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 injuries by Dr.SUNIL C
• PRESENTAR-Dr.SUNIL C
• P.G IN ORTHOPAEDICS
• ADICHUNCHANGIRI INSTITUTE OF MEDICAL
• Hand is one of the most important parts of the
human body due to its mechanical and sensory
• One of the most developed structures in the human
4 requirements for a functioning hand:
◦ Supple (moving with ease)
◦ pain free
• Relevant anatomy
• Clinical approach to hand trauma
• Specific injuries
◦ Thin and pliable.
◦ Attached to the hand's 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 .
◦ Thick and glabrous and not as pliable
◦ Strongly attached to the underlying fascia by numerous vertical
◦ Most firmly anchored to the deep structures at the palmar creases
◦ Contains a high concentration of sensory nerve endings
• Muscles and tendons
• Blood vessels ,
Spaces of the hand
Ref. Clinical Anatomy, Richard Snell, 6th edition
Clinical 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
• Hypothenar complex
Anatomy of the tendon arrangement in a finger
Extensor expansion - On the dorsum
Flexor sheath - on the volar aspect
• 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.
• Intrinsic muscle of the
• Have their origins and
insertions within the
• Consist the following:
– Thenar, Hypothenar,
adductor pollicies, the
interossei and the
lumbricals. (Refer to pg
1665 for anatomical
• Extensor Tendons:
– Courses over the dorsal side of the forearm, wrist
– 9 extensor tendons pass under the extensor
retinaculum and separate into 6 compartments
Surface anatomy of the hand.
The tendons that are palpated
with thumb abducted and
extended form an anatomic
• Extensor Tendons:
The extensor tendons gain entrance to the
hand from the forearm through a series of
six canals, five fibroosseous and one fibrous
The communis tendons are joined distally
near the MP joints by fibrous
interconnections called juncturae tendinum.
Beneath the retinaculum, the extensor
tendons are covered with a synovial sheath.
• Flexor Tendons:
• Courses over the volar side of the forearm, wrist, and
• Unlike the extensor tendons, the flexor tendons are
enclosed in synovial sheaths making them prone to
deep space infections.
• Flexor Tendons:
– Flexor carpi
carpi ulnaris, and
primarily flex the
• 9 flexor tendons pass through the carpel
• 1 tendon go to the base of the dist. Phalanx of the
• The other 4 digit has 2 tendon each (FDS / FDP).
– Flexor digitorum
superficialis (FDS) insert
into middle phalanx.
– Flexor digitorum
profundus (FDP) runs
deep to the FDS until the
level of the MP joint
where FDS bifurcates.
– FDP inserts at the base of
the distal phalanx and
acts primarily to flex the
DIP joint as well as all
other joints flexed by FDS.
• Blood supply (BS):
– Hand and digits has
dual (BS) with
contributions from the
radial and ulnar
• Blood supply (BS):
– Proximal portions of the hand (BS) come from the
deep and superficial arches on the palmar and
– BS of the fingers is distributed by the digital
arteries that arises from the superficial palmer
Motor supply to hand –
• All the intrinsic muscles - of the hand except radial 2
• Muscles of thenar eminence, with exception flexor pollicis
brevis .variations +
• Muscles of hypothenar eminence are innervated by ulnar
LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor
pollicis brevis and Flexor pollicis brevis
Ref. Wheeless' Textbook of Orthopaedics
Spaces of the hand
Important 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 hand
Space of Parona
• Hand consist of 27
– 14 Phalangeal bones
– 5 Metacarpal bones
– 8 Carpal bones
• Carpal bones are made
up of two rows of four
bones bridged by flexor
retinaculum which forms
the carpal tunnel.
• Carpal tunnel consist of
the median nerve and
the nine long flexor of
Hand trauma account for 5-10 % of trauma.
Mechanism of injury
• Blunt trauma
• Lacerations & punctures
• Avulsions ± soft tissue deficit
• Ring avulsions
• Cutaneous injuries
• Muscles and Tendons
• Neuro-vascular injuries
• Bones and associated soft tissues
Approach to Hand Trauma
Ref. 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,
Important points in the history of a patient with hand
▫ Hand dominance
▫ Occupation & hobbies
▫ When and how the injury occurred?
mechanism of trauma
▫ Previous history of hand trauma or relevant
Entire upper limb comparing both upper limbs.
Should follow the routine order of LOOK, FEEL, MOVE
• External appearance.
