Hand

1
Hand Wrist Injuries 2007

• Introduction Principles
• Soft Tissue Flaps
• Distal Radius Fractures
• Hand Fractures
• Amputations Replants

2
Know Your Anatomy
3
Management Priorities

• Evaluation
• Decision to amputate (best time is 1st OR)

4
Evaluation Priorities

• Occult trauma
• Classifying known injuries

5
Dough Mixer Rake
BUT
Dont miss the associated shoulder injury
6
Missed Injuries - Local

• Partial laceration
• Tendon, nerve, vessel
• Fractures
• Scaphoid, hamate, epiphyseal
• Dislocations
• MCP, PIP, perilunate
• Compartment Syndrome

7
(No Transcript)
8
Volkmanns
9
Ring Avulsion Injuries

• Appear minor
• Vessel damage
• Blood trapped in distal part

10
Partial Arterial Lacerations

• Control bleeding with local pressure elevation

11
Open Hand Fractures
12
Flexor Tendon Zones
13
Mechanism of Injury

• Avulsion, blast, or crush
• Increased risk for
• Swelling/stiffness
• Local flap necrosis

14
Treatment Priorities

• Circulation
• Bone soft tissue
• Tendons nerves

15
Shearing Forces vasc injury
16
Superficial Palmar Arch Points
17
Debridement

• Tourniquet
• Pseudo-tumour resection
• Excise
• Contaminated
• Severely contused
• Avascular
• Eliminate dead space
• Clean intact vital structures

18
Bone

• Bone penetration should be windowed explored

19
Proper Debridement
20
High Pressure Injection Injury
21
Restoration Of Blood Flow Order of Procedures

• After debridement
• Longitudinal incisions
• Compartment decompression
• Skeletal alignment/fixation
• Repair muscles
• Vessel repair/graft
• Best opportunity to repair nerves

22
Potato Picker
23
(No Transcript)
24
(No Transcript)
25
Nerve Repair

• Neurolysis
• Irrigate/epineural closure
• Repair partial nerve injury
• Do early never get a better chance

26
Partial Nerve Injury
27
Nerve Repair

• Nerve repair is fairly straightforward when
  acute...

28
Early Active Motion

• More than joint maintenance
• Also
• Reduces adhesions
• Increases strength
• Increase synovial uptake
• Increases excursion

29
Timing Wound Closure

• Traditional teaching early debridement then
  delayed 1 closure
• However current lit ? early or immed flap
  coverage for tissue loss

30
Skin Loss

• Impaired interaction with environment
• Susceptible to infection
• Loss of temperature regulation
• Tissue desiccation
• Swelling/Stiffness
• Necrosis

31
Methods of addressing skin deficits

• Direct suture
• Best reserved for dorsal defects
• Secondary intent -- granulation
• Non-critical areas
• Finger tips
• Skin grafts
• Split thickness
• Full thickness
• Flaps

32
Secondary Intent - Granulation

• Non-critical areas
• Finger tips

33
Flaps

• Contiguous
• Advancement

34
Flaps

• Contiguous
• Rotation
• Grinding injury exposes bone.
• full thickness flap of dorsal skin, based either
  radially or ulnarly on a pedicle which will
  permit sufficient rotation may be used to close
  the defect on a primary basis.

35
Flaps

• Non-contiguous
• Local same extremity
• Cross finger
• The donor site defect covered with a split
  thickness skin graft.
• separation at two weeks.
• follow up at 3 months with good function.

36
Flaps

• Other local flaps can be derived from sacrifice
  of unsatisfactory parts.

37
Fragment Specific Fixation of Distal Radius
Fractures
38
Basic Orthopaedic Principles

• Reduction
• Maintenance
• Rehabilitation

39
Distal Radius Fracture Elements
Medoff Classification
40
Radiographic Criteria for Reduction
Palmar Tilt
3mm
Radial Inclination
Radial Height
Ulnar Variance
41
Distal Radius Fractures
Technical Considerations
Specific difficulties for internal fixation

• Extensive comminution is usually present
• Small size of skeletal fragments
• Thin cortex in metaphysis
• Close apposition of tendons
• Close apposition of sensory and motor nerves

42
Variety of Implants
43
Materials Methods

• 72 cases
• March 2001 June 2005
• Age 18-60 yrs
• AO type C2 C3

44
Summary

• Used safely
• Correction of radiographic parameters
• Acceptable ROM strength
• Good outcome measure results
• Still implant removal problem

45
W.J.

• Mult trauma incl pelvis spine
• Bilat distal rad

46
R L
47
R temp exfix def RPP VBP
48
7 mos post op
49
L temp exfix RPP UPP VBP
50
7 mos post op
51
Radiographic Assessment

• minimal requirement ? PA, lateral and oblique
  views of the hand

52
(No Transcript)
53
Treatment Depends on

• Patient characteristics
• General health
• Level of activity
• Occupation
• Handedness

54
Management Principles

• Anatomic reduction of fractures
• Pain control
• Minimize scarring
• Early motion

55
Poor Prognostic Factors

• Patient factors
• age gt 50,
• systemic disease (diabetes)
• corticosteroid therapy
• lack of compliance

56
Poor Prognostic Factors

• Fractures
• bone loss
• intra-articular extension
• extensive soft tissue injury ? infection,
  scarring and loss of range of motion

