HAND INJURIES Peter Freeman. ESSENTIALS A thorough knowledge of hand anatomy and function is...
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![Page 1: HAND INJURIES Peter Freeman. ESSENTIALS A thorough knowledge of hand anatomy and function is essential for proper management of the injured hand Most.](https://reader030.fdocuments.us/reader030/viewer/2022032721/56649cd75503460f9499e939/html5/thumbnails/1.jpg)
HANDINJURIES
Peter Freeman
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ESSENTIALS
• A thorough knowledge of hand anatomy and function is essential for proper management of the injured hand
• Most hand injuries carry a good prognosis if treated early and appropriately
• Aftercare and rehabilitation are vital
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PRESENTATION
• History– Time taken eliciting an accurate history of
the mechanism of injury is never more important than in the case of hand injury
– When, how, where?– Hand dominance– Occupation
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EXAMINATION
• The injured hand must be examined in a well-lit cubicle with the patient comfortably reclined
• Deformity, swelling, position of wound• Resting position• Tenderness and sensation
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NERVE SUPPLY TO THE HAND
Radial
Median
Ulnar
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EXAMINATION
• Test function - tendons (FDP, FDS and extensors) - grip - joint stability• Deformity, rotation, loss of function• Pain
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INVESTIGATIONS
• Most information will be obtained from a full history and examination
• Radiology of the hand and fingers will be necessary if bone or joint deformity or tenderness is elicited
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CLASSIFICATION
• Hand injuries are usually described by tissue, e.g. tendon, nerve or bone injury
• A more practical approach is to describe injuries by anatomical site
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FINGERTIP INJURIES
• Classification of fingertip amputations
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NAILBED INJURIES
• Often underestimated• Trephine subungual haematoma <
25% • Remove nail if > 25%• Reduce # terminal phalanx• Repair nail bed with 6/0 absorbable• Nail regrowth - 1mm/wk
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TERMINALIZATION
• Explain options with patient• Discuss with specialist• Local anaesthetic• Remove nail root• Diathermy digital nerves and
vessels• Loose closure and avoid dog ears
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DIGITAL NERVE BLOCK- PALMAR APPROACH
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DISTAL INTERPHALANGEAL JOINT INJURIES
• Mallet finger (always Xray)• Dislocations• Fractures• Wounds - digital nerves
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MIDDLE PHALANGEAL INJURIES
• Profundus tendon• Fractures often require ORIF• Unstable• Discuss with hand specialist
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PROXIMAL INTERPHALANGEAL JOINT INJURIES
• Most unforgiving joint• Extensor apparatus• Boutonniere deformity • Volar plate• Wilson #• Joint instability• Splint and refer
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PROXIMAL PHALANGEAL INJURIES
• Profundus and superficialis tendons
• Unstable fractures require ORIF• Rotational deformity• Refer hand specilaist• Spint in position of
function/recovery
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METACARPOPHALANGEAL JOINT INJURIES
• MPJ subluxation - often missed• Fist-tooth injury - always involves joint - irrigation - antibiotics• Ulnar collateral ligament tears
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METACARPAL INJURIES
• 5th MCP fracture (punching) - best treated conservatively• Bennett’s fracture (intra-articular) - often requires ORIF• 2nd, 3rd and 4th MCP fracture - volar spint in position of recovery
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DORSAL HAND INJURIES
• Kessler technique of tendon repair. An alternative technique is to begin the suture between the tendon ends and tie, and bury the knot within the tendon.
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PALMAR HAND INURIES
• Penetrating wounds in no-mans land
- Nail gun injury (barbs) - Grease or Paint gun injury - Glass injury (always Xray) - Organic material (consider US)
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DISPOSITION
• Many hand injuries can be appropriately managed in a well equipped emergency department
• Refer early when indicated• Elevation• Analgesia
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PROGNOSIS
• Early definitive care optimal• Late injury difficult to salvage due
to stiffness• Functional splintage (extrinsic
plus)• Early guarded mobilisation• Desensitise finger tips
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PREVENTION
• Children's finger tips• Occupational injuries - butchers
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CONTROVERSIES
• Fingertip dressings• Hand splintage• Fifth metacarpal fractures• Foreign bodies• To suture or not?• Adrenaline• Antibiotics