RVHEM, profile picture
Uploaded byRVHEM
PDF, PPTX3,667 views

Hand injuries by Hilary Lee

1) Hand injuries account for 30-40% of all trauma visits and involve a highly functional body part with superficial tissues. 2) The document discusses the evaluation, management, and treatment of various common hand injuries including lacerations, fractures, dislocations and special considerations for different fingers. 3) Key physical exam maneuvers and imaging modalities are outlined to properly assess hand injuries. The document also provides guidance on splinting, referral indications, and when hand surgeon consultation is necessary.

Embed presentation

Download as PDF, PPTX
Hand Injuries Hilary Lee R2 EM May 24, 2015 Hilary Lee 2015
Overview • Review relevant anatomy • Physical exam maneuvers • Lacerations • Fractures • Dislocations • Special fingers • Crush, injection injuries Hilary Lee 2015
Objectives • Perform an appropriate evaluation of a hand injury • Know when to consult a hand surgeon immediately and with delay • Be familiar with the management of common hand trauma complaints Hilary Lee 2015
Hand Injuries • 30-40% of all trauma visits (major and minor) involve a significant hand complaint • Highly functional body part with multiple superficial tissues • Loss of productivity - 3rd highest reason for missed work days Hilary Lee 2015
Immediate/Prehospital Care • Control bleeding • Pressure, elevation • Tourniquet • Remove jewelry • Splint deformities • Preserve amputations • Cooling procedures Hilary Lee 2015
History • SAMPLE hx • Pain, ROM, function, strength, paralysis, numbness/ tingling, cold fingers, timeline, tetanus • Handedness, occupation • Prior injuries/surgeries • Immunocompromise, smoking, DM Hilary Lee 2015
Physical Inspection • Deformity, bleeding, rotation, amputations, avulsions, holding of limb • Skin integrity - lacerations, edema, scars • Fist and open Palpation • Tenderness, crepitus, AROM, PROM Ligaments, tendons • Varus/valgus stress (DIP, PIP, MCP) • Explore wound for tendinous injury Vascular • Warmth, colour, cap refill • Explore wounds for vascular injury (+/- tourniquet) Neurological • Ulnar, median, radial
 Hilary Lee 2015
Sensory 46% have crossover between median and ulnar nerves Hilary Lee 2015
Motor Hilary Lee 2015
Tendons Emergency Medicine Practice © 2011 6 ebmedicine.net • June 2011 ligaments, tendons, muscles, and nerves. Magnetic resonance angiography (MRA) can be used to evaluate vascular structures. Ultrasonography In the hands of a skilled operator, ultrasound can be used to visualize soft tissue structures. The small structures of the hand are, however, difficult to scan and usually require high-frequency linear probes and an experienced ultrasonographer. ogy’s published guidelines, any clinically suspected fracture or dislocation in the hand should be evalu- ated with at least posteroanterior and lateral views, and an oblique view should be strongly considered.6 Conventional radiography can also be used to evaluate lacerations that are suspected to contain a retained foreign body. The current gold standard for detecting radio-opaque materials (such as glass and metal) is careful scrutiny of multi-view x-rays.10,11 Clinicians must keep in mind that some materials Figure 3. Physical Examination Of Hand Tendons A, Extensor digitorum. B, Flexor digitorum superficialis. C, Flexor digitorum profundus. Used with permission of Aaron Andrade, MD. A B C Extensor digitorum Flexor digitorum superficialis Flexor digitorum profundus Hilary Lee 2015
Imaging • X ray • AP, lateral, oblique • CT • Ultrasound Hilary Lee 2015
Regional Anesthesia • Digital block • Disinfect • Volar approach • In skin crease • Pinch finger • Hit bone • Back 1-2mm • Inject 2-3cc Skin Lacerations After hemostasis is achieved and appropriate local or regional anesthesia provided, all skin lacerations Figure 4. The Volar Single-Injection Method For Digital Nerve Anesthesia Note the injection site is at the volar MCP skin crease and the clinician is lightly pinching the digit. A 25-gauge needle should be advanced until it hits bone, backed up 1-2 mm, and 2-3 cc of anesthetic in- jected. Used with permission of Aaron Andrade, MD. Hilary Lee 2015
Regional Anesthesia • Local infiltration • Forearm nerve blocks - ultrasound guided Emergency Medicine Practice © 2011 8 ebmedicine.net • June 2011 usually heal by secondary intention if less than 1 cm in diameter. If there is a small amount of exposed bone, the bone can be trimmed back in the ED with a rongeur until it is underneath the surrounding soft tissue and allowed to heal by secondary intention. Follow-up with a hand surgeon is advised. Imme- diate consultation of a hand surgeon is required in cases of wounds larger than 1 cm in diameter, per- sistently exposed bone, or amputation of the volar pad.33 Additionally, surgeons subclassify fingertip injuries into zones I, II, and III. (See Figure 7.) Zone I injuries are managed conservatively as described above. Zone II injuries may require rongeuring of ex- posed bone. Zone III injuries generally require distal phalanx amputation and warrant follow-up with a hand specialist.34 Fractures Perhaps the most important job of an emergency clinician in hand fractures is proper reduction and severe crush injuries with large losses of soft tissue. Intra-articular fractures require thorough examination to rule out associated tendon avulsions and should always be evaluated by a hand specialist.23 Subungual Hematoma/Nail Bed Lacerations In crush injuries of the finger, nail bed lacerations causing subungual hematomas are common. They are characterized by throbbing pain and purple discoloration under the nail. Two management strategies are commonly used in the ED: removal of the nail, with direct repair of nail bed laceration; and nail trephination with a heated paperclip, a cautery device, or a twirled 18-g needle. A review of the classic literature yields a long-standing debate about which management strategy is superior. The commonly taught “consensus” is that nail bed repair should be considered for subungual hematomas covering greater than 25% to 50% of the nail bed.25-30 However, a 1999 prospective study in children dem- Figure 5. Ultrasound Visualization Of Nerves And Arteries In The Forearm Ulnar, medial, and radial nerves are shown by the arrow across the bottom of the images. Arrowheads show arteries, A (ulnar), B (medial), and C (radial). Liebmann O, Price D, Mills C et al. Ann Emerg Med. 2006;48(5)558-562. Used with permission of Mosby, Inc. A B C Hilary Lee 2015
Lidocaine +/- Epinephrine • Digital ischemia secondary to epinephrine in nerve block extremely rare • 17 cases worldwide • Multiple large safety studies over last 10 years • Phentolamine -> injectable antidote • Epinephrine improves anesthesia, decreases bleeding, decreases systemic anesthetic absorption Hilary Lee 2015
Lidocaine +/- Epinephrine • Digital ischemia secondary to epinephrine in nerve block extremely rare • 17 cases worldwide • Multiple large safety studies over last 10 years • Phentolamine -> injectable antidote • Epinephrine improves anesthesia, decreases bleeding, decreases systemic anesthetic absorption Hilary Lee 2015
Lidocaine +/- Epinephrine • Digital ischemia secondary to epinephrine in nerve block extremely rare • 17 cases worldwide • Multiple large safety studies over last 10 years • Phentolamine -> injectable antidote • Epinephrine improves anesthesia, decreases bleeding, decreases systemic anesthetic absorption Hilary Lee 2015
Lidocaine +/- Epinephrine • Digital ischemia secondary to epinephrine in nerve block extremely rare • 17 cases worldwide • Multiple large safety studies over last 10 years • Phentolamine -> injectable antidote • Epinephrine improves anesthesia, decreases bleeding, decreases systemic anesthetic absorption Hilary Lee 2015
Lidocaine +/- Epinephrine • Digital ischemia secondary to epinephrine in nerve block extremely rare • 17 cases worldwide • Multiple large safety studies over last 10 years • Phentolamine -> injectable antidote • Epinephrine improves anesthesia, decreases bleeding, decreases systemic anesthetic absorption Hilary Lee 2015
