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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
OPEN INJURIES OF THE HAND
Over 75 per cent of work injuries affect the hands; inadequate treatment costs the patient (and
society) dear in terms of functional disability.
Clinical assessment
Open injuries comprise tidy or ‘clean’ cuts, lacerations, crushing and injection injuries,
burns and pulp defects.
The precise mechanism of injury must be understood. Was the instrument sharp or blunt?
Clean or dirty? The position of the fingers (flexed or extended) at the time of injury will
influence the relative damage to the deep and superficial flexor tendons.
A history of high pressure injection predicts major soft-tissue damage, however
innocuous the wound may seem.
What are the patient’s occupation, hobbies and aspirations? Is he or she right handed or
lefthanded?
Examination should be gentle and painstaking.
Skin damage is important, but it should be remembered that even a tiny, clean cut may
conceal nerve or tendon damage.
The circulation to the hand and each digit must be assessed.
The Allen test can be applied to the hand as a whole or to an individual finger
:-(The radial and
ulnar arteries at the wrist are simultaneously compressed by the examiner while the patient clenches his fist for several seconds before
relaxing; the hand should now be pale. The radial artery is then released; if the hand flushes it means that the radial blood supply is
intact. The test is repeated for the ulnar artery. An injured finger can be assessed in the same way. The digital arteries are occluded by
pinching the base of the finger. When blood is squeezed out of the finger the pulp will become noticeably pale; one digital artery is
then released and the pulp should pink up; the test is repeated forthe other digital artery).
Sensation is tested in the territory of each nerve.
Two-point discrimination may be reduced in partial injuries. In children, who are more
difficult to examine.
Tendons must be examined with similar care. Start by testing for ‘passive tenodesis :-
(
When the wrist is extended passively, the fingers automatically flex in a gentle and regular cascade; when the wrist is flexed, the
fingers fall into extension. These actions rely upon the balanced tension of the opposing flexor and extensor tendons to the fingers; if a
tendon is cut, thecascade will be disturbed).
Active movements are then tested for each individual tendon
:-(Flexor digitorum profundus is tested by
holding the proximal finger joint straight and instructing the patient to bend the distal joint. Flexor digitorum superficialis is tested by
the examiner holding all the fingers together out straight, then releasing one and asking the patient to bend the proximal joint).
if there is any doubt about the integrity of the tendons, the wound should be explored.
X-rays may show fractures, foreign bodies, air or paint.
Primary treatment
PREOPERATIVE CARE
The patient may need treatment for pain and shock.
If the wound is contaminated, it should be rinsed with sterile crystalloid;
antibiotics should be given as soon as possible.
Prophylaxis against tetanus and gas gangrene may also be needed.
The hand is lightly splinted and the wound is covered with an iodine-soaked
dressing.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
WOUND EXPLORATION
Under general or regional anaesthesia, the wound is cleaned and explored.
A pneumatic tourniquet is essential unless there is a crush injury where muscle
viability is in doubt.
Skin is too precious to waste and only obviously dead skin should be excised.
For adequate exposure the wound may need enlarging, but incisions must not
cross a skin crease or an interdigital web. Through the enlarged wound, loose
debris is picked out, dead muscle is excised and the tissues are thoroughly
irrigated with isotonic crystalloid solution.
A further assessment of the extent of the injury is then undertaken.
TISSUE REPAIR
Fractures are reduced and held appropriately (splintage, K-wires, external fixator
or plate and screws).
Unless there is some specific contraindication. Joint capsule and ligaments are
repaired.
Artery and vein repair may be needed if the hand or finger is ischaemic. This done
with the aid of an operating microscope. Any gap should be bridged with a vein
graft.
Severed nerves are sutured under an operating microscope (or at least loupe
magnification) with the finest, non-reactive material. If the repair cannot be
achieved without tension then a nerve graft (e.g. from the posterior interosseous
nerve at the wrist) should be performed.
Extensor tendon repair is not as easy and the results not as reliable as some have
suggested. Repair and postoperative management should be meticulous.
Flexor tendon repair is even more challenging, particularly in the region between
the distal palmar crease and the flexor crease of the proximal interphalangeal joint
where both the superficial and deep tendons run together in a tight sheath (Zone II
or, more dramatically, ‘no man’s land’ because injuries in this zone are the most
dangerous).
