Hand injury

HAND INJURY

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

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

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

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

5. Prehension Perception Identification Communication Cosmesis Functions

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

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

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

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

10. Blood supply

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

12. Extensor

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

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

15. Bony Injuries: Fracture Subluxation Dislocation Traumatic amputation Traumatic disarticulation Type of Hand Injuries

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

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

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

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

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

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

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

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

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

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

26. Prioritization Skeletal stabilization Vascular repair Skin cover Nerve repair Tendon repair Treatment

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

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

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

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

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

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

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

34. Technique Kessler Modified Kessler technique Bunnell Tendon repair

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

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

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

38. Neuropraxia Axonotmesis Neurotmesis Treatment options Primary repair: within 24 hours Delayed Primary repair: within 1 wk Secondary repair: >1 wk Nerve injuries

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

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

41. Clean guillotine amputation Amputation proximal to DIP Bilateral hand injuries Amputation of thumb Occupational value of the hand Amputation in children Indications for reimplantation

42. Severely crushed or mangled digit Amputation at multiple level Mentally unstable patient Unstable patient Contraindications to reimplantation

43. Other of reimplantation (BEFANV) Bone Extensor tendons Flexor tendons Artery Nerve Vain Reimplantation

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

45. Early presentation Injured structures Prognosis

46. Hand injury is common Can be devastating and disabling Prompt and adequate treatment is key Conclusion

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

48. Thank you for listening