Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5233_Библиотеки_им_академика_М_И_Перельмана.pdf
266
Fig. 25.1 Underwater seal
S. Chalasani
Assessment ofChest Drains
When one is called to assess a chest drain these are the features one needs to look
into to understand what could be the underlying pathology.
1. Location—Is this an apical chest drain placed for pneumothorax or a basal chest
drain placed for draining uid (blood/pus, etc.). It is also important to note which
side the chest drain is.
2. Pain—Larger surgical chest drains are often associated with increased amounts
of pain as they press on the intercostal nerves. There is a huge variation in the
analgesia pattern prescribed for these patients but most of them include: regular
paracetamol, regular NSAIDs (PO/PR) along with a PPI, regular long acting opiates (titrated based on their renal function and weight), neuropathic pain killer
(e.g. pregabalin) and prn short acting opiates. Some patients may need more
analgesia and often a paravertebral block with catheter where continuous
25 Clinical Examination ofThoracic Surgery
Fig. 25.2 Stay suture
267
infusion of local anesthetic can be delivered can prove very useful while the
chest drain is in position.
3. Subcutaneous emphysema—If there is crepitus in the skin it often signies that
the chest drain is blocked or there could be an air leak in the pulmonary ventilation. Placing the drain on suction often reduces the emphysema. Rarely upsizing
of the chest drain may be required.
4. Swinging—If the drain does not swing as soon as it is placed it usually needs
attention and is often due to the drain being kinked or misplaced (in the wrong
layer). If the drain does not swing after a few days or gradually then it usually
signies that lung is fully expanded. If the drain has been placed on suction it
could stop the swinging. In this scenario turn off the suction and see if the
drain swings.
5. Bubbling—Bubbling of a chest drain signies air leak. If the patient coughs
once and there are bubbles it usually is not signicant but recurrent bubbling
after few coughs signies air leak. Post robotic thoracic surgery sometime one
could see air leaks for a prolonged periods of more than 24h. In this scenario one
should leave the drain in for an extra day or so for the air leak.
6. Drain level—amount of blood or serous uid or pus. Quantity is recorded over
24h period.
268
Fig. 25.3 The thoracic
wall suction adapter
S. Chalasani
7. Suction—This is important in patients who have had pleurodesis procedure
where we aim to obliterate the space quickly. Post thoracic surgery patients will
often be placed on thoracic suction of 3–5kPa generally. It is very important to
familiarize oneself with the thoracic suction adaptor in your place of work. Wall
suction that is used regularly on the wards is much higher and is different from
the thoracic wall suction parameters. The thoracic wall suction adapter looks like
this (Fig.25.3).
8. CXR—any patient with a chest drain should have a chest x-ray on a daily basis.
Handling ofChest Drains
How to handle chest drains is as important as knowing how to insert them.
• One should familiarize themselves with the location of clamps in case of acci-
dental disconnection. The nurses usually ensure clamps are placed by the
patient’s bedside.
• Under-water drains have to always be placed/held at a level lower than the inser-
tion site.
• Drains should never be clamped unless its ready to be removed or while chang-
ing the underwater seal bottle if its full/damaged.
25 Clinical Examination ofThoracic Surgery
269
• If the chest drain is passed over the patient uid from the bottle can traverse back
into patients cavity. If this needs to be done during transfer etc. then the drain
should be clamped very briey.
• If there is accidental disconnection of chest drain from the underwater seal,
clamp the drain and call for help immediately.
• If the tube falls out of chest cavity or sentinel eye is out then place some Vaseline
soaked dressing and gauze and place pressure over the drain site. If the tube is
half out take it out fully and place pressure (as above) over drain site and call
for help.
When to remove a chest drain
• If the drain output is less than 100ml in 24h.
• If there is minimal swing in 24h.
• There is no bubbling or air leak passively or on coughing.
• CXR conrms re-expansion.
Chapter 26
Peripheral Nerve andHand Examination
HusamHosny
Abstracts The hand is a complex organ composed of skin, subcutaneous tissue,
neurovascular elements and musculoskeletal elements i.e. bones, joints, muscles
and tendons. Those elements work in an integrated manner so that any lesion affecting one of them may have detrimental effects on hand function if left untreated.
Thus assessment of the hand is never complete unless all these elements have been
examined.Nerve lesions of surgical importance include nerve injuries, compression
and tumours. Both sensory and motor functions should be evaluated. moreover,
special and provocative tests are important for accurate diagnosis and follow up.
