ACUTE HAND

INJURY
PRESENTER: GIRUM MESERET (MD, GSR II)
OUTLINE
 Objectives
 Introduction & Synopsis
 Approach to patients
 General principles of Management
 Specific injuries
 Tendon injury
 Nerve injury
 Finger tip & Nail injury
 Fractures
 Replantation & Revascularization
 Summary
 References

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OBJECTIVES
• List the spectrum of acute hand injury
• Brief proper ER care for patient with
acute hand injury
• Discuss perioperative consideration for
managing acute hand injury
• Discuss principles of management for
different types of acute hand injury

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INTRODUCTION
• Account for 5-10 % of hospital ER visits
• Hand derangements account 9% of worker
compensation
• Injuries have environmental, occupational,
and recreational causes and are seen in all
age groups
• The spectrum of injury includes lacerations,
tendon & NV injury, fractures, crush
wounds, amputations, and burns

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CON’T…INTRO

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APPROACH TO PATIENTS
History
• “HW” questions about the trauma
• General
• Age, hand dominance, occupation, previous hand problem,
medical Hx

P/E
• Expose the upper extremities
• Resting posture, Laceration, Muscle wasting, color, scar,
asymmetry & deformity, Joint RoM
• Neurovascular examination:- Motor examination, Sensation,
Tendon function

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 CON’T …P/E
Inspect
• Compare with the other side, Resting
posture, Deformity

Palpate
• Tenderness, Swelling

Range of Motion
• Passive & active RoM

Stability assessment
Musculotendinous Ass’t
• Posture, Motion, Power, Grip,
Test for specific Muscle
Nerve Ass’t
Vascular Ass’t

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CON’T …APPROACH
Investigation
• X-ray: Fracture, Foreign body, Tendon avulsion
• U/S: locating foreign bodies & ruptured tendons
• Doppler and angiography
• CT scan
• MRI: highly sensitive in detecting ruptured
tendons
• Neurophysiological studies

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 PRINCIPLES OF
MANAGEMENT
• Manage patients based
on ATLS protocol
• Maintain or restore distal
circulation, obtain a
healed wound, preserve
motion, and retain distal
sensation
• Set realistic goal
• Managed in the ER & OR
• TAT, Analgesics,
Antibiotic

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 CON’T …PRINCIPLES
PERIOPRATIVE CONSIDERATION

Scrubbing: alcohol, Iodine,

chlorhexidine
Anesthesia: GA or Regional
• Brachial, Peripheral nerve, IV or
Local
Tourniquet: Elastic, Esmarch,
Pneumatic
Incisions
• Avoid on deep crease &
perpendicular to finger crease
Closure, Splinting & Rehab
• Simple, graft or flap closure
• Immobilize at a position that

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promote healing
SPECIFIC INJURIES

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 FLEXOR TENDON INJURY
• 12 flexors in the
hand, 9 pass through
carpal tunnel
• In digits tendon pass
through fibrossious
structure covered by
digital sheath
• Pulley
• Injury can be open or
Closed

Finger pulley Thumb pulley

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CON’T …FLEXOR
Finger Zone’s of INJURY
I. From Insertion of the FDS tendon to the
terminal insertion of the FDP tendon
II. From Proximal reflection of the digital synovial
sheath to the FDS insertion
III. From Distal margin of the transverse carpal
ligament to the digital synovial sheath
IV. Area covered by the transverse carpal ligament
V. Proximal to the transverse carpal
ligament

Thumb zone’s of INJURY

VI. Distal to IP joint
VII. From IP to A1 pulley

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VIII. Area of thenar eminence
 CON’T …FLEXOR
Diagnosis
• Anticipate from Mechanism of injury
• Open injury in most cases -> tendon visible
• Assess tendon & nerve status

Timing of Repair
• Primary repair within 24 hrs
• Secondary repair 3 – 4 wks

General principles
• Sufficient strength & No gapping
• Repaired tendon should withstand 40N
• Smooth tendon gliding
• Easy to perform

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 CON’T …FLEXOR
Indications for Primary repair
• Clean-cut tendon injuries
• Tendon cut with limited peri-tendinous damage, No or limited defects in
soft-tissue coverage
• Within several days or at most 3 or 4 weeks after tendon laceration

Contraindications for Primary repair

• Severe wound contamination
• Bony injuries involving joint components or extensive soft-tissue loss
• Destruction of a series of annular pulleys and lengthy tendon defects
• Experienced surgeons are not available

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CON’T …FLEXOR Technique
 ≥4 core strands are
recommended
 Certain tension across the repair
site – 10% shortening of tendon
segment after repair
 Core suture purchase: 7–10 mm
 Locking tendon–suture junctions
in core suture
 Diameter of the locks: ≥ 2 mm
 Suture calibers: 3-0/4-0 for core
suture
 A variety of nylon sutures, or a
Fiber Wire suture
 A simple running or locking
peripheral suture
 Avoid extensive exposure of

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sutures over the tendon surface
CON’T …FLEXOR

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 CON’T …FLEXOR
Partial Tendon Laceration
• Less than 60% of the diameter of the tendon does not necessitate a
repair by core sutures
• Trim the tendon edge or epi-tendinous repair
• Laceration of 60–80% requires at least an epi-tendinous repair

