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Injuries of the Hand
Injuries of the Hand JOSEPH L. POSCH, M.D., F.A.C.S.*
INJURIES of the hand are common in the practice of most physicians. Not only are injuries encountered in industry and on the farm, but domestic activities also result in hand injuries. The chemotherapeutic and antibiotic agents have greatly decreased the number of severe infections in hands, but the incidence of trauma to the hand continues to rise. In 1951, the National Safety Council reported that there were 700,000 occupational accidents involving the hand and forearm. 1 Despite the fact that the hand is exposed and subject to many injuries, there is a tendency to neglect such trauma. Not only does the patient frequently pay little attention to an injury to the hand, but there is a tendency for the profession to consider such injuries of minor importance. In many hospitals they are considered under the questionable term of minor surgery, and assigned to the least skilled of emergency personnel. It is imperative that injuries to the hand receive the most skillful care since this structure is an intricate mechanism and loss of function causes great hardship, especially in those individuals who earn their living by use of their hands. DIAGNOSIS
Etiologic Diagnosis
An adequate history should always be taken in any type of hand injury. The determination of the etiologic agent is especially important. It should be determined just what force'caused the injury. In an injury caused by glass, small particles of foreign body not infrequently remain in the wound. Occasionally, a small laceration on the back of the hand, over the metacarpophalangeal joints, is caused by a human bite. This type of wound should never be closed. Rarely, a rupture of a tendon may be produced by sudden force. In any injury of the hand, the time from the original accident to the time 'of surgery should be carefully ascer... Clinical Instructor of Surgery, Wayne University College of Medicine, Detroit; ' Junior Associate in Surgery, Detroit Receiving Hospital. 1081
Joseph L. Posch
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tained, for it has an important bearing on treatment. Primary repair of tendons and nerves should not be carried out if there is danger of infection.
a
~III~II c
Median nerve
Fig. 295. Anatomical and physiological concepts in diagnosis of hand injuries.
Functional Diagnosis
The proper diagnosis in any injury of the hand is based on sound concepts of physiology and anatomy. Lacerations of tendons and nerves can be diagnosed by routine examination (Fig. 295).
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Involvements of the median and ulnar nerves give changes involving the intrinsic muscles of the hand, along with sensory changes (Fig. 295, a). In lacerations of the median nerve, for example, not only is there loss of sensation in the thumb, index, middle and radial side of the ring finger, but there is also inability to oppose the thumb to the little finger, and loss of abduction, that is, raising the thumb toward the ceiling2 (Fig. 295, c). In damage to the ulnar nerve, the little finger and ulnar side of the ring finger have loss of sensation (Fig. 295, a); and in addition, the intrinsic muscles of the hand are involved. This is manifested by inability to spread the fingers and to abduct and adduct the fingers away from and toward the midline of the hand (Fig. 295, d), by inability to form a circle by touching the thumb and index finger together,3 and also by inability to extend the distal two phalanges of the fingers. Radial nerve injury is illustrated by wristdrop (Fig. 295, b) and loss of sensation on the dorsal radial aspect of the hand (Fig. 295, a). Cut flexor digitorum sublimis and profundus tendons are manifested by inability to flex the distal two phalanges of the finger (Fig. 295, e) . A severed flexor digitorum profundis is illustrated by inability to flex the distal phalanx of the finger (Fig. 295, f). The most common missed diagnosis is that of a lacerated flexor digitorum profundus as a result of a very small laceration over the proximal two phalanges of the finger. Sublimis action will be retained and fair motion is present. However, the fact that the tip of the finger cannot be flexed is often missed. It should be borne in mind that the action of the lumbricales may produce mild flexion. Inability to flex the distal phalanx of the thumb is indicative of a lacerated flexor pollicis longus. The diagnosis of laceration of an extensor tendon is determined by inability to extend the proximal phalanx of the finger. In severe lacerations or injuries of the wrist, physiological motion of the thumb and fingers can be tested by voluntary motion. The findings in lacerations of the flexor digitorum sublimis and digitorum profundus tendons will be the same as those described above. SURGICAL MANAGEMENT
General Considerations
Lacerations that involve tendons, nerves and bones should be repaired under excellent operating conditions. The wound when first se~n should be wrapped in a dry sterile dressing. Bleeding may be controlled by pressure or, if necessary, a blood pressure cuff may be used as a pneumatic tourniquet. Thin, narrow rubber tubing, or narrow cuffs, should not be used to stop bleeding because of the nerve damage that occasionally results.
