Hand Injuries

Hand Injuries

Krister Freese, MD, Stephanie D. Malliaris, MD, Kyros Ipaktchi, MD, FACS CHAPTER 36 HAND INJURIES 1. How are hand fractures and hand injuries spl...

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Krister Freese, MD, Stephanie D. Malliaris, MD, Kyros Ipaktchi, MD, FACS

CHAPTER 36

HAND INJURIES

1. How are hand fractures and hand injuries splinted? Immobilization should include splinting the joint above and below the injury. For example, a splint for a metacarpal fracture includes the wrist and metacarpal phalangeal (MCP) joints.  2. Name commonly used splints •  Volar wrist splint: Ideal resting splint for the hand after burn and soft tissue injuries. •  Thumb spica splint: Ideal for injuries located on the radial side of the hand including tendinitis of the first dorsal compartment (de Quervain’s Tenosynovitis) and thumb fractures. •  Ulnar gutter splint: Commonly used for fractures of the fourth and fifth metacarpals (Boxer’s fracture). •  Stack splint: Immobilizes the distal interphalangeal joint (DIP) joint and is used for mallet finger injuries and nailbed trauma. It allows proximal interphalangeal joint (PIP) flexion, thereby decreasing risk of joint contractures. •  Moldable aluminum splint: Used for phalangeal fractures and PIP dislocations. Dorsal placement facilitates hand use. •  Dorsal blocking splint: Used for flexor tendon lacerations. The splint is placed over the dorsal hand and wrist, with wrist in slight flexion and MCP joints in 90 degrees of flexion. The interphalangeal (IP) joints are in full extension.  3. What are the signs of flexor tenosynovitis? The four Kanavel’s signs are (1) flexed posture of the digit, (2) circumferential swelling, (3) tenderness along the flexor tendon sheath, (4) and pain with passive extension of the digit.  4. How is flexor tenosynovitis treated? Urgent decompression of the tendon sheath in the operating room (OR), culture specific antibiotics, and wound care.  5. How and where should hand injuries be explored? Hand wounds should be explored under tourniquet control with adequate analgesia using delicate instruments in a well-lit surgery suite. Visual magnification is usually mandatory. As a general rule, dorsal wounds can be explored in the emergency department (ED), and simple, clean extensor tendons can be repaired there. Volar wounds with concomitant tendon or nerve injuries generally require exploration in the OR.  6. How is emergency hemostasis of injured hands achieved? In the acute setting (outside the operating suite), hemostasis may be achieved by elevating the extremity and applying constant direct compression of the wound. For persisting bleeding, a tourniquet above the level of injury may be applied. Application time must be documented and should not exceed 2 hours to prevent ischemic damage to muscle and nerves. Avoid blind clamping and/or suture tying of any deep structure in order to prevent iatrogenic neurovascular damage.  7. How are fingertip injuries treated? Wounds with minimal pulp disruption will heal spontaneously with daily cleansing and dressing changes with nonadherent, moist gauze. Larger defects may require a skin graft, which can be obtained from the defatted amputated piece. Locally exposed bone can often be successfully treated with occlusive dressings, which are changed twice per week until epithelialized tissue covers the defect. In cases of protruding exposed bone, flap coverage may be necessary if digital length is to be maintained as in thumb defects. In distal phalangeal defects of a digit, bony shortening can be an option. If shortening for coverage needs to exceed proximally beyond the flexor digitorum profundus insertion, then a flap is indicated. Digital nerves cannot be repaired distal to the DIP joint. 

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162   TRAUMA 8. What is the classification system for fingertip amputations? Fingertip amputations are classified based on the amount of remaining sensate volar skin. Favorably angulated amputations commonly involve loss of dorsal structures: nail and bone. In these injuries, the volar glabrous skin is still available for easy coverage. This amputation type can be treated by dressings only, allowing wound repair by contraction and epithelialization. Volarly angulated amputation angles are deemed “unfavorable” for conservative management and usually require reconstructive procedures (see Fig. 36.1). 

