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Presenter: DR. ALIHUSSEIN TARWADI Moderator: DR. AFULO 1.

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1 Presenter: DR. ALIHUSSEIN TARWADI Moderator: DR. AFULO 1

2 Introduction Approach to hand trauma patient Structural Injuries: ◦ Cutaneous Injuries ◦ Tendon Injuries ◦ Nerve Injuries ◦ Bone Injuries Amputation and Replantation 2

3 INTRODUCTION The hand is a very vital part of the human body 4 requirements for a functioning hand: ◦ Supple (moving with ease) ◦ Sensate Account for 5-10 % of hospital ER visits. Great potential for serious handicap Good understanding of hand anatomy and function, good physical examination skills, and knowledge of indications for treatment. Proper Initial diagnosis and timely appropriate treatment would reduce morbidity. 3 ◦ Pain free ◦ Coordinated

4 APPROACH TO HAND TRAUMA PATIENT History: General ◦ Age ◦ Hand dominance ◦ Occupation/hobbies ◦ History of previous hand problems When and where did this injury take place? ◦ Determine the likelihood of severe injury and probability of contamination with foreign matter. How was the trauma sustained? ◦ This gives clues to the most likely injury. Past history of treatment or surgery in the hand 4

5 Physical examination ◦ Entire upper limb should be exposed and carefully inspected (Muscle wasting, colour change, Asymmetry, fixed abnormal posture etc.) ◦ Extrinsic flexor and extensor muscles and their tendons’ injuries. ◦ Intrinsic muscles (Thenar, lumbricals, interossei, and hypothenar muscles) ◦ Joints’ pain and stability. ◦ Sensory examination. ◦ Circulation for colour change, Allen test. 5 APPROACH TO HAND TRAUMA PATIENT

6 Imaging Studies Radiography ◦ Plain-films of the hand or wrist should be obtained when a patient presents with a soft tissue injury suggestive of fracture or an occult foreign body. US ◦ Has a growing role in locating foreign bodies and in evaluating soft tissues ◦ Can detect ruptured tendons and assess dynamic function of tendons non-invasively. MRI ◦ Highly sensitive in detecting ruptured tendons. ◦ However, it does not have a role in emergent management of hand wounds. 6 APPROACH TO HAND TRAUMA PATIENT

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9 CUTANEOUS INJURIES 9

10 ANATOMY Dorsum surface ◦ Thin and pliable. ◦ Attached to the hand's skeleton only by loose areolar tissue, where lymphatics and veins course. ◦ Loose attachment makes it more vulnerable to degloving injuries. Palmar surface ◦ Thick and glabrous and not as pliable as the dorsal skin ◦ Strongly attached to the underlying fascia by numerous vertical fibers ◦ Most firmly anchored to the deep structures at the palmar creases ◦ Contains a high concentration of sensory nerve endings essential to the hand's normal function 10

11 PRESENTATION Cutaneous injuries are very common Two Types ◦ Open: Incised, laceration, punctured (bites), penetration, abrasion, degloving. ◦ Closed: Contusions, Hematomas Vary in depth from superficial to very deep involving underlying structures. Explore for underlying structural Injuries. 11

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13 MANAGEMENT Skin Laceration: ◦ Small: Rinse and cover. ◦ Large:  Infiltrate with Lidocaine  Irrigate wound profusely with sterile water  Drape and explore (underlying injuries and foreign bodies)  Close the skin wound with simple sutures. should not  Wounds older than 6-8 hours should not be closed primarily because of an increased likelihood of infections.  Irrigate, explore then apply sterile dressing. Re-check after 4 days for skin infection. Delayed primary closure at 4 days.  Update Tetanus vaccination. 13

14 MANAGEMENT Bites: ◦ Should not be closed primarily but should be given serial wound checks with delayed closure at 4 days if needed ◦ Antibiotic prophylaxis is indicated in human and animal bites. Contusions: ◦ Cold packs with pressure for 30 to 60 min. several times daily for 2 days. ◦ Two days after the injury, use warm compresses for 20 minutes at a time. ◦ Rest the bruised area and raise it above the level of the heart ◦ Do not bandage a bruise. 14