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Since the damage may be more extensive than anticipated and the operation prolonged, it is imperative to have as careful an evaluation of the patient as in any other case where an operative procedure of great magnitude is considered. This entails a careful history, physical examination and adequate laboratory studies. To make less than a complete evaluation in these patients is not only unfair but may be quite dangerous. In severe injuries, general anesthesia is often the best choice. In less severe injuries, or if the patient may have been eating or drinking just before suffering his injury, a local type of block, such as a brachial or digital nerve block, may be utilized. Recently, the longer acting local anesthetic agents have proved more useful than procaine. We prefer not to use local finger blocks because of the possibility of resulting gangrene of the tip of the finger. Instead, where anesthesia of the finger is desired, we prefer to use a local digital nerve block between the metacarpals. The injection is done from the dorsal aspect of the hand where the skin is soft. The hand should be thoroughly washed in soap and water for at least ten minutes. Some of the newer detergents do not appear to be harmful to the soft tissues and may be used, but are no better than soap and water. During the washing procedure, the hand is thoroughly irrigated several times with normal saline. The fingernails should be cleansed and cut short; if necessary, a scrubbing brush may be used on the fingers but not on the wound itself. Antiseptic solutions are not poured into the wound, or for th~t matter, ever used on the skin, for with the color they impart it is often difficult to determine whether cyanosis of skin flaps is present. A blood pressure cuff is. always used on the upper arm to control bleeding. A towel or sheet wadding is wrapped about the upper arm, then the blood pressure cuff is· placed over this. The cuff is held in place by means of roller gauze. 4 The arm is elevated in the air for several minutes, and then the cuff is rapidly inflated to 280 mm. of mercury. The cuff is left on from one to one and one-half hours, and then removed. Bleeding vessels are clamped and ligated. At the end of ten minutes the cuff may be inflated again and left on until the procedure is finished. When this method is used properly, we have had no difficulty in obtaining a bloodless field. If there is a question of devitalized tissue, however, it is used with caution. On one occasion, when the cuff was left on for one hour and fifty-five minutes, an annoying peripheral neuritis occurred. This subsided in several months. On another occasion we saw a patient with a prolonged complete paralysis of the arm and hand that resulted from a faulty narrow type of pneumatic cuff. In draping the hand, towels and sheets are placed so that the hand itself is exposed. The arm is placed on a wide board. A small pillow may
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be placed under the entire arm for support. In addition, after the draping is done, the hand may be supported under a rolled gown or several sheets. Incisions
Incisions in the fingers should not cross flexion creases but should be made midlaterally. In the palm, they may follow the flexion creases. It may appear to be easier to identify elusive tendons and nerves by making a longitudinal incision in the middle of the palmar aspect of the finger. Some tendon function may be obtained in this manner, but the resulting contracture with marked limitation of extension nullifies any flexor power that may have resulted. Open Fractures
In severe injuries of the hand, such as punch press injuries, cornpicker injuries and so forth, one should attempt to save all viable tissue. Fractures must be adequately reduced. The use of foreign material for fixation should be avoided if at all possible. Occasionally, a stainless steel wire may be utilized if absolutely necessary. The employment of the universal metal splint, as described by Mason and Allen, is excellent in severe crush injuries to maintain the hand in position of function and to reduce the fractures. In less severe injuries, or in those involving only one finger, reduction may be maintained by traction or splinting in a semiflexed position. A fractured finger should never be placed straight out on a splint. This also applies to a banjo type of splint with a straight pull. Severed tendons are best repaired after the fractures have healed. Adequate skin coverage must be provided. Soft Tissue Injury
Whenever there is loss of skin, attempts should be made to cover the denuded area. This can be done by split thickness skin grafts, sliding grafts, or pedicle grafts. It is extremely important to obtain good skin coverage on any exposed bone or tendon. If there is only superficial loss of skin on a finger tip, this can be readily replaced with a split thickness skin graft. However, if bone is exposed, then a pedicle type of graft is the procedure of choice. Full thickness grafts may be used, but often a sore, tender stump results. A pedicle can be obtained from the thenar or hypothenar eminence (Fig. 296, a) or, on occasion, from the abdomen. The difficulty with a pedicle graft from the abdomen for the tip of the finger is that it tends to become pigmented, and sensation is poor. We have arbitrarily determined that, if a traumatic amputation is through the tip or middle third of the distal phalanx, the patient is a good candidate for a pedicle graft from the
Fig. 296. Adequate covering of skin loss. a, Traumatic amputation of tip of finger in 18 year old school boy. Pedicle from thenar eminence. b, A severe crushing injury of the hand in a 30 year old white steel worker, suffered when it was caught in a steel roller. c, Necrotic skin excised and split thickness skin graft temporarily applied. A pedicle graft was applied later. d, Severe avulsion laceration of the dorsal aspect of the hand and traumatic amputation of little and ring fingers in a 26 year old white steel worker. Subcutaneous tissue removed and skin replaced as a full thickness skin graft. e, Flexion. j, Extension. g, Severe punch press injury in a 35 year old auto worker. Fractured third metacarpal transfixed with small Kirschner wires. h, Pedicle graft from abdomen to hand placed immediately. i, Appearance 2 months following injury. Limitation of motion present but good covering provided.