Lacerations Hilary Lee 2015
Lacerations • Hemostasis • Local anesthesia • Exploration • Irrigation Hilary Lee 2015
Primary Closure • Noncontaminated wounds - within 12 hours? • Delayed primary closure • Contaminated wounds • Irrigate • Pack • Reinspect after 3-5 days Hilary Lee 2015
Primary Closure • Nonabsorbable vs absorbable • Monofilament • Simple interrupted • 10-14 days (14-21 days palmar) Hilary Lee 2015
Distal Phalanx be splinted and fractures and th ceive immediat Figure 6. Radiograph Demonstrating Phalanx Fractures Left arrow notes a tuft fracture of digit IV. Right arrow notes a shaft Figure 7. Zon Zone I Zone I Hilary Lee 2015
Distal Phalanx • Fractures • Tuft • Shaft • Intraarticular Hilary Lee 2015
Distal Phalanx • Fractures • Tuft • Shaft • Intraarticular Reduce and repair soft tissues prn Splint in extension Hilary Lee 2015
Distal Phalanx • Fractures • Tuft • Shaft • Intraarticular Reduce and repair soft tissues prn Splint in extension Carefully assess tendons, +/- hand surgeon Hilary Lee 2015
Distal Phalanx • Amputations • Zone I - secondary intention • Zone II - file down bone, secondary intention, follow up • Zone III - distal phalanx amputation, immediate consult 9 Emergency Medicine Practice © 2011June 2011 • ebmedicine.net than 3 mm of digit length loss, and no rotational deformity.35 All metacarpal shaft fractures should be splinted and referred to a hand surgeon. Open fractures and those that fail reduction should re- ceive immediate surgical consultation.35 to the adjacent finger to promote early mobilization and reduce stiffness. (See Figure 9, page 10.) Figure 6. Radiograph Demonstrating Phalanx Fractures Left arrow notes a tuft fracture of digit IV. Right arrow notes a shaft fracture of the distal phalanx of digit III. Used with permission of John D. Lubahn, MD. Figure 7. Zones Of Fingertip Amputation © 2001. Renee L. Cannon. Used with permission. Zone I II III Zone I II IIIHilary Lee 2015
Nail • Subungual hematoma • Trephination • Nail removal and nail bed repair • Nail fold preservation Hilary Lee 2015
Proximal/Middle Phalanx • Require precise alignment • Stable, nondisplaced • Buddy tape • Oblique, angulated, malrotated • Digital block / hematoma block • Reduction • Post-reduction film • Splint in extension Hilary Lee 2015
Proximal/Middle Phalanx • Require precise alignment • Stable, nondisplaced • Buddy tape • Oblique, angulated, malrotated • Digital block / hematoma block • Reduction • Post-reduction film • Splint in extension Repeat if not properly aligned Hilary Lee 2015
Proximal/Middle Phalanx Middle and proximal phalangeal fractures are classified according to whether they involve the joint surface. Extraarticular Fractures Extraarticular fractures affect the part of the bone that is not involved with the joint surface. The main concern is whether a rotational deformity is present when the patient attempts to bend the fingers. See chapter 26, “Normal Hand Exam,” for discussion of rotational finger alignment. Any malrotation associated with metacarpal or phalangeal fractures must be corrected. Left, Normally all fingers point toward the region of the scaphoid when a fist is made. Right, Malrotation at the fracture site causes the affected finger to deviate. (From Crenshaw AH (ed): Campbell’s Operative Orthopaedics, 7th ed. St. Louis, Mosby, 1987, with permission.) Hilary Lee 2015
Proximal/Middle Phalanx consist of closed reduction (Bennett fracture only),ting Figure 9. “Buddy-Taping” An Injured Finger Hilary Lee 2015
Proximal/Middle Phalanx • Refer immediately if: • Open • Unsuccessful reduction • Malrotation • Intraarticular >30% joint surface Hilary Lee 2015
Proximal/Middle Phalanx Hilary Lee 2015
Fractures • Safe position / intrinsic plus rates of anxiety, borderline per antisocial personality disorder with boxer’s fractures should evaluation psychiatric questio vention strategies. Thumb Metacarpal Fractures: Fractures Fractures of the first metacarp than those of the remaining m be subdivided into extra-articu fractures. Extra-articular fractu conservative management prin carpal fractures, namely, close angulation goal of less than 20 thumb spica splinting for 4 we are unstable and require prom hand surgeon.43 Intra-articular fractures of involve the CMC joint and gen an axial injury to a partially fle Bennett fracture is an intra-art dislocation; a Rolando fracture intra-articular fracture.44 (See debate exists regarding the spe correction each fracture requir ture supports that emergency consist of closed reduction (Be surgical clinic follow-up. Unstable fractures of the II and III metacarpals generally require immediate consultation by a hand surgeon for surgical correc- tion. Unstable fractures in the IV and/or V meta- carpals, also known as a boxer’s fracture, can be reduced in the ED after adequate anesthesia. In the author’s experience, a forearm ulnar nerve block in conjunction with a hematoma block using 1% lido- caine without epinephrine provides excellent results. Reduction is achieved by traction decompression followed by the “90-90 method.” (See Figure 10.) The MCP, PIP, and DIP joints are flexed at 90° and volar-ward pressure is applied to the dorsum of the metacarpal shaft. An ulnar gutter splint should be applied with prompt clinic follow-up within 1 week. Much controversy exists in the literature regard- ing the goal of boxer’s fracture reduction. Classic literature supports acceptable angulation between 20° and 70°.37 More-recent studies are incongruent. A 1999 cadaveric study concluded that angulation greater than 30° resulted in measurable functional impairment.38 Two more recent prospective stud- ies, however, found good outcomes with 1 week of soft wrap followed by immediate buddy-wrapping Figure 8. The “Intrinsic Plus” Splinting Position Used with permission of Aaron Andrade, MD. Figure 9. “Buddy-Taping” Used with permission of Aaron Andrade, Hilary Lee 2015
Metacarpal Fractures Hilary Lee 2015
Metacarpal Fractures • Base or head • Rare • Volar splint and consultation • Shaft • Common • Reducible in ED Hilary Lee 2015
Metacarpal Shaft Fractures • Local anesthesia • Regional block • Hematoma block • Reduction goals • <10 degrees • <20 degrees • <3mm impaction • No rotation Hilary Lee 2015
Metacarpal Shaft Fractures • Splint (ulnar or radial gutter) • Refer Hilary Lee 2015
Metacarpal Neck Fracture • Nondisplaced, nonangulated • Gutter splint - immobilize CMP and MCP • Refer in 3-4 weeks • Unstable, MCP 2 or 3 • Immediate consultation for OR Hilary Lee 2015
Fractures Hilary Lee 2015
Fractures Hilary Lee 2015
Boxer’s Fracture • 5th (or 4th) metacarpal neck • Volar angulation of distal segment • Inexperienced punch -> axial load • >95% young adult males Hilary Lee 2015
Boxer’s Fracture • Local anesthesia • Hematoma block plus ulnar nerve block • Traction decompression • 90 / 90 method • Volar pressure to dorsum • Ulnar gutter splint, refer • 20-70 degrees angulation accepted 11June 2011 • ebmedicine.net sor tendon insertion into the distal phalanx, usually caused by forced flexion of the DIP joint. It is so named because the flexed DIP cannot be extended and looks like a mallet. The injury can sometimes be associated with an avulsion fracture of the dorsal base of the distal phalanx. The classic strategy for treating closed mallet finger injuries with less than one-third of the joint surface disrupted is continuous splinting of the DIP joint in full extension to hyper- Figure 10. The “90-90” Method Used with permission of Aaron Andrade, MD. From wit Fig Hy Use Hilary Lee 2015
Thumb Metacarpal Fractures • Less common • Extraarticular • Closed reduction • Goal 20-30 degrees angulation • Thumb spica splint x 4 weeks Hilary Lee 2015
Thumb Metacarpal Fractures Intraarticular Hilary Lee 2015
Thumb Metacarpal Fractures Bennett fracture • Intraarticular fracture / dislocation of 1st MCP • Fragment continues to articulate • Axial load on flexed digit • ORIF if >3mm displacement • Closed reduction, refer Hilary Lee 2015
