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Hand Injuries

Hand Injuries. Colin Del Castilho Dr Ian Rigby. Famous Hands . Outline. Hand exam Hand Infections High Pressure Injection Injuries Fractures/Dislocations Tendon injuries Amputations. Things Not Covered. Carpal fractures/ Wrist fractures Thermal injuries and Frostbite Nerve Blocks.

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Hand Injuries

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  1. Hand Injuries Colin Del Castilho Dr Ian Rigby

  2. Famous Hands

  3. Outline • Hand exam • Hand Infections • High Pressure Injection Injuries • Fractures/Dislocations • Tendon injuries • Amputations

  4. Things Not Covered • Carpal fractures/ Wrist fractures • Thermal injuries and Frostbite • Nerve Blocks

  5. 6 Finger Hand Exam • A Appearance: • Resting posture • Ischemia/cyanosis • Lacerations • Swelling • Erythema • Deformity

  6. 6 Finger Hand Exam, • B both hands • Compare to other hand

  7. 6 Finger Hand Exam • C Circulation • Allen’s test • Control lacerations- direct pressure, don’t clamp • Inflate BP cuff to 30>systolic pressure, no more than 30 min

  8. 6 Finger Hand Exam • D Neurological assessment • Sensory

  9. 6 Finger Hand exam • D Neurological Assessment • Motor • Screening exam • Thumbs up (hitchhiker • Spread finger apart • Maneuver tips of each finger and thumb around tip of pen • If deficit detected, proceed to more thorough motor exam

  10. E extension Test all digits 6 Finger Hand Exam

  11. F Flexion • Assess all joints • FDP and FSP separately

  12. Hand Infections

  13. What is this?

  14. Herpes Whitlow • HSV 1 60%, HSV 2 40% • Common in children, health care workers, immunocompromised • Inoculation occurs through breakage in skin barrier • Incubation period 2- 20 days • Prodrome- fever, malaise, burning, erythema, tingling in affected digit

  15. Herpes Whitlow • 1-3mm grouped vesicles on erythematous base lasting 7-10 days • Crust over- no longer infective • May recur (remains dormant in nerve ganglia) • Treatment: • Allow vesicles to rupture on own • Zovirax ointment • Oral acyclovir • Observe for bacterial superinfection- start keflex

  16. What is this?

  17. Paronychia • Acute infection of nail bed • Usually staph, may be oral anaerobes • Treatment • Incision around nail bed to drain pus • Antibiotics usually not necessary • May need to remove nail if abscess spreads under nail • Finger chewers- clinda

  18. Paronychia

  19. How about this?

  20. Felon • Abscess of finger tip • S. aureus, oral anaerobes • Treatment: • I and D • Keflex for 7-10 days • Referral to hand surgeon if does not improve

  21. Felon

  22. Complications • Finger tip necrosis • Tenosynovitis • Osteomyelitis • Neuroma (from I and D) • Admit to hospital----- immunocompromised, systemic symptoms, failure to respond to abx

  23. Famous Hands

  24. Famous Hands

  25. Name this Infection

  26. Pyogenic Flexor Tenosynovitis • Direct inoculation- Staph • Rarely hematogenous spread- NG

  27. Pyogenic Tenosynovitis • Cardinal Symptoms • Pain on passive extension (most sens) • Pain on palpation of flexor tendon • Symmetric/fusiform swelling • Finger held in flexion

  28. Pyogenic Tenosynovitis • Management • Urgent plastics consult • Antibiotics: IV 3rd gen Cephalosporin, then adjust based on C and S • Complications • Bacteremia • Compartment syndrome • Loss of finger function

  29. Clenched Fist Injury/Human Bite • Most commonly caused by “fight bite”

  30. Clenched Fist Injury/Human Bite • 75% involve extensor tendon, joint, bone or cartilage Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist injuries. Clin Orthop 1987;220: 237-40. May extend to joint capsule • May involve MCP or PIP fracture • 50% infection rate -Staph, Strep, Eikenella. On average- 5 organisms in wound • Examine in position of injury • Extend wound 3-5 mm either side

