Hand Rounds: Oct 31, 2002 Rob Hall MD and Lisa Campfens MD, FRCPC

1. Hand Rounds: Oct 31, 2002Rob Hall MD and Lisa Campfens MD, FRCPC Where would we be without our hands???

2. Goals for today • Recognize serious injuries • Manage common hand injuries • Appropriate referrals to plastics • Proper splinting of injuries • F/U of certain injuries in emerg • Recognize that management of many hand injuries is controversial

3. Fractures Dislocations Sprains Tendon injuries Amputations Mutilating injuries High pressure injection Digital nerve injury Not covering infections foreign bodies burns compartment syndromes Goals of Today

4. Position of Safety

5. CAM effect

6. Box of the Finger

7. Management?

8. Distal Phalanx Tuft Fractures • Distal hairpin splint • Do not immobilize PIP • Manage subungual hematoma

9. Subungual Hematoma • Previously recommended for nail removal and formal nail bed for all > 25% • 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

10. Approach to Phalanx Fractures • Stable • transverse, nondisplaced • Unstable • oblique, spiral, comminuted, displaced transverse, intraarticular with > 20% joint, rotational deformity • MUST rule out rotational deformity • symmetric flexion, point to scaphoid, nails

11. Dynamic Splinting (buddy tape) Early ROM (as soon as pain subsides - 3 to 5 days) Stable Phalanx Fractures

12. ED Management Reduce Splint Refer Unstable Phalanx Fracture

13. Pin early Unable to reduce Unable to maintain reduction Rotational deformity Intraarticular with > 20% of joint involved Closed reduction and splinting Splint X 3 weeks F/U Xray 7-10days to make sure reduction is held OR if unable to maintain reduction Unstable Phalanx Fracture: Options

14. Principles of Metacarpal Neck # • Why do Boxer’s # do well no matter what you do?? • Hand function can tolerate angulation in the metacarpal neck equal to the motion at the CMC joint + 10 degrees

15. Normal Accept 5 degrees 15 5 degrees 15 20 degrees 30 30 degrees 40 Principles of Metacarpal Neck Fractures

16. Metacarpal Head Fracture • Intra-articular • Needs precise anatomic reduction • Brewerton views can help identify • Splint in safe position and refer

17. “Well he was talkin’when he shoulda bin listen man” Management?

18. Boxer’s Fracture • Who needs reduction? • Displaced, angulated > 40 degrees, rotated • How to reduce? • Ulnar, metacarpal, hematoma blocks --> 90 - 90 • Follow up? • Xray at 1 week to r/o slip • F/U with GP (or ED) • Remove splint at 3 - 4 weeks and start ROM

19. Boxer’s Fracture • Indications for OR • Can obtain adequate reduction • Can’t maintain adequate reduction • Controversy • Study: pin vs no pin makes no difference • Van Bowen: pin anything that needs reduction • Generally fairly uncommon to need pinning • Rotational deformity/scissoring likely most common reason to pin

20. Proper splinting ESSENTIAL to maintaining reduction 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 Splinting Boxer’s Fractures

21. Open Boxer’s Fracture • “Fight Bite” ----> HIGH risk of infection • +++++ Irrigation and Explore • Look carefully for tendon disruption • Not into joint capsule • Leave open, clavulin/Keflex, check at 3 - 5 d • Into joint capsule • Leave open, clavulin or keflex po X 5 - 7 days • Wound check in 24 - 48hrs

22. Other MC neck Fractures • 4th: manage as per Boxer’s • 2nd and 3rd • Volar splint and refer • Less mobility accepted thus more likely to pin

23. Management?

24. Metacarpal Shaft Fractures • Can accept < 3mm shortening and 10 deg angulation in II/III or 20 deg in IV/V • Cannot accept rotation • Stable # (transverse, good reduction) • splint, could follow in ED but must ensure doesn’t slip (re Xray in one week) or could send to plastics • Unstable # (spiral, oblique, multiple #s, failed reduction, rotated) • splint, reduction prn, refer

25. Extra-articular Thumb Metacarpal Fracture • Unstable (oblique, spiral, comminuted) • Splint and refer for pinning • Stable (transverse) • Attempt reduction if > 20 degrees angulation • Splint in thumb spica X 4 weeks • Refer

