Transcript Hand Trauma - Latest News in Health Sciences | College of

Presenter:
DR. ALIHUSSEIN TARWADI
Moderator:
DR. AFULO
1
Introduction
 Approach to hand trauma patient
 Structural Injuries:

◦
◦
◦
◦

Cutaneous Injuries
Tendon Injuries
Nerve Injuries
Bone Injuries
Amputation and Replantation
2
INTRODUCTION

The hand is a very vital part of the human body

4 requirements for a functioning hand:
◦ Supple (moving with ease)
◦ Sensate
◦ Pain free
◦ Coordinated

Account for 5-10 % of hospital ER visits.

Great potential for serious handicap

Good understanding of hand anatomy and function, good
physical examination skills, and knowledge of indications
for treatment.

Proper Initial diagnosis and timely appropriate treatment
would reduce morbidity.
3
APPROACH TO HAND TRAUMA
PATIENT
History:
General
◦ Age
◦ Hand dominance
◦ Occupation/hobbies
◦ History of previous hand problems
 When and where did this injury take place?
◦ Determine the likelihood of severe injury and
probability of contamination with foreign
matter.
 How was the trauma sustained?
◦ This gives clues to the most likely injury.
 Past history of treatment or surgery in the hand

4
APPROACH TO HAND TRAUMA
PATIENT
Physical examination
◦ Entire upper limb should be exposed and carefully
inspected (Muscle wasting, colour change,
Asymmetry, fixed abnormal posture etc.)
◦ Extrinsic flexor and extensor muscles and their
tendons’ injuries.
◦ Intrinsic muscles (Thenar, lumbricals, interossei,
and hypothenar muscles)
◦ Joints’ pain and stability.
◦ Sensory examination.
◦ Circulation for colour change, Allen test.
5
APPROACH TO HAND TRAUMA
PATIENT
Imaging Studies
Radiography
◦ Plain-films of the hand or wrist should be obtained
when a patient presents with a soft tissue injury
suggestive of fracture or an occult foreign body.
 US
◦ Has a growing role in locating foreign bodies and in
evaluating soft tissues
◦ Can detect ruptured tendons and assess dynamic
function of tendons non-invasively.
 MRI
◦ Highly sensitive in detecting ruptured tendons.
◦ However, it does not have a role in emergent
management of hand wounds.

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8
CUTANEOUS
INJURIES
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ANATOMY
Dorsum surface
◦
Thin and pliable.
◦ Attached to the hand's skeleton only by loose areolar
tissue, where lymphatics and veins course.
◦ Loose attachment makes it more vulnerable to degloving
injuries.
Palmar surface
◦
Thick and glabrous and not as pliable as the dorsal skin
◦ Strongly attached to the underlying fascia by numerous
vertical fibers
◦ Most firmly anchored to the deep structures at the palmar
creases
◦ Contains a high concentration of sensory nerve endings
essential to the hand's normal function
10
PRESENTATION

Cutaneous injuries are very common
Two Types
◦ Open: Incised, laceration, punctured (bites),
penetration, abrasion, degloving.
◦ Closed: Contusions, Hematomas
Vary in depth from superficial to very
deep involving underlying structures.
 Explore for underlying structural
Injuries.

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MANAGEMENT
Skin Laceration:
◦ Small: Rinse and cover.
◦ Large:
 Infiltrate with Lidocaine
 Irrigate wound profusely with sterile water
 Drape and explore (underlying injuries and foreign
bodies)
 Close the skin wound with simple sutures.
 Wounds older than 6-8 hours should not be closed
primarily because of an increased likelihood of
infections.
 Irrigate, explore then apply sterile dressing. Re-check
after 4 days for skin infection. Delayed primary
closure at 4 days.
 Update Tetanus vaccination.
13
MANAGEMENT
Bites:
◦ Should not be closed primarily but should be given
serial wound checks with delayed closure at 4
days if needed
◦ Antibiotic prophylaxis is indicated in human and
animal bites.
Contusions:
◦ Cold packs with pressure for 30 to 60 min. several
times daily for 2 days.
◦ Two days after the injury, use warm compresses
for 20 minutes at a time.
◦ Rest the bruised area and raise it above the level
of the heart
◦ Do not bandage a bruise.
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MANAGEMENT

