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Severe Forearm Open-wound Muscular Laceration - Tips for Muscle Sutures
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Severe Forearm Open-wound Muscular Laceration - Tips for Muscle Sutures
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https://cadmoreoriginalmedia.blob.core.windows.net/463c5efa-b2dc-42bb-b9b4-341324089553/SEVERE FOREAM 0PEN-WOUD MUSCULAR LACERATION - TIPS FOR MUSCL.mp4?sv=2019-02-02&sr=c&sig=onEwmWZixqvepfguEMEsbxhKg95ZzsfT80N41Cx8p%2Fc%3D&st=2024-11-23T12%3A15%3A36Z&se=2024-11-23T14%3A20%3A36Z&sp=r
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2024-05-31T00:00:00.0000000
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Language: EN.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinski, from shoulder planet here from Sao Paulo, Brazil. In this video, I'm showing you an interesting case about a severe muscular laceration of the forearm, which, in spite of the very bad status, had a very, very good final clinical evolution. In this presentation, I want to comment upon important surgical aspects to deal with severe and difficult muscular, open wounds, open lacerations, in order to achieve a good final clinical result. And I want to comment upon what literature says about such cases.
So I hope you like the video. Please don't forget, my friends, subscribe, if your comment, give us your thumbs up and let's see the video. So this is a very interesting video. About a very serious soft tissue traumatic case. That was a 61-year-old man, as we are seeing here, who used to work in construction, and he had a very serious accident with a nail on the wall, falling from a stair.
He had a very big cut, about 40 centimeters, 35 to 40, 41 centiemters, in the medial part of the arm and the forearm, with no fractures involved. That was a soft tissue lesion, together with a very serious muscular laceration of the muscles around the forearm, especially on the flexo-pronator part. So this is a left forearm,
and what we are seeing here, is a big lesion all of the flexor pronator musculature. What I am pointing here, with my arrow, is the medial epicondyle, and here, below, we are seeing, from the arm to the elbow, and the path traject of the ulnar nerve, which continues, here, until the wrist, ulnar sided, as I am showing with my arrow.
That was a very serious and wide big, muscular laceration. And when I saw that case, I was absolutely sure that, in spite of all surgical efforts, the prognosis would be quite unfortunate, and bad. Nevertheless, that case had an outstanding, a very good clinical prognosis, and after searching in literature, I could understand why such, I would say, happy final clinical result happened.
And I want to share these ideas here, in this video. First of all, what I did in that case was, obviously, not only a big washing, with saline, of all of this wound, but a very, very meticulous suture of all of the muscular units, with simple sutures and Kessler sutures. And literature, in fact, says that there is absolutely no evidence that special sutures are needed to fix this case.
As long as you reattach the muscle units, with simple sutures, that is quite enough. You can use many other ideas. I used, here, some Kessler sutures, also. And what is very important in these cases, too, is that we must suture, in the end, all of the epimysium, which is the external layer, on the muscles and the muscle bellies.
So, in this video, that I am showing here, we can see the amount of soft tissue damage, all of the muscular lesions, ias I am showing here, in the flexor pronator muscular units. And, again, I was quite sure that the prognosis would be very bad. But, as I will show you, guys, it was quite outstanding. This is the final result, an extremely meticulous surgery.
The ulnar nerve hopefully was not affected, so I spent three hours doing all of these sutures, with no. two NYLON Kessler sutures, to start bringing the muscular units back to their anatomical position, and then I finalized with number 3 and number four nylon, which means ethilon sutures, and I paid a lot of attention, here, to suture the external layer of the muscle units, which is the epimysium.
This is the final view of the construction, when the muscles, they were working as muscular units, with extension and flexion of the wrist. And that was the final aspect of the wound. Something around 35 to 40 centimeters, and I immobilized that case with only one week of immobilization in a cast, and literature supports short periods of immobilization,
once you do a good surgical repair. So when we see, here, this patient, two weeks post-op, he was with a quite painless scenario. We are seeing, here, hopefully no signs of clinical infection, and he was, at that moment only three weeks after surgery. I'm going to show you now.
He was with an early ulnar claw, and that was because, for sure, for some compression phenomena over the ulnar nerve. But we didn't want to do anything, in terms of surgical, I would say, intervention, because we had seen, macroscopically, that the ulnar nerve was OK, intra operatively, and, in that sense, that would be, hence, a transient phenomenon.
