Download Hand Emergencies - St. Mary Medical Center

Hand Emergencies
Edward J. Armbruster, DO, CAQSH
Board Certified, Orthopaedic Surgery
Certificate of Added Qualification in Surgery of
the Hand
Mercer Bucks Orthopaedics
Top Ten List
1. Infection
2. Burn
3. Fracture
4. Acute Vascular Compromise
5. Compartment Syndrome
6. Amputation
7. Tendon Laceration
8. Dislocation
9. Nerve Laceration
10. Foreign Body
Revisited
• Acute Vascular Compromise
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Laceration
Compartment Syndrome
Amputation
Burn
• Laceration
– Nerve
– Tendon
• Fracture / Dislocation
• Infection / Foreign Body
Remember…
• You have specialized training
• What may be basic and mundane to you is
not general knowledge
• Respect your colleagues
• Use the opportunity to assist a patient in
need and learn from the experience
Vascular Compromise
• Direct Laceration
• Mass Effect / Burn
• Amputation
Vascular Compromise
• Arterial Supply
• Venous Supply
Vascular Compromise
Vascular Evaluation
• History
– Blunt or penetrating trauma
– Blunt injuries also associated with comp synd
• Physical Examination
– Allen Test
– Doppler Ultrasonography
• Radiographic Studies
– Arteriography
– MRA
Laceration
• Indications for Acute Repair (Absolute)
– Axillary or Brachial Artery
– Radial AND Ulnar Arteries
– Radial OR Ulnar Artery associated with poor
collateral circulation
Laceration
• Relative Indications
– Arterial and nerve injury
– Extensive distal soft tissue injury
– Repair of a single FA artery has patency rates
between 50% and 90%
• Digital Arteries
– Check cap refill
– Only need one digital artery, with good
collateral circulation
Compartment Syndrome
Compartment Syndrome
• Etiology
– Most are iatrogenic
• A-line
• Infiltrated IV medications
– Other causes
• Trauma, high-voltage electrical injury, pit viper
bites
Compartment Syndrome
• Clinical Diagnosis
– Beware the obtunded patient
– Early recognition based on PE
• POOP, pain with passive extension
– No abnormalities of sensory nerves
Compartment Syndrome
• Pressures
– Lower threshold than for leg compartments
– Relative indication: pressures > 15-20 mmHg
– Absolute: pressures above 30-40 mmHg
Compartment Syndrome
• 10 osteofascial compartments
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Thenar and Hypothenar
Dorsal interossei (4)
Volar Interossei (3)
Thumb adductor
Compartment Syndrome
• Released with CTR and 1-2 dorsal incisions
– Transverse carpal ligament requires release
– Dorsal metacarpal incisions
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Over 2nd and 4th MC
Retract extensor tendons
Access volar and dorsal interosseous compartments
Open these compartments
May close dorsal primarily, volar usually requires
delayed closure
Amputation
Amputation
• 80% viability rates
for amputated parts
• Challenging decisionmaking process
• Weigh options
• Xray amputated part
Amputation
• Indications for Replantation
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Thumb
Single digit distal to FDS
Multiple digits
Partial hand through palm, wrist or FA
Sharply amputated or moderately avulsed elbow and
above-elbow levels
– Almost any part in a child
– Distal fingertip (?)
– Ring avulsions (?)
Amputation
• Care of amputated part
– Ischemia time
• Warm
– Critical with prox amps with skeletal
muscle
– Replantation not recommended if warm
ischemia time >6h (prox to carpus) and
>12h for digital amps
• Cool
– Cool 4o – 10o C
– Extends ischemia time 10-12h prox to
carpus, 24h or more for digits
Amputation
• Handling of the Amputated Part
– Wrap digits in gauze moistened with LR or
NSS
– Place in plastic bag.
– Place part on ice.
– Never place amputated part directly on ice
– Never use dry ice
Amputation
• General Considerations
– Age of the patient
– Associated injuries and medical conditions
– Social factors
• Occupation, social habits, belief’s
Amputation
• Operative Sequence and Techniques
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Bone shortening and fixation
Extensor tendon repair
Flexor tendon repair
Artery anastomosis
Nerve repair
Vein anastamosis
In multiple amps, go structure-by-structure
• BE FAN V
Amputation
• Partial Treatment Options
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Secondary intention (open method)
Skin grafting
Shortening of the bone with primary closure
Local or regional flap coverage
Amputation
•
Allen’s Classification
I.
