вузов, 5482 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:

Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 391 - файл

.pdf
Скачиваний:
0
Добавлен:
29.08.2026
Размер:
45 Мб
Скачать
☆
412
https://t.me/medicina_free
A. Landi et al.
Group II was also divided into group IIA where CS occurs in muscle groups only for local causes ranging from hypothetical intrauterine compression to group IIB where this condition is associated with systemic aggravating factors that can be differentiated into maternal or foetal fac­tors (Table32.2). Finally, we introduced a group III where CS are multiple and are associated with systemic diseases [32, 33] completely different from those of the adult (Tables 32.1 and 32.2). In the different parallelism between children and adults, the clinical symptomatology should also be understood: if the adult still maintains the value of the ve Ps, the symptoms in the paediat­ric group are often inductive and are represented by the three As (anxiety, greater demand for anal­gesics, etc.). Volkmann’s syndrome has a specic clinical connotation in the perinatal period due to the almost constant association of the sentinel skin lesion overlying the affected muscle compartments.
The surgical treatment must be performed promptly and consists of a fasciotomy in the rst few hours after birth.
The subsequent stages of treatment require an early repair of the skin defect. After healing, the main nerves of the forearm should be supercial­ized. Subsequent reconstructive procedures should be postponed to the pre-school period in cases of intermediate severity and in Volkmann’s syndrome of the postero-lateral compartment, through scarring excision and the use of pallia­tive surgery. In the presence of irreversible dam­age in both compartments, there is no choice but to resort to free muscle transplantation. Nevertheless, a lesion as complex as Volkmann’s syndrome often requires interventions that have to be planned at a later age.
The natural history of the disease is objec­tively unfavourable, but young patients know how to use unimaginable coping strategies. The evaluation of the long-term surgical results must be made using both objective and subjective assessment tools to verify whether the overall medical case has ultimately positively inuenced the social integration of the young patient and his life in its wholeness [70].
In newborns presenting with forearm skin lesions, prompt, accurate diagnosis is imperative as a subgroup of them can undergo emergent fas­ciotomy with resultant normal or almost normal hand function. In less involved patients, timing and type of surgical intervention varies widely but is important to optimize the ultimate function of the upper extremity.
Acknowledgements Dr. Della Rosa for the documenta­tion concerning the case of amniotic band treated in the rst hours after birth.
Dr. Grazia Salimbeni for the collaboration on the sur­gical treatment and on the follow-up of the patience described in Fig.32.3.
Terri Beckwith, MPH, CCRP, Clinical Research Manager-Hand and Hip Divisions and Scottish Rite Hospital for Children for revising the manuscript.
References
1. Matsen FA, Veith RG. Compartmental syndromes in children. J Pediatr Orthop. 1981;1:33–41.
2. Lightwood R. Radial nerve palsy associated with localized subcutaneous fat necrosis in the newborn. Arch Dis Child. 1951;26(129):436–7.
3. Hayman M, Roland EH, Hill A.Newborn radial nerve palsy: Report of four cases and review of published reports. Pediatr Neurol. 1999;21(3):648–51.
4. Romana MC, Barthelemy R, Goubier JN. Ischemia neonatale degli arti superiori. In: Landi A, Bernasconi S, editors. L’arto superiore nell’ambito della patologia perinatale. Fidenza: Mattioli; 2003. p.72–6.
5. O’Donnel CJ, Beck DH, Taylor BL, Smith GB.Upper limb compartment syndromes: a complication of malignant hyperthermia in a patient with ill-dened myopathy. Br J Anesth. 1995;74:343–4.
6. Mokoena T, Hadley GP. Surgical management of multiple limb gangrene following dehydration in chil­dren. S Afr Med J. 1991;80:185–8.
7. Hosseinzadeh P, Hayes CB. Compartment syndrome in children. Orthop Clin N Am. 2016;47(3):579–87.
8. Ragland R, Moukoko D, Ezaki M, Carter PR, Mills J. Forearm compartment syndrome in the newborn: report of 24 cases. J Hand Surg. 2005;30(5):997–1003.
