Zone 1: Over the middle phalynx at insertion site (Mallet’s deformity)Zone 3: Over the apeces of the PIP joints (Boutonniere’s deformity)Zone 5: Over extensor hoods (MCP) and the dorsum of the handZone 7: Over extensor retinaculum
Treatment of Zone II was associated with increased incidence of post operative cross-adhesions. That is why in the past it was advised to perform secondary repair rather than primary. The area was known as “No Man’s Land”.But recently several studies have shown that primary repair can be achieved with minimal if no post-op adhesion once performed by a skilled hand surgeon.
Hand trauma - soft tissue injuries overview ,principles of management
Hand TraumaPrinciples of Management Prasad Abeyratne Registrar in surgery NHSL- Sri Lanka
• Hand is one of the most important parts of the human body due to its mechanical and sensory functions.• One of the most developed structures in the human evolution.4 requirements for a functioning hand: ◦ Supple (moving with ease) ◦ pain free ◦ Sensate ◦ Coordinated
Topics • Relevant anatomy • Clinical approach to hand trauma – History – Examination – Imaging • Specific injuries
Relevant AnatomyIntegument Dorsal skin ◦ Thin and pliable. ◦ Attached to the hands skeleton only by loose areolar tissue, where lymphatics and veins abundant. ◦ Edema is manifested predominantly at the dorsum ◦ Loose attachment makes it more vulnerable to skin avulsion injuries.-degloving injuries . Palmar skin ◦ Thick and glabrous and not as pliable ◦ Strongly attached to the underlying fascia by numerous vertical fibers ◦ Most firmly anchored to the deep structures at the palmar creases ◦ Contains a high concentration of sensory nerve endings 4
Soft tissues • Muscles and tendons • Blood vessels , lymphatics • Nerves Spaces of the handRef. Clinical Anatomy, Richard Snell, 6th editionClinical symposia Nov.1988 –surgical anatomy of the hand- earnest W.Lampe MD
Muscles and tendons• Muscles - two main groups: – Extrinsic group • Extrinsic extensors • Extrinsic flexors – Intrinsic group: • Thenar complex • lumbricals • Interosseous • Hypothenar complex 6
Anatomy of the tendon arrangement in a finger Extensor expansion - On the dorsum Flexor sheath - on the volar aspect
Blood vessels• 2 main vessels – ulnar (dominant in 80% ) and radial• Forms 2 arches in the palm-• Large Superficial – mainly by ulnar- at the level of distal border of the extended thumb.• Small deep- mainly by radial- at one finger breadth proximal to the superficial.• Fingers –proper digital arteries are end arteries .• Fingers neurovascular bundles – nerves are in more palmar than arteries in contrast to the palm.
• Osseous arteries – Lunate- blood supply from the volar and palmar ligaments- dislocation with tears in both ligaments will cause avascular necrosis . – Scaphoid – 1/3 of the people supply only from the distal end.
Motor supply to hand –Ulnar nerve.• All the intrinsic muscles - of the hand except radial 2 lumbricals• Muscles of thenar eminence, with exception flexor pollicis brevis .variations +• Muscles of hypothenar eminence are innervated by ulnar nerveMedian nerve LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevisRef. Wheeless Textbook of Orthopaedics
Spaces of the handImportant in infections• Radial bursa• Ulnar bursa• Mid palmar space ( continuous proximally with the space of Parona.)• Thenar space• Dorsal subcutaneous space• Dorsal subaponeurotic space• Finger pulp spaces
Deep spaces of the handRadialbursa Thenar space Mid palmar Ulnar bursa space Space of Parona
Hand TraumaHand trauma account for 5-10 % of trauma.Mechanism of injury• Blunt trauma• Lacerations & punctures• Avulsions ± soft tissue deficit• Ring avulsionsStructures injured• Cutaneous injuries• Muscles and Tendons• Neuro-vascular injuries• Bones and associated soft tissues
Approach to Hand Trauma • History • Examination • ImagingRef. Clinical Orthopedic examination -3rd Ed. Ronald McRae Bailey and Love’s –Short practice of surgical – 23rd Ed Concise system of orthopaedics and fractures- 2nd Ed. Alan Graham Apley, Louis Solomon
HistoryImportant points in the history of a patient with hand injury. ▫ Age ▫ Hand dominance ▫ Occupation & hobbies ▫ When and how the injury occurred? mechanism of trauma ▫ Previous history of hand trauma or relevant medical/Rheumatic conditions 18
Physical examinationEntire upper limb comparing both upper limbs.Should follow the routine order of LOOK, FEEL, MOVELOOK• External appearance. – local swellings - • Evidence of chronic disease(OA, RA, Gout) – Bleeding – Auto-amputations – Wounds / exposed tendons etc. – Deformities
Deformitiescan be due to tendon, bone , nerve injury and joint dislocations– Specific types – Tendon injuries • Mallet finger
Types of grips of the hand Power grip Hook grip Chuck gripPinch grip /precision grip
Imaging• X rays- AP, lateral &oblique views ◦ Plain-films of the hand or wrist should be obtained when injury suggestive of fracture or an occult foreign body. Ultra sound ◦ Has a growing role in locating foreign bodies and in evaluating soft tissues ◦ Can detect ruptured tendons and assess dynamic function of tendons non-invasively. MRI ◦ Highly sensitive but not have a role in management of hand wounds.
