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