1086
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palm. However, if extensive loss of tissue occurs proximal to the nail bed, amputation of the phalanx is usually the procedure of choice. In severe roller injuries when skin has been destroyed, a split thickness skin graft may be used to cover the defect temporarily. Later, full thickness or pedicle grafts may be applied (Fig. 296, b, c). If large areas of skin are avulsed and are still attached at one end, the subcutaneous tissue may be removed and the full thickness skin replaced as a graft 5 (Fig. 296, d, e, f). If large areas of skin are lost (Fig. 296, g), a pedicle graft may be raised from the abdomen and placed to the injured hand immediately, in order to preserve the remaining tissues. The site on the abdomen where the pedicle has been raised is covered with a split thickness skin graft, so as to provide a closed wound, thereby cutting down on the amount of drainage that occurs from granulating surfaces. These pedicles are detached at the end of eighteen to twentyone days, and then sutured in place to the hand (Fig. 296, h, i). Amputations
In amputations involving the finger it has been said one should attempt to save as much length as possible. However, adequate soft tissue padding must be provided, even at the sacrifice of some length of the digit. A long volar skin flap and a short dorsal one is ideal. This is important, for unless good skin flaps are provided a sore tender stump will result. The nerves are identified, sectioned sharply and allowed to retract into the good soft tissue proximal to the site of amputation. Vessels are carefully identified and ligated. Fexor tendons are not sutured to the extensor tendons at the end of the stump, for it has been noted repeatedly that limitation of motion in the other fingers results. If the amputation is at the joint, the prominent head of the distal portion of the phalanx is narrowed and the cartilage is removed so that the skin will adhere to the bone. In injuries to the thumb, attempts should be made to save all of the length possible. Nerves
Digital nerves can, and should, be sutured at every opportunity (Fig. to do an excellent job suturing a tendon, and to ignore the nerves. Later, the patient may have fairly good motion but he will complain persistently of numbness of the finger. This result can readily be prevented by careful suture of the digital nerves at the time of the original repair. Digital nerves are sutured with fine suture material (6-0 or 7-0 silk). Following the suture of a digital nerve, return of sensation usually occurs. In median and ulnar nerve injuries, good return of sensation usually follows repair. However, there is rarely complete return of motor power. 297, a, b, c). It is folly
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Postoperatively, the hand should be splinted periodically to prevent contractures, and galvanic stimulation should be applied to the intrinsic muscles of the hand at regular intervals. Tendons
Lacerated extensor tendons can be readily repaired with interrupted fine suture material using No. 60 cotton. Uniformly good results are obtained. Fexor tendons in the wrist, palm and fingers usually are difficult to repair, and especially so in the fingers themselves. In the finger, a lacerated flexor tendon, repaired even under the best circumstances, frequently gives only a fair result. It is for this reason that most adequate facilities should be available for the repair. If the injury is more than a few hours old and if there has been contamination, then the repair of this tendon should be delayed, the skin only being closed. This is possibly also true where the repair is attempted by the occasional operator, or one who is not enthusiastic about this interesting type of surgery. In the finger, adequate exposure is obtained by making a midlateral incision (Fig. 298, a). It is usually necessary to make a transverse incision in the distal portion of the palm to identify the proximal portions of the severed tendons (Fig. 298, b). Contracture of the muscle bellies in the forearm occurs and the tendon ends are usually retracted proximally for several centimeters. One should not grasp blindly for the proximal end with a hemostat, thereby injuring the tendon sheath and the end of the already traumatized tendon. "Tendons should be handled gently; never crushed, rubbed, or allowed to become dry."6 By making a proximal transverse incision in the palm, the end is readily identified, a suture is placed in it and, with a tendon leader,7 it can be readily transferred to the site of the original injury (Fig. 298, c). One method we have found to facilitate work on the tendon will be described. Once the tendon is brought into the wound and retracted as far distally as possible, a straight needle is placed at right angles, superficially, through it (Fig. 299, d), thereby preventing it from disappearing into the wound again. This may also be done with the distal tendon if it has a tendency to retract into the wound. The tendon ends are now freshened with a sharp razor. Suturing of the ends should be as atraumatic as possible. Fine suture material is extremely important. We have used Koch's method of placing a simple mattress suture of fine silk on either side of the tendon. 1 One may also use wire at a distance, as suggested by Bunnell.8 We also have employed, with good results, the use of six to eight interrupted No. 60 cotton sutures, placed very superficially through the tendons (Fig. 299, d).
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The suture ends are cut on the knot. Much of the difficulty encountered in the past has been the use of large suture material cut long, which not only prevents the tendon from gliding but retards healing so that drainage occurs. The most common query that one hears is, "What do you do with the
Fig. 297. Lacerated digital nerve and flexor pollicis longus tendon in a 13 year old school girl. a, Nerves repaired with 6-0 silk, and tendon repaired with number 60 cotton. b, Flexion. c, Extension. Sensation returned to thumb in 3 months.
Joseph L. Posch
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I Incision in palm
Passing profundus tendon
l]Fig. 298. Technique demonstrated. Midlateral incision locating tendon and returning it to its original location. a, Original laceration with midlateral incision for exposure. b, Transverse incision in distal portion of palm in order to locate tendon. e, Method of passing the proximal end of the flexor digitorum profundus to the site of the original injury. e' , Tendon leader of Bunnell.
I
,
, I I ,
I ,
~
~@ ,, I
I
I I Impalement
I: :: I I
of tendon by needle
I I
Fig. 299. Technique demonstrated (continued). Tendon suture and technique of leaving tendon sheath open. d, Method of obtaining relaxation of the proximal portion of tendon by inserting needle at right angle to the tendon to prevent retraction. d', Careful suture of tendon ends with fine suture material. e, Opening the fibrous tendon sheath (pulley) in order to allow gliding to occur. Note that the tendon sheath has been excised directly over the suture line. f, Gently roIling tendon ends between the fingers to insure adequate approximation of all fibers. g, The suturing of the proximal end of the sublimis to the proximal end of the profundus. The sublimis insertion has been cut short. h, Synovial tendon sheath excised, and fibrous tendon sheath open. i, Closure with fine suture material, and skin closure, if at all possible, is not directly over tendon suture.