9. Rombouts JJ, Debauche C, Verellen G, Lyon G.Paralysies congenitales par compression. Ann Chir Main. 1993;12(1):39–44.
10. Caouette-Laberge L, Bortoluzzi P, Egeszegi EP, Marton D.Neonatal Volkmann’s ischemic contracture of the forearm: a report of ve cases. Plast Reconstr Surg. 1992;90:621–8.
11. Chuang DCC, Carver N, Wei FC. A new strategy to prevent the sequelae of severe Volkmann’s ischemia. Plast Reconstr Surg. 1996;98:1023–31.
32 Compartment Syndromes (CS) and Volkmann’s and Upper Limb Vascular Pathology in the Peri…
https://t.me/medicina_free
413
12. Landi A, Schoenhuber R, Funicello R, Rasio G, Esposito M.Compartment syndrome of the scapula. Ann Hand Surg. 1992;11(5):383–8.
13. Zuker RM, Egerszegi EP, Manktelow RT, McLeod A, Candlish S. Volkmann’s ischemic contracture in children: the results of free vascularized muscle trans­plantation. Microsurgery. 1991;12:341.
14. Zuker RM, Bezuhly M, Manktelow RT.Selective fas­cicular coaptation of free functioning gracilis trans­fer for restoration of independent thumb and nger exion following Volkmann ischemic Contracture. J Reconstr Microsurg. 2011;27:439–44.
15. Esposito M, Busa R, Landi A.Sindromi compartimen­tali: acute, croniche, atipiche. In: Landi A, Catalano F, Luchetti R, editors. Trattato di chirurgia della mano. Roma: Verduci; 2007. p.319–36.
16. Landi A, Caserta G, Saracino A, Esposito M.Atypical compartment syndromes of the upper limb. In: Copeland SA, Gschwend N, Landi A, Saffar P, edi­tors. Joint stiffness of the upper limb. London: Martin Dunitz; 1997. p.335–79.
17. Landi A, Romana C, Abate M. Sindromi comparti­mentali (S.C.), di Volkmann e patologia vascolare dell’arto superiore nel periodo perinatale. In: Landi A, Catalano F, Luchetti R, editors. Trattato di chirurgia della mano. Roma: Verduci; 2007. p.937–48.
18. Bae DS, Kadiyala RK, Waters PM. Acute compart­ment syndrome in children: contemporary diagnosis, treatment, and outcome. J Ped Orthop. 2001;21:680–8.
19. Pereira N, Valenzuela D, Mangelsdorff G, Kufeke M, Roa R. Detection of perforators for free ap planning using smartphone thermal imaging: a con­cordance study with computed tomographic angi­ography in 120 perforators. Plast Reconstr Surg. 2018;141:787–92.
20. Hardwicke JT, Osmani O, Skillman JM.Detection of perforators using smartphone thermal imaging. Plast Reconstr Surg. 2016;137:39–41.
21. Stevanovic MV, Sharpe F. Compartment syndrome and Volkmann ischemic contracture. In: Wolfe S, Pederson W, Kozin SH, Cohen M, editors. Green’s operative hand surgery. Elsevier: Amsterdam; 2017. p.1763–87.
22. Volkmann R. Die ischaemic muskellahmungen und kontrakturen. Zbl Chir. 1881;8:801–3.
23. Mubarak SJ, Hargens AR. Compartment syndromes and Volkmann’s contracture. London: WB Saunders;
1981.
24. Mubarak SJ, Carrol NC. Volkmann’s contracture in children: aetiology and prevention. J Bone Joint Surg. 1979;61:285–93.
25. Comolli A.Uber ein deutliches Zeichen bei geswissen schulterbruchen. Zbl Chir. 1932;15:937–40.
26. Knappe DM, Truumes E.Posterior arm and deltoid compartment syndrome after vitamin B12 injection. Orthopedics. 2004;27(5):520–1.
