Hand Injuries Del Castilho Oct27 05

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Hand Injuries
Colin Del Castilho
Dr Ian Rigby
Famous Hands
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Outline
Hand exam
Hand Infections
High Pressure Injection Injuries
Fractures/Dislocations
Tendon injuries
Amputations
Things Not Covered

Carpal fractures/ Wrist fractures
Thermal injuries and Frostbite
Nerve Blocks
6 Finger Hand Exam

A
Appearance:
Resting posture
Ischemia/cyanosis
Lacerations
Swelling
Erythema
Deformity
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6 Finger Hand Exam,

B both hands
Compare to other hand
6 Finger Hand Exam

C
Circulation
Allens test
Control lacerations- direct pressure,
dont clamp
Inflate BP cuff to 30>systolic pressure,
no more than 30 min
6 Finger Hand Exam

D Neurological assessment
Sensory
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6 Finger Hand exam

D Neurological Assessment
Motor
Screening exam
Thumbs up (hitchhiker
Spread finger apart
Maneuver tips of each finger and thumb around
tip of pen
If deficit detected, proceed to more

thorough motor exam
6 Finger Hand Exam

E extension
Test all digits
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F Flexion
Assess all joints
FDP and FSP separately
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Hand Infections
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What is this?
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Herpes Whitlow
HSV 1 60%, HSV 2 40%
Common in children, health care
workers, immunocompromised
Inoculation occurs through breakage
in skin barrier
Incubation period 2- 20 days
Prodrome- fever, malaise, burning,
erythema, tingling in affected digit
Herpes Whitlow
1-3mm grouped vesicles on erythematous
base lasting 7-10 days
Crust over- no longer infective
May recur (remains dormant in nerve
ganglia)
Treatment:
Allow vesicles to rupture on own

Zovirax ointment
Oral acyclovir
Observe for bacterial superinfection- start keflex
What is this?
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Paronychia
Acute infection of nail bed
Usually staph, may be oral anaerobes
Treatment
Incision around nail bed to drain pus
Antibiotics usually not necessary
May need to remove nail if abscess
spreads under nail
Finger chewers- clinda
Paronychia
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How about this?
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Felon
Abscess of finger tip
S. aureus, oral anaerobes
Treatment:
I and D
Keflex for 7-10 days
Referral to hand surgeon if does not
improve
Felon
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Complications
Finger tip necrosis

Tenosynovitis
Osteomyelitis
Neuroma (from I and D)
Admit to hospital----immunocompromised, systemic
symptoms, failure to respond to abx
Famous Hands
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Famous Hands
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Name this Infection
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Pyogenic Flexor
Tenosynovitis
Direct inoculation- Staph
Rarely hematogenous spread- NG
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Pyogenic Tenosynovitis
Cardinal Symptoms
Pain on passive extension (most sens)

Pain on palpation of flexor tendon
Symmetric/fusiform swelling
Finger held in flexion
Pyogenic Tenosynovitis
Management
Urgent plastics consult
Antibiotics: IV 3rd gen Cephalosporin,
then adjust based on C and S
Complications
Bacteremia
Compartment syndrome
Loss of finger function
Clenched Fist
Injury/Human Bite
Most commonly caused by fight bite
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Clenched Fist
Injury/Human Bite
75% involve extensor tendon, joint,
bone or cartilage
Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist
injuries. Clin Orthop 1987;220: 237-40.
May extend to joint capsule

May involve MCP or PIP fracture
50% infection rate -Staph, Strep,
Eikenella. On average- 5 organisms in
wound
Examine in position of injury
Extend wound 3-5 mm either side
Clenched Fist Injury

Management
Uncomplicated early wounds:
Antibiotics: Clavulin
Clinda + Cipro or Septra
Pen + Clox
Avoid first gen cephs- Eikenella resistance
Debridement, irrigation, close by secondary intention

Splint in position of safety if tendon injured
Tetanus
Must have follow up
Complicated wounds:
Referral to plastics
IV antibiotics - cefoxitin, tazocin
Deep Space Hand

Infections
Deep Space 5
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Staph, Strep, coliforms

Management: IV Ancef and refer
Famous Hands
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High Pressure Injections

Only requires 100psi to break skin
commonly involve 1000-10,000psi
Index finger most common, non
dominant hand
1000psi = 450 lbs
falling 25 cm
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Damage determined by
Type of injection: Grease/oil, hydraulic
fluid, paint thinner, molding plastic,
paraffin, cement
Amount
Finger- 1st and 5th digit may lead to
compartment syndrome in wrist and arm
Direct tissue damage,

vasospasm/ischemia, inflammation

Management:
IV analgesia only. Avoid digital nerve blocksincrease ischemia
Immediate Plastics Consult
NPO
Factors associate with Amputation- 70% of oil
injections
100% if > 7000psi
Delayed presentation
Hand Fractures
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Distal Phalanx Fractures

