Presentation on theme: "HAND INJURIES AND THEIR MANAGEMENT"— Presentation transcript:
1HAND INJURIES AND THEIR MANAGEMENT Presenter:DR. ALIHUSSEIN TARWADIModerator:DR. AFULO
2OUTLINE Introduction Approach to hand trauma patient Structural Injuries:Cutaneous InjuriesTendon InjuriesNerve InjuriesBone InjuriesAmputation and Replantation
3INTRODUCTION The hand is a very vital part of the human body 4 requirements for a functioning hand:Supple (moving with ease)SensateAccount for 5-10 % of hospital ER visits.Great potential for serious handicapGood 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.Pain freeCoordinated
4APPROACH TO HAND TRAUMA PATIENT History:GeneralAgeHand dominanceOccupation/hobbiesHistory of previous hand problemsWhen 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
5APPROACH TO HAND TRAUMA PATIENT Physical examinationEntire 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.
6APPROACH TO HAND TRAUMA PATIENT Imaging StudiesRadiographyPlain-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.USHas a growing role in locating foreign bodies and in evaluating soft tissuesCan detect ruptured tendons and assess dynamic function of tendons non-invasively.MRIHighly sensitive in detecting ruptured tendons.However, it does not have a role in emergent management of hand wounds.
10ANATOMY Dorsum surface Palmar 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 surfaceThick and glabrous and not as pliable as the dorsal skinStrongly attached to the underlying fascia by numerous vertical fibersMost firmly anchored to the deep structures at the palmar creasesContains a high concentration of sensory nerve endings essential to the hand's normal function
11PRESENTATION Cutaneous injuries are very common Two Types Open: Incised, laceration, punctured (bites), penetration, abrasion, degloving.Closed: Contusions, HematomasVary in depth from superficial to very deep involving underlying structures.Explore for underlying structural Injuries.
13MANAGEMENT Skin Laceration: Small: Rinse and cover. Large: Infiltrate with LidocaineIrrigate wound profusely with sterile waterDrape and explore (underlying injuries and foreign bodies)Close the skin wound with simple sutures.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.
14MANAGEMENTBites:Should not be closed primarily but should be given serial wound checks with delayed closure at 4 days if neededAntibiotic 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 heartDo not bandage a bruise.
15MANAGEMENT Abrasions: Superficial: Deep: Rinse and cover. Prophylactic antibiotic ointmentDeep: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.
16FLAPSLarge 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.
21STANDARD 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.
22Reverse 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.
32Role of STSGCan be used if there is adequate tissue cover over bone and tendons with only loss of skin.Can be used with dermal allografts like AlloDerm ® (commercially available acellular dermis derived from human skin)Used to cover some donor sites
38PRESENTATION Extensor injury Extensors Injury:Divided into Zones according to anatomical location of injuryZone 1: Over the middle phalynx at insertion site (Mallet’s deformity)Zone 3: Over the apeces of the PIP joints (Boutonniere’s deformity)Zone 5: Over extensor hoods (MCP) and the dorsum of the handZone 7: Over extensor retinaculum
39PRESENTATION Mallet’s: Result from Open injuries (sharp or crushing lacerations), but closed injuries are more common.Commonest mechanism is sudden forceful flexion of the extended digit leading to rupture of the extensor tendon or avulsion of the tendon insertion with or without a small fragment of bone from the distal insertion.Boutonniere’s:Division of the extensor mechanism central slip at the PIP joint level. The lateral bands migrate volarly (laterally) causing increase of the flexion position and hyperextension of the DIP joint.Zone V:Usually injury results in disruption of the extensor mechanism and exposure of the underlying joint.Usually results from penetrating injury.Also can result from closed injuries causing traumatic sublaxation of the tendon. Due to forceful flexion or extension of the MCP joint. Middle finger is the most commonly involved digit.
40Boutonniere’s Deformity Zone 1Zone 5Boutonniere’s DeformityZone 3
42Boutonniere’s Deformity MANAGEMENTZonePresentationManagementIMallet’s DeformityClosed: splinting 6-8 weeksOpen: suture repair for fixation.Soft tissue reconstructionIIIBoutonniere’s DeformityClosed: splinting MCP and PIP in hyperextension for 6 weeksOpen: suture repair (figure of 8 suture)VFixed flexion of MCPClosed: splinting ,45 extension at wrist and 20 flexion at MCPOpen: suture repair.