  31. Clenched Fist Injury • Management • Uncomplicated early wounds: • Antibiotics: Clavulin • Clinda + Cipro or Septra • Pen + Clox • Avoid first gen cephs- Eikenella resistance • Debridement, irrigation, close by secondary intention • Splint in position of safety if tendon injured • Tetanus • Must have follow up • Complicated wounds: • Referral to plastics • IV antibiotics - cefoxitin, tazocin

  32. Deep Space Hand Infections • Deep Space 5 • Staph, Strep, coliforms • Management: IV Ancef and refer

  33. Famous Hands

  34. High Pressure Injections • Only requires 100psi to break skin commonly involve 1000-10,000psi • Index finger most common, non dominant hand • 1000psi = 450 lbs falling 25 cm

  35. High Pressure Injections • Damage determined by • Type of injection: Grease/oil, hydraulic fluid, paint thinner, molding plastic, paraffin, cement • Amount • Finger- 1st and 5th digit may lead to compartment syndrome in wrist and arm • Direct tissue damage, vasospasm/ischemia, inflammation

  36. High Pressure Injections • Management: • IV analgesia only. Avoid digital nerve blocks- increase ischemia • Immediate Plastics Consult • NPO • Factors associate with Amputation- 70% of oil injections • 100% if > 7000psi • Delayed presentation

  37. Hand Fractures

  38. Distal Phalanx Fractures • Usually from crush injury • Rarely displaced, usually comminuted • May have associated subungal hematoma • Management of tuft #: • Short finger splint 1-2 weeks (don’t immobilize PIP

  39. Distal Phalanx Fracture • Transverse or Longitudinal shaft # • Stack splint for 4 weeks • FDP avulsion • Refer to plastics • Intra-articular #’s- refer to plastics • Mallet finger will be discussed later

  40. Subungal Hematoma • Previously recommended for nail removal and formal nail bed for all > 25% of nail • Roser 1999 • No difference in long term outcome between nailbed repair, trephination, or observation only • Management • Trephinate the nail for pain control • Nail bed repair for (i) displaced # fragment (ii) disrupted nail (iii) consider for large hematoma (>50%)

  41. Middle and Proximal Phalanx Fracture • Assess for neurovascular and tendon/ligament stability • Stable shaft fractures: Buddy tape with early ROM • Uni or Bicondylar Fractures: unstable, require ORIF

  42. Middle and Proximal Phalanx Fractures • Unstable fractures: displaced, oblique or spiral fractures, comminuted, scissoring deformity/rotation, unable to reduce or maintain reduction • Rotational deformity: nail not in line with mcp, scissoring, finger does not point to scaphoid tubercle when flexed • Treatment: requires plastics referral • Splint index/ middle in radial gutter splint • Ring/little finger in ulnar gutter splint

  43. Unstable Phalanx Fractures

  44. Metacarpal Fractures • Head • Neck • Shaft • Base

  45. Metacarpal Fractures • Hand Function can tolerate angulation equal to CMC joint motion + 10o • Normal Accept • 5 degrees 15 • 5 degrees 15 • 20 degrees 30 • 30 degrees 40

  46. Variant of Boxers # Will need ORIF: >1mm step off >25% intraarticular surface displaced Splint in position of safety Look for fight bite Metacarpal Head Fracture

  47. Name the #

  48. Metacarpal Neck # • Attempt to reduce if: • Angulation > 40o -5th • 30o - 4th • 15o - 2, 3rd • Splint in position of safety • When to refer to plastics for k wire or ORIF • Any rotational deformity • Shortening > 3-4mm • Unable to maintain reduction

  49. Splint Metacarpal neck # • Position of safety to prevent MCP contractures • Hold in reduction and mold splint until set • Must include 4th MC • If MCPs aren’t flexed 90 degrees ---> loss of reduction

  50. Metacarpal Shaft Fracture • Accept same angulation as Neck # • No rotation • Shortening up to3-4mm • Reduction technique: • Jahss technique: flex both MCP and PIP to 90o. Press up on Middle phalanx and down just proximal to apex of# • Then splint in position of safety

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