MANAGEMENT OF ACUTE HAND INJURIES

By Ruhama Yoseph (R IV)July, 2014

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OUTLINE IntroductionClinical Assessment of injuriesSurgical AnatomyGeneral Principle of ManagementTypes of Hand InjuriesManagement of Specific injuries

◦ Fractures & Dislocations◦ Soft Tissue Reconstruction◦ Tendon injuries

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IntroductionContribute to 5-10% ED visits in

Western countries

The importance of functionality of the hand can’t be over emphasized

Meticulous evaluation, care and dedicated rehabilitation are rewarding in hand injuries7/1/2014

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Clinical AssessmentBrief History….

◦Mechanism of trauma◦Age◦‘Handedness’ of patient◦Occupation

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Clinical AssessmentExamination…

Superficial injuries and obvious deformities can be easily detected. But deeper injuries need time taking examination to disclose them.

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Clinical AssessmentExamination…

◦Circulation◦Soft-tissue cover◦Bones◦Joints◦Nerves◦Tendons

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Movements of the HandPinch

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Movements of the HandKey

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Movements of the HandTripod

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Movements of the HandGrasp

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Movements of the HandPower grip

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Movements of the HandResting position of the hand

during flexion and extension

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Movements of the Hand

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Movements of the HandThumb movements

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Movements of the HandFDP & FDS test for lesser fingers

FDP & FDS test for index finger

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Radiologic AssessmentStandard view of AP, Lateral &

Oblique should be done

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Radiologic AssessmentCT scan offers better information

about carpo-metacarpal fracture/dislocations

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Anatomy of the handBones

◦Composed of 19 bones & 8 carpal Bones

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Anatomy of the hand◦Ligaments

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Anatomy of the handTendons

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Anatomy of the handTendons

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Anatomy of the handCarpal Tunnel

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Anatomy of the handThe neurovascular bundles lay volar to the

midaxis of the digit with the artery dorsal to the nerve

Grayson's ligament (volar) and Cleland's ligament (dorsal) connect the bone to the skin surrounding the bundle

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General principles of management

Circulation◦If threatened prompt restoration

should be done with micro-vascular techniques

◦An example is when there is a crush injury of the proximal hand with disruption of the distal blood supply but an otherwise normal tissue.

◦Salvage of digits by using vein grafts bridging the zone of damage will contribute for the ultimate function of the hand 7/1/2014

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General principles of managementSwelling

◦Hand elevation initially, and early initiation of repetitive active hand exercise to prevent stiffness

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General principles of managementSplinting

◦Wrong splintages can potentially lead to hand stiffness

◦‘ Position of Safety’- MCP joints flexed to 90 degrees and the IP joints left almost straight

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General principles of managementNerve and Tendon injury

◦Primary repair always has best results depending on the patient and injury factor

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General principles of managementSkin cover

◦Takes precedence than deeper structure injuries

◦Skin cover takes priority over “healing by secondary intention” because of the undesired infection and fibrosis results

◦Early wound toilet and suturing or reconstruction with grafts or flaps depending on the type of injury is advantageous

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Types of hand injuriesThree main types depending on

injury patterns:◦Cutting and Slicing◦Crushing◦Degloving and Avulsion

Or they can be classified as Tidy and Untidy wounds

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Tidy injuryDamage to the skin is clear-cutUsually tendons and nerves are

injured which necessitates their immediate repair and reconstruction

For a bloodless field during reconstruction pneumatic tourniquet is used

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Untidy InjuryInitial assessment includes

deciding which tissues are viableThe non-viable tissue should be

removed Skin after injury though without blood

supply remains viable. So if undamaged it is worth considering its reapplication to the debrided surface as a full thickness skin graft after de-fatting it.

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Cutting & Slicing InjuriesIf without skin loss, the wound

can be closed primarily after sufficient excision of devitalized tissue

If bed exposed is suitable for grafting , then split thickness is used for primary coverage

The minimal tissue damage expected allows definitive repair of tendons or nerves.

