Hand Injuries

Brent Nossaman, D.O.

Tulsa Bone & Joint Associates

Initial Evaluation
History and mechanism of injury Number and nature of structures damaged Time elapse since injury Open or closed injury

Initial Evaluation
Examination
Skin Motor function Nerve function Circulation

Initial Evaluation
Examination
Skin Motor function Nerve function Circulation

Initial Evaluation
Examination
Skin Motor function Nerve function Circulation

Initial Evaluation
Examination
Skin Motor function Nerve function Circulation

Dislocation / Ligament Injury

Thumb
Gamekeeper Skiers Thumb UCL tear at MP joint ( Stenar Lesion) May have assoc avulsion fracture Sress X-ray
No clear consensus 15 degees opening more than opposite side 20-45 degees greater in flexion than opposite side

UCL 10X greater occurance than RCL Treatment

Complete tear early open repair late reconstruction with tendon graft Incomplete tear Thumb spica

Dislocations
Finger
MP
Dorsal most common Frequency- Index, thumb, small

Simple- markedly angulated

Reduce, early motion

Complex- minimally angulated

Usually irreducible, open treatment

Dislocation
Finger Pip
Jammed Finger Types
Dorsal, volar, and lateral

Dorsal
Most common injury of hand Reduce, start early motion Fx/dislocation Avulsion start early protected motion Large fragment operative fixation vs. early motion, soft tissue reconstruction

Dislocation
Volar
Rare Open reduction usually required Avulsion fx with extensor tendon

Lateral
Rupture of one collateral Protection followed by early motion

Dislocation
Dip
Rare Dorsal or lateral Often open injuries

Finger Tip Nail bed Injuries

Epidemiology
24% Surgical hand trauma 75% Patients male

Nail Physiology
Complete nail growth 70-160 days 21 day delay following injury Abnormal growth for 100 days after injury

Finger Tip Nail bed Injuries

Subungual hematoma
30-50% of total area can leave
Perforate nail to relieve pressure

50% or greater
Consider nail bed repair

Finger Tip Nail bed Injuries

Nail bed lacerations
Repair with absorbable suture under loupe magnification Approx 50% nail bed injuries have associated distal phalanx fracture usu comminuted tuft fx Proximal nail plate dislodgement
Remove nail, irrigate, repair nail matrix

Tendon Injuries
Initial treatment Evaluation Irrigation Skin closure Referral

Tendon Injuries
Flexor Tendons
Laceration Rupture Laceration
Commonly assoc with neurovas injury Radial & ulnar volar digital a&n Evaluate prior to anesthetizing finger Paperclip orientated longitudinal

Tendon Injuries
Independent Testing
FDS FDP

Tendon Injuries
Emergent repair avascular finger / hand Urgent Repair Less than 7-10 days better results Always less than normal function May require subsequent surgery Intensive hand therapy involved 8-12 wk recovery depending on use

Tendon Injuries

Flexor Rupture (Jersey Finger)

Closed injury Usually sports related Ring finger most common May be associated with distal phalanx fx Repair timing depends on retraction of tendon

Tendon Injuries
Extensor tendon
Mallet deformity (Rupture)
Tendon only Bone avulsion

Laceration Same treatment as flexor

Fractures
Distal phalanx
Tuft
Closed splint subungual hematoma Open debridemont and wound care Hypersensitivity to touch occasional Tenderness often lasts several months

Shaft
Usu stable Pin unstable

Base
Stable splint Unstable pin

Fractures
Proximal and Middle Phalanges
Condyles
Unicondylar Usually pin or screw to prevent displacement of articular surface

Neck
Pin or plate to prevent displacement

Shaft
Minimally displaced closed treatment Displaced or comminuted pinning or open

Fractures
Proximal and Middle Phalanges
Intraarticular
Collateral ligament avulsion Volar plate avulsion

Reduction with pin or screw

Fractures
Metacarpal
Head
Displaced pinning possible open treatment May accept 30-50 degrees angulation in 4th and 5th

