HAND INJURIES

Group D

2015

HAND INJURIES• The hands as the human executing organs are in the

center of daily life activities’, thus are always exposed to

injuries and overuse .

• We are more aware of our hands than any part of the

body

• Are important out of all proportion to their apparent

severity ,because of the need for perfect functions .

• Local edema and stiffness of the joints –common

accompaniments of all injuries- are more threatening in

the hand than anywhere else .

HAND INJURIES• Problems of hand arise for 3 reasons :

1- the defect may be unacceptable

2- function is impaired

3- deformed part becomes nuisance during

daily activities

HAND INJURIES• Superficial injuries and severe fracture are obvious but

deeper injuries are often poorly disclosed ,so it is

important in the initial examination to assess the

• circulation

• soft tissue cover

• bones

• joints and tendon

• nerves

• X-rays should include at least 3 views PA ,Lateral and

oblique

HAND INJURIES• Hand injuries the commonest of all injuries .

• in avarage the hand injuries account for 14-30% of all pt

in ED .

• Fractures 46% , tendon injuries 29% and skin lesions .

HAND INJURIESgeneral principle of treatment

• ABC

• Most hand injuries can be dealt with under local or

regional anaesthesia .

• Definitive treatment is dictated by the nature of the injury

, but common to all injuries are

• safe splintage

• prevention of swelling

• dedicated rehabilitation

HAND INJURIESgeneral principle of treatment

• Safe splintage

_ incorrect splintage is a potent cause of stiffness

so must be appropriate and kept to a minimum

-if the whole hand is splinted or bandage this must be in

‘’the position of safe immobilization’’

Anatomy of the hand• Bones

• Areas

• Zones

• Arches

• Ligaments

• Muscles

• Innervation

⥤is a prehensile, multi-fingered extremity located at the end of an arm or forelimb .

⥤...& are the richest source of tactile feedback, and have the greatest positioning capability of the body; thus the sense of touch is intimately associated with hands.

PALMAR DORSAL

ZONESExtensor Zones of Hand

Flexor Zones:Flexor Zones: The hand is divided into following 5 zones, which would determine the prognosis and approach to treatment. Zone 1:Only FDP involvedLoss of flx of DIP jointInstability in pinchLoss of grip strengthGood prognosisZone 2:“No man’s land”Pulleys present (prevent bow stringing) A2 and A4Vincula in area–provide vascular supply. Injury thus causes decreased tendon vascular nutrition.Poor prognosisZone 3:Good prognosisGood vascularity and no pulleysZone 4:Carpal tunnelUsually more than 1 tendon involvedIntendinous adhesions (close proximity of tendons)Relatively good prognosisZone 5:Usually presents with nerve involvement (ulnar / median nerve)Tendons superficial, thus adhesions to skin probable

The hand is divided into 8 zones when dealing with extensor tendon injuries.

Muscles & tendons* Extensor tendons of fingers :

-of the long extrinsic muscles .

-attaches to the middle phalanx in

central slip .

* system of flexor tendons of fingers :

-functional unit of tendons, tendon sheath and pulleys .

- flexor digitorum profundus .

- flexor digitorum superficial .

- flexor pollicis longus of the thumb .

FLEXORSEXTENSORS

ligaments• Tow important structures called collateral ligaments are

found in either sides of each finger joint .

• Volar plate is the strongest ligament .

Blood Supply

1. Ulnar A.

Forms the superficial palmar arch ?with superficial palmar br. of radial artery

Gives 4 common palmar digital art.

2. Radial A.

Forms the Deep

palmar arch with

deep br. of ulnar ar. 1

cm proximal to

Superficial arch

Nerve supply

Nerve supply

Median

Nerve

Ulnar

Nerve

Radial

Nerve

Bone & jointsinjuries

Metacarpal Fractures

The metacarpal bones are vulnerable to blows and falls upon the hands or the force of the boxer’s punch .

Injuries are common

Agulatory deformity is usually not very marked ,rotational deformity is serious .

2)Metacarpal Fractures Head

Intraarticular

Neck Usually unstable

Forwards tilting of distal fragement

Shaft Direct blow

Transverse or oblique #

Base Associated carpal bone injury

Impacted #

1st metacarpal Usually occurs at base

Presentation Pain/Tenderness

Swelling

Discoloration

Sensation

Circulation

ROM

Plain Films

Deformity of hand

Localized tenderness

Swelling of hand

Discoloration

Decreased movement

Numbness

Unequal temperatures

What next?

