Hand Trauma

Principles of Management

Prasad AbeyratneRegistrar in surgery

NHSL- Sri Lanka

• Hand is one of the most important parts of the human body due to its mechanical and sensory functions.

• One of the most developed structures in the human evolution.

4 requirements for a functioning hand:

◦ Supple (moving with ease)◦ pain free◦ Sensate◦ Coordinated

Topics

• Relevant anatomy • Clinical approach to hand trauma – History – Examination – Imaging

• Specific injuries

Relevant Anatomy

Integument Dorsal skin

◦ Thin and pliable. ◦ Attached to the hand's skeleton only by loose areolar tissue, where

lymphatics and veins abundant.◦ Edema is manifested predominantly at the dorsum◦ Loose attachment makes it more vulnerable to skin avulsion injuries.-

degloving injuries .

Palmar skin◦ Thick and glabrous and not as pliable◦ 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 4

Soft tissues

• Muscles and tendons • Blood vessels ,

lymphatics • Nerves

Spaces of the hand

Ref. Clinical Anatomy, Richard Snell, 6th editionClinical symposia Nov.1988 –surgical anatomy of the hand- earnest W.Lampe MD

Muscles and tendons

• Muscles - two main groups:– Extrinsic group• Extrinsic extensors• Extrinsic flexors

– Intrinsic group:• Thenar complex• lumbricals • Interosseous• Hypothenar complex

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Anatomy of the tendon arrangement in a finger

Extensor expansion - On the dorsum Flexor sheath - on the volar aspect

Blood vessels

• 2 main vessels – ulnar (dominant in 80% ) and radial• Forms 2 arches in the palm-

• Large Superficial – mainly by ulnar- at the level of distal border of the extended thumb.

• Small deep- mainly by radial- at one finger breadth proximal to the superficial.

• Fingers –proper digital arteries are end arteries .• Fingers neurovascular bundles – nerves are in more

palmar than arteries in contrast to the palm.

• Osseous arteries– Lunate- blood supply from the volar and palmar

ligaments- dislocation with tears in both ligaments will cause avascular necrosis .

– Scaphoid – 1/3 of the people supply only from the distal end.

Nerves

- Sensory Innervation

Motor supply to hand –

Ulnar nerve. • All the intrinsic muscles - of the hand except radial 2 lumbricals • Muscles of thenar eminence, with exception flexor pollicis

brevis .variations + • Muscles of hypothenar eminence are innervated by ulnar nerve

Median nerve LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis

Ref. Wheeless' Textbook of Orthopaedics

Spaces of the hand

Important in infections • Radial bursa • Ulnar bursa• Mid palmar space ( continuous proximally with the

space of Parona.)• Thenar space • Dorsal subcutaneous space • Dorsal subaponeurotic space • Finger pulp spaces

Deep spaces of the hand

Radial bursa

Ulnar bursaMid palmar space

Thenar space

Space of Parona

Bones of the hand

Hand Trauma

Hand trauma account for 5-10 % of trauma.

Mechanism of injury • Blunt trauma • Lacerations & punctures • Avulsions ± soft tissue deficit • Ring avulsions

Structures injured • Cutaneous injuries • Muscles and Tendons • Neuro-vascular injuries • Bones and associated soft tissues

Approach to Hand Trauma

• History • Examination • Imaging

Ref. Clinical Orthopedic examination -3rd Ed. Ronald McRaeBailey and Love’s –Short practice of surgical – 23rd EdConcise system of orthopaedics and fractures- 2nd Ed. Alan Graham Apley, Louis Solomon

History

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Important points in the history of a patient with hand

injury.▫ Age▫ Hand dominance ▫ Occupation & hobbies

▫ When and how the injury occurred? mechanism of trauma ▫ Previous history of hand trauma or relevant

medical/Rheumatic conditions

Physical examination

Entire upper limb comparing both upper limbs.Should follow the routine order of LOOK, FEEL, MOVE

LOOK • External appearance. – local swellings -

• Evidence of chronic disease(OA, RA, Gout)

– Bleeding – Auto-amputations – Wounds / exposed tendons etc. – Deformities

Deformities can be due to tendon, bone , nerve injury and joint dislocations

– Specific types –Tendon injuries

• Mallet finger

• Swan neck deformity

• Boutonniere deformity

• Z deformity of the thumb

Claw hand deformities – due to nerve injuries Median, ulnar nerve injuries

– Wasting of the thenar and hypothenar muscles, interossei etc. ( Chronic )

