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Hand Injuries
Colin Del Castilho
Dr Ian Rigby
Famous Hands
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Outline
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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
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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
• Allen’s test
• Control lacerations- direct pressure,
don’t 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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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:
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Allow vesicles to rupture on own
Zovirax ointment
Oral acyclovir
Observe for bacterial superinfection- start
keflex
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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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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
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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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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
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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.
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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
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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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High Pressure Injections
• 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
High Pressure Injections
• 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 (don’t
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
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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
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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 aren’t
flexed 90 degrees --> loss of reduction
Metacarpal Shaft Fracture
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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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Bennett’s Fracture
• Axial load on
partially flexed
thumb
• 2 part intraarticular
# w/ CMC
subluxation
• Management:
• Thumb spica
• Refer for ORIF
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Rolando
• 3 or more fragments, intraarticular
• Management:
• Thumb spica
• Refer for ORIF
Reverse Bennett’s
• 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
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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/Skier’s
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/Skier’s
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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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
TABLE 1 -- THE VERDAN EXTENSOR TENDON INJURY CLASSIFICATION
SYSTEM
Zone
Anatomic Location
I
DIP joint
II
Middle phalanx
III
PIP joint
IV
Proxim al phalanx
V
MCP joint
VI
Metacarpals
VII
Carpals
VIII
Proxim al wrist
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Extensor Tendons
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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
Refer for pin
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
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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
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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, don’t 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