Hand Injuries

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Hand Injuries

• Colin Del Castilho
• Dr Ian Rigby

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Famous Hands
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Outline

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

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Things Not Covered

• Carpal fractures/ Wrist fractures
• Thermal injuries and Frostbite
• Nerve Blocks

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6 Finger Hand Exam

• A Appearance
• Resting posture
• Ischemia/cyanosis
• Lacerations
• Swelling
• Erythema
• Deformity

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6 Finger Hand Exam,

• B both hands
• Compare to other hand

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6 Finger Hand Exam

• C Circulation
• Allens test
• Control lacerations- direct pressure, dont clamp
• Inflate BP cuff to 30gtsystolic pressure, no more
  than 30 min

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6 Finger Hand Exam

• D Neurological assessment
• Sensory

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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

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6 Finger Hand Exam

• E extension
• Test all digits

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• F Flexion
• Assess all joints
• FDP and FSP separately

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Hand Infections
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What is this?
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Herpes Whitlow

• HSV 1 60, HSV 2 40
• Common in children, health care workers,
  immunocompromised
• Inoculation occurs through breakage in skin
  barrier
• Incubation period 2- 20 days
• Prodrome- fever, malaise, burning, erythema,
  tingling in affected digit

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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

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What is this?
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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

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Paronychia
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How about this?
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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

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Felon
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Complications

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

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Famous Hands
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Famous Hands
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Name this Infection
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Pyogenic Flexor Tenosynovitis

• Direct inoculation- Staph
• Rarely hematogenous spread- NG

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Pyogenic Tenosynovitis

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

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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

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Clenched Fist Injury/Human Bite

• Most commonly caused by fight bite

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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
  1987220 237-40.
• 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

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Clenched Fist Injury

• Management
• 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

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Deep Space Hand Infections

• Deep Space 5
• Staph, Strep, coliforms
• Management IV Ancef and refer

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Famous Hands
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High Pressure Injections

• Only requires 100psi to break skin commonly
  involve 1000-10,000psi
• Index finger most common, non dominant hand
• 1000psi 450 lbs
• falling 25 cm

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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

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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 gt 7000psi
• Delayed presentation

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Hand Fractures
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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 (dont immobilize
  PIP

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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

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Subungal Hematoma

• Previously recommended for nail removal and
  formal nail bed for all gt 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
  (gt50)

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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

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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

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Unstable Phalanx Fractures
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Metacarpal Fractures

• Head
• Neck
• Shaft
• Base

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Metacarpal Fractures

• Hand Function can tolerate angulation equal to
  CMC joint motion 10o

• Normal Accept
• 5 degrees 15
• 5 degrees 15
• 20 degrees 30
• 30 degrees 40

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Metacarpal Head Fracture

• Variant of Boxers
• Will need ORIF
• gt1mm step off
• gt25 intraarticular surface
• displaced
• Splint in position of safety
• Look for fight bite

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Name the
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Metacarpal Neck

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

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Splint Metacarpal neck

• Position of safety to prevent MCP contractures
• Hold in reduction and mold splint until set
• Must include 4th MC
• If MCPs arent flexed 90 degrees ---gt loss of
  reduction

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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

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Metacarpal Shaft

• Unstable spiral, oblique, rotation, multiple
  s, failed reduction- will need to refer

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What is this?
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Bennetts Fracture

• Axial load on partially flexed thumb
• 2 part intraarticular w/ CMC subluxation
• Management
• Thumb spica
• Refer for ORIF

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How about this?
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Rolando

• 3 or more fragments, intraarticular
• Management
• Thumb spica
• Refer for ORIF

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Reverse Bennetts

• Intraarticular fracture of 5th metacarpal base
• Unstable extensor carpi ulnaris
• Management plastics referral for K wire
  insertion or ORIF if any displacement

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Famous Hands
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Dislocations
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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

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PIP Dislocation

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

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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
• gt 20o instability with passive ROM
• Volar dislocation attempt closed reduction

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Reduction Technique
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PIP Subluxation /-
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PIP Subluxation /-

• Xray in full extension
• Wont be able to maintain reduction in extension
• Splint and refer for extension pin

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MCP dislocation

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

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MCP DislocationManagement

• 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

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Gamekeeper's/Skiers thumb

• Rupture (partial/complete) of ulnar collateral
  ligament
• Mechanism valgus stress on MCP or fall onto
  abducted thumb
• Exam gt35o complete tear

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Gamekeeper's/Skiers Thumb

• Xray
• Management
• Partial thumb spica for 4 weeks then physio
• Complete refer
• Stener lesion abductor aponeurosis in joint
  space- refer

• Associated

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Famous Hands
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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

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Extensor Tendon Injuries
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Extensor Tendons

• Examine in position of injury
• gt50 repair
• May have normal function with gt90
• Can be repaired in ED
• If open- abx
• Technique
• Figure of 8 or horizontal mattress

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Suturing Technique

• Bunnel

• Kessler

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Zone 1

• Check Xray
• Closed Incomplete- splint 6-8 weeks
• Closed Complete (Mallet finger)- splint 6-8 weeks

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(No Transcript)
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Open Mallet Finger

• Open Incomplete- repair
• Open Complete-
• Repair with Roll Sutures
• Splint 6-8 weeks
• Complication Swan neck deformity

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Zone II

• Treat like zone I

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Zone III

• Mechanism extended finger forced into flexion ie
  jammed finger

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Zone III

• Mx
• 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

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Zone III

• Open may attempt repair
• Complication Boutonniere deformity (volar slip
  of lateral bands)

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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

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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

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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

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Famous Hands
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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

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Amputations
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Amputations distal to DIP
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Management

• Amputated part--- clean, wrap in saline soaked
  gauze, place in sealed bag, place in half
  ice/half H20 (4oC)
• Stump clean, dont 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.

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Local Hand Resources

• Foothills hand clinic 944 1432
• Lindsay Park 221-8340
• PLC 291-8785
• RVH ph 943-3575, fax [phone]
• fill out form, refer from ED
• OT/PT will contact pt based on priority
• ACH ph 229-7912, fax [phone]
• fill out form, refer from ED
• OT/PT will contact pt w/i 48h