1. HAND INJURIES Peter Freeman

2. 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

3. 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

4. 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

5. NERVE SUPPLY TO THE HAND Radial Median Ulnar

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

7. 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

8. 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

9. FINGERTIP INJURIES Classification of fingertip amputations

10. 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

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

12. DIGITAL NERVE BLOCK- PALMAR APPROACH

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

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

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

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

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

18. 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

19. 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.

20. 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)

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

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

23. PREVENTION Children's finger tips Occupational injuries - butchers

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