The document discusses hand injuries and their management. It covers relevant hand anatomy, types of common hand injuries including tendon injuries, fractures, and dislocations. The key principles of management are early debridement and stabilization of injuries, restoration of anatomy, and rapid mobilization. Specific techniques are described for repairing tendons, fixing fractures like Bennett's fracture, and achieving proper skeletal stabilization while preserving hand function.

1. HAND INJURIES & THEIR
MANAGEMENTS
DR. ROBERT GAYFLOR MULBAH
DEPT OF ORTHOPAEDIC SURGERY
UNIVERSITY OF NAIROBI/ KNH

2. OUTLINE OF
PRESENTATION
 INTRODUCTION
 RELEVANT ANATOMY &
BIOMECHANICS
 HAND INJURIES
 PRINCIPLES OF MANAGEMENT
 CONCLUSION
 REFERENCES

3. Learning Objectives…
 To understand important anatomical
features of the hand
 To appreciate the spectrum of injuries to
the hand
 To understand principles of management
of hand injuries

4. INTRODUCTION
 A prehensile organ with structural
adaptations to functions
 Injuries to the hand are not uncommon
 present as isolated injury or component of
multiple injuries.
 Injury can be soft tissue or bony/skeletal
 These injuries can be
definitively/temporarily managed in the
first clinical setting.

5. RELEVANT ANATOMY

6. HAND ANATOMY
SKELETAL
ANATOMY
SOFT
TISSUE
NEUROVASCUL
AR
MUSCLES &
TENDONS
Extrinsic &
intrinsic
muscles +
ligaments
Extensors &
flexors tendon
& pulley
systems
 Carpals, metacarpals,
phalanges, joints
 Schematic by R. Mulbah

7. Flexor pulley
system

9. BIOMECHANICS
 The hand has 7 maneuvers that make
up most hand functions.
1. The precision pinch ( terminal pinch,):
 flexion of the interphalangeal (IP) joint
of the thumb and the distal IP (DIP)
joint of the index finger.
The fingernail tips are brought
together so that a small item, such as
a pen, can be picked up.

10. Precision/terminal pinch

11. …
2. The oppositional pinch ( subterminal
pinch)
 pulp of the thumb and index finger are
brought together with the IP and DIP
joints in extension
 Allows for increased forces to be
generated through thumb opposition.
First dorsal interosseous contracts with
simultaneous flexion of Index finger
profundus

12. oppositional pinch ( subterminal pinch)

13. …
3. Key pinch
 The thumb is adducted to the radial
aspect of the index finger’s middle
phalanx.
 It also requires adequate length of the
digit and a metacarpal phalangeal joint
(MCP), which is capable of resisting
thumb adduction

14. Key pinch

15. ---
4. The chuck grip (directional grip)
allows the index finger, long finger,
and thumb to come together to
envelop a cylindrical object.
A rotational and axial force is usually
applied to the object when using this
type of grip

16. The chuck grip (directional grip)

17. …
5. The hook grip
 requires finger flexion at the IP joints
and extension at the MCP joints.
 This grip is used, for example, when
one picks up a suitcase or a briefcase.
 It does not require thumb function

18. The hook grip

19. …
6. power grasp
The fingers are flexed and the thumb is
flexed and opposed relative to the other
digits such as gripping a club or bat.

20. power grasp

21. ---
7. The span grasp
The DIP joints and the proximal IP (PIP)
joints flex to approximately 30 degrees
and the thumb is palmarly abducted
Forces are generated between the
thumb and fingers.
Stability is needed at the thumb, MCP,
and IP joints.
This type of grip is used, for example, to
grab a ball

22. span grasp

23. HAND INJURIES
 Hand injury: any pathological change
occurring in the part of the upper limb
distal to the wrist as a result of
exchange of energy between an
individual and his environment
(Bashiru et al )
SKELETAL
INJURIES
SOFT TISSUE
INJURIES

24. EPIDEMIOLOGY
 Paucity of data locally: 2.7% of RTA
(Hassan 2000)
 USA :5-10% of emergency department
(ED)
 Males › Females 26.9 years
average
 3.7:1 ratio at KNH (Kaisha 2006)
 right hand distal phalanges
 ›50% right hand dominance
 Commonest etiology: work related

