Injuries to Hands & Feet

Overview

• Intro• Hand • Foot

Intro

• Small injuries to hands or feet can cause serious disability

• Lacerations and crush injuries are common and can cause compartment syndrome

Hand

• Wounds that may appear minor can result in serious infection- maintain a low threshold for wound exploration

• Treatment:– First, expose the upper extremity and remove

rings, watches, and other constricting materials– Perform and document neuro exam– Check vascular status of radial and ulnar artery

(Allen test)

Hand

• Allen test: – Induce pallor by clenching fist. – Occlude radial and ulnar arteries– Release ulnar artery and check to ensure color returns.– Repeat process to check radial artery

Hand

• Compartment syndrome: the hand has 10 separate compartments!

Hand

• Treatment of compartment syndrome: fasciotomy consisting of 4 separate incisions

Hand

• Compartments are not well defined in the fingers, but swelling may require fasciotomy as shown

Hand

• Surgical technique– Do not blindly clamp bleeding tissues as nerve may be

damaged. Must directly visualize the bleeding vessel before clamping or tying off

– Local anesthetic is not sufficient, give general or regional anesthesia

– May ligate either radial or ulnar artery, never both– Explore thoroughly down to normal tissue to define extent of

injury– Debride foreign material and devitalized tissue– Do not amputate fingers unless irreparably mangled– Viable tissue is left in place for later reconstruction

Hand

• Specific tissue management– Bone: Fragments are left in place for later reconstruction unless

severely contaminated or protruding– Tendon: Minimal excision of tendons should occur. No attempt

at tendon reconstruction should be made in the field.– Nerve: Do not excise. Do not attempt to reconstruct in the field– May tag nerves or tendons with 4-0 suture for later recognition– Closure of wounds is delayed, but exposed bone/tendon/nerves

should be covered with viable skin if at all possible

Hand

• Splinting– Splint the hand in the safe position: the wrist is

extended to 20◦, the metacarpophalangeal joints are flexed 70-90◦, and the fingers are in full extension

Hand

• Dressing:– Fine mesh gauze is placed directly on the wounds

and a generous layer fluffy gauze is laid on the outside

– Leave fingertips exposed, if possible, to allow for evaluation of perfusion

Foot

• Foot injuries can cause significant disability, particularly if the following occur:– Loss of heel pad– Significant neurovascular injury– Contamination of deep plantar space

• The goal of treatment is pain-free, plantigrade foot with intact plantar sensation

Foot

• Evaluation and management– Assess vascular status by palpating dorsalis pedis and

posterior tibial pulses– Assess capillary refill of the toes (compartment syndrome

can exist even with intact pulses)– Check sensation of the plantar surface. Numbness indicates

damage to posterior tibial nerve and poor prognosis– Debride the wound and remove any bone fragments

without soft tissue attachment– Irrigate the wound (high volume)– All wounds should be left open

Foot

• Injuries to the hindfoot– Talus is best debrided through anterolateral approach

to the ankle extended to the base of the 4th metatarsal– Penetrating wound into plantar aspect of the talus can

be approached through heel-splitting incision to avoid excessive damage to this specialized skin

– Transverse gunshot wounds of the hindfoot are best managed by medial and lateral incisions with surgery performed laterally to avoid medial neurovascular structures

Foot

• Injuries to the midfoot– Tarsals and metatarsals are best approached through

dorsal longitudinal incisions– Compartment release can be performed through

longitudinal incisions medial to the 2nd metatarsal and lateral to the 4th metatarsal

– Contamination of deep plantar space can be managed through a plantar medial incision that begins 1 inch proximal and 1 inch posterior to the medial malleolus extending across the medial arch and ending on the plantar surface between the 2nd and 3rd metatarsal heads

Foot

• Injuries to the toes– Make every effort to preserve the big toe– Amputation of the lateral toes tends to be well

tolerated

Foot

• Compartment syndrome: the foot has 5 compartments– Interosseous compartment– Lateral compartment– Central compartment– Medial compartment– Calcaneal compartment

Foot

• Compartment syndrome: release is accomplished by a double dorsal incision– One incision medial to the second metatarsal (medial compartment)– Second incision lateral to the 4th metatarsal (lateral compartment)

Foot

• Compartment syndrome: single incision medial fasciotomy can be done to spare dorsal soft tissue– A medial approach is made through the medial compartment,

reaching through the central compartment into the interosseous compartment dorsally and into the lateral compartment

Foot

• Fasciotomy wound management: – Following fasciotomy, all devitalized tissue is

removed– The fasciotomy is left open and covered with a

sterile dressing• Stabilization:– K-wires can be used for temporary stabilization– Bi-valved cast or splint is adequate during

transport to definitive care