1. Colin Del Castilho Dr Ian Rigby
Hand Injuries
Colin Del Castilho
Dr Ian Rigby

2. Famous Hands

3. Outline Hand exam Hand Infections High Pressure Injection Injuries
Fractures/Dislocations
Tendon injuries
Amputations

4. Things Not Covered Carpal fractures/ Wrist fractures
Thermal injuries and Frostbite
Nerve Blocks

5. 6 Finger Hand Exam A Appearance: Resting posture Ischemia/cyanosis
Lacerations
Swelling
Erythema
Deformity

6. 6 Finger Hand Exam,
B both hands
Compare to other hand

7. 6 Finger Hand Exam C Circulation Allen’s test
Control lacerations- direct pressure, don’t clamp
Inflate BP cuff to 30>systolic pressure, no more than 30 min

8. 6 Finger Hand Exam
D Neurological assessment
Sensory

9. 6 Finger Hand exam D Neurological Assessment Motor
Screening exam
Thumbs up (hitchhiker
Spread finger apart
Maneuver tips of each finger and thumb around tip of pen
If deficit detected, proceed to more thorough motor exam

10. 6 Finger Hand Exam
E extension
Test all digits

11. F Flexion
Assess all joints
FDP and FSP separately

12. Hand Infections

13. What is this?

14. Herpes Whitlow HSV 1 60%, HSV 2 40%
Common in children, health care workers, immunocompromised
Inoculation occurs through breakage in skin barrier
Incubation period days
Prodrome- fever, malaise, burning, erythema, tingling in affected digit

15. Herpes Whitlow
1-3mm grouped vesicles on erythematous base lasting 7-10 days
Crust over- no longer infective
May recur (remains dormant in nerve ganglia)
Treatment:
Allow vesicles to rupture on own
Zovirax ointment
Oral acyclovir
Observe for bacterial superinfection- start keflex

16. What is this?

17. Paronychia Acute infection of nail bed
Usually staph, may be oral anaerobes
Treatment
Incision around nail bed to drain pus
Antibiotics usually not necessary
May need to remove nail if abscess spreads under nail
Finger chewers- clinda

18. Paronychia

19. How about this?

20. Felon Abscess of finger tip S. aureus, oral anaerobes Treatment:
I and D
Keflex for 7-10 days
Referral to hand surgeon if does not improve

21. Felon

22. Complications Finger tip necrosis Tenosynovitis Osteomyelitis
Neuroma (from I and D)
Admit to hospital----- immunocompromised, systemic symptoms, failure to respond to abx

23. Famous Hands

24. Famous Hands

25. Name this Infection

26. Pyogenic Flexor Tenosynovitis
Direct inoculation- Staph
Rarely hematogenous spread- NG

27. Pyogenic Tenosynovitis
Cardinal Symptoms
Pain on passive extension (most sens)
Pain on palpation of flexor tendon
Symmetric/fusiform swelling
Finger held in flexion

28. Pyogenic Tenosynovitis
Management
Urgent plastics consult
Antibiotics: IV 3rd gen Cephalosporin, then adjust based on C and S
Complications
Bacteremia
Compartment syndrome
Loss of finger function

29. Clenched Fist Injury/Human Bite
Most commonly caused by “fight bite”

30. Clenched Fist Injury/Human Bite
75% involve extensor tendon, joint, bone or cartilage
Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist injuries. Clin Orthop 1987;220:
May extend to joint capsule
May involve MCP or PIP fracture
50% infection rate -Staph, Strep, Eikenella. On average- 5 organisms in wound
Examine in position of injury
Extend wound 3-5 mm either side

31. Clenched Fist Injury Management Complicated wounds:
Uncomplicated early wounds:
Antibiotics: Clavulin
Clinda + Cipro or Septra
Pen + Clox
Avoid first gen cephs- Eikenella resistance
Debridement, irrigation, close by secondary intention
Splint in position of safety if tendon injured
Tetanus
Must have follow up
Complicated wounds:
Referral to plastics
IV antibiotics - cefoxitin, tazocin

32. Deep Space Hand Infections
Staph, Strep, coliforms
Management: IV Ancef and refer

33. Famous Hands

34. High Pressure Injections
Only requires 100psi to break skin commonly involve ,000psi
Index finger most common, non dominant hand
1000psi = 450 lbs
falling 25 cm