44PRESENTATION FLEXOR TENDON INJURY Flexor InjuryDivided into Zones according to anatomical location of injuryZone 1: area between PIP joint and the insertion of the profundus tendon into the base of the distal phalynxZone 2: from the Distal palmar crease to the PIP joint.Here the superficialis and profundus tendons are both enclosed by the fibroosseous sheath and lie in proximity to one another.Zone 3: area of the fibroosseous sheath of the thumbZone 4: area at the base of the thumb (thenar complex surround long flexor tendon)Zone 5: Middle of the palmZone 6: carpal tunnel areaZone 7: area proximal to the carpal tunnel, including the forearm.
47PRESENTATION Zone Presentation Management I II Loss of active flexion at DIP jointHyperextension of DIP jointPrimary or Secondary tendon repairCareful suturing prevent post-op adhesions.II(No Man’s Land)Loss of active flexion at MCP jointSkin closure then secondary repair by tendon graftingPrimary repair performed by skilled hand surgeon to minimize post-op adhesions.III, IVThumbSamePrimary or secondary tendon repairExamine carefully for thenar muscle injury and recurrent branches of median nerve.Treatment of Zone II was associated with increased incidence of post operative cross-adhesions. That is why in the past it was advised to perform secondary repair rather than primary. The area was known as “No Man’s Land”.But recently several studies have shown that primary repair can be achieved with minimal if no post-op adhesion once performed by a skilled hand surgeon.
48PRESENTATION Zone Presentation Management V Palm VI, VII Wrist UncommonLie deep and protected by palmar fasciaSame presentationSuperior to Tendon division: repair is unnecessary.Both muscles’ tendon division: primary repairVI, VIIWristMultiple flexor tendon injuryImpaired active flexion of multiple digitsPrimary tendon suturing further proximal in the forearm to prevent post-op cross-adherence.Injuries to muscles in forearm require primary repairPost-op splinting of wrist in flexion position and elevation for 4 weeks.
50CHRONIC TENDON INJURIES OF THE HAND Swan Neck DeformityFlexed DIP, hyperextended PIPInterruption of distal extensor mechanismCauses:Chronic Mallet fingerFracture malunionVolar plate injury to PIPRheumatoid arthritisLigament laxityTreatment: surgical mostly but splints can be used to relieve contractures
51Gamekeeper’s/ skier’s thumb Injury to ulnar collateral lig of the 1st MCPJ, sometimes associated with fractr base of PPConservative managmnt with splint but mostly requires surgical repair
52De QUERVAIN’S TENOSYNOVITIS Stenosing tenosynovitis of the first dorsal compartmentAPL & EPB trapped in fibroosseous tunnel formed by radial styloid and flexor retinaculumSymptoms include: pain over styloid process on thumb or wrist movemnt and a positive finklestein testTreatment: thumb spica, NSAIDS and steroid injection in 1st compartment.
53Trigger 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/coldLocal steroid injSx release of A1 pully
54EPL Tendinitis (Drummer boy palsy) Seen in rheumatoid arthritis or previous distal radius fracture.Pain, swelling and crepitus over 3rd dorsal compartmentTreatment:SpicaNSAIDSSurgical releaseNO steroid injection
55Dupuytren'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=FAffects mostly ring and little finger and middle finger in severe cases.Initially starts as nodules in palm of hand.
56Positive table top test Pts ability to grip Treatment: Early-Radiation-collagenase injLate- fasciectomy-Dermofasciectomy
58ANATOMYRadial Nerve:Motor: Supply extensors of the wrist and digits up in the forearm. Injury to this nerve in the hand will not lead to any motor deficit.Sensory: supplies the area of the anatomical snuffbox.
59Presentation Mechanisms of injury: Traction: force is longitudinal to nerve axonCompression: 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
60Presentation 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.
61Presentation 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.
62PresentationTesting motor function of the median, ulnar and radial nerves. (A and B) The median nerve: (A) abducting the thumb; (B) testing opposition. (C-E) The ulnar nerve: (C) testing the interossei; (D) testing the first interosseus; (E) testing adductor pollicis. (F) The radial nerve: testing the extensors of the wrist and fingers.