Favorable

Guillotine

Unfavorable

Fig. 36.1  Fingertip amputations. From Ditmars Jr, DM. Fingertip and nail bed injuries. In Kasdan ML, ed. Occupational Hand and Upper Extremity Injuries and Disease. Philadelphia: Hanley & Belfus; 1991; with permission.

9. How are nailbed injuries repaired? Repair of disrupted germinal matrix must be meticulously approximated under magnification and the nailbed splinted, preferably with the avulsed part. Nailbed injuries are repaired with 5-0 fast absorbing chromic sutures. Alternatively, a cyanoacrylate tissue adhesive can be used. This does not obviate the need for meticulous reapproximation of the nailbed. Subungual hematomas can be evacuated by a hot-tipped paperclip or battery-powered electric cautery. The eponychial fold should be stented with either the original nail plate or some other inert material. Often, nailbed disruptions cannot be diagnosed without removal of the nail. The nail plate should be removed if a subungual hematoma extends to >50% of the nail surface area.  10. What is the initial management of flexor tendon laceration? Flexor tendon lacerations are not an emergency, and should therefore not be repaired in the ED. If a hand surgeon is unavailable, the wound is copiously irrigated and skin sutured closed. Prophylactic antibiotics need to be administered and the hand splinted in a metacarpophalangeal (MP) and IP joint flexing dorsal splint. This injury should be treated within the first 10 days. Delays in treatment can preclude the ability to perform primary tendon repairs.  11. What is the proper management of an open fracture? Open fractures proximal to the MCP joint should be cleaned and dressed in the ED, but not probed or cultured. A first-generation cephalosporin, such as Ancef, is administered and tetanus immunization updated. Open fractures meeting the criteria of the Gustilo and Anderson classification should receive additional penicillin and an aminoglycoside, such as Gentamicin. A saline-soaked dressing is applied over the wound, and the hand is splinted in a functional position using a bulky dressing. Urgent irrigation and debridement in the OR is indicated followed by fracture stabilization and wound closure. Open fractures distal to the MCP joint can be washed out in the ED and treated nonemergently.  12. What is the proper treatment for hand infections? The extremity should be immobilized and elevated, and antibiotics should be administered. Serial examinations should be used to assess for improvement. The patient should be referred for possible surgical drainage especially if concern for abscess or deeper infection exists.  13. What is the proper management of human and animal bites? After wound cleansing, radiographs are obtained to rule out foreign bodies (e.g., broken teeth). Wounds are left open and antibiotics are started. Keep a high level of suspicion for infection in all puncture bites that inoculate deep structures and have no drainage (e.g., cat bites). All wounds are rechecked at 24 and 48 hours. If evidence of infection is present, parenteral antibiotics should be instituted and the patient referred for possible surgical drainage. In human bites, the most common microorganisms are Staphylococcus aureus, alpha hemolytic Streptococcus, and Eikenella corrodens. They are best treated with penicillinase resistant penicillin, such as amoxicillin/clavulanate. In animal

