hand injuries are common. this is to describe basics in soft tissue injuries of the hand with some anatomical description to recapitulate.

1. Hand Trauma
Principles of Management
Prasad Abeyratne
Registrar in surgery
NHSL- Sri Lanka

2. • Hand is one of the most important parts of the
human body due to its mechanical and sensory
functions.
• One of the most developed structures in the human
evolution.
4 requirements for a functioning hand:
◦ Supple (moving with ease)
◦ pain free
◦ Sensate
◦ Coordinated

3. Topics
• Relevant anatomy
• Clinical approach to hand trauma
– History
– Examination
– Imaging
• Specific injuries

4. Relevant Anatomy
Integument
 Dorsal skin
◦ Thin and pliable.
◦ Attached to the hand's skeleton only by loose areolar tissue, where
lymphatics and veins abundant.
◦ Edema is manifested predominantly at the dorsum
◦ Loose attachment makes it more vulnerable to skin avulsion
injuries.-degloving injuries .
 Palmar skin
◦ Thick and glabrous and not as pliable
◦ Strongly attached to the underlying fascia by numerous vertical
fibers
◦ Most firmly anchored to the deep structures at the palmar creases
◦ Contains a high concentration of sensory nerve endings
4

5. Soft tissues
• Muscles and tendons
• Blood vessels
, lymphatics
• Nerves
Spaces of the hand
Ref. Clinical Anatomy, Richard Snell, 6th edition
Clinical symposia Nov.1988 –surgical anatomy of the hand- earnest W.Lampe MD

6. Muscles and tendons
• Muscles - two main groups:
– Extrinsic group
• Extrinsic extensors
• Extrinsic flexors
– Intrinsic group:
• Thenar complex
• lumbricals
• Interosseous
• Hypothenar complex
6

7. Anatomy of the tendon arrangement in a finger
Extensor expansion - On the dorsum
Flexor sheath - on the volar aspect

9. Blood vessels
• 2 main vessels – ulnar (dominant in 80% ) and radial
• Forms 2 arches in the palm-
• Large Superficial – mainly by ulnar- at the level of distal
border of the extended thumb.
• Small deep- mainly by radial- at one finger breadth
proximal to the superficial.
• Fingers –proper digital arteries are end arteries .
• Fingers neurovascular bundles – nerves are in more
palmar than arteries in contrast to the palm.

10. • Osseous arteries
– Lunate- blood supply from the volar and palmar
ligaments- dislocation with tears in both ligaments
will cause avascular necrosis .
– Scaphoid – 1/3 of the people supply only from the
distal end.

11. Nerves
- Sensory Innervation

12. Motor supply to hand –
Ulnar nerve.
• All the intrinsic muscles - of the hand except radial 2
lumbricals
• Muscles of thenar eminence, with exception flexor pollicis
brevis .variations +
• Muscles of hypothenar eminence are innervated by ulnar
nerve
Median nerve
LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor
pollicis brevis and Flexor pollicis brevis
Ref. Wheeless' Textbook of Orthopaedics

13. Spaces of the hand
Important in infections
• Radial bursa
• Ulnar bursa
• Mid palmar space ( continuous proximally with the
space of Parona.)
• Thenar space
• Dorsal subcutaneous space
• Dorsal subaponeurotic space
• Finger pulp spaces

14. Deep spaces of the hand
Radial
bursa
Thenar space
Mid palmar
Ulnar bursa space
Space of Parona

15. Bones of the hand

16. Hand Trauma
Hand trauma account for 5-10 % of trauma.
Mechanism of injury
• Blunt trauma
• Lacerations & punctures
• Avulsions ± soft tissue deficit
• Ring avulsions
Structures injured
• Cutaneous injuries
• Muscles and Tendons
• Neuro-vascular injuries
• Bones and associated soft tissues

17. Approach to Hand Trauma
• History
• Examination
• Imaging
Ref. Clinical Orthopedic examination -3rd Ed. Ronald McRae
Bailey and Love’s –Short practice of surgical – 23rd Ed
Concise system of orthopaedics and fractures- 2nd Ed. Alan Graham Apley,
Louis Solomon

