1. Hand Rounds: Oct 31, 2002 Rob Hall MD and Lisa Campfens MD, FRCPC
Where would we be without our hands???

2. Goals for today Recognize serious injuries Manage common hand injuries
Appropriate referrals to plastics
Proper splinting of injuries
F/U of certain injuries in emerg
Recognize that management of many hand injuries is controversial

3. Goals of Today Fractures Dislocations Sprains Tendon injuries
Amputations
Mutilating injuries
High pressure injection
Digital nerve injury
Not covering
infections
foreign bodies
burns
compartment syndromes

4. Position of Safety

5. CAM effect

6. Box of the Finger

7. Management?

8. Distal Phalanx Tuft Fractures
Distal hairpin splint
Do not immobilize PIP
Manage subungual hematoma

9. Subungual Hematoma
Previously recommended for nail removal and formal nail bed for all > 25%
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

10. Approach to Phalanx Fractures
Stable
transverse, nondisplaced
Unstable
oblique, spiral, comminuted, displaced transverse, intraarticular with > 20% joint, rotational deformity
MUST rule out rotational deformity
symmetric flexion, point to scaphoid, nails

11. Stable Phalanx Fractures
Dynamic Splinting (buddy tape)
Early ROM (as soon as pain subsides - 3 to 5 days)

12. Unstable Phalanx Fracture
ED Management
Reduce
Splint
Refer

13. Unstable Phalanx Fracture: Options
Closed reduction and splinting
Splint X 3 weeks
F/U Xray 7-10days to make sure reduction is held
OR if unable to maintain reduction
Pin early
Unable to reduce
Unable to maintain reduction
Rotational deformity
Intraarticular with > 20% of joint involved

14. Principles of Metacarpal Neck #
Why do Boxer’s # do well no matter what you do??
Hand function can tolerate angulation in the metacarpal neck equal to the motion at the CMC joint + 10 degrees

15. Principles of Metacarpal Neck Fractures
Normal Accept
5 degrees
20 degrees
30 degrees

16. Metacarpal Head Fracture
Intra-articular
Needs precise anatomic reduction
Brewerton views can help identify
Splint in safe position and refer

17. Management?
“Well he was talkin’when he shoulda bin listen man”

18. Boxer’s Fracture Who needs reduction? How to reduce? Follow up?
Displaced, angulated > 40 degrees, rotated
How to reduce?
Ulnar, metacarpal, hematoma blocks -->
Follow up?
Xray at 1 week to r/o slip
F/U with GP (or ED)
Remove splint at weeks and start ROM

19. Boxer’s Fracture Indications for OR Can obtain adequate reduction
Can’t maintain adequate reduction
Controversy
Study: pin vs no pin makes no difference
Van Bowen: pin anything that needs reduction
Generally fairly uncommon to need pinning
Rotational deformity/scissoring likely most common reason to pin

20. Splinting Boxer’s Fractures
Proper splinting ESSENTIAL to maintaining reduction
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

21. Open Boxer’s Fracture “Fight Bite” ----> HIGH risk of infection
+++++ Irrigation and Explore
Look carefully for tendon disruption
Not into joint capsule
Leave open, clavulin/Keflex, check at d
Into joint capsule
Leave open, clavulin or keflex po X days
Wound check in hrs

22. Other MC neck Fractures
4th: manage as per Boxer’s
2nd and 3rd
Volar splint and refer
Less mobility accepted thus more likely to pin

23. Management?

24. Metacarpal Shaft Fractures
Can accept < 3mm shortening and 10 deg angulation in II/III or 20 deg in IV/V
Cannot accept rotation
Stable # (transverse, good reduction)
splint, could follow in ED but must ensure doesn’t slip (re Xray in one week) or could send to plastics
Unstable # (spiral, oblique, multiple #s, failed reduction, rotated)
splint, reduction prn, refer

25. Extra-articular Thumb Metacarpal Fracture
Unstable (oblique, spiral, comminuted)
Splint and refer for pinning
Stable (transverse)
Attempt reduction if > 20 degrees angulation
Splint in thumb spica X 4 weeks
Refer

26. Management?
Who the heck is Bennet?????

27. Bennett’s Fracture
Two part intra-articular fracture at base of thumb metacarpal
Commonly see CMC joint subluxation
Thumb spica splint and refer for pinning
Abductor pollicus longus pulls fragment off