Hand Injuries   163 bites, Pasteurella multocida, Staphylococcus aureus, and alpha hemolytic Streptococci prevail and are treated with amoxicillin/clavulanate. So-called “fight bites” occur over the MCP or PIP joint when a clenched fist is impaled on the incisors of an adversary. This often inoculates the MCP joint with anaerobic Streptococci. The resulting traumatic arthrotomy can be difficult to identify, especially when examining the hand flat on the examination table and not in the initial clenched position. These injuries require irrigation and debridement in the OR.  14. Name common hand infections •  Paronychia: Infection of the dorsal soft tissue surrounding the nail plate. Early infections can be treated with antibiotics and soaks. More established infections require drainage under digital block. •  Felon: Infection of the fingertip pulp. Drainage through a longitudinal incision is the recommended treatment. Other incisions may destabilize the fingertip pulp from the underlying distal phalanx. •  Collar button abscess: Infection of the web space that involves both the palmar and dorsal sides. •  Deep space infections: Three deep fascial spaces in the hand are known as sites for deep infections: The thenar space, midpalmar space, and hypothenar space. Infections in these locations can be missed.  15. How are injection injuries treated? Despite their innocuous appearance, injection injuries may cause profound destruction of hand structures. Any such injury requires immediate hospitalization with emergent irrigation and debridement. Multiple, second look debridements may be required. The prognosis is guarded when oil-based paint or industrial solvents are involved. Latex and water-based paints cause less tissue damage.  16. What are the most preventable causes of secondary functional disability in hand injuries? Edema and infection lead to increased scarring and restricted function. Prolonged immobilization in a poor position also impairs function. Failure to obtain radiographs may lead to a missed or delayed diagnosis of an injury.  17. What is the proper ED treatment of the patient with an amputated part? Patients need to be treated according to the advanced trauma life support protocol. In addition to cardiopulmonary stabilization, tetanus immunization and prophylactic antibiotics are administered. Broad-spectrum antibiotics should be given in heavily contaminated wounds or in diabetic or immunocompromised patients. Radiographs of the injured extremity and the amputated part are ordered as are laboratory studies such as hemoglobin/hematocrit content, blood type and screening, and other tests as indicated (blood glucose for diabetics, etc.). Photo documentation of soft tissue injuries is helpful. While tests are pending, a replantation center is contacted for transfer. Prolonged ischemia of the amputated part risks the possible success of replantation attempt. Once the patient is accepted, expedited transfer is mandatory, which may include airlifting. Digital replantation is usually possible up to 24 hours. The larger the amputate size including the amount of severed muscle (forearm and arm level injuries) the shorter the ischemia tolerance. Major amputations (proximal to the palmar arch) are usually not replantable beyond 6 hours of cold ischemia time.  18. How should the amputated part be transported to the replantation center? The amputated part is wrapped in saline-soaked gauze and sealed in a plastic bag. This bag in turn is placed in a container with iced saline maintaining the temperature around 4°C. Direct contact with ice must be avoided to prevent freezing. Hypotonic and hypertonic solution should not be used to prevent osmotic damage to the part.  19. What is acute carpal tunnel syndrome? Acute compression of the median nerve in the carpal tunnel is a condition associated with trauma to the hand, wrist, or forearm. Examples are distal radius fractures or a perilunate dislocation. This clinical diagnosis presents with worsening wrist pain and sensory changes in the median nerve distribution, which typically include paresthesias in the volar thumb, index, middle, and half of the ring finger. The hallmark of acute carpal tunnel syndrome is progressive neurologic changes in the median nerve distribution.  20. How is acute carpal tunnel treated? Emergent decompression of median nerve by releasing the transverse carpal ligament.

164   TRAUMA K EY POIN T S: E M E RGE N C Y R O O M C A R E O F H A N D I N J U RIES 1. Do not explore volar sided lacerations in the ER. When concerned for possible neurovascular and/or tendinous injuries, examine and document in writing neurovascular status and motor function in a standardized hand examination format. 2. Never clamp or suture tie suspected upper extremity arterial bleeders in the field or the emergency room. Instead, use direct pressure/elevation, compression dressings or a tourniquet placed above injury level. Document tourniquet time, which cannot exceed >2 hours of tourniquet ischemia. 3. Always obtain x-rays for bite injuries or suspected foreign body intrusion. Consider ultrasound/MRI when dealing with possible radiolucent/organic foreign bodies (e.g., wood splinters/rose thorns). 4. Always leave puncture wounds and bite injuries open to drain. No suture closure of bite wounds in the ER. 5. Mandatory operative exploration and debridement in the OR of: a. All fight bite injuries to the MCP joint area b. Paint gun injuries c. Suspected flexor tendon sheath (FTS) (positive Kanavel’s Signs)

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