| Specialty Care for the Shoulder, Elbow, Wrist & Hand | |
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FOR OUR PATIENTS |
Farm InjuriesFarming continues to be one of the nation's most dangerous occupations. Although some recent evidence suggests that the American farm is getting safer, each year approximately 120,000 individuals working in agricultural jobs experience some type of injury that limits their ability to perform their daily productive work.(1) Of these injuries, nearly one-third involve the upper extremity, with a majority of these injuries occurring to the fingers, hand, wrist, and forearm.(2) Traditionally, the months of May, June, July, October, and November have the highest incidence of reported farm injuries. Of particular interest are the late spring and early summer months, during which time the farm family is busy with spring planting, and has more daylight hours available for working. While farming injuries continue to occur throughout the summer months, the fall harvest season also shows a dramatic increase in frequency of accidental farm injuries and farm fatalities. It is during the time-critical harvest that farmers work long hours to get their valuable crops out of the field, and then transported to local grain elevators, or to the farmer's own storage bins for drying. Grain augers, that commonly are used to move large volumes of grain from one storage area to another, may put the farm laborer at the greatest risk of severe injury. The auger's open-ended intake area, the electric motor's pulleys, or the tractor's PTO shafts (even with safety devices in place) pose a great threat of hand and arm injury. The auger's spiral, rotating blade is efficient in its task of moving grain (or what ever has entered the intake area) up and out of the auger cylinder into a wagon, truck, or adjacent storage area. As with many older pieces of farm equipment, often the safety shields and guards have broken, have vibrated loose, or may have been completely removed. The daily exposure to a multitude of powerful and complex machinery leaves the farmer vulnerable to many types of upper extremity injury. Of the 64 farm-related injuries reported in one recent study, 29 injuries (or 45%) involved the upper extremity.(3) Farming equipment such as combines, tractors, corn pickers, bush-hogs, grain augers, elevators, conveyors, power-take-off shafts, and mowers all potentially may cause severe or mutilating injuries to the hand and arm. Shop equipment such as welders, acetylene torches, chain hoists, grinders, and hydraulic jacks also may pose the threat of injury when used improperly or in haste. When injuries do occur from farm equipment, they may range from small fingertip lacerations, to the more severe hand or forearm amputation. In addition, life-threatening injury and even death following a farm-related accident is an all-too-common occurrence in Indiana and other Midwestern states. Today's high horsepower and high torque farm equipment can not only injure the upper extremity, but it may also may pull the individual's shoulder or leg into the device as well. In some instances of trauma, the patient's shoulder or chest will serve as a "stop" or "block," and will keep the rest of the body from being pulled into the machine. This mechanism of injury may cause a hidden or closed injury to the head or chest that may go unnoticed. This associated trauma to the chest or another body area may, in fact, be very life threatening, and requires early intervention by paramedics and local emergency room personnel. In Indiana, local hospital triage systems and air ambulance services are making large trauma centers and replant centers, like The Indiana Hand Center in Indianapolis, available to the rural patient in need of such care. It is important to note that Indiana has excellent primary care physicians, as well as emergency room physicians and support staff. Such expertise in recognizing the severity of injury early, and then stabilizing the patient for transfer has greatly facilitated the referral and subsequent surgical reconstruction process. Primary Care of the Injured PatientThe immediate care of the injured patient, as well as the care of the amputated part, is crucial. Because many farm injuries occur while the worker is out in the field, emergency medical care provided by EMTs or other emergency personnel is essential. Recognizing and appreciating the fact that surgical reattachment may be a possibility is fundamental to the process. Appropriate care needs to be directed immediately to the injured patient. Bleeding can usually be stopped at the site of amputation after saline cleansing and the application of direct pressure. This direct pressure may be applied by a family member, companion, co-worker, paramedic, or by patients themselves. As severed arteries will frequently go into spasm following transection and will constrict (close down), stopping the bleeding with direct pressure should be relatively simple. Avoid using clamps or tourniquets on the injured stump, as damage to the blood vessels, nerves, and other soft tissue may result. Such damage may compound, lengthen, or even preclude the reattachment process. A complete physical exam should be carried out to determine if the patient is stable enough for transportation and subsequent referral to the replantation center by ground or air. Because the equipment responsible for the trauma has been contaminated with dirt and organic material, these injuries require careful debridement