Amputation of a finger as a primary procedure should be avoided unless the
damage involves many tissues and is clearly irreparable.
Ring avulsion is a special case. When a finger is caught by a ring, the soft tissues
are sheared away from the underlying skeleton. Depending on the amount of
damage, skin reattachment, microvascular reconstruction or even amputation may
be required.
CLOSURE
The tourniquet is deflated and bipolar diathermy is used to stop bleeding.
Haematoma formation leads to poor healing and tendon adhesions.
Unless the wound is contaminated, the skin is closed – either by direct suture without
tension or, if there is skin loss, by skin grafting. Skin grafts are conveniently taken
from the inner aspect of the upper arm.
If tendon or bare bone is exposed, this must be covered by a rotation or pedicled flap.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
Sometimes a severely mutilated finger is sacrificed and its skin used as a rotation flap
to cover an adjacent area of loss.
Pulp and finger-tip injuries In full thickness wounds without bone exposure, the
wound should be thoroughly cleaned and then covered with a nonadherent dressing,
and inspected only infrequently, then re-covered with the non-adherent dressing, until
it heals. If the open area is greater than 1 cm in diameter, healing will be quicker with
a split-skin or full thickness graft.
Nail bed injuries Nail bed injuries are often seen in association with fractures of the
terminal phalanx. If appearance is important, meticulous repair of the nail bed under
magnification.
DRESSING AND SPLINTAGE
The wound is covered with a single layer of paraffin gauze and ample wool roll.
A light plaster slab holds the wrist and hand in the position of safety (wrist extended,
metacarpo-phalangeal joints flexed to 90 degrees, interphalangeal joints straight,
thumb abducted). This is the position in which the metacarpo-phalangeal and
interphalangeal ligaments are fully stretched and fibrosis therefore least likely to
cause contractures. Failure to appreciate this point is the commonest cause of
irrecoverable stiffness after injury
POSTOPERATIVE MANAGEMENT
IMMEDIATE AFTER CARE
o Following an operation, the hand is kept elevated in a roller towel or high
sling.
o If the latter is used, the sling must be removed several times a day to
exercise the elbow and shoulder. Too much elbow flexion can stop
venous return and make swelling worse.
o Antibiotics are continued as necessary.
REHABILITATION
o Movements of the hand must be commenced within a few days at
most.
o Splintage should allow as many joints as possible to be exercised,
consistent with protecting the repair.
Replantation
With modern microsurgical techniques and appropriate skill, amputated digits or hands
can be replanted.
An amputated part should be wrapped in sterile saline gauze and placed in a plastic bag,
which is itself placed in watery ice.
The ‘cold ischaemic time’ for a finger, which contains so little muscle, is about 30 hours,
but the ‘warm time’ less than six.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
For a hand or forearm, the cold ischaemic time is only about 12 hours and the warm time
much less.
After resuscitation and attention to other potentially life-threatening injuries, the patient
and the amputated part should be transferred to a centre where the appropriate surgical
skills and facilities are available.
INDICATIONS
The decision to replant depends on the patient’s age, his or her social and professional
requirements.
The condition of the part (whether clean-cut, mangled, crushed or avulsed), and the warm
and cold ischaemic time.
Furthermore, whether the replanted part is likely to give better function than an
amputation.
The thumb should be replanted whenever possible.
Multiple digits also should be replanted, and in a child even a single digit.
Proximal amputations (through the palm, wrist or forearm) likewise merit an attempt at
replantation.
RELATIVE CONTRAINDICATIONS
Single digits do badly if replanted.
There is a high complication rate, including stiffness, non-union, poor sensation, and cold
intolerance.
Severely crushed, mangled or avulsed parts may not be replantable.
A long ischaemic time may not survive.
General medical disorders or other injuries may engender unacceptable risks from the
prolonged anaesthesia needed for replantation.
MANAGEMENT OF BURNS
Generally, hand burns should be dealt with in a specialized unit.
Superficial burns are covered with moist non-adherent dressings.
The hand is elevated and finger movements are encouraged.