We are seeing, again, here, something about three to four weeks, the ulnar claw, and we can see, here, by the skin marks in the hand of the patient that he was a very, very strong heavy worker in construction. So this is something about five weeks, post-op, the clinical evaluation of the hand of the patient, with the Egawa test, to test the ulnar nerve.
We are seeing, now, the contralateral side, in which as we can see here, all of the intrinsic hand muscles, they were working normally, but when we see the same scenario on the affected side, no, as we are seeing here, we had transient ulnar palsy and, in that sense, the intrinsic muscles, they were not working in a proper way.
But, at that moment, we still wanted, as I have said, to do nothing but observation. And then, two months after that video, what means three months after the trauma, the ulnar nerve palsy was getting better, the patient was with quite, I'm going to show you now, the patient was, just a second, with quite a good flexion of all of the fingers, but the little finger, as we can see here.
So, the distal part of the little finger could not flex fully, he lost that motion, but that was, I would say, quite nothing, compared to everything that happened. And after that, this is another video, four months after the trauma, in which the normal, the grip of the hands were almost OK. And, at that moment, the patient told me that his strength, as his personal opinion, was something about 80% to 90%. So he disappeared after that, but that was a very, very good final clinical result.
And I want to discuss, in literature, some aspects, to make us understand why meticulous sutures of muscular lacerations can lead to quite, I would say, outstanding and surprising final clinical results. So, when we analyze literature, about this issue, it's quite easy for us to understand that, in fact, we have many, many few articles about this, which means, we have very poor literature about how to manage and operate open muscular tears and laceration.
Nevertheless, I found a very, very nice article, together with a very nice chapter of a book, which, I would say, in summary says the same aspects. So in this beautiful article, which is surgical repair of muscle laceration, which was published in this nice journal, which is Muscle, Ligaments and Tendons Journal, we find very interesting, important information. The first one is exactly this, which is There are different suture techniques that have been described in literature, but still the best is to be debated, which means, still we don't know which is the best suture technique to be used.
And the article is quite clear. Whenever you feel comfortable with simple sutures, you can add simple sutures to another, more complex sutures, when doing these muscle sutures. And this is exactly what we have done in this case. We we use it, modified Kessler sutures, together with simple sutures, and our results were as shown in this case, quite good. This is another important information, which is when you do a very good suture, you can allow early rehabilitation of the patient, of the affected muscle and joint, with a very low risk of real rupture.
And this is exactly what happened in this case. So we kept this arm in an axilo palmar cast for only one week, and after that, the patient was feeling very, very comfortable to start rehabilitation, and using his arm, and that was, for sure, due to a very good suturing of the whole muscular lesion. In the same way, it's very important for us to understand this The incorporation of the epimyseum dramatically improves the biomechanical properties of the repair, and still the preservation and the incorporation, in the suture, of the epimysium, in the repair, increases the resistance of such repair to tensile forces.
So this is something very important, which also explains why we had such a lovely result in such challenging case. And in this chapter, published in a sports medicine book, we find basically the same information. So, here we see the very same idea a well executed suture allows early rehabilitation with a very low risk of re rupture.
Just as the other article was saying, here we have this information. The preservation of the epimysium, and the possibility of suturing it, makes the repair more resistant. So essentially the same thing, as we were seeing, two minutes ago, in the other article. In fact, the epimysium is the key to a robust suture, and this is something that is written in all of the few articles that I could find.
And nevertheless, we know that there are, in literature, no significant differences between the sutures used So this chapter says basically the same information that I have found in the other article. So, having said that, this is the take-home message of this presentation whenever you have a big, serious muscular laceration as an open wound, meticulous suturing is elemental to achieve a good result.
There is no evidence of the best suture techniques, so that you can use mattress sutures, you can use Kessler sutures, you can use, modified Mason Ellen sutures, or even simple sutures. But, as long as you do the job, a meticulous suture is the elemental point. And, still, obviously suturing the epimysium is absolutely a key point for you to achieve success. And, of course, with a good suture of the lesion, and especially the epimysium, you can allow your patient to early rehabilitation, and to achieve the best possible final clinical result.
So having said that, thank you, my good friends. Thank you for watching. I hope you likethis video please, if you have any doubt, Don't forget, subscribe, leave a comment on this video, or you can even send me an email, it's a pleasure for me to reply you, whenever you wish. And please help me spread this channel to your friends. It's difficult to keep such high quality videos, but I'm counting on you, my friends, always to help me spreading.