Thumb Metacarpal Fractures • Rolando fracture • Comminuted intraairticular 1st metacarpal fracture with dislocation • Unstable, requires ORIF Hilary Lee 2015
Tendon Injuries • Laceration, crush, hyperflexion, hyperextension • XR - r/o associated avulsion or # • Closed tendon injuries - splint, close follow up • Open tendon injuries…. Hilary Lee 2015
Tendon Injuries • Laceration, crush, hyperflexion, hyperextension • XR - r/o associated avulsion or # • Closed tendon injuries - splint, close follow up • Open tendon injuries…. Hilary Lee 2015
Tendon Injuries • Laceration, crush, hyperflexion, hyperextension • XR - r/o associated avulsion or # • Closed tendon injuries - splint, close follow up • Open tendon injuries…. Hilary Lee 2015
Tendon Injuries • Laceration, crush, hyperflexion, hyperextension • XR - r/o associated avulsion or # • Closed tendon injuries - splint, close follow up • Open tendon injuries…. Hilary Lee 2015
Tendon Injuries • Extensor • Generally reparable in ED • Few associated structures • Flexor • Wound closure and referral • Many associated structures, evaluate carefully for nerve or vascular injury Hilary Lee 2015
Tendon Injuries • Extensor • Generally reparable in ED • Few associated structures • Flexor • Wound closure and referral • Many associated structures, evaluate carefully for nerve or vascular injury Hilary Lee 2015
Mallet Finger Hilary Lee 2015
Mallet Finger Hilary Lee 2015
Mallet Finger • Hyperflexion injury at DIP • Extensor digitorum tear +/- avulsion # dorsal base distal phalanx • Splint DIP in hyperextension for 6 weeks, refer • Do not splint DIP • If open or >30% articular surface avulsed, ORIF Hilary Lee 2015
Mallet Finger • Hyperflexion injury at DIP • Extensor digitorum tear +/- avulsion # dorsal base distal phalanx • Splint DIP in hyperextension for 6 weeks, refer • Do not splint PIP • If open or >30% articular surface avulsed, ORIF Hilary Lee 2015
Jersey Finger • Extension against resistance injury • Flexor digitorum profundus tear • Named after jersey tugging at a sports match…. Hilary Lee 2015
Jersey Finger Hilary Lee 2015
Jersey Finger • Isolated or plus avulsion fracture • Immediate consultation for surgical intervention Hilary Lee 2015
Hilary Lee 2015
Hilary Lee 2015
Fight Bite • Laceration to MCP • High rate of associated tendon, joint or bone injury - 75% • Clenched fist mechanism - with relaxation, oral bacteria on extensor tendon sheath track back Hilary Lee 2015
Fight Bite • Aggressive early management • XR r/o foreign body or fracture • Irrigate, elevate, immobilize • Early surgical consultation Hilary Lee 2015
Fight Bite • Polymicrobial • alpha-hemolytic streptococcus (s viridans) • staphylococcus aureus • eikonella corrodens (25%) • gram negatives, anaerobes • If joint or tendon sheath involved • Admit for IV antibiotics (ampicillin/sulbactam, cefoxitin, carbapenem) • OR for I&D • PO amox-clav at discharge for 5-7 days • Complications: osteomyelitis, tenosynovitis, septic arthritis Hilary Lee 2015
Fight Bite • Polymicrobial • alpha-hemolytic streptococcus (s viridans) • staphylococcus aureus • eikonella corrodens (25%) • gram negatives, anaerobes • If joint or tendon sheath involved • Admit for IV antibiotics (ampicillin/sulbactam, cefoxitin, carbapenem) • OR for I&D • PO amox-clav at discharge for 5-7 days • Complications: osteomyelitis, tenosynovitis, septic arthritis Hilary Lee 2015
Fight Bite • Polymicrobial • alpha-hemolytic streptococcus (s viridans) • staphylococcus aureus • eikonella corrodens (25%) • gram negatives, anaerobes • If joint or tendon sheath involved • Admit for IV antibiotics (ampicillin/sulbactam, cefoxitin, carbapenem) • OR for I&D • PO amox-clav at discharge for 5-7 days • Complications: osteomyelitis, tenosynovitis, septic arthritis Hilary Lee 2015
Hilary Lee 2015
Dislocations/Subluxations • Closed reduction with local anesthesia • XR r/o avulsion #, confirm post-reduction alignment • Avulsion >30% articular surface = immediate consult • Splint in slight flexion x 2-3 weeks • Consultation as outpatient Hilary Lee 2015
Hilary Lee 2015
Skiier’s/Gamekeeper’s Thumb • Ulnar collateral ligament tear • Forceful radial deviation of the thumb • Pain, swelling on ulnar aspect of 1st MCP joint • Valgus stress / radial deviation on 1st MCP with thumb fully extended and in 30 degrees flexion • Distal deviation >35 degrees or 15 degrees more than unaffected thumb = complete tear Hilary Lee 2015
Skiier’s/Gamekeeper’s Thumb • Ulnar collateral ligament tear • Forceful radial deviation of the thumb • Pain, swelling on ulnar aspect of 1st MCP joint • Valgus stress / radial deviation on 1st MCP with thumb fully extended and in 30 degrees flexion • Distal deviation >35 degrees or 15 degrees more than unaffected thumb = complete tear Hilary Lee 2015
d place CP in 30° greater umb is mplete ner omes Figure 15. Valgus Stress Testing Of The First MCP Joint Ulnar deviation by greater than 35° or 15° more than the unaffected side is diagnostic of a complete UCL rupture. From Rhee S, Cobiella C. Trauma. 2007;9:163-170, copyright © 2007ateral bands Hilary Lee 2015
Skiier’s/Gamekeeper’s Thumb • High incidence of Stener lesion (adductor pollicis aponeurosis sticks between ends of UCL) -> poor healing • Consult, requires ORIF within 3 weeks • Partial tear -> thumb spica x 4 weeks, outpatient follow up Hilary Lee 2015
Vascular Injuries • Rarely causing significant morbidity -> ulnar and radial collaterals • Direct pressure, tourniquet • Distal ischemia -> immediate consultation • Doppler u/s, pulse oximetry Hilary Lee 2015
Nerve Injuries • Splint to prevent further damage • Closed -> likely neurapraxia or axonotmesis • Endoneurium intact, will spontaneously regenerate • Outpatient referral for repeat physical exams • Open -> likely severed • Without endoneurium, regeneration not possible • Immediate referral for repair Hilary Lee 2015
Nerve Injuries • Splint to prevent further damage • Closed -> likely neurapraxia or axonotmesis • Endoneurium intact, will spontaneously regenerate • Outpatient referral for repeat physical exams • Open -> likely severed • Without endoneurium, regeneration not possible • Immediate referral for repair Hilary Lee 2015
High Pressure Injection • Nondominant hand of industrial workers • Paint, oil, water, air, solvents, metal, cement • Cannot estimate tissue damage with superficial signs or imaging • High risk of infection, vascular compromise, amputation • Immediate consultation for debridement • Splint, elevate, pain control, broad spectrum abx • Nerve blocks contraindicated Hilary Lee 2015
High Pressure Injection • Nondominant hand of industrial workers • Paint, oil, water, air, solvents, metal, cement • Cannot estimate tissue damage with superficial signs or imaging • High risk of infection, vascular compromise, amputation • Immediate consultation for debridement • Splint, elevate, pain control, broad spectrum abx • Nerve blocks contraindicated Hilary Lee 2015
Amputations • Wrap amputated part in saline-moistened gauze, place in sealed plastic bag, in insulated container with sealed bag of ice • Proper cooling -> viable for 12-24 hrs • Control hemorrhage, pain • Immediate consultation Hilary Lee 2015
Compartment Syndrome • Rare • Difficult to identify, 10 compartments in the hand • Pain -> parasthesias -> paresis -> pallor -> pulselessness • Suspect if… • Crush • Circumferential burn with eschar • Pain out of proportion or rapidly increasing • Palpably tense tissues • Nerve/vascular injuries • Immediate consultation, limb elevation, removal of constricting materials Hilary Lee 2015
Summary • Impossible • Extensive, highly specific knowledge that is not generalizable • If in doubt, discuss case with a hand surgeon for appropriate guidance • Always manage pain, provide immobilization, thoroughly investigate functional components • Practice defensively - hands are the most occupationally significant limb and disability will have lasting consequences Hilary Lee 2015
Hilary Lee 2015

