Hand Emergencies Rutvi Patel - PowerPoint Presentation

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Hand Emergencies

Rutvi

Patel

Slide2

Goals and Objectives

The goal of this presentation is for the audience to review and understand:-

A proper clinical hand examination

Selected traumatic hand injuries

Selected infectious hand emergencies

When treatment in the ED is sufficient and when hand surgery consult is needed.

The functional position of the hand with the appropriate splints

Different anesthesia techniques for the hand

Slide3

Topics Covered

Clinical examination of the hand

Finger tip injury/Finger

amputation

Nail bed injury/laceration/avulsion

High pressure Injection Injury

Flexor

tenosynovitis

Felon

Paronychia

Splints

Metacarpal fractures

Phalanx fractures

Anesthesia techniques

Slide4

Clinical Hand exam

Inspection:

Swelling, deformity, cuts/lacerations, color

change

Natural lie of the hand

Palpation:

 

Temperature: warm – infection/inflammation, cool -vascular pathologyFor tenderness, Crepitus (fracture), Joint effusion (infection, inflammation, trauma)

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Range of Motion/strength:

Active and passive

Flexion/extension at DIP/PIP/MCP joint of each finger checking for tendon injury

MCP: 0° extension to 85° of flexion

PIP: 0° extension to 110° of flexion

DIP: 0° extension to 65° of flexion

Abduction/adduction of all fingers

Flexion/extension of wrist60° flexion, 60° extension, 50° radioulnar deviation arcClinical Hand exam

Slide6

Clinical Hand

exam - ROM

Slide7

Rotatory

displacement:

Assess by asking the patient to flex their fingers and observing the resulting orientation.

Normally - all fingers directed toward the

scaphoid

+ no overlap or rotation.

Any abnormality in rotation is bad.

Clinical Hand exam

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Sensation

 

Test over dorsal and

volar

area of the entire hand.

Test two-point discrimination (normal is 2.5 -6 mm)

Clinical Hand exam

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Motor

R

adial nerve: test thumb IP joint extension against

resistence

(thumbs-up sign)

M

edian nerve

recurrent motor branch: palmar abduction of thumbanterior interosseous branch: flexion of thumb IP and index DIP ("A-OK sign")Ulnar nerve: cross-fingers or abduct fingers against resistenceVascularRadial and Ulnar pulseAllen’s testCapillary refill

Clinical Hand exam

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Median nerve

Ulnar

nerve

Radial nerve

Clinical Hand exam

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Fingertip avulsions/minor Amputations

Irrigate

the wound

thoroughly

Hemorrhage

control,

A

nalgesia, Tetanus PPx, ABx, Assess the neurovascular status. Assess for exposure of bone, if laceration/avulsion or complete amputation.Assess for flexor and extensor tendon involvementPrompt referral to a hand surgeon is mandated if there is tendon involvement. (consult immediately if available; or follow-up within 5 days).

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Fingertip avulsions/minor Amputations

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Fingertip avulsions/minor Amputations- Treatment Options

Healing by secondary intention

-

no

bone or tendon exposed with < 2cm of skin loss 

Revision amputation with primary skin closure in the ED (

Rongeuring

) If< 0.5 cm bone is exposed Minor amputation distal to the DIP jointPrompt evaluation and operative Tx by Hand surgery if –No exposed bone and > 2cm of tissue lossExposed

bone or tendon where rongeuring bone proximally is not an optionConsult in the ED if available , or f/u within 5 days

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If a small bony protuberance (<0.5 cm in length) distal to the DIP is exposed in a wound, skin closure may not be possible without cutting back the bone.

Perform digital

block + oral/IV pain meds

Use a

rongeur

bone cutter to slowly cutback the bone until enough soft tissue or skin over the bone for closure with

simple interrupted

sutures. Revision amputation and Primary closure

(

Rongeuring

)

Slide15

Fingertip avulsions/minor Amputations- Treatment Options

All of the

Tx

options

require

following steps before discharge

Apply antibiotic ointment and cover with dressing.

24-48 hour wound recheck in the ED, as well as F/U with hand surgery within 1 week. Discharge with Abx course (for example, Keflex) effective against skin pathogens.Consider splinting the finger if fractured or to allow for soft tissue rest.

Slide16

Actual Digital amputations

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Actual Digital amputations

Wrap the Amputated digit in a moistened sterile gauze, Place in sealed water tight bag and then place the bag on

ICE.

N

ote the time

digit went on ICE.

Assess the viability of an amputation for

replantationContact hand-surgeon immediately, to review and arrange for urgent re-implantation if digit is still viable.Replantation should nearly always be considered, and surgical repair is required even if replantation is contraindicated.

