1. BLOCK A.Abesamis.Agustin.Albano.Alcasabas.Asto.Asuncion.Balderia.

2. Ramos, Nelson Inolva 18/M, single Roman Catholic from Squatter Unex, Manila

3. DOI: 6/23/09 TOI: 3pm POI: Unex, Manila MOI: laceration - Pt seen at the ER 3 hours post-injury.

4. 3 hrs PTC: Pt was drinking alcohol with his friends when they had an argument. He was chased by his 3 friends. Pt was then holding a knife with his left hand. As he ran, he hit his back and left arm to the wall. He continued running and tripped hitting his right knee to the ground (with his left knee flexed supporting his body). The knife that he was holding slipped and he accidentally gripped on the blade as he leaned on his outstretched left forearm. Pt ran to the baranggay hall and was then brought to PGH.

5. Pt was seen at the ER 3 hrs post-injury. Pt is intoxicated and was apparently chased by 3 unknown assailants. Pt was then hacked by a bolo for which he used his left hand to block.

6. (-) HTN, DM, BA, PTB, goiter, allergies (+) sutured laceration at left supraorbital area (PGH, July 2008)

7. (+) DM- father (-) HTN, BA, PTB, goiter, allergies

8. - Educational Attainment - 1 st yr HS - construction worker -vices: (+) smoking hx (0.3pack yrs) (+) alcohol intake – 1bottle of hard drink (2x/wk) (+) illicit drug use: methamphetamine (13-15yrs. Old 1 pack/day) marijuana – 1 stick/day in 2008 cough syrup – once consuming 1 bottle

9. Pt is awake, intoxicated, not in cardiorespiratory distress BP: 120/80 HR: 80 RR: 20 T: - E/N systemic findings Abdomen: soft, nontender Chest/Lungs: clear breath sounds, (-)rales/wheezes

10. Injuries noted: (+) Abrasion - posterior aspect of Left upper arm - Left shoulder - Right knee (+) Laceration - middle phalanx: 2 nd digit - proximal phalanx: 3 rd, 4 th and 5 th digit

11. 6/23/09: Pt seen by SOD. A> Multiple laceration 2° to hacking 1) middle phalanx plantar aspect, digit 2, Lt hand 2) PIP, plantar aspect, digit 3 and 4, Lt hand 3) prox. phalanx plantar aspect, digit 5, Lt hand 4) MCP, dorsal aspect, digit 2, Lt hand 5) Abrasions, posterior upper back and lower abdomen

12. P> Dxtics: Hand APOL, Lt Meds: 1) Vit. B Complex 1 amp IM 2) ATS 3000 U IM + TeAna 0.5 U IM Refer to Ortho-Hand. Refer to MSS.

13. Pt seen and examined by Ortho. O> Multiple digit lacerations 2° to hacking: 1) middle phalanx, digit 2 2) PIP, digits 3 and 4 3) proximal phalanx, digit 5 at palmar aspect Lt hand (+) extended tone MF, RF Lt hand Sensory and Motor Function - can’t be assessed for pt is intoxicated Multiple abrasions Lt upper back

14. A> t/c Flexor Tendon Transection (FDS,FDP), MF and RF, Left Hand (Zone II) P> Dxtcs: Hand APOL, Lt Meds: Start IV Oxacillin 1 gm IV q6 ()ANST or Cefazolin 1 gm q8 hrs. Maintain splint at all times. Pt transferred to ward8/bed35 and for OR on Wed.

15. CBC: Hgb 162/Hct0.509/WBC 4.23/Neut 0.428/ Lym 0.348/ RBC 5.99/Plt 265 Bloodchem: Na 133↓/ K 4.2/ Cl 102 APTT: Ctrl 35.2/ Pt 41 Urinalysis: yellow/clear/sg 1.030/pH 6.0/ sugar (-)/pro (-)/ RBC (-)/WBC 0-1/EC (-)/Bac rare/ MT (-)/ c/c (-)

16. Pt is conscious, coherent, not in cardiorespiratory distress BP: 110/80 HR: 84 RR: 20 afebrile HEENT: anicteric sclerae, pink conjunctivae, 3mm pupils EBRTL, full EOMs;(-)TPC/CLAD/ANM Chest/Lungs: (-)ICS retractions; clear breath sounds, equal chest expansion,(-)rales/wheezes CVS: (-)heaves/thrills; AB at 5 th ICS MCL, distinct heart sounds, normal rate and regular rhythm, (-) murmurs Abdomen: flat, normoactive bowel sounds, soft, (-) masses/ tenderness/rigidity GU: deferred

17. Extremities: full and equal pulses, pink nailbeds, (-) edema Left Upper Extremity: (+) splinted left hand and forearm, with full ROM of the Lt. elbow and 1 st digit of left hand (-) sensory deficits on exposed area (other digits can’t be assessed) Right Upper Extremity: (+) tattoo, (-) lacerations and abrasions, with intact motor and sensory function Lower Extremities: (+) abrasion at right knee, grossly normal left lower extremity.

20. 1)Longitudinal vessels that enter the palm and extend down the intertendinous channels 2)Vessels entering at the level of the proximal synovial fold in the palm 3)Vincula (2 short and 2 long) harboring segmental branches from the digital arteries 4)Osseous insertions

21. synovial fluid diffusion that occurs as synovial fluid is pumped into the tendon fibers during flexion and extension of the fingers

22. Zone I contains only the FDP tendon insertion of the FDP to the insertion of the FDS tendon Zone II "no man's land” insertion of the FDS tendon to the proximal end of the A1 pulley Zone III - lumbrical origin in the palm Zone IV - in the carpal tunnel Zone V - proximal to the carpal tunnel in the forearm

23. disruption of normal cascade disruption of normal tenodesis positioning testing of individual tendons

24. intravenous (IV) antibiotics when indicated evaluation of the patient's tetanus immunization status Equivalent functional outcomes if the repair is done the day of injury (primary repair) or within the first 7-10 days after the injury (delayed primary repair)

25. Most problematic Care in preservation of the vincular blood supply Repair both profundus and superficialis Greater digital independence of motion Lower risk of tendon rupture Decreased likelihood of PIP hyperextension deformity

26. 30 0 wrist flexion 45 0 MTP flexion IP 0-15 0 flexion

27. Passive ROM by rubber band splinting 4-6 wks post-repair – active flexion-extension as splinting is d/c 6-8 wks post-repair – passive extension and isolated blocking > 8 wks – flexion against resistance

28. Active assisted motion in the 1 st 2 wks Earlier active motion

29. 17 (81%) out of 21 digits in 15 out of 16 patients achieved an excellent-to-good functional grade. The remaining patient with concomitant injuries to 4 (19%) digits attained a poor functional grade, attributable to poor compliance with the rehabilitation protocol mean rehabilitation period: 130 days mean grip strength: 78% that of the uninjured side. Concomitant digital nerve injury did not adversely affect the final outcome Only one (4.8%) patient experienced a rupture