27. Gulgonen A. Invited review article: surgery for Volkmann’s ischaemic contracture. J Hand Surg. 2001;26B:283–96.
28. Grottkau BE, Epps HR, Di Scala C. Compartment syndrome in children and adolescents. J Pediatr Surg. 2004;40:678–82.
29. Romana MC, Bartelemy R, Goubier JN. Ischemia neonatale degli arti superiori. Soc Ital Chirur Mano. 2003;5:73–6.
30. Moazzam A, Riaz M, Brennen MD.Neonatal gan­grene in an extremity of an infant of a diabetic mother. Int J Obs Gynaecol. 2003;110:74–6.
31. Gilbert A. Sindrome da costrizione da bre amni­otiche. In: Landi A, Bernasconi S, editors. L’arto superiore nell’ambito della patologia perinatale. Fidenza: Mattioli; 2003. p.72–6.
32. Bozzini MA, Milani GP, Bianchetti MG, Fossali EF, Lava SAG. Idiopathic systemic capillary leak syn­drome (Clarkson syndrome) in childhood: systemic literature review. Eur J Pediatr. 2018;177(8):1149–54.
33. Varon J, Chen K, Sternbach GL. Rupert Waterhouse and Carl Friderichsen: adrenal apoplexy. J Emerg Med. 1998;16:643–7.
34. Miedema A, Stubenitsky BM, Jansen NJ, van der Molen AB, van Vught AJ. Improving outcome in meningococcal disease: don’t forget compartment syndrome! Pediatr Crit Care Med. 2008;9(3):e20–2.
35. Dakourè PWH, Beogo R, Barro D, Somè DA, Cessouma R, Kambou T.Ischemie in utero du mem­bre superior et de l’hèmiface droits: à propos d’une observation. Chir Main. 2010;29:121–4.
36. Martin B, Treharne L. Neonatal compartment syn­drome. Ann R Coll Surg Engl. 2016;98:e111–3.
37. Burke T, Kehl D. Intraosseus infusion in infants. J Bone Joint Surg. 1993;75A:428–9.
38. D’addato M, Testi M, Ferri M, Gentili A, Freyrie A, Baroncini S. Le lesioni vascolari perinatali dell’arto superiore. Soc Ital Chir Mano. 2003;5:98–104.
39. Habenicht R, Hülsemann W, Lohmeyer JA, Mann M. Ten-year experience with one-step correction of constriction rings by complete circular resection and linear circumferential skin closure. J Plast Reconstr Aesthet Surg. 2013;66(8):1117–22.
40. Engel J, Heim M, Tsur H.Late complications of neo­natal Volkmann’s ischemia. Hand. 1982;14:162–3.
41. Carr MM, etal. Extremity gangrene in utero. J Hand Surg. 1996;21(5):652–5.
42. Isshiki H, et al. Ischemic contracture in an infant’s forearm-a case report. J Hand Surg. 2004;29(5):510–3.
43. Cham PMH, et al. Congenital Volkmann ischaemic contracture: a case report and review. Br J Dermatol. 2004;150:357–63.
44. Taylor GI, Palmer JH.The vascular territories (angio­somes) of the body: experimental study and clinical applications. Br J Plast Surg. 1995;34:81–3.
45. Rowland AR. The treatment of compartment syn­drome. In: Green DP, Hotchkiss RN, Pederson WC, editors. Green’s operative hand surgery, vol.
1. Philadelphia: Churchill Livingstone; 1998. p.689–710.
46. Esposito M, Caserta G, Saracino A, etal. La misura­zione della pressione compartimentale nella sindrome
414
https://t.me/medicina_free
A. Landi et al.
compartimentale acuta. In: Le sindromi comparti­mentali della gamba e del piede, vol. 5. Bologna: Aulo Gaggi; 1996. p.55–62.
47. Guyton AC.A concept of interstitial negative pressure based on pressures in implanted perforated capsules. Circ Res. 1963;12:339–414.