25. SEVERITY OF INJURIES

26. CATEGORIES OF INJURIES
SOFT TISSUE INJURIES
 Lacerations
 Burns
 Degloving injuries
 Tendon Injury Extensor tendons
Flexor tendons
 Ligamental & neurovascular injuries
SKELETAL INJURIES
 Fractures
 Dislocations

27. TENDON INJURIES
 17% reported among Hand injuries @
KNH (Kaisha 2006)
 Flexor digitorum superficialis and
profundus + extensor digitorum
communis commonly injured

28. Flexor Tendon Injuries
 volar lacerations plus/minus
concomitant neurovascular injury
 Classified by the zone of injury
 Courte of orthobullet

29. Flexor pulley system
 Digits 1-4 contain
5 annular pulleys (A1 to A5)
3 cruciate pulleys (C1 to C3)
A2 and A4 are the most important
pulleys to prevent flexor tendon
bowstringing
 thumb contains
2 annular pulley
interposed oblique pulley (most
important)

30. Flexor pulley system

31. ---
Flexor digitorum profundus (FDP)
Flexor digitorum superficialis (FDS)
FDS to 5th finger (absent in 25% of
people
Flexor pollicis longus (FPL)
Flexor carpi radialis (FCR)
Flexor carpi ulnaris (FCU)

32. Extensor Tendon Injuries
 caused by laceration, trauma, or
overuse
 long finger (most injured) & zone VI (
most frequently injured zone)
Mechanism
 Zone I : forced flexion of extended DIP
joint
 Zone II :dorsal laceration or crush injury
 Zone V : commonly from "fight bite"
sagittal band rupture ("flea flicker
injury")

33. Zones of Extensor Tendon
Injuries

34. Special tendon related injuries
 Jersey finger:
Avulsion injury of FDP from insertion at
the base of distal phalanx
A zone I flexor tendon injury with 75%
at the tip of the ring finger
 Boutonniere deformity:
Zone III extensor tendon injury resulting
to PIP flexion and DIP extension

35. VASCULAR INJURIES
 Are not uncommon
 Can involve Radial or ulnar arteries
and digital branches + associated
veins

36. NERVE INJURIES
 Nerve injury
 Classification by Sedon:
 Neurapraxia
 Axonotmesis
 Neurotmesis
 Sunderland’s classification:
 Grade 1 : neurapraxia
 Grade 11 : axonotmesis
 Grade 111 : Neurotmesis (intact peri &
epineurium)
 Grade 1V : Neurotmesis (intact epineurium
only)
 Grade V : Complete transection (not
recoverable)

37. SKELETAL INJURIES
 27 bones & complex articulations
amenable to fractures and dislocations
 Fractures & dislocations
Carpal: Scaphoid, perilunate
dislocation
Metacarpal FX, MCP dislocation
Phalanx FX

38. Special fractures/dislocation
 Intraarticular fractures of the Thumb
Bennett FX :
Intra-articular fracture/dislocation of base of
1st metacarpal characterized by volar lip of
metacarpal based attached to volar oblique
ligament
small fragment of 1st metacarpal continues
to articulate with trapezium
Rolando FX:
Intra-articular fracture of base of 1st
metacarpal characterized by intra-articular

39. Extraarticular fx
 Pseudo Bennett's fracture (also
called Epibasal fractures of the thumb)
are two piece fractures of the proximal
first metacarpal bone which is usually
stable

40. …
 Fracture stability depends upon its
specific pattern, location, relationship to
tendon and ligament insertions, and any
associated Injuries
 Common fracture patterns in the hand
metacarpals.
I. Spiral fracture
II. Oblique fracture
III. Multifragmentary fracture
IV. Partial articular fracture
V. Complete articular fracture

41. MANAGEMENT
 HX + PE + Investigations
 Basic concepts in repair are similar for
different zones
 Location of laceration directly affects
healing potential
 Principle of management can be tailored
to severity of injury and structure injured
(tendon, vascular, nerve, skeletal etc)

42. Examination

43. Investigation

44. Basic principles
 Multidisciplinary
 Treatment is directed at structures
injured
 In emergency situations, the goals of
treatment are
 Distal circulation
 Bone frame work
 Skin cover

45. Intraoperative principles

46. …
 Debridement & fracture stabilization
for open injuries
 Primary tendon repair reserved for
cleanly cut tendons.
 Delayed primary repair is indicated for
potentially contaminated wounds
 Bayonet incision

47. Principles of hand fracture
management
AO Guiding principles of hand fracture
(FX) management
I. restoration of articular anatomy;
II. correction of angular or rotational
deformity;
III. stabilization of fractures;
IV. surgical approach not compromising
hand function;
V. rapid mobilization
Open Hand fractures…management
principle remains the same

48. …
 Many fXs of the hand can effectively be
treated using nonoperatively.
 Stable skeletal fixation maybe required
in the following groups of fractures:
multifragmentary
 severely displaced
multiple metacarpal
short oblique or spiral metacarpal with
associated soft-tissue injury.

