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Hand injuries

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Hand injuries
Taiz University , faculty of medicine and health sciences
By Dr : Mohammed Abdulsatar

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Hand injuries

  1. 1. HAND INJURIES Group D 2015
  2. 2. HAND INJURIES • The hands as the human executing organs are in the center of daily life activities’, thus are always exposed to injuries and overuse . • We are more aware of our hands than any part of the body • Are important out of all proportion to their apparent severity ,because of the need for perfect functions . • Local edema and stiffness of the joints –common accompaniments of all injuries- are more threatening in the hand than anywhere else .
  3. 3. HAND INJURIES • Problems of hand arise for 3 reasons : 1- the defect may be unacceptable 2- function is impaired 3- deformed part becomes nuisance during daily activities
  4. 4. HAND INJURIES • Superficial injuries and severe fracture are obvious but deeper injuries are often poorly disclosed ,so it is important in the initial examination to assess the • circulation • soft tissue cover • bones • joints and tendon • nerves • X-rays should include at least 3 views PA ,Lateral and oblique
  5. 5. HAND INJURIES • Hand injuries the commonest of all injuries . • in avarage the hand injuries account for 14-30% of all pt in ED . • Fractures 46% , tendon injuries 29% and skin lesions .
  6. 6. HAND INJURIES general principle of treatment • ABC • Most hand injuries can be dealt with under local or regional anaesthesia . • Definitive treatment is dictated by the nature of the injury , but common to all injuries are • safe splintage • prevention of swelling • dedicated rehabilitation
  7. 7. HAND INJURIES general principle of treatment • Safe splintage _ incorrect splintage is a potent cause of stiffness so must be appropriate and kept to a minimum -if the whole hand is splinted or bandage this must be in ‘’the position of safe immobilization’’
  8. 8. Anatomy of the hand • Bones • Areas • Zones • Arches • Ligaments • Muscles • Innervation ⥤is a prehensile, multi-fingered extremity located at the end of an arm or forelimb . ⥤...& are the richest source of tactile feedback, and have the greatest positioning capability of the body; thus the sense of touch is intimately associated with hands. PALMAR DORSAL
  9. 9. ZONES Extensor Zones of Hand
  10. 10. Flexor Zones: Flexor Zones: The hand is divided into following 5 zones, which would determine the prognosis and approach to treatment. Zone 1: Only FDP involved Loss of flx of DIP joint Instability in pinch Loss of grip strength Good prognosis Zone 2: “No man’s land” Pulleys present (prevent bow stringing) A2 and A4 Vincula in area–provide vascular supply. Injury thus causes decreased tendon vascular nutrition. Poor prognosis Zone 3: Good prognosis Good vascularity and no pulleys Zone 4: Carpal tunnel Usually more than 1 tendon involved Intendinous adhesions (close proximity of tendons) Relatively good prognosis Zone 5: Usually presents with nerve involvement (ulnar / median nerve) Tendons superficial, thus adhesions to skin probable The hand is divided into 8 zones when dealing with extensor tendon injuries.
  11. 11. Muscles & tendons * Extensor tendons of fingers : -of the long extrinsic muscles . -attaches to the middle phalanx in central slip . * system of flexor tendons of fingers : -functional unit of tendons, tendon sheath and pulleys . - flexor digitorum profundus . - flexor digitorum superficial . - flexor pollicis longus of the thumb .
  12. 12. FLEXORSEXTENSORS
  13. 13. ligaments • Tow important structures called collateral ligaments are found in either sides of each finger joint . • Volar plate is the strongest ligament .
  14. 14. Blood Supply 1. Ulnar A.  Forms the superficial palmar arch ?with superficial palmar br. of radial artery  Gives 4 common palmar digital art. 2. Radial A.  Forms the Deep palmar arch with deep br. of ulnar ar. 1 cm proximal to Superficial arch
  15. 15. Nerve supply
  16. 16. Nerve supply
  17. 17. Median Nerve Ulnar Nerve Radial Nerve
  18. 18. Bone & joints injuries
  19. 19. Metacarpal Fractures  The metacarpal bones are vulnerable to blows and falls upon the hands or the force of the boxer’s punch .  Injuries are common  Agulatory deformity is usually not very marked ,rotational deformity is serious .
  20. 20. 2)Metacarpal Fractures  Head  Intraarticular  Neck  Usually unstable  Forwards tilting of distal fragement  Shaft  Direct blow  Transverse or oblique #  Base  Associated carpal bone injury  Impacted #  1st metacarpal  Usually occurs at base
  21. 21. Presentation  Pain/Tenderness  Swelling  Discoloration  Sensation  Circulation  ROM  Plain Films  Deformity of hand Localized tenderness Swelling of hand Discoloration Decreased movement Numbness Unequal temperatures What next?