More Related Content

PPTX
Acute hand injury management
byZelalem Semegnew
 
PPT
Hand Trauma
byAhmed Shammasi
 
PPTX
Hand injury
bySalihi Abdulmalik
 
PPTX
Hand trauma - soft tissue injuries overview ,principles of management
byKamil PrasadAbeyratne
 
PPTX
Hand and facial injuries
byHossam Elkafrawi
 
PPTX
Hand injuries by Dr.SUNIL C
bySunil Chandrashekar
 
PPTX
Hand injury
byHossam Elkafrawi
 
PPTX
Hand injuries
byAbdul Rahim Shaan
 
Acute hand injury management
byZelalem Semegnew
 
Hand Trauma
byAhmed Shammasi
 
Hand injury
bySalihi Abdulmalik
 
Hand trauma - soft tissue injuries overview ,principles of management
byKamil PrasadAbeyratne
 
Hand and facial injuries
byHossam Elkafrawi
 
Hand injuries by Dr.SUNIL C
bySunil Chandrashekar
 
Hand injury
byHossam Elkafrawi
 
Hand injuries
byAbdul Rahim Shaan
 

What's hot

PPTX
Management of hand injuries
byRuhama Imana
 
PPT
Hand Injuries Overview- Surgery
byChukwuma-Ikem Okoye
 
PPTX
Distal phalanx fracture
byNaranjargalan Nyamsuren
 
PPTX
Hand injury assessment
bySCGH ED CME
 
PPSX
Hand injuries
bymelbourneshouldersurgeon
 
PPTX
Common hand injuries
bytbf413
 
PPTX
Hand Injuries & Their Managements
byRobert G. Mulbah
 
PPTX
Tendon injuries of hand by Dr Saumya Agarwal
byCentral Institute of Orthopaedics, Safdarjang Hospital and VMMC, New Delhi
 
PDF
Hand injuries (compiled by Dr. Sanjib Kumar Das)
byDr Sanjib Kumar Das
 
PPTX
Crush injuries of hand
byDr. Monsur Rahman
 
PPTX
Hand injuries
byHumanitarian Healthcare field
 
PPTX
Tendon injuries of hand
byVivek Mathew Philip
 
PPTX
Trigger finger - adult and congenital
byYeshwanth Nandimandalam
 
PPTX
Extensor tendon injuries hand
byNousfierNuchu
 
PPTX
Hand injuries
byUtkarsh Shahi
 
PPTX
Mallet finger
bySantosh Batajoo
 
PPTX
Trigger finger/ Stenosing tenosynovitis
byDr. Zunaira Ahmad
 
PPTX
Flexor tendon injuries slideshare
byDr Ajay Shah IOM TUTH Nepal
 
PPTX
Management of hand injuries &amp;
byMakafui Yigah
 
PPTX
Hand rehabilitation following flexor tendon injuries
byAbey P Rajan
 
Management of hand injuries
byRuhama Imana
 
Hand Injuries Overview- Surgery
byChukwuma-Ikem Okoye
 
Distal phalanx fracture
byNaranjargalan Nyamsuren
 
Hand injury assessment
bySCGH ED CME
 
Hand injuries
bymelbourneshouldersurgeon
 
Common hand injuries
bytbf413
 
Hand Injuries & Their Managements
byRobert G. Mulbah
 
Tendon injuries of hand by Dr Saumya Agarwal
byCentral Institute of Orthopaedics, Safdarjang Hospital and VMMC, New Delhi
 
Hand injuries (compiled by Dr. Sanjib Kumar Das)
byDr Sanjib Kumar Das
 
Crush injuries of hand
byDr. Monsur Rahman
 
Hand injuries
byHumanitarian Healthcare field
 
Tendon injuries of hand
byVivek Mathew Philip
 
Trigger finger - adult and congenital
byYeshwanth Nandimandalam
 
Extensor tendon injuries hand
byNousfierNuchu
 
Hand injuries
byUtkarsh Shahi
 
Mallet finger
bySantosh Batajoo
 
Trigger finger/ Stenosing tenosynovitis
byDr. Zunaira Ahmad
 
Flexor tendon injuries slideshare
byDr Ajay Shah IOM TUTH Nepal
 
Management of hand injuries &amp;
byMakafui Yigah
 
Hand rehabilitation following flexor tendon injuries
byAbey P Rajan
 

Similar to Hand injuries by Hilary Lee

PPTX
Acute Hand injury powerpoint presentation .pptx
byKumudLohbariya
 
PPTX
4. Hand Injury Manageme bbbbnt 2021.pptx
bymekuriatadesse
 
PPTX
4. Hand Injury Management 2gggggg021.pptx
bymekuriatadesse
 
PPTX
Presentation on Wound Management_06 .pptx
byhiem6thbatch
 
PPTX
HandTrauma-1_0.pptx
byCharitheLakshitheCha
 
PPTX
"Comprehensive Management of Hand Injuries: Approach, Treatment, and Rehabili...
byDr Bodhisatwa Choudhuri
 