• FEEL – Temperature – Tenderness – Distal neurovascular status

MOVE

Finger cascade ( flexion and extension tendon injuries/ fractures ) Muscles- intrinsic and extrinsic Joints

pain and stabilitynormal ROM – Fingers MP – 0- 90° Passive - further 45 ° PIP – 0- 100 ° DIP - 0- 80 ° Thumb –MP - ext. – 55 ° IP - flex. – 80 ° Ext. - 20 ° Carpometacarpal- ext.- 20 ° , flex.- 15 ° abduction- 60 °

(excess mobility may be due to collateral lig. Injury Ex. Gamekeepers thumb )

Functional capacity – • Grips

– Pinch grip /precision grip – Chuck grip – Palmar grip/hook grip– power grip

Types of grips of the hand

Pinch grip /precision grip

Power grip Hook grip Chuck grip

Imaging

• X rays- AP, lateral &oblique views ◦ Plain-films of the hand or wrist should be obtained when

injury suggestive of fracture or an occult foreign body.

Ultra sound◦ 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 but not have a role in management of

hand wounds.

General Operative Principles

• A bloodless field (eg, by tourniquet ischemia) is essential. The pressure of the cuff will 100 mm Hg above systolic pressure.- 200-250 mmHg ( max-250) This is readily tolerated by the unanesthetized arm for 30 minutes and by the anesthetized arm for 2 hours.

• Incisions must be either zigzagged across lines of tension (eg, must never cross perpendicularly to a flexion crease), termed Brunner incisions, or run longitudinally in "neutral" zones- so that a healthy skin-fat flap is raised over the zone of repair of a tendon, nerve, or artery.

Cutaneous injuries • Cutaneous injuries are very common injury.• Two Types– Open: Incised, laceration, punctured (bites),

penetration, abrasion.– Closed: Contusions, Hematomas

• Vary in depth• May need to explore for underlying structural Injuries.• Conservative excision of the skin is the rule.

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Management

Skin Laceration:◦Small: Rinse and cover.◦Large: Wound exploration under LA

Irrigate wound profusely with betadine or sterile water and Explore

Close the skin wound with simple sutures. Wounds older than 6-8 hours should not be

closed primarily. Irrigate, explore then apply sterile dressing.

Delayed primary closure at 4 days.

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Bites:◦Should not be closed primarily but delayed closure

at 4 days if needed◦Antibiotic prophylaxis is indicated in human

(including fight-bites) and cat bites and may be of benefit in dog bites as well.

Contusions:◦Cold packs with pressure for 30 to 60 min. several

times daily for 2 days. Then use warm compresses for 20 minutes at a time.

◦Rest, elevate ◦Do not bandage a bruise.

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Abrasions:◦Superficial:

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 (Tegaderm)

Changed every few days. Keep wound moist. Enhance healing process.

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Injured components may include skin, bone, nail, nail bed, tendon, and the pulp, the padded area of the fingertip .

The skin on the palm side of fingertips is specialized in that it has many more nerve endings than most other parts of our body enabling the fine sensation.

When this specialized skin is injured, exact replacement may be difficult.

Finger tip Injuries

• Severe crush or avulsion injuries can completely remove some or all of the tissue at the fingertip.

• If just skin is removed and the defect is less than a centimeter in diameter, it is often possible to treat these injuries with simple dressing changes.

• If there is a little bit of bone exposed at the tip, it can sometimes be trimmed back slightly and treated with V-Y plasty

Cross finger flap

• For larger skin defects, skin grafting is recommended. • Smaller grafts can be obtained from the little finger

side of the hand. - Cross finger flap • Larger grafts may be harvested from the forearm or

groin.

Extensor tendon Injury:– Divided into Zones according to anatomical

location of injury– In the hand and wrist there are 7 extensor

tendon zones

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Tendon injuries

Ref. http://emedicine.medscape.com Orthopedic Surgery for Flexor Tendon Lacerations Author: Michael Neumeister, MD, FRCSC, FRCSC, FACS; Chief Editor: Harris Gellman, MD http://www.orthobullets.com- Flexor Tendon Injuries- Derek Moore MD

Zone Presentation Management

I Mallet 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.