18. History
Important points in the history of a patient with hand
injury.
▫ Age
▫ Hand dominance
▫ Occupation & hobbies
▫ When and how the injury occurred?
mechanism of trauma
▫ Previous history of hand trauma or relevant
medical/Rheumatic conditions
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19. Physical examination
Entire upper limb comparing both upper limbs.
Should follow the routine order of LOOK, FEEL, MOVE
LOOK
• External appearance.
– local swellings -
• Evidence of chronic disease(OA, RA, Gout)
– Bleeding
– Auto-amputations
– Wounds / exposed tendons etc.
– Deformities

20. Deformities
can be due to tendon, bone , nerve injury and joint dislocations
– Specific types –
Tendon injuries
• Mallet finger

21. • Swan neck deformity

22. • Boutonniere deformity
• Z deformity of the thumb

23. Claw hand deformities – due to nerve injuries
Median, ulnar nerve injuries
– Wasting of the thenar and hypothenar
muscles, interossei etc. ( Chronic )

24. • FEEL
– Temperature
– Tenderness
– Distal neurovascular status

25. MOVE
 Finger cascade ( flexion and extension tendon injuries/ fractures )
 Muscles- intrinsic and extrinsic
 Joints
pain and stability
normal ROM –
Fingers MP – 0- 90° Passive - further 45 °
PIP – 0- 100 °
DIP - 0- 80 °
Thumb –MP - ext. – 55 °
IP - flex. – 80 ° Ext. - 20 °
Carpometacarpal- ext.- 20 ° , flex.- 15 °
abduction- 60 °
(excess
mobility may be due to collateral lig. Injury Ex.
Gamekeepers thumb )

26. Functional capacity –
• Grips
– Pinch grip /precision grip
– Chuck grip
– Palmar grip/hook grip
– power grip

27. Types of grips of the hand
Power grip Hook grip Chuck grip
Pinch grip /precision grip

28. Imaging
• X rays- AP, lateral &oblique views
◦ Plain-films of the hand or wrist should be obtained when
injury suggestive of fracture or an occult foreign body.
 Ultra sound
◦ Has a growing role in locating foreign bodies and in
evaluating soft tissues
◦ Can detect ruptured tendons and assess dynamic function
of tendons non-invasively.
 MRI
◦ Highly sensitive but not have a role in management of hand
wounds.

29. General Operative Principles
• A bloodless field (eg, by tourniquet ischemia) is essential.
The pressure of the cuff will 100 mm Hg above systolic
pressure.- 200-250 mmHg ( max-250)
This is readily tolerated by the unanesthetized arm for 30
minutes and by the anesthetized arm for 2 hours.
• Incisions must be either zigzagged across lines of tension
(eg, must never cross perpendicularly to a flexion crease),
termed Brunner incisions, or run longitudinally in "neutral"
zones- so that a healthy skin-fat flap is raised over the zone of
repair of a tendon, nerve, or artery.

32. Cutaneous injuries
• Cutaneous injuries are very common injury.
• Two Types
– Open: Incised, laceration, punctured
(bites), penetration, abrasion.
– Closed: Contusions, Hematomas
• Vary in depth
• May need to explore for underlying structural Injuries.
• Conservative excision of the skin is the rule.
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33. Management
 Skin Laceration:
◦ Small: Rinse and cover.
◦ Large: Wound exploration under LA
 Irrigate wound profusely with betadine or sterile
water and Explore
 Close the skin wound with simple sutures.
 Wounds older than 6-8 hours should not be
closed primarily.
 Irrigate, explore then apply sterile dressing.
Delayed primary closure at 4 days.
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34.  Bites:
◦ Should not be closed primarily but delayed
closure at 4 days if needed
◦ Antibiotic prophylaxis is indicated in human
(including fight-bites) and cat bites and may be of
benefit in dog bites as well.
 Contusions:
◦ Cold packs with pressure for 30 to 60 min. several
times daily for 2 days. Then use warm compresses
for 20 minutes at a time.
◦ Rest, elevate
◦ Do not bandage a bruise.
34

35.  Abrasions:
◦ Superficial:
 Rinse and cover.
 Prophylactic antibiotic ointment
◦ Deep:
 Rinse with antiseptic or warm normal saline. Scrub gently
with gauze if necessary.
 Dress with semi-permeable dressing (Tegaderm)
Changed every few days.
 Keep wound moist. Enhance healing process.
35

36. Finger tip Injuries
Injured components may include skin, bone, nail, nail
bed, tendon, and the pulp, the padded area of the
fingertip .
The skin on the palm side of fingertips is specialized
in that it has many more nerve endings than most other
parts of our body enabling the fine sensation.
When this specialized skin is injured, exact replacement
may be difficult.