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Cutting & Slicing InjuriesWhen raw area includes structure

unsuitable grafting, flap cover should be provided

Examples are pulp of finger tip, exposed tendon…

For injury resulting in guillotine amputation of a finger, the preferred option is trimming the phalanx and doing soft tissue reconstruction

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Cutting & Slicing InjuriesBut the greater the number of

fingers amputated, the greater the need to conserve the length of individual fingers

For thumb injuries, maintaining the length for gaining a good length opposable thumb is emphasized

No excessive trimming and use of skin grafts as temporary measures for covering tip is recommended

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Crushing InjuriesUltimate loss is much greater

than the immediately apparentCan be mild as subungual

hematoma or severe as a power-press injury leaving a shapeless pulp

The ‘hidden’ damage has consequence of severe edema post-op and fibrosis later with disappointing functional result

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Crushing InjuriesImmediate management involves

ruthless debridement of non-viable tissue

Second assessment will be done where the decision of preserving damaged but viable structures will be done

There are two contending ideas regarding the salvage of digits…

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Crushing Injuries1) Amputation of a finger even

when viable but with damage of individual components (nerve, tendon, skin, bone)

2) Retention of individual digit even in the knowledge that it will be stiff when there is a greater damage to other fingers and the rest of the hand

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Crushing InjuriesGrafts are less likely to take in

the presence of crush injury in the early post-op periods

In conclusion, crushing injury carries a much longer period of disability and poorer results with stiffness and function

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Degloving & Avulsion InjuriesThe distinction between

degloving and avulsion injuries lies in the tissue involved

Degloving◦Confined to the skin & fascia◦Important pathological factor is

disruption of blood vessels◦Damage to tendon, bone and joints

is not typical pattern

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Degloving & Avulsion InjuriesAvulsion

◦Involves the deeper tissues like tendons, muscle, nerves

◦Can be combined degloving/avulsion injury as in pulling out of a digit

◦Such a digit can be salvageable with microsurgery depending on the severity of the neurovascular damage

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Degloving & Avulsion InjuriesDorsum and palm have different

coping capacityPalm

◦ Degloving plane between palmar aponeurosis (as a single structure attached to skin) and flexor tendon

◦ The strength and relative inextensibility of the aponeurosis protects the circulation of the overlying skin

Dorsum:◦ Degloving plane leaves the extensor tendons

exposed within their paratenon

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Degloving & Avulsion InjuriesAfter injury, assessment of skin

viability is difficult, the common mistake being underestimation

Early excision and skin cover is good for rapid healing

Delayed primary treatment, waiting the necrotic area to declare itself, is another option

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Degloving & Avulsion InjuriesSplit thickness graft is usual form

of cover at the acute stage, and sometimes for permanency

Primary flap considered if bare tendon, cortical bone or open joint is present

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Degloving & Avulsion InjuriesDegloving of ring finger…by a

fixed ring◦Injury may involve phalangeal

fracture, partial or complete stripping off the skin

◦Management of skeletonized finger but intact tendon and joint function depends on the availability of micro-vascular expertise

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Degloving & Avulsion InjuriesIf skin still attached distally, it can be

re-vascularized by bridging lost veins and arteries, while at the same time suturing nerves

If expertise unavailable or if attempt fails, amputation is advised

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Degloving & Avulsion InjuriesA degloved thumb needs special Mx

Temporary salvage of skeletonized thumb by ‘burying’ it under the skin of abdomen or chest

Inserting the thumb into a tubed flap like groin, delto-pectoral or random pattern flaps

A neurovascular ‘island’ flap by using the hemi-pulp of a functionally less important finger, brings sensation and blood supply to the tip of the thumb

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Degloving & Avulsion InjuriesTransfer of big toe or the second

toe are other options to replace an amputated or near amputated thumb

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Degloving & Avulsion InjuriesDorsum of hand:

◦Degloving plane leaves the extensor tendons exposed within their paratenon

◦This is suitable for early grafting

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Finger tip injuriesContribute to significant

percentage of upper extremity injuries

The integrity of the three elements of the distal segment of digit is essential◦Pulp◦Nail◦Phalanx

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Finger tip injuries◦Smoothness and integrity of nail-bed

is crucial◦Once the generative element of nail

is damaged irregular and patchy growth develops

◦Nail beds should be repaired before replacing back of nails

◦Immobilization of distal phalanx fracture

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FRACTURES

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FRACTURESThings special about hand

fractures◦Consist of small fragments often

difficult for anatomical reduction◦Risk of tendon and joint adhesions

with sequela of function impairment◦Surgical incision itself can cause

function limiting scar formation

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FRACTURESThe goals in treatment of

metacarpal and phalangeal fractures:◦Restoration of articular anatomy◦Elimination of angular and rotational

deformity◦Stabilization of fracture◦Surgically acceptable wound◦Rapid mobilization