YouTube shoulder planet channel. OK, thank you a lot, my friends. Bye bye. So I hope you liked the video, about tips, ideas to deal with open muscular lesions, so don't forget my friends, subscribe, leave your comment, give your thumbs up and as Doctor Sergio always says, never stop flying.
See you, folks.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinski, from shoulder planet here from Sao Paulo, Brazil. In this video, I'm showing you an interesting case about a severe muscular laceration of the forearm, which, in spite of the very bad status, had a very, very good final clinical evolution. In this presentation, I want to comment upon important surgical aspects to deal with severe and difficult muscular, open wounds, open lacerations, in order to achieve a good final clinical result. And I want to comment upon what literature says about such cases.
So I hope you like the video. Please don't forget, my friends, subscribe, if your comment, give us your thumbs up and let's see the video. So this is a very interesting video. About a very serious soft tissue traumatic case. That was a 61-year-old man, as we are seeing here, who used to work in construction, and he had a very serious accident with a nail on the wall, falling from a stair.
He had a very big cut, about 40 centimeters, 35 to 40, 41 centiemters, in the medial part of the arm and the forearm, with no fractures involved. That was a soft tissue lesion, together with a very serious muscular laceration of the muscles around the forearm, especially on the flexo-pronator part. So this is a left forearm,
and what we are seeing here, is a big lesion all of the flexor pronator musculature. What I am pointing here, with my arrow, is the medial epicondyle, and here, below, we are seeing, from the arm to the elbow, and the path traject of the ulnar nerve, which continues, here, until the wrist, ulnar sided, as I am showing with my arrow.
That was a very serious and wide big, muscular laceration. And when I saw that case, I was absolutely sure that, in spite of all surgical efforts, the prognosis would be quite unfortunate, and bad. Nevertheless, that case had an outstanding, a very good clinical prognosis, and after searching in literature, I could understand why such, I would say, happy final clinical result happened.
And I want to share these ideas here, in this video. First of all, what I did in that case was, obviously, not only a big washing, with saline, of all of this wound, but a very, very meticulous suture of all of the muscular units, with simple sutures and Kessler sutures. And literature, in fact, says that there is absolutely no evidence that special sutures are needed to fix this case.
As long as you reattach the muscle units, with simple sutures, that is quite enough. You can use many other ideas. I used, here, some Kessler sutures, also. And what is very important in these cases, too, is that we must suture, in the end, all of the epimysium, which is the external layer, on the muscles and the muscle bellies.
So, in this video, that I am showing here, we can see the amount of soft tissue damage, all of the muscular lesions, ias I am showing here, in the flexor pronator muscular units. And, again, I was quite sure that the prognosis would be very bad. But, as I will show you, guys, it was quite outstanding. This is the final result, an extremely meticulous surgery.
The ulnar nerve hopefully was not affected, so I spent three hours doing all of these sutures, with no. two NYLON Kessler sutures, to start bringing the muscular units back to their anatomical position, and then I finalized with number 3 and number four nylon, which means ethilon sutures, and I paid a lot of attention, here, to suture the external layer of the muscle units, which is the epimysium.
This is the final view of the construction, when the muscles, they were working as muscular units, with extension and flexion of the wrist. And that was the final aspect of the wound. Something around 35 to 40 centimeters, and I immobilized that case with only one week of immobilization in a cast, and literature supports short periods of immobilization,
once you do a good surgical repair. So when we see, here, this patient, two weeks post-op, he was with a quite painless scenario. We are seeing, here, hopefully no signs of clinical infection, and he was, at that moment only three weeks after surgery. I'm going to show you now.
He was with an early ulnar claw, and that was because, for sure, for some compression phenomena over the ulnar nerve. But we didn't want to do anything, in terms of surgical, I would say, intervention, because we had seen, macroscopically, that the ulnar nerve was OK, intra operatively, and, in that sense, that would be, hence, a transient phenomenon.
We are seeing, again, here, something about three to four weeks, the ulnar claw, and we can see, here, by the skin marks in the hand of the patient that he was a very, very strong heavy worker in construction. So this is something about five weeks, post-op, the clinical evaluation of the hand of the patient, with the Egawa test, to test the ulnar nerve.
