HANDINJURIES

Peter Freeman

ESSENTIALS

• A thorough knowledge of hand anatomy and function is essential for proper management of the injured hand

• Most hand injuries carry a good prognosis if treated early and appropriately

• Aftercare and rehabilitation are vital

PRESENTATION

• History– Time taken eliciting an accurate history of

the mechanism of injury is never more important than in the case of hand injury

– When, how, where?– Hand dominance– Occupation

EXAMINATION

• The injured hand must be examined in a well-lit cubicle with the patient comfortably reclined

• Deformity, swelling, position of wound• Resting position• Tenderness and sensation

NERVE SUPPLY TO THE HAND

Radial

Median

Ulnar

EXAMINATION

• Test function - tendons (FDP, FDS and extensors) - grip - joint stability• Deformity, rotation, loss of function• Pain

INVESTIGATIONS

• Most information will be obtained from a full history and examination

• Radiology of the hand and fingers will be necessary if bone or joint deformity or tenderness is elicited

CLASSIFICATION

• Hand injuries are usually described by tissue, e.g. tendon, nerve or bone injury

• A more practical approach is to describe injuries by anatomical site

FINGERTIP INJURIES

• Classification of fingertip amputations

NAILBED INJURIES

• Often underestimated• Trephine subungual haematoma <

25% • Remove nail if > 25%• Reduce # terminal phalanx• Repair nail bed with 6/0 absorbable• Nail regrowth - 1mm/wk

TERMINALIZATION

• Explain options with patient• Discuss with specialist• Local anaesthetic• Remove nail root• Diathermy digital nerves and

vessels• Loose closure and avoid dog ears

DIGITAL NERVE BLOCK- PALMAR APPROACH

DISTAL INTERPHALANGEAL JOINT INJURIES

• Mallet finger (always Xray)• Dislocations• Fractures• Wounds - digital nerves

MIDDLE PHALANGEAL INJURIES

• Profundus tendon• Fractures often require ORIF• Unstable• Discuss with hand specialist

PROXIMAL INTERPHALANGEAL JOINT INJURIES

• Most unforgiving joint• Extensor apparatus• Boutonniere deformity • Volar plate• Wilson #• Joint instability• Splint and refer

PROXIMAL PHALANGEAL INJURIES

• Profundus and superficialis tendons

• Unstable fractures require ORIF• Rotational deformity• Refer hand specilaist• Spint in position of

function/recovery

METACARPOPHALANGEAL JOINT INJURIES

• MPJ subluxation - often missed• Fist-tooth injury - always involves joint - irrigation - antibiotics• Ulnar collateral ligament tears

METACARPAL INJURIES

• 5th MCP fracture (punching) - best treated conservatively• Bennett’s fracture (intra-articular) - often requires ORIF• 2nd, 3rd and 4th MCP fracture - volar spint in position of recovery

DORSAL HAND INJURIES

• Kessler technique of tendon repair. An alternative technique is to begin the suture between the tendon ends and tie, and bury the knot within the tendon.

PALMAR HAND INURIES

• Penetrating wounds in no-mans land

- Nail gun injury (barbs) - Grease or Paint gun injury - Glass injury (always Xray) - Organic material (consider US)

DISPOSITION

• Many hand injuries can be appropriately managed in a well equipped emergency department

• Refer early when indicated• Elevation• Analgesia

PROGNOSIS

• Early definitive care optimal• Late injury difficult to salvage due

to stiffness• Functional splintage (extrinsic

plus)• Early guarded mobilisation• Desensitise finger tips

PREVENTION

• Children's finger tips• Occupational injuries - butchers

CONTROVERSIES

• Fingertip dressings• Hand splintage• Fifth metacarpal fractures• Foreign bodies• To suture or not?• Adrenaline• Antibiotics