Transcript Hand Rounds: Oct 31, 2002 Rob Hall MD and Lisa Campfens MD

Hand Rounds: Oct 31, 2002
Rob Hall MD and Lisa Campfens MD, FRCPC
Where would we be without
our hands???
Goals for today
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Recognize serious injuries
Manage common hand injuries
Appropriate referrals to plastics
Proper splinting of injuries
F/U of certain injuries in emerg
Recognize that management of many hand
injuries is controversial
Goals of Today
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Fractures
Dislocations
Sprains
Tendon injuries
Amputations
Mutilating injuries
High pressure
injection
• Digital nerve injury
• Not covering
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infections
foreign bodies
burns
compartment
syndromes
Position of Safety
CAM effect
Box of the Finger
Management?
Distal Phalanx Tuft Fractures
• Distal hairpin splint
• Do not immobilize PIP
• Manage subungual hematoma
Subungual Hematoma
• Previously recommended for nail removal
and formal nail bed for all > 25%
• Roser 1999
– No difference in long term outcome between
nailbed repair, trephination, or observation only
• Management
– Trephinate the nail for pain control
– Nail bed repair for (i) displaced # fragment (ii)
disrupted nail (iii) consider for large hematoma
Approach to Phalanx Fractures
• Stable
– transverse, nondisplaced
• Unstable
– oblique, spiral, comminuted, displaced
transverse, intraarticular with > 20% joint,
rotational deformity
• MUST rule out rotational deformity
– symmetric flexion, point to scaphoid, nails
Stable Phalanx Fractures
• Dynamic Splinting
(buddy tape)
• Early ROM (as soon
as pain subsides - 3 to
5 days)
Unstable Phalanx Fracture
• ED Management
– Reduce
– Splint
– Refer
Unstable Phalanx Fracture:
Options
• Closed reduction and
splinting
– Splint X 3 weeks
– F/U Xray 7-10days to
make sure reduction is
held
– OR if unable to
maintain reduction
• Pin early
– Unable to reduce
– Unable to maintain
reduction
– Rotational deformity
– Intraarticular with >
20% of joint involved
Principles of Metacarpal Neck #
• Why do Boxer’s # do well no
matter what you do??
• Hand function can tolerate
angulation in the metacarpal
neck equal to the motion at the
CMC joint + 10 degrees
Principles of Metacarpal
Neck Fractures
• Normal
Accept
– 5 degrees
15
– 5 degrees
15
– 20 degrees
30
– 30 degrees
40
Metacarpal Head Fracture
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Intra-articular
Needs precise anatomic reduction
Brewerton views can help identify
Splint in safe position and refer
Management?
• “Well he was
talkin’when he
shoulda bin listen
man”
Boxer’s Fracture
• Who needs reduction?
– Displaced, angulated > 40 degrees, rotated
• How to reduce?
– Ulnar, metacarpal, hematoma blocks --> 90 - 90
• Follow up?
– Xray at 1 week to r/o slip
– F/U with GP (or ED)
– Remove splint at 3 - 4 weeks and start ROM
Boxer’s Fracture
• Indications for OR
– Can obtain adequate reduction
– Can’t maintain adequate reduction
– Controversy
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Study: pin vs no pin makes no difference
Van Bowen: pin anything that needs reduction
Generally fairly uncommon to need pinning
Rotational deformity/scissoring likely most common
reason to pin
Splinting Boxer’s Fractures
• Proper splinting
ESSENTIAL to
maintaining reduction
• Position of safety to
prevent MCP
contractures
• Hold in reduction and
mold splint until set
• Must include 4th MC
• If MCPs aren’t flexed
90 degrees ---> loss of
reduction
Open Boxer’s Fracture
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“Fight Bite” ----> HIGH risk of infection
+++++ Irrigation and Explore
Look carefully for tendon disruption
Not into joint capsule
– Leave open, clavulin/Keflex, check at 3 - 5 d
• Into joint capsule
– Leave open, clavulin or keflex po X 5 - 7 days
– Wound check in 24 - 48hrs
Other MC neck Fractures
• 4th: manage as per Boxer’s
• 2nd and 3rd
– Volar splint and refer
– Less mobility accepted thus more likely to pin
Management?