28. Bennett’s Fracture

29. Management?

30. Rolando’s Fracture
Three (or more) part intra-articular fracture at base of thumb metacarpal
Commonly see Y or T pattern but comminuted fracture is also called Rolando’s fracture
Thumb spica splint and refer

31. “Reverse Bennet’s” Fracture
Commonly missed
Xray: look carefully for clear, even space b/w base of 5th MC and hamate
Unstable b/c ext carpi ulnaris pulls at base
Needs pinning

32. The Pediatric Hand

33. The Pediatric Hand Salter - Harris classification used
Tuft # and SH II of proximal phalanx common
Thick periosteum thus hold position well and heal quickly
Generally: closed reduction, splint X 3 wks
OR: can’t reduce, can’t maintain reduction, displace intraarticular #, SH IV/V

34. Salter Harris I Closed reduction
Immobilize with splint X 3 weeks or K wire
Can present with “paronychia” not responding to Rx

35. Salter Harris II Common Reduce Splint with gutter splint
Splint X 3 wks

36. Salter Harris III - V SH III SH IV: reduce prn, splint and refer
Minimally displaced, < 25% joint surface involved: splint X 3 wks
Displaced, > 25% joint surface involved: splint and refer
SH IV: reduce prn, splint and refer
SH V: reduce prn, splint and refer

37. Assessment of Finger Joint Stability
Blocks may be required for assessment
Active stability
can pt move finger through full ROM without displacement?
Passive stability
apply stress to collaterals, and volar plate

38. Finger Sprains Xray Stable joint Unstable joint R/O fracture/avulsion
LOOK carefully for subluxation
Stable joint
buddy tape or gutter splint
ROM early to prevent stiffness (3-5 days)
Unstable joint
splint and refer

39. Finger Sprains Flexion Contractures Prevention Common complication
MUST SPLINT PIP/DIP IN EXTENSION
MUST SPLINT MCP in FLEXION
Early ROM
Minimize dressings to allow ROM
See physio at two weeks if becoming stiff

40. Management?

41. PIP Dislocations Dorsal/Lateral Volar dislocation Ring block, Xray
Reduce, examine stability
Buddy tape and EARLY ROM (better than splint X 3 weeks)
refer: can’t reduce, unstable joint, avulsion > 1/3 of joint surface
Volar dislocation
Controversial
Attempt closed reduction
Splint and refer

42. PIP Subluxation +/- Fracture

43. PIP Joint Subluxation +/- Fracture
Do NOT miss this injury
Must Xray fingers in full extension
Will not stay reduced in extension
Can’t splint in flexion (flexion contracture) Mx
splint and refer for extension pin
also will need special rehab

44. Dorsal MCP Dislocations
Simple dislocation (subluxation)
hyperextended degrees, articular surfaces contacting w/o interposed soft tissue
metacarpal block
reduction
splint in safety position
refer
Complex dislocation
hyperextension LESS than 60 degrees
Xray: wide joint space, sesamoid in joint space is pathognomonic
Splint and refer (will not be reducible)

45. Dorsal MCP Dislocation
Volar plate prevents reduction
Wide joint space, sesamoid in joint

46. CMC Subluxation +/- Fracture
Commonly missed
Look at CMC joint space carefully
Compare shaft of MC with adjacent MC
Reduction
Splint
Refer (often slip and need pinning)

47. Management?

48. Gamekeeper’s (Skier’s) Thumb
Ulnar Collateral Ligament of the thumb
Stress MCP in full extension and 30 deg of flexion to offset stabilization of volar plate
Xray to r/o avulsion
Sprain (partial): thumb spica X 4 weeks
Rupture (complete)
Splint and refer for pinning
Stener’s lesion (adductor pollicus in the way)

49. Management?

50. High Pressure Injection Injuries
Consider all SEVERE injuries
Paint and paint thinners worse than grease Mx
Tetanus
IV analgesia (NO digital blocks)
Antibiotic, splint, elevate, NPO
Consult plastics (early - don’t wait ‘til am)

51. Management?

52. Mutilating Hand Injuries
R/O other injuries
Tetanus, Analgesia, Antibiotics
Irrigate gross contamination
Sterile saline dressing
Xray
NPO and consult plastics

