Hand Rounds: Oct 31, 2002 Rob Hall MD and Lisa Campfens MD, FRCPC

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Hand Rounds Oct 31, 2002Rob Hall MD and Lisa
Campfens MD, FRCPC

• Where would we be
  without our hands???

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Goals for today

• Recognize serious injuries
• Manage common hand injuries
• Appropriate referrals to plastics
• Proper splinting of injuries
• F/U of certain injuries in emerg
• Recognize that management of many hand injuries
  is controversial

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Goals of Today

• Fractures
• Dislocations
• Sprains
• Tendon injuries
• Amputations
• Mutilating injuries
• High pressure injection
• Digital nerve injury

• Not covering
• infections
• foreign bodies
• burns
• compartment syndromes

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Position of Safety
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CAM effect
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Box of the Finger
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Management?
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Distal Phalanx Tuft Fractures

• Distal hairpin splint
• Do not immobilize PIP
• Manage subungual hematoma

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Subungual Hematoma

• Previously recommended for nail removal and
  formal nail bed for all gt 25
• 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

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Approach to Phalanx Fractures

• Stable
• transverse, nondisplaced
• Unstable
• oblique, spiral, comminuted, displaced
  transverse, intraarticular with gt 20 joint,
  rotational deformity
• MUST rule out rotational deformity
• symmetric flexion, point to scaphoid, nails

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Stable Phalanx Fractures

• Dynamic Splinting (buddy tape)
• Early ROM (as soon as pain subsides - 3 to 5 days)

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Unstable Phalanx Fracture

• ED Management
• Reduce
• Splint
• Refer

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Unstable Phalanx Fracture Options

• Pin early
• Unable to reduce
• Unable to maintain reduction
• Rotational deformity
• Intraarticular with gt 20 of joint involved

• Closed reduction and splinting
• Splint X 3 weeks
• F/U Xray 7-10days to make sure reduction is held
• OR if unable to maintain reduction

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Principles of Metacarpal Neck

• Why do Boxers do well no matter what you do??
• Hand function can tolerate angulation in the
  metacarpal neck equal to the motion at the CMC
  joint 10 degrees

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Principles of Metacarpal Neck Fractures

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

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Metacarpal Head Fracture

• Intra-articular
• Needs precise anatomic reduction
• Brewerton views can help identify
• Splint in safe position and refer

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Management?

• Well he was talkinwhen he shoulda bin listen
  man

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Boxers Fracture

• Who needs reduction?
• Displaced, angulated gt 40 degrees, rotated
• How to reduce?
• Ulnar, metacarpal, hematoma blocks --gt 90 - 90
• Follow up?
• Xray at 1 week to r/o slip
• F/U with GP (or ED)
• Remove splint at 3 - 4 weeks and start ROM

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Boxers Fracture

• Indications for OR
• Can obtain adequate reduction
• Cant maintain adequate reduction
• Controversy
• Study pin vs no pin makes no difference
• Van Bowen pin anything that needs reduction
• Generally fairly uncommon to need pinning
• Rotational deformity/scissoring likely most
  common reason to pin

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Splinting Boxers Fractures

• Proper splinting ESSENTIAL to maintaining
  reduction

• 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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Open Boxers Fracture

• Fight Bite ----gt HIGH risk of infection
• Irrigation and Explore
• Look carefully for tendon disruption
• Not into joint capsule
• Leave open, clavulin/Keflex, check at 3 - 5 d
• Into joint capsule
• Leave open, clavulin or keflex po X 5 - 7 days
• Wound check in 24 - 48hrs

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Other MC neck Fractures

• 4th manage as per Boxers
• 2nd and 3rd
• Volar splint and refer
• Less mobility accepted thus more likely to pin

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Management?
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Metacarpal Shaft Fractures

• Can accept lt 3mm shortening and 10 deg angulation
  in II/III or 20 deg in IV/V
• Cannot accept rotation
• Stable (transverse, good reduction)
• splint, could follow in ED but must ensure
  doesnt slip (re Xray in one week) or could send
  to plastics
• Unstable (spiral, oblique, multiple s, failed
  reduction, rotated)
• splint, reduction prn, refer

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Extra-articular Thumb Metacarpal Fracture

• Unstable (oblique, spiral, comminuted)
• Splint and refer for pinning
• Stable (transverse)
• Attempt reduction if gt 20 degrees angulation
• Splint in thumb spica X 4 weeks
• Refer

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Management?

• Who the heck is Bennet?????