15 MANAGEMENT Abrasions: ◦ Superficial:  Rinse and cover.  Prophylactic antibiotic ointment ◦ Deep:  Rinse with antiseptic or warm normal saline. Scrub gently with gauze if necessary.  Dress with semi-permeable dressing. Changed every few days.  Keep wound moist. Enhance healing process. 15

16 FLAPS Large skin defects on the hand should always be covered with a full thickness skin graft or flaps (local or distant) especially on the dorsum of the hand where the tendons are superficial and application of a STSG will tether the tendons and lead to loss of hand function. 16

17 LOCAL FLAPS 17 RHOMBOID LIMBERG FLAP

18 LOCAL ROTATIONAL FLAP 18

19 V-Y ADVANCEMENT FLAP 19

20 KUTLER’S BILATERAL TRIANGULAR ADVANCEMENT FLAP 20

21 STANDARD CROSS FINGER FLAP When there is a loss of greater that 1/3 of the volar tissue of the fingertip especially with exposed flexor tendon, joint, or bone. Where more tissue is required than with advancement-type flaps. 21

22 Reverse cross finger flap The epidermis and papillary dermis are divided and the reticular dermis and subcutaneous tissue have been used to cover the dorsum of an adjacent digit. The skin flap is laid back into place over the donor site and a full-thickness graft is then placed on the reverse flap. 22

23 THENAR FLAP 23

24 ANNULAR FLAP 24

25 Homodigital bipedicle island advancement flap 25

26 Reverse vascular pedicle island flap 26

27 REGIONAL FLAPS Reverse radial artery flap 27

28 DORSAL ULNAR ARTERY FLAP 28

29 Posterior interosseous forearm flap 29

30 DISTANT FLAPS Sub mammary flap 30

31 GROIN FLAP 31

32 Role of STSG Can be used if there is adequate tissue cover over bone and tendons with only loss of skin. AlloDerm ® Can be used with dermal allografts like AlloDerm ® (commercially available acellular dermis derived from human skin) Used to cover some donor sites 32

33 TENDON INJURIES 33 Acute Chronic

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38 PRESENTATION Extensor injury Extensors Injury: ◦ Divided into Zones according to anatomical location of injury 38

39 PRESENTATION 39

40 40 Zone 5 Zone 1 Boutonniere’s Deformity Zone 3

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42 MANAGEMENT ZonePresentationManagement IMallet’s Deformity Closed: splinting 6-8 weeks Open: suture repair for fixation. Soft tissue reconstruction III Boutonniere’s Deformity Closed: splinting MCP and PIP in hyperextension for 6 weeks Open: suture repair (figure of 8 suture) V Fixed flexion of MCP Closed: splinting,45 extension at wrist and 20 flexion at MCP Open: suture repair. 42

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44 PRESENTATION FLEXOR TENDON INJURY Flexor Injury ◦ Divided into Zones according to anatomical location of injury 44

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47 PRESENTATION 47 ZonePresentationManagement I Loss of active flexion at DIP joint Hyperextension of DIP joint Primary or Secondary tendon repair Careful suturing prevent post- op adhesions. II (No Man’s Land) Loss of active flexion at MCP joint Skin closure then secondary repair by tendon grafting Primary repair performed by skilled hand surgeon to minimize post-op adhesions. III, IV Thumb Same Primary or secondary tendon repair Examine carefully for thenar muscle injury and recurrent branches of median nerve.

48 PRESENTATION 48 ZonePresentationManagement V Palm Uncommon Lie deep and protected by palmar fascia Same presentation Superior to Tendon division: repair is unnecessary. Both muscles’ tendon division: primary repair VI, VII Wrist Multiple flexor tendon injury Impaired active flexion of multiple digits Primary tendon suturing further proximal in the forearm to prevent post-op cross- adherence. Injuries to muscles in forearm require primary repair Post-op splinting of wrist in flexion position and elevation for 4 weeks.