Abrasions:
◦ Superficial:
 Rinse and cover.
 Prophylactic antibiotic ointment
◦ Deep:
 Rinse with antiseptic or warm normal saline.
Scrub gently with gauze if necessary.
 Dress with semi-permeable dressing. Changed
every few days.
 Keep wound moist. Enhance healing process.
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FLAPS

Large skin defects on the hand should
always be covered with a full
thickness skin graft or flaps (local or
distant) especially on the dorsum of
the hand where the tendons are
superficial and application of a STSG
will tether the tendons and lead to loss
of hand function.
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LOCAL FLAPS
RHOMBOID LIMBERG FLAP
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LOCAL ROTATIONAL FLAP
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V-Y ADVANCEMENT FLAP
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KUTLER’S BILATERAL
TRIANGULAR ADVANCEMENT
FLAP
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STANDARD CROSS FINGER FLAP


When there is a loss of
greater that 1/3 of the
volar tissue of the
fingertip especially with
exposed flexor tendon,
joint, or bone.
Where more tissue is
required than with
advancement-type
flaps.
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Reverse cross finger flap


The epidermis and
papillary dermis are
divided and the reticular
dermis and subcutaneous
tissue have been used to
cover the dorsum of an
adjacent digit.
The skin flap is laid back
into place over the donor
site and a full-thickness
graft is then placed on the
reverse flap.
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THENAR FLAP
23
ANNULAR FLAP
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Homodigital bipedicle island
advancement flap
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Reverse vascular pedicle island
flap
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REGIONAL FLAPS
Reverse radial artery flap
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DORSAL ULNAR ARTERY FLAP
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Posterior interosseous forearm
flap
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DISTANT FLAPS
Sub mammary flap
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GROIN FLAP
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Role of STSG
Can be used if there is adequate
tissue cover over bone and tendons
with only loss of skin.
 Can be used with dermal allografts
like AlloDerm ® (commercially
available acellular dermis derived from
human skin)
 Used to cover some
donor sites

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TENDON
INJURIES
•Acute
•Chronic
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PRESENTATION
Extensor injury

Extensors
Injury:
◦ Divided into
Zones
according to
anatomical
location of
injury
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PRESENTATION
39
Zone 1
Boutonniere’s
Deformity
Zone 3
Zone 5
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MANAGEMENT
Zone
I
III
V
Presentation
Management
Mallet’s Deformity
•Closed: splinting 6-8 weeks
•Open: suture repair for
fixation.
•Soft tissue reconstruction
Boutonniere’s
Deformity
•Closed: splinting MCP and
PIP in hyperextension for 6
weeks
•Open: suture repair (figure of
8 suture)
Fixed flexion of
MCP
•Closed: splinting ,45
extension at wrist and 20
flexion at MCP
•Open: suture repair.
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43
PRESENTATION
FLEXOR TENDON INJURY

Flexor Injury
◦ Divided into
Zones
according to
anatomical
location of
injury
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45
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PRESENTATION
Zone
Presentation
Management
I
Loss of active flexion
at DIP joint
Hyperextension of
DIP joint
•Primary or Secondary tendon
repair
•Careful suturing prevent postop adhesions.
Loss of active
flexion at MCP
joint
•Skin closure then secondary
repair by tendon grafting
•Primary repair performed by
skilled hand surgeon to
minimize post-op adhesions.
Same
•Primary or secondary tendon
repair
•Examine carefully for thenar
muscle injury and recurrent
branches of median nerve.
II
(No
Man’s
Land)
III, IV
Thumb
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PRESENTATION
Zone
Presentation
Management
V
Palm
• Uncommon
• Lie deep and
protected by
palmar fascia
• Same presentation
•Superior to Tendon division:
repair is unnecessary.
•Both muscles’ tendon
division: primary repair
VI, VII
Wrist
• Multiple flexor
tendon injury
• Impaired active
flexion of multiple
digits
•Primary tendon suturing
further proximal in the forearm
to prevent post-op crossadherence.
•Injuries to muscles in forearm
require primary repair
•Post-op splinting of wrist in
flexion position and elevation
for 4 weeks.
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CHRONIC TENDON INJURIES
OF THE HAND
Swan Neck Deformity
 Flexed DIP, hyperextended PIP
 Interruption of distal extensor mechanism
 Causes:
◦
◦
◦
◦
◦

