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1. Management Of Acute Hand Injury
Presenter: Dr Nagasa Wirtu (SR-II)
Moderator: Dr Abraham (General
and PRS surgeon)

2. Out line
♦ Anatomy of the Hand
♦ Epidemiology of acute hand injury
♦ Approach to the patient
♦ Management principles
♦ Specific trauma
♦ Summary
♦ Reference
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3. Objectives
♦ Understanding basic anatomy of hand
♦ Knowing how to approach patient with acute hand injury
♦ Getting overview on management of hand bone fractures,
tendon injury and neurovascular damages
♦ When to refer the patient to hand surgeon
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4. Introduction
♦ Hand is one of the most important part of the human body due to
its sensory and mechanical function.
♦ One of the most developed structure in the human evolution. even
adaptable enough to read for the blind and speak for the mute.
♦ Four requirements for a functioning hand: pain free, sensitive,
move with ease and coordinated.
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5. Relevant anatomy
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• Form follows function.

6. Hand skeleton
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♦ 27 bones in total

7. Muscles of the hand
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♦ Both intrinsic and extrinsic

8. Fibrous structure of the hand
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♦ Multiple pulley systems

9. Vascular supply of the hand
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♦ Radial and ulnar arteries

10. Innervations
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♦ Radial, median and ulnar nerves

11. Epidemiology of acute hand injury
♦ Hand injuries are common and account for 5-10% ED visits in US.
♦ Majority are soft tissue injuries; 37%
♦ > 50% are male.
♦ Common age group 18-44.
♦ Occupational hazard are the commonest causes.
♦ Mechanisms: blunt trauma or penetrating injuries.
♦ Structures injured: cutaneous injury, muscle and tendon injury,
neurovascular injury, bone and associated soft tissue injury.
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12. Epidemiology
♦ Mean age 24.5yr
♦ male to female ratio
4:1
♦ Mostly right hand
♦ Home and fall
accident followed by
machine injury
♦ Sampled 178/2yrs
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13. Approach to patient
♦ ABCs
♦ AMPLE
♦ Focused history
♦ Examine the hand & joint(s) proximal
and distal to any injury.
♦ Order appropriate X-rays, select
other imaging studies as needed.
♦ Tetanus prophylaxis and antibiotics if
needed
♦ Definitive management
♦ rehabilitation
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14. Focused history
♦ The most important tool in developing an accurate diagnosis.
♦ Should include:
 Information on the patient’s demographics,(age, occupation )
 Current complaint:
- symptoms of pts.
- time of injury and interval of pt presentation.
- type of injury.
- mechanism of injury.
- any previous trauma or infection.
- hand dominance and activity status
 Medical history: hypertension and diabetics
 Allergies, medications( allergy to food and drug. Pt medication hx.
 Socioeconomic status( alcohol, smoking, infection, HIV/ Heptitis.
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15. Physical examination
Look
Feel
 Tenderness and temperature
 Vascular assessment
 Neurologic assessment
Move
Assessment of musculotendinous function.
 Joint stability taste.
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16. Inspection
 Look for external appearance.
 Compare to the uninjured hand.
 Note the skin (color, swelling,
laceration, abrasion)
 Wounds/exposed tendons.
 Cascade of the fingers.
 Abnormal positioning
 Gross deformities
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17. Vascular examination
♦ Radial artery is found radial to
the FCR
♦ Ulnar artery is found radial
to the FCU
♦ Allen’s test
♦ Capillary refill
♦ Skin T⁰, color & turgor
♦ Atrophic skin changes
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18. Neurologic examination
 Sensory
♦ Check before anesthesia
administration.
♦ Light and sharp touch.
♦ Two point discrimination
(innervations density).
♦ Specific nerve test.
♦ Provocative nerve tests:-
Tinel’s sign, Phalen’s sign
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19. “Quick and simple” nerve exam
Median nerve: Sensation at the tip
of IF ability to make “OK” sign:
Demonstrates FPL, FDP, and OP
Ulnar nerve: Sensation at the tip of
SF; ability to abduct/adduct/cross
fingers. Test AdP
Radial nerve: Sensation dorsal first
web space; give “thumbs up” (EPL)
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20. Assess Muscle/tendon function and ROM
♦ Specific movements are used to
isolate and test the functions of
the specific muscle or tendon
♦ Bone
– Angulation/rotational
deformity
– Pain or instability
– Prominences
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21. Investigations
♦ Plain radiography-
rule of 2
Gilula arc
♦ Ultrasound- fluids, lig &
tendon rupture
♦ CT- bone details
♦ MRI- ST details
♦ Angiography-MRA
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22. Principles of management
♦ The goal of any hand injury intervention must be to obtain:
Structural healing,
Relief of pain, and
Maximization of function.
♦ Rx is directed at the specific structures damaged: skeletal, tendon,
nerve, vessel, and integument.
♦ Reconstructive priorities::
1. Restore circulation 2. Obtain good soft-tissue coverage
3. Align and stabilize the skeleton 4. Restore nerve function
5. Mobilize joints 6. Restore tendon function.
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23. Initial treatment
♦ Control bleeding :- Use sterile compressive dressings and elevation of
the hand.
♦ Avoiding swelling and stiffness: - elevation, splintage and controlled
mobilization.
♦ Analgesics, TAT and antibiotics as required.
♦ Severe soft tissue injuries:- early and adequate debridement is essential, but
appropriate soft tissue coverage must be achieved as soon as possible
thereafter.
♦ In open and contaminated or a severe crushing injury:- best to delay repair
of both tendon and nerve injuries E.g. gunshot wounds.
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24. Anesthesia
• Axillary block
• Wrist block (ulnar, median or
radial block)
• Digital block
• Local infiltration
• Lidocaine/bupivacaine/epine
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25. Tourniquet use
♦ To maintain bloodless fields.
♦ Main factors for tourniquet safety are its
pressure, area of distribution and
duration of application.
♦ BP cuffs make good arm tourniquets in the
ER.
♦ The skin beneath the cuff must be well
padded and kept dry.
♦ When the operation is limited to a finger, a
digital tourniquet can be used..
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♦ Tourniquet pressure should be >125 -
150 mmHg above SBP (usually set
around 230 to 250 mmHg).
♦ Nerves are the most vulnerable to
pressure/hypoxia.
♦ Limit continuous tourniquet time to 2
hours to prevent permanent damage
and minimize patient discomfort from
tourniquet.