Metacarpal Shaft Fractures
• Can accept < 3mm shortening and 10 deg
angulation in II/III or 20 deg in IV/V
• Cannot accept rotation
• Stable # (transverse, good reduction)
– splint, could follow in ED but must ensure doesn’t slip
(re Xray in one week) or could send to plastics
• Unstable # (spiral, oblique, multiple #s, failed
reduction, rotated)
– splint, reduction prn, refer
Extra-articular Thumb
Metacarpal Fracture
• Unstable (oblique, spiral, comminuted)
– Splint and refer for pinning
• Stable (transverse)
– Attempt reduction if > 20 degrees angulation
– Splint in thumb spica X 4 weeks
– Refer
Management?
• Who the heck is
Bennet?????
Bennett’s Fracture
• Two part intra-articular fracture at base of
thumb metacarpal
• Commonly see CMC joint subluxation
• Thumb spica splint and refer for pinning
• Abductor pollicus longus pulls fragment off
Bennett’s Fracture
Management?
Rolando’s Fracture
• Three (or more) part intra-articular fracture
at base of thumb metacarpal
• Commonly see Y or T pattern but
comminuted fracture is also called
Rolando’s fracture
• Thumb spica splint and refer
“Reverse Bennet’s” Fracture
• Commonly missed
• Xray: look carefully
for clear, even space
b/w base of 5th MC
and hamate
• Unstable b/c ext carpi
ulnaris pulls at base
• Needs pinning
The Pediatric Hand
The Pediatric Hand
• Salter - Harris classification used
• Tuft # and SH II of proximal phalanx
common
• Thick periosteum thus hold position well
and heal quickly
• Generally: closed reduction, splint X 3 wks
• OR: can’t reduce, can’t maintain reduction,
displace intraarticular #, SH IV/V
Salter Harris I
• Closed reduction
• Immobilize with
splint X 3 weeks or
K wire
• Can present with
“paronychia” not
responding to Rx
Salter Harris II
• Common
• Reduce
• Splint with
gutter splint
• Splint X 3 wks
Salter Harris III - V
• SH III
– Minimally displaced, < 25% joint surface
involved: splint X 3 wks
– Displaced, > 25% joint surface involved: splint
and refer
• SH IV: reduce prn, splint and refer
• SH V: reduce prn, splint and refer
Assessment of Finger Joint
Stability
• Blocks may be required for assessment
• Active stability
– can pt move finger through full ROM without
displacement?
• Passive stability
– apply stress to collaterals, and volar plate
Finger Sprains
• Xray
– R/O fracture/avulsion
– LOOK carefully for subluxation
• Stable joint
– buddy tape or gutter splint
– ROM early to prevent stiffness (3-5 days)
• Unstable joint
– splint and refer
Finger Sprains
• Flexion Contractures
– Common complication
• Prevention
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MUST SPLINT PIP/DIP IN EXTENSION
MUST SPLINT MCP in FLEXION
Early ROM
Minimize dressings to allow ROM
See physio at two weeks if becoming stiff
Management?
