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HAND INJURIES Peter Freeman

HAND INJURIES 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

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HAND INJURIES Peter Freeman

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  1. HAND INJURIES Peter Freeman

  2. 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

  3. 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

  4. 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

  5. NERVE SUPPLY TO THE HAND Radial Median Ulnar

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

  7. 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

  8. 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

  9. FINGERTIP INJURIES • Classification of fingertip amputations

  10. 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

  11. TERMINALIZATION • Explain options with patient • Discuss with specialist • Local anaesthetic • Remove nail root • Diathermy digital nerves and vessels • Loose closure and avoid dog ears

  12. DIGITAL NERVE BLOCK- PALMAR APPROACH

  13. DISTAL INTERPHALANGEAL JOINT INJURIES • Mallet finger (always Xray) • Dislocations • Fractures • Wounds - digital nerves

  14. MIDDLE PHALANGEAL INJURIES • Profundus tendon • Fractures often require ORIF • Unstable • Discuss with hand specialist

  15. PROXIMAL INTERPHALANGEAL JOINT INJURIES • Most unforgiving joint • Extensor apparatus • Boutonniere deformity • Volar plate • Wilson # • Joint instability • Splint and refer

  16. PROXIMAL PHALANGEAL INJURIES • Profundus and superficialis tendons • Unstable fractures require ORIF • Rotational deformity • Refer hand specilaist • Spint in position of function/recovery

  17. METACARPOPHALANGEAL JOINT INJURIES • MPJ subluxation - often missed • Fist-tooth injury - always involves joint - irrigation - antibiotics • Ulnar collateral ligament tears

  18. 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

  19. 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.

  20. 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)

  21. DISPOSITION • Many hand injuries can be appropriately managed in a well equipped emergency department • Refer early when indicated • Elevation • Analgesia

  22. PROGNOSIS • Early definitive care optimal • Late injury difficult to salvage due to stiffness • Functional splintage (extrinsic plus) • Early guarded mobilisation • Desensitise finger tips

  23. PREVENTION • Children's finger tips • Occupational injuries - butchers

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

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