49. …
 FXs at particular anatomical locations:
subcondylar, proximal phalanx; palmar
base middle phalanx.
 Displaced articular and periarticular
fractures:
Bennett’s FX
Rolando’s FX
Pseudo Bennette Fx
unicondylar and bicondylar FX

50. Types of fixation
 CRPP
 ORIF
 K-WIRES, SCREWS, PLATES
 ARTHROSCOPY (also described)

51. Management of special fx
Scaphoid fracture
 Modalities:
Non-operative
 Stable & nondisplaced fx:
 Thumb spica cast immobilization for 12-
21 days and reevaluate
 Nonunion increase with delayed
immobilization of > 4 weeks after injury
 Risk of nonunion

52. …
Operative: Screw fixation
(percutaneous/ORIF)
 Indications:
Unstable fractures
I. Proximal pole fractures
II. Displacement > 1 mm
III. 15° scaphoid humpback deformity
IV. Radiolunate angle > 15°
V. Intrascaphoid angle of > 35°
VI. scaphoid fractures associated with
perilunate dislocation
VII. comminuted fractures
VIII.unstable vertical or oblique fracture

53. Thumb Intraarticular fractures
I. BENNETTE
 Nonoperative : closed reduction & cast
immobilization
 Indications: nondisplaced fractures
 Technique: reduction maneuver with
traction, extension, pronation, and
abduction

54. ..
 Operative :
A. CRPP
 Indications
Small volar fragment to hold a screw
anatomic reduction unstable
 Technique
 can attempt reduction of shaft to trapezium
to hold reduction
B. ORIF
 Indications
large fragment
2mm+ joint displacement

55. ---
2. ROLANDO FX
 Nonoperative : Cast immobilization
Indications : severe comminution, stable
Early ROM
 Operative : external fixation, CRPP
Indications
severe comminution, unstable fx
Technique: Approximate large fragments
with k-wires

56. ---
 ORIF : T-plate/k-wire
Indications
most common fixation method
Technique
use t-plate or blade plate
use k-wires for small fragments
 Complications : post-traumatic
osteoarthritis

58. TENDON REPAIRS
Principle
 Primary repair of tendon for cleanly cut
tendons
 Delayed primary repair for contaminated
wounds
 Retraction after 4 weeks results in joint
flexion.
 Tendon graft repair may be required
Methods:
Kessler, Bunnell, Modified Kessler,
Pulvertaft etc
Variations in methods globally with no

59. Units Core Sutures Peripheral
Sutures
Country
Mayo Clinic Modified
Pennington,
double Tsuge,
double Kessler
Simple running or
simple locking
USA
Stanford
University,
Palo
Alto (CA
Modified Kessler
plus 2-strand
horizontal
mattress suture
Simple running USA
Saint John
Regional
Hospital
Double Kessler Simple running Canada
Verona
University
4-strand Kessler Simple running Italy
Broomfield
Hospital,
Chelmsford
4-strand
Evans/Smith
6-strand Tang
Simple running
None
United Kingdom
The methods used currently in some hand surgery units in direct end-
to-end flexor tendon repairs

60. Tendon repair techniques

61. Contraindications for primary
repair
 Injuries more than 12 hours old
Crush wounds with poor skin
coverage
Contaminated wounds, especially
human bites
Tendon loss more than 1 cm
Injury at multiple sites along the
tendon
Destruction of the pulley system

63. Principles of mgt of vascular
injuries
 Assess adequacy of collateral
 Non critical Injury:
-Nondominant Radial artery
 Critical injury:
Radial & ulnar artery
Radial or ulnar injury & poor collateral
digital brachial index of 0.7 or more