Neck (Boxer)
May accept 10 degrees angulation in 2nd and 3rd Closed pinning possible open treatment

Shaft
Check rotation when flexing fingers! Transverse or short oblique or border digits usually require internal fixation Long oblique 3rd 4th minimally displaced may treat closed

Fractures

Fractures
Metacarpal
Base
Commonly 4th and 5th Associated with dislocation CMC Closed pinning, possible open treatment

Intraarticular with possible arthrodesis

Fractures
Scaphoid
Most common carpal bone fracture Unique blood supply predisposing to AVN Fracture pattern
Proximal 20% Middle (waist) 70% Distal 10%

Clinical Exam (Pain)

Snuff box tenderness Axial load of thumb Tubercle tenderness

Fractures
Scaphoid 10-15% nonunion despite early treatment may be decreasing due to early screw fixation Trend toward aggressive treatment with screw fixation

Fractures
Scaphoid Occult fracture
Day 2-3 MRI Day 4 Bone Scan Day 10 X-rays usually positive

Treatment
Distal pole Thumb spica short arm Waist
nondisplaced long arm thumb spica Displaced internal fixation

Foreign Bodies
Determine type if possible and location X-ray Under penetrated for better soft tissue Can see metal, bone, teeth, pencil lead, certain plastics, glass (all), gravel, stone, fish spines, wood, aluminum

Hand infections
Organism 50-80% Staphlococcus aureus Streptococcal IVDA, DM, Farm, Bite Gram Human bite Eikenella Corrodens Animal bite Pasteurella Multocida Immunocompromised Atypical Myco

Hand infections
Occupational/Habit Assoc
Dental hygienist herpes lesions Dishwasher fungal Nail biter paronychia Manicure -- paronychia

Hand infections
Cellulitis
Usually Streptococcus (Group A beta) Occasional Staphylococcus
Treatment
Cephalosporin (2nd gen)

Abscess
Usually Staphylococcus Farm anaerobic IVDA / DM Gram
Treatment
Surgical drainage and antibiotic

Hand Infection

Hand infections
Paronychia
Disruption of seal btw nail plate and nail fold Infection beneath eponychial fold Can track under nail plate ( subungual)

Usually Staphylococcus aureus

Hand infections
Paronychia
Treatment
Early
Soaks and antibiotics

Established
Drainage and antibiotics

Felon (abscess)
Infection of pulp space tip of finger Usually Staph
Treatment
Incision High midlateral or volar if pointing AVOID fish mouth Antibiotics

Hand Infections
Flexor tenosynovitis Associated with puncture or injury on palmar side of finger with contamination of flexor sheath Heamatologic? Clinical Suspicion
Kanavals Cardinal Signs
Tenderness over tendon sheath Flexed posture Fusiform swelling Pain on passive stretch

Hand Infections
Flexor tenosynovitis
Treatment
Early
Antibiotics (IV) reasses 24 hours

Established
I&D

Hand Infections
Animal Bites
Dog
Crush type injury

Cat
Puncture

May produce significant infection

Chemical Injury
Treatment
hydrofluoric acid
Calcium gluconate gel Calcium gluconate (10%) injection

Phenol
Shower to remove Observation for CVS complications

White Phosphorus
Mineral oil Copper sulfate 1%

Na+, K+--explode on contact with water

Mineral oil Na+--isopropyl alcohol K+--tert-butyl alcohol

Chemical Injury
Determine contaminant and duration of contact
Hydrofluoric acid
severe pain no initial skin changes progressive necrosis

Phenol
Observe for CVS complication

Na+, K+ White Phorphorus

Gun shot wounds

Hand guns low velocity 1000ft/sec or less
Local wound care Oral antibiotics Outpatient care Occasional vascular injury/ Compartment syndrome Fractures usually stable, early motion Nerve deficits common usually neuropraxia

Military/Rifles high velocity

Gun shot wounds

Military/Rifles high velocity
Extensive bone and soft tissue damage Debridemont Evaluation for vascular compromise