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Presentation on theme: "HAND INJURIES AND THEIR MANAGEMENT"— Presentation transcript:


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

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. Pain free Coordinated

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

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.

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.



9 Cutaneous injuries

10 ANATOMY 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 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

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.


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. 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.

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.

15 MANAGEMENT Abrasions: Superficial: Deep: 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.

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.





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.

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.



25 Homodigital bipedicle island advancement flap

26 Reverse vascular pedicle island flap

27 REGIONAL FLAPS Reverse radial artery flap


29 Posterior interosseous forearm flap

30 DISTANT FLAPS Sub mammary flap


32 Role of STSG Can 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

33 Tendon injuries Acute Chronic





38 PRESENTATION Extensor injury
Extensors Injury: Divided into Zones according to anatomical location of injury Zone 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 hand Zone 7: Over extensor retinaculum

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.

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


42 Boutonniere’s Deformity
MANAGEMENT Zone Presentation Management I Mallet’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.


Flexor Injury Divided into Zones according to anatomical location of injury Zone 1: area between PIP joint and the insertion of the profundus tendon into the base of the distal phalynx Zone 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 thumb Zone 4: area at the base of the thumb (thenar complex surround long flexor tendon) Zone 5: Middle of the palm Zone 6: carpal tunnel area Zone 7: area proximal to the carpal tunnel, including the forearm.



47 PRESENTATION Zone Presentation Management I II
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. 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.

48 PRESENTATION Zone Presentation Management V Palm VI, VII Wrist
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.


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

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

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 1st compartment.

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

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

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.

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

57 Nerve injuries

58 ANATOMY Radial 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.

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

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.

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.

62 Presentation Testing 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.




66 MANAGEMENT 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.


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

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

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

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

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

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.

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

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

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.

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

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.

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.

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

81 Bone injuries


83 PRESENTATION History: Physical Examination: Radiographic studies:
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

84 CARPAL 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 AVN Deep tenderness in anatomical snuffbox is felt. Treatment: Stable: Cast for 12 weeks Unstable or non-union: ORIF


86 CARPAL 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 exercise Displaced: Closed reduction and pinning or Open reduction and fixation


88 Metacarpal 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


90 Thumb Fractures Bennett’s fracture: Rolando’s fracture:
Fracture at the base of the 1st 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

91 Bennett’s Rolando’s


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

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.

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.



98 Amputation and replantation

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.

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


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.


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


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