Keywords Hand · Nerves · Examination · Tests · Function · Deformity ·
Contracture · Injury
Introduction
The hand is a complex organ composed of skin, subcutaneous tissue, neurovascular
elements and musculoskeletal elements i.e. bones, joints, muscles and tendons.
Those elements work in an integrated manner so that any lesion affecting one of
them may have detrimental effects on hand function if left untreated. Thus assessment of the hand is never complete unless all these elements have been examined.
Nerve pathologies of surgical importance include nerve injury, compression
and tumors.
Nerve injury due to trauma is seldom isolated and commonly associated with
other injuries e.g. bony fractures, tendon injuries, vascular injuries and muscle tear.
Moreover, multiple nerves may be injured e.g. median and ulnar nerve injuries by
wounds near the wrist. Thus examination of all these structures is essential in every
H. Hosny (*)
Cairo University, Cairo, Egypt
e-mail: husamhosny@kasralainy.edu.eg
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_26
271© The Author(s), under exclusive license to Springer Nature
272
H. Hosny
case of suspected nerve injury similar to examination of all abdominal organs and
viscera in cases of abdominal trauma or disease.
Compression can affect multiple sites along the affected nerve coarse, thus
examination of all sites of possible entrapment is paramount. Moreover, nerve compression at particular site decreases the threshold along other sites of compression
of the same nerve due to changes in the interior environment of circulating substances and neurotransmitters within the affected nerve giving rise to additional
symptoms of proximal compression in cases of distal compression and vice versa.
In cases of nerve compression, motor affection is a late sign, while sensory
abnormalities start early even before electro-physiologic changes are detected, thus
sensory examination and provocative tests are needed to early diagnose these cases
before irreversible histo-pathologic changes occur.
Sensory receptors include slowly adapting receptors; concerned with static touch
and quickly adapting receptors; concerned with moving touch. Clinical evaluation
of sensory receptors includes assessment of sensory threshold (minimum stimulus
needed to elicit a response) and innervation density (number of innervated receptors).
The aim of history and physical examination is to identify the level of the lesion,
documentation of improvement or decline in motor and sensory functions and determination of treatment options.
History
Personal history: As usual with special emphasis on occupation and hand
dominance.
Complaint:
• Altered sensation: complete loss of sensation (anesthesia) or abnormal sensation
e.g. tingling, pricking, compression (paresthesia).
• Inability to perform a previous movement/ function.
• Deformity.
Present history: (How?—When?—Sequelae?)
• Spontaneous (nerve compression) or related to trauma (cut/lacerated wounds,
crush injuries, fractures).
• Time of injury is crucial as denervated muscles for more than 12months will
pass into an irreversible degeneration and regain of function is unlikely even
after nerve repair. This fact will determine the treatment options whether nerve
repair or other options as proximal nerve transfer or tendon transfer may
be needed.
• Effect of the pathology on patient’s quality of life and psychological state.
Patients may lose their job or change their career and psychological instability
may occur.
26 Peripheral Nerve andHand Examination
273
Past history:
• Previous trauma or surgical intervention within the affected limb and its outcome.
• Exposure to neurotoxic substances e.g. lead or arsenic metals.
• Any chronic disease especially diabetes and leprosy, or comorbidities.
Examination
(See, feel& move).
• Ι -Inspection (see)
(scars- swelling- wasting- deformity-trophic changes)
Posture: the patient is examined while sitting in front of the examiner resting his/
her forearm and hand on a table or pillow. Both hands, forearms, arms, shoulders
and neck should be exposed to compare both sides.
Start in a systematic way, from distal to proximal i.e. dorsum of ngers, hands,
wrist, forearm, elbow and arm then ask the patient to turn his hands to inspect volar
aspect of the whole limb and nally the neck.
1. Scars/wounds especially those over the course of the nerve or at sites of surgical
decompression should be reported including its length, width, direction, and type
of healing.
2. Swelling over the course of a nerve may arise from the nerve itself (neuroma or
nerve tumor) or others compressing the nerve.
3. Wasting (compare both sides) at the areas of muscles supplied by the affected
nerve will develop due to muscle atrophy in long standing cases. For instance,
wasting of the medial aspect of the hand, 1st web space and guttering of hand
dorsum occur due to atrophy of Hypothenar muscles, adductor pollicus and
interossei muscles in cases of ulnar nerve injury (Fig. 26.1). In higher level ulnar
Fig. 26.1 Wasting of 1st
web space, guttering at the
hand dorsum and wasting
at medial side of the right
hand in ulnar nerve injury
274
H. Hosny
nerve injury, wasting of the medial aspect of the forearm will occur due to atro-
phy of exor carpi ulnaris.