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Bennetts Fracture

• Two part intra-articular fracture at base of
  thumb metacarpal
• Commonly see CMC joint subluxation
• Thumb spica splint and refer for pinning
• Abductor pollicus longus pulls fragment off

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Bennetts Fracture
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Management?
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Rolandos Fracture

• Three (or more) part intra-articular fracture at
  base of thumb metacarpal
• Commonly see Y or T pattern but comminuted
  fracture is also called Rolandos fracture
• Thumb spica splint and refer

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Reverse Bennets Fracture

• Commonly missed
• Xray look carefully for clear, even space b/w
  base of 5th MC and hamate
• Unstable b/c ext carpi ulnaris pulls at base
• Needs pinning

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The Pediatric Hand
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The Pediatric Hand

• Salter - Harris classification used
• Tuft and SH II of proximal phalanx common
• Thick periosteum thus hold position well and heal
  quickly
• Generally closed reduction, splint X 3 wks
• OR cant reduce, cant maintain reduction,
  displace intraarticular , SH IV/V

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Salter Harris I

• Closed reduction
• Immobilize with splint X 3 weeks or K wire
• Can present with paronychia not responding to Rx

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Salter Harris II

• Common
• Reduce
• Splint with gutter splint
• Splint X 3 wks

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Salter Harris III - V

• SH III
• Minimally displaced, lt 25 joint surface
  involved splint X 3 wks
• Displaced, gt 25 joint surface involved splint
  and refer
• SH IV reduce prn, splint and refer
• SH V reduce prn, splint and refer

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Assessment of Finger Joint Stability

• Blocks may be required for assessment
• Active stability
• can pt move finger through full ROM without
  displacement?
• Passive stability
• apply stress to collaterals, and volar plate

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Finger Sprains

• Xray
• R/O fracture/avulsion
• LOOK carefully for subluxation
• Stable joint
• buddy tape or gutter splint
• ROM early to prevent stiffness (3-5 days)
• Unstable joint
• splint and refer

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Finger Sprains

• Flexion Contractures
• Common complication
• Prevention
• MUST SPLINT PIP/DIP IN EXTENSION
• MUST SPLINT MCP in FLEXION
• Early ROM
• Minimize dressings to allow ROM
• See physio at two weeks if becoming stiff

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Management?
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PIP Dislocations

• Dorsal/Lateral
• Ring block, Xray
• Reduce, examine stability
• Buddy tape and EARLY ROM (better than splint X 3
  weeks)
• refer cant reduce, unstable joint, avulsion gt
  1/3 of joint surface

• Volar dislocation
• Controversial
• Attempt closed reduction
• Splint and refer

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PIP Subluxation /- Fracture
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PIP Joint Subluxation /- Fracture

• Do NOT miss this injury
• Must Xray fingers in full extension
• Will not stay reduced in extension
• Cant splint in flexion (flexion contracture)
• Mx
• splint and refer for extension pin
• also will need special rehab

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Dorsal MCP Dislocations

• Simple dislocation (subluxation)
• hyperextended 60 - 90 degrees, articular surfaces
  contacting w/o interposed soft tissue
• metacarpal block
• reduction
• splint in safety position
• refer

• Complex dislocation
• hyperextension LESS than 60 degrees
• Xray wide joint space, sesamoid in joint space
  is pathognomonic
• Splint and refer (will not be reducible)

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Dorsal MCP Dislocation

• Volar plate prevents reduction
• Wide joint space, sesamoid in joint

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CMC Subluxation /- Fracture

• Commonly missed
• Look at CMC joint space carefully
• Compare shaft of MC with adjacent MC
• Reduction
• Splint
• Refer (often slip and need pinning)

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Management?
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Gamekeepers (Skiers) Thumb

• Ulnar Collateral Ligament of the thumb
• Stress MCP in full extension and 30 deg of
  flexion to offset stabilization of volar plate
• Xray to r/o avulsion
• Sprain (partial) thumb spica X 4 weeks
• Rupture (complete)
• Splint and refer for pinning
• Steners lesion (adductor pollicus in the way)

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Management?
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High Pressure Injection Injuries

• Consider all SEVERE injuries
• Paint and paint thinners worse than grease
• Mx
• Tetanus
• IV analgesia (NO digital blocks)
• Antibiotic, splint, elevate, NPO
• Consult plastics (early - dont wait til am)

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Management?
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Mutilating Hand Injuries

• R/O other injuries
• Tetanus, Analgesia, Antibiotics
• Irrigate gross contamination
• Sterile saline dressing
• Xray
• NPO and consult plastics

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Management?
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Amputations

• R/O other injuries
• Tetanus, analgesia, antibiotics, NPO
• Xray, consult plastics early
• Stump Mx irrigate, saline dressing, splint
• Amputated parts
• Place in sealed plastic bag
• Place bag in ice water (NOT on ice b/c frostbite
  will cause tissue damage) ---gt ideal temp 4 deg

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Amputations Continued

• Canada/US early
• UK late (surgery the next morning)
• Plastics to decide to Replant and who not
• Contraindications for Replantation
• Unstable patient with other injuries
• Multiple level amputations
• Single digit proximal to FDS insertion (relative)
• Vasoculopath DM, PVD, CAD, CVA
• Age

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Management?

