Hand Trauma CT3 –MSK Day

1. Hand Trauma CT3 –MSK Day Vijay Kama Consultant EM Peterborough City Hospital

2. Let us look ……… • Why is it important? • Basic anatomy • Clinical examination • Common injuries

4. Hand Injuries

5. The Importance of the Hand • Communication • Sensation • Employment • Independent Living

6. The Hand - Communication • Greetings

7. Communication… • Gestures

8. Communication… • Sign Language

9. Sensation • Large area brain structure devoted to touch. Highly sensitive.

10. Sensation… • Relationships

11. Employment • Use of hands fundamental to most vocations.

12. Independent Living • Without the use of our hands, most people would find independent living impossible.

13. This equals 6-8 weeks off work!! No income for 2 months. How would your finances cope?

14. Basic Anatomy of the Hand

15. Anatomy - Tendons

17. Anatomy - Nerves

19. Anatomy of the Hand • Small area – lots to injure. • Even small lacerations may cause functional issues.

20. Assessing the Injured Hand - Look

21. Assess the Finger Posture

22. Feel • Is it cold? • Is sensation intact?

23. Frequently Presenting Hand Injuries • Fractures • Lacerations/Penetrating Injuries • Amputations • De-gloving Injuries • Human (punch) Bites • Animal Bites • Hand infections

24. Lacerations • Very common cause of trauma. • Typical culprits –

25. Common Results

26. Lacerations • Regardless of size, always have a high suspicion for more serious injury. • Remember, glass only ever stops cutting when it hits bone. • Lacerated tendon when repaired takes 6-8 weeks of healing and hand therapy to recover. • Nerve repairs often take 3-6 months to get some benefit from the repair

27. Tendon injuries Extensor tendon Injury: • Divided into Zones according to anatomical location of injury • In the hand and wrist there are 7extensor tendon zones 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

30. Deformities can be due to tendon, bone , nerve injury and joint dislocations • Specific types – Tendon injuries • Mallet finger

31. Boutonniere deformity • Z deformity of the thumb

32. Swan neck deformity

33. 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

34. Presentation Flexor injury

35. Amputations • Can occur at any level. • Ability to re-plant / re-vascularise depends on both the level of amputation and the mechanism. • Once past the distal third of the distal phalanx the vessels are too small to be anastamosed.

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

37. 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

38. Amputation...

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

40. 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

41. 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.

42. De-gloving Injuries

43. Followup • Can get large areas of skin loss. • Typically treated as a skin graft with original skin, or debrided and skin grafted from the thigh. • Can get contraction of the scar.

44. Punch Bite Injuries • Very common. • Injury occurs after punching someone in the mouth. Usually small laceration to the 2nd or 3rd MCPJ. Often extends into the joint with damage to the extensor tendon. • Always requires IVABs and a washout. • Common consequences – septic arthritis, extensor tendon loss.

45. Punch Bite

46. Followup • Usually require at least 1 washout. Sometime multiple. • Tendon cannot be repaired if already infected. • Tendon, although intially intact can be completely destroyed by infection. • Always, always refer.

47. Animal Bites • Cat bites – frequently become infected. Cat teeth puncture like a needle and deposit bacteria at the base to then form an abscess. • Dog bites – easier to treat than cat bites as dog teeth typically tear leaving the wound open and able to be irrigated. Cosmetically more difficult to treat.

48. Fractures and dislocations

49. Diagnosis….. • Tenderness in anatomical Snuff box • Xray- fracture line

50. Treatment • Scaphoid cast (3-4 months) • Dorsiflexion & radial deviation (glass holding position)