35. High Pressure Injections
Damage determined by
Type of injection: Grease/oil, hydraulic fluid, paint thinner, molding plastic, paraffin, cement
Amount
Finger- 1st and 5th digit may lead to compartment syndrome in wrist and arm
Direct tissue damage, vasospasm/ischemia, inflammation

36. High Pressure Injections
Management:
IV analgesia only. Avoid digital nerve blocks- increase ischemia
Immediate Plastics Consult
NPO
Factors associate with Amputation- 70% of oil injections
100% if > 7000psi
Delayed presentation

37. Hand Fractures

38. Distal Phalanx Fractures
Usually from crush injury
Rarely displaced, usually comminuted
May have associated subungal hematoma
Management of tuft #:
Short finger splint 1-2 weeks (don’t immobilize PIP

39. Distal Phalanx Fracture
Transverse or Longitudinal shaft #
Stack splint for 4 weeks
FDP avulsion
Refer to plastics
Intra-articular #’s- refer to plastics
Mallet finger will be discussed later

40. Subungal Hematoma
Previously recommended for nail removal and formal nail bed for all > 25% of nail
Roser 1999
No difference in long term outcome between nailbed repair, trephination, or observation only
Management
Trephinate the nail for pain control
Nail bed repair for (i) displaced # fragment (ii) disrupted nail (iii) consider for large hematoma (>50%)

41. Middle and Proximal Phalanx Fracture
Assess for neurovascular and tendon/ligament stability
Stable shaft fractures: Buddy tape with early ROM
Uni or Bicondylar Fractures: unstable, require ORIF

42. Middle and Proximal Phalanx Fractures
Unstable fractures: displaced, oblique or spiral fractures, comminuted, scissoring deformity/rotation, unable to reduce or maintain reduction
Rotational deformity: nail not in line with mcp, scissoring, finger does not point to scaphoid tubercle when flexed
Treatment: requires plastics referral
Splint index/ middle in radial gutter splint
Ring/little finger in ulnar gutter splint

43. Unstable Phalanx Fractures

44. Metacarpal Fractures
Head
Neck
Shaft
Base

45. Metacarpal Fractures Normal Accept 5 degrees 15 20 degrees 30
Hand Function can tolerate angulation equal to CMC joint motion + 10o
Normal Accept
5 degrees
20 degrees
30 degrees

46. Metacarpal Head Fracture
Variant of Boxers #
Will need ORIF:
>1mm step off
>25% intraarticular surface
displaced
Splint in position of safety
Look for fight bite

47. Name the #

48. Metacarpal Neck # Attempt to reduce if: Splint in position of safety
Angulation > 40o -5th
30o th
15o - 2, 3rd
Splint in position of safety
When to refer to plastics for k wire or ORIF
Any rotational deformity
Shortening > 3-4mm
Unable to maintain reduction

49. Splint Metacarpal neck #
Position of safety to prevent MCP contractures
Hold in reduction and mold splint until set
Must include 4th MC
If MCPs aren’t flexed 90 degrees ---> loss of reduction

50. Metacarpal Shaft Fracture
Accept same angulation as Neck #
No rotation
Shortening up to3-4mm
Reduction technique:
Jahss technique: flex both MCP and PIP to 90o. Press up on Middle phalanx and down just proximal to apex of#
Then splint in position of safety

51. Metacarpal Shaft #
Unstable: spiral, oblique, rotation, multiple #’s, failed reduction- will need to refer

52. What is this?

53. Bennett’s Fracture Axial load on partially flexed thumb
2 part intraarticular # w/ CMC subluxation
Management:
Thumb spica
Refer for ORIF

54. How about this?

55. Rolando 3 or more fragments, intraarticular Management: Thumb spica
Refer for ORIF

56. Reverse Bennett’s Intraarticular fracture of 5th metacarpal base
Unstable: extensor carpi ulnaris
Management: plastics referral for K wire insertion or ORIF if any displacement

57. Famous Hands

58. Dislocations

59. DIP Dislocation
Less common- more stability due to insertion of extensor/FDP tendons
Usually associated with skin breakage- need antibiotics
Reduce similar to PIP dislocations
If not reducible or unstable - refer to plastics

60. PIP Dislocation Mostly dorsal-- hyperextension injury Maybe ulnar
Need Xray to rule out fracture
May have associated avulsion