26. Incisions of the hand
♦ Preoperation preparations
♦ Should be longitudinal.
♦ Not cross flexion creases:- use zigzag
Bruner incisions or midaxial
incisions of the digits.
♦ Incise long enough to do the job
♦ Work from normal to abnormal, known
to unknown
♦ If it does not look right, it will not work
right
♦ Dorsal incisions may follow longitudinal
straight lines.
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27. Hand splinting
♦ Protected position
 Wrist at 20⁰ extension
 MP joint 70⁰ flexed
 IP joint at 0⁰ degree
 Thumb in palmar
abduction
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28. Management of specific hand injuries

29. Soft tissue injuries
♦ Could be due to blunt trauma (crush
injuries, contusion, abrasion) or
laceration, bites, degloved or avulsion
wounds.
♦ Achieve homeostasis using
tourniquet
♦ Drape and examine to rule out
underline structure injury.
♦ Copious irrigation
♦ Wound care, debridement if needed
♦ Antibiotic
♦ Primarily closure: <8hr and clean
♦ Delayed primary repair: dirty or bites
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30. Finger tip injury
♦ Commonest injury of the hand
– Frequently injured:- 3rd > 4th > 2nd > 1st & 5th finger tip’s
♦ Majority occur in 4 – 30 yrs of age and 3/ 4th in males
♦ In 50% of injury there is minimally displaced DP # with
complex lacerations and no loss of perfusion, this
wound is cleansed, sutured, and splinted in the ED.
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31. Con’t …Finger tip
 Goal of Rx: restore painless,
functional digit with protective
sensation.
 Depend on amount of local
tissue homodigital or
regional flap can be done.
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32. Nail Bed injuries
 Subungual hematoma:
♦ Bleeding under the nail plate after crush injury to the fingertip.
♦ If nail plate is intact and injuries to the nail bed managed with
conservative(<25%) or trephination alone.
♦ In the setting of concomitant disruption of the nail or >50%
hematoma fingernail is removed and lacerations are repaired.
♦ Tuft fractures can be treated non surgically by immobilizing the
finger in a splint for 3 to 4 weeks.
♦ Fixation with K-wire
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33. Finger Phalangeal fracture
♦ Usually result from direct trauma and therefore any part may be
affected( condyle, shaft or base)
♦ Transverse # are usually stable. But oblique or spiral # are unstable.
 Management :
A. Undisplaced # :
- functional splintage (buddy splintage ) for 2-3 wks .
- movement are encouraged from the outset.
B. Displaced fractures of the proximal or the middle phalanx :
• Reduced and immobilized under local anaesthesia, avoiding malrotation.
• Then splinted leaving the other fingers free for 3 wks.
•Open reduction( two K-wires or screw fixation)
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34. Finger Metacarpal Fractures
A. Metacarpal shaft #
– Axial load, torsion, or crush.
– Can be transverse, oblique or
spiral.
– Apex dorsal angulation.
Rx options:
– splinting or casting for 3-4wks.
– Operative mgt.
Operative indications:
– Open #.
– Malrotation.
– Unacceptable angulation.
– Multiple #.
Options:
– Pc pinning.
– IM wire.
– Interfragmentery or plate screw)
– Temporary or Definitive EX-Fix.
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B. Metacarpal Neck Fractures
Boxer’s Fracture:
– Common metacarpal #( 5th neck #)
– Direct impact with closed fist
Treatment
– Closed Reduction (Jahss maneuver)
– Splint- ulnar gutter
– Follow-up within 1 week
 Operative Indications:
– Malrotation and Unacceptable alignment
like pseudoclawing and angulation.
 Options:
– Closed reduction and PC pinning.
– Intramedullary wire or K-wire
C. Metacarpal Base fracture.
– A high energy trauma.
– Can be extra or intra articular.
– Often involve 5th metacarpal.
– Results in T or Y shaped injury.
– Usually require operative treatment.
D. Metacarpal head fracture
– Uncommon
– Associated with collateral lig injury.
– Intra or extra articular.
– Dx: radiograph(Brewerton view)
– Majority of the # require surgical
fixation(>3mm and >25% articular inv.t).

