orthopedics lends a hand in management of hand and upper ......orthopedics lends a hand in...
TRANSCRIPT
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Orthopedics Lends a Hand in Management of Hand and Upper
Extremity InjuryAmerican College of Physicians Virginia Chapter
Annual MeetingMarch 3-4, 2017
Charlottesville, Virginia
Jonathan Isaacs, M.D.
Chief, Division of Hand Surgery
Department of Orthopaedic Surgery
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Disclosures
Contracted research AxoGen, Inc.
Contracted research CookBiotech, Inc.
Other partial research support AxoGen, Inc. and CookBiotech, Inc.
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Objectives
At the end of this session participants should be able to– Recognize common traumatic injuries of the
hand and wrist – Appropriately evaluate these conditions– Initiate or provide nonoperative treatment– Recognize which injuries need to be referred for
specialty care
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Introduction
Simple and straightforward hand trauma can frequently be handled by non-surgically trained physicians
Often the 1st point of contact
Often better/easier for patient
Don’t want to miss a “surgical” injury
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Palmar digital lacerations
What can be cut?
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Lacerations-superficial
Flexor tendons
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Nerves or vessels
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How do you assess?
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Assessment Vascularity- color,
capillary refill
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Assessment
Sensation
– Does this feel sharp? How many points? Does this feel the same as your other fingers?
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Don’t
Try to locally explore the wound
Ask them to “wiggle” their finger
Ask, “can you feel this?”
Numb them up before doing sensory exam!
Blow off a small laceration b/c “couldn’t possibly have cut anything deep”
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Do… Do digital block after sensory exam if necessary to
complete tendon exam
Wash with antiseptic/skin cleanser (like Hibiclens)
Irrigate wound with sterile Normal Saline
Close with nylon (or monofilament) suture
Splint for comfort
– Refer acutely (not to ER) to surgical colleague
– Start ROM and advance activity in 1-14 days if referal not necessary
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Digital block
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Extensor Tendons
Very broad- may have partial tendon laceration even if able to extend
– May be able to see in wound
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For a tendon laceration over the dorsum of the hand… could a person extend their IP joints even if an extensor tendon was cut?
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Partial extension by junctura
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For a tendon laceration over the dorsum of the hand… could a person extend their IP joints even if an extensor tendon was cut?
Yes… remember that the instrinsic muscles/tendons go volar to MCP joint
and dorsal to IP joints
--firing intrinsics makes MCPs flex… but IP’s extend
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Don’t…. Get fooled by partial extension or
extension of wrong joint
Miss “fight bite”
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Do…
Anesthetize to get “good” exam
Check for full/strong extension
Immobilize in extension suspected partial tendon injuries (for 4-6 weeks)
Clean wound and close
Refer suspected “significant” tendon lacerations
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Twisting,
jamming, crushing
Present with swelling, pain, possible
deformity
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What are you worried about?
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What are you worried about?
Think bone, joint, ligaments (dislocation or sprains)
Closed tendon injcan give deformity
Can have “soft tissue injury”(contusion)
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How do you assess?
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How do you assess?
Start w/ xray
Looking for fractures
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Dislocations…
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….Or both
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Management
Check for open wounds
Check neurovascular status
Not all fractures need formal treatment
– Tuft fractures
– Nondisplaced (linear)
– Avulsion fractures
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Stable:
No or little displacement
Isolated
Intact soft tissue
Unstable: Rotated spiral
fxs
Comminuted
Some short oblique fxs
Displaced articular
Functional alignment…
does not necessarily mean anatomic alignment
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Nail bed injuries
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Treatment objectives
Relieve pain
Normal-appearing/ functioning nail– Few reconstructive options later
Tuft fracture treated symptomatically– base treatment on nail bed injury– Of note… significantly
displacement will be associated with soft tissue injury
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Spectrum of injuries
Contained hematoma
Nail avulsions
Complex injuries
refer!
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Trephination
-- finger splint for comfort!!
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Not the same thing….
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Nondisplaced
3-4 weeks
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Other fractures…need treatment… but not necessarily a hand surgeon
-Minimally displaced boxer’s fractures
-Most Mallet fracture
-Small avulsion fractures
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Boxer’s fractures
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Bony Mallet
Henry and Ingari, “Mallet
Finger” In Essential
Orthopaedics 2009
-Less than 50% joint involvement-Splint full time for 6 weeks (like soft tissue Mallet)
More than 50% jointJoint is subluxedRefer!
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Soft tissue Mallet
Acute loss of ability to extend finger tip
Usually after minor trauma (neg xrays)
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Treatment- 6 wks constant ext splinting
Can pin if unable to wear splint (pin will act as internal splint)
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Volar plate avulsion fractures
Fleck bone pulls off with volar plate
Really a sprain
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Displaced, Unstable or worrisome…
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Dislocations/sprains
Reduced dislocation is now a sprain
A sprain may have been a dislocation that popped back into place
– Localized swelling, stiffness, point tender (over lig)
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PIPs are very stable
From Slade, J. Dislocations and Ligament Injuries of the Small Joints of the Hand.
ASSH Comprehensive Hand Review
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PIP Dorsal Dislocation Hyperextension
– Volar plate ruptures
– Collateral ligs split
– Spectrum of injury
Eaton and Littler 1976
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Lateral dislocations
One collateral and volar plate rupture
– >20deg deviation
Soft tissue can get interposed
From Slade, J. Dislocations and Ligament Injuries of the
Small Joints of the Hand. ASSH Comprehensive Hand
Review
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Volar Dislocation
Rare
Associated tendon injury
Hard to reduce
Peimer et al. Palmar dislocation of the proximal interphalangeal joint. JHS 1984.
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Treatment Pop it back (gentle traction) Check stability (under block)
– Active ROM, passive stability
If stable- protect injured structure and early mobilization– Dorsal splint (30deg), buddy tape (6wks)
If unstable, can’t reduce, suspected tendon injury….refer
Prolonged immobilization
is bad!
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Finger sprains
Hurt for a long time!
– Often 3 months
– May be permanently enlarged
– Beware of flexion contracture
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Gamekeepers thumb…usually need to be fixed
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Assess like other sprains… xray and test stability
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If stable….
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The wrist
Approach is fairly analogous to hand/fingers
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What are you worried about?
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What are you worried about?
Fractures, dislocations, sprains
– Patient may be able to localize pain and you can look for focal swelling and point tenderness to fine tune your focus
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Assess with x-rays first
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Identified fracture Most should be further evaluated by specialist
– Splint and refer
Except…
Triquetral
avulsion fx…
Treat like a
sprain
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Significant ligament injuries
”suspect scapholunate
ligament injury”…
“recommend MRI”
Just refer…
Don’t waste time or money
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What if initial films are normal? Can there still be a significant injury?
Yes–-can have occult scaphoid fracture or can have a scapholunate ligament tear
– Look for tenderness (or swelling) over snuff box and over scapholunate interval
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Get x-rays with dedicated scaphoid view and stress view
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MRI– if worried about occult scaphoid fracture
If still not clear but suspect occult fracture (regular xrays should pick up 97% of fractures) or ligament injury
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If “sprain” … treat symptomatically
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Thank you
If in doubt… talk to your hand surgery colleagues
Many hand injuries can be and should be treated by primary care docs!