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Joseph L. Posch
tendon sheath?" This, as Mason 9 and Bunnell10 have repeatedly emphasized,)s excised both above and below the sutured tendon. The sutured tendon is then allowed to come in contact with the subcutaneous tissue. In addition, the fibrous portion of the tendon sheath must be split to allow the sutured portion of the tendon sliding space (Fig. 299, e, h). This is extremely important, for in healing the tendon swells and it would adhere to the sheath if it were not open. This procedure of excising and opening the tendon sheath is an important factor in obtaining a good result in primary tenorrhaphy. Once the tendon is repaired, it is then gently rolled between the fingers to insure accurate approximation of all of the tendon fibers (Fig. 299, f); the needle that had previously been placed at right angles is removed; and the skin is carefully closed with interrupted sutures. If possible, the sutured tendon should not be directly under the closed skin incision (Fig. 299, i). Drains are not necessary. If both the profundus and sublimis are severed in the finger, it has been advocated that only the profundus be repaired. The sublimis is cut short at its insertion, while the proximal end is sutured to the proximal profundus in the palm (Fig. 299, g). In the palm and the wrist, however, both the deep and superficial tendons should be sutured. In the palm, the lumbrical muscle can be placed between the two sutured tendons (Fig. 300). Primary tendon grafting is not indicated in the initial treatment of hand injuries, for as Koch has aptly said, "if infection then supervenes, we practically burn all our bridges be~nd US."ll In a wound that heals without infection, tendon grafting can be done three weeks after the injury. Postoperatively, the hand is dressed in the best position to relax the tendons. This can be done with a plaster-of-paris splint or with metal. For extensor tendons, the wrist and fingers fl,re moderately extended. If only one extensor tendon to a finger is involved, only that finger and the one next to it need be placed in a splint. It is not necessary to place all of the fingers in extension. For flexor tendons, tension is removed from the sutured tendon ends by moderately flexing the wrist, with the fingers slightly flexed. Acute flexion of the fingers into the palm, after a primary repair in the tendon sheath, usually results in their staying that way when attempts to resume motion are undertaken. The hand is kept elevated for several days; a sling is used when the patient is ambulatory. Care must be taken to insure against swelling and the dressings should be loosened the day following surgery. Skin sutures should remain over a week. The supporting splint is worn for three weeks, and then gradually increasing exercises are started. These consist of warm soapy hand baths several times daily. Lanolin or cocoa
Fig. 300. a, Lacerated flexor tendons to middle, ring and little fingers in the 33 year old wife of a physician. Flexor digitorum sublimis removed from little and ring fingers, and primary tenorrhaphy carried out of flexor digitorum profundus in middle, ring and little fingers. b, Flexion at the end of one year. c, Extension. There is limitation of extension of the little finger but this is not severe. d, Severe laceration of palm with severance of all of the flexor tendons and nerves to the middle, ring and little fingers in a 26 year old auto worker. e, Primary repair of flexor digitorum profundi. Sublimis tendons removed because the suture line was in the tendon sheath. Digital nerves also sutured. j, Function at the end of three months. g, Laceration of palm in a 23 year old auto worker, suffered when it was cut on a porcelain faucet. There was inability to flex the middle, ring and little fingers, and anesthesia was present over the ring and middle fingers. Severe blood loss required the transfusion of 1000 cc. of whole blood. Primary repair of flexor digitorum profundi and sublimi to middle, ring and little fingers. Primary neurorrhaphy of digital nerve to ring finger and middle finger. h, Flexion possible at the end of 3 months. i, Extension.
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butter is applied to the healing areas, morning and night, with gentle massage. To facilitate the postoperative care of hand injuries, a clinic was established at the City of Detroit Receiving Hospital in 1937. As part of the surgical residency training program, two residents are assigned to the clinic, and under the supervision of a staff man, all hand cases are seen. There, care is coordinated and facilitated. This has been important in stimulating interest in the care of hand injuries by the house staff, and provides better care for the patient. REFERENCES 1. Koch, S. L.: The Working Man's Hand. Bull. Am. ColI. Surgeons 38: 5-14, 1952. 2. Winfield, J. M.: Anatomic Diagnosis of Injuries of the Hand. J.A.M.A. 116: 1367-1370, 1941. 3. Couch, J. H.: Surgery of the Hand. Toronto, University of Toronto Press, 1939. 4. Bruner, J. M.: Safety Factors in the Use of the Pneumatic Tourniquet for Hemostasis in Surgery of the Hand. J. Bone & Joint Surg. 33-a (1): 221224, 1951. 5. Mulholland, J. H. and Mahoney, J. H.: Massive Avulsion of Skin. Am. J. Surg. 83: 359-c363, 1951. 6. The Care of Hand Injuries. IV. Pamphlet. Committee on Trauma, American College of Surgeons. 7. Bunnell, S.: Surgery of the Hand. 2nd Ed. Philadelphia, J. B. Lippincott Co., 1948, p. 89. 8. Bunnell, S.: Surgery ofcthe Hand. 2nd Ed. Philadelphia, J. B. Lippincott Co., 1948, p. 425. 9. Mason, M. L.: Primary and Secondary Tendon Suture. Surg., Gynec. & Obst. 70: 392-402, 1940. 10. Bunnell, S.: Surgery of the Hand. 2nd Ed. Philadelphia, J. B. Lippincott Co., 1948, p. 627. 11. Koch, S. L.: J. Bone & Joint Surg. 36-a (1): 140-171, 1953.