35. Thumb fractures
 Thumb metacarpal fracture
– 2nd next to boxer (30-40%)
– Mostly involve the base of the
thumb(80%).
– Can be extra or intraarticular.
 Bennett fracture
– When a flexed metacarpal receives an
axial load.
– oblique intraarticular fracture at the volar
base of 1st metacarpal.
– metacarpal subluxates proximally,
radially, and dorsally .
– Immob. on thumb spica splint(4-5wks.)
– ORIF
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Rolando’s Fracture
– Comminuted intra articular fracture.
– Less common than Bennett’s Fracture.
– Worse prognosis
 Treatment:
– Closed reduction & K-wire
 Stabilization.
– ORIF
 Complications:
– Mal union and pain

36. Scaphoid fracture
♦ Commonly injured carpal bone(70%).
♦ Tenderness in the anatomic snuff box.
♦ 20% chance of avascular necrosis even
if its not displaced.
♦ Scaphoid view xray.
♦ Thumb spica splint(6wks) or Operative
♦ Reevaluation after 02 weeks is needed
if there is suspicion
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37. Flexor tendon injury
♦ Flexor tendons are divided in to 5
zones
♦ assess of the tenodesis effect /
isolation
♦ Zone 2 is known as no mans land
♦ Best repaired in the OR
♦ They may not need emergent
repair but best repaired with in 7
days but w/n 6wk
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♦ Core sutures:- At least four-strand core
sutures placed 1 cm from the tendon
ends
♦ Epitendinous sutures augment flexor
tendon repair strength
♦ Shortening of a single digit FDP tendon
>1 cm should be avoided to prevent the
quadriga effect
♦ Early protective motion improves the
functional outcome of flexor tendon
repair

38. Extensor tendon injury
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♦ Extrinsic extensors of the digits primarily
mediate metacarpophalangeal (MP) joint
extension.
♦ Have nine zones, odd zones are over joints,
while the even zones are in between
♦ Extensor tendons can be repaired in ER
♦ Acute closed injuries of the digital extensor
system are best treated with splinting in full
extension for 4-6wks.
♦ Open injuries usually require exploration

39. Cont…
 Tendon injury repair:
– >80% of tendon– repair
– 60-80% of tendon may need
epitendinous repair
– <60% of tendon-- conservative
♦ The mainstay of rehabilitation at the
digital level (zones 1–4) remains static
splinting; but early motion in more
proximal injuries (zones 5–8)
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Indications for Primary repair:
– Clean-cut tendon injuries
– Tendon cut with limited peri-
tendinous damage,
– No or limited defects in soft-tissue
coverage.
– Within several days or at most 3 or
4 weeks after tendon laceration.
♦ Mallet fingers/boutonnière
deformity can be treated with
extension splinting of the joints for
6weeks.
♦ dermatotenodesis suture may be
done in open injuries
♦ Post-op day 10 is the most common time
for rupture after primary repair.
♦ Majority of strength back 4 to 6 wks
after repair. Maximum strength at 6
months

40. Nerve injury
 Neuropraxia:
– is a physiologic block of impulse conduction
without anatomic destruction of nerve fibers
– Related with external compression, surgical
traction or local ischemia.
– Complete recovery occur with in days to
months with splinting and conservative mgt
 Axonotmesis:
– refers to injuries in which the axonal fibers are
completely divided but the covering neural
tubes are intact.
 Neurotmesis:
– is the most severe degree of nerve injury and
refers to a complete transection of the nerve.
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♦ Repair timing:-
I. Primary within 24 hrs
II. Delayed primary within 3 wks
III. Secondary after 3 wks
– Primary repair is associated with the best functional recovery.
– Secondary repair :- extensive soft tissue & nerve loss, wound contamination,
presence of multiple limb injury
– Nerves regenerate at a maximal rate of 1 mm per day (1 inch per month).
– The longer the delay the poorer the return of motor function
– and little recovery is expected if nerve repair occurs later than 18 to 24
months post injury.