26. Who the heck is Bennet????? Management?

27. Bennett’s Fracture • Two part intra-articular fracture at base of thumb metacarpal • Commonly see CMC joint subluxation • Thumb spica splint and refer for pinning • Abductor pollicus longus pulls fragment off

28. Bennett’s Fracture

29. Management?

30. Rolando’s Fracture • Three (or more) part intra-articular fracture at base of thumb metacarpal • Commonly see Y or T pattern but comminuted fracture is also called Rolando’s fracture • Thumb spica splint and refer

31. Commonly missed Xray: look carefully for clear, even space b/w base of 5th MC and hamate Unstable b/c ext carpi ulnaris pulls at base Needs pinning “Reverse Bennet’s” Fracture

32. The Pediatric Hand

33. The Pediatric Hand • Salter - Harris classification used • Tuft # and SH II of proximal phalanx common • Thick periosteum thus hold position well and heal quickly • Generally: closed reduction, splint X 3 wks • OR: can’t reduce, can’t maintain reduction, displace intraarticular #, SH IV/V

34. Closed reduction Immobilize with splint X 3 weeks or K wire Can present with “paronychia” not responding to Rx Salter Harris I

35. Common Reduce Splint with gutter splint Splint X 3 wks Salter Harris II

36. Salter Harris III - V • SH III • Minimally displaced, < 25% joint surface involved: splint X 3 wks • Displaced, > 25% joint surface involved: splint and refer • SH IV: reduce prn, splint and refer • SH V: reduce prn, splint and refer

37. Assessment of Finger Joint Stability • Blocks may be required for assessment • Active stability • can pt move finger through full ROM without displacement? • Passive stability • apply stress to collaterals, and volar plate

38. Finger Sprains • Xray • R/O fracture/avulsion • LOOK carefully for subluxation • Stable joint • buddy tape or gutter splint • ROM early to prevent stiffness (3-5 days) • Unstable joint • splint and refer

39. Finger Sprains • Flexion Contractures • Common complication • Prevention • MUST SPLINT PIP/DIP IN EXTENSION • MUST SPLINT MCP in FLEXION • Early ROM • Minimize dressings to allow ROM • See physio at two weeks if becoming stiff

40. Management?

41. Dorsal/Lateral Ring block, Xray Reduce, examine stability Buddy tape and EARLY ROM (better than splint X 3 weeks) refer: can’t reduce, unstable joint, avulsion > 1/3 of joint surface Volar dislocation Controversial Attempt closed reduction Splint and refer PIP Dislocations

42. PIP Subluxation +/- Fracture

43. PIP Joint Subluxation +/- Fracture • Do NOT miss this injury • Must Xray fingers in full extension • Will not stay reduced in extension • Can’t splint in flexion (flexion contracture) • Mx • splint and refer for extension pin • also will need special rehab

44. Simple dislocation (subluxation) hyperextended 60 - 90 degrees, articular surfaces contacting w/o interposed soft tissue metacarpal block reduction splint in safety position refer Complex dislocation hyperextension LESS than 60 degrees Xray: wide joint space, sesamoid in joint space is pathognomonic Splint and refer (will not be reducible) Dorsal MCP Dislocations

45. Volar plate prevents reduction Wide joint space, sesamoid in joint Dorsal MCP Dislocation

46. Commonly missed Look at CMC joint space carefully Compare shaft of MC with adjacent MC Reduction Splint Refer (often slip and need pinning) CMC Subluxation +/- Fracture

47. Management?

48. Gamekeeper’s (Skier’s) Thumb • Ulnar Collateral Ligament of the thumb • Stress MCP in full extension and 30 deg of flexion to offset stabilization of volar plate • Xray to r/o avulsion • Sprain (partial): thumb spica X 4 weeks • Rupture (complete) • Splint and refer for pinning • Stener’s lesion (adductor pollicus in the way)

49. Management?

50. High Pressure Injection Injuries • Consider all SEVERE injuries • Paint and paint thinners worse than grease • Mx • Tetanus • IV analgesia (NO digital blocks) • Antibiotic, splint, elevate, NPO • Consult plastics (early - don’t wait ‘til am)