64. method
 Control of bleeding: compression, use of
BP cuff, or tourniquet at 200-250 mmHg
≤15-20 min.
 Digital arteries: repair skin lacerations
and apply pressure dressing
 Large vessels: End to end anastomosis
of healthy vessels
 Healthy intima must be visualized
 Appropriate length of vein grafts are
used from the saphenous vein

65. Principles of mgt of nerve injuries
 Repair requires skills & instrumentation
 Identified injured nerve
 Digital nerve: single suture technique
to bring edges together
 Large nerves:
Place sutures in the epineurium (nerve
fibers)
Avoid tension suturing
Immobilize for 10-14 days

66. …
 Primary nerve repair in 72 hours of
injury
 Delayed primary repair 72 hours to 14
days
 Secondary nerve repairs 14 days or
longer after injury.
 Adequate debridement of edges
 May use nylon 8-0
 collagen tubes for gaps or nerve grafts
for large gaps

67. Amputation
 In general if any four of the following
basic six are irreparably damaged
Skin
Extensor and
Flexor tendons
Vessels
nerves
Skeleton
 Prosthesis-total, partial, digital or active
or passive

68. Principle of Replantation
Indications
Clean
Guillotine
Early presentation ≤ 6hrs
Proper preservation of the injured part
thumb at any level , multiple digits,
through the palm, wrist level or
proximal to wrist
almost all parts in children

69. CONTRAINDICATIONS
Absolute
contraindications
 Severe associated
injuries (crushed
injury)
 Multiple injury in
same part
 Systemic illness &
vascular disorders
 Ischemic time more
than 6 hrs
Relative
contraindications
 Age
 Avulsion injury
 Prolonged warm
ischemic time more
than 12hrs
 Massive
contamination
 Psychiatric patient

70. Transport of amputated tissue
 Modality
keep amputated tissue wrapped in
moist gauze in lactate ringers solution
place in sealed plastic bag and place in
ice water (avoid direct ice or dry ice)
wrap, cover and compress stump with
moistened gauze

71. Operative sequence of
replantation
Bone fixation +/- shortening
Extensor tendon repair
Artery repair(repair second after bone if
ischemic time is >3-4 hours)
Venous anastomoses
Flexor tendon repair, Nerve repair
Skin closure +/- fasciotomy
finger order : thumb, long, ring, small,
index

73. General Postoperative care
 Immobilization, limb Elevation &
analgesia ± antibiotics
 Early physiotherapy when edema
subsides
 Rehabilitation should start early
 Clinical follow-up
 Revision when necessary
 Prognosis is multifactorial
Watch for postop compartment
syndrome, infections and other postop

74. Position of safe
immobilization

75. GENERAL COMPLICATIONS
Immediate and Early
1. Compartment syndrome
2. Infection-fasciitis, abscess, wound
dehiscence
late
1. Hand stiffness
2. Loss of function
3. Implantation cysts
4. Volkmann contractures
5. contractures

76. PROGNOSTIC FACTORS
 Severity of injury
 Time of presentation
 Other associated injuries
 Skill of the surgeon
 Availability of skilled hand surgeon
 Adequate physiotherapy

77. CONCLUSION
“Nowhere in the body does function follow
form as closely as in the hand. The stability
of its small articulations, the balance between
its extrinsic and intrinsic muscles, and the
complexity of the tendon systems require a
stable and well aligned supporting skeleton.
The outcome of skeletal injuries in the hand
may be judged more on the return of function
of the soft-tissue structures rather than on
skeletal union.” AO Principle of fracture
management vol 2
Therefore surgeons have to be meticulous in
managing hand injuries

78. REFERENCES
 Brinker, M.R: Review of Orthopaedic Trauma 2nd
ed. Lippincott william & Wilkins 2013;p.938-1027
 Duncan, S.F. M et al. Biomechanics of the Hand.
Hand Clin 29: 483-492 2013
 Dy CJ, Hernandez-Soria A, Ma Y, et al.
Complications after flexor tendon repair: a
systematic review and meta-analysis. J Hand
Surg (Am) 37:543-551,2012
 Karunadasa K. Management of the injured
hand-basic principles of care. Sri Lanka Journal
of Surg 2015;33(1): 9-13
 Ruedi T. P et al: A O Principles of Fracture
Management 2nd Ed. Vol 2 ; 2007
 www.orthobullet.com