We are seeing, now, the contralateral side, in which as we can see here, all of the intrinsic hand muscles, they were working normally, but when we see the same scenario on the affected side, no, as we are seeing here, we had transient ulnar palsy and, in that sense, the intrinsic muscles, they were not working in a proper way.
But, at that moment, we still wanted, as I have said, to do nothing but observation. And then, two months after that video, what means three months after the trauma, the ulnar nerve palsy was getting better, the patient was with quite, I'm going to show you now, the patient was, just a second, with quite a good flexion of all of the fingers, but the little finger, as we can see here.
So, the distal part of the little finger could not flex fully, he lost that motion, but that was, I would say, quite nothing, compared to everything that happened. And after that, this is another video, four months after the trauma, in which the normal, the grip of the hands were almost OK. And, at that moment, the patient told me that his strength, as his personal opinion, was something about 80% to 90%. So he disappeared after that, but that was a very, very good final clinical result.
And I want to discuss, in literature, some aspects, to make us understand why meticulous sutures of muscular lacerations can lead to quite, I would say, outstanding and surprising final clinical results. So, when we analyze literature, about this issue, it's quite easy for us to understand that, in fact, we have many, many few articles about this, which means, we have very poor literature about how to manage and operate open muscular tears and laceration.
Nevertheless, I found a very, very nice article, together with a very nice chapter of a book, which, I would say, in summary says the same aspects. So in this beautiful article, which is surgical repair of muscle laceration, which was published in this nice journal, which is Muscle, Ligaments and Tendons Journal, we find very interesting, important information. The first one is exactly this, which is There are different suture techniques that have been described in literature, but still the best is to be debated, which means, still we don't know which is the best suture technique to be used.
And the article is quite clear. Whenever you feel comfortable with simple sutures, you can add simple sutures to another, more complex sutures, when doing these muscle sutures. And this is exactly what we have done in this case. We we use it, modified Kessler sutures, together with simple sutures, and our results were as shown in this case, quite good. This is another important information, which is when you do a very good suture, you can allow early rehabilitation of the patient, of the affected muscle and joint, with a very low risk of real rupture.
And this is exactly what happened in this case. So we kept this arm in an axilo palmar cast for only one week, and after that, the patient was feeling very, very comfortable to start rehabilitation, and using his arm, and that was, for sure, due to a very good suturing of the whole muscular lesion. In the same way, it's very important for us to understand this The incorporation of the epimyseum dramatically improves the biomechanical properties of the repair, and still the preservation and the incorporation, in the suture, of the epimysium, in the repair, increases the resistance of such repair to tensile forces.
So this is something very important, which also explains why we had such a lovely result in such challenging case. And in this chapter, published in a sports medicine book, we find basically the same information. So, here we see the very same idea a well executed suture allows early rehabilitation with a very low risk of re rupture.
Just as the other article was saying, here we have this information. The preservation of the epimysium, and the possibility of suturing it, makes the repair more resistant. So essentially the same thing, as we were seeing, two minutes ago, in the other article. In fact, the epimysium is the key to a robust suture, and this is something that is written in all of the few articles that I could find.
And nevertheless, we know that there are, in literature, no significant differences between the sutures used So this chapter says basically the same information that I have found in the other article. So, having said that, this is the take-home message of this presentation whenever you have a big, serious muscular laceration as an open wound, meticulous suturing is elemental to achieve a good result.
There is no evidence of the best suture techniques, so that you can use mattress sutures, you can use Kessler sutures, you can use, modified Mason Ellen sutures, or even simple sutures. But, as long as you do the job, a meticulous suture is the elemental point. And, still, obviously suturing the epimysium is absolutely a key point for you to achieve success. And, of course, with a good suture of the lesion, and especially the epimysium, you can allow your patient to early rehabilitation, and to achieve the best possible final clinical result.
So having said that, thank you, my good friends. Thank you for watching. I hope you likethis video please, if you have any doubt, Don't forget, subscribe, leave a comment on this video, or you can even send me an email, it's a pleasure for me to reply you, whenever you wish. And please help me spread this channel to your friends. It's difficult to keep such high quality videos, but I'm counting on you, my friends, always to help me spreading.
YouTube shoulder planet channel. OK, thank you a lot, my friends. Bye bye. So I hope you liked the video, about tips, ideas to deal with open muscular lesions, so don't forget my friends, subscribe, leave your comment, give your thumbs up and as Doctor Sergio always says, never stop flying.
See you, folks.
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