INJURIES of the hand are common in the practice of most physicians. Not only are injuries encountered in industry and on the farm, but domestic activities also result in hand injuries. The chemotherapeutic and antibiotic agents have greatly decreased the number of severe infections in hands, but the incidence of trauma to the hand continues to rise. In 1951, the National Safety Council reported that there were 700,000 occupational accidents involving the hand and forearm. 1 Despite the fact that the hand is exposed and subject to many injuries, there is a tendency to neglect such trauma. Not only does the patient frequently pay little attention to an injury to the hand, but there is a tendency for the profession to consider such injuries of minor importance. In many hospitals they are considered under the questionable term of minor surgery, and assigned to the least skilled of emergency personnel. It is imperative that injuries to the hand receive the most skillful care since this structure is an intricate mechanism and loss of function causes great hardship, especially in those individuals who earn their living by use of their hands. DIAGNOSIS
Etiologic Diagnosis
An adequate history should always be taken in any type of hand injury. The determination of the etiologic agent is especially important. It should be determined just what force'caused the injury. In an injury caused by glass, small particles of foreign body not infrequently remain in the wound. Occasionally, a small laceration on the back of the hand, over the metacarpophalangeal joints, is caused by a human bite. This type of wound should never be closed. Rarely, a rupture of a tendon may be produced by sudden force. In any injury of the hand, the time from the original accident to the time 'of surgery should be carefully ascer... Clinical Instructor of Surgery, Wayne University College of Medicine, Detroit; ' Junior Associate in Surgery, Detroit Receiving Hospital. 1081
Joseph L. Posch
1082
tained, for it has an important bearing on treatment. Primary repair of tendons and nerves should not be carried out if there is danger of infection.
a
~III~II c
Median nerve
Fig. 295. Anatomical and physiological concepts in diagnosis of hand injuries.
Functional Diagnosis
The proper diagnosis in any injury of the hand is based on sound concepts of physiology and anatomy. Lacerations of tendons and nerves can be diagnosed by routine examination (Fig. 295).
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Involvements of the median and ulnar nerves give changes involving the intrinsic muscles of the hand, along with sensory changes (Fig. 295, a). In lacerations of the median nerve, for example, not only is there loss of sensation in the thumb, index, middle and radial side of the ring finger, but there is also inability to oppose the thumb to the little finger, and loss of abduction, that is, raising the thumb toward the ceiling2 (Fig. 295, c). In damage to the ulnar nerve, the little finger and ulnar side of the ring finger have loss of sensation (Fig. 295, a); and in addition, the intrinsic muscles of the hand are involved. This is manifested by inability to spread the fingers and to abduct and adduct the fingers away from and toward the midline of the hand (Fig. 295, d), by inability to form a circle by touching the thumb and index finger together,3 and also by inability to extend the distal two phalanges of the fingers. Radial nerve injury is illustrated by wristdrop (Fig. 295, b) and loss of sensation on the dorsal radial aspect of the hand (Fig. 295, a). Cut flexor digitorum sublimis and profundus tendons are manifested by inability to flex the distal two phalanges of the finger (Fig. 295, e) . A severed flexor digitorum profundis is illustrated by inability to flex the distal phalanx of the finger (Fig. 295, f). The most common missed diagnosis is that of a lacerated flexor digitorum profundus as a result of a very small laceration over the proximal two phalanges of the finger. Sublimis action will be retained and fair motion is present. However, the fact that the tip of the finger cannot be flexed is often missed. It should be borne in mind that the action of the lumbricales may produce mild flexion. Inability to flex the distal phalanx of the thumb is indicative of a lacerated flexor pollicis longus. The diagnosis of laceration of an extensor tendon is determined by inability to extend the proximal phalanx of the finger. In severe lacerations or injuries of the wrist, physiological motion of the thumb and fingers can be tested by voluntary motion. The findings in lacerations of the flexor digitorum sublimis and digitorum profundus tendons will be the same as those described above. SURGICAL MANAGEMENT
General Considerations
Lacerations that involve tendons, nerves and bones should be repaired under excellent operating conditions. The wound when first se~n should be wrapped in a dry sterile dressing. Bleeding may be controlled by pressure or, if necessary, a blood pressure cuff may be used as a pneumatic tourniquet. Thin, narrow rubber tubing, or narrow cuffs, should not be used to stop bleeding because of the nerve damage that occasionally results.
