This document discusses hand trauma and injuries. It begins by introducing the group members and providing an overview of the topics to be covered, which include structural injuries like cuts, tendon injuries, nerve injuries, bone injuries, amputation and replantation, and hand infections. It then discusses the importance of the hand and approaches to examining a hand trauma patient. The remainder of the document provides details on managing specific types of structural injuries to the hand.

1. Group Members
1. P.Y.Sudusinghe
2. R.S.Kumar
3. W.A.K.Suwandika
4. N.G.S.Tharaka
5. P.W.A.R.Thilakarathna
6. S.M.A.Thusari
1

2.  Introduction
 Importance of the Hand
 Approach to hand trauma patient
 Structural Injuries and Management
◦ Cutaneous Injuries
◦ Tendon Injuries
◦ Nerve Injuries
◦ Bone Injuries
 Amputation and Replantation
 Hand Infections
2

3. INTRODUCTION
 The hand is a very vital part of the human body
 4 requirements for a functioning hand:
◦ Supple (moving with ease)
◦ Sensate
 Account for 5-10 % of hospital ER visits.
 Great potential for serious handicap
 Good understanding of hand anatomy and function, good
physical examination skills, and knowledge of indications
for treatment.
 Proper Initial diagnosis and timely appropriate treatment
would reduce morbidity.
3
◦ Pain free
◦ Coordinated

4. The Importance of the Hand
Communication
Sensation
Employment
Independent Living

5. The Hand - Communication
 Greetings

6. Communication…
 Gestures

7. Communication…
 Sign Language

8. Sensation
 Large area brain structure devoted to
touch. Highly sensitive.

9. Sensation…
 Relationships

10. Employment
• Use of hands fundamental to most vocations.

11. Independent Living
 Without the use of our hands, most
people would find independent living
impossible.

12. • This equals 6-8 weeks off work!! No
income for 2 months. How would your
finances cope?

13. APPROACH TO HAND TRAUMA
PATIENT
History:
 General
◦ Age
◦ Hand dominance
◦ Occupation/hobbies
◦ History of previous hand problems
 When and where did this injury take place?
◦ Determine the likelihood of severe injury and
probability of contamination with foreign
matter.
 How was the trauma sustained?
◦ This gives clues to the most likely injury.
 Past history of treatment or surgery in the hand
13

14. Physical examination
◦ Entire upper limb should be exposed and carefully
inspected (Muscle wasting, colour change,
Asymmetry, fixed abnormal posture etc.)
◦ Extrinsic flexor and extensor muscles and their
tendons’ injuries.
◦ Intrinsic muscles (Thenar, lumbricals, interossei,
and hypothenar muscles)
◦ Joints’ pain and stability.
◦ Sensory examination.
◦ Circulation for colour change, Allen test.
14
APPROACH TO HAND TRAUMA
PATIENT

15. Imaging Studies
 Radiography
◦ Plain-films of the hand or wrist should be obtained
when a patient presents with a soft tissue injury
suggestive of fracture or an occult foreign body.
 US
◦ Has a growing role in locating foreign bodies and in
evaluating soft tissues
◦ Can detect ruptured tendons and assess dynamic
function of tendons non-invasively.
 MRI
◦ Highly sensitive in detecting ruptured tendons.
◦ However, it does not have a role in emergent
management of hand wounds. 15
APPROACH TO HAND TRAUMA
PATIENT

16. CUTANEOUS
INJURIES
16

17. ANATOMY
Dorsum surface
◦ Thin and pliable.
◦ Attached to the hand's skeleton only by loose areolar
tissue, where lymphatics and veins course.
◦ Loose attachment makes it more vulnerable to degloving
injuries.
Palmar surface
◦ Thick and glabrous and not as pliable as the dorsal skin
◦ Strongly attached to the underlying fascia by numerous
vertical fibers
◦ Most firmly anchored to the deep structures at the palmar
creases
◦ Contains a high concentration of sensory nerve endings
essential to the hand's normal function
17