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50 CHRONIC TENDON INJURIES OF THE HAND Swan Neck Deformity Flexed DIP, hyperextended PIP Interruption of distal extensor mechanism Causes: ◦ Chronic Mallet finger ◦ Fracture malunion ◦ Volar plate injury to PIP ◦ Rheumatoid arthritis ◦ Ligament laxity Treatment: surgical mostly but splints can be used to relieve contractures 50

51 Gamekeeper’s/ skier’s thumb Injury to ulnar collateral lig of the 1 st MCPJ, sometimes associated with fractr base of PP Conservative managmnt with splint but mostly requires surgical repair 51

52 De QUERVAIN’S TENOSYNOVITIS Stenosing tenosynovitis of the first dorsal compartment APL & EPB trapped in fibroosseous tunnel formed by radial styloid and flexor retinaculum Symptoms include: pain over styloid process on thumb or wrist movemnt and a positive finklestein test Treatment: thumb spica, NSAIDS and steroid injection in 1 st compartment. 52

53 Trigger finger and Thumb Stenosing tenosynovitis, leading to inability to extend the flexed digit “triggering”. Involvement of the first annular part of the flexor sheath (A1 annulus) Treatment: ◦ Splinting +heat/cold ◦ Local steroid inj ◦ Sx release of A1 pully 53

54 EPL Tendinitis (Drummer boy palsy) Seen in rheumatoid arthritis or previous distal radius fracture. Pain, swelling and crepitus over 3 rd dorsal compartment Treatment: ◦ Spica ◦ NSAIDS ◦ Surgical release NO steroid injection 54

55 Dupuytren's contracture Inherited proliferative connective tissue disease affecting the palmar fascia causing it to harden (collagen I- III) Incidence after 40, M>F. after 80 M=F Affects mostly ring and little finger and middle finger in severe cases. Initially starts as nodules in palm of hand. 55

56 Positive table top test Pts ability to grip Treatment: ◦ Early-Radiation -collagenase inj ◦ Late- fasciectomy -Dermofasciectomy 56

57 NERVE INJURIES 57

58 ANATOMY 58

59 Presentation Mechanisms of injury: ◦ Traction: force is longitudinal to nerve axon ◦ Compression: force is cross-sectional to nerve axon. ◦ Laceration: sharp object injury. Blunt trauma delivers forces that stretch and compress nerves. Nerve my undergo total disruption or avulsion. Less favorable outcome. Sharp laceration can cause complete transection of nerve but it is associated with best prognosis 59

60 Presentation Effect of injury: “Seddon’s Classification” ◦ Neuropraxia:  Disruption of Schwann cell sheath but no loss of continuity. ◦ Axonotmesis:  Injury to both Schwann sheath and axon.  Distal part undergoes Wallerian degeneration.  Stimulation of nerve 72 hours after injury does not elicit response.  Regeneration occurs with the average rate of 1-2 mm/day.  Regeneration is supported and guided by the surrounding endoneurium. 60

61 Presentation ◦ Neurotmesis:  Injury to all anatomical components, myelin sheath, axons and the surrounding connective tissue.  This total nerve disruption makes regeneration impossible.  Surgical intervention is necessary. ◦ Examine carefully to document any sensory or motor injury and for follow up. 61

62 Presentation 62

63 PRESENTATION OF MEDIAN NERVE INJURY 63

64 PRESENTATION OF RADIAL NERVE INJURY 64

65 PRESENTATION OF ULNAR NERVE INJURY 65

66 MANAGEMENT Neurolysis: ◦ Removal of any scar or tethering attachments to surroundings that obstruct nerve ability to glide. Neurorrhaphy: ◦ End-to-end repair. ◦ Resection of the proximal and distal nerve stumps and then approximation. Autologus Nerve grafting: ◦ Gold standard for clinical treatment of large lesion gaps. ◦ Nerve segments taken from another parts of the body. ◦ Provide endoneural tubes to guide regeneration. Allograft, Xenograft. ◦ Two types: Allograft, Xenograft. 66

67 67 EPINEURAL NEURORAPHY GROUP FASSICULAR NEURORAPHY

68 CHRONIC NERVE INJURY Carapal tunnel syndrome Compression of median nerve in the carpal tunnel. Hand numbness( night, driving car) with pain, parasthesias in distribution, clumsiness or weakness Thenar wasting Age: 30-60, F:M ratio 5:1 68