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Since the damage may be more extensive than anticipated and the operation prolonged, it is imperative to have as careful an evaluation of the patient as in any other case where an operative procedure of great magnitude is considered. This entails a careful history, physical examination and adequate laboratory studies. To make less than a complete evaluation in these patients is not only unfair but may be quite dangerous. In severe injuries, general anesthesia is often the best choice. In less severe injuries, or if the patient may have been eating or drinking just before suffering his injury, a local type of block, such as a brachial or digital nerve block, may be utilized. Recently, the longer acting local anesthetic agents have proved more useful than procaine. We prefer not to use local finger blocks because of the possibility of resulting gangrene of the tip of the finger. Instead, where anesthesia of the finger is desired, we prefer to use a local digital nerve block between the metacarpals. The injection is done from the dorsal aspect of the hand where the skin is soft. The hand should be thoroughly washed in soap and water for at least ten minutes. Some of the newer detergents do not appear to be harmful to the soft tissues and may be used, but are no better than soap and water. During the washing procedure, the hand is thoroughly irrigated several times with normal saline. The fingernails should be cleansed and cut short; if necessary, a scrubbing brush may be used on the fingers but not on the wound itself. Antiseptic solutions are not poured into the wound, or for th~t matter, ever used on the skin, for with the color they impart it is often difficult to determine whether cyanosis of skin flaps is present. A blood pressure cuff is. always used on the upper arm to control bleeding. A towel or sheet wadding is wrapped about the upper arm, then the blood pressure cuff is· placed over this. The cuff is held in place by means of roller gauze. 4 The arm is elevated in the air for several minutes, and then the cuff is rapidly inflated to 280 mm. of mercury. The cuff is left on from one to one and one-half hours, and then removed. Bleeding vessels are clamped and ligated. At the end of ten minutes the cuff may be inflated again and left on until the procedure is finished. When this method is used properly, we have had no difficulty in obtaining a bloodless field. If there is a question of devitalized tissue, however, it is used with caution. On one occasion, when the cuff was left on for one hour and fifty-five minutes, an annoying peripheral neuritis occurred. This subsided in several months. On another occasion we saw a patient with a prolonged complete paralysis of the arm and hand that resulted from a faulty narrow type of pneumatic cuff. In draping the hand, towels and sheets are placed so that the hand itself is exposed. The arm is placed on a wide board. A small pillow may
Injuries of the Hand
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be placed under the entire arm for support. In addition, after the draping is done, the hand may be supported under a rolled gown or several sheets. Incisions
Incisions in the fingers should not cross flexion creases but should be made midlaterally. In the palm, they may follow the flexion creases. It may appear to be easier to identify elusive tendons and nerves by making a longitudinal incision in the middle of the palmar aspect of the finger. Some tendon function may be obtained in this manner, but the resulting contracture with marked limitation of extension nullifies any flexor power that may have resulted. Open Fractures
In severe injuries of the hand, such as punch press injuries, cornpicker injuries and so forth, one should attempt to save all viable tissue. Fractures must be adequately reduced. The use of foreign material for fixation should be avoided if at all possible. Occasionally, a stainless steel wire may be utilized if absolutely necessary. The employment of the universal metal splint, as described by Mason and Allen, is excellent in severe crush injuries to maintain the hand in position of function and to reduce the fractures. In less severe injuries, or in those involving only one finger, reduction may be maintained by traction or splinting in a semiflexed position. A fractured finger should never be placed straight out on a splint. This also applies to a banjo type of splint with a straight pull. Severed tendons are best repaired after the fractures have healed. Adequate skin coverage must be provided. Soft Tissue Injury
Whenever there is loss of skin, attempts should be made to cover the denuded area. This can be done by split thickness skin grafts, sliding grafts, or pedicle grafts. It is extremely important to obtain good skin coverage on any exposed bone or tendon. If there is only superficial loss of skin on a finger tip, this can be readily replaced with a split thickness skin graft. However, if bone is exposed, then a pedicle type of graft is the procedure of choice. Full thickness grafts may be used, but often a sore, tender stump results. A pedicle can be obtained from the thenar or hypothenar eminence (Fig. 296, a) or, on occasion, from the abdomen. The difficulty with a pedicle graft from the abdomen for the tip of the finger is that it tends to become pigmented, and sensation is poor. We have arbitrarily determined that, if a traumatic amputation is through the tip or middle third of the distal phalanx, the patient is a good candidate for a pedicle graft from the
Fig. 296. Adequate covering of skin loss. a, Traumatic amputation of tip of finger in 18 year old school boy. Pedicle from thenar eminence. b, A severe crushing injury of the hand in a 30 year old white steel worker, suffered when it was caught in a steel roller. c, Necrotic skin excised and split thickness skin graft temporarily applied. A pedicle graft was applied later. d, Severe avulsion laceration of the dorsal aspect of the hand and traumatic amputation of little and ring fingers in a 26 year old white steel worker. Subcutaneous tissue removed and skin replaced as a full thickness skin graft. e, Flexion. j, Extension. g, Severe punch press injury in a 35 year old auto worker. Fractured third metacarpal transfixed with small Kirschner wires. h, Pedicle graft from abdomen to hand placed immediately. i, Appearance 2 months following injury. Limitation of motion present but good covering provided.