Midshaft vs. Base vs. Neck

Complete vs. Incomplete vs. Comminuted

Dorsal vs. Volar Angulation

Transverse vs. Oblique vs. Spiral

Unstable vs. Stable

Management of metacarpal #

A- undispalced # :

require only a firm crepe-bandage for comfort

2-3 wks

Management of metacarpal #

B- dispalced # :

1-of the shaft

- reducion by traction and pressure hand then held by plaster slap for 3 wks .

-ORIF with small plates and screws

or by percutaneous K-ware

is the best because these

unstable #

Management of metacarpal #

B- dispalced # :

2- of the neck (boxer’s fracture )

* usually of the 5th finger

* angulation of upto 40 degrees can be accepted as long as there is no rotational deformity .

* reduction traction and pressure then held by plaster slap 1-2wks

* fixation with percutaneous

intramedullary wires

usually preferred

Metacarpal Neck Fractures

(Boxer’s Fracture)

Common Direct impact with closed fist

Dorsal angulation Unstable

Treatment Reduction (90-90 method)

Splint

Follow-up within 1 week

Complications Malunion with volar angulation

Pain

Rotational deformity

Stiffness

Metacarpal Base Fractures

Stable

Infrequent

Associated injury Ulnar nerve

Carpal bone injury

Treatment Volar splint

Complications Tendon damage

Stiffness

Thumb Metacarpal Fractures

Uncommon Most involve the base Extraarticular

Direct trauma or impaction 20-30 degrees of angulation is

tolerated

Intraarticular Bennett’s Fracture Rolando’s Fracture

Treatment Thumb spica

Complications Malunion and arthritis

Bennett’s Fracture:

At base of first metacarpal bone

Oblique intra-articular # Unstable Due to punching . X-ray show that a small

triangular fragment has remained in contact with the medial edge of the trapezium , while the remainder of the thumb has proximally pulled upon by the abductor pollicis longustendon .

Bennett’s Fracture: Perfect reduction is essential by pulling on the thumb

,abducting it and extending it .and then held by plaster or internal fixation

Surgical fixation is achieved by passing a k-ware across the metacarpal base into the carpus

a)Bennett’s Fracture:

Intraarticular fracture

Dislocation/Subluxation CMC joint

Fragment pulled dorsally Abductor pollicis longus

Adductor pollicis

Ligament disruption

Treatment Thumb spica

Early referral

b)Rolando’s Fracture

Comminuted intraarticular fracture

Less common than Bennett’s Fracture Worse prognosis

Treatment Thumb spica

Early referral

Complications Malunion and pain

fractures of phalanges

Phalangeal # usually result from direct trauma and therefore any part may be affected .

Management :

A) undisplaced # :

functional splintage (buddy splintage )

for 2-3 wks .

- movement are encouraged from the outset .

fractures of phalanges

B) – displaced fractures

1- of the proximal or the middle phalanx :

* the bone # reduced and immobilized under

local anaesthesia , carefully avoiding

malrotation , then splintaed leaving the other

fingers free 3 wks .

fractures of phalanges

B) – displaced fractures

1- of the distal phalanx :

distal phalangeal # are usually due to crushing injuries or a blow from a hammer .

- the soft tissue damage must be treated .

-The majority of fractures can be treated

conservatively, and it is normally the initial repair

of the surrounding soft tissues that is most

important .

3) Phalanx Fractures

15-30% of hand fxs

Tuft Nail bed injury

Shaft

Intraarticular Tendon injury

Complications Pain, hyperesthesia, cold

sensitivity, osteomyelitis

1)Distal Phalanx FracturesMechanism:

No Problem Refer!

Treatment: padded or “C” splint; extend past the tip

Refer: transverse, angulated

Healing Time: 3-4 weeks

Return to Work/Sport: okay with splint as tolerated

exception: transverse fx –needs longer protection from potential re-injury activity

•Mechanism: direct blow or twisting

•Sxs & Exam: local swelling; examine for deformity or malrotation; check PIP and DIP fxn

2)Middle Phalanx Fractures

•Transverse Fx or short oblique: Low risk

•Nondisplaced fx’s do well with buddy taping

•Healing Time: 4-6 weeks (buddy tape for 3-4 wk)

•Return to Work/Sport: okay as long as you have some protection via splint or buddy tape