48. Landi A, De Santis G, Torricelli P, Colombo A, Bedeschi P.CT in established Volkmann’s contracture in forearm muscles. J Hand Surg. 1989;14B:49–52.
49. Tominaga A, Shimada K, Temporin K, Noguchi R. Post-exertional MRI is useful as a tool for diag­nosis and treatment evaluation for chronic exertional compartment syndrome of forearms. J Hand Surg Asian Pac. 2019;24(3):311–6.
50. Ko WS, Chiu T. Detection of perforators using smartphone thermal imaging. Plast Reconstr Surg. 2016;138(2):380.
51. Tattersal GJ. Infrared thermography: a non-invasive window into thermal physiology. Comp Biochem Physiol. 2016;2016:1–21.
52. Innocenti M, Ceruso M, Angeloni R, Lauri G, Nigi M, Beltrami G, Bufalini C. Reinnervated free gracilis muscle transplantation in the treatment of Volkmann’s syndrome of the forearm. Chir Organi Mov. 1996;81:287–93.
53. Strange FGSC.An operation for nerve pedicle graft­ing. Br J Surg. 1947;34(136):423–5.
54. Greenberg BM, Cuadros CL, Panda M, May JW. St. Claire strange procedure indications, tech­nique, and long-term evaluation. J Hand Surg. 1988;13(6):928–35.
55. Friedman J, et al. Treatment of acute neonatal vas­cular injuries. The utility of multiple interventions. J Pediatr Surg. 1999;34(6):940–5.
56. Nazer H, Abu Rajab A, Qaryouti S, Tarawneh M, Hamzeh Y, Arda H, et al. Neonatal limb gan­grene and renal vein thrombosis. Eur J Pediatr. 1987;146:429–31.
57. Oppenheimer EH, Esterly JR. Thrombosis in the newborn: comparison between infants of diabetic and nondiabetic mothers. J Pediatr. 1965;67(4):549–56.
58. Vallerame E, etal. Peripheral gangrene in a newborn infant associated with renal and adrenal vein throm­bosis. J Pediatr. 1972;80:101–3.
59. Marcelletti CF, et al. La patologia cardiovascolare. Soc Ital Chir Mano. 2003;5:45–50.
60. Duteille F, Costargent A, Perrot P, Pannier M.False aneurism of a brachial artery in a very premature new­born. J Reconstr Microsurg. 2008;24:147–50.
61. Dhar A, Bagga D, Taneja SB. Extremity gangrene following intramuscular injection. Indian Pediatr. 1988;25(12):1209–11.
62. Choi PD, Melikian R, Skaggs DL. Risk factors for vascular repair and compartment syndrome in the pulseless supracondylar humerus fracture in children. J Pediatr Orthop. 2010;30(1):50–6.
63. Tsur H, Yaffe B, Engel Y.Impending Volkmann’s con­tracture in a newborn. Ann Plast Surg. 1980;5:317–20.
64. Eichler GR, Lipscomb PR. The changing treatment of Volkmann’s ischemic contractures from 1955 to 1965 at the Mayo Clinic. Clin Orthop Relat Res. 1967;50:215–23.
65. Feldman GV.Radial nerve palsy in the newborn. Arch Dis Child. 1957;32(165):469–71.
66. Zeb A, Darmstadt GL. Sclerema neonatorum: a review of nomenclature, clinical presentation, histo­logical features, differential diagnoses and manage­ment. J Perinatol. 2008;28(7):453–60.
67. Xiong G, Sun Y, Wang S.Congenital exion defor­mity of the long, ring, and little ngers with an aber­rant origin of the exor digitorum profundus: case report. J Hand Surg Am. 2008;33(8):1358–61.
68. Quintero RA, Morales WJ, Phillips J, et al. In utero lysis of amniotic bands. Ultrasound Obstet. 1997;10:316–20.
69. Dogru S, Acar A. Fetoscopic surgery for amni­otic band syndrome: case series. Congenit Anom. 2023;63(1):4–8.
70. Chaudhry S. Upper extremity care for children: unique medical and psychosocial aspects. J Hand Surg Am. 2019;44(7):606–9.
