Brent Nossaman, DO

Hand InjuriesHand InjuriesBrent Nossaman, D.O.

Tulsa Bone & Joint Associates

Initial Evaluation

• History and mechanism of injury

• Number and nature of structures damaged

• Time elapse since injury

• Open or closed injury

Initial Evaluation

• Examination– Skin– Motor function– Nerve function– Circulation

Initial Evaluation


Initial Evaluation


Initial Evaluation


Dislocation / Ligament Injury

• Thumb– “Gamekeeper” “Skier’s Thumb”– UCL tear at MP joint ( Stenar Lesion)– May have assoc avulsion fracture– Sress X-ray

• No clear consensus• 15 degees opening more than opposite side• 20-45 degees greater in flexion than opposite side

– UCL 10X greater occurance than RCL– Treatment

• Complete tear– early open repair late reconstruction with tendon graft

• Incomplete tear– Thumb spica

Dislocations

• Finger– MP

• Dorsal most common• Frequency- Index, thumb, small

– Simple- markedly angulated• Reduce, early motion

– Complex- minimally angulated• Usually irreducible, open treatment

Dislocation

• Finger• Pip

– “Jammed Finger”– Types

• Dorsal, volar, and lateral

– Dorsal• Most common injury of hand• Reduce, start early motion• Fx/dislocation• Avulsion – start early

protected motion• Large fragment – operative

fixation vs. early motion, soft tissue reconstruction

Dislocation

• Volar– Rare– Open reduction usually required– Avulsion fx with extensor tendon

• Lateral– Rupture of one collateral– Protection followed by early motion

Dislocation

• Dip– Rare– Dorsal or lateral– Often open injuries

Finger Tip Nail bed Injuries

• Epidemiology– 24% Surgical hand

trauma– 75% Patients male

• Nail Physiology– Complete nail growth

70-160 days– 21 day delay following

injury– Abnormal growth for

100 days after injury


• Subungual hematoma– 30-50% of total area

can leave• Perforate nail to relieve

pressure

– 50% or greater• Consider nail bed repair


• Nail bed lacerations– Repair with absorbable

suture under loupe magnification

– Approx 50% nail bed injuries have associated distal phalanx fracture usu comminuted tuft fx

– Proximal nail plate dislodgement

• Remove nail, irrigate, repair nail matrix

Tendon Injuries

• Initial treatment• Evaluation• Irrigation• Skin closure• Referral

Tendon Injuries

• Flexor Tendons– Laceration– Rupture

– Laceration• Commonly assoc with

neurovas injury• Radial & ulnar volar digital

a&n• Evaluate prior to

anesthetizing finger• Paperclip orientated

longitudinal

Tendon Injuries

• Independent Testing– FDS– FDP

Tendon Injuries

• Emergent repair avascular finger / hand

• Urgent Repair

• Less than 7-10 days better results

• Always less than normal function

• May require subsequent surgery

• Intensive hand therapy involved

• 8-12 wk recovery depending on use

Tendon Injuries

• Flexor Rupture (Jersey Finger)– Closed injury– Usually sports related– Ring finger most common– May be associated with distal phalanx fx– Repair timing depends on retraction of tendon