– local swellings -
• Evidence of chronic disease(OA, RA, Gout)
– Wounds / exposed tendons etc.
can be due to tendon, bone , nerve injury and joint dislocations
– Specific types –
• Mallet finger
Types of grips of the hand
Pinch grip /precision grip
Power grip Hook grip Chuck grip
• 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.
◦ 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.
◦ Highly sensitive but not have a role in management of hand
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 are very common injury.
• Two Types
– Open: Incised, laceration, punctured (bites),
– Closed: Contusions, Hematomas
• Vary in depth
• May need to explore for underlying structural Injuries.
• Conservative excision of the skin is the rule.
◦ 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
Irrigate, explore then apply sterile dressing.
Delayed primary closure at 4 days.
◦ 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.
◦ 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.
Rinse and cover.
Prophylactic antibiotic ointment
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.
Injured 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.
Finger tip Injuries
• 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
Cross finger flap
• 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
Extensor tendon Injury:
– Divided into Zones according to anatomical
location of injury
– In the hand and wrist there are 7 extensor
Ref. http://emedicine.medscape.com Orthopedic Surgery for Flexor Tendon
Lacerations Author: Michael Neumeister, MD, FRCSC, FRCSC, FACS; Chief
Editor: Harris Gellman, MD
http://www.orthobullets.com- Flexor Tendon Injuries- Derek Moore MD
Zone Presentation Management
I Mallet Deformity
•Closed: splinting 6-8 weeks
•Open: suture repair for fixation.
Soft tissue reconstruction
•Closed: splinting MCP and PIP in
hyperextension for 6 weeks
•Open: suture repair (figure of 8
V Fixed flexion of MCP
•Closed: splinting ,45 extension at
wrist and 20 flexion at MCP
•Open: suture repair.
VII Fixed flexion of MCP
•Suture repair followed by post-op
Flexor tendon injuries –
5 zones in the hand and the wrist
Zone 1 One tendon only (FDP)
from middle of middle phalanx
Zone 2 Two tendons (FDS &
FDP) from MCP joints to middle
of middle phalanx
Zone 3 Central palm
Zone 4 Tendons in the carpal
Zone 5 Tendons proximal to the
Presentation Flexor injuryZone Presentation Management
Loss of active flexion at
Hyperextension of DIP
(Jersey finger )
•Primary or Secondary tendon
•Careful suturing prevent post-op
Loss of active flexion
at MCP joint
•Skin closure then secondary
repair by tendon grafting
•Primary repair performed by
skilled hand surgeon to minimize
•Primary or secondary tendon
•Examine carefully for thenar
muscle injury and recurrent
branches of median nerve. 54
Zone Presentation Management
Lie deep and protected by
•Superior to Tendon division: repair
•Both muscles’ tendon division:
Multiple flexor tendon
Impaired active flexion of
•Primary tendon suturing in the
forearm to prevent post-op cross-
•Injuries to muscles in forearm
require primary repair
•Post-op splinting of wrist in flexion
position and elevation for 4 weeks.
Effect of injury: “Seddon’s Classification”
Disruption of Schwann cell sheath but no loss of continuity.
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.
• 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
◦ Removal of any scar or tethering attachments to
surroundings that obstruct nerve ability to glide.
◦ End-to-end repair.
◦ Resection of the proximal and distal nerve stumps and then
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.
• Fractures and Dislocations are the most
common musculoskeletal injuries
• The potential for functional loss is often
underappreciated and difficult to measure
PRINCIPLES OF MANAGEMENT
• Fundamental principles of management is
that the negative effects of surgery on the
tissues should not exceed the negative effects
of the original injury.
• If the injury is reducible at all, gentle
manipulation will accomplish the reduction far
more successfully than forceful longitudinal
traction. The principle is relaxation of
deforming forces through proximal joint
positioning such as metacarpophalangeal
(MP) joint flexion to relax the intrinsics or
wrist flexion to relax the digital flexor tendons.
• Splints should immobilize the minimum
number of joints possible and allow
unrestricted motion of all other joints
• Setting appropriate length-tension
relationships in the extrinsic motors (in cases
where they are deforming forces) is most
easily accomplished through immobilization of
the wrist in 25 to 35 degrees of extension.
Signs and Symptoms
• Symptoms associated with a fracture or
dislocation of the hand include pain, swelling,
stiffness, weakness, deformity, and loss
of coordination. Numbness and tingling signify
associated nerve involvement (either direct
injury to the nerve or as a secondary effect of
swelling). Signs include tenderness, swelling,
ecchymosis, deformity, crepitus, and
• Open Injuries
• Nerves and Vessels
• Combined Injuries
• Massive Hand Trauma
• Bone Loss
• Critical elements in selecting between
nonoperative and operative treatment are the
assessments of rotational malalignment and
• Contraction of soft tissues begins
approximately 72 hours following injury.