53. Management?

54. Amputations R/O other injuries Tetanus, analgesia, antibiotics, NPO
Xray, consult plastics early
Stump Mx: irrigate, saline dressing, splint
Amputated parts
Place in sealed plastic bag
Place bag in ice water (NOT on ice b/c frostbite will cause tissue damage) ---> ideal temp 4 deg

55. Amputations Continued
Canada/US = early
UK = late (surgery the next morning)
Plastics to decide to Replant and who not
Contraindications for Replantation
Unstable patient with other injuries
Multiple level amputations
Single digit proximal to FDS insertion (relative)
Vasoculopath: DM, PVD, CAD, CVA
Age

56. Management?
I cut my finger here...

57. Digital Nerve Laceration
Refer for potential repair for anything proximal to DIP
DIP and distal > multiple branches thus difficult to repair

58. Fingertip Amputations
Zones
Management controversial
Maintain as much length as possible
Children heal well by secondary intention

59. Fingertip Amputations
NO exposed bone
< 1cm exposed: Polysporin, jelonet dressing, heal by secondary intention
> 1cm exposed: consider referral for flap if there isn’t adequate soft tissue coverage
Exposed bone
rongeur bone back enough to get tissue coverage, dress, heal by secondary intention, Drsg changes,f/u

60. Flexor Tendons Close wounds, splint, refer to plastics
FDP Avulsion/Rupture
Common athletic injury
Hyperextension of flexed finger (jursi grab)
Tendon can retract into the palm
Splint and refer for repair

61. Extensor Tendon Injuries: ED Management and Follow-up

62. Can emerg do this? One Study (Evans JD; 1995)
EM housestaff in UK repaired 65 extensor tendon lacs
follow-up within 6 mos. re: functional outcome
Proximal injuries: 80% good to excellent results
Distal injuries: 18% good to excellent
weaknesses: unconventional splinting of distal injuries, poor physio f/u, small numbers
conclusion: we don’t know how we’re doing!

63. Emerg role in repair of extensor?
Make sure you know what you’re doing
Appropriate splinting and referral to hand physio
Proximal injuries easier to repair
Consider discussing with plastics b/f repair especially if you want them to follow
Splint and refer
can’t locate ends, ends shattered, can’t decifer anatomy, inadequate previous experience

64. Verdan’s zones of injury
each zone has:
particular injuries
variations in acute management
different splinting requirements
not all extensor tendon injuries are the same!!

65. Which suture material? No evidence
Absorbable vs. non-absorbable synthetics
non-absorbs most often used, but may cause knot irritation at site of repair
absorbs less prone to producing knot irritation, but ? strength
Size:

66. Which suture technique?
No consensus in literature or amongst hand surgeons
Options
Figure of Eight
Box
Bunnel
Kessler

67. suture techniques Bunnel suture advantages: disadvantages: strong
time constraints
technical skills
need good tendon cross-sectional area

68. suture techniques Kessler suture advantages: disadvantages: strong
time constraints
technical skills
need good tendon cross-sectional area

69. suture techniques horizontal mattress suture advantages:
easy to do, even on thinner tendons
disadvantages:
decreased strength

70. Incomplete lacerations: General Recommendations
Recommendations NOT literature based
< 25%
do not need repair %
may be repaired
? splint for shorter time
> 50%
should be repaired

71. What about antibiotics?
Little evidence specific to simple tendon lacs
ACEP Guidelines:
abx indicated for both hand and tendon lacs
Absolute indications:
bites, crush injuries, associated open fractures, joint capsule disruption

72. Splinting and Hand Physiotherapy
Complicated > ROM and strengthening exercises differ for each injury
Need to when to send to physio
Distal Injuries (Zones 1 - 4)
Splint and see physio at 6 weeks
Proximal Injuries (Zone 5 - 7)
Splint and see physio at 4 weeks

73. Zone 1: mallet finger Common injury Goals of management
<10 degrees of extension lag
good flexion
prevention of swanneck deformity

74. Closed Mallet Finger

75. Open mallet finger Roll or figure of 8 suture Splint
Remove suture 14days
Splint X 6 weeks
Cover with abx

76. Mallet finger: physio STRICT extension 6wk
MUST keep in extension when splint off
At 6 weeks
Start ROM
20 degrees week 6, 30 degrees week 7
Night splinting x 2w
Extension lag: stop ROM and wear splint X 2wks