•Refer: displaced, long oblique, spiral or intra-articular fx

•Mechanism:

direct blow: transverse; often unstable

due to tendon insertions

twisting: oblique or spiral; may be more

stable

Sxs & Exam: local

swelling; examine

for deformity or

malrotation

3)Proximal Phalanx Fractures

Apex volar angulation is common

•proximal fragment pulled into flexion by

interosseous

•distal fragment pulled into extension by

extensor mechanism

•Nondisplaced fx’s do well with buddy taping; use

gutter splint for additional stability

•Healing Time: 4-6 weeks (buddy tape for 3-4

wk)

•Return to Work/Sport: okay as long as you have

some protection via splint or buddy tape

•Refer: angulated, displaced, intra-articular fx

Proximal Phalanx Fx: Treatment

Alternative:

Burkhalter

Splint

dorsal half to

PIP

volar half to

palmar crease

Joints

CMC joint dislocation:

Mechanism :forceful dorsiflexion of the wrist combined with longitudinal impact ,

Seen typically in boxers and in motorcyclists .

Dx : X-rays

After regional anaesthesia , the dislocation is reduced by traction , manipulation, and pressure on the metacarpal base , then protective slap is worn for 6 wks .

CMC joint dislocation

Carpometacarpal (CMC) dislocation(a) Thumb

dislocation. (b) Dislocation of the fourth andfifth CMC joints treated by closed reduction andKirschner wires (c). Complete CMC dislocation (d).

Thumb CMC dislocation :

Isolated dislocation is rare

compared to the more common Bennett fracture dislocation.

Easy to reduce but unstable after reduction.

Apply thumb spica splint after reduction.

Need surgical referral.

Dislocation of MCP joint

Metacarpophalangeal Joint Relatively rare injury

Dorsal displacement

Hyperextension forces

Dorsal displacement

Volar plate can enter joint space

Volar dislocations

Usually surgical

Treatment

Reduce

Splint in flexion

Dislocation of MCP joint The thumb is most frequently affected and clinically

the injury resembles a BENNETT’ fracture –dislocation

Dx : by Xrays

The displaced is easily reduced by traction & hyperpronation , but reduction is unstable and can be held by a K-wire for 5 wks and then protective splint for 8 wks because risk of instability .

MCP of the Thumb Strong but vulnerable

5 times more likely to be injured

Difficult reduction

Volar plate entrapment

Ulnar collateral ligament injury

Gamekeeper’s or Skier’s thumb

Radial collateral ligament injury

Less common

Forced adduction with or without hyperextension

Skier’s Thumb

Scottish gamekeeper’s Repeated twisting

Forced radial deviation Associated avulsion fracture

Valgus stress testing Extension and flexion

Complete ligament tears >35 degrees of laxity

Treatment Thumb spica

Dislocation InterphalangealJoint

1)Proximal Interphalangeal Joint Dislocation pattern

Dorsal

Most common ligamentous hand injury

Lateral

Volar

Associated fracture

> 33% of articular surface = unstable

Violent twist with finger flexed (palmer) or extended (dorsal)

SHARP, deformity, disability

RICE, splint, meds, reduction/surgery, protect

• Nondisplaced Fx: Initially use extension block

splint for first 2-3 weeks followed by buddy

taping in sight flexion. Work on restoring ROM.

• Healing Time: 6-12 weeks; monitor progress

every 2-3 weeks

2)Distal Interphalangeal Joint Most are dorsal

Often open

Reduction Traction

Hyperextension

Dorsal pressure

Irreducible Avulsion fracture

Buttonhole tear

Open dislocation Irrigation

Antibiotics

Tendons Injuries

Tendon injuries

• Are the second most common injuries of the hand

• After clinical examination , ultrasound and MRI imaging

have provide to be important diagnostic tools .

• Treated by conservative or surgical

• For later case where the joint is still passively correctable

, treated by is to divide the extensor tendon in just

proximal to its insertion into the distal phalanx .

• long standing fixed deformity may be better left alone .

Carpal Tunnel Syndrome

pressure in carpal tunnel (swelling, inflammation) via trauma, rep flexion

Pressure on median n

Sensory (lat palm), motor (wrist, finger flex) deficits

A. Mechanism: overuse, congenital, trauma

B. Pathology: Compression of the median nerve in the tunnel

, surgical decompression

Signs and Symptoms:

Pain in wrist

Numbness and tingling in the thumb and first two fingers

Positive Phalen’s test

Positive tap test

TreatmentConservative: Immobilization and Rest ice

.NSAIDS, corticosteroid injection

Radical: Surgery to increase space in the tunnel

وفق هللا الجميع

GDمحمد عبدالستار