PIP Dislocations
• Dorsal/Lateral
– Ring block, Xray
– Reduce, examine stability
– Buddy tape and EARLY ROM
(better than splint X 3 weeks)
– refer: can’t reduce, unstable
joint, avulsion > 1/3 of joint
surface
• Volar
dislocation
– Controversial
– Attempt closed
reduction
– Splint and refer
PIP Subluxation +/- Fracture
PIP Joint Subluxation +/Fracture
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Do NOT miss this injury
Must Xray fingers in full extension
Will not stay reduced in extension
Can’t splint in flexion (flexion contracture)
Mx
– splint and refer for extension pin
– also will need special rehab
Dorsal MCP Dislocations
• Simple dislocation
(subluxation)
– hyperextended 60 - 90
degrees, articular
surfaces contacting w/o
interposed soft tissue
– metacarpal block
– reduction
– splint in safety position
– refer
• Complex dislocation
– hyperextension LESS
than 60 degrees
– Xray: wide joint space,
sesamoid in joint space
is pathognomonic
– Splint and refer (will
not be reducible)
Dorsal MCP
Dislocation
• Volar plate prevents
reduction
• Wide joint space,
sesamoid in joint
CMC Subluxation +/- Fracture
• Commonly missed
• Look at CMC joint
space carefully
• Compare shaft of MC
with adjacent MC
• Reduction
• Splint
• Refer (often slip and
need pinning)
Management?
Gamekeeper’s (Skier’s) Thumb
• Ulnar Collateral Ligament of the thumb
• Stress MCP in full extension and 30 deg of
flexion to offset stabilization of volar plate
• Xray to r/o avulsion
• Sprain (partial): thumb spica X 4 weeks
• Rupture (complete)
– Splint and refer for pinning
– Stener’s lesion (adductor pollicus in the way)
Management?
High Pressure Injection Injuries
• Consider all SEVERE injuries
• Paint and paint thinners worse than grease
• Mx
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Tetanus
IV analgesia (NO digital blocks)
Antibiotic, splint, elevate, NPO
Consult plastics (early - don’t wait ‘til am)
Management?
Mutilating Hand Injuries
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R/O other injuries
Tetanus, Analgesia, Antibiotics
Irrigate gross contamination
Sterile saline dressing
Xray
NPO and consult plastics
Management?
Amputations
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R/O other injuries
Tetanus, analgesia, antibiotics, NPO
Xray, consult plastics early
Stump Mx: irrigate, saline dressing, splint
Amputated parts
– Place in sealed plastic bag
– Place bag in ice water (NOT on ice b/c frostbite
will cause tissue damage) ---> ideal temp 4 deg
Amputations Continued
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Canada/US = early
UK = late (surgery the next morning)
Plastics to decide to Replant and who not
Contraindications for Replantation
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Unstable patient with other injuries
Multiple level amputations
Single digit proximal to FDS insertion (relative)
Vasoculopath: DM, PVD, CAD, CVA
Age
Management?
• I cut my
finger here...
• I cut my
finger here...
Digital Nerve Laceration
• Refer for potential repair for anything
proximal to DIP
• DIP and distal -----------> multiple branches
thus difficult to repair
Fingertip Amputations
• Zones
• Management
controversial
• Maintain as much
length as possible
• Children heal well by
secondary intention
Fingertip Amputations
• NO exposed bone
– < 1cm exposed: Polysporin, jelonet dressing,
heal by secondary intention
– > 1cm exposed: consider referral for flap if
there isn’t adequate soft tissue coverage
• Exposed bone
– rongeur bone back enough to get tissue
coverage, dress, heal by secondary intention,
Drsg changes,f/u
Flexor Tendons
• Close wounds, splint, refer to plastics
• FDP Avulsion/Rupture
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Common athletic injury
Hyperextension of flexed finger (jursi grab)
Tendon can retract into the palm
Splint and refer for repair
Extensor Tendon Injuries:
ED Management and Follow-up
Can emerg do this?
• One Study (Evans JD; 1995)
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EM housestaff in UK repaired 65 extensor tendon lacs
follow-up within 6 mos. re: functional outcome
Proximal injuries: 80% good to excellent results
Distal injuries: 18% good to excellent
weaknesses: unconventional splinting of distal injuries,
poor physio f/u, small numbers
• conclusion: we don’t know how we’re doing!
Emerg role in repair of extensor?