Chronic Mallet finger
Fracture malunion
Volar plate injury to PIP
Rheumatoid arthritis
Ligament laxity
Treatment: surgical mostly but splints can
be used to relieve contractures
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Gamekeeper’s/ skier’s thumb
Injury to ulnar collateral lig of the 1st
MCPJ, sometimes associated with
fractr base of PP
 Conservative managmnt
with splint but mostly
requires surgical repair

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De QUERVAIN’S TENOSYNOVITIS
Stenosing tenosynovitis of the first
dorsal compartment
 APL & EPB trapped in fibroosseous
tunnel formed by radial styloid and
flexor retinaculum
 Symptoms include: pain over styloid
process on thumb or wrist movemnt
and a positive finklestein test
 Treatment: thumb spica, NSAIDS and
steroid injection in 1st compartment.
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Trigger finger and Thumb
Stenosing tenosynovitis, leading to
inability to extend the flexed digit
“triggering”.
 Involvement of the first annular part of
the flexor sheath (A1 annulus)
 Treatment:

◦ Splinting +heat/cold
◦ Local steroid inj
◦ Sx release of A1 pully
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EPL Tendinitis
(Drummer boy palsy)
Seen in rheumatoid arthritis or
previous distal radius fracture.
 Pain, swelling and crepitus over 3rd
dorsal compartment
 Treatment:

◦ Spica
◦ NSAIDS
◦ Surgical release
NO steroid injection
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Dupuytren's contracture
Inherited proliferative connective
tissue disease affecting the palmar
fascia causing it to harden (collagen IIII)
 Incidence after 40, M>F. after 80 M=F
 Affects mostly ring and little finger and
middle finger in severe cases.
 Initially starts as nodules in palm of
hand.

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Positive table top test
 Pts ability to grip
 Treatment:

◦ Early-Radiation
-collagenase inj
◦ Late- fasciectomy
-Dermofasciectomy
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NERVE INJURIES
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ANATOMY
58
Presentation

Mechanisms of injury:
◦ Traction: force is longitudinal to nerve axon
◦ Compression: force is cross-sectional to nerve
axon.
◦ Laceration: sharp object injury.
Blunt trauma delivers forces that stretch
and compress nerves. Nerve my undergo
total disruption or avulsion. Less favorable
outcome.
 Sharp laceration can cause complete
transection of nerve but it is associated
with best prognosis

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Presentation

Effect of injury: “Seddon’s Classification”
◦ Neuropraxia:
 Disruption of Schwann cell sheath but no loss of
continuity.
◦ Axonotmesis:
 Injury to both Schwann sheath and axon.
 Distal part undergoes Wallerian degeneration.
 Stimulation of nerve 72 hours after injury does not
elicit response.
 Regeneration occurs with the average rate of 1-2
mm/day.
 Regeneration is supported and guided by the
surrounding endoneurium.
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Presentation
◦ Neurotmesis:
 Injury to all anatomical components, myelin
sheath, axons and the surrounding connective
tissue.
 This total nerve disruption makes regeneration
impossible.
 Surgical intervention is necessary.
◦ Examine carefully to document any
sensory or motor injury and for follow up.
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Presentation
62
PRESENTATION OF MEDIAN
NERVE INJURY
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PRESENTATION OF RADIAL
NERVE INJURY
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PRESENTATION OF ULNAR
NERVE INJURY
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MANAGEMENT

Neurolysis:
◦ Removal of any scar or tethering attachments to
surroundings that obstruct nerve ability to glide.

Neurorrhaphy:
◦ End-to-end repair.
◦ Resection of the proximal and distal nerve stumps
and then approximation.

Autologus Nerve grafting:
◦ Gold standard for clinical treatment of large lesion
gaps.
◦ Nerve segments taken from another parts of the
body.
◦ Provide endoneural tubes to guide regeneration.
◦ Two types: Allograft, Xenograft.
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EPINEURAL
NEURORAPHY
GROUP FASSICULAR
NEURORAPHY
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CHRONIC NERVE INJURY
Carapal tunnel syndrome
Compression of median nerve in the
carpal tunnel.
 Hand numbness( night, driving car)
with pain, parasthesias in distribution,
clumsiness or weakness
 Thenar wasting
 Age: 30-60,
 F:M ratio 5:1

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Causes of CTS
Decrease in Size of Carpal Tunnel
Bony abnormalities of the carpal bones
 Acromegaly
 Flexion or extension of wrist