69 Causes of CTS Decrease in Size of Carpal Tunnel Bony abnormalities of the carpal bones Acromegaly Flexion or extension of wrist Increase in Contents of Canal Forearm and wrist fractures (Colles, scaphoid #) Dislocations and subluxations of carpal bones Post-traumatic arthritis (osteophytes) Aberrant muscles (lumbrical, palmaris longus) Local tumors Persistent medial artery (thrombosed or patent) Hypertrophic synovium Hematoma 69

70 Causes of CTS Inflammatory Conditions Rheumatoid arthritis Gout Nonspecific tenosynovitis Infection External Forces Vibration Direct pressure 70

71 Causes of CTS Alterations of Fluid Balance Pregnancy Menopause Hypothyroidism Renal failure Long-term hemodialysis Obesity Lupus erythematosus Scleroderma Amyloidosis 71

72 DIAGNOSIS History which brings out any of the causes Clinical tests: ◦ Phalen's wrist flexion test ◦ Tinel's nerve percussion test ◦ Durkan's compression test Treatment: ◦ NSAIDS, elevation and splinting ◦ Local corticosteroid injections ◦ Surgical decompression 72

73 Factors that don’t favor conservative treatment Age over 50 years Duration longer than 10 months Constant paresthesia Stenosing flexor tenosynovitis Positive Phalen test in less than 30 seconds. 73

74 Cubital tunnel syndrome Mechanism Mechanism ◦ repeated elbow flexion ◦ Trauma: fracture or dislocation of supracondylar or medial epicondylar Typical complaint Typical complaint ◦ aching or sharp pain( night) in proximal and medial forearm ◦ decreased sensation ◦ weakness 74

75 Evaluation Evaluation ◦ Atrophy in first web space, hypothenar eminence, medial forearm ◦ Elbow flexion test( passive flex elbow, holding 60 seconds) Treatment Treatment ◦ Conservative therapy: splinting( prevent sleeping with elbow 30 。 flex), padding elbow, positioning guideline 75

76 Ulnar tunnel syndrome (Guyon’s Tunnel) Compression of the ulnar nerve within a tight triangular fibroosseous Guyon’s canal commonly seen in regular cyclists due to prolonged pressure of the Guyon canal against bicycle handlebars. 76

77 TYPES Type I ◦ Proximal compression leads to motor weakness in all of the intrinsic muscles of the hand ◦ There is also sensory loss in the ulnar nerve territory 77

78 Type II ◦ This is the most common ◦ compression of the ulnar nerve at the distal wrist. ◦ Impairment in motor function of the hand, with sensory innervation unaffected. 78

79 Type III This is the least common type Compression of the superficial branch of ulnar nerve at the distal portion of Guyon's canal. Loss of sensation from the cutaneous territory of the hand which is served by the ulnar nerve. There is no motor function impairment. 79

80 Bowler’s Thumb Perineural fibrosis caused by repetitious compression of the ulnar digital nerve of the thumb while grasping a bowling ball. Tingling and hyperesthesia about the pulp of the thumb. Treatment: ◦ splint and rest from bowling ◦ Occasionally neurolysis and dorsal transfer of the nerve 80

81 BONE INJURIES 81

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83 PRESENTATION History: ◦ Handedness ◦ Occupation ◦ Mechanism of injury ◦ Time since injury “golden period” ◦ Place of injury Physical Examination: ◦ Inspection for open fractures, swelling ◦ Deformities (angulation, rotation, shortening) ◦ Alignment. ◦ Range of motion (active and passive) ◦ Neurovascular status Radiographic studies: ◦ 3 planes: AP, Lateral and Oblique 83

84 CARPAL FRACTURES Scaphoid fractures: ◦ Most common carpal fracture (15% of wrst inj) ◦ Results from force applied on distal end with wrist hyper extended (fall on outstretched hand). ◦ Unless treated effectively it would result in mal- union and permanent weakness and pain in the wrist. ◦ Blood supply retrograde so proximal fragment at risk of AVN ◦ Deep tenderness in anatomical snuffbox is felt. ◦ Treatment:  Stable: Cast for 12 weeks  Unstable or non-union: ORIF 84