• I cut my finger here...
• I cut my finger here...

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Digital Nerve Laceration

• Refer for potential repair for anything proximal
  to DIP
• DIP and distal -----------gt multiple branches
  thus difficult to repair

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Fingertip Amputations

• Zones

• Management controversial
• Maintain as much length as possible
• Children heal well by secondary intention

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Fingertip Amputations

• NO exposed bone
• lt 1cm exposed Polysporin, jelonet dressing, heal
  by secondary intention
• gt 1cm exposed consider referral for flap if
  there isnt adequate soft tissue coverage
• Exposed bone
• rongeur bone back enough to get tissue coverage,
  dress, heal by secondary intention, Drsg
  changes,f/u

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Flexor Tendons

• Close wounds, splint, refer to plastics
• FDP Avulsion/Rupture
• Common athletic injury
• Hyperextension of flexed finger (jursi grab)
• Tendon can retract into the palm
• Splint and refer for repair

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• Extensor Tendon Injuries ED
  Management and Follow-up

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Can emerg do this?

• One Study (Evans JD 1995)
• EM housestaff in UK repaired 65 extensor tendon
  lacs
• follow-up within 6 mos. re functional outcome
• Proximal injuries 80 good to excellent results
• Distal injuries 18 good to excellent
• weaknesses unconventional splinting of distal
  injuries, poor physio f/u, small numbers
• conclusion we dont know how were doing!

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Emerg role in repair of extensor?

• Make sure you know what youre doing
• Appropriate splinting and referral to hand physio
• Proximal injuries easier to repair
• Consider discussing with plastics b/f repair
  especially if you want them to follow
• Splint and refer
• cant locate ends, ends shattered, cant decifer
  anatomy, inadequate previous experience

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Verdans zones of injury

• 8 zones of injury
• each zone has
• particular injuries
• variations in acute management
• different splinting requirements
• not all extensor tendon injuries are the same!!

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Which suture material?

• No evidence
• Absorbable vs. non-absorbable synthetics
• non-absorbs most often used, but may cause knot
  irritation at site of repair
• absorbs less prone to producing knot irritation,
  but ? strength
• Size 4.0-5.0

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Which suture technique?

• No consensus in literature or amongst hand
  surgeons
• Options
• Figure of Eight
• Box
• Bunnel
• Kessler

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suture techniques

• Bunnel suture
• advantages
• strong
• disadvantages
• time constraints
• technical skills
• need good tendon cross-sectional area

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suture techniques

• Kessler suture
• advantages
• strong
• disadvantages
• time constraints
• technical skills
• need good tendon cross-sectional area

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suture techniques

• horizontal mattress suture
• advantages
• easy to do, even on thinner tendons
• disadvantages
• decreased strength

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Incomplete lacerations General Recommendations

• Recommendations NOT literature based
• lt 25
• do not need repair
• 25 - 50
• may be repaired
• ? splint for shorter time
• gt 50
• should be repaired

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What about antibiotics?

• Little evidence specific to simple tendon lacs
• ACEP Guidelines
• abx indicated for both hand and tendon lacs
• Absolute indications
• bites, crush injuries, associated open fractures,
  joint capsule disruption

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Splinting and Hand Physiotherapy

• Complicated --------gt ROM and strengthening
  exercises differ for each injury
• Need to when to send to physio
• Distal Injuries (Zones 1 - 4)
• Splint and see physio at 6 weeks
• Proximal Injuries (Zone 5 - 7)
• Splint and see physio at 4 weeks

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Zone 1 mallet finger

• Common injury
• Goals of management
• lt10 degrees of extension lag
• good flexion
• prevention of swanneck deformity

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Closed Mallet Finger
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Open mallet finger

• Roll or figure of 8 suture
• Splint
• Remove suture 14days
• Splint X 6 weeks
• Cover with abx

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Mallet finger physio

• STRICT extension 6wk
• MUST keep in extension when splint off
• At 6 weeks
• Start ROM
• 20 degrees week 6, 30 degrees week 7
• Night splinting x 2w
• Extension lag stop ROM and wear splint X 2wks

