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Colin Del Castilho Dr Ian Rigby

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Presentation on theme: "Colin Del Castilho Dr Ian Rigby"— Presentation transcript:

1 Colin Del Castilho Dr Ian Rigby
Hand Injuries Colin Del Castilho Dr Ian Rigby

2 Famous Hands

3 Outline Hand exam Hand Infections High Pressure Injection Injuries
Fractures/Dislocations Tendon injuries Amputations

4 Things Not Covered Carpal fractures/ Wrist fractures
Thermal injuries and Frostbite Nerve Blocks

5 6 Finger Hand Exam A Appearance: Resting posture Ischemia/cyanosis
Lacerations Swelling Erythema Deformity

6 6 Finger Hand Exam, B both hands Compare to other hand

7 6 Finger Hand Exam C Circulation Allen’s test
Control lacerations- direct pressure, don’t clamp Inflate BP cuff to 30>systolic pressure, no more than 30 min

8 6 Finger Hand Exam D Neurological assessment Sensory

9 6 Finger Hand exam D Neurological Assessment Motor
Screening exam Thumbs up (hitchhiker Spread finger apart Maneuver tips of each finger and thumb around tip of pen If deficit detected, proceed to more thorough motor exam

10 6 Finger Hand Exam E extension Test all digits

11 F Flexion Assess all joints FDP and FSP separately

12 Hand Infections

13 What is this?

14 Herpes Whitlow HSV 1 60%, HSV 2 40%
Common in children, health care workers, immunocompromised Inoculation occurs through breakage in skin barrier Incubation period days Prodrome- fever, malaise, burning, erythema, tingling in affected digit

15 Herpes Whitlow 1-3mm grouped vesicles on erythematous base lasting 7-10 days Crust over- no longer infective May recur (remains dormant in nerve ganglia) Treatment: Allow vesicles to rupture on own Zovirax ointment Oral acyclovir Observe for bacterial superinfection- start keflex

16 What is this?

17 Paronychia Acute infection of nail bed
Usually staph, may be oral anaerobes Treatment Incision around nail bed to drain pus Antibiotics usually not necessary May need to remove nail if abscess spreads under nail Finger chewers- clinda

18 Paronychia

19 How about this?

20 Felon Abscess of finger tip S. aureus, oral anaerobes Treatment:
I and D Keflex for 7-10 days Referral to hand surgeon if does not improve

21 Felon

22 Complications Finger tip necrosis Tenosynovitis Osteomyelitis
Neuroma (from I and D) Admit to hospital----- immunocompromised, systemic symptoms, failure to respond to abx

23 Famous Hands

24 Famous Hands

25 Name this Infection

26 Pyogenic Flexor Tenosynovitis
Direct inoculation- Staph Rarely hematogenous spread- NG

27 Pyogenic Tenosynovitis
Cardinal Symptoms Pain on passive extension (most sens) Pain on palpation of flexor tendon Symmetric/fusiform swelling Finger held in flexion

28 Pyogenic Tenosynovitis
Management Urgent plastics consult Antibiotics: IV 3rd gen Cephalosporin, then adjust based on C and S Complications Bacteremia Compartment syndrome Loss of finger function

29 Clenched Fist Injury/Human Bite
Most commonly caused by “fight bite”

30 Clenched Fist Injury/Human Bite
75% involve extensor tendon, joint, bone or cartilage Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist injuries. Clin Orthop 1987;220: May extend to joint capsule May involve MCP or PIP fracture 50% infection rate -Staph, Strep, Eikenella. On average- 5 organisms in wound Examine in position of injury Extend wound 3-5 mm either side

31 Clenched Fist Injury Management Complicated wounds:
Uncomplicated early wounds: Antibiotics: Clavulin Clinda + Cipro or Septra Pen + Clox Avoid first gen cephs- Eikenella resistance Debridement, irrigation, close by secondary intention Splint in position of safety if tendon injured Tetanus Must have follow up Complicated wounds: Referral to plastics IV antibiotics - cefoxitin, tazocin

32 Deep Space Hand Infections
Staph, Strep, coliforms Management: IV Ancef and refer

33 Famous Hands

34 High Pressure Injections
Only requires 100psi to break skin commonly involve ,000psi Index finger most common, non dominant hand 1000psi = 450 lbs falling 25 cm

