hand surgery for trauma

1. Hand Surgery for Trauma Mr CW Oliver FRCS (Tr & Orth) DM Lecture Notes and images of the practice of Hand Surgery for trauma. Presentation for medical students, BST and SpR. Notes prepared by CWO. Slides mainly by GJM. Some material from Mr Hooper, St John’s and Charles Eaton, Handworld (www.eatonhand.com). Copyright of this material remains with the original authors.Lecture Notes and images of the practice of Hand Surgery for trauma. Presentation for medical students, BST and SpR. Notes prepared by CWO. Slides mainly by GJM. Some material from Mr Hooper, St John’s and Charles Eaton, Handworld (www.eatonhand.com). Copyright of this material remains with the original authors.

2. Manual worker v Housewife Different functions Manual worker v Housewife Different functions

3. Normal hand position Important to identify what is physiological and what is pathological. Note smooth arcade and position of fingers With no malrotation. No abnormal position of fingers indication possible tendon rupture. Nomenclature of fingers is thumb, index, middle, ring, little (pinkie). DO NOT use 1st, 2nd, 3rd, 4th, 5th finger as this causes confusionImportant to identify what is physiological and what is pathological. Note smooth arcade and position of fingers With no malrotation. No abnormal position of fingers indication possible tendon rupture. Nomenclature of fingers is thumb, index, middle, ring, little (pinkie). DO NOT use 1st, 2nd, 3rd, 4th, 5th finger as this causes confusion

4. Position of rest As in normal hand positionAs in normal hand position

5. Hand - oedema Oedema in hand makes it stiff quickly Oedema forms on dorsal surface as volar surface is fixed to palm to stop skin slidingOedema in hand makes it stiff quickly Oedema forms on dorsal surface as volar surface is fixed to palm to stop skin sliding

6. Position of immobilisation “Edinburgh position”. Keeps Collateral ligaments of phalanges taunt under tension so will make hand easier to rehabilitate in longer term. Supervise all Zimmer Splint Application.“Edinburgh position”. Keeps Collateral ligaments of phalanges taunt under tension so will make hand easier to rehabilitate in longer term. Supervise all Zimmer Splint Application.

7. Hand functional positions Functional positions of hand are important to achieve everyday tasksFunctional positions of hand are important to achieve everyday tasks

8. Elevation? Poor practice. Oedema tends to flow downhill, this hand will remain swollen. Look for other areas of constriction around elbowPoor practice. Oedema tends to flow downhill, this hand will remain swollen. Look for other areas of constriction around elbow

9. Missed Upper Limb Injuries Look for missed injuries in upper limb. Hand trauma - commonly missed injuries: Partial laceration, Fracture Scaphoid, Hamate, epiphyseal, Dislocations – perilunate, Compartment syndrome, Posterior Dislocation of shoulderLook for missed injuries in upper limb. Hand trauma - commonly missed injuries: Partial laceration, Fracture Scaphoid, Hamate, epiphyseal, Dislocations – perilunate, Compartment syndrome, Posterior Dislocation of shoulder

10. Hand incisions Classic safe hand incisions. Always beware of nerves. Respect soft tissue flaps.Classic safe hand incisions. Always beware of nerves. Respect soft tissue flaps.

11. Hand incisions Classic safe hand incisionsClassic safe hand incisions

12. Normal alignment and rotational deformity Malrotation is difficult to cope with and requires correction. Do not accept more than 3 to 5 degrees. Look at end of nails to assess malrotation. Watch the fingers move also if hand not too painful to assess malrotation.Malrotation is difficult to cope with and requires correction. Do not accept more than 3 to 5 degrees. Look at end of nails to assess malrotation. Watch the fingers move also if hand not too painful to assess malrotation.

13. Hand Fractures A logical approach to hand fractures requires a understanding of the structure and function of the hand. Not all hand fractures need surgery. Always look for malrotation and shortening as the patient will cope with these potential deformities lees well. Multiple fractures require stable internal fixation.A logical approach to hand fractures requires a understanding of the structure and function of the hand. Not all hand fractures need surgery. Always look for malrotation and shortening as the patient will cope with these potential deformities lees well. Multiple fractures require stable internal fixation.