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Make sure you know what you’re doing
Appropriate splinting and referral to hand physio
Proximal injuries easier to repair
Consider discussing with plastics b/f repair
especially if you want them to follow
• Splint and refer
– can’t locate ends, ends shattered, can’t decifer anatomy,
inadequate previous experience
Verdan’s zones of injury
• 8 zones of injury
• each zone has:
– particular injuries
– variations in acute
management
– different splinting
requirements
• not all extensor tendon
injuries are the same!!
Which suture material?
• No evidence
• Absorbable vs. non-absorbable synthetics
– non-absorbs most often used, but may cause
knot irritation at site of repair
– absorbs less prone to producing knot irritation,
but ? strength
• Size: 4.0-5.0
Which suture technique?
• No consensus in literature or amongst hand
surgeons
• Options
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Figure of Eight
Box
Bunnel
Kessler
suture techniques
• Bunnel suture
• advantages:
– strong
• disadvantages:
– time constraints
– technical skills
– need good tendon
cross-sectional area
suture techniques
• Kessler suture
• advantages:
– strong
• disadvantages:
– time constraints
– technical skills
– need good tendon
cross-sectional area
suture techniques
• horizontal mattress
suture
• advantages:
– easy to do, even on
thinner tendons
• disadvantages:
– decreased strength
Incomplete lacerations:
General Recommendations
• Recommendations NOT literature based
• < 25%
– do not need repair
• 25 - 50%
– may be repaired
– ? splint for shorter time
• > 50%
– should be repaired
What about antibiotics?
• Little evidence specific to simple tendon lacs
• ACEP Guidelines:
– abx indicated for both hand and tendon lacs
• Absolute indications:
– bites, crush injuries, associated open fractures, joint
capsule disruption
Splinting and Hand
Physiotherapy
• Complicated --------> ROM and
strengthening exercises differ for each
injury
• Need to when to send to physio
• Distal Injuries (Zones 1 - 4)
– Splint and see physio at 6 weeks
• Proximal Injuries (Zone 5 - 7)
– Splint and see physio at 4 weeks
Zone 1: mallet finger
• Common injury
• Goals of management
– <10 degrees of
extension lag
– good flexion
– prevention of
swanneck deformity
Closed Mallet Finger
Management of
Closed Mallet Finger
Tendon Rupture but
NO fracture
Splint X 6
weeks
Avulsion Fracture
Small frag
(<25%)
Large frag
(>25%)
Splint X 6wks
Refer for pin
Open mallet finger
• Roll or figure of 8
suture
• Splint
• Remove suture 14days
• Splint X 6 weeks
• Cover with abx
Mallet finger: physio
• STRICT extension 6wk
• MUST keep in extension when splint off
• At 6 weeks
– Start ROM
• 20 degrees week 6, 30 degrees week 7
– Night splinting x 2w
– Extension lag: stop ROM and wear splint X
2wks
Swan-neck deformity
• Complication of
Mallet finger
• DIP is flexed b/c of
loss of extension
• Lateral bands displace
dorsally and lock PIP
in hyperextension
Zone 2: middle phalanx injuries
• most injuries are either partial lacs/crush injuries
• referral criteria similar to open mallet
• suture technique:
– lateral bands are very friable and difficult to suture
– suture type: figure-of-8
– epl on thumb: use core-type suture
• splinting and follow-up as for mallet finger
– wound care and splinting x 7-10d for partial lacs <50%
Zone 3: the PIP
• worst prognosis of
extensor tendon
injuries
• consider central slip
and lateral bands
Closed zone 3: Central Slip
Rupture or Avulsion
• Second MC athletic finger injury
• Forced flexion of extended finger (finger jam)
• High degree of suspicion if:
– PIP extensor lag > 20 degrees (with MCP/wrist flexed)
– Decreased strength or pain with resistance to extension
– Tenderness over dorsal PIP and appropriate mechanism
• May present with acute Boutonniere deformity