Volar Oblique Without
Exposed Bone
II. Volar Oblique With
Exposed Bone
III. Transverse
IV. Dorsal Oblique
Allen I
• Small (< 1cm2)
• Open treatment
• Heal in 1-2 weeks
– Contracture
– Epithelialization
• May be grafted
Allen II, III, IV
• Soft tissue coverage
• No composite graft
• Revision amputation
Allen III
Local Flaps
• V-Y Flap
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Method
Allen III or IV
All digits
Advancement of 1 cm
• Kutler Flap
– 2 Lateral V-Y flaps
V-Y Flap
Kutler Flap
Regional F;aps
• Cross-Finger Flap
– Preserve the paratenon
of the extensor tendon
• Thenar Flap
– Used on any finger tip
– Maximum width 2 cm
– Should be 1.5x the
width of the defect
Injury to the Thumb
• Preservation of length is critical
• Depending upon the extent of injury,
several flaps are commonly used
– Moberg
– First Dorsal Metacarpal Artery-Island Pedicle
Flap
– Neurovascular-Island Pedicle Flap (Littler)
Moberg Advancement Flap
• Advances a pedicle flap to cover thumb-tip
injuries
• Flexion contracture is possible
First Dorsal Metacarpal ArteryIsland Pedicle Flap
• One stage
• Donor site covered with full-thickness graft from groin
First Dorsal Metacarpal ArteryIsland Pedicle Flap
First Dorsal Metacarpal ArteryIsland Pedicle Flap
•
First Dorsal Metacarpal ArteryIsland Pedicle Flap
Fingertip Injuries in Children
• Most managed by the open method
• If age <2 y.o., open method may be used
even in case of exposed bone
• Composite grafting is acceptable
Nail Bed Injuries
• Subunugal Hematoma
• Laceration
• Nail-Matrix Avulsion
Subungual Hematoma
• Decompression
– Relieve pain
– <50% nail area
• Plate removal
Lacerations
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Remove the plate
5-0 Nylon on skin
6-0 Gut on the bed
Space occupier
Nail Bed Repair
Nail-Matrix Avulsions
• Proximal detachment
• 3 Suture repair
– horizontal mattress
• Grafting
– from plate
– from other digits
Thermal Burns
• 36% of thermal or chemical injuries
involve the hand or upper extremity
• 90% of patients with major burns will have
hand involvement
• Early and aggressive treatment keys to
success
Thermal Burns
• First Degree
– Involve epidermis only
– Skin is erythematous
– Symptomatic treatment only
• Second Degree
– Involves part of the dermis
– Vesicles, swelling and moist surface
– Hypersensitive to light touch
Thermal Burns
• Second Degree (cont.)
– Early excision and grafting to avoid
hypertrophic scarring and joint immobility
• Third Degree
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Involve entire dermis
Leathery appearance
Anesthetic to pin prick
Large areas require excision and delayed
grafting
Thermal Burns
Burn Treatment
• Fluid Resuscitation
– Parkland Formula
• Escharotomies
– Edema and circumferential
burns restrict perfusion
– Not needed if burn is supple
– Edema occurs within 36h of
injury
– Performed at bedside
Burn Treatment
• Splinting
– Prevent contractures
– Burn claw deformity
– Splint in “anti-claw” position
• Wound Care
• Rehabilitation
Nerve Laceration
Nerve Laceration
• Indications
– Deep paralysis after a wound over the course of a
major nerve or after an injection close to the course of
that nerve
– Deep paralysis after a closed injury, especially highenergy injuries, with severe damage to soft tissues and
skeleton
– Deep paralysis after closed traction injury of the
brachial plexus
– A nerve lesion associated with an arterial injury
Nerve Laceration
• Indications (cont.)