14. Metacarpal fracture: transverse Held stable by inter-transverse ligaments. Generally does not need fixation. Malrotation is rare. Neighbour strap ring/middle finger for 3/52. If malrotation ORIF with plate.Held stable by inter-transverse ligaments. Generally does not need fixation. Malrotation is rare. Neighbour strap ring/middle finger for 3/52. If malrotation ORIF with plate.

15. Hand Fracture Treatment

16. Metacarpal fracture: oblique Held stable by inter-transverse ligaments. Generally does not need fixation. Malrotation is rare. Neighbour strap ring/middle finger for 3/52. If malrotation ORIF with plate. If two metacarpals or more fractured on either ulnar or radial side of hand ORIF with plate. Held stable by inter-transverse ligaments. Generally does not need fixation. Malrotation is rare. Neighbour strap ring/middle finger for 3/52. If malrotation ORIF with plate. If two metacarpals or more fractured on either ulnar or radial side of hand ORIF with plate.

17. Boxer’s fracture Common injury. Fighting + Alcohol. May not get true story from patient. Literature says can accept up to 70 degrees deformity in volar plane. Correct any malrotation by K wire fixation as this does not remodel. Two wires in mal-rotated little finger metacarpal head going to ring finger metacarpal, retain wire for 3/52. Warn of dropped knuckle in long term.Common injury. Fighting + Alcohol. May not get true story from patient. Literature says can accept up to 70 degrees deformity in volar plane. Correct any malrotation by K wire fixation as this does not remodel. Two wires in mal-rotated little finger metacarpal head going to ring finger metacarpal, retain wire for 3/52. Warn of dropped knuckle in long term.

18. Inter articular Fracture ORIF as involve joint. Thumb – plate and screws 1.5mm, Ring Finger – screws only 1.0mmORIF as involve joint. Thumb – plate and screws 1.5mm, Ring Finger – screws only 1.0mm

19. Blade Plate Fixation Phalanx Difficult mal-rotated basal fracture of little finger held with blade plateDifficult mal-rotated basal fracture of little finger held with blade plate

20. Epiphyseal fracture Damage to nail bed. Reduce nail bed and fracture. Retain nail as acts as splint. Generally does not need crossed K wire.Avoid Axial K wire as can damage tip of finger shape and sensation permanently.Damage to nail bed. Reduce nail bed and fracture. Retain nail as acts as splint. Generally does not need crossed K wire.Avoid Axial K wire as can damage tip of finger shape and sensation permanently.

21. Bennett’s fracture Extra-articular fracture. Reduce and hold in POP for %/52. If significantly displaced need to K wire using Wagner technique. Retain wires for no longer than 4/52. Hold in Pop for a further 2/52.Extra-articular fracture. Reduce and hold in POP for %/52. If significantly displaced need to K wire using Wagner technique. Retain wires for no longer than 4/52. Hold in Pop for a further 2/52.

22. Rolando fracture Intra-articular fracture base of thumb. K wire using Wagner technique.Intra-articular fracture base of thumb. K wire using Wagner technique.

23. Scaphoid waist fracture Undisplaced. Hold in scaphoid cast for 6/52. If displaced ORIF with Herbert screw (as above) Two screws as more stable if you are clever. Alternative is Acutrack cannulated screw which can be inserted percutanoeusly by skilled surgeon. If ORIF not attempted will go onto to become scaphoid non-malunion.Undisplaced. Hold in scaphoid cast for 6/52. If displaced ORIF with Herbert screw (as above) Two screws as more stable if you are clever. Alternative is Acutrack cannulated screw which can be inserted percutanoeusly by skilled surgeon. If ORIF not attempted will go onto to become scaphoid non-malunion.

24. Unstable scaphoid non-union Proximal CID (Carpal Instability Dissociative). DISI (Dorsal Intercalated Segmental Instability) pattern of carpal malalignment volar wedge shaped graft+/- ORIF The treatment of wrist instability. Instructional Course Lecture - JBJS(b) ~ July 97 Garcia-Elias 684-690Proximal CID (Carpal Instability Dissociative). DISI (Dorsal Intercalated Segmental Instability) pattern of carpal malalignment volar wedge shaped graft+/- ORIF The treatment of wrist instability. Instructional Course Lecture - JBJS(b) ~ July 97 Garcia-Elias 684-690

