hand injury - chiang mai university · •70 degrees of mp flexion •pip joints are held in nearly...

Hand Injury

นพ.โอภาส พณไชย หนวยศลยศาสตรตกแตง

ภาควชาศลยศาสตร คณะแพทยศาสตร มหาวทยาลยเชยงใหม

2562

วตถประสงค

• มความร ความเขาใจ เกยวกบการท างานของมอ, การซกประวต, การตรวจรางกาย, Diagnostic imaging และ Anesthesia ในHand injury

• สามารถใหการรกษาแกผ ปวย และสงตอผ ปวยอยางเหมาะสม

เนอหา 1.Hand function

2.Hand anatomy

3.History and Physical Examination

4.Diagnostic imaging

5.Anesthesia

6.Emergency treatment

7.Definitive treatment

1.Hand function

http://www.oandplibrary.org/popup.asp?frmItemId=B157577C-D50F-4974-96BD-92AC74805FF6&frmType=image&frmId=5

Hand function

• Sensory perception

• Pincer function

• Power grip

https://www.pregmed.org/baby-developmental-milestones/pincer-grasp http://specialtranslations.ru/wp-content/uploads/2019/01/dynamic-sperical-grip.jpg

Hand motion

The hand:examination and diadnosis.American society for surgery of the hand.

2.Hand anatomy

The hand:examination and diadnosis.American society for surgery of the hand.

Peter C. Neligan, plastic Surgery, fourth edition Peter C. Neligan, plastic Surgery, fourth edition

Peter C. Neligan, plastic Surgery, fourth edition

3.History and Physical Examination

• Medical history

• Allergies and medications

• Social history

• Patient demographics : age, occupation, hand

dominance, and hobbies

• Current complaint : time of the injury, environment, mechanism of injury, previous treatment

History

occupation

https://www.bloggang.com/viewdiary.php?id=vitaminc&month=02-2009&date=19&group=20&gblog=3

Cause/mechanism of injury

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2878993/

Physical Examination

• Inspection: discoloration, deformity, posture of the fingers,

swelling, status of skin

• Palpation : tenderness, crepitation

• Assessment of musculotendinous function: passive and active ranges of motion, Muscle power

• Assessment of stability

• Assessment of peripheral nerves

• Assessment of the vascular system

Inspection

• Discoloration : pale/purple–blue

• Status of skin : laceration/cut/avulsion wound/avulsion flap

• Posture of the fingers

• Swelling

• Deformity : rotation/shortening /deviation/angulation

http://christem.com/eruditionem/2015/1/8/boxers-fracture-back-to-basics.html

rotation

Assessment of musculotendinous function

Asking the patient to lift the MP joints of four fingers (the index to the small finger) keeping the PIP and DIP joints flexed.

The hand:examination and diadnosis.American society for surgery of the hand.

EDC test

Assessment of stability

Assessment of peripheral nerves

• motor evaluation : muscle testing

• Sensory evaluation

-pain sensation (pin prick),

-light touch sensation (brush)

-two-point discrimination (2PD) testing

:fingertips

3 mm(moving 2PD test)

6 mm(static 2PD test)

-Semmes–Weinstein monofilament testing

-vibrotactile threshold testing -cold-heat testing

Froment’s test

• Pt was asked to hold a piece of paper

• Examiner slowly pulls the paper

• If the patient has weakness of thumb adduction caused by ulnar nerve palsy, the patient attempts to hold the paper by flexing the thumb IP joint using the flexor pollicis longus

(median nerve)

Assessment of the vascular system

• Arterial insufficiency

• Venous insufficiency

color capillary refill : normal within 2 seconds pressure (turgor) temperature

purple–blue discoloration Prompt refilling Congested warm

-color -capillary refill : normal within 2 seconds

-pressure (turgor) -temperature

Allen’s test

http://media.atitesting.com/RM/01_AMS/Media_01/RM_AMS_CH18_respiratory_diagnostic_procedures/index.html

Allen’s test

• The examiner compresses both arteries.

• The patient is asked to make and release a tight fist repeatedly to exsanguinate the hand

• The fingers are held in a relaxed position

• releases the pressure on the radial artery

• A normal interval for this process is 2–5 seconds (positive)

4.Diagnostic imaging

• Plain radiograph : PA, oblique, lateral view

• Ultrasound

• Computed tomography(CT)

• Magnetic resonance imaging(MRI)

• CT angiography

• Radionuclide imaging : bone scintigraphy

posteroanterior (PA) view

Fractures, osseous tumors, and even soft-tissue masses

Peter C. Neligan, plastic Surgery, fourth edition

Peter C. Neligan, plastic Surgery, fourth edition

oblique view

assess the metacarpals

https://www.orthopaedicsone.com/display/MSKMed/Metacarpal+fractures

Peter C. Neligan, plastic Surgery, fourth edition

lateral view

Assess angulation of the fracture

https://openi.nlm.nih.gov/detailedresult.php?img=PMC2684218_12178_2007_9014_Fig5_HTML&req=4

Peter C. Neligan, plastic Surgery, fourth edition

5.Anesthesia

-Digital Block -Wrist Block

-Elbow Block

-Axillary Block

-Infraclavicular Block

-Supraclavicular Block

-Interscalene Block

Digital Block • four nerve branches—two dorsal and two volar

• 3 approaches

1.transthecal block

2.transmetacarpal block

3.subcutaneous block

Scott W. Wolfe, Green’s Operative Hand Surgery, seventh edition.

-Lidocaine(1.5-3h) -local anesthetic with the addition of epinephrine was safe in digital nerve blockade

Transthecal digital nerve block

2 ml

Scott W. Wolfe, Green’s Operative Hand Surgery, seventh edition.