77. Swan-neck deformity Complication of Mallet finger
DIP is flexed b/c of loss of extension
Lateral bands displace dorsally and lock PIP in hyperextension

78. Zone 2: middle phalanx injuries
most injuries are either partial lacs/crush injuries
referral criteria similar to open mallet
suture technique:
lateral bands are very friable and difficult to suture
suture type: figure-of-8
epl on thumb: use core-type suture
splinting and follow-up as for mallet finger
wound care and splinting x 7-10d for partial lacs <50%

79. Zone 3: the PIP worst prognosis of extensor tendon injuries
consider central slip and lateral bands

80. Closed zone 3: Central Slip Rupture or Avulsion
Second MC athletic finger injury
Forced flexion of extended finger (finger jam)
High degree of suspicion if:
PIP extensor lag > 20 degrees (with MCP/wrist flexed)
Decreased strength or pain with resistance to extension
Tenderness over dorsal PIP and appropriate mechanism
May present with acute Boutonniere deformity
need to assess laxity of lateral bands via passive PIP extension
Xray to r/o avulsion

81. Closed zone 3: central slip rupture or avulsionMx
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

82. Boutonierre Deformity
Complication of Zone III rupture
DIP in extension
PIP in flexion b/c lateral bands slip volarly hand hold in flexion

83. Open zone 3 tendon injury
Lacs rarely involve entire dorsal apparatus
Also may result in Boutonniere deformity
Suture, abx, extension splint, refer to hand physio at 6 weeks
Refer
distal central slip stump too short to repair
associated w/open #
acute boutonniere deformity

84. Zone 3 injuries: physio 8 weeks 10 weeks
Much more complex than DIP (hand physio at 6w)
6 w weeks:
active PIP extension w/MCP in flexion
reapply splint between hand physio sessions
if extensor lag develops, reapply splint
8 weeks
continue active flexion, gentle resistance applied; splint at night
10 weeks
increase resistance exercises, progress to full grasp

85. Zone 4 injuries: proximal phalanx
Tendon very broad at this level; usually partial lac
Partial laceration (extension intact)
Consider repair if > %
Splint X 3 weeks and then begin active motion
Complete laceration
Suture as for PIP lacs
Mobilize at 3-4w b/c of higher degree of “scarring down” at this zone
f/u and OT/PT as for PIP injuries

86. Closed zone 5
Injuries are rare and usually due to a crush mechanism over the MCP
Classic: tendon dislocation and relocation with passive extension
Suspect sagittal band/dorsal hood disruption when painful flexion at MCP occurs
Who to refer: all injuries
ED management:
splint w/MCP in extension at place of tendon relocation
leave other MCPs free to move

87. Open zone 5 Fight bite +++ irrigation and exploration required
evaluate for joint capsule and tendon disruption: abx and refer
underlying structures OK: leave wound open, abx, wound check in 3 - 5d
tendon laceration: leave wound open, abx, splint, refer to plastics

88. Zone 5 Anatomy Saggital bands Dorsal hood
arise from interMC ligaments, volar plate, lumbrical and cover the tendon to prevent subluxation
Dorsal hood
is another name for saggital bands as they extend dorsally over the tendon

89. Open zone 5 Suture and splint X 4weeks; f/u with physio
Splint wrist in 40 degrees extension, MCPs 20 degrees flexion, and IPs in 0 degrees
Saggital band and dorsal hood
repair if involved
isolated sagittal band or dorsal hood lac:
avoiding abduction/adduction motion, buddy tape, begin flexion/extension in 3-5 days

90. open zone 5: f/u & OT/PT 5weeks 7 weeks 4 weeks
gentle active extension at MCP
alternating flexion of MCP and IPs
splint worn b/w sessions
5weeks
claw postion to encourage extrinsic extension
alternate finger and wrist flexion
night splinting only, unless extensor lag persists
7 weeks
resisted exercises

91. Zone 6 and 7 injuries Easier to locate and suture Splinting
wrist in 40 degrees extension, MCPs 20 degrees flexion, and IPs in 0 degrees X 4 weeks
Physio at 4 weeks for ROM exercises

92. hand resources: OT & PT FHH hand clinic: 670-1432
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

93. The End of the DAY Know how to manage common injuries
Recognize serious injuries
If you don’t know, ask
Be willing to follow some things in ED