• Motion should be instituted by this time for all
joints stable enough to tolerate rehabilitation
DISTAL PHALANX (P3) FRACTURES
• The soft tissue coverage is limited and local
signs of fracture can usually be detected at the
surface. When fractures accompany a nail bed
injury, hematoma can be seen beneath the
nail plate. When the seal between the nail
plate and the hyponychium is also broken, the
fracture is open and should be treated
• Fractures in the distal phalanx can be conceived of
as occurring in three primary regions: the tuft, the
shaft, and the base
• The two mechanisms of injury experienced most
frequently are a sudden axial load (as in ball-
handling sports) or crush injuries.
• Dorsal base intra-articular fractures because of the
shearing component of an axial load injury should
be distinguished from avulsion fractures occurring
under tension from the terminal tendon.
The latter are smaller fragments with the fracture line
perpendicular to the line of tensile force in the tendon,
whereas the former are larger fragments comprising a
significant (greater than 20%) portion of the articular
surface with the fracture line being perpendicular to the
articular surface. These are very different injuries with
different treatment requirements.
the majority of bone flakes at the volar base of P3
are really flexor digitorum profundus (FDP) tendon
ruptures occurring through bone.
TYPES OF P3 FRACTURES
• Tuft Fractures
• Shaft Fractures
• Dorsal Base Fractures
• Volar Base Fractures
DISTAL INTERPHALANGEAL AND THUMB
INTERPHALANGEAL JOINT DISLOCATIONS
• The DIP/IP joint is a bicondylar ginglymus joint
stabilized on each side by proper and accessory
collateral ligaments and the volar plate.
• The joint is inherently stable owing to articular
congruity and the dynamic balance of flexor and
• However, the DIP/IP joint is not as intrinsically stable
as the PIP joint and depends to a greater degree on
• Nonoperative Management-Dorsal dislocation
should be immobilized in 20 degrees of flexion
for up to 3 weeks before instituting AROM
• CRIF- K-wire stabilization
• Open Reduction
MIDDLE PHALANX FRACTURES
• These are perhaps the most functionally
devastating of all fractures, and dislocations of
the hand and the most technically difficult to
treat. Many other fracture patterns that occur
in the middle phalanx are the same as those
patterns seen in the proximal phalanx.
Surgical and Applied Anatomy
• Fractures of the middle phalanx can be grouped by the
anatomic regions of head, neck, shaft, and base.Tendon
insertions that play a role in fracture deformation include the
central slip at the dorsal base and the terminal tendon acting
through the DIP joint. The flexor digitorum superficialis has a
long insertion along the volar lateral margins of the shaft of
the middle phalanx from the proximal fourth to the distal
• Base fractures can be divided into partial articular fractures of
the dorsal base, volar base, and lateral base or complete
articular fractures that are usually comminuted and often
referred to as “pilon” fractures
• “Pilon” fractures are unstable in every direction including
Fractures at the neck of the middle phalanx will usually
angulate apex volar as the proximal fragment is flexed by the
FDS and the distal fragment is extended by the terminal
tendon. Those at the base will usually angulate apex dorsal
as the distal fragment is flexed by the FDS and the proximal
fragment is extended by the central slip
PROXIMAL PHALANX FRACTURES
• Types of proximal phalanx fractures that have
been recognized include intra-articular
fractures of the head, extra-articular fractures
of the neck and shaft, and both extra-articular
and intraarticular fractures of the base
Surgical and Applied Anatomy
• Local Soft Tissue Relationships
The proximal phalanx is closely invested by a
sheetlike extensor mechanism with a complex
array of decussating collagen fibers . Surgical
disturbance of the fine balance between these
fibers can permanently alter the long-term
function of the digit.
At the proximal phalangeal level, both intrinsic and
extrinsic tendon forces deform the fracture. They result
in a predictable apex volar deformity for transverse and
short oblique fractures. These forces can be used with
benefit during rehabilitation. If the MP joints are
maximally flexed (the intrinsic plus position), the
intrinsic muscle forces acting through the extensor
mechanism overlying P1 create a tension band effect
that helps to maintain fracture reduction
• Nonoperative management should restrict
splinting to 3 weeks followed by AROM that
can include adjacent digit strapping if
necessary. Similarly, CRIF should allow for pin
removal at 3 weeks, with AROM beginning no
later than this time. If ORIF is chosen, AROM
should begin within 72 hours of surgery and
edema control should be foremost in the
treatment plan using cohesive elastic
• Dorsal MP joint dislocations are the most common.