18. PRESENTATION
 Cutaneous injuries are very common
Two Types
◦ Open: Incised, laceration, punctured (bites),
penetration, abrasion, degloving.
◦ Closed: Contusions, Hematomas
 Vary in depth from superficial to very
deep involving underlying structures.
 Explore for underlying structural
Injuries.
18

19. 19

20. MANAGEMENT
Skin Laceration:
◦ Small: Rinse and cover.
◦ Large:
 Infiltrate with Lidocaine
 Irrigate wound profusely with sterile water
 Drape and explore (underlying injuries and foreign
bodies)
 Close the skin wound with simple sutures.
 Wounds older than 6-8 hours should not be closed
primarily because of an increased likelihood of
infections.
 Irrigate, explore then apply sterile dressing. Re-check
after 4 days for skin infection. Delayed primary
closure at 4 days.
 Update Tetanus vaccination.
20

21. MANAGEMENT
Bites:
◦ Should not be closed primarily but should be given
serial wound checks with delayed closure at 4
days if needed
◦ Antibiotic prophylaxis is indicated in human and
animal bites.
Contusions:
◦ Cold packs with pressure for 30 to 60 min. several
times daily for 2 days.
◦ Two days after the injury, use warm compresses
for 20 minutes at a time.
◦ Rest the bruised area and raise it above the level
of the heart
◦ Do not bandage a bruise.
21

22. MANAGEMENT
 Abrasions:
◦ Superficial:
 Rinse and cover.
 Prophylactic antibiotic ointment
◦ Deep:
 Rinse with antiseptic or warm normal saline.
Scrub gently with gauze if necessary.
 Dress with semi-permeable dressing. Changed
every few days.
 Keep wound moist. Enhance healing process.
22

23. FLAPS
 Large skin defects on the hand should
always be covered with a full
thickness skin graft or flaps (local or
distant) especially on the dorsum of
the hand where the tendons are
superficial and application of a STSG
will tether the tendons and lead to loss
of hand function.
23

24. 24

25. Role of STSG
 Can be used if there is adequate
tissue cover over bone and tendons
with only loss of skin.
 Can be used with dermal allografts
like AlloDerm ® (commercially
available acellular dermis derived from
human skin)
 Used to cover some
donor sites
25

26. TENDON
INJURIES
26
•Acute
•Chronic

27. 27

28. 28

29. 29

30. PRESENTATION
Extensor injury
 Extensors
Injury:
◦ Divided into
Zones
according to
anatomical
location of
injury
30

31. PRESENTATION
31

32. 32
Zone 5
Zone 1
Boutonniere’s
Deformity
Zone 3

33. MANAGEMENT
Zone Presentation Management
I Mallet’s Deformity
•Closed: splinting 6-8 weeks
•Open: suture repair for
fixation.
•Soft tissue reconstruction
III
Boutonniere’s
Deformity
•Closed: splinting MCP and
PIP in hyperextension for 6
weeks
•Open: suture repair (figure of
8 suture)
V
Fixed flexion of
MCP
•Closed: splinting ,45°
extension at wrist and 20°
flexion at MCP
•Open: suture repair.
33

34. 34

35. PRESENTATION
FLEXOR TENDON INJURY
 Flexor Injury
◦ Divided into
Zones
according to
anatomical
location of
injury
35

36. 36

37. PRESENTATION
37
Zone Presentation Management
I
Loss of active flexion
at DIP joint
Hyperextension of
DIP joint
•Primary or Secondary tendon
repair
•Careful suturing prevent post-
op adhesions.
II
(No
Man’s
Land)
Loss of active
flexion at MCP
joint
•Skin closure then secondary
repair by tendon grafting
•Primary repair performed by
skilled hand surgeon to
minimize post-op adhesions.
III, IV
Thumb
Same
•Primary or secondary tendon
repair
•Examine carefully for thenar
muscle injury and recurrent
branches of median nerve.

38. PRESENTATION
38
Zone Presentation Management
V
Palm
• Uncommon
• Lie deep and
protected by
palmar fascia
•Superior to Tendon division:
repair is unnecessary.
•Both muscles’ tendon
division: primary repair
VI, VII
Wrist
• Multiple flexor
tendon injury
• Impaired active
flexion of multiple
digits
•Primary tendon suturing
(further proximal in the
forearm to prevent post-op
cross-adherence)
•Injuries to muscles in forearm
require primary repair
•Post-op splinting of wrist in
flexion position and elevation
for 4 weeks.

