1. HAND INJURIES AND THEIR MANAGEMENT
Presenter:
DR. ALIHUSSEIN TARWADI
Moderator:
DR. AFULO

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

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

5. APPROACH TO HAND TRAUMA PATIENT
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.

6. APPROACH TO HAND TRAUMA PATIENT
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.

17. LOCAL FLAPS
RHOMBOID LIMBERG FLAP

18. LOCAL ROTATIONAL FLAP

19. V-Y ADVANCEMENT FLAP

20. KUTLER’S BILATERAL TRIANGULAR ADVANCEMENT FLAP

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.

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.

23. THENAR FLAP

24. ANNULAR FLAP

25. Homodigital bipedicle island advancement flap

26. Reverse vascular pedicle island flap

27. REGIONAL FLAPS Reverse radial artery flap

28. DORSAL ULNAR ARTERY FLAP

29. Posterior interosseous forearm flap

30. DISTANT FLAPS Sub mammary flap

31. GROIN 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

39. PRESENTATION 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.

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.

44. PRESENTATION FLEXOR TENDON INJURY
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.

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

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

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 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.

63. PRESENTATION OF MEDIAN NERVE INJURY

64. PRESENTATION OF RADIAL NERVE INJURY

65. PRESENTATION OF ULNAR NERVE INJURY

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.

67. GROUP FASSICULAR NEURORAPHY
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

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.

97. HAND INCISIONS

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.

103. THANK YOU

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.