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Metacarpal fracturesMajority of fractures are closed, simple and

stable◦ Brief immobilization followed by active exercises

suffices for management of thoseMechanisms

◦ Blows, falls on the hand, boxers punch…Common sites of fracture

◦ Base, neck or shaft

Rotational deformity is a serious problem , whereas angular deformity is not of major concern

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Metacarpal fractures

a) Spiral metacarpal fractureb) Oblique metacarpal fracturec) Multi-fragmented metacarpal fractured) Simple articular fracturee) Bicondylar fracture

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Metacarpal fracturesIndications for operative stabilization

◦Significant displacement 2nd & 5th metacarpal fractures are liable to

shortening Angulations of >30o& shortening >4mm or a

combination of the two are not tolerated◦Rotational malalignment

As little as 5o rotation results in 1.5 cm finger overlap during flexion

◦Multiple fractures◦Gross deformities◦Association with significant soft tissue injury

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Metacarpal fracturesSurgical approaches

a) Incisions for individual metacarpal exposure

b) Incisions for exposure of all metacarpals

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Metacarpal shaft fracturesThey tend to angulate with the

apex dorsally due to the pull of intrinsic muscles of the hand

In the 4th & 5th fingers up to 20 degrees angulations are acceptable

Index & middle fingers, only up to 5 -10 degrees acceptable

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Metacarpal shaft fracturesTransverse/ oblique fractures with

slight displacement◦Crepe bandage with active mobilization

Transverse fractures with displacement◦Reduction and splint immobilization of the

involved finger/s for 3 wks◦ If unstable one, operative management

preferred (compression plates or K-wire)Spiral fractures

◦Operative management (plate, lag screws, percutaneous K-wiring)

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Metacarpal shaft fractures

K-wire fixation of unstable transverse metacarpal fracture

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Metacarpal shaft fractures

Spiral fractures of ring & long finger metacarpals with rotational deformities

Lag screw fixations

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Metacarpal neck fracturesPatients present with pain and

flattening of knucklesBoxer’s fracture- the 5th digit is

involvedAre fairly unstable fractures with

volar angulations because of the unproportional pool of flexor tendons and typically volar communition character of the fracture

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Metacarpal neck fracturesBoxer’s fracture which should be

treated with early mobilization

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Metacarpal neck fractures4th and 5th digits:

◦As much as 40 degrees angulations acceptable since their main function is in flexion, Power grip

◦Splint for 2wks with flexion of MCP joint and extension of IP joints

Index and middle fingers◦Since their functionality is mainly at

extension only 20 degrees angulations are tolerated

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Metacarpal neck fracturesFirst reduction after a local blockIf it redisplaces, fixation with two

or three bent wires passed distally through a hole in the styloid process of the fifth metacarpal base is particularly effective

Complication, usually malunion◦Volar angulations of the distal

fragment◦The digit may assume ‘Z

appearance’7/1/2014

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Metacarpal head fracturesBrewerton X-ray view

◦Obtained by flexing MCP joint to see articular detail

◦Intra-articular fracture is common, and thus ORIF recommended

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Metacarpal base fracturesExtra-articular ones are usually stable

because of their impaction◦ But if multiple or intrinsic capsular

ligaments disrupted fracture should be fixed with plates

Intra-articular fractures are common on the 5th digit◦ The option of operative management is

distraction with ex-fix & grafting of the defect

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Metacarpal base fractures

Multiple extra-articular metacarpal base fractures fixed with mini-condylar plates

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Fractures of the PhalanxTheir typical features are:

◦Unstable fractures tend to angulate dorsally

◦They are prone to adhesion & stiffness

◦Fracture displacement is less tolerated at phalanx than metacarpal

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Fractures of the Phalanx

Cross-section through the proximal phalanx showing the proximity of the tendon sheaths to the bone

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Fractures of the PhalanxFor reducible and stable injuries

◦3 wks immobilization with cast or splint followed by gentle mobilization with interval protective splinting

◦Hand based functional splint for proximal phalanx fractures

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Fractures of the PhalanxFor reducible & unstable injuries:

◦Per cutaneous K-wire fixation◦Limited internal fixation with screws

known as “closed reduction & internal fixxation”

◦External fixation

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Fractures of the Phalanx

Per-cutaneous pinning7/1/2014

Soft Tissue Reconstruction of the Hand

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Soft Tissue ReconstructionThe objective is to achieve

primary wound healing since it◦Decreases inflammatory reaction◦Decreases scar formation◦Decreases joint stiffening

