hand injuries
DESCRIPTION
Hand InjuriesTRANSCRIPT
![Page 1: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/1.jpg)
Dr Nathan StewartDepartment of Plastic and
Reconstructive Surgery Royal Perth Hospital.
![Page 2: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/2.jpg)
Plastic surgery is not cosmetic surgery. Specialty born from the world wars, from
soldiers with devastating injuries that required complex reconstruction.
Plastic surgeons aim to reconstruct both form and function.
Crucial for any trauma unit. Here at RPH our unit does 1/3 of ALL
operating by case numbers.
![Page 3: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/3.jpg)
![Page 4: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/4.jpg)
![Page 5: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/5.jpg)
![Page 6: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/6.jpg)
![Page 7: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/7.jpg)
![Page 8: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/8.jpg)
![Page 9: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/9.jpg)
![Page 10: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/10.jpg)
![Page 11: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/11.jpg)
![Page 12: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/12.jpg)
![Page 13: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/13.jpg)
Breast reconstruction Sarcoma reconstruction Skin cancers
![Page 14: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/14.jpg)
![Page 15: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/15.jpg)
![Page 16: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/16.jpg)
Easily the majority of our work here at Royal Perth.
Why? Because its such a common injury! Front line trauma staff need to
understand the significance of a hand injury.
![Page 17: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/17.jpg)
![Page 18: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/18.jpg)
Communication
Sensation
Employment
Independent Living
![Page 20: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/20.jpg)
Gestures
![Page 21: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/21.jpg)
Sign Language
![Page 22: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/22.jpg)
Large area brain structure devoted to touch. Highly sensitive.
![Page 23: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/23.jpg)
Relationships
![Page 24: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/24.jpg)
Use of hands fundamental to most vocations.
![Page 25: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/25.jpg)
Without the use of our hands, most people would find independent living impossible.
![Page 26: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/26.jpg)
Small injury = massive impact to functional ability, employment and employability, cause financial and relationship strains, have severe long term implications.
Simple (and very common) example. Right hand dominant male, mechanic by trade, gets drunk and punches a wall one Saturday night. Presents complaining of a sore hand.
![Page 27: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/27.jpg)
This equals 6-8 weeks off work!! No income for 2 months. How would your finances cope?
![Page 28: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/28.jpg)
![Page 29: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/29.jpg)
![Page 30: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/30.jpg)
![Page 31: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/31.jpg)
Small area – lots to injure. Even small lacerations may cause
functional issues.
![Page 32: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/32.jpg)
![Page 33: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/33.jpg)
![Page 34: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/34.jpg)
![Page 35: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/35.jpg)
Is it cold? Is sensation intact?
![Page 36: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/36.jpg)
Digital Nerves
![Page 37: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/37.jpg)
Arterial bleeding in the finger.
![Page 38: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/38.jpg)
Individual movements to test the function of each tendon.
Also groups of movements that can test for the motor loss from nerve damage.
Dont need to know how to perform these, but useful to ask is there anything the patient obviously cant do or that causes pain?
![Page 39: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/39.jpg)
Fractures Lacerations/Penetrating Injuries Amputations De-gloving Injuries Human (punch) Bites Animal Bites Hand infections
![Page 40: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/40.jpg)
Open or closed?
![Page 41: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/41.jpg)
![Page 42: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/42.jpg)
![Page 43: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/43.jpg)
Open fractures – should have appropriate first aid. Thorough irrigation IV antibiotics Dressings
Closed fractures – some can be manipulated, most require fixation. General rule is to plaster all fractures.
![Page 44: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/44.jpg)
All hand fractures should be seen in clinic.
There is a treatment window of around 10-14 days to fix a fracture.
After this it is very difficult to correct. Should be referred early, to allow time to
get into an elective operating list. ORIFs often moved early. K-Wires stay in
plaster 4 weeks. Healing time of bone the same.
![Page 45: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/45.jpg)
Be carefull with your plasters!! Like anything in medicine, there are
always risks associated with any medical intervention, plastering included.
Plasters must immobilise the joint above and below, maintain a functional position and not be too tight.
If a patient complains of pain in a plaster then always take it off and re-do it.
![Page 46: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/46.jpg)
![Page 47: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/47.jpg)
![Page 48: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/48.jpg)
![Page 49: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/49.jpg)
Very common cause of trauma. Typical culprits –
![Page 50: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/50.jpg)
![Page 51: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/51.jpg)
Regardless of size, always have a high suspicion for more serious injury.