PDF
hand injuries ,.......................pdf
byyekatitintern36
 
PPTX
Hand injueirs.pptx
bySingh99882
 
PDF
Hand Soft Tissue Injuries
byluantran92
 
PPTX
Principles of Acute Care of Hand injuries.pptx
byM. Taqi Ehsani
 
PPTX
Dr. Haley Dusek’s CMC Pediatric Orthopedic X-Ray Mastery Project: #6 Presenta...
bySean M. Fox
 
PPTX
WOUND MANAGEMENT.pptx, wound care, aseptic technique
byarpitaurukuzhil
 
PDF
1320221012Wrist and Hand--chapter 39.pdf
bySachiVerma3
 
PPTX
Bennett , rolando , tendon injuries
bySagar Savsani
 
PDF
GEMC: A Potpourri of Wound Care Issues: Resident Training
byOpen.Michigan
 
PPTX
Emergency Wound Management
bySubhankar Paul
 
PPTX
Finger tip injury
byAbdulla Kamal
 
PPT
Unit c musculoskeletal_chpt_46 part i voice and no underline (1)
bymfairch
 
PPTX
Plastic Surgery Emergencies for ER residents
byBrSandeep
 
PPTX
Upper limb trauma part 2
byabdullah alzahrani
 
Acute Hand injury powerpoint presentation .pptx
byKumudLohbariya
 
4. Hand Injury Manageme bbbbnt 2021.pptx
bymekuriatadesse
 
4. Hand Injury Management 2gggggg021.pptx
bymekuriatadesse
 
Presentation on Wound Management_06 .pptx
byhiem6thbatch
 
HandTrauma-1_0.pptx
byCharitheLakshitheCha
 
"Comprehensive Management of Hand Injuries: Approach, Treatment, and Rehabili...
byDr Bodhisatwa Choudhuri
 
hand injuries ,.......................pdf
byyekatitintern36
 
Hand injueirs.pptx
bySingh99882
 
Hand Soft Tissue Injuries
byluantran92
 
Principles of Acute Care of Hand injuries.pptx
byM. Taqi Ehsani
 
Dr. Haley Dusek’s CMC Pediatric Orthopedic X-Ray Mastery Project: #6 Presenta...
bySean M. Fox
 