  22. 22.  Midshaft vs. Base vs. Neck  Complete vs. Incomplete vs. Comminuted  Dorsal vs. Volar Angulation  Transverse vs. Oblique vs. Spiral  Unstable vs. Stable
  23. 23. Management of metacarpal #  A- undispalced # : require only a firm crepe-bandage for comfort 2-3 wks
  24. 24. Management of metacarpal #  B- dispalced # : 1-of the shaft - reducion by traction and pressure hand then held by plaster slap for 3 wks . -ORIF with small plates and screws or by percutaneous K-ware is the best because these unstable #
  25. 25. Management of metacarpal #  B- dispalced # : 2- of the neck (boxer’s fracture ) * usually of the 5th finger * angulation of upto 40 degrees can be accepted as long as there is no rotational deformity . * reduction traction and pressure then held by plaster slap 1-2wks * fixation with percutaneous intramedullary wires usually preferred
  26. 26. Metacarpal Neck Fractures (Boxer’s Fracture)  Common  Direct impact with closed fist  Dorsal angulation  Unstable  Treatment  Reduction (90-90 method)  Splint  Follow-up within 1 week  Complications  Malunion with volar angulation  Pain  Rotational deformity  Stiffness
  27. 27. Metacarpal Base Fractures  Stable  Infrequent  Associated injury  Ulnar nerve  Carpal bone injury  Treatment  Volar splint  Complications  Tendon damage  Stiffness
  28. 28. Thumb Metacarpal Fractures  Uncommon  Most involve the base  Extraarticular  Direct trauma or impaction  20-30 degrees of angulation is tolerated  Intraarticular  Bennett’s Fracture  Rolando’s Fracture  Treatment  Thumb spica  Complications  Malunion and arthritis
  29. 29. Bennett’s Fracture:  At base of first metacarpal bone  Oblique intra-articular #  Unstable  Due to punching .  X-ray show that a small triangular fragment has remained in contact with the medial edge of the trapezium , while the remainder of the thumb has proximally pulled upon by the abductor pollicis longus tendon .
  30. 30. Bennett’s Fracture:  Perfect reduction is essential by pulling on the thumb ,abducting it and extending it .and then held by plaster or internal fixation  Surgical fixation is achieved by passing a k-ware across the metacarpal base into the carpus
  31. 31. a)Bennett’s Fracture:  Intraarticular fracture  Dislocation/Subluxation  CMC joint  Fragment pulled dorsally  Abductor pollicis longus  Adductor pollicis  Ligament disruption  Treatment  Thumb spica  Early referral
  32. 32. b)Rolando’s Fracture  Comminuted intraarticular fracture  Less common than Bennett’s Fracture  Worse prognosis  Treatment  Thumb spica  Early referral  Complications  Malunion and pain
  33. 33. fractures of phalanges  Phalangeal # usually result from direct trauma and therefore any part may be affected .  Management :  A) undisplaced # :  functional splintage (buddy splintage ) for 2-3 wks . - movement are encouraged from the outset .
  34. 34. fractures of phalanges  B) – displaced fractures 1- of the proximal or the middle phalanx : * the bone # reduced and immobilized under local anaesthesia , carefully avoiding malrotation , then splintaed leaving the other fingers free 3 wks .
  35. 35. fractures of phalanges  B) – displaced fractures 1- of the distal phalanx : distal phalangeal # are usually due to crushing injuries or a blow from a hammer . - the soft tissue damage must be treated . -The majority of fractures can be treated conservatively, and it is normally the initial repair of the surrounding soft tissues that is most important .
  36. 36. 3) Phalanx Fractures  15-30% of hand fxs  Tuft  Nail bed injury  Shaft  Intraarticular  Tendon injury  Complications  Pain, hyperesthesia, cold sensitivity, osteomyelitis 1)Distal Phalanx Fractures Mechanism:
  37. 37. No Problem Refer!  Treatment: padded or “C” splint; extend past the tip  Refer: transverse, angulated  Healing Time: 3-4 weeks  Return to Work/Sport: okay with splint as tolerated  exception: transverse fx – needs longer protection from potential re-injury activity
  38. 38. •Mechanism: direct blow or twisting •Sxs & Exam: local swelling; examine for deformity or malrotation; check PIP and DIP fxn 2)Middle Phalanx Fractures •Transverse Fx or short oblique: Low risk
  39. 39. •Nondisplaced fx’s do well with buddy taping •Healing Time: 4-6 weeks (buddy tape for 3-4 wk) •Return to Work/Sport: okay as long as you have some protection via splint or buddy tape •Refer: displaced, long oblique, spiral or intra- articular fx
  40. 40. •Mechanism: direct blow: transverse; often unstable due to tendon insertions twisting: oblique or spiral; may be more stable Sxs & Exam: local swelling; examine for deformity or malrotation 3)Proximal Phalanx Fractures
  41. 41. Apex volar angulation is common •proximal fragment pulled into flexion by interosseous •distal fragment pulled into extension by extensor mechanism
  42. 42. •Nondisplaced fx’s do well with buddy taping; use gutter splint for additional stability •Healing Time: 4-6 weeks (buddy tape for 3-4 wk) •Return to Work/Sport: okay as long as you have some protection via splint or buddy tape •Refer: angulated, displaced, intra-articular fx Proximal Phalanx Fx: Treatment
  43. 43. Alternative: Burkhalter Splint dorsal half to PIP volar half to palmar crease
  44. 44. Joints
  45. 45. CMC joint dislocation:  Mechanism :forceful dorsiflexion of the wrist combined with longitudinal impact ,  Seen typically in boxers and in motorcyclists .  Dx : X-rays  After regional anaesthesia , the dislocation is reduced by traction , manipulation, and pressure on the metacarpal base , then protective slap is worn for 6 wks .