Increase in Contents of Canal




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


Forearm and wrist fractures (Colles, scaphoid #)
Dislocations and subluxations of carpal bones
Post-traumatic arthritis (osteophytes)
Aberrant muscles (lumbrical, palmaris longus)
Local tumors
Persistent medial artery (thrombosed or patent)
Hypertrophic synovium
Hematoma
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Causes of CTS
Inflammatory Conditions
Rheumatoid arthritis
 Gout
 Nonspecific tenosynovitis
 Infection

External Forces
Vibration
 Direct pressure

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Causes of CTS
Alterations of Fluid Balance









Pregnancy
Menopause
Hypothyroidism
Renal failure
Long-term hemodialysis
Obesity
Lupus erythematosus
Scleroderma
Amyloidosis
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DIAGNOSIS
History which brings out any of the
causes
 Clinical tests:

◦ Phalen's wrist flexion test
◦ Tinel's nerve percussion test
◦ Durkan's compression test

Treatment:
◦ NSAIDS, elevation and splinting
◦ Local corticosteroid injections
◦ Surgical decompression
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Factors that don’t favor
conservative treatment
Age over 50 years
 Duration longer than 10 months
 Constant paresthesia
 Stenosing flexor tenosynovitis
 Positive Phalen test in less than 30
seconds.

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Cubital tunnel syndrome

Mechanism
◦ repeated elbow flexion
◦ Trauma: fracture or dislocation of
supracondylar or medial epicondylar

Typical complaint
◦ aching or sharp pain( night) in proximal
and medial forearm
◦ decreased sensation
◦ weakness
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
Evaluation
◦ Atrophy in first web space, hypothenar
eminence, medial forearm
◦ Elbow flexion test( passive flex elbow,
holding 60 seconds)

Treatment
◦ Conservative therapy: splinting( prevent
sleeping with elbow 30。flex), padding
elbow, positioning guideline
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Ulnar tunnel syndrome
(Guyon’s Tunnel)
Compression of the ulnar nerve within
a tight triangular fibroosseous Guyon’s
canal
 commonly seen in
regular cyclists due to
prolonged pressure of the Guyon
canal against bicycle
handlebars.

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TYPES
Type I
◦ Proximal compression leads to motor
weakness in all of the intrinsic muscles of
the hand
◦ There is also sensory loss in the ulnar
nerve territory
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
Type II
◦ This is the most common
◦ compression of the ulnar nerve at the
distal wrist.
◦ Impairment in motor function of the hand,
with sensory innervation unaffected.
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Type III
 This is the least common type
 Compression of the superficial
branch of ulnar nerve at the distal
portion of Guyon's canal.
 Loss of sensation from the cutaneous
territory of the hand which is served by
the ulnar nerve.
 There is no motor function impairment.
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Bowler’s Thumb
Perineural fibrosis caused by
repetitious compression of the ulnar
digital nerve of the thumb while
grasping a bowling ball.
 Tingling and hyperesthesia about the
pulp of the thumb.
 Treatment:

◦ splint and rest from bowling
◦ Occasionally neurolysis and dorsal
transfer of the nerve
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BONE INJURIES
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PRESENTATION

History:
◦
◦
◦
◦
◦

Physical Examination:
◦
◦
◦
◦
◦

Handedness
Occupation
Mechanism of injury
Time since injury “golden period”
Place of injury
Inspection for open fractures, swelling
Deformities (angulation, rotation, shortening)
Alignment.
Range of motion (active and passive)
Neurovascular status
Radiographic studies:
◦ 3 planes: AP, Lateral and Oblique
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CARPAL FRACTURES
Scaphoid fractures:
◦ Most common carpal fracture (15% of wrst inj)
◦ Results from force applied on distal end with
wrist hyper extended (fall on outstretched
hand).
◦ Unless treated effectively it would result in malunion and permanent weakness and pain in the
wrist.
◦ Blood supply retrograde so proximal fragment
at risk of AVN
◦ Deep tenderness in anatomical snuffbox is
felt.
◦ Treatment:
 Stable: Cast for 12 weeks
 Unstable or non-union: ORIF
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CARPAL FRACTURES

