Hand InjurySoft Tissue

Hossam Elkafrawi M.D.

• Hand injuries are common and account for 5-10% of emergency department visits nationwide

• Good physical examination skills, and knowledge of indications for treatment are indispensable for the emergency physician.

Anatomy

Bony anatomy:• The wrist is composed of 8 carpal bones arranged in 2

rows of 4. The flexor retinaculum together with the carpal bones forms the carpal tunnel

• The metacarpal bones articulate with the wrist at the carpometacarpal (CMC) joints

• The thumb has only 1 interphalangeal (IP) joint, while the rest of the digits have proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints.

• Intrinsic muscles of the hand: • They can be divided into 4 groups as follows: • The thenar eminence is formed by the extensor pollicis brevis and the 3 short

thenar muscles: the abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis. innervated by the recurrent branch of the median nerve. The superficial location of this branch renders it vulnerable to seemingly trivial trauma to the thenar eminence.

• hypothenar (little finger),• Lumbricals: flex the digits at the MCP joints and extend the IP joints. They

place the fingers in the writing position. • Seven interosseous muscles are located between the metacarpal bones; 3 are

palmar and 4 are dorsal. The palmar interossei adduct, while the dorsal interossei abduct.

• The adductor pollicis. It is innervated by the ulnar nerve.

Evaluation of inuries

• Skin• Circulation• Tendons• Nerves• Bones and joints

Principle of treatment

• Anaesthesia• Tourniquet• Careful wound toilet. • Splints and dressing• Avoidance of swelling and stiffness

• Tidy hand Injuries• Untidy Hand Injuries• Undeterminable hand injuries

Skin loss

• Finger tip injuries• Skin loss without exposure of deeper

structures• Skin loss with exposure to deeper structures

Tendon injuries

• Early : – Primary repair

• Delayed: – Secondary Repair– Tendon grafts– Tendon transferes

Anatomy of the flexor tendons• Superficialis tendons maintain

constant arrangement in the distal wrist: – the tendons to the middle and ring

fingers lie palmar to those of the index and little fingers.

• Profundus tendons travel in a single layer deep to the superficialis tendons in the wrist and the palm.

Anatomy of the flexor tendons

• The lumbrical muscles originate from the FDP distal to the carpal tunnel.

Anatomy of the flexor tendons

•Over the proximal phalanx, the FDS tendon splits into two slips around the FDP tendon and then reunite deep to it with decussation of half of the fibers (Camper’s chiasma).

• The pulleys of the fingers consists of a palmar aponeurosis pulley, five annular pulleys and three cruciate pulleys.

• The annular pulleys A2 and A 4 are crucial for normal digital function, they prevent tendon bowstringing and provide optimal joint flexion.

Verdan’s flexor tendon zones

• The actual level of tendon injury in relation to its surrounding tissue is of significance in estimating the prognosis.

• No man’s land of Bunnell.

Diagnosis of flexor tendon injury:

Surgical repair of flexor tendon:

1- Primary. (within 24 hours).

2- Delayed primary. (1-14 days).3- Early secondary. (2-5 weeks).4- Late secondary. (> 5 weeks).5- Tendon grafts.6- Tenolysis.

1- Adequate anaesthesia.2- complete aseptic technique.3- Bloodless field. (tourniquet).4- Good magnification.5- Atraumatic technique.6- Adequate exposure.

Repair of flexor tendons should be carried out under optimal conditions:

Retrieval of flexor tendons:

Multiple maneuvers:• Blind retrieval.• Catheter retrieval.• Tendon retrievers.• Endoscopy.

Suture techniques:

• Any suture technique should include:

1- Core suture. 2- Circumferential epitenon

suture.• Many suture techniques for flexor

tendon repairs have been advocated; Bunnell, modified Kessler-Tajima, augmented Becker, Strickland, Kleinert, Pulvertaft and epitenon-first.

Suture techniques:

• Modified Kessler

Suture Techniques

• Kleinert suture

Suture Techniques

• Strickland

Postoperative mobilization• There are three methods of postoperative

motion:1- Controlled passive motion. (Duran & Houser) Non-compliant.2- Controlled active extension. (Kleinert) Compliant patients3- Early active motion. (Chow) Highly motivated patient.

• Duran &Houser

Postoperative mobilization

Postoperative mobilization

• Kleinert

Early Active Mobilization

• This is carried out under strict supervision of a physiatrist then by the patient.

• The aim is to do selective 5 daily active FDP and FDS flexions separately.

• This will help the differential function of the separate muscles.