General Operative Principles• A bloodless field (eg, by tourniquet ischemia) is essential. The pressure of the cuff will 100 mm Hg above systolic pressure.- 200-250 mmHg ( max-250) This is readily tolerated by the unanesthetized arm for 30 minutes and by the anesthetized arm for 2 hours.• Incisions must be either zigzagged across lines of tension (eg, must never cross perpendicularly to a flexion crease), termed Brunner incisions, or run longitudinally in "neutral" zones- so that a healthy skin-fat flap is raised over the zone of repair of a tendon, nerve, or artery.
Cutaneous injuries• Cutaneous injuries are very common injury.• Two Types – Open: Incised, laceration, punctured (bites), penetration, abrasion. – Closed: Contusions, Hematomas• Vary in depth• May need to explore for underlying structural Injuries.• Conservative excision of the skin is the rule. 32
Management Skin Laceration: ◦ Small: Rinse and cover. ◦ Large: Wound exploration under LA Irrigate wound profusely with betadine or sterile water and Explore Close the skin wound with simple sutures. Wounds older than 6-8 hours should not be closed primarily. Irrigate, explore then apply sterile dressing. Delayed primary closure at 4 days. 33
Bites: ◦ Should not be closed primarily but delayed closure at 4 days if needed ◦ Antibiotic prophylaxis is indicated in human (including fight-bites) and cat bites and may be of benefit in dog bites as well. Contusions: ◦ Cold packs with pressure for 30 to 60 min. several times daily for 2 days. Then use warm compresses for 20 minutes at a time. ◦ Rest, elevate ◦ Do not bandage a bruise. 34
Abrasions: ◦ Superficial: Rinse and cover. Prophylactic antibiotic ointment ◦ Deep: Rinse with antiseptic or warm normal saline. Scrub gently with gauze if necessary. Dress with semi-permeable dressing (Tegaderm) Changed every few days. Keep wound moist. Enhance healing process. 35
Finger tip InjuriesInjured components may include skin, bone, nail, nail bed, tendon, and the pulp, the padded area of the fingertip .The skin on the palm side of fingertips is specialized in that it has many more nerve endings than most other parts of our body enabling the fine sensation. When this specialized skin is injured, exact replacement may be difficult.
• Severe crush or avulsion injuries can completely remove some or all of the tissue at the fingertip.• If just skin is removed and the defect is less than a centimeter in diameter, it is often possible to treat these injuries with simple dressing changes.• If there is a little bit of bone exposed at the tip, it can sometimes be trimmed back slightly and treated with V-Y plasty
• For larger skin defects, skin grafting is recommended.• Smaller grafts can be obtained from the little finger side of the hand. - Cross finger flap• Larger grafts may be harvested from the forearm or groin.Cross finger flap
Tendon injuries Extensor tendon Injury: – Divided into Zones according to anatomical location of injury – In the hand and wrist there are 7 extensor tendon zonesRef. http://emedicine.medscape.com Orthopedic Surgery for Flexor TendonLacerations Author: Michael Neumeister, MD, FRCSC, FRCSC, FACS; ChiefEditor: Harris Gellman, MDhttp://www.orthobullets.com- Flexor Tendon Injuries- Derek Moore MD 39
Zone Presentation Management •Closed: splinting 6-8 weeks I Mallet Deformity •Open: suture repair for fixation. Soft tissue reconstruction •Closed: splinting MCP and PIP in Boutonniere’s hyperextension for 6 weeks III •Open: suture repair (figure of 8 Deformity suture) •Closed: splinting ,45 extension at V Fixed flexion of MCP wrist and 20 flexion at MCP •Open: suture repair. •Suture repair followed by post-op VII Fixed flexion of MCP splinting 41
Flexor tendon injuries – 5 zones in the hand and the wrist Zone 1 One tendon only (FDP) from middle of middle phalanxFDS Insertion distally Zone 2 Two tendons (FDS & FDP) from MCP joints to middleFlexor Sheath of middle phalanx Zone 3 Central palm Zone 4 Tendons in the carpal tunnel Zone 5 Tendons proximal to the carpal tunnel
Zone Presentation Presentation Management Flexor injury Loss of active flexion at •Primary or Secondary tendon DIP joint repair I Hyperextension of DIP •Careful suturing prevent post-op joint adhesions. (Jersey finger ) •Skin closure then secondary repair by tendon grafting Loss of active flexion II •Primary repair performed by at MCP joint skilled hand surgeon to minimize post-op adhesions. •Primary or secondary tendon repair III, IV Same •Examine carefully for thenarThumb muscle injury and recurrent branches of median nerve. 43
Zone Presentation Management V Uncommon •Superior to Tendon division: repairPalm Lie deep and protected by is unnecessary. palmar fascia •Both muscles’ tendon division: Same presentation primary repairVI, VII Multiple flexor tendon •Primary tendon suturing in theWrist injury forearm to prevent post-op cross- Impaired active flexion of adherence. multiple digits •Injuries to muscles in forearm require primary repair •Post-op splinting of wrist in flexion position and elevation for 4 weeks. 44
Nerve injuries Effect of injury: “Seddon’s Classification” ◦ Neuropraxia: Disruption of Schwann cell sheath but no loss of continuity. ◦ Axonotmesis: Injury to both Schwann sheath and axon. Distal part undergoes Wallerian degeneration. Stimulation of nerve 72 hours after injury does not elicit response. Regeneration occurs with the average rate of 1-2 mm/day. Neorutmesis: • Injury to all anatomical components, myelin sheath, axons and the surrounding connective tissue. • This total nerve disruption makes regeneration impossible. • Surgical intervention is necessary.