41. Vascular injury
– Causes: Trauma, iatrogenic injury, fractures or
dislocations and traction injuries
– Control: direct pressure for >10min with dressings.
Tourniquet can be applied. Avoid blind clamping of
vessels.
– Radial/ulnar artery injuries need repair
– vascular compromise requires urgent operative
exploration b/c devascularization without amputation
produces warm ischemia.
– Digital arterial injuries: assess clinically; if no ischemia,
does not need repair (collateral circulation) and also
assess for associated nerve injury.
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42. Amputation and Replantation
♦ Replantation: reattachment of a severed
part of the extremity.
♦ Not all patients with amputation are
candidates for replantation.
♦ Patients are selected based on:
– Amputation factor: type, level, time,
amount…
– Patient factor: age, comorbidity…
– Socioeconomic factor: cost, will…
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 Indication
♦ Multiple digit amputation.
♦ Thumb amputation.
♦ Whole or partial hand amputation.
♦ Any amputation in a child.
♦ Transmetacarpal
 Contraindication
♦ In time of life over limb situations.
♦ Unfit patient.
♦ Multiple segment
♦ Extreme contamination
♦ Prolonged time(warm ischemia >12hr or
cold ischemia > 24hrs in finger)

43. Preparations
♦ Radiograph of both amputated and stump
parts to determine level of injury &
suitability for replantation.
♦ Care for amputated part
♦ Care for the stump
♦ Operation preparation
♦ Till patient resuscitated amputated part
examined in the OR
– Tag NVS with prolene 7-0
♦ Once patient in the OR
– Proximal level exploration
♦ Use Axillary brachial plexus block
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♦ Operation Sequence:-
1. Bone fixation
1. Shortening might be considered
2. Tendon repair ( extensor then flexor)
3. Artery repair
1. Debride beyound zone of injury & explore for
intimal flap
2. Flush with dilute heparin 100IU/ml & see
pulsatile flow
3. Repair all arteries as possible => vein graft
can be used
4. Vein repair – as many as possible
5. Nerve repair – non tension
6. Skin closure – can use SSG
 Postop care
♦ Anticoagulant – lower microvascular thrombosis
♦ Physical & Psychological therapy
 Outcome
♦ 90% survival of replanted part.
♦ Better outcome with sharp amputation.
♦ Studies have demonstrated that patients can
expect to achieve 50% functional & 50%
sensation of replanted part.

44. Mangled hand
♦ “cut to pieces” is injury with
significant loss of tissue and function.
♦ acceptable hand:- stable wrist and
two opposing, sensate, and painless
digits
♦ Mangling injury result in less than
acceptable function of hand.
♦ Decision making:- assess
♦ Repair or reconstruction of tissue.
♦ Communicate the plan to the patient
as suitable to the time.
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♦ Priorities of reconstruction:
– A stable and opposable thumb
(>IPJ).
– At least one, and preferable two
digits with adequate length and
mobility
– Good sensation
– Good skin and soft tissue cover
♦ Initial surgery
– Removal of devitalized tissue
– Removal of contamination
– Restoring good vascularity to
the remaining tissues and
replantation as required
– Haemostasis
– Achieving bony stabilization
– Repair and reconstruction of
other tissues if the situation
is suitable.
♦ Next management:
– Relook and definitive
reconstruction- within 24-72hrs
– Skin and soft tissue cover- flaps
– Nerve and tendon repair – when
the wound is good
– Early physiotherapy
– prosthesis

45. Summary
♦ Knowledge of anatomy is very important in managing
hand injury
♦ Examination of the hand and x-ray play key role in
diagnosis
♦ Management should be specific to the type of injury with a
goal of restorating a painless, functional digit with
protective sensation.
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46. References
♦ Green’s operative hand surgery 8th ed
♦ Frank H. Netter: Atlas of Human Anatomy
♦ Grabb and Smith’s : Plastic surgery, 8th ed;
♦ Keneth J. koval’s Hand book of fracture,3rd ed; 2006
♦ Schwartz’s: principles of surgery,11th ed.
♦ Online uptodate
♦ google
♦ Survival after Digit Replantation and Revascularization Is Not Affected by the
Use of Interpositional Grafts during Arterial Repair - PubMed (nih.gov)
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47. Thank you!
Comments, suggestions or questions are
welcomed.