Tendon Grafts

• 2-staged (tendon spacers)• Intercalary

Tendon Transfers

• Superficialis to flexor pollicis• Transfer sets in radial and posterior

interosseous nerve injuries.• Opponens plasty

Nerve iujuries

• Primary repair• Delayed repair

Vascular injuries

• Re-vasucularization

• Replantation

Replantation

• Replantation is the reattachment of a completely detached body part.

• Fingers and thumbs are the most common but the Hands, ear, scalp, hand, arm and penis have all been replanted.

• Generally replantation involves restoring blood flow, restoring the bony skeleton and connecting tendons and nerves as required.

• Initially, success was defined in terms of a survival of the amputated part alone.

• However, as more experience was gained in this field, surgeons began to understand that survival of the amputated piece was not enough

• In this way, functional demands of the amputated specimen became paramount in guiding which amputated pieces should and should not be replanted.

Facial Injuries

• soft tissue injuries

• facial bone fractures

Etiology of Facial Injuries

• Road Traffic Accidents• Interpersonel violence• Sport accidents• Home accidents• Occupational accidents• Shot-gun injuries

Emergency Treatment• Airway

• Cleaning of blood, vomit and theet from inside of mouth with fingers• Aspiration of blood, saliva, and gastric contents • Early Intubation or Tracheostomy

• Bleeding• Direct pressure on the wound• Tying of bleeding vessels(Facial, superficial temporal, angular or ext.

carotid)• Anterior-posterior nasal packing

• Circulation • Evaluate Associated Injuries ( cervical vertebrea, skull base, intracranial,

thoracal, intraabdominal)• Diagnosis and treatment of facial injuries

Indications of Tracheostomy• Panfacial fracures(combined mandible, maxilla and nasal

fractures)• The multiply fractured mandible with significant swelling of

the neck and floor of the mouth• Patients who require prolonged intermaxillary fixation who

have significant head or chest injuries• Possibility of prolonged postop. airway problems• Severe facial and neck edema resulting from soft tissue

injuries such as severe facial burns• Unrelieved obstruction of airway in the region of larynx or the

hypopharynx

Clear Airway and provide patent airway

Soft tissue Injuries

• Abrasion • Contusion (with or without hematoma) • Laceration(most common form of facial injury)• Avulsion • Puncture• Accidental Tattoo • Retained Foreign Bodies

Symptom and Signs • Soft tissue Injury• Swelling• Pain or localized tenderness• Crepitation from areas of

underlying bone fracture• Hypostesia and paralysis in the

distribution of specific nerve• Malocclusion

Class I :Normal oclusion Class II :Retrognathi Class III :Prognathi

• Visual disturbance• Diplopia or decrease in vision

• Facial asimmetry, deformity• Obstructed respiration• Lacerations inside of mouth• Ecchymosis• Bleeding

Clinical Examination-I• Evaluation for symmetry and deformity• Inspection of face ( comparing 2 sides)• Palpation of all bony surfaces in an orderly manner

(sup. and inf. orbital rims, nose, the brows, the zygomatic arches, malar eminence, border of mandible)

• Inspection of intraoral area for lacerations and abnormalities of the dentition

• Palpation of dental arches for abnormal mobility

Clinical Examination-II• Maxillary and mandibular dental arches are carefully

visualized and palpated for bone irregularity, bruise, hematoma, tenderness or crepitus

• Sensory and motor nerve functions in the facial area evaluated

• Extraocular movements and muscle of facial expression must be examined

• Globe functions (pupillary size and symmetry, globe excursion, eyelid excursion, double vision and visual loss) and fundoscopic examination

Treatment of Soft Tissue Injuries

• Primary closure• Delayed primary closure• Secondary healing• Tertiary healing (skin grafts, flaps)

Wound Closure-I

• The time lapse between injury and repair is important in terms of the possibility of infection and the choice of repair techniques

• Primary closure is treatment of choice• It is applied immediately after the trauma if the

wound is sharp and clean• debridement, excision of a millimeter or two of the

wound edge• The wound edges is approximated with sutures

Wound Closure-II

• The contused, dirty and heavy contamined wounds are not closed by primaryly

• Shotgun wounds, animal and human bites are not closed primarly as well

Delayed Primary Closure

• The wound must be prepared with debridment and dressing

Cleaning Irrigation Debridment

• The wound can be closed primarly after 24-48 hours, If it is clean and free of devitalized tissue

Secondary Closure

• If the wound is heavily contamined and infected, contains necrotic and devital tissues after 48 hours, The wound can be closed after cleaning of the wound or can be left to secondary healing

• Secondary healing occurs with secondary wound contracture and marginal epithelization

Thank You