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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

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HAND

INJURIES

Peter Freeman


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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


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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


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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


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NERVE SUPPLY TO THE HAND

Radial

Median

Ulnar


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EXAMINATION

  • Test function

    - tendons (FDP, FDS and extensors)

    - grip

    - joint stability

  • Deformity, rotation, loss of function

  • Pain


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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


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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


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FINGERTIP INJURIES

  • Classification of fingertip amputations


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NAILBED INJURIES

  • Often underestimated

  • Trephine subungual haematoma < 25%

  • Remove nail if > 25%

  • Reduce # terminal phalanx

  • Repair nail bed with 6/0 absorbable

  • Nail regrowth - 1mm/wk


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TERMINALIZATION

  • Explain options with patient

  • Discuss with specialist

  • Local anaesthetic

  • Remove nail root

  • Diathermy digital nerves and vessels

  • Loose closure and avoid dog ears



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DISTAL INTERPHALANGEAL JOINT INJURIES

  • Mallet finger (always Xray)

  • Dislocations

  • Fractures

  • Wounds

    - digital nerves


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MIDDLE PHALANGEAL INJURIES

  • Profundus tendon

  • Fractures often require ORIF

  • Unstable

  • Discuss with hand specialist


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PROXIMAL INTERPHALANGEAL JOINT INJURIES

  • Most unforgiving joint

  • Extensor apparatus

  • Boutonniere deformity

  • Volar plate

  • Wilson #

  • Joint instability

  • Splint and refer


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PROXIMAL PHALANGEAL INJURIES

  • Profundus and superficialis tendons

  • Unstable fractures require ORIF

  • Rotational deformity

  • Refer hand specilaist

  • Spint in position of function/recovery


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METACARPOPHALANGEAL JOINT INJURIES

  • MPJ subluxation - often missed

  • Fist-tooth injury

    - always involves joint

    - irrigation

    - antibiotics

  • Ulnar collateral ligament tears


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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


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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.


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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)


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DISPOSITION

  • Many hand injuries can be appropriately managed in a well equipped emergency department

  • Refer early when indicated

  • Elevation

  • Analgesia


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PROGNOSIS

  • Early definitive care optimal

  • Late injury difficult to salvage due to stiffness

  • Functional splintage (extrinsic plus)

  • Early guarded mobilisation

  • Desensitise finger tips


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PREVENTION

  • Children's finger tips

  • Occupational injuries

    - butchers


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CONTROVERSIES

  • Fingertip dressings

  • Hand splintage

  • Fifth metacarpal fractures

  • Foreign bodies

  • To suture or not?

  • Adrenaline

  • Antibiotics


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