Hand injuries by Dr.SUNIL C

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POWER POINT PRESENTATION ON HAND INJURIES

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  • 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

    1. 1. Hand Trauma • PRESENTAR-Dr.SUNIL C • P.G IN ORTHOPAEDICS • MODERATOR-Dr.MANJAPPA • ADICHUNCHANGIRI INSTITUTE OF MEDICAL • SCIENCES
    2. 2. • 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
    3. 3. Topics • Relevant anatomy • Clinical approach to hand trauma – History – Examination – Imaging • Specific injuries
    4. 4. Relevant Anatomy Integument  Dorsal skin ◦ 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 .  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
    5. 5. Soft tissues • Muscles and tendons • Blood vessels , lymphatics • Nerves Spaces of the hand Ref. Clinical Anatomy, Richard Snell, 6th edition Clinical symposia Nov.1988 –surgical anatomy of the hand- earnest W.Lampe MD
    6. 6. Muscles and tendons • Muscles - two main groups: – Extrinsic group • Extrinsic extensors • Extrinsic flexors – Intrinsic group: • Thenar complex • lumbricals • Interosseous • Hypothenar complex 6
    7. 7. Anatomy of the tendon arrangement in a finger Extensor expansion - On the dorsum Flexor sheath - on the volar aspect
    8. 8. 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.
    9. 9. Hand Anatomy • Intrinsic muscle of the hand: • Have their origins and insertions within the hand. • Consist the following: – Thenar, Hypothenar, adductor pollicies, the interossei and the lumbricals. (Refer to pg 1665 for anatomical description)
    10. 10. Hand Anatomy • Extensor Tendons: – Courses over the dorsal side of the forearm, wrist and hand. – 9 extensor tendons pass under the extensor retinaculum and separate into 6 compartments
    11. 11. Surface anatomy of the hand. The tendons that are palpated with thumb abducted and extended form an anatomic snuff-box.
    12. 12. Hand Anatomy • 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.
    13. 13. Hand Anatomy • Flexor Tendons: • Courses over the volar side of the forearm, wrist, and hand. • Unlike the extensor tendons, the flexor tendons are enclosed in synovial sheaths making them prone to deep space infections.
    14. 14. Hand Anatomy • Flexor Tendons: – Flexor carpi radialis, flexor carpi ulnaris, and palmaris longus primarily flex the wrist
    15. 15. Hand Anatomy
    16. 16. Hand Anatomy • 9 flexor tendons pass through the carpel tunnel: • 1 tendon go to the base of the dist. Phalanx of the thumb • The other 4 digit has 2 tendon each (FDS / FDP).
    17. 17. Hand Anatomy – 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. (Figure 268-5).
    18. 18. Hand Anatomy • Blood supply (BS): – Hand and digits has dual (BS) with contributions from the radial and ulnar arteries.
    19. 19. Hand Anatomy • Blood supply (BS): – Proximal portions of the hand (BS) come from the deep and superficial arches on the palmar and dorsal side. – BS of the fingers is distributed by the digital arteries that arises from the superficial palmer arch.
    20. 20. Nerves - Sensory Innervation
    21. 21. 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 nerve Median nerve LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis Ref. Wheeless' Textbook of Orthopaedics
    22. 22. 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
    23. 23. Deep spaces of the hand Radial bursa Ulnar bursa Mid palmar space Thenar space Space of Parona
    24. 24. Bones of the hand
    25. 25. Hand Anatomy • Hand consist of 27 bones: – 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 the fingers
    26. 26. Hand Trauma Hand trauma account for 5-10 % of trauma. Mechanism of injury • Blunt trauma • Lacerations & punctures • Avulsions ± soft tissue deficit • Ring avulsions Structures injured • Cutaneous injuries • Muscles and Tendons • Neuro-vascular injuries • Bones and associated soft tissues
    27. 27. Approach to Hand Trauma • History • Examination • Imaging 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, Louis Solomon
    28. 28. History 29 Important 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
    29. 29. Physical examination Entire upper limb comparing both upper limbs. Should follow the routine order of LOOK, FEEL, MOVE LOOK • External appearance. – local swellings - • Evidence of chronic disease(OA, RA, Gout) – Bleeding – Auto-amputations – Wounds / exposed tendons etc. – Deformities
    30. 30. Deformities can be due to tendon, bone , nerve injury and joint dislocations – Specific types – Tendon injuries • Mallet finger
    31. 31. • Swan neck deformity
    32. 32. • Boutonniere deformity • Z deformity of the thumb
    33. 33. Claw hand deformities – due to nerve injuries Median, ulnar nerve injuries – Wasting of the thenar and hypothenar muscles, interossei etc. ( Chronic )
    34. 34. • FEEL – Temperature – Tenderness – Distal neurovascular status
    35. 35. MOVE  Finger cascade ( flexion and extension tendon injuries/ fractures )  Muscles- intrinsic and extrinsic  Joints pain and stability normal ROM – Fingers MP – 0- 90° Passive - further 45 ° PIP – 0- 100 ° DIP - 0- 80 ° Thumb –MP - ext. – 55 ° IP - flex. – 80 ° Ext. - 20 ° Carpometacarpal- ext.- 20 ° , flex.- 15 ° abduction- 60 ° (excess mobility may be due to collateral lig. Injury Ex. Gamekeepers thumb )
    36. 36. Functional capacity – • Grips – Pinch grip /precision grip – Chuck grip – Palmar grip/hook grip – power grip
    37. 37. Types of grips of the hand Pinch grip /precision grip Power grip Hook grip Chuck grip
    38. 38. 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.
    39. 39. 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.
    40. 40. 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. 43
    41. 41. 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. 44
    42. 42.  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. 45
    43. 43.  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. 46
    44. 44. 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
