Injuries to Hands & Feet

1. Injuries to Hands & Feet

2. Overview • Intro • Hand • Foot

3. Intro • Small injuries to hands or feet can cause serious disability • Lacerations and crush injuries are common and can cause compartment syndrome

4. 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)

5. 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

6. Hand • Compartment syndrome: the hand has 10 separate compartments!

7. Hand • Treatment of compartment syndrome: fasciotomy consisting of 4 separate incisions

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Foot • Evaluation and management • Assess vascular status by palpating dorsalispedis 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

15. 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

16. 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

17. Foot • Injuries to the toes • Make every effort to preserve the big toe • Amputation of the lateral toes tends to be well tolerated

18. Foot • Compartment syndrome: the foot has 5 compartments • Interosseous compartment • Lateral compartment • Central compartment • Medial compartment • Calcaneal compartment

19. 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)

20. 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

21. 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