Transmetacarpal digital nerve block

2 ml on one side

Scott W. Wolfe, Green’s Operative Hand Surgery, seventh edition.

Subcutaneous digital nerve block

2-3 ml

Scott W. Wolfe, Green’s Operative Hand Surgery, seventh edition.

avoid creating a circumferential ring

6.Emergency treatment

• Priority

1.Save Life

2.Save Limb

3.Save Function

Emergency treatment

• Save Life : Life-threatening

1. Hemorrhage

2. Necrotizing fasciitis

• Save limb : 3.Ischemia

Hemorrhage

• Elevation

• Direct pressure

Pitfalls 1.Delay 2.Not effective 3.Blind clamp

https://www.medicalnewstoday.com/articles/319433.php

Necrotizing fasciitis

• Cellulitis in a toxic patient

• Drug abuse, immunocompromised

https://www.bjs.co.uk/image/patient-necrotizing-fasciitis/ https://www.reddit.com/r/WTF/comments/17wltf/necrotizing_fasciitis_of_the_arm_warning_gore

Ischemia

https://www.slideshare.net/nattakul/replantation

-wrapped in moist saline gauze -placed in a waterproof plastic bag -The plastic bag is placed in a container of ice

“No direct contact with the ice/water”

Peter C. Neligan, plastic Surgery, fourth edition

7.Definitive treatment

• Skin and soft tissue injury

• Fingertip injury

• Tendon injury

• Vascular injury

• Nerve injury

• Bone and joint injury

• Hand infection

7.1 Skin and soft tissue injury

Skin repair

Degloving injury

https://www.healthline.com/health/degloving

Surgical treatment : vascular repair

Wound care and refer

Clenched-fist Injury

https://sinaiem.org/fight-bite/ Surgical treatment

Wound care and refer

7.2 Fingertip injury

Scott W. Wolfe, Green’s Operative Hand Surgery, seventh edition. Surgical treatment 1.evaluation of the nail edges 2.nail is broken

7.3 Tendon injury

Surgical treatment

Wound care and refer

FDP test

-presses down on the proximal and middle phalanges of the target finger to keep the metacarpophalangeal(MP) and PIP joints in extension -asks the patient to flex the DIP joint.

The hand:examination and diadnosis.American society for surgery of the hand.

-presses down on the distal phalanges of all fingers except that of the finger to be tested to keep the MP,PIP, and DIP joints of the other fingers in full extension. -the patient is then asked to flex the finger to be tested

FDS test

The hand:examination and diadnosis.American society for surgery of the hand.

Mallet finger

Mallet finger

Type I : Closed injury, with or without small dorsal avulsion fracture

Less than 20%

Scott W. Wolfe, Green’s Operative Hand Surgery, seventh edition.

Mallet finger

Splint for 6 to 8 weeks

Slightly hyperextension

https://emedicine.medscape.com/article/1242305-treatment

7.4 Vascular injury

• Hard sign

1 . Pallor

2 . Pulselessness

3 . Pain

4 . Pulsatile expanding hematoma

5 . Loss of function

6 . Profuse bleeding

• Soft sign

1 . Proximity

2 . Nerve injury

3 . Small nonexpanding and nonpulsatile hematoma

4 . Hx. Of profuse hemorrage that ceased by the time

7.5 Nerve injury

• motor evaluation

• Sensory evaluation

“Diagnosis”

7.6 Bone and joint injury

• Nonoperative treatment : splint

• Operative treatment : ORIF

“Diagnosis”

Splinting

Safe or intrinsic-plus position

• 30 degrees of wrist extension • 70 degrees of MP flexion • PIP joints are held in nearly full extension

Scott W. Wolfe, Green’s Operative Hand Surgery, seventh edition.

7.7 Hand infection

• Cellulitis • subcutaneous abscess • fasciitis • Osteomyelitis • Paronychia • Felon • Flexor tenosynovitis

1.Conservative treatment(24 – 48 hours) (1) splinting (2) elevation (3) moist heat(4) systemic oral or intravenous antibiotics

2.Surgical treatment

Cellulitis/subcutaneous abscess

Conservative treatment Surgical treatment

Paronychia

1.Conservative treatment(24 – 48 hours) (1) splinting (2) elevation (3) moist heat(4) systemic oral or intravenous antibiotics 2.Surgical treatment

Felon

https://www.google.com/search?q=felon+infection&rlz=1C1KMZB_enTH558TH558&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiNyJ_AwqzgAhWEuI8KHRALAQEQ_A

UIDigB&biw=1920&bih=969#imgrc=iNyK0yd-u9ifqM: http://www.rachelrohdemd.com/Hand_Infections.html

Surgical treatment

Flexor tenosynovitis

https://www.google.com/search?q=flexor+tenosynovitis&rlz=1C1KMZB_enTH558TH558&source=lnms&tbm=isch&sa=X&ved=0ahUKEwi49qnCxKzgAhURS48KHZNHDk8Q_AUIDigB&biw=1920&bih=969#imgrc=Di0ZhjgRDychnM:

1.Conservative treatment(24 – 48 hours) (1) splinting (2) elevation (3) moist heat(4) systemic oral or intravenous antibiotics 2.Surgical treatment

conclusion

• 1.Hand function

• 2.Hand anatomy

• 3.History and Physical Examination

• 4.Diagnostic imaging

• 5.Anesthesia

• 6.Emergency treatment

• 7.Definitive treatment

References

• The hand:examination and diagnosis. American society for surgery of the hand.

• Scott W. Wolfe, Green’s Operative Hand Surgery, seventh edition.

• Peter C. Neligan, plastic Surgery, fourth edition