1. Hand Injuries Part 3 Dr Mark Putland

2. Metacarpals Others 2 and 3 – Need ORIF – Look for other injuries as this implies a big force 4 th – no impairment 5 th – no impairment – Test for rotational deformity Do not hold position well so do not reduce. Analgesia +/- block, gutter slab, sling, plastics clinic

3. Carpals

4. Scaphoid Common injury Much fear Little evidence. Blood supply from distal

5. Carpals Scaphoid Common injury Much fear Little evidence. Blood supply from distal Normal Xray but sore scaphoid – 5% have a fracture – 10% of the fractures will fail to heal without immobilisation

6. Carpals Scaphoid Options – Immobilise and 10/7 R/V with XR XR has low sensitivity at day 1 and day 10 – Bone scan Low sensitivity on Day 1 100% sensitivity day 4 Whole body radiation – CT on Day 1 Very high sensitivity from day 1 Also finds other carpal bone fractures – MRI on day 1 100% sensitive Availability and cost are problems

7. Carpals Carpal dislocations Disastrous to miss Severe morbidity Know your carpal bones Look at the patient Terry Thomas Sign

8. Carpals Carpal Dislocations If the proximal row or part of it is dislocated from the radius it is a lunate or scaphoid dislocation Nomenclature is complex

9. Carpals Carpal Dislocations If the proximal row is on the radius and the distal row is dislocated posteriorly it is a peri-lunate dislocation Gets more complex when there is an associated fracture (e.g. Trans-scapho peri-lunate etc) Nomenclature

10. Carpals Carpal Dislocations Slab Elevate Analgesia Refer urgently for operative reduction

11. Amputations Fingertip Do nothing if – Minimal palmar skin loss – <50% nail bed loss Graft/terminalisation – >50% nail bed lost – >1cm skin loss – NB: may still use amputated part for grafting

12. Amputations Hand Good prognostic factors – Clean cut – Time Warm <6-8 hours Cool <12 hours (24 hours for skin only e.g. finger tips) – Site and muscle content – Contamination minimal – Water damage minimal – Age (young) – Not Smoker, diabetic, steroids, PVD Try hardest with – Thumb – Index finger – Multiple fingers ( may only aim to get one or to back) – Children

13. Amputations Care of the parts Patient – ABC Especially fluids, especially blood – Analgesia IV narcotic, consider ketamine in low doses, NON-ischaemic block – Antibiotics, tetanus, other injuries, psychological Stump – Remove any tourniquet – NO vascular clamping – Moist N-saline compress – X-ray Part – Wash gross contamination in sterile saline – Moist N-saline gauze – Double bag and then put in ice slurry in the bottom shelf of the fridge – X-ray