The tiers of surgical approach:Primary Closure Skin Graft Flap

Free Tissue Transfer

Depending on injury and patient factors7/1/2014

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Soft Tissue ReconstructionPrinciples of replacement:

As early as possible, but not when tissue viability is questionable

Donor sites:Hand itself is superiorBecause it has the best tissue match, recovery of sensibility, and simplicity for wound care

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Skin GraftsDorsal and volar skin of the hand

have different requirementsDorsal Skin Volar SkinThin ThickerLoose enough not to restrict flexion

Tougher but allowing motion

Protecting tendons and joints

Increased sensibility because of its encapsulated nerve endingsAbsence of pilo-sebaceous units

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Skin GraftsSplit Thickness Skin Graft:

◦Are thin, usually 0.015 inch thick recommended for adults

◦Used for covering major defects◦Immobilization is an important

technical factor for taking of grafts

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Skin GraftsFull Thickness Skin Graft:

◦Advantages are: Increases sensibility Decreases contraction Thicker protected tissue covering

◦But these can be used for small defects only

◦Donor sites for glabrous skin: Hypothenar eminence, non-weight

bearing instep of the foot, volar surface of wrist, hairless inguinal fold skin

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FlapsThree indications

1. Wound unsuitable for re-vascularization of a skin graft

2. Need to replace subcutaneous tissue as well as skin

3. Protection required of an exposed vital structure like nerve or joint

Donor sites can be local, regional or distant

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FlapsTechnical considerations:

◦Planning starts by measuring the patterns of the recipient site

◦Cutting should be done deep to the level/plane of fascia

◦Sharp dissection elevating it from deep fascia within the layer of areolar tissue

◦Severing of pedicled flaps can be done on 10-14th day for local flaps & 14-21st day for distant flaps

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Local FlapsBilateral V-Y Advancement Flaps:

◦ For transverse finger tip amputations or for slightly volar amputations at mid-nail level

◦ Cut from the sides of the injured finger and advanced over the tip by dividing the fibrous septa

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Local FlapsVolar V-Y Advancement Flap

◦ For transverse or dorsally directed finger tip amputation at mid-nail level

◦ A ‘V’ shaped flap raised with its tip at crease of DIP joint, septa divided from underlying phalanx and flap advanced

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Local FlapsMoberg Flap ( Volar

Neurovascular Advancement Flap)◦For thumb tip injury◦Volar aspect of remaining skin raised

from flexor tendon sheath including the neurovascular bundle on both sides

◦Base of flap is MCP joint creaseThis is not suitable for other

fingers since it causes necrosis of dorsal skin

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Local FlapsMoberg Flap …

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Local FlapsCross-Finger Flap

◦For cases of volar finger-tip amputations

◦The dorsal skin over the middle phalanx of an adjoining finger is elevated above the extensor peritenon

◦It is taken like a page of an open book and sutured on the tip of injured finger which is positioned in flexion

◦Donor grafted and flap divided on 9-10th day

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Local FlapsCross-Finger Flap…

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Local FlapsReversed Cross-Finger Flap

◦For soft tissue coverage of dorsal finger injuries

◦A standard cross-finger flap is designed and de-epithelialized.

◦ Flap is then elevated in a routine fashion and turned 180 degrees upside down

◦The donor defect and undersurface of the flap are then skin grafted

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Local FlapsVolar Cross-Finger Flap

◦For thumb tip injuries, flap is constructed from volar surface of middle finger above the middle or proximal phalanx

◦Immobilization is maintained at comfortable position

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Local FlapsVolar Cross-Finger Flap…

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Local Flaps Dorsal cross-finger flaps

have blood supply of longitudinal distribution

Volar-cross-finger flaps get blood supply form vertically oriented vessels and therefore flap size is limited

Also pedicle of flap is in close proximity of the neurovascular bundle

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Local FlapsFlag Flap

◦axial flaps based on the dorsal branches of the digital vessels, allowing for a very narrow pedicle and thus a mobile flap

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Local FlapsThenar Flap

◦Excellent for covering defect of major phalangeal amputations

◦It has the best tissue match with sufficient subcutaneous tissue

◦To prevent stiffness, the MCP of recipient finger should be fully flexed

◦Flap is proximally based taken from the highest point of thenar eminence with its lateral border at MCP crease

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Local FlapThenar Flap

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Local FlapNeurovascular Island Flap