39. 39

40. CHRONIC TENDON INJURIES
OF THE HAND
Swan Neck Deformity
 Flexed DIP, hyperextended PIP
 Interruption of distal extensor mechanism
 Causes:
◦ Chronic Mallet finger
◦ Fracture malunion
◦ Volar plate injury to PIP
◦ Rheumatoid arthritis
◦ Ligament laxity
 Treatment: surgical mostly but splints can
be used to relieve contractures
40

41. De QUERVAIN’S TENOSYNOVITIS
 Stenosing tenosynovitis of the first
dorsal compartment
 APL & EPB trapped in fibroosseous
tunnel formed by radial styloid and
flexor retinaculum
 Symptoms include: pain over styloid
process on thumb or wrist movement
Treatment: thumb spica splint,
NSAIDS and steroid injection in 1st
compartment.
41

42. Trigger finger and Thumb
 Stenosing tenosynovitis, leading to
inability to extend the flexed digit
“triggering”.
 Involvement of the first annular part of
the flexor sheath (A1 annulus)
 Treatment:
◦ Splinting +heat/cold
◦ Local steroid inj
◦ Sx release of A1 pully
42

43. Dupuytren's contracture
 Inherited proliferative connective
tissue disease affecting the palmar
fascia causing it to harden (collagen I-
III)
 Incidence after 40, M>F. after 80 M=F
 Affects mostly ring and little finger and
middle finger in severe cases.
 Initially starts as nodules in palm of
hand.
43

44.  Positive table top test
 Pts ability to grip
 Treatment:
◦ Early-Radiation
-collagenase inj
◦ Late- fasciectomy
-Dermofasciectomy
44

45. NERVE INJURIES
45

46. ANATOMY
46

47. Presentation
 Mechanisms of injury:
◦ Traction: force is longitudinal to nerve axon
◦ Compression: force is cross-sectional to nerve
axon.
◦ Laceration: sharp object injury.
 Blunt trauma delivers forces that stretch
and compress nerves. Nerve my undergo
total disruption or avulsion. Less favorable
outcome.
 Sharp laceration can cause complete
transection of nerve but it is associated
with best prognosis
47

48. Presentation
 Effect of injury: “Seddon’s Classification”
◦ Neuropraxia:
 Disruption of Schwann cell sheath but no loss of
continuity.
◦ Axonotmesis:
 Injury to both Schwann sheath and axon.
 Distal part undergoes Wallerian degeneration.
 Stimulation of nerve 72 hours after injury does not
elicit response.
 Regeneration occurs with the average rate of 1-2
mm/day.
 Regeneration is supported and guided by the
surrounding endoneurium.
48

49. Presentation
◦ Neurotmesis:
 Injury to all anatomical components, myelin
sheath, axons and the surrounding connective
tissue.
 This total nerve disruption makes regeneration
impossible.
 Surgical intervention is necessary.
◦ Examine carefully to document any
sensory or motor injury and for follow up.
49

50. PRESENTATION OF MEDIAN
NERVE INJURY
50

51. PRESENTATION OF RADIAL
NERVE INJURY
51

52. PRESENTATION OF ULNAR
NERVE INJURY
52

53. MANAGEMENT
 Neurolysis:
◦ Removal of any scar or tethering attachments to
surroundings that obstruct nerve ability to glide.
 Neurorrhaphy:
◦ End-to-end repair.
◦ Resection of the proximal and distal nerve stumps
and then approximation.
 Autologus Nerve grafting:
◦ Gold standard for clinical treatment of large lesion
gaps.
◦ Nerve segments taken from another parts of the
body.
◦ Provide endoneural tubes to guide regeneration.
◦ Two types: Allograft, Xenograft.
53

54. 54
EPINEURAL
NEURORAPHY
GROUP FASSICULAR
NEURORAPHY

55. CHRONIC NERVE INJURY
Carapal tunnel syndrome
 Compression of median nerve in the
carpal tunnel.
 Hand numbness( night, driving car)
with pain, parasthesias in distribution,
clumsiness or weakness
 Thenar wasting
 Age: 30-60,
 F:M ratio 5:1
55