35 High Pressure Injections
Damage determined by Type of injection: Grease/oil, hydraulic fluid, paint thinner, molding plastic, paraffin, cement Amount Finger- 1st and 5th digit may lead to compartment syndrome in wrist and arm Direct tissue damage, vasospasm/ischemia, inflammation

36 High Pressure Injections
Management: IV analgesia only. Avoid digital nerve blocks- increase ischemia Immediate Plastics Consult NPO Factors associate with Amputation- 70% of oil injections 100% if > 7000psi Delayed presentation

37 Hand Fractures

38 Distal Phalanx Fractures
Usually from crush injury Rarely displaced, usually comminuted May have associated subungal hematoma Management of tuft #: Short finger splint 1-2 weeks (don’t immobilize PIP

39 Distal Phalanx Fracture
Transverse or Longitudinal shaft # Stack splint for 4 weeks FDP avulsion Refer to plastics Intra-articular #’s- refer to plastics Mallet finger will be discussed later

40 Subungal Hematoma Previously recommended for nail removal and formal nail bed for all > 25% of nail Roser 1999 No difference in long term outcome between nailbed repair, trephination, or observation only Management Trephinate the nail for pain control Nail bed repair for (i) displaced # fragment (ii) disrupted nail (iii) consider for large hematoma (>50%)

41 Middle and Proximal Phalanx Fracture
Assess for neurovascular and tendon/ligament stability Stable shaft fractures: Buddy tape with early ROM Uni or Bicondylar Fractures: unstable, require ORIF

42 Middle and Proximal Phalanx Fractures
Unstable fractures: displaced, oblique or spiral fractures, comminuted, scissoring deformity/rotation, unable to reduce or maintain reduction Rotational deformity: nail not in line with mcp, scissoring, finger does not point to scaphoid tubercle when flexed Treatment: requires plastics referral Splint index/ middle in radial gutter splint Ring/little finger in ulnar gutter splint

43 Unstable Phalanx Fractures

44 Metacarpal Fractures Head Neck Shaft Base

45 Metacarpal Fractures Normal Accept 5 degrees 15 20 degrees 30
Hand Function can tolerate angulation equal to CMC joint motion + 10o Normal Accept 5 degrees 20 degrees 30 degrees

46 Metacarpal Head Fracture
Variant of Boxers # Will need ORIF: >1mm step off >25% intraarticular surface displaced Splint in position of safety Look for fight bite

47 Name the #

48 Metacarpal Neck # Attempt to reduce if: Splint in position of safety
Angulation > 40o -5th 30o th 15o - 2, 3rd Splint in position of safety When to refer to plastics for k wire or ORIF Any rotational deformity Shortening > 3-4mm Unable to maintain reduction

49 Splint Metacarpal neck #
Position of safety to prevent MCP contractures Hold in reduction and mold splint until set Must include 4th MC If MCPs aren’t flexed 90 degrees ---> loss of reduction

50 Metacarpal Shaft Fracture
Accept same angulation as Neck # No rotation Shortening up to3-4mm Reduction technique: Jahss technique: flex both MCP and PIP to 90o. Press up on Middle phalanx and down just proximal to apex of# Then splint in position of safety

51 Metacarpal Shaft # Unstable: spiral, oblique, rotation, multiple #’s, failed reduction- will need to refer

52 What is this?

53 Bennett’s Fracture Axial load on partially flexed thumb
2 part intraarticular # w/ CMC subluxation Management: Thumb spica Refer for ORIF

54 How about this?

55 Rolando 3 or more fragments, intraarticular Management: Thumb spica
Refer for ORIF

56 Reverse Bennett’s Intraarticular fracture of 5th metacarpal base
Unstable: extensor carpi ulnaris Management: plastics referral for K wire insertion or ORIF if any displacement

57 Famous Hands

58 Dislocations

59 DIP Dislocation Less common- more stability due to insertion of extensor/FDP tendons Usually associated with skin breakage- need antibiotics Reduce similar to PIP dislocations If not reducible or unstable - refer to plastics

60 PIP Dislocation Mostly dorsal-- hyperextension injury Maybe ulnar
Need Xray to rule out fracture May have associated avulsion