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palm. However, if extensive loss of tissue occurs proximal to the nail bed, amputation of the phalanx is usually the procedure of choice. In severe roller injuries when skin has been destroyed, a split thickness skin graft may be used to cover the defect temporarily. Later, full thickness or pedicle grafts may be applied (Fig. 296, b, c). If large areas of skin are avulsed and are still attached at one end, the subcutaneous tissue may be removed and the full thickness skin replaced as a graft 5 (Fig. 296, d, e, f). If large areas of skin are lost (Fig. 296, g), a pedicle graft may be raised from the abdomen and placed to the injured hand immediately, in order to preserve the remaining tissues. The site on the abdomen where the pedicle has been raised is covered with a split thickness skin graft, so as to provide a closed wound, thereby cutting down on the amount of drainage that occurs from granulating surfaces. These pedicles are detached at the end of eighteen to twentyone days, and then sutured in place to the hand (Fig. 296, h, i). Amputations
In amputations involving the finger it has been said one should attempt to save as much length as possible. However, adequate soft tissue padding must be provided, even at the sacrifice of some length of the digit. A long volar skin flap and a short dorsal one is ideal. This is important, for unless good skin flaps are provided a sore tender stump will result. The nerves are identified, sectioned sharply and allowed to retract into the good soft tissue proximal to the site of amputation. Vessels are carefully identified and ligated. Fexor tendons are not sutured to the extensor tendons at the end of the stump, for it has been noted repeatedly that limitation of motion in the other fingers results. If the amputation is at the joint, the prominent head of the distal portion of the phalanx is narrowed and the cartilage is removed so that the skin will adhere to the bone. In injuries to the thumb, attempts should be made to save all of the length possible. Nerves
Digital nerves can, and should, be sutured at every opportunity (Fig. to do an excellent job suturing a tendon, and to ignore the nerves. Later, the patient may have fairly good motion but he will complain persistently of numbness of the finger. This result can readily be prevented by careful suture of the digital nerves at the time of the original repair. Digital nerves are sutured with fine suture material (6-0 or 7-0 silk). Following the suture of a digital nerve, return of sensation usually occurs. In median and ulnar nerve injuries, good return of sensation usually follows repair. However, there is rarely complete return of motor power. 297, a, b, c). It is folly
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Postoperatively, the hand should be splinted periodically to prevent contractures, and galvanic stimulation should be applied to the intrinsic muscles of the hand at regular intervals. Tendons
Lacerated extensor tendons can be readily repaired with interrupted fine suture material using No. 60 cotton. Uniformly good results are obtained. Fexor tendons in the wrist, palm and fingers usually are difficult to repair, and especially so in the fingers themselves. In the finger, a lacerated flexor tendon, repaired even under the best circumstances, frequently gives only a fair result. It is for this reason that most adequate facilities should be available for the repair. If the injury is more than a few hours old and if there has been contamination, then the repair of this tendon should be delayed, the skin only being closed. This is possibly also true where the repair is attempted by the occasional operator, or one who is not enthusiastic about this interesting type of surgery. In the finger, adequate exposure is obtained by making a midlateral incision (Fig. 298, a). It is usually necessary to make a transverse incision in the distal portion of the palm to identify the proximal portions of the severed tendons (Fig. 298, b). Contracture of the muscle bellies in the forearm occurs and the tendon ends are usually retracted proximally for several centimeters. One should not grasp blindly for the proximal end with a hemostat, thereby injuring the tendon sheath and the end of the already traumatized tendon. "Tendons should be handled gently; never crushed, rubbed, or allowed to become dry."6 By making a proximal transverse incision in the palm, the end is readily identified, a suture is placed in it and, with a tendon leader,7 it can be readily transferred to the site of the original injury (Fig. 298, c). One method we have found to facilitate work on the tendon will be described. Once the tendon is brought into the wound and retracted as far distally as possible, a straight needle is placed at right angles, superficially, through it (Fig. 299, d), thereby preventing it from disappearing into the wound again. This may also be done with the distal tendon if it has a tendency to retract into the wound. The tendon ends are now freshened with a sharp razor. Suturing of the ends should be as atraumatic as possible. Fine suture material is extremely important. We have used Koch's method of placing a simple mattress suture of fine silk on either side of the tendon. 1 One may also use wire at a distance, as suggested by Bunnell.8 We also have employed, with good results, the use of six to eight interrupted No. 60 cotton sutures, placed very superficially through the tendons (Fig. 299, d).
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The suture ends are cut on the knot. Much of the difficulty encountered in the past has been the use of large suture material cut long, which not only prevents the tendon from gliding but retards healing so that drainage occurs. The most common query that one hears is, "What do you do with the
Fig. 297. Lacerated digital nerve and flexor pollicis longus tendon in a 13 year old school girl. a, Nerves repaired with 6-0 silk, and tendon repaired with number 60 cotton. b, Flexion. c, Extension. Sensation returned to thumb in 3 months.
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I Incision in palm
Passing profundus tendon
l]Fig. 298. Technique demonstrated. Midlateral incision locating tendon and returning it to its original location. a, Original laceration with midlateral incision for exposure. b, Transverse incision in distal portion of palm in order to locate tendon. e, Method of passing the proximal end of the flexor digitorum profundus to the site of the original injury. e' , Tendon leader of Bunnell.
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of tendon by needle
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Fig. 299. Technique demonstrated (continued). Tendon suture and technique of leaving tendon sheath open. d, Method of obtaining relaxation of the proximal portion of tendon by inserting needle at right angle to the tendon to prevent retraction. d', Careful suture of tendon ends with fine suture material. e, Opening the fibrous tendon sheath (pulley) in order to allow gliding to occur. Note that the tendon sheath has been excised directly over the suture line. f, Gently roIling tendon ends between the fingers to insure adequate approximation of all fibers. g, The suturing of the proximal end of the sublimis to the proximal end of the profundus. The sublimis insertion has been cut short. h, Synovial tendon sheath excised, and fibrous tendon sheath open. i, Closure with fine suture material, and skin closure, if at all possible, is not directly over tendon suture.