◦Sensate, vascularized tissue from the ulnar side of the ring or long finger is transferred to the thumb in a single stage

◦The digital proper branch of sensory nerve is used

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Local FlapNeurovascular Island Flap

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Distant FlapThree types

◦Axial FlapsThose with specific vascular pedicle

◦Random FlapsNo specific vascular pedicle

◦Free Flaps

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Distant FlapAxial Flaps

◦Superficial Inferior Epigastric Artery Flap

◦Superficial Circumflex Iliac Artery Flap ( Groin Flap)

◦Lateral Thoracic Artery Flap

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Distant FlapAxial Flap

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Distant FlapSuperficial Inferior Epigastric

Artery Flap◦Preferred if situated on the contra-

lateral side of the injured hand◦Causes minimal shoulder and elbow

pain◦Upto 12 cm wide donor defect can

be closed directly

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Distant FlapSuperficial inferior epigastric

artery flap

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Distant FlapSuperficial Circumflex Iliac Artery

Flap ( Groin Flap)◦Advantage is that it is a flap with

minimal hair transfer◦Up to 15 cm wide defects can be

closed directly◦Has problem with elbow and

shoulder discomfort

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Distant FlapSuperficial Circumflex Iliac Artery

Flap ( Groin Flap)

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Distant FlapLateral Thoracic Artery Flap

◦Contralateral to injury side is used◦Superior based flap following the

down course of the artery on the lateral wall of the chest

◦Position is well tolerated, but has bad cosmetic results

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Distant FlapLateral Thoracic Artery Flap

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Random FlapAbdominal source

◦Superior or inferior based flap with length to width ratio of 1.5:1

Medial surface of Contralateral arm ◦The good vascularity of the area

allows flaps to be elvated with length to width ratio of 2:1

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Free FlapProvides wound coverage as well as

transfer of bone, nerve and tendonsA commonly used free tissue transfer

for hand reconstruction is the fasciocutaneous lateral arm flap, which is supplied by the posterior radial collateral artery, a branch of the profundi brachial artery

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Free FlapLateral arm flap supplied by the posterior

radial collateral artery

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TENDON INJURIES

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TENDON INJURIESThe tendon repair must be strong

and accurate enough to allow early mobilization (usually passive) so that the tendons can glide freely and independently from each other and the sheath

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TENDON INJURIESPrimary repair

In first 24 hours timeDelayed Primary repair

Within 24 hrs to 10 days periodSecondary repair

After 10-14 days

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TENDON INJURIESThree phases of intrinsic healing

in tendon repair:1. Inflammatory (48-72 hrs)2. Fibroblastic (5 days-4 wks)3. Remodeling (4wks- 3.5 mo)

Extrinsic activity by peripheral fibroblasts plays the role in formation of adhesion and scars

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TENDON INJURIESImportant technical aspects

◦Minimal handling with instruments◦Smooth juncture of two ends◦Secure knots◦Minimal interference with vascularity

of tendon◦Proper suture material

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TENDON INJURIESKessler grasping

suture

Bunnel suture

Modified Kessler suture

Fish-mouth E-to-E suture (PluverTaft)

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Flexor Tendon InjuryIncisions for

exploration of the hand

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Flexor Tendon InjuryRepair of flexor tendons is difficult in

the region labeled as “No-Man’s Land” or Zone II◦Here both SFD & PFD run together in

a single sheath◦Primary repair and specialized post-

op physiotherapy bring good results

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Flexor Tendon InjuryNo-Mans Land:

Between the distal palmar crease and the flexor crease of the proximal inter-phalangeal joint

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Flexor Tendon InjuryFlexor tendon sheath and pulleys

◦Five annular and three cruciate pulleys

◦ From these, A2 & A4 are important tethering effect and must be preserved or always repaired

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Extensor Tendon InjuryThere are 8 zones the odd numbered

ones lying over jointsRepair is relatively easier since tendon

ends are less likely to retract

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Extensor Tendon Injury

Mallet Finger Dropped fingers from extensor tendon rupture

Swan-neck deformities

Boutonniere deformity

EPB ruptureEPL rupture

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Extensor Tendon InjuryMallet finger results from avulsion of

extensor tendon from its insertion

Stack Splint for 6-8 wks suffices for management

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Extensor Tendon InjuryButton-hole deformity- results

from rupture of central slip of extensor expansion

Loss of extension of PIP and thus persistent flexion

Hyperextension of DIP joint

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REFERENCES

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THANK YOU!

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