56. Causes of CTS
Decrease in Size of Carpal Tunnel
 Bony abnormalities of the carpal bones
 Acromegaly
 Flexion or extension of wrist
Increase in Contents of Canal
 Forearm and wrist fractures (Colles, scaphoid #)
 Dislocations and subluxations of carpal bones
 Post-traumatic arthritis (osteophytes)
 Aberrant muscles (lumbrical, palmaris longus)
 Local tumors
 Persistent medial artery (thrombosed or patent)
 Hypertrophic synovium
 Hematoma
56

57. Causes of CTS
Inflammatory Conditions
 Rheumatoid arthritis
 Gout
 Nonspecific tenosynovitis
 Infection
External Forces
 Vibration
 Direct pressure
57

58. Causes of CTS
Alterations of Fluid Balance
 Pregnancy
 Menopause
 Hypothyroidism
 Renal failure
 Long-term hemodialysis
 Obesity
 Lupus erythematosus
 Scleroderma
 Amyloidosis
58

59. DIAGNOSIS
 History which brings out any of the
causes
 Clinical tests:
◦ Phalen's wrist flexion test
◦ Tinel's nerve percussion test
 Treatment:
◦ NSAIDS, elevation and splinting
◦ Local corticosteroid injections
◦ Surgical decompression
59

60. Factors that don’t favor
conservative management
 Age over 50 years
 Duration longer than 10 months
 Constant paresthesia
 Stenosing flexor tenosynovitis
 Positive Phalen test in less than 30
seconds.
60

61. Bowler’s Thumb
 Perineural fibrosis caused by
repetitious compression of the ulnar
digital nerve of the thumb while
grasping a bowling ball.
 Tingling and hyperesthesia about the
pulp of the thumb.
 Treatment:
◦ splint and rest from bowling
◦ Occasionally neurolysis and dorsal
transfer of the nerve
61

62. BONE INJURIES
62

63. 63

64. PRESENTATION
 History:
◦ Handedness
◦ Occupation
◦ Mechanism of injury
◦ Time since injury “golden period”
◦ Place of injury
 Physical Examination:
◦ Inspection for open fractures, swelling
◦ Deformities (angulation, rotation, shortening)
◦ Alignment.
◦ Range of motion (active and passive)
◦ Neurovascular status
 Radiographic studies:
◦ 3 planes: AP, Lateral and Oblique
64

65. CARPAL FRACTURES
Scaphoid fractures:
◦ Most common carpal fracture (15% of wrst inj)
◦ Results from force applied on distal end with
wrist hyper extended (fall on outstretched
hand).
◦ Unless treated effectively it would result in mal-
union and permanent weakness and pain in the
wrist.
◦ Blood supply retrograde so proximal fragment
at risk of AVN
◦ Deep tenderness in anatomical snuffbox is
felt.
◦ Treatment:
 Stable: Cast for 12 weeks
 Unstable or non-union: ORIF
65

66. 66

67. CARPAL FRACTURES
 Triquetral fracture:
◦ 2nd most common carpal fracture
◦ Direct blow to the dorsum of the hand or
extreme dorsiflexion.
◦ Treatment:
 Chip fracture:
 symptomatic with 2-3 weeks immobilization.
 Body fracture:
 Minimally displaced: cast immobilization for 4-6
weeks
 Displaced: Closed reduction and pinning or
Open reduction and fixation
67

68. 68

69. Metacarpal Fractures
 Relatively common. 30-40% of hand
fractures
 Result from direct or indirect trauma.
 Most fractures are easily reducible,
stable and managed non-operatively.
 Indications of surgical intervention:
◦ Intra-articular fractures,
◦ Displaced and angulated fractures,
◦ Unstable fracture patterns,
◦ Combined or open injuries,
◦ Irreducible and unstable dislocations
69

70. 70

71. Phalangeal Fractures
 Distal Phalanx:
◦ Crush injuries from a perpendicular force
(injuries from a car door or hammer)
◦ Closed treatment is recommended with
splinting and if necessary closed reduction
71