  46. 46. CMC joint dislocation Carpometacarpal (CMC) dislocation (a) Thumb dislocation. (b) Dislocation of the fourth and fifth CMC joints treated by closed reduction and Kirschner wires (c). Complete CMC dislocation (d).
  47. 47.  Thumb CMC dislocation :  Isolated dislocation is rare compared to the more common Bennett fracture dislocation.  Easy to reduce but unstable after reduction.  Apply thumb spica splint after reduction.  Need surgical referral.
  48. 48. Dislocation of MCP joint
  49. 49. Metacarpophalangeal Joint  Relatively rare injury  Dorsal displacement  Hyperextension forces  Dorsal displacement  Volar plate can enter joint space  Volar dislocations  Usually surgical  Treatment  Reduce  Splint in flexion
  50. 50. Dislocation of MCP joint  The thumb is most frequently affected and clinically the injury resembles a BENNETT’ fracture –dislocation  Dx : by Xrays  The displaced is easily reduced by traction & hyperpronation , but reduction is unstable and can be held by a K-wire for 5 wks and then protective splint for 8 wks because risk of instability .
  51. 51. MCP of the Thumb  Strong but vulnerable  5 times more likely to be injured  Difficult reduction  Volar plate entrapment  Ulnar collateral ligament injury  Gamekeeper’s or Skier’s thumb  Radial collateral ligament injury  Less common  Forced adduction with or without hyperextension
  52. 52. Skier’s Thumb  Scottish gamekeeper’s  Repeated twisting  Forced radial deviation  Associated avulsion fracture  Valgus stress testing  Extension and flexion  Complete ligament tears  >35 degrees of laxity  Treatment  Thumb spica
  53. 53. Dislocation Interphalangeal Joint
  54. 54. 1)Proximal Interphalangeal Joint  Dislocation pattern  Dorsal  Most common ligamentous hand injury  Lateral  Volar  Associated fracture  > 33% of articular surface = unstable  Violent twist with finger flexed (palmer) or extended (dorsal)  SHARP, deformity, disability  RICE, splint, meds, reduction/surgery, protect
  55. 55. • Nondisplaced Fx: Initially use extension block splint for first 2-3 weeks followed by buddy taping in sight flexion. Work on restoring ROM. • Healing Time: 6-12 weeks; monitor progress every 2-3 weeks
  56. 56. 2)Distal Interphalangeal Joint  Most are dorsal  Often open  Reduction  Traction  Hyperextension  Dorsal pressure  Irreducible  Avulsion fracture  Buttonhole tear  Open dislocation  Irrigation  Antibiotics
  57. 57. Tendons Injuries
  58. 58. Tendon injuries • Are the second most common injuries of the hand • After clinical examination , ultrasound and MRI imaging have provide to be important diagnostic tools . • Treated by conservative or surgical
  59. 59. • For later case where the joint is still passively correctable , treated by is to divide the extensor tendon in just proximal to its insertion into the distal phalanx . • long standing fixed deformity may be better left alone .
  60. 60. Carpal Tunnel Syndrome pressure in carpal tunnel (swelling, inflammation) via trauma, rep flexion Pressure on median n Sensory (lat palm), motor (wrist, finger flex) deficits A. Mechanism: overuse, congenital, trauma B. Pathology: Compression of the median nerve in the tunnel , surgical decompression
  61. 61. Signs and Symptoms: Pain in wrist Numbness and tingling in the thumb and first two fingers Positive Phalen’s test Positive tap test
  62. 62. Treatment Conservative: Immobilization and Rest ice .NSAIDS, corticosteroid injection Radical: Surgery to increase space in the tunnel
  63. 63. ‫الجميع‬ ‫هللا‬ ‫وفق‬ ‫عبدالستار‬ ‫محمد‬GD
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Hand injuries Taiz University , faculty of medicine and health sciences By Dr : Mohammed Abdulsatar

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