66MANAGEMENT Neurolysis: Neurorrhaphy: Autologus Nerve grafting: 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.Two types: Allograft, Xenograft.
68CHRONIC 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 weaknessThenar wastingAge: 30-60,F:M ratio 5:1
69Causes of CTS Decrease in Size of Carpal Tunnel Bony abnormalities of the carpal bonesAcromegalyFlexion or extension of wristIncrease in Contents of CanalForearm and wrist fractures (Colles, scaphoid #)Dislocations and subluxations of carpal bonesPost-traumatic arthritis (osteophytes)Aberrant muscles (lumbrical, palmaris longus)Local tumorsPersistent medial artery (thrombosed or patent)Hypertrophic synoviumHematoma
71Causes of CTS Alterations of Fluid Balance Pregnancy Menopause HypothyroidismRenal failureLong-term hemodialysisObesityLupus erythematosusSclerodermaAmyloidosis
72DIAGNOSIS History which brings out any of the causes Clinical tests: Phalen's wrist flexion testTinel's nerve percussion testDurkan's compression testTreatment:NSAIDS, elevation and splintingLocal corticosteroid injectionsSurgical decompression
73Factors that don’t favor conservative treatment Age over 50 yearsDuration longer than 10 monthsConstant paresthesiaStenosing flexor tenosynovitisPositive Phalen test in less than 30 seconds.
74Cubital tunnel syndrome Mechanismrepeated elbow flexionTrauma: fracture or dislocation of supracondylar or medial epicondylarTypical complaintaching or sharp pain( night) in proximal and medial forearmdecreased sensationweakness
75EvaluationAtrophy in first web space, hypothenar eminence, medial forearmElbow flexion test( passive flex elbow, holding 60 seconds)TreatmentConservative therapy: splinting( prevent sleeping with elbow 30。flex), padding elbow, positioning guideline
76Ulnar tunnel syndrome (Guyon’s Tunnel) Compression of the ulnar nerve within a tight triangular fibroosseous Guyon’s canalcommonly seen in regular cyclists due to prolonged pressure of the Guyon canal against bicycle handlebars.
77TYPESType IProximal compression leads to motor weakness in all of the intrinsic muscles of the handThere is also sensory loss in the ulnar nerve territory
78Type 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.
79Type IIIThis is the least common typeCompression 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.
80Bowler’s ThumbPerineural 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 bowlingOccasionally neurolysis and dorsal transfer of the nerve
83PRESENTATION History: Physical Examination: Radiographic studies: HandednessOccupationMechanism of injuryTime since injury “golden period”Place of injuryPhysical Examination:Inspection for open fractures, swellingDeformities (angulation, rotation, shortening)Alignment.Range of motion (active and passive)Neurovascular statusRadiographic studies:3 planes: AP, Lateral and Oblique
84CARPAL FRACTURES Scaphoid fractures: Treatment: 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 AVNDeep tenderness in anatomical snuffbox is felt.Treatment:Stable: Cast for 12 weeksUnstable or non-union: ORIF
86CARPAL FRACTURES Triquetral fracture: 2nd 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 exerciseDisplaced: Closed reduction and pinning or Open reduction and fixation
88Metacarpal Fractures Relatively common. 30-40% 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
90Thumb Fractures Bennett’s fracture: Rolando’s fracture: Fracture at the base of the 1st Metacarpal.Intra-articular fracture subluxationSwelling and pain at the thumb baseClosed reduction and immobilization with thumb spica splintORIFRolando’s fracture:Comminuted (displaced) thumb base fracture.Improper healing = restriction of motion around CMJSwollen, tender thumb base. If significant varus has developed, a clinically visible deformity may be present.ORIF
93Phalangeal 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
94Phalangeal 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 tendernessTreatment:Nondisplaced without impaction: require only dynamic splinting for 2-3 weeks.Angulation and rotation require closed reduction and splinting to restore finger alignment.
95Phalangeal 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 statusPalpation 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.
99INTRODUCTIONReplantation: reattachment of a severed digit of extremity.Not all patients with amputation are candidates for replantationDecision based on:Importance of the partLevel of injuryExpected 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.
100Recommended 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
102OUTCOME 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.