61 PIP Dislocation Management
Splint in 30o flexion or buddy tape for 3 weeks, refer to hand clinic Early ROM Refer if Unable to reduce Instability with active ROM > 20o instability with passive ROM Volar dislocation: attempt closed reduction

62 Reduction Technique

63 PIP Subluxation +/- #

64 PIP Subluxation +/-# Xray in full extension
Wont’ be able to maintain reduction in extension Splint and refer for extension pin

65 MCP dislocation PIP almost always dorsally angulated
Associated with volar plate injury May be associated with avulsion fracture or sesmoid bone in joint

66 MCP Dislocation Management
Flex wrist (relax flexor tendons) and press on proximal phalange in volar direction Do not hyperextend or place traction on finger as this may pull volar plate into joint Cant reduce if volar plate in joint- refer If sesmoid bone in joint- refer Volar dislocations require ORIF

67 Gamekeeper's/Skier’s thumb
Rupture (partial/complete) of ulnar collateral ligament Mechanism: valgus stress on MCP or fall onto abducted thumb Exam: >35o = complete tear

68 Gamekeeper's/Skier’s Thumb
Xray Management Partial: thumb spica for 4 weeks then physio Complete: refer Stener lesion: abductor aponeurosis in joint space- refer Associated #

69 Famous Hands

70 Flexor Tendon Injuries
Test FDP and FSP separately Closed wounds uncommon- exception is jersey pull of fifth digit Explore open wounds If suspected: splint wrist in 30° of flexion, MPs at 70° of flexion, and PIPs at 30-45° of flexion and refer for repair in OR

71 Extensor Tendon Injuries

72 Extensor Tendons Examine in position of injury >50% repair
May have normal function with >90% Can be repaired in ED If open- abx Technique: Figure of 8 or horizontal mattress

73 Suturing Technique Bunnel Kessler

74 Zone 1 Check Xray Closed Incomplete- splint 6-8 weeks
Closed Complete (Mallet finger)- splint 6-8 weeks


76 Open Mallet Finger Open Incomplete- repair Open Complete-
Repair with Roll Sutures Splint 6-8 weeks Complication: Swan neck deformity

77 Zone II Treat like zone I

78 Zone III Mechanism: extended finger forced into flexion ie jammed finger

79 Zone III Mx Splint and refer for
Extension splint for 6 weeks (leave DIP free) Refer to physio at 6 weeks for ROM exercises Splint and refer for avulsion # at base of middle phalanx unstable joint (associated collateral injury) irreducible volar dislocation Boutonniere deformity not correctable by passive PIP extension

80 Zone III Open: may attempt repair
Complication: Boutonniere deformity (volar slip of lateral bands)

81 Zone IV Bigger tendon, easier to repair Partial-splint 4 weeks
Complete and Closed: Splint 6 weeks with physio at 6 weeks Complete and Open: repair

82 Zone V and Zone VI May be repaired in ED
Zone V- if associated with sagittal band and dorsal hood injury- repair or refer Splint with wrist 30o extension, MCP 20o flexion, digits in neutral

83 Nerve Injuries Median and Ulna- refer for immediate or delayed repair (10days) Radial nerve repairs may delayed up to 3 months Digital Nerve: repair depends on finger Thumb, radial aspect index, middle = grip , ulnar aspect of 5th Only refer if proximal to DIP

84 Famous Hands

85 Arterial Injuries Radial/Ulnar artery injuries need referral
Digital arterial injuries: assess clinically- if no ischemia, does not need repair (collateral circulation) Assess for associated nerve injury

86 Amputations

87 Amputations distal to DIP

88 Management Amputated part--- clean, wrap in saline soaked gauze, place in sealed bag, place in half ice/half H20 (4oC) Stump: clean, don’t debride, wrap in saline soaked gauze Tissue bridge- leave intact, may contain nerves/arteries Complications post replantation: cold intolerance, loss of ROM , pain, anesthesia, paresthesias, poor 2 point discrimination, malunions, and nonunions.

89 Local Hand Resources Foothills hand clinic 944 1432
Lindsay Park: PLC: RVH: ph , fax fill out form, refer from ED OT/PT will contact pt based on priority ACH: ph , fax OT/PT will contact pt w/i 48h

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