Simple dislocations are reducible and present with a
• The other variety of MP joint dislocation is a complex
dislocation, which is by definition irreducible, most
often because of volar plate interposition.Complex
dislocations occur most frequently in the index
finger. A pathognomonic radiographic sign of
complex dislocation is the appearance of a sesamoid
in the joint space.
Most dorsal dislocations will be stable following reduction
and do not need surgical repair of the ligaments or volar
plate. Volar dislocations are rare but particularly unstable.
Volar dislocations risk late instability and should have
repair of the ligaments.113 Obstructions to reducing volar
dislocations include the volar plate, collateral ligament, and
dorsal capsule. Open dislocations may be either reducible
or irreducible.Isolated collateral ligament injuries are more
common on the radial aspect of the small finger followed
by the index finger. A rare variant injury to the MP joint is a
dorsal capsular tear (Boxer's knuckle) that can prove
Thumb Metacarpophalangeal Joint
• Complete rupture of the ulnar collateral ligament (UCL) of the
thumb MP joint is a common injury that less frequently may
accompany a full MP joint dislocation.Circumferential
palpation of the MP joint can often localize pain to the UCL,
radial collateral ligament (RCL), volar plate, or combinations of
• stress testing in full extension and 30 degrees of flexion
(eliminates the false-negative conclusion of stability in the
setting of a ruptured proper collateral ligament but an intact
volar plate) should reveal any instability
Thumb Metacarpophalangeal Joint
The thumb MP joint, in addition to its primary flexion
and extension, allows abduction-adduction and a
slight amount of rotation (pronation with flexion).
The ulnar collateral ligament may have a two-level
injury consisting of a fracture of the ulnar base of P1
with the ligament also rupturing off the fracture
fragment.59 Of particular importance is the proximal
edge of the adductor aponeurosis that forms the
anatomic basis of the Stener lesion. The torn UCL
stump comes to lie dorsal to the aponeurosis and is
thus prevented from healing to its anatomic insertion
on the volar, ulnar base of the proximal phalanx
• Fracture patterns may be broken down into those of
the metacarpal head, neck, and shaft. Transverse
metacarpal neck and shaft fractures will typically
demonstrate apex dorsal angulation. Pseudoclawing
is a term used to describe a dynamic imbalance
manifested as a hyperextension deformity of the MP
joint and a flexion deformity of the PIP joint. This
occurs as a compensatory response to the apex
dorsal angulation of the metacarpal fracture (usually
at the neck) and represents a clinical indication for
correcting the fracture angulation
CARPOMETACARPAL JOINT DISLOCATIONS
• Dislocations and fracture-dislocations at the finger
CMC joints are usually high-energy injuries with
involvement of associated structures, often
neurovascular.Particular care must be given to the
examination of ulnar nerve function, especially
motor, because of its close proximity to the fifth CMC
joint. Frequent pattern is one of fracture-dislocation
involving the metacarpal bases, the distal carpal
bones, or both.9
Thumb Carpometacarpal Fracture-
• The majority of thumb CMC joint injuries are
fracture-dislocations rather than pure dislocations.
The smaller fracture fragment at the thumb
metacarpal volar base is deeply placed and not
palpable. These fracture-dislocations are known az
Bennett (partial articular), and Rolando (complete
Replantation: reattachment of a severed digit of
Chinese surgeons at the Sixth People's Hospital
performed successful replantations in the 1960s.
However, in 1968 Komatsu and Tamai's reported o a
successful thumb reattachment
Not all patients with amputation are candidates for
Approximately 100,000 digital amputations occur per
year in the US. Of these, an estimated 30% are
suitable for replantation
Ref. http://emedicine.medscape.com- Hand, Amputations and
Replantation- Author: Bradon J Wilhelmi, MD; Chief Editor: Joseph A
Molnar, MD, PhD, FACS
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
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
◦ Digit: 12 hours for warm ischemia and 24 hours for
Preoperative preparation: radiography of both
amputated and stump parts to determine the level
of injury and suitability for replantation
The normal sequence of the operative procedure
• 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
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
Ref. Plastic Surgery, Goldwyn and Cohen, 3rd edition.
Plastic Surgery, Grabb and Smith, 3rd edition.