Usually from crush injury
Rarely displaced, usually
comminuted
May have associated subungal
hematoma
Management of tuft #:
Short finger splint 1-2 weeks (dont
immobilize PIP
Distal Phalanx Fracture

Transverse or Longitudinal shaft #
Stack splint for 4 weeks
FDP avulsion
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Refer to plastics
Intra-articular #s- refer to plastics

Mallet finger will be discussed later
Subungal Hematoma
Previously recommended for nail removal
and formal nail bed for all > 25% of nail
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
(>50%)
Middle and Proximal

Phalanx Fracture
Assess for neurovascular and
tendon/ligament stability
Stable shaft fractures: Buddy tape
with early ROM
Uni or Bicondylar Fractures:
unstable, require ORIF
Middle and Proximal

Phalanx Fractures
Unstable fractures: displaced, oblique or
spiral fractures, comminuted, scissoring
deformity/rotation, unable to reduce or
maintain reduction
Rotational deformity: nail not in line with
mcp, scissoring, finger does not point to
scaphoid tubercle when flexed
Treatment: requires plastics referral
Splint index/ middle in radial gutter splint
Ring/little finger in ulnar gutter splint
Unstable Phalanx
Fractures
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Metacarpal Fractures
Head
Neck
Shaft
Base
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Metacarpal Fractures
Hand Function can tolerate angulation equal to
CMC joint motion + 10o
Normal
5 degrees
Accept
15
5 degrees
15
20 degrees
30
30 degrees
40
Metacarpal Head Fracture

Variant of Boxers #
Will need ORIF:
>1mm step off
>25% intraarticular
surface
displaced
Splint in position of
safety
Look for fight bite
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Name the #
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Metacarpal Neck #
Attempt to reduce if:
Angulation > 40o -5th
30o - 4th
15o - 2, 3rd
Splint in position of safety

When to refer to plastics for k wire or ORIF
Any rotational deformity
Shortening > 3-4mm
Unable to maintain reduction
Splint Metacarpal neck #
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Position of safety to
prevent MCP
contractures
Hold in reduction
and mold splint until
set
Must include 4th MC
If MCPs arent
flexed 90 degrees
---> loss of reduction
Metacarpal Shaft Fracture
Accept same angulation as Neck #

No rotation
Shortening up to3-4mm
Reduction technique:
Jahss technique: flex both MCP and PIP
to 90o. Press up on Middle phalanx and
down just proximal to apex of#
Then splint in position of safety
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Metacarpal Shaft #
Unstable: spiral, oblique, rotation,
multiple #s, failed reduction- will
need to refer
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Bennetts Fracture
Axial load on
partially flexed
thumb
2 part intraarticular
# w/ CMC
subluxation
Management:
Thumb spica
Refer for ORIF
How about this?
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Rolando
3 or more fragments, intraarticular
Management:
Thumb spica
Refer for ORIF
Reverse Bennetts
Intraarticular fracture
of 5th metacarpal
base
Unstable: extensor
carpi ulnaris
Management: plastics
referral for K wire
insertion or ORIF if
any displacement
Famous Hands
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Dislocations
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DIP Dislocation
Less common- more stability due to
insertion of extensor/FDP tendons
Usually associated with skin
breakage- need antibiotics
Reduce similar to PIP dislocations
If not reducible or unstable - refer to
plastics
PIP Dislocation
Mostly dorsal-- hyperextension injury

Maybe ulnar
Need Xray to rule out fracture
May have associated avulsion
PIP Dislocation
Management
Splint in 30o flexion or buddy tape for 3
weeks, refer to hand clinic
Early ROM
Refer if
Unable to reduce
Instability with active ROM
> 20o instability with passive ROM
Volar dislocation: attempt closed reduction
Reduction Technique
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PIP Subluxation +/- #
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PIP Subluxation +/-#

Xray in full extension
Wont be able to maintain reduction
in extension
Splint and refer for extension pin
MCP dislocation
PIP almost always
dorsally angulated
Associated with
volar plate injury
May be associated
with avulsion
fracture or sesmoid
bone in joint
MCP Dislocation
Management
Management
Flex wrist (relax flexor tendons) and press on
proximal phalange in volar direction
Do not hyperextend or place traction on finger as this
may pull volar plate into joint
Cant reduce if volar plate in joint- refer
If sesmoid bone in joint- refer
Volar dislocations require ORIF
Gamekeeper's/Skiers
thumb
Rupture (partial/complete) of ulnar
collateral ligament
Mechanism: valgus stress on MCP or
fall onto abducted thumb
Exam: >35o = complete tear
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Gamekeeper's/Skiers
Thumb
Xray
Management
Partial: thumb
spica for 4 weeks
then physio
Complete: refer
Stener lesion:
abductor
aponeurosis in
joint space- refer
Associated #
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Famous Hands
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Flexor Tendon Injuries