Triquetral fracture:
◦ 2nd most common carpal fracture
◦ Direct blow to the dorsum of the hand or extreme
dorsiflexion.
◦ Palpation of the triquetrum is facilitated by radial
deviation of the hand.
◦ Point directly over the triquetrum.
◦ Treatment:
 Chip fracture:
 symptomatic with 2-3 weeks immobilization. ROM
exercise once symptoms decrease.
 Body fracture:
 Minimally displaced: cast immobilization for 4-6
weeks + ROM exercise
 Displaced: Closed reduction and pinning or Open
reduction and fixation
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Metacarpal Fractures
Relatively common. 30-40% of hand
fractures
 Result from direct or indirect trauma.
 Direct trauma commonly results in
transverse fracture, usually midshaft.
 Most fractures are easily reducible, stable
and managed non-operatively.
 Indications of surgical intervention:

◦
◦
◦
◦
◦
Intra-articular fractures,
Displaced and angulated fractures,
Unstable fracture patterns,
Combined or open injuries,
Irreducible and unstable dislocations
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Thumb Fractures

Bennett’s fracture:

Rolando’s fracture:
◦ Fracture at the base of
the 1st Metacarpal.
◦ Comminuted (displaced)
thumb base fracture.
◦ Intra-articular fracture
subluxation
◦ Improper healing =
restriction of motion
around CMJ
◦ Swelling and pain at
the thumb base
◦ Closed reduction and
immobilization with
thumb spica splint
◦ ORIF
◦ Swollen, tender thumb
base. If significant varus
has developed, a
clinically visible
deformity may be
present.
◦ ORIF
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Bennett’s
Rolando’s
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Phalangeal Fractures

Distal Phalanx:
◦ Extra-articular fractures are common,
associated with significant soft tissue injury.
◦ Crush injuries from a perpendicular force
(injuries from a car door or hammer)
◦ Intra-articular fractures are associated with
extensor tendon avulsion (Mallet’s finger), FDP
tendon avulsion (Jersey finger).
◦ Examination:
 Inspection:.
 Neurovascular status should be examined.
 Palpation is done for tenderness.
◦ Closed treatment is recommended with
splinting and if necessary closed reduction
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Phalangeal Fractures

Middle Phalanx:
◦ Blunt or crush force perpendicular to the long axis
of the bone.
◦ Angulation and rotation are two features of
instability that must be examined.
◦ Rotational deformities are serious injuries and are
detected clinically.
◦ Examination:
 Inspection: for dislocations and sublaxations. Ask patient to
fully flex the phalanx to examine alignment of digits.
 Palpation: swelling and tenderness
◦ Treatment:
 Nondisplaced without impaction: require only dynamic
splinting for 2-3 weeks.
 Angulation and rotation require closed reduction and
splinting to restore finger alignment.
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Phalangeal Fractures

Proximal Phalanx:
◦ More common than middle phalanx fractures.
◦ May result in a great deal of disability.
◦ Dorsal or palmar angulation may occur with
these fractures.
◦ Examination:
 Inspection:
 Neurovascular status
 Palpation is done for tenderness.
◦ Treatment:
 Nondisplaced fractures: usually stable and treated
by closed reduction and dynamic splinting.
 Angulated or unstable fractures may require internal
or external fixation.
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AMPUTATION AND
REPLANTATION
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INTRODUCTION
Replantation: reattachment of a severed digit
of extremity.
 Not all patients with amputation are candidates
for replantation
 Decision based on:

 Importance of the part
 Level of injury
 Expected return of function.
Hand function is severely compromised if
thumb or multiple fingers are lost so replants
of these should be attempted.
 Mechanism of injury may be the most predictive
variable for successful replantation.

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
Recommended ischemia times for
reliable success:
◦ Digit: 12 hours for warm ischemia and 24
hours for cold ischemia.
◦ Major replant: 6 hours of warm and 12
hours of cold ischemia.

Preoperative preparation:
radiography of both amputated and
stump parts to determine the level of
injury and suitability for replantation
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OUTCOME
Overall success rates for replantation
approach 80%.
 Better outcome with Guillotine (sharp)
amputation (77%) compared to
severely crushed and mangled body
parts(49%).
 Studies have demonstrated that
patients can expect to achieve 50%
function and 50% sensation of the
replanted part.

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References
Plastic Surgery, Goldwyn and Cohen,
3rd edition.
 Plastic Surgery, Grabb and Smith, 3rd
edition.
 Clinical Anatomy, Richard Snell, 6th
edition.
 Macleod’s Clinical Examination, 11th
edition.
 www.emedicine.com

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