25. Hook of Hamate Fracture Hook of hamate fracture. Seen only on the 2d and 3D CT. Leave alone treat in splint for 3/52. May have ulnar nerve compression symptoms Hook of hamate fracture. Seen only on the 2d and 3D CT. Leave alone treat in splint for 3/52. May have ulnar nerve compression symptoms

26. Lunate dislocation Rare. Often missed. Always take care to look as carpus in on all x-rays of the wrist. Can present with acute median nerve compression which is very painful. If acute median nerve compression will have to decompress through a volar approach. Otherwise MUA and reduce. EUA for stability, My preference is to always stabilise with K wires similar to Scapholunate dissociation.Rare. Often missed. Always take care to look as carpus in on all x-rays of the wrist. Can present with acute median nerve compression which is very painful. If acute median nerve compression will have to decompress through a volar approach. Otherwise MUA and reduce. EUA for stability, My preference is to always stabilise with K wires similar to Scapholunate dissociation.

27. Scapholunate dissociation Complete disruption of SL ligament. scaphoid rotates around the radiocapitate ligaments. repair dorsal portion of SL interosseous membrane. stabilise with K wires two months. Can repair SL ligament with suture anchors (Mitek). Hold in cast for 6/52 then splint for 6/52. Retain K wires for 6/52. Best results are achieved if repairs done within first one week after injury. Complete disruption of SL ligament. scaphoid rotates around the radiocapitate ligaments. repair dorsal portion of SL interosseous membrane. stabilise with K wires two months. Can repair SL ligament with suture anchors (Mitek). Hold in cast for 6/52 then splint for 6/52. Retain K wires for 6/52. Best results are achieved if repairs done within first one week after injury.

28. PIPJ dislocation Reduce by ring block. Always use plain lignocaine NO Adrenaline. Buddy strap mobilise early. Send straight to physio from hand clinic.Reduce by ring block. Always use plain lignocaine NO Adrenaline. Buddy strap mobilise early. Send straight to physio from hand clinic.

29. Volar avulsion Volar plate injury. Buddy strap mobilise early. Can use Bedford sleeve. Send straight to physio from hand clinic. Warn all patients that they will have swelling around PIPJ for several months. Some more elder patients may develop permanent swelling around PIPJ. Volar plate injury. Buddy strap mobilise early. Can use Bedford sleeve. Send straight to physio from hand clinic. Warn all patients that they will have swelling around PIPJ for several months. Some more elder patients may develop permanent swelling around PIPJ.

30. MCPJ dislocation Reduce by ring block. Always use plain lignocaine NO Adrenaline. Buddy strap mobilise early. Send straight to physio from hand clinic. Reduce by ring block. Always use plain lignocaine NO Adrenaline. Buddy strap mobilise early. Send straight to physio from hand clinic.

31. UCL sprain Compare both hands. Look for stop end point. Compare both hands. Look for stop end point.

32. UCL rupture My own preference is to put in Bennett's cast for 3/52 then Examine in clinic. Send to physio. May need a removable Orthotic thumb splint for a few weeks once in physio. My own preference is to put in Bennett's cast for 3/52 then Examine in clinic. Send to physio. May need a removable Orthotic thumb splint for a few weeks once in physio.

33. ‘Bony’ UCL Repair with Acier wire if available. Cast for 5/52. Then physioRepair with Acier wire if available. Cast for 5/52. Then physio

34. Mallet deformity Need to x-ray to determine if a boney mallet. If boney and > 1/3 of articular surface ORIF either with 1.0mm mini-screw if fresh fracture of K wire. Otherwise hold in Mallet splint for 6/52. Whatever treatment all patients end up with an extension loss of around 20 degrees.Need to x-ray to determine if a boney mallet. If boney and > 1/3 of articular surface ORIF either with 1.0mm mini-screw if fresh fracture of K wire. Otherwise hold in Mallet splint for 6/52. Whatever treatment all patients end up with an extension loss of around 20 degrees.

35. Flexor tendon injury Examine for profundus and superficialis. “Expect the worst and hope for the best”. Check for Never damageExamine for profundus and superficialis. “Expect the worst and hope for the best”. Check for Never damage

36. Zones for tendon repair Five zones. Zone 2 was the no-mans land which is now a historical concept in terms of tendon repair but repairs are more difficult in this area.Five zones. Zone 2 was the no-mans land which is now a historical concept in terms of tendon repair but repairs are more difficult in this area.