Postoperative Dressings and Care
https://t.me/medicina_free
EllenKroin andTerryR.Light
33
Abstract
The postoperative management following pediatric hand surgery depends upon a secure dressing that provides immobilization, protec­tion, compression, and absorption of wound uids. The dressing should be simple to remove and should minimize the child’s pain and anxiety in the removal process. We pres­ent the author’s approach to applying and managing pediatric postoperative dressings. Several additional strategies which may also consistently achieve these goal are presented.
Keywords
Pediatric dressing · Postoperative care
33.1 Introduction
David Green’s Basic Principles introductory chapter in his eponymous text states: “In no other eld of surgery does the post-operative manage­ment of the patient play so critical role as it does in hand surgery” [1]. This is particularly true in the young child. The ideal pediatric dressing
E. Kroin (*) Northwestern Medical Group, Lake Forest, IL, USA
T. R. Light Department Orthopaedic Surgery, Loyola Stritch School of Medicine, Maywood, IL, USA e-mail: tlight@lumc.edu
should be exible enough to protect and immobi­lize the small squirming hand. By compressing the hand, edema is reduced and hemostasis is facilitated. The dressing should absorb any bleed­ing and should facilitate adsorption of medica­tions applied to the wound. The appearance should also be attractive to families.
The pediatric hand dressing is an essential ele­ment of postoperative care. The dressing must protect soft tissue reconstruction, tendon trans­fers, and pin xation, and it must limit motion of skin grafts. In other children, tendon repairs or tendon transfers are protected by the immobiliza­tion with the postoperative dressing. It is impera­tive that the pediatric hand dressing be reliably maintained during the postoperative period [2]. As Kleinman and Bowers observed, “Young chil­dren have an enormous predisposition to either destroy or wiggle out of their immobilization. In the absence of internal xation, standard casting techniques used in adults are often ineffective in children” [3]. Because the dressing is by design conning, children may persist in their attempts to wiggle out of splints, casts, or other forms of immobilization. The goal is to create a dressing that stays in place, in spite of the best efforts of our young patients.
Several elements contribute to the effective­ness of the hand dressing. The dressing must pro­tect the surgical wound during initial healing. To provide stable immobilization, the dressing may incorporate a plaster splint or be surrounded by a cast. The portion of the dressing that is in direct
© Springer Nature Switzerland AG 2023 G. Pajardi (ed.), Pediatric Hand Surgery, https://doi.org/10.1007/978-3-031-30984-7_33
415
416
https://t.me/medicina_free
E. Kroin and T. R. Light
contact with the wound will act to absorb postop­erative uid drainage. When medication such as bacitracin or silvadene is applied directly to the wound, the dressing facilitates their adsorption. A conforming compressive dressing provides uniform pressure on the hand to minimize capil­lary oozing and thus provide hemostasis.
The appearance of the dressing is important, since it is the rst visible evidence of the surgery seen by the patient and family. It should appear neat, without blood or other uid staining.
Repeated uncomfortable dressing changes are unnecessary if the initial dressing is carefully and thoughtfully applied to the child’s hand. We nd it unnecessary to change the pediatric dressing during the rst week following surgery and yet recognize that parents are anxious to see the operated part as soon as possible. Repeated dress­ing changes are uncomfortable and may be dis­tressing for the child, as well as for the parents and surgeon. Developing a comfortable dressing routine can minimize the stress experienced by the child. In addition, developing rapport with the child while removing the dressing can help ease the distress to the child. It is essential that the par­ents understand the importance of the dressing and its role in postoperative care [4]. If the dress­ing is applied and maintained properly, it can be left in place for several weeks.
the dressing on a fully anesthetized child is a worthwhile investment of time to maximize the result of the just completed surgical procedure. The inner dressing is held in place by a Kling wrap secured about the ipsilateral wrist; the sec­ond element is a plaster splint crossing the exed ipsilateral elbow, while the outer layer is a Velpeau sleeve secured to the contralateral shoul­der and axilla.