Wasting of thenar area occurs in median nerve injury.
4. Deformity: the deformity is usually characteristic and reveals underlying
nerve injury.
Wrist drop and nger drop (due to paralysis of wrist and ngers extensors) occur
in radial nerve injury (Fig. 26.2).
Finger drop alone occurs in posterior interossei nerve injury.
Partial claw hand (extension at 4th & 5th MP joints and exion of interphalan-
geal joints of little and ring ngers) occur in distal ulnar nerve injury due to
paralysis of interossei and medial two lumbricals muscles while nger exors
(FDS & FDP) and extensors action are unopposed (Fig. 26.3)
Fig. 26.2 Inability to
extend the wrist “wrist
drop” in case of radial
nerve injury
Fig. 26.3 “Partial claw
hand” extension of 4th and
5th metacarpo-phalangeal
joints while the
interphalangeal joints are
exed in ulnar nerve injury
ab
26 Peripheral Nerve andHand Examination
275
N.B. Ulnar paradox describes less deformity in cases of higher level ulnar nerve
injury as paralysis of exor carpi ulnaris (FCU) and exor digitorum profundus
(FDP) to the little and ring ngers results in less exion deformity at interphalan-
geal joints.
Complete claw hand affecting all medial 4 ngers occurs in T1 lesions or com-
bined ulnar and median nerves injury (Figure ).
Ape hand deformity (at hand at thenar eminence) occurs in median nerve injury
due to atrophy of thenar muscles and loss of opposition.
Policeman tip deformity (shoulder adducted& internally rotated and elbow
extended and pronated) occurs in upper brachial plexus injury due to paralysis of
abductors and lateral rotators of the shoulder (deltoid, supra and infraspinatus
muscles), and paralysis of elbow exors and supinators (biceps, brachialis, bra-
chioradialis and supinator muscles) (Fig. 26.4).
Any other deformity due to fractures malunion or soft tissue contractures e.g.
Duputryn’s contracture(Fig. 26.5) or post burn deformities should be recorded.
5. Trophic changes at the tips and nails of affected ngers may be present due to
frequent trauma or burns that pass unnoticed.
II-Palpation: (feel)
• Assess hand vascularity by feeling both radial and ulnar arteries at the wrist.
• Capillary pulsation or/rell at each nger especially in cases of recent trauma.
Fig. 26.4 Antero-posterior view (a), and lateral view (b) of the right hand; showing wasting and
attening of the thenar eminence due to median nerve injury. Note a fasciocutaneous ap and skin
graft reconstruction of the traumatic soft tissue defect at the anterior aspect of the forearm
276
Fig. 26.5 Abnormal
thickening of the skin and
palmar fascia to form cord
like structure and nodules
pulling the ring nger
towards the palm in
Dupuytren’s disease
H. Hosny
• Feel (on the dorsum of the hand) along each nger and related metacarpal to
elicit tenderness e.g. Fractures or abnormality e.g. nodules that are not visible.
• Feel (on the volar aspect) along the course of ulnar, median, supercial radial
nerves for any tender swelling e.g. Neuroma.
• Examine the joints DIP, PIP & MP joints by pressing each joint mildly between
your thumb and index ngers to elicit tenderness due to intra-articular fracture or
joint disease e.g. Rheumatoid arthritis.
III-Move
A. Passive movements of each joint (DIP, PIP, MP, wrist, elbow, and shoulder)
through its whole range of movement (ROM) to reveal limitation, stiffness or
tenderness.
B. Active movements (without resistance then against resistance) for assessment of
intrinsic and extrinsic muscle of the hand.
Fingers abduction and adduction (spread ngers apart then bring them back
together) to test interossei muscles (ulnar nerve).
Little nger abduction (ulnar nerve).
Bring thumb tip against index tip (Ok sign) or the little nger to test opponens
pollicus (median nerve).
C. Sensory assessment (Light moving touch) -by the examiner index tip- of both
sides of all digits is a simple and rapid test for sensation (as unilateral digital
nerve pathology will result in sensory loss along the border of affected nger).
Test sensation on the lateral aspect of the palm (median n.), then the medialaspect;
both ventrally and dorsally (Ulnar n.) and nally, at the dorsal aspect of the
thumb base (Radial n.).
N.B.Detailed assessment of sensory threshold and innervation density of slowly
and rapidly adapting receptors is provided within the special tests (Table26.1).