– A nerve lesion associated with fracture or dislocation
requiring urgent open reduction and internal fixation
– Worsening of nerve injury while under observation
– Failure to progress toward recovery in the expected
time after a closed injury
– Failure to recover from conduction block within 6
weeks of injury
– Persistent pain
– Treatment of the painful neuroma
Nerve Laceration
• Younger pts have better functional outcome
• Age is most important factor in nerve
function recovery
• Primary Repair
– Immediate repair, or within several hours
– Indicated for sharp nerve transections
Nerve Laceration
• Delayed Primary Repair
– Completed within 5-7d
– Best for avulsion-type injuries
• Secondary Repair
– Performed >7d from injury
Nerve Laceration
• Techniques for Repair
– Epineurial
– Group Fascicular
– Nerve Grafts
• Autogenous vein conduits
• Neural tubes
• Autogenous nerve (sural)
Nerve Laceration
Nerve Laceration
Nerve Laceration
Nerve Laceration
• Repair must be tension-free
• Use graft if tension-free repair not possible
Tendon Laceration
Anatomy
• Flexor Digitorum Superficialis
– Origin - Medial epicondyle,
Coronoid process, Prox radius
– Insertion – Middle phalanx of
digits (not thumb)
– Innervation – Median
– Action – Flex PIP
Anatomy
• Flexor Digitorum Profundus
– Origin – Anterior ulna & Interosseous membrane
– Insertion – Distal phalanges
– Innervation –
• IF/MF – Median/AIN
• RF/SF – Ulnar
– Action – Flex DIP
Flexor Zones of Hand
I – FDS insertion to distal tip
II – Origin of fibroosseous sheath
in distal palm  FDS
insertion
“NO MAN’S LAND”
III – Distal edge of transverse
carpal
ligament(TCL) 
digital sheath
IV- deep to TCL/Carpal Tunnel
V – Musculotendinous junction 
entrance of carpal canal
Thumb
I – IP joint to distal tip
II – Thumb MP  IP Joint
III – Thenar
Diagnosis/Evaluation
• Laceration vs Avulsion
• Active Flexion
– FDS – isolate digit
– FDP – stabilize PIP joint
• Injury to FDS and/or FDP
– FDP is superficial to FDS in digit
• Sensory Testing
– 2PD for digital nerve injuries –
5mm
– Arterial injury is likely
• Ultrasound
• Intubated/Unresponsive pt:
– Cascade
– Squeeze Forearm
Basic Treatment Principles
• Not surgical emergency
– Close skin in ER
– Delayed primary tendon repair in OR under loupe
magnification within 10 – 14 days
– Results of delayed repair are equal to or better than
immediate repair
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Axillary block/General Anesthesia
Tourniquet for hemostasis
Meticulous & Minimal handling of tissues
Strickland et al –
– Better to repair both FDS & FDP, than just FDP alone
– FDS repaired first
What to Repair?
• Numerous studies have shown that:
< 60% - Debridement only
> 60% - Repair
Extensor Tendon Lacerations
• In acute situations, closed injuries are
treated closed and open are treated open
• Repair with non-absorbable with a core
suture (modified Kessler)
• Partial tears
– repaired if >50% is involved
• Core stitch, splint 4-6w, ROM
– Splinted if <50% is involved
• For 14d, then protected ROM
Extensor Zones
Extensor Tendon Lacerations
• Splinting
– If repair is proximal to P1
• Wrist ext 45 deg
• MP flex 10 deg
– Dynamic extension splinting
Extensor Tendon Lacerations
• More proximal injuries fare better than
distal
Fracture / Dislocation
• Most fractures may be splinted and
followed as an outpatient
• Caution with those with associated
findings
– Numbness, paresthesias, POOP, etc.
• Beware the carpus!
Perilunate Dislocation
Perilunate Dislocation
Dislocations
• Should be reduced, or at least attempted
• Counsel patient re. treatment
• May require surgical (open) reduction
– Dorsal MP dislocations, volar PIP, unstable
baby Bennett
Infection
• Evaluate for degree of injury
• Assess patient’s medical condition
– DM, immune suppressed, PVD
• XR for periosteal reaction
• Advanced imaging for collection
• May aspirate and send for cell count /
culture
Infection
• Special attention
– Septic flexor tenosynovitis
• Kanavel’s Signs
– Joint space
• “fight bite”
Infection
• Be aggressive!
– Although hand is vascular structure, infection
can progress rapidly to involve multiple
structures
Animal Bites
Animal Bites
• May be best to admit for observation/IV
abx, depending on severity
• Most common organism
– Staph aureus
• Cats and dogs
– Pasteurella
• Humans
– The worst kind of bite
– Animals and saliva
Foreign Body
• May attempt removal
if can be visualized
• Nidus of infection
• No need to remove
bullets that are extraarticular
Injection Injury
Injection Injury
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Most are industry-related
Grease and spray guns
Diesel injector
Paint injector
Aggressive surgical tx
Pack wounds open
May require amputation
Summary
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High index of suspicion
When in doubt, evaluate the patient
Admit for observation
Refer to tertiary care / friend in field
Use resources
www.mbortho.com
www.orthomanus.com
Mercer-Bucks
Orthopaedics
Thank You!