The rst or inner dressing includes Xeroform and 4 × 4 sterile mesh gauze in sufcient quantity to create even compression as a Kling bandage is wrapped around the hand. The Kling is wrapped circumferentially around the gauze pads and around the wrist in order to secure the dressing to the hand (Fig.33.1). After syndactyly release, we place saline-soaked cotton balls over the skin
33.2 Authors’ Preferred Method
Our technique of applying the postoperative dressing has proven adaptable and durable in young children. We build the dressing to include three independent components, each layer will separately resist the young child’s efforts to remove the dressing. The dressing is best placed while the child is asleep. Communication with the anesthesiologist is essential to keep the child soundly asleep while the nal elements of the dressing are being secured behind the child’s neck. If the child starts to awaken while one is applying the dressing, it is best to ask that the child be reanesthetized so that a secure dressing may be placed. A hastily applied dressing may be easily dislodged. The time spent properly placing
Fig. 33.1 The hand is wrapped circumferentially with Kling around the gauze pads and the wrist securing the dressing to the hand
33 Postoperative Dressings andCare
https://t.me/medicina_free
grafts to compress the grafts and to hold the n­gers apart. Oozing of uids from the incisions and grafted sites will cause the dressing to adhere to the wound. Two weeks after syndactyly sur­gery, the ngers are soaked in saline freeing the cotton balls from the healing ngers. Any resid­ual open area is covered with a simple Band-Aid.
The second component, a sugar-tong plaster splint, is extended to cover the operative site and any protruding pins. The splint extends above the elbow and positions the elbow in exion (Fig.33.2). We apply the splint while the child is under anesthesia to assure proper elbow position­ing. The plaster splint wraps around the elbow in a sugar-tong fashion while also covering the wrist and hand. It is important to ensure that the plaster splint sits anterior to the axis of the elbow. The extremity is maintained with the wrist in neutral position, the forearm in mid-rotation, and the elbow at 100° of exion. A bias-cut stockinette is wrapped circumferentially around the plaster and secured with tape. Additional tape reinforces the exed position of the elbow (Fig.33.3).
The third component of the pediatric postop­erative dressing is the Velpeau stockinette sling depicted in Fig.33.4a–c. This sleeve secures the hand, forearm, and arm close to the body with the hand elevated. The sleeve is created from a length of 3- or 4-inch-wide stockinette cut to approxi­mately one and a half times the height of the child. The sling has three components: the sleeve, the back, and the ties (Fig. 33.4a). The hand
Fig. 33.2 Cast padding is applied extending the dressing above the elbow and positioning the elbow in greater than 90° of exion prior to applying the plaster sugar-tong splint
417
Fig. 33.3 A bias-cut stockinette is wrapped circumferen­tially around the plaster component. This is secured down with cloth tape crossing the exed elbow
dressing is slipped into the cut stockinette sleeve. The stockinette is then passed behind the back and neck from the ipsilateral axilla to the contra­lateral axilla (Fig. 33.4b). One of two ties is passed up through the contralateral axilla while the other tie is passed over the shoulder. The two ties are secured to one another with a knot tied over the contralateral shoulder (Fig.33.4c). The dressing is then secured through to the contralat­eral shoulder. A hole in the stockinette adjacent to the hand allows the two ties to be tied together with a bow (Figs. 33.4d and 33.5). The knot should not be disturbed. The family is instructed that they may temporarily untie the bow to change the child’s clothes or to provide a sponge bath.