37. • Severe crush or avulsion injuries can completely remove some
or all of the tissue at the fingertip.
• If just skin is removed and the defect is less than a
centimeter in diameter, it is often possible to treat these
injuries with simple dressing changes.
• If there is a little bit of bone exposed at the tip, it can
sometimes be trimmed back slightly and treated with V-Y
plasty

38. • For larger skin defects, skin grafting is recommended.
• Smaller grafts can be obtained from the little finger
side of the hand. - Cross finger flap
• Larger grafts may be harvested from the forearm or
groin.
Cross finger flap

39. Tendon injuries
Extensor tendon Injury:
– Divided into Zones according to anatomical
location of injury
– In the hand and wrist there are 7 extensor
tendon zones
Ref. http://emedicine.medscape.com Orthopedic Surgery for Flexor Tendon
Lacerations Author: Michael Neumeister, MD, FRCSC, FRCSC, FACS; Chief
Editor: Harris Gellman, MD
http://www.orthobullets.com- Flexor Tendon Injuries- Derek Moore MD
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41. Zone Presentation Management
•Closed: splinting 6-8 weeks
I Mallet Deformity •Open: suture repair for fixation.
Soft tissue reconstruction
•Closed: splinting MCP and PIP in
Boutonniere’s hyperextension for 6 weeks
III •Open: suture repair (figure of 8
Deformity
suture)
•Closed: splinting ,45 extension at
V Fixed flexion of MCP wrist and 20 flexion at MCP
•Open: suture repair.
•Suture repair followed by post-op
VII Fixed flexion of MCP splinting
41

42. Flexor tendon injuries –
5 zones in the hand and the wrist
Zone 1 One tendon only (FDP)
from middle of middle phalanx
FDS Insertion
distally
Zone 2 Two tendons (FDS &
FDP) from MCP joints to middle
Flexor Sheath of middle phalanx
Zone 3 Central palm
Zone 4 Tendons in the carpal
tunnel
Zone 5 Tendons proximal to the
carpal tunnel

43. Zone Presentation
Presentation Management
Flexor injury
Loss of active flexion at
•Primary or Secondary tendon
DIP joint
repair
I Hyperextension of DIP
•Careful suturing prevent post-op
joint
adhesions.
(Jersey finger )
•Skin closure then secondary
repair by tendon grafting
Loss of active flexion
II •Primary repair performed by
at MCP joint skilled hand surgeon to minimize
post-op adhesions.
•Primary or secondary tendon
repair
III, IV
Same •Examine carefully for thenar
Thumb muscle injury and recurrent
branches of median nerve. 43

44. Zone Presentation Management
V Uncommon •Superior to Tendon division: repair
Palm Lie deep and protected by is unnecessary.
palmar fascia •Both muscles’ tendon division:
Same presentation primary repair
VI, VII Multiple flexor tendon •Primary tendon suturing in the
Wrist injury forearm to prevent post-op cross-
Impaired active flexion of adherence.
multiple digits •Injuries to muscles in forearm
require primary repair
•Post-op splinting of wrist in flexion
position and elevation for 4 weeks.
44

45. Nerve injuries
 Effect of injury: “Seddon’s Classification”
◦ Neuropraxia:
 Disruption of Schwann cell sheath but no loss of continuity.
◦ Axonotmesis:
 Injury to both Schwann sheath and axon.
 Distal part undergoes Wallerian degeneration.
 Stimulation of nerve 72 hours after injury does not elicit response.
 Regeneration occurs with the average rate of 1-2 mm/day.
 Neorutmesis:
• Injury to all anatomical components, myelin sheath, axons and the
surrounding connective tissue.
• This total nerve disruption makes regeneration impossible.
• Surgical intervention is necessary.