57
Distal Phalangeal Fractures

• result of a crush injury with loss of the finger
  pulp or a nail bed.
• treat soft tissue use minimal type of splinting
  strategy

58
Mid Prox Phal Fractures

• Unstable prox phalanx angulate anteriorly
• Unstable mid phalanx distal to the FDS insertion
  angulate anteriorly
• Unstable middle phalanx fractures proximal to the
  FDS insertion angulate dorsally

59
Treatment

• Closed reduction and splinting (or buddy taping)
  ? stable reduction can be obtained
• percutaneous Kwires
• open reduction with Kwires, intraosseous wires,
  lag screws, minifragment plates and screws
• External fixation

60
(No Transcript)
61
Intra-op
4 months
? nonunion
62
1 year later
63
Metacarpal Neck Fractures

• rotational or lateral angulation must be
  corrected.
• lt 15 deformity for index and long finger
• 35-45 deformity for ring and little finger

64
Metacarpal Shaft Fractures

• lt 5 mm of shortening
• lt 30 degrees in little finger,
• lt20 degrees in ring finger
• No rotation

65
(No Transcript)
66
Intra op
67
2 months
68
Mallet fracture

• nondisplaced ? subluxated DIP joint.
• Most recommend closed treatment

69
Dorsal PIP dislocation

• Joint is usually stable after reduction
• Buddy taping allows active flexion and avoids
  hyperextension

70
Fract/dislocation of PIP Joint

• axial load
• reduction ? longitudinal traction.
• Extension block splinting ? if a closed reduction
  of the PIP joint
• if the fracture includes a large single fragment
  ? ORIF
• Hinged external fixator

71
Condylar Fractures of the Proximal and Distal
Phalanges

• ORIF

72
Carpometacarpal Fracture/Dislocations

• 70 ? fifth CMC jt
• pull of the flexor extensor carpi ulnaris
  abductor digiti minimi
• K-wires

73
Thumb Metacarpal Shaft Fracture

• apex dorsal and radial.
• 25 - 30 is acceptable because of compensatory
  motion at the CMC joint
• K-wires

74
Carpometacarpal jt inj

• Bennett's fracture
• Rolando's fracture
• Reduction

75
(No Transcript)
76
(No Transcript)
77
(No Transcript)
78
(No Transcript)
79
(No Transcript)
80
Indications for digit replants

• Strong indications
•    
• Thumb amputations   
• Multiple finger amputations   
• Any amputation in a child
• Mid metacarpal, wrist, forearm 
•   

81
Indications for digit replants

• Relative indications 
•   
• Single digit amputation distal to the FDS
  insertion  
•  Ring finger avulsion injury

82
Contraindications

• Other injuries
• Major medical conditions
• Type of injury (crush, avulsion, etc.)
• Prolonged ischemia time
• Multiple levels of injury
• Extreme contamination
• Single digit
• Psychiatric disorder relative contraind

83
Transport of Part

• Moist gauze in sealed bag
• Container ice/saline 4 C
• Warm ischemia time
• 6 hrs wrist proximal
• 12 hrs digits

84
Swansons Impairment Ratings
85
Chung JASSH May 2002
86
Postoperative Care

• Principles
• Prevent vasospasm vasoconstriction
• Assess the arterial and venous circulation
• NO!!! Tight dressings

87
Accomplished by

• Quiet room
• Warm temperature
• Limited visitors
• Bedrest
• IV hydration
• Transfusion as necessary
• Adequate pain control (pain catheters work well
  with added vasodilation)

88
Accomplished by

• Pharmacologic support prn
• Sc or IV heparin
• IV dextran
• Leeches
• Prophylactic ciprofloxacin
• Heparin soaks

89
Class IIC ring avulsion injury. (A) 3 days after
the initial injury. (B) fourth day of leech
therapy (C) (D) 17-month follow-up evaluation.
90
Mr C.G.

• 84 yo man snowblower to his right dominant hand
• amputated parts retrieved
• no medical problems

91
Examination

• amputated long and ring fingers
• badly injured thumb, index, and little fingers

92
Injury Films PA
93
Film Amputated Parts
94
General Principles

• Vascularity
• Bone Soft Tissue equal importance
• Tendons Nerves last priority

95
General Principles

• Repair versus Primary Reconstruction
• If repair unpredictable, go for function (ie.
  reconstruction)
• Thumb, index, long finger stability for pinch
• Ring, little finger mobility for grip

96
Amputated Parts

• Red streaks (ribbon signs) thrombosis
• Not replantable
• However prepped and used for cancellous bone graft

97
Procedures

• Wound excision
• Copious cleaning by irrigation
• ORIF phalanx s
• Repair DIP/MCP dislocations
• FDP/ext tendon repairs
• Pulley recon using FDS distal attach
• Primary thumb IP fusion
• Revision amp long ring

98
Post Op Films PA
99
Post Op Films Lateral
100
Cdn J Surg 1987
101
Bomb Explosion
102
Post-op
Pre-op
103
Replantation Outcome

• Avg 7 mos off work
• 50 get only protective sensation
• Avg motion 50 of normal
• 60 need gt 2 surgeries
• Medical cost 5-15 X amp

104
Technically Salvageable
105
Better Option
106
Thank you