Nerve injury – surgical interventions Neurolysis: ◦ Removal of any scar or tethering attachments to surroundings that obstruct nerve ability to glide. Neurorrhaphy: ◦ End-to-end repair. ◦ Resection of the proximal and distal nerve stumps and then approximation. Autologus Nerve grafting: ◦ Gold standard for clinical treatment of large lesion gaps. ◦ Nerve segments taken from another parts of the body. ◦ Provide endoneural tubes to guide regeneration. ◦ Two types: Allograft, Xenograft.
Hand infections• Commonly seen by orthopedic surgeons as well as emergency room Identifying the cause of the infection and initiating prompt and appropriate medical or surgical treatment can prevent substantial morbidity.• The most common bacteria Staphylococcus aureus and Streptococcus species• Best treated with empiric antibiotic therapy until the organism can be confirmed.• Types of infections include cellulitis, superficial abscesses, deep abscesses, septic arthritis, and osteomyelitis
• In recent years, treatment of these infections has become challenging owing to increased virulence of some organisms and drug resistance.• Treatment involves a combination of proper antimicrobial therapy, immobilization, edema control, and adequate surgical therapy.• Best practice management requires use of appropriate diagnostic tools, understanding by the surgeon of the unique and complex anatomy of the hand, and proper antibiotic selection in consultation with microbiology opinion.Ref. Hand infections. J Hand Surg Am. 2011 Aug;36(8):1403-12.
Introduction Replantation: reattachment of a severed digit of extremity. Chinese surgeons at the Sixth Peoples Hospital performed successful replantations in the 1960s. However, in 1968 Komatsu and Tamais reported o a successful thumb reattachment Not all patients with amputation are candidates for replantation Approximately 100,000 digital amputations occur per year in the US. Of these, an estimated 30% are suitable for replantationRef. http://emedicine.medscape.com- Hand, Amputations and Replantation- Author: Bradon J Wilhelmi, MD; Chief Editor: Joseph A Molnar, MD, PhD, FACS 50
Decision is based on: Importance of the part, level of injury, mechanism of injury expected return of function. Because hand function is severely compromised if the thumb or multiple fingers are not present to oppose each other, thumb and multiple-finger replants should be attempted. Hand Muscles at room temperature are irreversibly damaged in 6-8 hours; if cooled, it can withstand a maximum of 8-12 hours of ischemia. However, if digits are cooled without freezing, they may survive longer than 100 hours
Recommended ischemia times for replantation: ◦ Major replant: 6 hours of warm and 12 hours of cold ischemia. ◦ Digit: 12 hours for warm ischemia and 24 hours for cold ischemia. Preoperative preparation: radiography of both amputated and stump parts to determine the level of injury and suitability for replantation 52
The normal sequence of the operative procedure• Debridement• Identification and/or tagging of vital structures• Skeletal stabilization- appropriate shortening, the bone may be stabilized interosseous wires, interosseous wire and pin, or miniplate and/or miniscrews. Joint damage may be managed with prosthetic joints, resection arthroplasty, or fusion.• Extensor tenorrhaphy• Placing sutures within flexor tendon ends• Digital artery repair• Neurorrhaphy of digital nerve• Repair of flexor digitorum profundus• Venous repair• Skin closure• Dressing
Outcome Overall success rates for replantation approach 80%. Better outcome with Guillotine (sharp) amputation (77%) compared to severely crushed and mangled body parts(49%). In general, the prognosis for ring avulsion injuries is poor. Studies have demonstrated that patients can expect to achieve 50% function and 50% sensation of the replanted part. Ref. Plastic Surgery, Goldwyn and Cohen, 3rd edition. Plastic Surgery, Grabb and Smith, 3rd edition. 55
Thank you Bone injuries–fractures • To be continued…