The Velpeau stockinette and plaster splint are usually removed one or two weeks postopera­tively. For the dressing changes, young children
418
a
bc
https://t.me/medicina_free
E. Kroin and T. R. Light
d
Fig. 33.4 (a) A 3- or 4-inch-wide stockinette is cut to approximately to one and a half times the height of the child. The three components of the sling are the arm sleeve, the back portion, which is the width of the chest wall, and the two straps used to tie the knot and bow. (b) The dressed hand is slipped into the cut stockinette arm sleeve. The stockinette back portion is passed behind the back and neck from the ipsilateral axilla to the contralat­eral axilla. (c) One of two ties is passed up and around the
contralateral axilla while the other tie is passed over the shoulder. The two ties are secured to one another with a knot tied over the top of the contralateral shoulder. This creates straps of unequal length. (d) The operative hand is secured to the contralateral shoulder by tying a bow through the hole in the stockinette adjacent to the hand. The longer strap is passed from behind to the front of the hole where it is then tied to the shorter strap with a bow
33 Postoperative Dressings andCare
https://t.me/medicina_free
Fig. 33.5 The Velpeau stockinette sling is slipped on the arm and anchored to the opposite shoulder with a knot and a bow
sit in their seated parents’ lap. The person remov­ing the dressing is also seated to avoid hovering over the apprehensive child. Dressing change is facilitated by sequentially removing each of the three layers. The stockinette is simply divided at both axilla and slid off. The sugar-tong plaster splint is then removed. The inner dressing may be partially removed and a new Kling can be wrapped about the hand and wrist.
Our hand therapist then fabricates a protective thermoplastic splint. We retain the inner dress­ings compressing the skin grafts for two weeks after syndactyly release. In thumb duplication cases, if K-wires are used, the pin is retained in place for 5–6 weeks and protected and immobi­lized during that time. We have the luxury of hav­ing a hand therapist available at each of our outpatient sessions who will make a thermoplas­tic u-shaped splint to protect the underlying dressings and/or pins. The advantages of the ther­moplastic splint over plaster include direct access to the wound, easy reapplication, simple modi­cation, minimal bulk, and greater durability [5]. Removal and reapplication are made easier with the use of Velcro straps. This strategy also avoids the noise and terror involved with berglass cast removal.
We employ a simple soft dressing following trigger thumb release, which is removed in a
419
week. If the child removes it earlier, we advise the family to cover it with a Band-Aid.
The dressing removal is performed in a quiet room in the ofce. The child is held in the par­ent’s arms. No cast saw is necessary. The three segments of the dressing are removed separately.
33.3 Alternative Approaches
There are many effective postoperative dressing strategies. Several American pediatric hand sur­geons were queried about the specics of their dressing protocols for four common procedures. Table33.1 lists hand surgeons’ protocols that are based on procedure type.
The main difference between the protocols is the use of a cast or plaster splint for several weeks for immobilization and protection. Many surgeons use a circumferential cast made of berglass material applied in the operating room. Some immobilize the entire limb in a long arm cast for ve or six weeks. All surgeons queried use a thermoplastic splint constructed by a hand therapist for protection after cast removal.
Dr. Douglas Hutchinson describes his tech­nique with the use of a tape cast (Fig.33.6a–c). This consists of plaster, layered tape, and Coban wrapped over the tape. The plaster is only used on the hand over the surgical areas. This leaves the wrist and elbow exible while the digits are protected. It allows improved ease of use of the arm while caring for the child. The Coban is used as a protective layer and can be replaced by the family if it gets soiled. The child is also usually hesitant to pull tape off their own skin; thus the tape cast is able to stay in place for a full 4–5 weeks. The Coban is then removed and the fam­ily is asked to soak the tape cast in warm water before the child comes into clinic. This loosens the tape and minimizes the discomfort of pulling it off. Overall, this eliminates multiple dressing changes and does not require a loud saw and child’s fear when removing [6].