– need to assess laxity of lateral bands via passive PIP
extension
• Xray to r/o avulsion
Closed zone 3: central slip
rupture or avulsion
• Mx
– Extension splint for 6 weeks (leave DIP free)
– Refer to physio at 6 weeks for ROM exercises
• Splint and refer for
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avulsion # at base of middle phalanx
unstable joint (associated collateral injury)
irreducible volar dislocation
Boutonniere deformity not correctable by
passive PIP extension
Boutonierre Deformity
• Complication of Zone
III rupture
• DIP in extension
• PIP in flexion b/c
lateral bands slip
volarly hand hold in
flexion
Open zone 3 tendon injury
• Lacs rarely involve entire dorsal apparatus
• Also may result in Boutonniere deformity
• Suture, abx, extension splint, refer to hand
physio at 6 weeks
• Refer
– distal central slip stump too short to repair
– associated w/open #
– acute boutonniere deformity
Zone 3 injuries: physio
• Much more complex than DIP (hand physio at 6w)
• 6 w weeks:
– active PIP extension w/MCP in flexion
– reapply splint between hand physio sessions
– if extensor lag develops, reapply splint
• 8 weeks
– continue active flexion, gentle resistance applied; splint
at night
• 10 weeks
– increase resistance exercises, progress to full grasp
Zone 4 injuries: proximal
phalanx
• Tendon very broad at this level; usually partial lac
• Partial laceration (extension intact)
– Consider repair if > 25 - 50%
– Splint X 3 weeks and then begin active motion
• Complete laceration
– Suture as for PIP lacs
– Mobilize at 3-4w b/c of higher degree of “scarring
down” at this zone
– f/u and OT/PT as for PIP injuries
Closed zone 5
• Injuries are rare and usually due to a crush
mechanism over the MCP
• Classic: tendon dislocation and relocation with
passive extension
• Suspect sagittal band/dorsal hood disruption when
painful flexion at MCP occurs
• Who to refer: all injuries
• ED management:
– splint w/MCP in extension at place of tendon relocation
– leave other MCPs free to move
Open zone 5
• Fight bite
– +++ irrigation and exploration required
– evaluate for joint capsule and tendon disruption: abx
and refer
– underlying structures OK: leave wound open, abx,
wound check in 3 - 5d
– tendon laceration: leave wound open, abx, splint, refer
to plastics
Zone 5 Anatomy
• Saggital bands
– arise from interMC
ligaments, volar plate,
lumbrical and cover the
tendon to prevent
subluxation
• Dorsal hood
– is another name for
saggital bands as they
extend dorsally over
the tendon
Open zone 5
• Suture and splint X 4weeks; f/u with physio
• Splint wrist in 40 degrees extension, MCPs
20 degrees flexion, and IPs in 0 degrees
• Saggital band and dorsal hood
– repair if involved
– isolated sagittal band or dorsal hood lac:
• avoiding abduction/adduction motion, buddy tape,
begin flexion/extension in 3-5 days
open zone 5: f/u & OT/PT
• 4 weeks
– gentle active extension at MCP
– alternating flexion of MCP and IPs
– splint worn b/w sessions
• 5weeks
– claw postion to encourage extrinsic extension
– alternate finger and wrist flexion
– night splinting only, unless extensor lag persists
• 7 weeks
– resisted exercises
Zone 6 and 7 injuries
• Easier to locate and suture
• Splinting
– wrist in 40 degrees extension, MCPs 20 degrees
flexion, and IPs in 0 degrees X 4 weeks
• Physio at 4 weeks for ROM exercises
hand resources: OT & PT
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FHH hand clinic: 670-1432
Lindsay Park: 221-8340
PLC: 291-8785
RVH: ph 943-3575, fax 943-3332
– fill out form, refer from ED
– OT/PT will contact pt based on priority
• ACH: ph 229-7912, fax 541-7501
– fill out form, refer from ED
– OT/PT will contact pt w/i 48h
The End of the DAY
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Know how to manage common injuries
Recognize serious injuries
If you don’t know, ask
Be willing to follow some things in ED