Closed rupture of the flexor tendons and pulleys

• Usually associated with athletic activities:- football, climbing
• FDP tendon-bone junction avulsion & A2 pulley commonly affected
 Early recognition & primary repair
 Free tendon graft otherwise

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 CON’T …FLEXOR
Postop care
 Elevation
 Splinting
1. Kleinert
• Active extension – passive
flexion motion protocol
2. Duran & Houser
• Controlled finger flexion

3. Combined active
passive

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CON’T …FLEXOR
Secondary procedures
• Failed primary repair or wide tendon defect
1. Free tendon grafting
2. Staged reconstruction
3. Tenolysis

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CON’T …FLEXOR
Outcome
• Good active finger RoM in ¾ primary repairs

Complication
• Adhesion
• Finger joint stiffness
• Rupture

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EXTENSOR TENDON
INJURY
 All extensor tendons
pass through the
extensor retinaculum

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 CON’T …EXTENSOR
Diagnosis
 Perform P/E with maneuvers
 Partial lesions might be missed
 Open lesions => EXPLORE

 Zone V laceration retract – Fight

bite injury

Elevation of
thumb off the
table – test for

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EPL
 CON’T …EXTENSOR
Zones
I. At DIP -> Mallet finger
II. Over middle phalanx
III. At PIP – Boutonnier deformity
IV. At proximal phalanx
V. At MCP -> Fight bite
VI. At MC bones -> better prognosis
VII. At extensor retinaculum -> direct open or closed
(often after distal radial #)
VIII/IX. Musculotendinous junctions & muscle bellies
• Identification of tendons is challenging

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CON’T …EXTENSOR
Repair Techniques
 Simple laceration can be repaired at ER & those proximal
to zone VI need OR exploration & repair
 Zone I-V the tendon is wide and flat and Zone VI-VIII the
tendon is narrow and thick
 Repair techniques must take this into consideration

 Same principle of repair as flexor tendon, EXCEPT

• Distal zones locking & grasping is difficult
 Unlike flexor tendon’s minimal change in length results
movement difficulty

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 CON’T …EXTENSOR
• Zone I: splint DIP in
extension for 6 – 8wks
fulltime
• Zone II: if <50%
laceration no Rx,
otherwise running +
Silfverskiold cross stitch
• Zone III: splint PIP in
extension for closed,
like Zone II in open
injury
• Zone IV & above as

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flexor repair
CON’T …EXTENSOR

Postop care
• Rx protocol should
address flexor
antagonism
• Immobilization –
splinting
Outcome
• Distal (to zone VI)
lesions less favorable
outcome

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NERVE INJURY
Patient assessment
1. Type if injury: laceration, traction/stretching
2. Sensibility: sensation along the nerve distribution (pain, touch & two
point discrimination)
3. Motor function
• Ulnar:- FCU, FDP(4th, 5th), FPB, AdP,
AbDM,FDM,ODM,Interossios
• Holding paper b/n thumb-index web
• Median:- FCU, FDP (2nd,3rd), FPL, PQ, OP, AbPB, lumbrical for
2nd & 3rd digit
• Apposition of thumb to little finger
4. Sedomotor

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• No sweating on affected site 30min after nerve injury
 CON’T …NERVE
Types of Injury
1. Neurapraxia:- minor contusion or compression
2. Axonotmesis:- axons are interrupted but schwann cells &
endoneural tube anatomic continuity preserved
3. Neurotmesis:- actual disruption of continuity

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 CON’T …NERVE
Nerve Regeneration after injury
• Proximal element increased cellular activity at the cell body &
axonal sprouting within 1 – 3 wks
• Distally Wallerian degeneration (myelin sheath disruption &
phagocytosis)

• Affected site: anesthesia -> parasthesia -> hyperesthesia ->

Normal (18 – 24 months)

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 CON’T …NERVE
Repair
Timing
I. Primary within 24 hrs
II. Delayed primary within 3 wks
III. Secondary after 3 wks

• Indication for secondary:- extensive soft tissue & nerve loss,

wound contamination, presence of multiple limb injury
• The longer the delay the poorer the return of motor function

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CON’T …NERVE
Suturing
• Keep internal alignment
• Mobilize
• Suture material: 8-0/9-0
monofilament
• Suture arrangment
• Perineural
neurorrhaphy
• Combined epineural &
perineural neurorrhaphy

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CON’T …NERVE
Nerve graft
• When there is gap & tension
• Sources:- sural nerve, lateral & medial antebracheal
cutaneous nerve, digital nerve from amputated finger

Other Alternatives
• Silcone tubes: for gap ≤5mm
• Polyglcolic acid tube: for gap <3cm
• Vein conduit: for gap of 5cm

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FINGER TIP INJURY
• Commonest injury of the hand
• Frequently injured:- 3rd > 4th > 2nd > 1st & 5th finger tip’s
• Majority occur in 4 – 30 yrs of age and 3/ 4th in males
• In 50% of nail bed injury there is distal phalangeal #

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CON’T …FINGER TIP
Subungual Hematoma
• Cause pain & separation of nail from nail bed
• Drain if large
• Hematoma >50% of area has 60% incidence of nail bed
laceration which require repair

Distal phalanx #
• Rx:- Nail bed repair & replacement of nail
• In large fracture use K-wire fixation

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CON’T …FINGER TIP
Nail bed Laceration
• Rx:- explore nail bed
• Repair laceration with 7-0 chromic suture

• A. 36%-simple B. 27%-stellate
C. 22%-crushing D. 15%-avulsion of germinal epithelium

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 FRACTURES &
DISLOCATION
Carpal bone fractures
 Scaphoid #
• Commonest
• Results from fall on outstretched hand
• Pain on the radial side of the wrist and tenderness is maximal in the
anatomical snuff box
Management
 Cast immobilization for non displaced # until radiologically healed
(6-12 wks)
 ORIF
 >1mm displacement
 Non union (early stage)
 Proximal pole fracture

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CON’T …FRACTURE
Metacarpal #
• Categorized as head, neck, shaft, or base fractures.
• 2nd and 3rd metacarpals are relatively immobile and
fractures require anatomic reduction

• Management
• Closed reduction & Immobilization
• ORIF for rotation & Unacceptable misalignment

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CON’T …FRACTURE
Phalanx Fracture
Middle phalanx #
• 2 – 3 wk immobilization followed by protected motion for
transverse #
• K-wire for 4 – 6wks for spiral or oblique #
• ORIF is alternative but higher adhesion rate

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CON’T …FRACTURE
THUMB MC #
Bennett’s fracture: Rolando’s fracture:
• Intra articular fracture- • Comminuted displaced
dislocation of the thumb intra articular thumb base
fracture.
metacarpal base.
Rx
Rx
• ORIF
• Closed reduction with traction,
palmar abduction an pronation
• ORIF

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 CON’T …DISLOCATION
DIP Joint
• Reduce with longitudinal traction & hyperextension
• Apply Dorsal Splint with flexion for volar & in extension for Dorsal
dislocations

PIP Joint
• Dorsal dislocation:- Reduce by longitudinal traction & mild
hyperextension with dorsal pressure on proximal aspect of middle
phalanx. Buddy tapping or splint for pt’s on vulnerable activity
• Volar dislocation:- uncommon & usually associated with tendon
injury
• Open reduction & immobilize briefly in slight flexion

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 CON’T …DISLOCATION
MCP of the Fingers
• Dislocation uncommon b/c of strong periarticular structure; but if it
occurs often on 4th & 5th finger
• Closed reduction by using traction & pushing the base of
dislocated phalanx toward MCP joint
• Open reduction if associated volar plate injury

MCP of Thumb
• Anterior dislocation classified as simple or complex
• Simple dislocation: avoid traction & push the phalanx to MCP,
then thumb Spica
• Complex dislocation:- open reduction

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REPLANTATION &
REVASCULARIZATION

• Should be considered for

all amputation
Indication
• Multiple digit amputation
• Thumb amputation
• Whole or partial hand amputation
• Any amputation in a child
• Single digit amputation distal to FDS
insertion
Contraindication
• In time of life over limb situations

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• Unfit patient
CON’T …REPLANTATION
Care for amputated part
• Warm ischemia time 6 hrs
• Cold ischemia time 12 hrs

Operation preparation
• Till patient resuscitated amputated part examined in the
OR
• Tag NVS with prolene 7-0
• Look for string/ribbon sign => no replantation
• Once patient in the OR
• Proximal level exploration

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CON’T …REPLANTATION
Operation Sequence
1. Bone fixation
1. Shortening might be considered
2. Tendon repair
3. Artery repair
1. Debride beyound zone of injury & explore for intimal flap
2. Flush with dilute heparin 100IU/ml & see pulsatile flow
3. Repair all arteries as possible => vein graft can be used
4. Vein repair
5. Nerve repair
6. Skin closure

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CON’T …REPLANTATION
Postop care
• Anticoagulant
• Physical & Psychological therapy
Outcome
• 90% survival of replanted part
• Different functional outcome

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 SUMMARY

• Proper patient examination not to miss injuries

• transfer to specialist center
• Tendon repair outcome is dependent on technique,
concomitant injury, timing of repair & postop care
• For Revascularization 12 hr. cold ischemia & 6 hr.
warm ischemia time
• Remember transport for amputated part

 Consultant experience on acute hand injury

management

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REFERENCES
 Bruce D. Browner: Skeletal Trauma; Basic Science, Management,
and Reconstruction; 5th Ed, 2015
 Frank H. Netter: Atlas of Human Anatomy
 Leon Dorn: An Atlas of Surgical Anatomy; 2005 UK
 Peter C. Naligan: Plastic Surgery Vol. 6 (Hand); 3 rd Ed, 2013
 S. Terry Canale, James H. Beaty: Campbell’s Operative
Orthopedics; 12th Ed, 2013
 www.emedicine.medscape.com
 Soft Tissue Hand Injury
 Hand Fracture
 Emergent Management of Hand Dislocation
 www.Suzyred.com
 Iceberg picture

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END

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