WOUND MANAGEMENT.pptx, wound care, aseptic technique
byarpitaurukuzhil
 
1320221012Wrist and Hand--chapter 39.pdf
bySachiVerma3
 
Bennett , rolando , tendon injuries
bySagar Savsani
 
GEMC: A Potpourri of Wound Care Issues: Resident Training
byOpen.Michigan
 
Emergency Wound Management
bySubhankar Paul
 
Finger tip injury
byAbdulla Kamal
 
Unit c musculoskeletal_chpt_46 part i voice and no underline (1)
bymfairch
 
Plastic Surgery Emergencies for ER residents
byBrSandeep
 
Upper limb trauma part 2
byabdullah alzahrani
 

More from RVHEM

PPTX
Endocrine emergency cases
byRVHEM
 
PPTX
Hip pain
byRVHEM
 
DOCX
GI emergencies questions only
byRVHEM
 
PDF
Asthma lecture google slides
byRVHEM
 
PPTX
The red and painful eye
byRVHEM
 
DOCX
Electrolyte emergencies cases (C. Meyers)
byRVHEM
 
Endocrine emergency cases
byRVHEM
 
Hip pain
byRVHEM
 
GI emergencies questions only
byRVHEM
 
Asthma lecture google slides
byRVHEM
 
The red and painful eye
byRVHEM
 
Electrolyte emergencies cases (C. Meyers)
byRVHEM
 

Hand injuries by Hilary Lee

  • 1.
    Hand Injuries Hilary LeeR2 EM May 24, 2015 Hilary Lee 2015
  • 2.
    Overview • Review relevantanatomy • Physical exam maneuvers • Lacerations • Fractures • Dislocations • Special fingers • Crush, injection injuries Hilary Lee 2015
  • 3.
    Objectives • Perform anappropriate evaluation of a hand injury • Know when to consult a hand surgeon immediately and with delay • Be familiar with the management of common hand trauma complaints Hilary Lee 2015
  • 4.
    Hand Injuries • 30-40%of all trauma visits (major and minor) involve a significant hand complaint • Highly functional body part with multiple superficial tissues • Loss of productivity - 3rd highest reason for missed work days Hilary Lee 2015
  • 5.
    Immediate/Prehospital Care • Controlbleeding • Pressure, elevation • Tourniquet • Remove jewelry • Splint deformities • Preserve amputations • Cooling procedures Hilary Lee 2015
  • 6.
    History • SAMPLE hx •Pain, ROM, function, strength, paralysis, numbness/ tingling, cold fingers, timeline, tetanus • Handedness, occupation • Prior injuries/surgeries • Immunocompromise, smoking, DM Hilary Lee 2015
  • 7.
    Physical Inspection • Deformity, bleeding,rotation, amputations, avulsions, holding of limb • Skin integrity - lacerations, edema, scars • Fist and open Palpation • Tenderness, crepitus, AROM, PROM Ligaments, tendons • Varus/valgus stress (DIP, PIP, MCP) • Explore wound for tendinous injury Vascular • Warmth, colour, cap refill • Explore wounds for vascular injury (+/- tourniquet) Neurological • Ulnar, median, radial
 Hilary Lee 2015
  • 8.
    Sensory 46% have crossoverbetween median and ulnar nerves Hilary Lee 2015
  • 9.
  • 10.
    Tendons Emergency Medicine Practice© 2011 6 ebmedicine.net • June 2011 ligaments, tendons, muscles, and nerves. Magnetic resonance angiography (MRA) can be used to evaluate vascular structures. Ultrasonography In the hands of a skilled operator, ultrasound can be used to visualize soft tissue structures. The small structures of the hand are, however, difficult to scan and usually require high-frequency linear probes and an experienced ultrasonographer. ogy’s published guidelines, any clinically suspected fracture or dislocation in the hand should be evalu- ated with at least posteroanterior and lateral views, and an oblique view should be strongly considered.6 Conventional radiography can also be used to evaluate lacerations that are suspected to contain a retained foreign body. The current gold standard for detecting radio-opaque materials (such as glass and metal) is careful scrutiny of multi-view x-rays.10,11 Clinicians must keep in mind that some materials Figure 3. Physical Examination Of Hand Tendons A, Extensor digitorum. B, Flexor digitorum superficialis. C, Flexor digitorum profundus. Used with permission of Aaron Andrade, MD. A B C Extensor digitorum Flexor digitorum superficialis Flexor digitorum profundus Hilary Lee 2015
  • 11.
    Imaging • X ray •AP, lateral, oblique • CT • Ultrasound Hilary Lee 2015
  • 12.
    Regional Anesthesia • Digitalblock • Disinfect • Volar approach • In skin crease • Pinch finger • Hit bone • Back 1-2mm • Inject 2-3cc Skin Lacerations After hemostasis is achieved and appropriate local or regional anesthesia provided, all skin lacerations Figure 4. The Volar Single-Injection Method For Digital Nerve Anesthesia Note the injection site is at the volar MCP skin crease and the clinician is lightly pinching the digit. A 25-gauge needle should be advanced until it hits bone, backed up 1-2 mm, and 2-3 cc of anesthetic in- jected. Used with permission of Aaron Andrade, MD. Hilary Lee 2015
  • 13.
    Regional Anesthesia • Localinfiltration • Forearm nerve blocks - ultrasound guided Emergency Medicine Practice © 2011 8 ebmedicine.net • June 2011 usually heal by secondary intention if less than 1 cm in diameter. If there is a small amount of exposed bone, the bone can be trimmed back in the ED with a rongeur until it is underneath the surrounding soft tissue and allowed to heal by secondary intention. Follow-up with a hand surgeon is advised. Imme- diate consultation of a hand surgeon is required in cases of wounds larger than 1 cm in diameter, per- sistently exposed bone, or amputation of the volar pad.33 Additionally, surgeons subclassify fingertip injuries into zones I, II, and III. (See Figure 7.) Zone I injuries are managed conservatively as described above. Zone II injuries may require rongeuring of ex- posed bone. Zone III injuries generally require distal phalanx amputation and warrant follow-up with a hand specialist.34 Fractures Perhaps the most important job of an emergency clinician in hand fractures is proper reduction and severe crush injuries with large losses of soft tissue. Intra-articular fractures require thorough examination to rule out associated tendon avulsions and should always be evaluated by a hand specialist.23 Subungual Hematoma/Nail Bed Lacerations In crush injuries of the finger, nail bed lacerations causing subungual hematomas are common. They are characterized by throbbing pain and purple discoloration under the nail. Two management strategies are commonly used in the ED: removal of the nail, with direct repair of nail bed laceration; and nail trephination with a heated paperclip, a cautery device, or a twirled 18-g needle. A review of the classic literature yields a long-standing debate about which management strategy is superior. The commonly taught “consensus” is that nail bed repair should be considered for subungual hematomas covering greater than 25% to 50% of the nail bed.25-30 However, a 1999 prospective study in children dem- Figure 5. Ultrasound Visualization Of Nerves And Arteries In The Forearm Ulnar, medial, and radial nerves are shown by the arrow across the bottom of the images. Arrowheads show arteries, A (ulnar), B (medial), and C (radial). Liebmann O, Price D, Mills C et al. Ann Emerg Med. 2006;48(5)558-562. Used with permission of Mosby, Inc. A B C Hilary Lee 2015
  • 14.
    Lidocaine +/- Epinephrine •Digital ischemia secondary to epinephrine in nerve block extremely rare • 17 cases worldwide • Multiple large safety studies over last 10 years • Phentolamine -> injectable antidote • Epinephrine improves anesthesia, decreases bleeding, decreases systemic anesthetic absorption Hilary Lee 2015
  • 15.
    Lidocaine +/- Epinephrine •Digital ischemia secondary to epinephrine in nerve block extremely rare • 17 cases worldwide • Multiple large safety studies over last 10 years • Phentolamine -> injectable antidote • Epinephrine improves anesthesia, decreases bleeding, decreases systemic anesthetic absorption Hilary Lee 2015
  • 16.
    Lidocaine +/- Epinephrine •Digital ischemia secondary to epinephrine in nerve block extremely rare • 17 cases worldwide • Multiple large safety studies over last 10 years • Phentolamine -> injectable antidote • Epinephrine improves anesthesia, decreases bleeding, decreases systemic anesthetic absorption Hilary Lee 2015
  • 17.
    Lidocaine +/- Epinephrine •Digital ischemia secondary to epinephrine in nerve block extremely rare • 17 cases worldwide • Multiple large safety studies over last 10 years • Phentolamine -> injectable antidote • Epinephrine improves anesthesia, decreases bleeding, decreases systemic anesthetic absorption Hilary Lee 2015