46. Nerve injury – surgical interventions
 Neurolysis:
◦ Removal of any scar or tethering attachments to
surroundings that obstruct nerve ability to glide.
 Neurorrhaphy:
◦ End-to-end repair.
◦ Resection of the proximal and distal nerve stumps and then
approximation.
 Autologus Nerve grafting:
◦ Gold standard for clinical treatment of large lesion gaps.
◦ Nerve segments taken from another parts of the body.
◦ Provide endoneural tubes to guide regeneration.
◦ Two types: Allograft, Xenograft.

47. Hand infections
• Commonly seen by orthopedic surgeons as well as emergency
room Identifying the cause of the infection and initiating
prompt and appropriate medical or surgical treatment can
prevent substantial morbidity.
• The most common bacteria Staphylococcus aureus and
Streptococcus species
• Best treated with empiric antibiotic therapy until the
organism can be confirmed.
• Types of infections include cellulitis, superficial
abscesses, deep abscesses, septic arthritis, and osteomyelitis

48. • In recent years, treatment of these infections has
become challenging owing to increased virulence of
some organisms and drug resistance.
• Treatment involves a combination of proper
antimicrobial therapy, immobilization, edema
control, and adequate surgical therapy.
• Best practice management requires use of appropriate
diagnostic tools, understanding by the surgeon of the
unique and complex anatomy of the hand, and proper
antibiotic selection in consultation with microbiology
opinion.
Ref. Hand infections. J Hand Surg Am. 2011 Aug;36(8):1403-12.

49. AMPUTATION AND
REPLANTATION
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50. Introduction
 Replantation: reattachment of a severed digit of
extremity.
 Chinese surgeons at the Sixth People's Hospital
performed successful replantations in the 1960s.
However, in 1968 Komatsu and Tamai's reported o a
successful thumb reattachment
 Not all patients with amputation are candidates for
replantation
 Approximately 100,000 digital amputations occur per
year in the US. Of these, an estimated 30% are
suitable for replantation
Ref. http://emedicine.medscape.com- Hand, Amputations and
Replantation- Author: Bradon J Wilhelmi, MD; Chief Editor: Joseph A
Molnar, MD, PhD, FACS
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51.  Decision is based on:
 Importance of the part,
 level of injury,
 mechanism of injury
 expected return of function.
 Because hand function is severely compromised if the thumb or
multiple fingers are not present to oppose each other, thumb
and multiple-finger replants should be attempted.
 Hand Muscles at room temperature are irreversibly damaged in 6-8
hours; if cooled, it can withstand a maximum of 8-12 hours of
ischemia.
 However, if digits are cooled without freezing, they may survive
longer than 100 hours

52.  Recommended ischemia times for replantation:
◦ Major replant: 6 hours of warm and 12 hours of
cold ischemia.
◦ Digit: 12 hours for warm ischemia and 24 hours for
cold ischemia.
 Preoperative preparation: radiography of both
amputated and stump parts to determine the level
of injury and suitability for replantation
52

53. 53

54. The normal sequence of the operative procedure
• Debridement
• Identification and/or tagging of vital structures
• Skeletal stabilization- appropriate shortening, the bone may be
stabilized interosseous wires, interosseous wire and pin, or miniplate
and/or miniscrews. Joint damage may be managed with prosthetic
joints, resection arthroplasty, or fusion.
• Extensor tenorrhaphy
• Placing sutures within flexor tendon ends
• Digital artery repair
• Neurorrhaphy of digital nerve
• Repair of flexor digitorum profundus
• Venous repair
• Skin closure
• Dressing

55. Outcome
 Overall success rates for replantation approach 80%.
 Better outcome with Guillotine (sharp) amputation
(77%) compared to severely crushed and mangled
body parts(49%). In general, the prognosis for ring
avulsion injuries is poor.
 Studies have demonstrated that patients can expect to
achieve 50% function and 50% sensation of the
replanted part.
Ref. Plastic Surgery, Goldwyn and Cohen, 3rd edition.
Plastic Surgery, Grabb and Smith, 3rd edition.
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56. Thank you
Bone injuries–fractures
• To be continued…