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86 CARPAL FRACTURES Triquetral fracture: ◦ 2 nd most common carpal fracture ◦ Direct blow to the dorsum of the hand or extreme dorsiflexion. ◦ Palpation of the triquetrum is facilitated by radial deviation of the hand. ◦ Point directly over the triquetrum. ◦ Treatment:  Chip fracture:  symptomatic with 2-3 weeks immobilization. ROM exercise once symptoms decrease.  Body fracture:  Minimally displaced: cast immobilization for 4-6 weeks + ROM exercise  Displaced: Closed reduction and pinning or Open reduction and fixation 86

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88 Metacarpal Fractures Relatively common % of hand fractures Result from direct or indirect trauma. Direct trauma commonly results in transverse fracture, usually midshaft. Most fractures are easily reducible, stable and managed non-operatively. Indications of surgical intervention: ◦ Intra-articular fractures, ◦ Displaced and angulated fractures, ◦ Unstable fracture patterns, ◦ Combined or open injuries, ◦ Irreducible and unstable dislocations 88

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90 Thumb Fractures Bennett’s fracture: ◦ Fracture at the base of the 1 st Metacarpal. ◦ Intra-articular fracture subluxation ◦ Swelling and pain at the thumb base ◦ Closed reduction and immobilization with thumb spica splint ◦ ORIF Rolando’s fracture: ◦ Comminuted (displaced) thumb base fracture. ◦ Improper healing = restriction of motion around CMJ ◦ Swollen, tender thumb base. If significant varus has developed, a clinically visible deformity may be present. ◦ ORIF 90

91 Bennett’sRolando’s 91

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93 Phalangeal Fractures Distal Phalanx: ◦ Extra-articular fractures are common, associated with significant soft tissue injury. ◦ Crush injuries from a perpendicular force (injuries from a car door or hammer) ◦ Intra-articular fractures are associated with extensor tendon avulsion (Mallet’s finger), FDP tendon avulsion (Jersey finger). ◦ Examination:  Inspection:.  Neurovascular status should be examined.  Palpation is done for tenderness. ◦ Closed treatment is recommended with splinting and if necessary closed reduction 93

94 Phalangeal Fractures Middle Phalanx: ◦ Blunt or crush force perpendicular to the long axis of the bone. ◦ Angulation and rotation are two features of instability that must be examined. ◦ Rotational deformities are serious injuries and are detected clinically. ◦ Examination:  Inspection: for dislocations and sublaxations. Ask patient to fully flex the phalanx to examine alignment of digits.  Palpation: swelling and tenderness ◦ Treatment:  Nondisplaced without impaction: require only dynamic splinting for 2-3 weeks.  Angulation and rotation require closed reduction and splinting to restore finger alignment. 94

95 Phalangeal Fractures Proximal Phalanx: ◦ More common than middle phalanx fractures. ◦ May result in a great deal of disability. ◦ Dorsal or palmar angulation may occur with these fractures. ◦ Examination:  Inspection:  Neurovascular status  Palpation is done for tenderness. ◦ Treatment:  Nondisplaced fractures: usually stable and treated by closed reduction and dynamic splinting.  Angulated or unstable fractures may require internal or external fixation. 95

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97 HAND INCISIONS 97

98 AMPUTATION AND REPLANTATION 98

99 INTRODUCTION Replantation: reattachment of a severed digit of extremity. Not all patients with amputation are candidates for replantation Decision based on: Importance of the part Level of injury Expected return of function. Hand function is severely compromised if thumb or multiple fingers are lost so replants of these should be attempted. Mechanism of injury may be the most predictive variable for successful replantation. 99

100 Recommended ischemia times for reliable success: ◦ Digit: 12 hours for warm ischemia and 24 hours for cold ischemia. ◦ Major replant: 6 hours of warm and 12 hours of cold ischemia. Preoperative preparation: radiography of both amputated and stump parts to determine the level of injury and suitability for replantation 100

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102 OUTCOME Overall success rates for replantation approach 80%. Better outcome with Guillotine (sharp) amputation (77%) compared to severely crushed and mangled body parts(49%). Studies have demonstrated that patients can expect to achieve 50% function and 50% sensation of the replanted part. 102

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104 References Plastic Surgery, Goldwyn and Cohen, 3 rd edition. Plastic Surgery, Grabb and Smith, 3 rd edition. Clinical Anatomy, Richard Snell, 6 th edition. Macleod’s Clinical Examination, 11 th edition. 104


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