  • 18.
    Lidocaine +/- Epinephrine •Digital ischemia secondary to epinephrine in nerve block extremely rare • 17 cases worldwide • Multiple large safety studies over last 10 years • Phentolamine -> injectable antidote • Epinephrine improves anesthesia, decreases bleeding, decreases systemic anesthetic absorption Hilary Lee 2015
  • 19.
  • 20.
    Lacerations • Hemostasis • Localanesthesia • Exploration • Irrigation Hilary Lee 2015
  • 21.
    Primary Closure • Noncontaminatedwounds - within 12 hours? • Delayed primary closure • Contaminated wounds • Irrigate • Pack • Reinspect after 3-5 days Hilary Lee 2015
  • 22.
    Primary Closure • Nonabsorbablevs absorbable • Monofilament • Simple interrupted • 10-14 days (14-21 days palmar) Hilary Lee 2015
  • 23.
    Distal Phalanx be splintedand fractures and th ceive immediat Figure 6. Radiograph Demonstrating Phalanx Fractures Left arrow notes a tuft fracture of digit IV. Right arrow notes a shaft Figure 7. Zon Zone I Zone I Hilary Lee 2015
  • 24.
    Distal Phalanx • Fractures •Tuft • Shaft • Intraarticular Hilary Lee 2015
  • 25.
    Distal Phalanx • Fractures •Tuft • Shaft • Intraarticular Reduce and repair soft tissues prn Splint in extension Hilary Lee 2015
  • 26.
    Distal Phalanx • Fractures •Tuft • Shaft • Intraarticular Reduce and repair soft tissues prn Splint in extension Carefully assess tendons, +/- hand surgeon Hilary Lee 2015
  • 27.
    Distal Phalanx • Amputations •Zone I - secondary intention • Zone II - file down bone, secondary intention, follow up • Zone III - distal phalanx amputation, immediate consult 9 Emergency Medicine Practice © 2011June 2011 • ebmedicine.net than 3 mm of digit length loss, and no rotational deformity.35 All metacarpal shaft fractures should be splinted and referred to a hand surgeon. Open fractures and those that fail reduction should re- ceive immediate surgical consultation.35 to the adjacent finger to promote early mobilization and reduce stiffness. (See Figure 9, page 10.) Figure 6. Radiograph Demonstrating Phalanx Fractures Left arrow notes a tuft fracture of digit IV. Right arrow notes a shaft fracture of the distal phalanx of digit III. Used with permission of John D. Lubahn, MD. Figure 7. Zones Of Fingertip Amputation © 2001. Renee L. Cannon. Used with permission. Zone I II III Zone I II IIIHilary Lee 2015
  • 28.
    Nail • Subungual hematoma •Trephination • Nail removal and nail bed repair • Nail fold preservation Hilary Lee 2015
  • 29.
    Proximal/Middle Phalanx • Requireprecise alignment • Stable, nondisplaced • Buddy tape • Oblique, angulated, malrotated • Digital block / hematoma block • Reduction • Post-reduction film • Splint in extension Hilary Lee 2015
  • 30.
    Proximal/Middle Phalanx • Requireprecise alignment • Stable, nondisplaced • Buddy tape • Oblique, angulated, malrotated • Digital block / hematoma block • Reduction • Post-reduction film • Splint in extension Repeat if not properly aligned Hilary Lee 2015
  • 31.
    Proximal/Middle Phalanx Middle andproximal phalangeal fractures are classified according to whether they involve the joint surface. Extraarticular Fractures Extraarticular fractures affect the part of the bone that is not involved with the joint surface. The main concern is whether a rotational deformity is present when the patient attempts to bend the fingers. See chapter 26, “Normal Hand Exam,” for discussion of rotational finger alignment. Any malrotation associated with metacarpal or phalangeal fractures must be corrected. Left, Normally all fingers point toward the region of the scaphoid when a fist is made. Right, Malrotation at the fracture site causes the affected finger to deviate. (From Crenshaw AH (ed): Campbell’s Operative Orthopaedics, 7th ed. St. Louis, Mosby, 1987, with permission.) Hilary Lee 2015
  • 32.
    Proximal/Middle Phalanx consist ofclosed reduction (Bennett fracture only),ting Figure 9. “Buddy-Taping” An Injured Finger Hilary Lee 2015
  • 33.
    Proximal/Middle Phalanx • Referimmediately if: • Open • Unsuccessful reduction • Malrotation • Intraarticular >30% joint surface Hilary Lee 2015
  • 34.
  • 35.
    Fractures • Safe position/ intrinsic plus rates of anxiety, borderline per antisocial personality disorder with boxer’s fractures should evaluation psychiatric questio vention strategies. Thumb Metacarpal Fractures: Fractures Fractures of the first metacarp than those of the remaining m be subdivided into extra-articu fractures. Extra-articular fractu conservative management prin carpal fractures, namely, close angulation goal of less than 20 thumb spica splinting for 4 we are unstable and require prom hand surgeon.43 Intra-articular fractures of involve the CMC joint and gen an axial injury to a partially fle Bennett fracture is an intra-art dislocation; a Rolando fracture intra-articular fracture.44 (See debate exists regarding the spe correction each fracture requir ture supports that emergency consist of closed reduction (Be surgical clinic follow-up. Unstable fractures of the II and III metacarpals generally require immediate consultation by a hand surgeon for surgical correc- tion. Unstable fractures in the IV and/or V meta- carpals, also known as a boxer’s fracture, can be reduced in the ED after adequate anesthesia. In the author’s experience, a forearm ulnar nerve block in conjunction with a hematoma block using 1% lido- caine without epinephrine provides excellent results. Reduction is achieved by traction decompression followed by the “90-90 method.” (See Figure 10.) The MCP, PIP, and DIP joints are flexed at 90° and volar-ward pressure is applied to the dorsum of the metacarpal shaft. An ulnar gutter splint should be applied with prompt clinic follow-up within 1 week. Much controversy exists in the literature regard- ing the goal of boxer’s fracture reduction. Classic literature supports acceptable angulation between 20° and 70°.37 More-recent studies are incongruent. A 1999 cadaveric study concluded that angulation greater than 30° resulted in measurable functional impairment.38 Two more recent prospective stud- ies, however, found good outcomes with 1 week of soft wrap followed by immediate buddy-wrapping Figure 8. The “Intrinsic Plus” Splinting Position Used with permission of Aaron Andrade, MD. Figure 9. “Buddy-Taping” Used with permission of Aaron Andrade, Hilary Lee 2015
  • 36.
  • 37.
    Metacarpal Fractures • Baseor head • Rare • Volar splint and consultation • Shaft • Common • Reducible in ED Hilary Lee 2015
  • 38.
    Metacarpal Shaft Fractures •Local anesthesia • Regional block • Hematoma block • Reduction goals • <10 degrees • <20 degrees • <3mm impaction • No rotation Hilary Lee 2015
  • 39.
    Metacarpal Shaft Fractures •Splint (ulnar or radial gutter) • Refer Hilary Lee 2015
  • 40.
    Metacarpal Neck Fracture •Nondisplaced, nonangulated • Gutter splint - immobilize CMP and MCP • Refer in 3-4 weeks • Unstable, MCP 2 or 3 • Immediate consultation for OR Hilary Lee 2015
  • 41.
  • 42.
  • 43.
    Boxer’s Fracture • 5th(or 4th) metacarpal neck • Volar angulation of distal segment • Inexperienced punch -> axial load • >95% young adult males Hilary Lee 2015
  • 44.
    Boxer’s Fracture • Localanesthesia • Hematoma block plus ulnar nerve block • Traction decompression • 90 / 90 method • Volar pressure to dorsum • Ulnar gutter splint, refer • 20-70 degrees angulation accepted 11June 2011 • ebmedicine.net sor tendon insertion into the distal phalanx, usually caused by forced flexion of the DIP joint. It is so named because the flexed DIP cannot be extended and looks like a mallet. The injury can sometimes be associated with an avulsion fracture of the dorsal base of the distal phalanx. The classic strategy for treating closed mallet finger injuries with less than one-third of the joint surface disrupted is continuous splinting of the DIP joint in full extension to hyper- Figure 10. The “90-90” Method Used with permission of Aaron Andrade, MD. From wit Fig Hy Use Hilary Lee 2015
  • 45.
    Thumb Metacarpal Fractures • Lesscommon • Extraarticular • Closed reduction • Goal 20-30 degrees angulation • Thumb spica splint x 4 weeks Hilary Lee 2015
  • 46.
  • 47.
