Transcript No Slide Title

HAND
INJURIES
Peter Freeman
ESSENTIALS
• A thorough knowledge of hand anatomy
and function is essential for proper
management of the injured hand
• Most hand injuries carry a good
prognosis if treated early and
appropriately
• Aftercare and rehabilitation are vital
PRESENTATION
• History
– Time taken eliciting an accurate history of
the mechanism of injury is never more
important than in the case of hand injury
– When, how, where?
– Hand dominance
– Occupation
EXAMINATION
• The injured hand must be examined in
a well-lit cubicle with the patient
comfortably reclined
• Deformity, swelling, position of wound
• Resting position
• Tenderness and sensation
NERVE SUPPLY TO THE
HAND
Radial
Median
Ulnar
EXAMINATION
• Test function
- tendons (FDP, FDS and extensors)
- grip
- joint stability
• Deformity, rotation, loss of function
• Pain
INVESTIGATIONS
• Most information will be obtained from
a full history and examination
• Radiology of the hand and fingers will
be necessary if bone or joint deformity
or tenderness is elicited
CLASSIFICATION
• Hand injuries are usually described by
tissue, e.g. tendon, nerve or bone injury
• A more practical approach is to describe
injuries by anatomical site
FINGERTIP INJURIES
• Classification of fingertip amputations
NAILBED INJURIES
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Often underestimated
Trephine subungual haematoma < 25%
Remove nail if > 25%
Reduce # terminal phalanx
Repair nail bed with 6/0 absorbable
Nail regrowth - 1mm/wk
TERMINALIZATION
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Explain options with patient
Discuss with specialist
Local anaesthetic
Remove nail root
Diathermy digital nerves and vessels
Loose closure and avoid dog ears
DIGITAL NERVE BLOCK- PALMAR
APPROACH
DISTAL INTERPHALANGEAL JOINT
INJURIES
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Mallet finger (always Xray)
Dislocations
Fractures
Wounds
- digital nerves
MIDDLE PHALANGEAL
INJURIES
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Profundus tendon
Fractures often require ORIF
Unstable
Discuss with hand specialist
PROXIMAL INTERPHALANGEAL
JOINT INJURIES
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Most unforgiving joint
Extensor apparatus
Boutonniere deformity
Volar plate
Wilson #
Joint instability
Splint and refer
PROXIMAL PHALANGEAL INJURIES
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Profundus and superficialis tendons
Unstable fractures require ORIF
Rotational deformity
Refer hand specilaist
Spint in position of function/recovery
METACARPOPHALANGEAL JOINT
INJURIES
• MPJ subluxation - often missed
• Fist-tooth injury
- always involves joint
- irrigation
- antibiotics
• Ulnar collateral ligament tears
METACARPAL INJURIES
• 5th MCP fracture (punching)
- best treated conservatively
• Bennett’s fracture (intra-articular)
- often requires ORIF
• 2nd, 3rd and 4th MCP fracture
- volar spint in position of recovery
DORSAL HAND INJURIES
• Kessler technique of tendon repair. An alternative
technique is to begin the suture between the tendon
ends and tie, and bury the knot within the tendon.
PALMAR HAND INURIES
• Penetrating wounds in no-mans land
- Nail gun injury (barbs)
- Grease or Paint gun injury
- Glass injury (always Xray)
- Organic material (consider US)
DISPOSITION
• Many hand injuries can be appropriately
managed in a well equipped emergency
department
• Refer early when indicated
• Elevation
• Analgesia
PROGNOSIS
• Early definitive care optimal
• Late injury difficult to salvage due to
stiffness
• Functional splintage (extrinsic plus)
• Early guarded mobilisation
• Desensitise finger tips
PREVENTION
• Children's finger tips
• Occupational injuries
- butchers
CONTROVERSIES
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Fingertip dressings
Hand splintage
Fifth metacarpal fractures
Foreign bodies
To suture or not?
Adrenaline
Antibiotics