37. Methods of tendon repair Strickland variants and Kessler.Strickland variants and Kessler.

38. Profundus Avulsion Rugger jersey injury. Often missed. Needs replantation of avulsed tendon urgently as tendon tends to continue to migrate more proximally.Rugger jersey injury. Often missed. Needs replantation of avulsed tendon urgently as tendon tends to continue to migrate more proximally.

39. Open fractures - classification Type I tidy wound < 1cm Type II tidy wound 1-2 cm Type IIIA >2cm; soiled Type IIIB IIIA + periosteal stripping Type IIIC neurovascular damage Duncan JHS 1993 Duncan JHS 1993

40. Severe hand injury survey Blood supply Stable skeleton Viable skin cover Basic function Occupation Blood supply, Stable skeleton, Viable skin cover, Basic function, Occupation Blood supply, Stable skeleton, Viable skin cover, Basic function, Occupation

41. Serious hand trauma-after debridement Longitudinal/ extensile exposures Compartment decompression Skeletal alignment/ fixation Musculo-tendon repair Vessel repair/ graft Nerve repair Serious hand trauma after debridementSerious hand trauma after debridement

42. Replantation - indications All amputations at the level of the arm, forearm, carpus and metacarpus All amputations of thumb prox to mid distal phalanx In multiple digits replant as many as possible Most digits amputated distal to prox phalanx Children Think about avulsed digits and crushed distal parts Replantation - indicationsReplantation - indications

43. Hand Replantation 7 months off work 50% get only protective sensation 50% range of movement 60% need > 2 operations Medical cost 5-15 times amputation Consider occupation Consider occupation

44. Nerve Repair Partial nerve Full nerve Regrow at 1mm per day Splintage rehabilitation

45. Hand Infection Bacterial Viral Fungal Protozoal 64% grow multiple organisms Stern JHS-A 1983 60% Staphylococcus, 16% Streptococcus, 16% Enterococci, 2% PseudomonasStern JHS-A 1983 60% Staphylococcus, 16% Streptococcus, 16% Enterococci, 2% Pseudomonas

46. Hand Infection: anatomical compartments Nail fold (paronychia) Pulp space Tendon sheath Web space Deep palmar space Septic arthritis

47. Infection: history Occupation dentists/nurses (H Simplex) barbers (pilonidal sinus) water (m. marinum) Systemic disease HIV, diabetes, immunocompromise Previous injury (human) bite, needle stick Human bites worse than animalHuman bites worse than animal

48. Infection: history Time lapse cellulitis 24 hours tendon sheath 48 hours web space deep palm days paronychia pulp space 4-5 days septic arthritis <2 weeks

49. Web space infection Web space infection. Suspect diagnosisWeb space infection. Suspect diagnosis

50. Deep palmar infection Severe pain, Gross oedema (dorsal), Loss of palmar concavity, Fixed posture of fingers, May passively flex IP jointsSevere pain, Gross oedema (dorsal), Loss of palmar concavity, Fixed posture of fingers, May passively flex IP joints

51. Collar stud abscess Look for underlying abscess formationLook for underlying abscess formation

52. Infection: tendon sheath Finger in slight flexion Uniformly red and swollen Intense pain on attempted extension Tenderness along line of sheath Often missed diagnosis as treated septic arthritis or masked by earlier antibiotic admistration. Beware immunosupressed.Often missed diagnosis as treated septic arthritis or masked by earlier antibiotic admistration. Beware immunosupressed.

53. Drainage of tendon sheath Catheter wash through techniqueCatheter wash through technique

54. Drainage of mid-palmar space IncisionsIncisions

55. Infection: septic arthritis Usually secondary to human bite Swelling out of proportion to inflammation Restricted motion Instability Discharging sinus X-ray changes (2/52)

56. Paronychia Drain, lateral nail fold incisionDrain, lateral nail fold incision

57. Pulp space infection Drain laterally, appropriate IV antibioticsDrain laterally, appropriate IV antibiotics

58. Herpetic whitlow Antiviral treatmentAntiviral treatment

59. Hand trauma and IV Drug Abuse HIV, immunocompromised. Heparin overdose, IV dug abusers.HIV, immunocompromised. Heparin overdose, IV dug abusers.