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Swan-neck deformity

• Complication of Mallet finger
• DIP is flexed b/c of loss of extension
• Lateral bands displace dorsally and lock PIP in
  hyperextension

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Zone 2 middle phalanx injuries

• most injuries are either partial lacs/crush
  injuries
• referral criteria similar to open mallet
• suture technique
• lateral bands are very friable and difficult to
  suture
• suture type figure-of-8
• epl on thumb use core-type suture
• splinting and follow-up as for mallet finger
• wound care and splinting x 7-10d for partial lacs
  lt50

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Zone 3 the PIP

• worst prognosis of extensor tendon injuries
• consider central slip and lateral bands

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Closed zone 3 Central Slip Rupture or Avulsion

• Second MC athletic finger injury
• Forced flexion of extended finger (finger jam)
• High degree of suspicion if
• PIP extensor lag gt 20 degrees (with MCP/wrist
  flexed)
• Decreased strength or pain with resistance to
  extension
• Tenderness over dorsal PIP and appropriate
  mechanism
• May present with acute Boutonniere deformity
• need to assess laxity of lateral bands via
  passive PIP extension
• Xray to r/o avulsion

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Closed zone 3 central slip rupture or avulsion

• 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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Boutonierre Deformity

• Complication of Zone III rupture
• DIP in extension
• PIP in flexion b/c lateral bands slip volarly
  hand hold in flexion

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Open zone 3 tendon injury

• Lacs rarely involve entire dorsal apparatus
• Also may result in Boutonniere deformity
• Suture, abx, extension splint, refer to hand
  physio at 6 weeks
• Refer
• distal central slip stump too short to repair
• associated w/open
• acute boutonniere deformity

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Zone 3 injuries physio

• Much more complex than DIP (hand physio at 6w)
• 6 w weeks
• active PIP extension w/MCP in flexion
• reapply splint between hand physio sessions
• if extensor lag develops, reapply splint
• 8 weeks
• continue active flexion, gentle resistance
  applied splint at night
• 10 weeks
• increase resistance exercises, progress to full
  grasp

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Zone 4 injuries proximal phalanx

• Tendon very broad at this level usually partial
  lac
• Partial laceration (extension intact)
• Consider repair if gt 25 - 50
• Splint X 3 weeks and then begin active motion
• Complete laceration
• Suture as for PIP lacs
• Mobilize at 3-4w b/c of higher degree of
  scarring down at this zone
• f/u and OT/PT as for PIP injuries

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Closed zone 5

• Injuries are rare and usually due to a crush
  mechanism over the MCP
• Classic tendon dislocation and relocation with
  passive extension
• Suspect sagittal band/dorsal hood disruption when
  painful flexion at MCP occurs
• Who to refer all injuries
• ED management
• splint w/MCP in extension at place of tendon
  relocation
• leave other MCPs free to move

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Open zone 5

• Fight bite
• irrigation and exploration required
• evaluate for joint capsule and tendon disruption
  abx and refer
• underlying structures OK leave wound open, abx,
  wound check in 3 - 5d
• tendon laceration leave wound open, abx, splint,
  refer to plastics

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Zone 5 Anatomy

• Saggital bands
• arise from interMC ligaments, volar plate,
  lumbrical and cover the tendon to prevent
  subluxation
• Dorsal hood
• is another name for saggital bands as they extend
  dorsally over the tendon

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Open zone 5

• Suture and splint X 4weeks f/u with physio
• Splint wrist in 40 degrees extension, MCPs 20
  degrees flexion, and IPs in 0 degrees
• Saggital band and dorsal hood
• repair if involved
• isolated sagittal band or dorsal hood lac
• avoiding abduction/adduction motion, buddy tape,
  begin flexion/extension in 3-5 days

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open zone 5 f/u OT/PT

• 4 weeks
• gentle active extension at MCP
• alternating flexion of MCP and IPs
• splint worn b/w sessions
• 5weeks
• claw postion to encourage extrinsic extension
• alternate finger and wrist flexion
• night splinting only, unless extensor lag
  persists
• 7 weeks
• resisted exercises

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Zone 6 and 7 injuries

• Easier to locate and suture
• Splinting
• wrist in 40 degrees extension, MCPs 20 degrees
  flexion, and IPs in 0 degrees X 4 weeks
• Physio at 4 weeks for ROM exercises

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hand resources OT PT

• FHH hand clinic 670-1432
• 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

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The End of the DAY

• Know how to manage common injuries
• Recognize serious injuries
• If you dont know, ask
• Be willing to follow some things in ED