    45. 45. • 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
    46. 46. 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 groin.
    47. 47. Extensor tendon Injury: – Divided into Zones according to anatomical location of injury – In the hand and wrist there are 7 extensor tendon zones 50 Tendon injuries 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
    48. 48. Zone Presentation Management I Mallet Deformity •Closed: splinting 6-8 weeks •Open: suture repair for fixation. Soft tissue reconstruction III Boutonniere’s Deformity •Closed: splinting MCP and PIP in hyperextension for 6 weeks •Open: suture repair (figure of 8 suture) 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 splinting 52
    49. 49. Flexor tendon injuries – 5 zones in the hand and the wrist Zone 1 One tendon only (FDP) from middle of middle phalanx distally Zone 2 Two tendons (FDS & FDP) from MCP joints to middle of middle phalanx Zone 3 Central palm Zone 4 Tendons in the carpal tunnel Zone 5 Tendons proximal to the carpal tunnel FDS Insertion Flexor Sheath
    50. 50. Presentation Flexor injuryZone Presentation Management I Loss of active flexion at DIP joint Hyperextension of DIP joint (Jersey finger ) •Primary or Secondary tendon repair •Careful suturing prevent post-op adhesions. II Loss of active flexion at MCP joint •Skin closure then secondary repair by tendon grafting •Primary repair performed by skilled hand surgeon to minimize post-op adhesions. III, IV Thumb Same •Primary or secondary tendon repair •Examine carefully for thenar muscle injury and recurrent branches of median nerve. 54
    51. 51. Zone Presentation Management V Palm Uncommon Lie deep and protected by palmar fascia Same presentation •Superior to Tendon division: repair is unnecessary. •Both muscles’ tendon division: primary repair VI, VII Wrist Multiple flexor tendon injury Impaired active flexion of multiple digits •Primary tendon suturing in the forearm to prevent post-op cross- adherence. •Injuries to muscles in forearm require primary repair •Post-op splinting of wrist in flexion position and elevation for 4 weeks. 55
    52. 52. 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.
    53. 53. 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.
    54. 54. HAND FRACTURES • INDRODUCTION • Fractures and Dislocations are the most common musculoskeletal injuries • The potential for functional loss is often underappreciated and difficult to measure
    55. 55. 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.
    56. 56. Fracture Reduction • 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.
    57. 57. Splinting • 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.
    58. 58. 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 instability.
    59. 59. Associated Injuries • Open Injuries • Tendons • Nerves and Vessels • Combined Injuries • Massive Hand Trauma • Bone Loss
    60. 60. Treatment Selection • Critical elements in selecting between nonoperative and operative treatment are the assessments of rotational malalignment and stability • 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
    61. 61. 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 Aggresively.
    62. 62. • 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.
    63. 63. 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.
    64. 64. TYPES OF P3 FRACTURES • Tuft Fractures • Shaft Fractures • Dorsal Base Fractures • Volar Base Fractures
    65. 65. 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 extensor tendons. • However, the DIP/IP joint is not as intrinsically stable as the PIP joint and depends to a greater degree on its ligaments
    66. 66. TREATEMENT • 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
    67. 67. 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.
    68. 68. 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 fourth • 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 axially.
    69. 69. 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
    70. 70. TREATEMENT
    71. 71. 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
    72. 72. 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.
    73. 73. Deforming Forces 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
    74. 74. Rehabilitation • 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 bandages.
    75. 75. METACARPOPHALANGEAL JOINT DISLOCATIONS • Dorsal MP joint dislocations are the most common. Simple dislocations are reducible and present with a hyperextension posture • 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.
    76. 76. 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 persistently symptomatic
    77. 77. Thumb Metacarpophalangeal Joint Ligament Injuries • 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 these • 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
    78. 78. 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
    79. 79. TREATEMENT
    80. 80. METACARPAL FRACTURES • 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
    81. 81. CARPOMETACARPAL JOINT DISLOCATIONS AND FRACTURE-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
    82. 82. Thumb Carpometacarpal Fracture- Dislocations • 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 articular) fractures.
    83. 83. COMPLICATIONS • Infection • Stiffness • Hypersensitivity • Malunion and Deformity • Nonunion • Residual Instability • Posttraumatic Arthritis • Hardware Complications • Tendon Rupture
    84. 84. AMPUTATION AND REPLANTATION 100
    85. 85. Introduction  Replantation: reattachment of a severed digit of extremity.  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 replantation  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 101
    86. 86.  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
    87. 87.  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 103
    88. 88. 104
    89. 89. 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
    90. 90. 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. 106
    91. 91. •THANK YOU

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