HAND INJURY

1. By
Dr Salihi Abdulmalik
National Orthopaedic Hospital Dala-Kano
9th March, 2021

2.  Introduction
 Epidemiology
 Relevant anatomy
 Functions of the hand
 Aetiology
 Classification
 Principles of management
 Principles of management of specific injuries
 Rehabilitation
 Conclusion

3. ◦ The hand is one of the most complex part of the
body
◦ The muscles, tendons, joints, nerves & other tissues
allows for variety of simple and complex tasks
◦ Hand injuries are likely when the wrong tool is used
or the right tool is used improperly.

4. ◦ 5-10% of A&E cases
◦ Male are more affected 5:1
◦ Commoner in young adults (mean 25yr)
◦ Occupational injuries most common setting (54.8%)

5. ◦ Prehension
◦ Perception
◦ Identification
◦ Communication
◦ Cosmesis

6.  Thumb- 40%
 Index Finger-20%
 Middle Finger- 20%
 Ring Finger-10%
 Little Finger- 10%

7. ◦ Complex and intricate structure
◦ Skin
◦ Blood supply
◦ Nerve supply
◦ Intrinsic muscles
◦ Extrinsic muscles and tendons
◦ Tendon sheaths and pulley systems
◦ Bones and joints

8.  Skin is glaborous
 Thick keratin layer with ridges to enhance grip
increase contact
 Palmar creases attach the skin to the palmar
aponeurosis
 No sebaceous glands, no hair
 This anatomy prevents shearing, maximizes
stability and provides a cushion

9.  Thin and stretches with motion
 loose areolar attachment to the underlying
structures and is readily avulsed
 Allows for swelling

11.  Zone I: distal to FDS
insertion
 Zone II: FDS insertion –
distal palmer
crease/proximal A1
pulley
 Zone III: distal palmer
crease – distal aspect of
carpal ligament (palm)
 Zone IV: carpal tunnel
 Zone IV: carpal tunnel to
forearm

13. Open/close
Rank and Wakefield
a). Tidy wounds
-Incised
-Sliced-With tissue loss-skin,
flap
-Puncture
b). Untidy
-avulsion
-crushed
-injected

14.  Soft tissue injuries
◦ Blunt trauma (crush injury, contusions, abrasions)
◦ Laceration
◦ Avulsion
◦ Ring avulsion
◦ Burns
 Nerve injuries
 Tendon injuries (extensor/flexor)
 Vascular injury

15.  Bony Injuries:
◦ Fracture
◦ Subluxation
◦ Dislocation
◦ Traumatic amputation
◦ Traumatic disarticulation

16.  Management is multidisciplinary
 Primary and secondary surveys
 History
 Age
 Hand dominance
 Occupation/hobbies
 History of previous hand problems

17. •Current injury-When and where did this
injury take place?
Circumstances: Assault ? suicide? Accident?
Mechanism of injury

18.  Past medical history- diabetes, vascular
problems, epilepsy
 Smoking history
 Past history of treatment or surgery in the hand
 Pre-injury hand functional limitations from
contractures/scars/surgeries

19. Look
 Expose all upper limb and remove rings
 Skin-
◦ Colour Change
◦ Swellings
◦ Asymmetry, Shape, Wasting
◦ Scars
◦ Cuts
◦ compare contralateral limb


20.  Feel
◦ Tenderness
◦ Temperature
◦ Sensation(nerve distribution zone)
◦ Tinel’s test

21. Movement
◦ Active and passive ROM
◦ Tendon assessment(flexors and extensors)

22.  Clinical photograph
 X-ray-
◦ AP, Oblique, Lateral
◦ Foreign bodies, air, bones & joints
 Wound swab
 FBC
 FBS
 Urinalysis

23.  CT scan-especially for carpal bone/ligament
injuries
 MRI: high sensitivity for detection of soft tissue
injuries (ruptured ligaments/tendons)
 USS & Doppler:- Soft Tissue and Vascular lesions
 Angiography / MR angiography.

24.  Aim
◦ To achieve a supple, sensate, pain-free and
coordinated acceptable hand
 General guidelines
◦ Wound dressing/pressure dressing
◦ Elevation
◦ Splinting
◦ Infection prevention (tetanus and antibiotics
prophylaxis)
◦ Analgesics

25.  Principles
◦ Adequate anesthesia
◦ Good lighting
◦ Hand rest
◦ Fine sutures
◦ Bloodless field
◦ Magnification
◦ Alert and competent team
◦ Adequate debridement without tissue wastage
◦ Prioritization for repair

26.  Prioritization
◦ Skeletal stabilization
◦ Vascular repair
◦ Skin cover
◦ Nerve repair
◦ Tendon repair

27.  Based on cleanliness of injury
◦ Tidy : primary repair of all structures
◦ Untidy:
 convert to tidy and close skin
 2o repair 3wks after skin wound healed
◦ Discourage granulation tissue formation (single
scar theory)