Partial thickness burns can usually be allowed to heal spontaneously;the hand is dressed
with an antimicrobial cream and splinted in the position of safety.
Full thickness burns will not heal.
Devitalized tissue should be excised; the wound is cleaned and dressed and 2–5 days later
skin-grafted.
Full thickness circumferential burns may need early escharotomy to preserve the distal
circulation.
Skin flaps are sometimes needed in sites such as the thumb web which are prone to
contracture.
The hand should be splinted in the position of safety; K-wires may be needed to maintain
this position.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
Electric burns
o may cause extensive damage and thrombosis which become apparent only
after several days.
o The patient may of course need resuscitation (treating cardiac anomalies
and myoglobinuria).
o The arm needs to be monitored and fasciotomy with debridement of dead
tissue is often needed.
Chemical burns should be irrigated copiously for 20 or 30 minutes, usually with water or
saline but sometimes with a specific reagent (calcium gluconate for hydrogen fluoride
burns, soda lime or magnesium solution for hydrochloric acid, mineral oil for sodium).
MANAGEMENT OF INJECTION INJURIES
Oil, grease, solvents, hydraulic fluid or paint injected under pressure are damaging
because of tension, toxicity or both.
The thumb or index finger is usually involved.
Substances can gain entry even through intact skin.
Air or lead paint may show on x-ray.
Immediate decompression and removal of the foreign substance offers the best hope.
This means an extensive dissection.
The outcome is often poor, with amputation sometimes being necessary.
FROSTBITE
Frostbite requires special treatment.
The limb is rewarmed in a water bath at 40–42 degrees for 30 minutes.
Oedema is minimized by elevation, and blisters are drained.
Digits sometimes need amputation.
SECONDARY OPERATIONS
The primary treatment of hand injuries should always be carried out with an eye to any
future reconstructive procedures that might be necessary.
These are of three kinds:
• secondary repair or replacement of damaged structures
• amputation of fingers
• reconstruction of a mutilated hand.
Delayed repair
SKIN
o If the skin cover is unsuitable for primary closure or has broken down it is replaced
by a graft or flap.
o As always, the skin creases must be respected.
o Contractures are dealt with by Z-plasty, skin grafting, or local flaps, regional flaps or
free flaps.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
TENDONS
o Primary suture may have been contraindicated by wound contamination, undue delay
between injury and repair, massive skin loss or inadequate operating facilities.
o In these circumstances secondary repair or tendon grafting may be necessary.
NERVES
o Late-presenting nerve injuries must be carefully assessed.
o The results of repair deteriorate with time, particularly for motor nerves where the
end plate begins to fail and the muscle begins to fibrose.
o If several months have passed, tendon transfer may be a more reliable alternative.
JOINTS
o The proximal interphalangeal joint is most prone to a flexion contracture.
o Active and passive exercises can be supplemented by serial static splints or dynamic
splints.
o Surgery (capsulotomy, palmar plate and collateral ligament release) may be required
but these operations themselves can invite further stiffness.
o Unstable or painful joints are best fused.
BONES
o Malunion, especially if rotational, may require treatment.
o Non-union is very uncommon, but if present grafting may be required.
o Extensor tendons may stick to bone, most commonly after plate fixation of the
proximal phalanx.
o Plate removal and tenolysis is followed by aggressive active and passive movements:
a fair result is usually achieved.
AMPUTATION
o A finger is amputated only if it remains painful or unhealed, or if it is a nuisance (i.e.
the patient cannot bend it, straighten it or feel with it), and then only if repair is
impossible or uneconomic.
LATE RECONSTRUCTION
o A severely mutilated hand should be dealt with by a hand expert.
o If all the fingers have been lost but the thumb is present, a new finger can sometimes
be constructed with cortical bone, covered by a tubular flap of skin.
o An alternative is a neurovascular microsurgical transfer from the second toe.
o If the thumb has been lost, the options include pollicization (rotating a finger to
oppose the other fingers), second toe transfer and osteoplastic reconstruction (a
cortical bone graft surrounded by a skin flap).
THANK YOU
DR.JAMAL AL-SAIDY
M.B.CH.B..…… F.I.C.M.S