72.  Middle Phalanx:
◦ Blunt or crush force perpendicular to the
long axis of the bone.
◦ Treatment:
 Nondisplaced without impaction: require only
dynamic splinting for 2-3 weeks.
 Angulation and rotation require closed reduction
and splinting to restore finger alignment.
72

73.  Proximal Phalanx:
◦ More common than middle phalanx
fractures.
◦ May result in a great deal of disability.
◦ Treatment:
 Nondisplaced fractures: usually stable and
treated by closed reduction and dynamic
splinting.
 Angulated or unstable fractures may require
internal or external fixation.
73

74. 74

75. AMPUTATION AND
REPLANTATION
75

76. INTRODUCTION
 Replantation: reattachment of a severed digit
of extremity.
 Not all patients with amputation are candidates
for replantation
 Decision based on:
 Importance of the part
 Level of injury
 Expected return of function.
 Hand function is severely compromised if
thumb or multiple fingers are lost so replants
of these should be attempted.
 Mechanism of injury may be the most predictive
variable for successful replantation.
76

77.  Recommended ischemia times for
reliable success:
◦ Digit: 12 hours for warm ischemia and 24
hours for cold ischemia.
◦ Major replant: 6 hours of warm and 12
hours of cold ischemia.
 Preoperative preparation:
radiography of both amputated and
stump parts to determine the level of
injury and suitability for replantation
77

78. 78

79. OUTCOME
 Overall success rates for replantation
approach 80%.
 Better outcome with Guillotine (sharp)
amputation (77%) compared to
severely crushed and mangled body
parts(49%).
 Studies have demonstrated that
patients can expect to achieve 50%
function and 50% sensation of the
replanted part.
79

80. Hand Infections

81. Hand
Infections
Palmar Space
Infections
Tendon
sheath
Infections
Bone
Infections
Joint
Infections

82. Spaces of Forearm and
Hand
Forearm space of Parona
Palmar Spaces
Thenar space
Midpalmar space
Web spaces
Ulnar space
Radial space
Dorsal Spaces of The Hand
Dorsal subcutaneous space
Dorsal subaponeurotic space
Superficial Pulp Space of Fingers

83. Etiology and Risk Factors
Organisms
 Staphylococcus aureus
 Streptococcus
 Herpes simplex
 Mycobacterial infections
 Fungal infections
Risk Facors
 Diabetic patients/Immunocompromised
 IDU
 BItes

84. Principles of Management
If there is any suspicion of sepsis
Asses Airway
Breathing
Circulation
qSOFA
Limb
Pain management
Therapeutic antibiotics
Elevation of hand

85. In History,
Co-Morbidities
Occupation
Handedness
During Examination
Felon Paronychia

86. Tenosynovitis

87. Deep Space Infections

89. Rx
Felon Paronychia

90. Deep Space Infections

91. Post-Op
Elevation of the hand
Antibiotics
Early physiotherapy
Analgesics
Tetanus toxoid
Confirm other co-morbidities
Refer to Plastic surgical team
Hand Surgeries-No place for 2ry
intention
of healing

92. Osteomyelitis
Almost always the result of
adjacent spread or direct
penetration
Commonest organism,
Staph.aureus
Bone necrosis;Hallmark

93. Diagnosis
X-Ray
Bone Scan
Surgical exploration-Best method
Treatment
Depends on the site
Surgical removal of debris
Decompression of the infection
Post-op care or constant irrigation

94. Septic Arthritis
 As a result of trauma
 Spreading from adjacent bony and
soft
tissues
CF
 Swelling
 Warmth
 Tenderness
 Pain on passive motion
 Pain with axial loading

95. Diagnosis
Clinical findings
X-rays
Arthrocentesis, culture and ABST
Treatment
IV antibiotics
Arthroscopy

96. 96

97. References
 Clinical Anatomy, Richard Snell, 9th
edition.
 Apley’s System of Orthopaedics and
Fractures 9th edition
 Macleod’s Clinical Examination, 13th
edition.
 www.medscape.com
97