Test FDP and FSP separately
Closed wounds uncommonexception is jersey pull of fifth digit
Explore open wounds
If suspected: splint wrist in 30 of
flexion, MPs at 70 of flexion,
and PIPs at 30-45 of flexion and
refer for repair in OR
Extensor Tendon Injuries

TABLE1THEVERDANEXTENSORTENDONINJURYCLASSIFICATION
SYSTEM
Zone
AnatomicLocation
DIPjoint
II
Middlephalanx
III
PIPjoint
IV
Proximalphalanx
MCPjoint
VI
Metacarpals
VII
Carpals
VIII
Proximalwrist
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Extensor Tendons
Examine in position of injury

>50% repair
May have normal function with >90%
Can be repaired in ED
If open- abx
Technique:
Figure of 8 or horizontal mattress
Suturing Technique
Bunnel
Kessler
Zone 1
Check Xray
Closed Incomplete- splint 6-8 weeks
Closed Complete (Mallet finger)splint 6-8 weeks
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Management of
Closed Mallet Finger
Tendon Rupture but
NO fracture
Splint X 6
weeks
Avulsion Fracture
Small frag
(<25%)
Large frag
(>25%)
Splint X 6wks
for pin
Refer
Open Mallet Finger

Open Incompleterepair
Open Complete Repair with Roll
Sutures
Splint 6-8 weeks
Complication: Swan
neck deformity
Zone II
Treat like zone I
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Zone III
Mechanism: extended finger forced
into flexion ie jammed finger
Zone III
Mx
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
Zone III
Open: may attempt repair
Complication: Boutonniere deformity
(volar slip of lateral bands)
Zone IV
Bigger tendon,
easier to repair
Partial-splint 4
weeks
Complete and
Closed: Splint 6
weeks with physio
at 6 weeks
Complete and
Open: repair
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Zone V and Zone VI

May be repaired in ED
Zone V- if associated
with sagittal band and
dorsal hood injuryrepair or refer
Splint with wrist 30o
extension, MCP 20o
flexion, digits in
neutral
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Nerve Injuries
Median and Ulna- refer for immediate
or delayed repair (10days)
Radial nerve repairs may delayed up
to 3 months
Digital Nerve: repair depends on
finger
Thumb, radial aspect index, middle =
grip , ulnar aspect of 5th
Only refer if proximal to DIP
Famous Hands
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Arterial Injuries
Radial/Ulnar artery injuries need
referral
Digital arterial injuries: assess
clinically- if no ischemia, does not
need repair (collateral circulation)
Assess for associated nerve injury
Amputations
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Amputations distal to DIP
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Management
Amputated part--- clean, wrap in saline soaked
gauze, place in sealed bag, place in half ice/half
H20 (4oC)
Stump: clean, dont debride, wrap in saline
soaked gauze
Tissue bridge- leave intact, may contain
nerves/arteries
Complications post replantation: cold
intolerance, loss of ROM , pain,
anesthesia, paresthesias, poor 2 point
discrimination, malunions, and nonunions.
Local Hand Resources

Foothills hand clinic 944 1432
Lindsay Park: 221-8340
PLC: 291-8785
RVH: ph 943-3575, fax 943-3332
fill out form, refer from ED
OT/PT will contact pt based on priority
ACH: ph 229-7912, fax 541-7501

fill out form, refer from ED
OT/PT will contact pt w/i 48h

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TIFF (Uncompressed) decompressor

Things Not Covered

6 Finger Hand Exam

6 Finger Hand Exam,

6 Finger Hand Exam

6 Finger Hand Exam

6 Finger Hand exam

If deficit detected, proceed to more

6 Finger Hand Exam

Allow vesicles to rupture on own

How about this?

Finger tip necrosis

Name this Infection

Pain on passive extension (most sens)

May extend to joint capsule

Clenched Fist Injury

Debridement, irrigation, close by secondary intention

Deep Space Hand

Staph, Strep, coliforms

High Pressure Injections

High Pressure Injections

Direct tissue damage,

High Pressure Injections

Distal Phalanx Fractures

Distal Phalanx Fracture

Intra-articular #s- refer to plastics

Middle and Proximal

Middle and Proximal

Metacarpal Head Fracture

Splint in position of safety

Splint Metacarpal neck #

Metacarpal Shaft Fracture

Accept same angulation as Neck #

How about this?

Mostly dorsal-- hyperextension injury

Volar dislocation: attempt closed reduction

PIP Subluxation +/- #

PIP Subluxation +/-#

Volar dislocations require ORIF

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Flexor Tendon Injuries

Extensor Tendon Injuries

Examine in position of injury

Open Mallet Finger

Splint and refer for

avulsion # at base of middle phalanx

Zone V and Zone VI

Amputations distal to DIP

Local Hand Resources

ACH: ph 229-7912, fax 541-7501

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