and decontamination. Appropriate and aggressive antibiotic treatment is necessary for these patients. An up to date tetanus toxoid and immunization should also be verified. Microsurgical Reattachment This surgical reconnection, under the high power magnification provided by these specialized microscopes, has been termed "microsurgery." It is this magnification during surgery that has given our Center's microsurgeons the ability, in some instances, to reattach fingers and hands that were amputated by farm machinery. The specialty trained hand surgeons at The Indiana Hand Center are pioneers relating to these and other innovative surgical techniques, and they continue to be national leaders in this and other important areas. The same surgical reconstruction techniques that allow our surgeons to "sew on" amputated fingers and thumbs, have also permitted our hand surgeons to surgically move or transplant tissue from one body area to another. These procedures known as "free tissue transfers" have provided new sources of body tissue for complex or staged upper extremity reconstructions. For example, our physicians may remove a large flap of tissue or a muscle from the back, thigh, lower abdomen, or groin area, and relocate it onto an injured hand or forearm that had little remaining normal tissue left for adequate reconstruction. Donor areas are most typically closed with skin grafts or by other methods. Toe-to-hand transfers have made it possible to create new thumbs in individuals whose own thumbs were amputated and not located, or in a patient whose thumb was not able to be salvaged. While this tissue transfer is not applicable or even desirable for everyone with a thumb or other type of amputation, it offers yet another reconstructive option. It is important to realize that not every amputated part can be successfully reattached. Some patients may have other associated injuries or medical conditions that do not safely allow an immediate or lengthy surgical reattachment process. Other Types of Farm InjuriesLess severe and more common farm-related injuries may include wrist sprains, abrasions, cuts and lacerations, burns, fractures, joint dislocations, ligament injuries, high pressure grease injections, finger tip and nail injuries, animal bites, and infections. While these more minor injuries may appear to be "not bad enough to go to the doctor," a delay in the appropriate treatment by a physician may further complicate and even lengthen the recovery time. Certainly any severe burn, fracture or deformity, and infection should be evaluated promptly by a physician. Recent DevelopmentsRecently, small microvascular couplers, introduced by the 3M Corporation, have significantly reduced the surgical time required to reconnect extremely small, severed arteries and veins in the hand. Now, in some select hand reattachment cases, these hollow ring-type connectors may be employed, instead of using more traditional suturing techniques. The Indiana Hand Center was instrumental in the clinical investigation of these devices during the developmental process. The results of our own clinical case studies using these couplers have been presented nationally by our team of surgeons. Educational efforts geared toward the farming community, firemen, police, EMT-responders, emergency room personnel, trauma nurses, and primary care physicians have increased an awareness relating to severe farm injuries and amputations. Instructions on the care and transportation of patients (and amputated parts) have been made available by our Center in Indianapolis. This education has become a valuable tool in the treatment, and even prevention, of traumatic farm injuries. Farm injuries may come in all shapes and sizes. Many of these patients have the all too familiar combination of amputations, injuries, and contaminated hand wounds. An aggressive surgical debridement of the wound and proper surgical care, followed by an appropriate post-operative therapy program, will help insure the best possible results for each patient. Farming is essential to Indiana's success and well-being. It is our goal to return the injured farmer or farm family member back to a productive way of life. Gary W. Schnitz, M.A. © The Indiana Hand Center, February 2007 REFERENCES:1. Agribility Fact Sheet, Purdue University, Spring 1996. ……………………………………………………….. Photo Captions: Illustration showing use of a grain auger to transfer grain from a storage bin (seen in cross-section) to a truck. A hand can easily be amputated by a grain auger's spiral blade, and can travel up the auger cylinder at a rate of 3 feet per second. A four finger amputation (left) and a complete hand amputation (right) reflect the severity of Indiana farm injuries. A surgical microscope allows surgeons to successfully reconnect the hand's small arteries, veins, and nerves. The reattachment of a completely amputated hand involves a thorough cleaning and debridement of the part, identification of all anatomical structures involved, bone fixation with surgical plates and screws, repair of severed arteries, veins, nerves, tendons, and soft tissue. A post-operative therapy program assures each patient of the best possible outcome. Couplers placed on a millimeter scale for size comparison (on left); a completed anastomosis (repair) of a 1 mm artery (on right). Safety magnets alert the worker to the dangers of upper extremity injuries. Instructions on the emergency care and transportation of the patient with an amputated finger, hand, or upper extremity. |