    Thumb Metacarpal Fractures Bennett fracture •Intraarticular fracture / dislocation of 1st MCP • Fragment continues to articulate • Axial load on flexed digit • ORIF if >3mm displacement • Closed reduction, refer Hilary Lee 2015
  • 48.
    Thumb Metacarpal Fractures • Rolandofracture • Comminuted intraairticular 1st metacarpal fracture with dislocation • Unstable, requires ORIF Hilary Lee 2015
  • 49.
    Tendon Injuries • Laceration,crush, hyperflexion, hyperextension • XR - r/o associated avulsion or # • Closed tendon injuries - splint, close follow up • Open tendon injuries…. Hilary Lee 2015
  • 50.
    Tendon Injuries • Laceration,crush, hyperflexion, hyperextension • XR - r/o associated avulsion or # • Closed tendon injuries - splint, close follow up • Open tendon injuries…. Hilary Lee 2015
  • 51.
    Tendon Injuries • Laceration,crush, hyperflexion, hyperextension • XR - r/o associated avulsion or # • Closed tendon injuries - splint, close follow up • Open tendon injuries…. Hilary Lee 2015
  • 52.
    Tendon Injuries • Laceration,crush, hyperflexion, hyperextension • XR - r/o associated avulsion or # • Closed tendon injuries - splint, close follow up • Open tendon injuries…. Hilary Lee 2015
  • 53.
    Tendon Injuries • Extensor •Generally reparable in ED • Few associated structures • Flexor • Wound closure and referral • Many associated structures, evaluate carefully for nerve or vascular injury Hilary Lee 2015
  • 54.
    Tendon Injuries • Extensor •Generally reparable in ED • Few associated structures • Flexor • Wound closure and referral • Many associated structures, evaluate carefully for nerve or vascular injury Hilary Lee 2015
  • 55.
  • 56.
  • 57.
    Mallet Finger • Hyperflexioninjury at DIP • Extensor digitorum tear +/- avulsion # dorsal base distal phalanx • Splint DIP in hyperextension for 6 weeks, refer • Do not splint DIP • If open or >30% articular surface avulsed, ORIF Hilary Lee 2015
  • 58.
    Mallet Finger • Hyperflexioninjury at DIP • Extensor digitorum tear +/- avulsion # dorsal base distal phalanx • Splint DIP in hyperextension for 6 weeks, refer • Do not splint PIP • If open or >30% articular surface avulsed, ORIF Hilary Lee 2015
  • 59.
    Jersey Finger • Extensionagainst resistance injury • Flexor digitorum profundus tear • Named after jersey tugging at a sports match…. Hilary Lee 2015
  • 60.
  • 61.
    Jersey Finger • Isolatedor plus avulsion fracture • Immediate consultation for surgical intervention Hilary Lee 2015
  • 62.
  • 63.
  • 64.
    Fight Bite • Lacerationto MCP • High rate of associated tendon, joint or bone injury - 75% • Clenched fist mechanism - with relaxation, oral bacteria on extensor tendon sheath track back Hilary Lee 2015
  • 65.
    Fight Bite • Aggressiveearly management • XR r/o foreign body or fracture • Irrigate, elevate, immobilize • Early surgical consultation Hilary Lee 2015
  • 66.
    Fight Bite • Polymicrobial •alpha-hemolytic streptococcus (s viridans) • staphylococcus aureus • eikonella corrodens (25%) • gram negatives, anaerobes • If joint or tendon sheath involved • Admit for IV antibiotics (ampicillin/sulbactam, cefoxitin, carbapenem) • OR for I&D • PO amox-clav at discharge for 5-7 days • Complications: osteomyelitis, tenosynovitis, septic arthritis Hilary Lee 2015
  • 67.
    Fight Bite • Polymicrobial •alpha-hemolytic streptococcus (s viridans) • staphylococcus aureus • eikonella corrodens (25%) • gram negatives, anaerobes • If joint or tendon sheath involved • Admit for IV antibiotics (ampicillin/sulbactam, cefoxitin, carbapenem) • OR for I&D • PO amox-clav at discharge for 5-7 days • Complications: osteomyelitis, tenosynovitis, septic arthritis Hilary Lee 2015
  • 68.
    Fight Bite • Polymicrobial •alpha-hemolytic streptococcus (s viridans) • staphylococcus aureus • eikonella corrodens (25%) • gram negatives, anaerobes • If joint or tendon sheath involved • Admit for IV antibiotics (ampicillin/sulbactam, cefoxitin, carbapenem) • OR for I&D • PO amox-clav at discharge for 5-7 days • Complications: osteomyelitis, tenosynovitis, septic arthritis Hilary Lee 2015
  • 69.
  • 70.
    Dislocations/Subluxations • Closed reductionwith local anesthesia • XR r/o avulsion #, confirm post-reduction alignment • Avulsion >30% articular surface = immediate consult • Splint in slight flexion x 2-3 weeks • Consultation as outpatient Hilary Lee 2015
  • 71.
  • 72.
    Skiier’s/Gamekeeper’s Thumb • Ulnar collateralligament tear • Forceful radial deviation of the thumb • Pain, swelling on ulnar aspect of 1st MCP joint • Valgus stress / radial deviation on 1st MCP with thumb fully extended and in 30 degrees flexion • Distal deviation >35 degrees or 15 degrees more than unaffected thumb = complete tear Hilary Lee 2015
  • 73.
    Skiier’s/Gamekeeper’s Thumb • Ulnar collateralligament tear • Forceful radial deviation of the thumb • Pain, swelling on ulnar aspect of 1st MCP joint • Valgus stress / radial deviation on 1st MCP with thumb fully extended and in 30 degrees flexion • Distal deviation >35 degrees or 15 degrees more than unaffected thumb = complete tear Hilary Lee 2015
  • 74.
    d place CP in 30° greater umbis mplete ner omes Figure 15. Valgus Stress Testing Of The First MCP Joint Ulnar deviation by greater than 35° or 15° more than the unaffected side is diagnostic of a complete UCL rupture. From Rhee S, Cobiella C. Trauma. 2007;9:163-170, copyright © 2007ateral bands Hilary Lee 2015
  • 75.
    Skiier’s/Gamekeeper’s Thumb • High incidenceof Stener lesion (adductor pollicis aponeurosis sticks between ends of UCL) -> poor healing • Consult, requires ORIF within 3 weeks • Partial tear -> thumb spica x 4 weeks, outpatient follow up Hilary Lee 2015
  • 76.
    Vascular Injuries • Rarelycausing significant morbidity -> ulnar and radial collaterals • Direct pressure, tourniquet • Distal ischemia -> immediate consultation • Doppler u/s, pulse oximetry Hilary Lee 2015
  • 77.
    Nerve Injuries • Splintto prevent further damage • Closed -> likely neurapraxia or axonotmesis • Endoneurium intact, will spontaneously regenerate • Outpatient referral for repeat physical exams • Open -> likely severed • Without endoneurium, regeneration not possible • Immediate referral for repair Hilary Lee 2015
  • 78.
    Nerve Injuries • Splintto prevent further damage • Closed -> likely neurapraxia or axonotmesis • Endoneurium intact, will spontaneously regenerate • Outpatient referral for repeat physical exams • Open -> likely severed • Without endoneurium, regeneration not possible • Immediate referral for repair Hilary Lee 2015
  • 79.
    High Pressure Injection •Nondominant hand of industrial workers • Paint, oil, water, air, solvents, metal, cement • Cannot estimate tissue damage with superficial signs or imaging • High risk of infection, vascular compromise, amputation • Immediate consultation for debridement • Splint, elevate, pain control, broad spectrum abx • Nerve blocks contraindicated Hilary Lee 2015
  • 80.
    High Pressure Injection •Nondominant hand of industrial workers • Paint, oil, water, air, solvents, metal, cement • Cannot estimate tissue damage with superficial signs or imaging • High risk of infection, vascular compromise, amputation • Immediate consultation for debridement • Splint, elevate, pain control, broad spectrum abx • Nerve blocks contraindicated Hilary Lee 2015
  • 81.
    Amputations • Wrap amputatedpart in saline-moistened gauze, place in sealed plastic bag, in insulated container with sealed bag of ice • Proper cooling -> viable for 12-24 hrs • Control hemorrhage, pain • Immediate consultation Hilary Lee 2015
  • 82.
    Compartment Syndrome • Rare •Difficult to identify, 10 compartments in the hand • Pain -> parasthesias -> paresis -> pallor -> pulselessness • Suspect if… • Crush • Circumferential burn with eschar • Pain out of proportion or rapidly increasing • Palpably tense tissues • Nerve/vascular injuries • Immediate consultation, limb elevation, removal of constricting materials Hilary Lee 2015
  • 83.
    Summary • Impossible • Extensive,highly specific knowledge that is not generalizable • If in doubt, discuss case with a hand surgeon for appropriate guidance • Always manage pain, provide immobilization, thoroughly investigate functional components • Practice defensively - hands are the most occupationally significant limb and disability will have lasting consequences Hilary Lee 2015
  • 84.