VII Fixed flexion of MCP •Suture repair followed by post-op splinting

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Flexor tendon injuries –5 zones in the hand and the wrist

Zone 1 One tendon only (FDP) from middle of middle phalanx distallyZone 2 Two tendons (FDS & FDP) from MCP joints to middle of middle phalanxZone 3 Central palmZone 4 Tendons in the carpal tunnelZone 5 Tendons proximal to the carpal tunnel

FDS Insertion

Flexor Sheath

Presentation Flexor injuryZone Presentation Management

I

Loss of active flexion at DIP joint

Hyperextension of DIP joint

(Jersey finger )

•Primary or Secondary tendon repair•Careful suturing prevent post-op adhesions.

II 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, IVThumb Same

•Primary or secondary tendon repair•Examine carefully for thenar muscle injury and recurrent branches of median nerve.

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Zone Presentation ManagementV

PalmUncommon

Lie deep and protected by palmar fascia

Same presentation

•Superior to Tendon division: repair is unnecessary.•Both muscles’ tendon division: primary repair

VI, VIIWrist

Multiple flexor tendon injury

Impaired active flexion of multiple digits

•Primary tendon suturing 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.

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Nerve injuries 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.

Neorutmesis:• Injury to all anatomical components, myelin sheath, axons and the

surrounding connective tissue.• This total nerve disruption makes regeneration impossible.• Surgical intervention is necessary.

Nerve injury – surgical interventions Neurolysis:◦ 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.

Hand infections

• Commonly seen by orthopedic surgeons as well as emergency room Identifying the cause of the infection and initiating prompt and appropriate medical or surgical treatment can prevent substantial morbidity.

• The most common bacteria Staphylococcus aureus and Streptococcus species

• Best treated with empiric antibiotic therapy until the organism can be confirmed.

• Types of infections include cellulitis, superficial abscesses, deep abscesses, septic arthritis, and osteomyelitis

• In recent years, treatment of these infections has become challenging owing to increased virulence of some organisms and drug resistance.

• Treatment involves a combination of proper antimicrobial therapy, immobilization, edema control, and adequate surgical therapy.

• Best practice management requires use of appropriate diagnostic tools, understanding by the surgeon of the unique and complex anatomy of the hand, and proper antibiotic selection in consultation with microbiology opinion.

Ref. Hand infections. J Hand Surg Am. 2011 Aug;36(8):1403-12.

AMPUTATION ANDREPLANTATION

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IntroductionReplantation: reattachment of a severed digit of extremity. Chinese surgeons at the Sixth People's Hospital performed

successful replantations in the 1960s. However, in 1968 Komatsu and Tamai's reported o a successful thumb reattachment

Not all patients with amputation are candidates for replantation

Approximately 100,000 digital amputations occur per year in the US. Of these, an estimated 30% are suitable for replantation

Ref. http://emedicine.medscape.com- Hand, Amputations and Replantation- Author: Bradon J Wilhelmi, MD; Chief Editor: Joseph A Molnar, MD, PhD, FACS

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Decision is based on: Importance of the part, level of injury, mechanism of injury expected return of function.

Because hand function is severely compromised if the thumb or multiple fingers are not present to oppose each other, thumb and multiple-finger replants should be attempted.

Hand Muscles at room temperature are irreversibly damaged in 6-8 hours; if cooled, it can withstand a maximum of 8-12 hours of ischemia.

However, if digits are cooled without freezing, they may survive longer than 100 hours

Recommended ischemia times for replantation:◦Major replant: 6 hours of warm and 12 hours of

cold ischemia.◦Digit: 12 hours for warm ischemia and 24 hours for

cold ischemia.

Preoperative preparation: radiography of both amputated and stump parts to determine the level of injury and suitability for replantation

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The normal sequence of the operative procedure

• Debridement• Identification and/or tagging of vital structures

• Skeletal stabilization- appropriate shortening, the bone may be stabilized interosseous wires, interosseous wire and pin, or miniplate and/or miniscrews. Joint damage may be managed with prosthetic joints, resection arthroplasty, or fusion.

• Extensor tenorrhaphy• Placing sutures within flexor tendon ends• Digital artery repair• Neurorrhaphy of digital nerve• Repair of flexor digitorum profundus• Venous repair• Skin closure• Dressing

Outcome

Overall success rates for replantation approach 80%.Better outcome with Guillotine (sharp) amputation (77%)

compared to severely crushed and mangled body parts(49%). In general, the prognosis for ring avulsion injuries is poor.

Studies have demonstrated that patients can expect to achieve 50% function and 50% sensation of the replanted part.

Ref. Plastic Surgery, Goldwyn and Cohen, 3rd edition.Plastic Surgery, Grabb and Smith, 3rd edition.

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Thank you

Bone injuries–fractures• To be continued…