28. Finger Tip:-the portion of the digit distal to the insertion of the
profundus and extensor tendons
Most common hand injury
May lead to significant disability-pain, sensory loss, deformity
Goals of treatment
Adequate sensation
Minimum tenderness
Maximum length
Satisfactory appearance
Full joint motion
Principles of treatment
Preserve all viable tissue
Choose the simplest procedure possible-

29. Healing by secondary intention(defects≤ 1cm2)
Composite graft(replacement)
Skin graft(full and split thickness)
Bone shortening + direct closure
Local flaps: V-Y, volar advancement
Regional flap: Cross finger, thenar, hypothenar
Distant flap: arm flap, chest wall flap

30. Nailbed lacerations need to be repaired
Use 6-0 absorbable to repair matrix
Prevents nail growth problems
Reinsert nail and secure

Subungual Hematoma
Results from blunt trauma to nail
Very painful
Relieved by-Cautery, Heated paperclip, 18g
needle

31. Usually results from RTA and machine injuries
Initial assessment of vital and non vital tissues
Serial debridement may be needed
Remove non viable tissue
Tissue repair depends on what tissue is damaged-skin, bone,
vessels, tendon, nerve
Wound closure may involve skin graft, distant flaps, microvascular
tissue transfer, tendon and nerve repair, fixation of fractures. Some
form of amputation

32. Aims
◦ Restore functional length ,alignment and stabilit
◦ regain full and rapid restoration of function
◦ All methods of fixations should allow early
mobilization
Treatment option
◦ Reduction- open and closed
◦ Fixation-Splint or internal or external fixation
immobilisation

34.  Repair options
◦ Primary tendon repair- < 24hrs
◦ Delayed primary repair- 24hrs- 2wks
◦ Early secondary repair- 2wks- 5wks
◦ late secondary repair- > 5wks
◦ Tendon graft-palmaris longus, plantaris as
common sources
◦ Bunnel/Kesler/modified Kesler

35. Technique
◦ Kessler
◦ Modified Kessler technique
◦ Bunnell
◦

36.  Extension block splint
 Wrist at 30 degree of flexion: weakens the flexor
tendons and minimises risk of tendon rupture
 MP joints at 45-75 deg of flexion
IP joints in near full flexion or slight flexion
 Rehabilitation
Early controlled mobilisation protocols are
the standard
Active extension, passive flexion

37.  Subcutaneous location; vulnerability
Thinner, less substantial, less likely to hold suture
less retraction due to multiple attachments
Proximal injuries
 Repair as in flexor tendons
 Distal injuries, in extensor hood, use horizontal
mattress sutures, figure-of-eight
 Rehabilitation:- same principles as for flexor
tendons.

38. Arterial Repair
◦ Under magnification
◦ Vessels are sequentially resected until normal
intima is reached
◦ Tension-free repair- Interposition with reversed
vein grafts.
Fasciotomy
◦ after repair as muscles would have swollen due to
ischaemia
◦ If late, Reperfusion Syndrome may occur.

39.  Neuropraxia
 Axonotmesis
 Neurotmesis
Treatment options
◦ Primary repair: within 24 hours
◦ Delayed Primary repair: within 1 wk
◦ Secondary repair: >1 wk

40. Nerve Repair
◦ Primary repair when possible
◦ Under good magnification
◦ Must be Tension-free.
◦ Epineural or Perineural repair
◦ If under tension, Interposition with sural graft,
Splint, Physiotherapy, Tinel’s to assess

41. Cold ischaemic time for a finger- 30hrs.
Warm ischaemic time- <6hrs..
Amputated digits
Initial care
IVF, antibiotics, tetanus prophylaxis
Control of bleeding (don’t ligate vessel)
Stump cleansed with saline and dressed with a nonadherent gauze
and bulky dressing.
Care of Amputated part
Washed with ringers lactate and wrapped in moist gauze
Placed in sealed plastic bag
Bag placed in ice water bath

42.  Clean guillotine amputation
 Amputation proximal to DIP
 Bilateral hand injuries
 Amputation of thumb
 Occupational value of the hand
 Amputation in children

43.  Severely crushed or mangled digit
 Amputation at multiple level
 Mentally unstable patient
 Unstable patient

44.  Other of reimplantation (BEFANV)
◦ Bone
◦ Extensor tendons
◦ Flexor tendons
◦ Artery
◦ Nerve
◦ Vain

45.  Training of staff properly
 Use of protective gadget
 Avoid operating machines while on drugs or
feeling sleepy

46.  Early presentation
 Injured structures

47.  Hand injury is common
 Can be devastating and disabling
 Prompt and adequate treatment is key

48.  Louis Solomon, David Warwick, Selvadurai
Nayagam, Apley’s System of Orthopaedics
and Fractures, 9th edition p.798
 Kamal Gbadomasi, Management of hand
injuries and infections, WACS update course
2019
 Peter B. Olaitan, Management of hand
injuries, update course

49. Thank you for
listening