Remember, glass only every stops cutting when it hits bone.
Lacerated tendon when repaired takes 6-8 weeks of healing and hand therapy to recover.
Nerve repairs often take 3-6 months to get some benefit from the repair
![Page 52: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/52.jpg)
Any altered sensation or obvious deep injury should be seen in ED by a surgeon.
Tendons may appear intact but be partially lacerated and “break” about 2 weeks later. Harder to repair at this stage.
Nerves/arteries usually protected in a cast for 2 weeks to heal. Tendons if strong repair for early movement. If a weak repair then 3 weeks in cast.
Hand therapy crucial in healing. 2-3 weeks is classic time for repair to
break.
![Page 53: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/53.jpg)
Can occur at any level. Ability to re-plant / re-vascularise
depends on both the level of amputation and the mechanism.
Once past the distal third of the distal phalanx the vessels are too small to be anastamosed.
![Page 54: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/54.jpg)
Common ED presentation.
![Page 55: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/55.jpg)
![Page 56: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/56.jpg)
![Page 57: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/57.jpg)
Usually the most impressive of ED hand injuries. Ischaemic time critical.
Vessels re-anastomosed and tendons repaired.
Usually go onto aspirin for 3 months. Typically protected by a split for 3 weeks. Sharp clean amputations easier to fix.
Traumatic blunt amputations much more difficult as zone of trauma large. May need grafts to bridge wide areas of vessel and nerve loss.
![Page 58: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/58.jpg)
![Page 59: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/59.jpg)
Can get large areas of skin loss. Typically treated as a skin graft with
original skin, or debrided and skin grafted from the thigh.
Can get contraction of the scar.
![Page 60: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/60.jpg)
Very common. Injury occurs after punching someone in
the mouth. Usually small laceration to the 2nd or 3rd MCPJ. Often extends into the joint with damage to the extensor tendon.
Always requires IVABs and a washout. Common consequences – septic arthritis,
extensor tendon loss.
![Page 61: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/61.jpg)
![Page 62: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/62.jpg)
Usually require at least 1 washout. Sometime multiple.
Tendon cannot be repaired if already infected.
Tendon, although intially intact can be completely destroyed by infection.
Always, always refer.
![Page 63: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/63.jpg)
Cat bites – frequently become infected. Cat teeth puncture like a needle and deposit bacteria at the base to then form an abscess.
Dog bites – easier to treat than cat bites as dog teeth typically tear leaving the wound open and able to be irrigated. Cosmetically more difficult to treat.
Sharks!! – If the patient survives the attack, can be a devastating injury.
![Page 64: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/64.jpg)
![Page 65: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/65.jpg)
![Page 66: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/66.jpg)
![Page 67: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/67.jpg)
![Page 68: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/68.jpg)
Most people only present with cat bites once infected. Always need a washout and debridement.
Dog bites usually present the same day. As for all wounds – good irrigation as soon as possible is the key to limiting infection.
Shark bites – often need resuscitation and control of haemorrhage.
![Page 69: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/69.jpg)
These are commonly as a result of minor trauma.
Rarely can be spontaneous Either way needs prompt review, surgical
drainage if required, strict arm elevation and antibiotics.
![Page 70: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/70.jpg)
![Page 71: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/71.jpg)
![Page 72: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/72.jpg)
![Page 73: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/73.jpg)
![Page 74: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/74.jpg)
Relatively minor appearing injuries can have poor outcomes. Proximal phalanx fractures Tendon lacerations Uncontrolled oedema Scar formation
![Page 75: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/75.jpg)
![Page 76: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/76.jpg)
![Page 77: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/77.jpg)
![Page 78: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/78.jpg)
Contracture of the scar leads to poor mobility.
Those crossing longitudinally across a joint crease likely to cause the most problems.
Massage and hand therapy the solution.
![Page 79: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/79.jpg)
Small area with complex anatomy. No referral is ever a bad referral. Realise that even a 0.5cm lac with a
kitchen knife can 100% lacerate a tendon or nerve. This represents months of treatment and time off work.
Irrigate everything
![Page 80: Hand Injuries](https://reader034.vdocuments.us/reader034/viewer/2022050805/557aaa81d8b42a74488b48c0/html5/thumbnails/80.jpg)