420
https://t.me/medicina_free
Trigger Thumb—
36 months
• Soft dressing
• Coban wrap
Syndactyly release—18
months
• Soft dressing mitten
• Long arm berglass
• Family
cast
• Remove long arm cast
removes on
day 7 at home
ve days
• Band- Aid for
at three weeks
• Thermoplastic splint
day 7 at home
• Soft dressing
• Coban
space
• Wet cotton balls in web
• Soft dressing
• Long arm cast
• Removed at
• Band- Aid
at one month
• Remove long arm cast
until sutures
dissolve
• Soft dressing
• Coban
mineral oil
• Cotton balls soaked in
• Loose gauze
• Above-elbow tape cast
E. Kroin and T. R. Light
days postop
• Removed 5–7
• Band- Aid
by soaking in bathtub
before clinic
• Removed at 4–5 weeks
• Wet gauze
• Soft dressing
• Bivalved long arm cast
(plaster or berglass
optional)
weeks
• Cast removed at 2.5–3
• Thermoplastic splint
three weeks
• Soft dressing mitten
• Long arm berglass cast
• Remove long arm cast at
• Thermoplastic splint
ve weeks
Thumb duplication—18 months Pollicization—18 months
• Long arm berglass cast
• Remove long arm cast at
• Thermoplastic splint
Materials • Soft dressing mitten
Timing of postoperative
dressing change
• Soft dressing
• Long arm cast
reconstructed
• Long arm cast if ligament
Materials • Soft dressing
month
• Remove long arm cast at one
• Thermoplastic splint
one month
• Remove long arm cast at
Timing of postoperative
dressing change
• Soft dressing
• Small conform
• Small conform
Materials • Soft dressing
soaking in bathtub before
clinic visit
• Above-elbow tape cast
• Above-elbow tape cast if
• Removed at 4–5 weeks by
weeks by soaking in
ligament reconstruction
required
bathtub before clinic
• Remove dressing at 4–5
Timing of postoperative
dressing change
three months
• Thermoplastic splint for
two months if ligament
reconstruction
• Thermoplastic splint for
• Soft dressing
Materials • Wet gauze
• Bivalved long arm cast
(plaster or berglass)
weeks
• Cast removed at 2.5–3
• Thermoplastic splint
Timing of postoperative
dressing change
Dr. Charles Goldfarb—
Washington University St.
Table 33.1 Pediatric hand surgeons’ postoperative dressing and care protocols
Louis
Dr. Ann Van Heest—
University of Minnesota
Dr. Douglas Hutchinson—
University of Utah
Dr. Joseph Upton—Beth
Israel Deaconess Medical
Center
ab
33 Postoperative Dressings andCare
https://t.me/medicina_free
421
c
Fig. 33.6 (a–c) Dr. Hutchinson’s tape cast technique consists of plaster covering the surgical site, layered tape, and Coban wrapped over the tape. The colored Coban is
33.4 Summary
The postoperative management following pediat­ric hand surgery depends upon a secure dressing that provides immobilization, protection, com­pression, and absorption of wound uids. The dressing should be simple to remove and should minimize trauma to the child in the removal pro­cess. Several different strategies may consistently achieve this goal.
References
1. Green DP. General principles. In: Green DP, editor. Operative hand surgery. 3rd ed. NewYork: Churchill Livingstone; 1993. p.15–9.
used as a protective layer and can be replaced by the fam­ily if it gets soiled
2. Cooney WP III, Dobyns JH.Pediatric hand dressing: technical report. J Hand Surg. 2005;13:1009–13.
3. Kleinman WB, Bowers WH. Fractures, ligamentous injuries to the hand. In: Bora FW, editor. The pedi­atric upper extremity: diagnosis and management. Philadelphia: WB Saunders; 1986. p.150–76.
4. Dobyns JH, Wood VE, Bayne LG. Congenital hand deformities. In: Green DP, editor. Operative hand sur­gery. 3rd ed. NewYork: Churchill Livingstone; 1993. p.251–548.
5. Osterhout BM.Postoperative splinting of the pediatric upper extremity. Hand Clin. 1990;6(4):693–5.
6. Hutchinson DT, Frenzen SW. Digital syndactyly release. In: Jupiter J, editor. Techniques in hand and upper extremity surgery. Philadelphia: Lippincott Williams & Wilkins; 2010. p.33–7.
Соседние файлы в папке @xirurgi_2025
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности