HAND INJURIES Peter Freeman

ESSENTIALS A thorough knowledge of hand anatomy and function is essential for proper management of the injured hand Most hand injuries carry a good prognosis if treated early and appropriately Aftercare and rehabilitation are vital

PRESENTATION History –Time taken eliciting an accurate history of the mechanism of injury is never more important than in the case of hand injury –When, how, where? –Hand dominance –Occupation

EXAMINATION The injured hand must be examined in a well-lit cubicle with the patient comfortably reclined Deformity, swelling, position of wound Resting position Tenderness and sensation

NERVE SUPPLY TO THE HAND Radial Median Ulnar

EXAMINATION Test function - tendons (FDP, FDS and extensors) - grip - joint stability Deformity, rotation, loss of function Pain

INVESTIGATIONS Most information will be obtained from a full history and examination Radiology of the hand and fingers will be necessary if bone or joint deformity or tenderness is elicited

CLASSIFICATION Hand injuries are usually described by tissue, e.g. tendon, nerve or bone injury A more practical approach is to describe injuries by anatomical site

FINGERTIP INJURIES Classification of fingertip amputations

NAILBED INJURIES Often underestimated Trephine subungual haematoma < 25% Remove nail if > 25% Reduce # terminal phalanx Repair nail bed with 6/0 absorbable Nail regrowth - 1mm/wk

TERMINALIZATION Explain options with patient Discuss with specialist Local anaesthetic Remove nail root Diathermy digital nerves and vessels Loose closure and avoid dog ears

DIGITAL NERVE BLOCK- PALMAR APPROACH

DISTAL INTERPHALANGEAL JOINT INJURIES Mallet finger (always Xray) Dislocations Fractures Wounds - digital nerves

MIDDLE PHALANGEAL INJURIES Profundus tendon Fractures often require ORIF Unstable Discuss with hand specialist

PROXIMAL INTERPHALANGEAL JOINT INJURIES Most unforgiving joint Extensor apparatus Boutonniere deformity Volar plate Wilson # Joint instability Splint and refer

PROXIMAL PHALANGEAL INJURIES Profundus and superficialis tendons Unstable fractures require ORIF Rotational deformity Refer hand specilaist Spint in position of function/recovery

METACARPOPHALANGEAL JOINT INJURIES MPJ subluxation - often missed Fist-tooth injury - always involves joint - irrigation - antibiotics Ulnar collateral ligament tears

METACARPAL INJURIES 5th MCP fracture (punching) - best treated conservatively Bennett’s fracture (intra-articular) - often requires ORIF 2nd, 3rd and 4th MCP fracture - volar spint in position of recovery

DORSAL HAND INJURIES Kessler technique of tendon repair. An alternative technique is to begin the suture between the tendon ends and tie, and bury the knot within the tendon.

PALMAR HAND INURIES Penetrating wounds in no-mans land - Nail gun injury (barbs) - Grease or Paint gun injury - Glass injury (always Xray) - Organic material (consider US)

DISPOSITION Many hand injuries can be appropriately managed in a well equipped emergency department Refer early when indicated Elevation Analgesia

PROGNOSIS Early definitive care optimal Late injury difficult to salvage due to stiffness Functional splintage (extrinsic plus) Early guarded mobilisation Desensitise finger tips

PREVENTION Children's finger tips Occupational injuries - butchers

CONTROVERSIES Fingertip dressings Hand splintage Fifth metacarpal fractures Foreign bodies To suture or not? Adrenaline Antibiotics