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tendon sheath?" This, as Mason 9 and Bunnell10 have repeatedly emphasized,)s excised both above and below the sutured tendon. The sutured tendon is then allowed to come in contact with the subcutaneous tissue. In addition, the fibrous portion of the tendon sheath must be split to allow the sutured portion of the tendon sliding space (Fig. 299, e, h). This is extremely important, for in healing the tendon swells and it would adhere to the sheath if it were not open. This procedure of excising and opening the tendon sheath is an important factor in obtaining a good result in primary tenorrhaphy. Once the tendon is repaired, it is then gently rolled between the fingers to insure accurate approximation of all of the tendon fibers (Fig. 299, f); the needle that had previously been placed at right angles is removed; and the skin is carefully closed with interrupted sutures. If possible, the sutured tendon should not be directly under the closed skin incision (Fig. 299, i). Drains are not necessary. If both the profundus and sublimis are severed in the finger, it has been advocated that only the profundus be repaired. The sublimis is cut short at its insertion, while the proximal end is sutured to the proximal profundus in the palm (Fig. 299, g). In the palm and the wrist, however, both the deep and superficial tendons should be sutured. In the palm, the lumbrical muscle can be placed between the two sutured tendons (Fig. 300). Primary tendon grafting is not indicated in the initial treatment of hand injuries, for as Koch has aptly said, "if infection then supervenes, we practically burn all our bridges be~nd US."ll In a wound that heals without infection, tendon grafting can be done three weeks after the injury. Postoperatively, the hand is dressed in the best position to relax the tendons. This can be done with a plaster-of-paris splint or with metal. For extensor tendons, the wrist and fingers fl,re moderately extended. If only one extensor tendon to a finger is involved, only that finger and the one next to it need be placed in a splint. It is not necessary to place all of the fingers in extension. For flexor tendons, tension is removed from the sutured tendon ends by moderately flexing the wrist, with the fingers slightly flexed. Acute flexion of the fingers into the palm, after a primary repair in the tendon sheath, usually results in their staying that way when attempts to resume motion are undertaken. The hand is kept elevated for several days; a sling is used when the patient is ambulatory. Care must be taken to insure against swelling and the dressings should be loosened the day following surgery. Skin sutures should remain over a week. The supporting splint is worn for three weeks, and then gradually increasing exercises are started. These consist of warm soapy hand baths several times daily. Lanolin or cocoa
Fig. 300. a, Lacerated flexor tendons to middle, ring and little fingers in the 33 year old wife of a physician. Flexor digitorum sublimis removed from little and ring fingers, and primary tenorrhaphy carried out of flexor digitorum profundus in middle, ring and little fingers. b, Flexion at the end of one year. c, Extension. There is limitation of extension of the little finger but this is not severe. d, Severe laceration of palm with severance of all of the flexor tendons and nerves to the middle, ring and little fingers in a 26 year old auto worker. e, Primary repair of flexor digitorum profundi. Sublimis tendons removed because the suture line was in the tendon sheath. Digital nerves also sutured. j, Function at the end of three months. g, Laceration of palm in a 23 year old auto worker, suffered when it was cut on a porcelain faucet. There was inability to flex the middle, ring and little fingers, and anesthesia was present over the ring and middle fingers. Severe blood loss required the transfusion of 1000 cc. of whole blood. Primary repair of flexor digitorum profundi and sublimi to middle, ring and little fingers. Primary neurorrhaphy of digital nerve to ring finger and middle finger. h, Flexion possible at the end of 3 months. i, Extension.
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butter is applied to the healing areas, morning and night, with gentle massage. To facilitate the postoperative care of hand injuries, a clinic was established at the City of Detroit Receiving Hospital in 1937. As part of the surgical residency training program, two residents are assigned to the clinic, and under the supervision of a staff man, all hand cases are seen. There, care is coordinated and facilitated. This has been important in stimulating interest in the care of hand injuries by the house staff, and provides better care for the patient. REFERENCES 1. Koch, S. L.: The Working Man's Hand. Bull. Am. ColI. Surgeons 38: 5-14, 1952. 2. Winfield, J. M.: Anatomic Diagnosis of Injuries of the Hand. J.A.M.A. 116: 1367-1370, 1941. 3. Couch, J. H.: Surgery of the Hand. Toronto, University of Toronto Press, 1939. 4. Bruner, J. M.: Safety Factors in the Use of the Pneumatic Tourniquet for Hemostasis in Surgery of the Hand. J. Bone & Joint Surg. 33-a (1): 221224, 1951. 5. Mulholland, J. H. and Mahoney, J. H.: Massive Avulsion of Skin. Am. J. Surg. 83: 359-c363, 1951. 6. The Care of Hand Injuries. IV. Pamphlet. Committee on Trauma, American College of Surgeons. 7. Bunnell, S.: Surgery of the Hand. 2nd Ed. Philadelphia, J. B. Lippincott Co., 1948, p. 89. 8. Bunnell, S.: Surgery ofcthe Hand. 2nd Ed. Philadelphia, J. B. Lippincott Co., 1948, p. 425. 9. Mason, M. L.: Primary and Secondary Tendon Suture. Surg., Gynec. & Obst. 70: 392-402, 1940. 10. Bunnell, S.: Surgery of the Hand. 2nd Ed. Philadelphia, J. B. Lippincott Co., 1948, p. 627. 11. Koch, S. L.: J. Bone & Joint Surg. 36-a (1): 140-171, 1953.