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HAND INJURIES Peter Freeman

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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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Presentation Transcript
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HAND

INJURIES

Peter Freeman

essentials
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
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
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
NERVE SUPPLY TO THE HAND

Radial

Median

Ulnar

examination6
EXAMINATION
  • Test function

- tendons (FDP, FDS and extensors)

- grip

- joint stability

  • Deformity, rotation, loss of function
  • Pain
investigations
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
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
FINGERTIP INJURIES
  • Classification of fingertip amputations
nailbed injuries
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
terminalization
TERMINALIZATION
  • Explain options with patient
  • Discuss with specialist
  • Local anaesthetic
  • Remove nail root
  • Diathermy digital nerves and vessels
  • Loose closure and avoid dog ears
distal interphalangeal joint injuries
DISTAL INTERPHALANGEAL JOINT INJURIES
  • Mallet finger (always Xray)
  • Dislocations
  • Fractures
  • Wounds

- digital nerves

middle phalangeal injuries
MIDDLE PHALANGEAL INJURIES
  • Profundus tendon
  • Fractures often require ORIF
  • Unstable
  • Discuss with hand specialist
proximal interphalangeal joint injuries
PROXIMAL INTERPHALANGEAL JOINT INJURIES
  • Most unforgiving joint
  • Extensor apparatus
  • Boutonniere deformity
  • Volar plate
  • Wilson #
  • Joint instability
  • Splint and refer
proximal phalangeal injuries
PROXIMAL PHALANGEAL INJURIES
  • Profundus and superficialis tendons
  • Unstable fractures require ORIF
  • Rotational deformity
  • Refer hand specilaist
  • Spint in position of function/recovery
metacarpophalangeal joint injuries
METACARPOPHALANGEAL JOINT INJURIES
  • MPJ subluxation - often missed
  • Fist-tooth injury

- always involves joint

- irrigation

- antibiotics

  • Ulnar collateral ligament tears
metacarpal injuries
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
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
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
DISPOSITION
  • Many hand injuries can be appropriately managed in a well equipped emergency department
  • Refer early when indicated
  • Elevation
  • Analgesia
prognosis
PROGNOSIS
  • Early definitive care optimal
  • Late injury difficult to salvage due to stiffness
  • Functional splintage (extrinsic plus)
  • Early guarded mobilisation
  • Desensitise finger tips
prevention
PREVENTION
  • Children\'s finger tips
  • Occupational injuries

- butchers

controversies
CONTROVERSIES
  • Fingertip dressings
  • Hand splintage
  • Fifth metacarpal fractures
  • Foreign bodies
  • To suture or not?
  • Adrenaline
  • Antibiotics
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