Tendon Injuries

• Extensor tendon– Mallet deformity

(Rupture)• Tendon only• Bone avulsion

– Laceration– Same treatment as

flexor

Fractures

• Distal phalanx– Tuft

• Closed – splint subungual hematoma

• Open – debridemont and wound care

• Hypersensitivity to touch occasional

• Tenderness often lasts several months

– Shaft• Usu stable• Pin unstable

– Base• Stable splint• Unstable pin

Fractures

• Proximal and Middle Phalanges– Condyles

• Unicondylar• Usually pin or screw to

prevent displacement of articular surface

– Neck• Pin or plate to prevent

displacement

– Shaft• Minimally displaced

closed treatment• Displaced or comminuted

pinning or open

Fractures

• Proximal and Middle Phalanges– Intraarticular

• Collateral ligament avulsion

• Volar plate avulsion

– Reduction with pin or screw

Fractures• Metacarpal

– Head• Displaced pinning possible open

treatment• May accept 30-50 degrees

angulation in 4th and 5th

– Neck (Boxer)• May accept 10 degrees

angulation in 2nd and 3rd

• Closed pinning possible open treatment

– Shaft• Check rotation when flexing

fingers!• Transverse or short oblique or

border digits usually require internal fixation

• Long oblique 3rd 4th minimally displaced may treat closed

Fractures

Fractures

• Metacarpal– Base

• Commonly 4th and 5th

• Associated with dislocation CMC• Closed pinning, possible open treatment

• Intraarticular with possible arthrodesis

Fractures

• Scaphoid– Most common carpal bone

fracture– Unique blood supply

predisposing to AVN– Fracture pattern

• Proximal 20%

• Middle (waist) 70%

• Distal 10%

– Clinical Exam (Pain)• Snuff box tenderness

• Axial load of thumb

• Tubercle tenderness

Fractures

• Scaphoid• 10-15% nonunion

despite early treatment may be decreasing due to early screw fixation

• Trend toward aggressive treatment with screw fixation

Fractures

• Scaphoid• Occult fracture

– Day 2-3 MRI– Day 4 Bone Scan– Day 10 X-rays usually positive

• Treatment– Distal pole Thumb spica short arm– Waist

• nondisplaced long arm thumb spica• Displaced internal fixation

Foreign Bodies

• Determine type if possible and location

• X-ray• Under penetrated for

better soft tissue• Can see metal, bone,

teeth, pencil lead, certain plastics, glass (all), gravel, stone, fish spines, wood, aluminum

Hand infections

• Organism 50-80% Staphlococcus aureus Streptococcal

• IVDA, DM, Farm, Bite Gram –

• Human bite Eikenella Corrodens

• Animal bite Pasteurella Multocida

• Immunocompromised Atypical Myco

Hand infections

• Occupational/Habit Assoc– Dental hygienist – herpes lesions– Dishwasher – fungal– Nail biter – paronychia– Manicure -- paronychia

Hand infections

• Cellulitis– Usually Streptococcus

(Group A beta)– Occasional

Staphylococcus• Treatment

– Cephalosporin (2nd gen)

• Abscess– Usually Staphylococcus– Farm anaerobic– IVDA / DM Gram –

• Treatment– Surgical drainage and

antibiotic

Hand Infection

Hand infections

• Paronychia– Disruption of seal btw nail plate and nail fold– Infection beneath eponychial fold– Can track under nail plate ( subungual)

• Usually Staphylococcus aureus

Hand infections

• Paronychia– Treatment

• Early– Soaks and antibiotics

• Established– Drainage and antibiotics

• Felon (abscess)– Infection of pulp space tip

of finger– Usually Staph

• Treatment– Incision– High midlateral or volar if

pointing– AVOID fish mouth– Antibiotics

Hand Infections

• Flexor tenosynovitis• Associated with puncture or injury on palmar

side of finger with contamination of flexor sheath• Heamatologic?• Clinical Suspicion

– Kanaval’s Cardinal Signs• Tenderness over tendon sheath• Flexed posture• Fusiform swelling• Pain on passive stretch

Hand Infections

• Flexor tenosynovitis– Treatment

• Early– Antibiotics (IV) reasses 24 hours

• Established– I & D

Hand Infections

• Animal Bites– Dog

• Crush type injury

– Cat• Puncture

– May produce significant infection

Chemical Injury

• Treatment– hydrofluoric acid

• Calcium gluconate gel• Calcium gluconate (10%) injection

– Phenol• Shower to remove• Observation for CVS complications

– White Phosphorus• Mineral oil• Copper sulfate 1%

– Na+, K+--explode on contact with water• Mineral oil• Na+--isopropyl alcohol• K+--tert-butyl alcohol

Chemical Injury

• Determine contaminant and duration of contact– Hydrofluoric acid

• severe pain• no initial skin changes• progressive necrosis

– Phenol• Observe for CVS complication

– Na+, K+– White Phorphorus

Gun shot wounds

• Hand guns– low velocity 1000ft/sec or less– Local wound care– Oral antibiotics– Outpatient care– Occasional vascular injury/ Compartment

syndrome– Fractures usually stable, early motion– Nerve deficits common usually neuropraxia

• Military/Rifles– high velocity

Gun shot wounds

• Military/Rifles– high velocity– Extensive bone and soft tissue damage– Debridemont– Evaluation for vascular compromise

Documents

Brent Nossaman, DO