61. PIP Dislocation Management
Splint in 30o flexion or buddy tape for 3 weeks, refer to hand clinic
Early ROM
Refer if
Unable to reduce
Instability with active ROM
> 20o instability with passive ROM
Volar dislocation: attempt closed reduction

62. Reduction Technique

63. PIP Subluxation +/- #

64. PIP Subluxation +/-# Xray in full extension
Wont’ be able to maintain reduction in extension
Splint and refer for extension pin

65. MCP dislocation PIP almost always dorsally angulated
Associated with volar plate injury
May be associated with avulsion fracture or sesmoid bone in joint

66. MCP Dislocation Management
Flex wrist (relax flexor tendons) and press on proximal phalange in volar direction
Do not hyperextend or place traction on finger as this may pull volar plate into joint
Cant reduce if volar plate in joint- refer
If sesmoid bone in joint- refer
Volar dislocations require ORIF

67. Gamekeeper's/Skier’s thumb
Rupture (partial/complete) of ulnar collateral ligament
Mechanism: valgus stress on MCP or fall onto abducted thumb
Exam: >35o = complete tear

68. Gamekeeper's/Skier’s Thumb
Xray
Management
Partial: thumb spica for 4 weeks then physio
Complete: refer
Stener lesion: abductor aponeurosis in joint space- refer
Associated #

69. Famous Hands

70. Flexor Tendon Injuries
Test FDP and FSP separately
Closed wounds uncommon- exception is jersey pull of fifth digit
Explore open wounds
If suspected: splint wrist in 30° of flexion, MPs at 70° of flexion, and PIPs at 30-45° of flexion and refer for repair in OR

71. Extensor Tendon Injuries

72. Extensor Tendons Examine in position of injury >50% repair
May have normal function with >90%
Can be repaired in ED
If open- abx
Technique:
Figure of 8 or horizontal mattress

73. Suturing Technique
Bunnel
Kessler

74. Zone 1 Check Xray Closed Incomplete- splint 6-8 weeks
Closed Complete (Mallet finger)- splint 6-8 weeks

76. Open Mallet Finger Open Incomplete- repair Open Complete-
Repair with Roll Sutures
Splint 6-8 weeks
Complication: Swan neck deformity

77. Zone II
Treat like zone I

78. Zone III
Mechanism: extended finger forced into flexion ie jammed finger

79. Zone III Mx Splint and refer for
Extension splint for 6 weeks (leave DIP free)
Refer to physio at 6 weeks for ROM exercises
Splint and refer for
avulsion # at base of middle phalanx
unstable joint (associated collateral injury)
irreducible volar dislocation
Boutonniere deformity not correctable by passive PIP extension

80. Zone III Open: may attempt repair
Complication: Boutonniere deformity (volar slip of lateral bands)

81. Zone IV Bigger tendon, easier to repair Partial-splint 4 weeks
Complete and Closed: Splint 6 weeks with physio at 6 weeks
Complete and Open: repair

82. Zone V and Zone VI May be repaired in ED
Zone V- if associated with sagittal band and dorsal hood injury- repair or refer
Splint with wrist 30o extension, MCP 20o flexion, digits in neutral

83. Nerve Injuries
Median and Ulna- refer for immediate or delayed repair (10days)
Radial nerve repairs may delayed up to 3 months
Digital Nerve: repair depends on finger
Thumb, radial aspect index, middle = grip , ulnar aspect of 5th
Only refer if proximal to DIP

84. Famous Hands

85. Arterial Injuries Radial/Ulnar artery injuries need referral
Digital arterial injuries: assess clinically- if no ischemia, does not need repair (collateral circulation)
Assess for associated nerve injury

86. Amputations

87. Amputations distal to DIP

88. Management
Amputated part--- clean, wrap in saline soaked gauze, place in sealed bag, place in half ice/half H20 (4oC)
Stump: clean, don’t debride, wrap in saline soaked gauze
Tissue bridge- leave intact, may contain nerves/arteries
Complications post replantation: cold intolerance, loss of ROM , pain, anesthesia, paresthesias, poor 2 point discrimination, malunions, and nonunions.

89. Local Hand Resources Foothills hand clinic 944 1432
Lindsay Park:
PLC:
RVH: ph , fax
fill out form, refer from ED
OT/PT will contact pt based on priority
ACH: ph , fax
OT/PT will contact pt w/i 48h