Slide18

Approximate

allowable ischemia times are

:

Digits - 12

hours warm

, 24

hours

cold ischemiaMajor body parts - 6 hours warm, 12 hours cold ischemiaRadiograph and Photograph both amputated part + stump pre-operatively for planning. Success rates for reimplantation depend on ischemia time, degree of tissue damage, and mechanism of injuryActual Digital amputations

Slide19

Assessing viability for

Reimplantation

Patients who benefit functionally are :

T

humb

at any level  

M

ultiple digits Through the palmWrist level or proximal to wrist  Possibly single digit amputations in setting of prior finger amputations of the same hand, Almost all parts in childrenContraindications:

Severe vascular disorderMangled limb or crush injury 

S

egmental

amputation 

P

rolonged

ischemia time with large muscle content (>6 hours)

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C

rushing-type

injury causing bleeding beneath nail

If < 50% nail involved - drainage of hematoma by perforation

Puncture nail using sterile needle

electrocautery

to perforate nail

If > 50% nail involved –nail removal, D&I, nail bed repairUsually involves nailbed laceration as well.Remove nail and soak in

Betadine while repairing nail bed

Repair nail bed with ≤ 6.0 absorbable suture or

dermabond

– equal results

Splint

eponychial

fold with original nail, aluminum, or non-adherent gauze for protection

Nail Bed Injuries –

Subungal

hematoma

Slide21

Avulsion of nail and portion of underlying nail bed 

Commonly

associated with distal phalanx fracture

Treatment

Nail removal, Nail bed repair, +/-

fx

fixationTetanus and Abx prophylaxisSplint eponychial fold with original nail, aluminum, or non-adherent gauze for protection

Consult Hand surgery (in the ED if available or F/U within 5 days) IfE

xtensive

injury, Significant loss of nail matrix, complicated fractures, as it may require split thickness graft vs. nail matrix

transfer

Nail Bed Injuries –

Nailbed

Laceration/Avulsion

Slide22

Subungal

Hematoma drainage

https://www.youtube.com/watch?v=bLEGfl9WE30

Nail Bed removal

https://www.youtube.com/watch?v=hYDggOKqG5A

Slide23

High Pressure Injection Injury

High-pressure injection device - paint or grease gun.

Up to 50% amputation rate for organic solvents (paint, paint thinner, diesel fuel, jet fuel, oil)

Benign Entry wound + extensive internal soft tissue damage

Dissection along planes of least resistance (along neurovascular bundles)

Vascular occlusion → local soft tissue necrosis

Severity of the injury depends on

Time to treatment + Force of injection + Volume injectedComposition of material

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Imaging to rule out foreign bodies/Bony injuries

Non Operative - only for air or water injection.

TDAP, broad spectrum

ABx

, limb elevation, early mobilization, monitoring for compartment syndrome

Operative (Emergent hand surgery consult) - most cases

Immediate irrigation & surgical debridement

Transfer if ortho/Hand surgery unavailableHigher rates of amputation seen when surgery delayed > 10 hours after injury

High Pressure Injection Injury - Management

Slide25

High Pressure Injection Injury

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Flexor

Tenosynovitis

Infection of the synovial sheath that surrounds the flexor tendon

Organisms

–

Staph

aureus/strep (most common), Eikenella/ Pasteurella for dog/human bites, MRSA (Iv drug users), Mixed flora/Gram negatives (immunocompromised pts) Symptoms/PE - Kanavel signs (4 total):Flexed posturing of the involved digitTenderness to palpation over the tendon sheathMarked pain with passive extension of the digit Fusiform swelling of the digit along with warmth/

erythemaImaging – looking for injury/foreign bodies/evidence of gas or

osteomyelitis

.

Slide27

Emergent Hand surgery Consult

Nonoperative

–

Rare and only If early presentation

hospital admission, IV

ABx

, hand immobilization , observation.No surgery needed if improvement within 24 hoursOperative If late presentation or no improvement after 24 hours of non-operative Tx.I&D followed by culture-specific IV antibiotics 

Flexor Tenosynovitis

- Treatment

Slide28

Felon

Infection of

the finger

tip pulp

From penetrating injury - blood glucose needle stick , splinters, local spread

Swelling and pressure within micro-compartments, leading to "compartment syndromes" of the pulp

Treatment:

I&D of the finger pulp in the ER. May need I&D in the OR if extensive or not improving.Keep incision distal to DIP creaseLoose dressing + finger splint + Tdap + oral Abx. IV ABx only for very extensive casesF/U for wound recheck in 48 hours with hand surgery/ortho/ER/PCP

Slide29

Felon drainage

https://www.youtube.com/watch?v=90ywj8nHwYM

Felon

Slide30

Paronychia

Inflammatory/Infectious involvement of nail fold with Pus +

erythema

+ swelling + pain

Treatment - Drainage

Longitudinal incision parallel to the nail edge across the nail fold to release the

pus

Soak in a saline solution → irrigate debris → apply dressingWarm water soaks + elevate digit at homeAbx only needed for immunocompromised, DM, cellulitis, PVDF/U in 48 hours with PCP or ER.

Slide31

Paronychia

drainage

https://www.youtube.com/watch?v=BzarVK_7Jsk

Paronychia

Slide32

Functional Position for hand fracture splints

Wrist –

10 to 20 degrees of extension. Avoids contracture and maintain maximum hand strength.

(MCP) joint –

60 to 70 degrees of flexion to keep the ligaments taut.

(PIP) joint –

Full extension to avoid contracture of ligaments

(DIP) joint – Full extension to avoid stressing the terminal tendon and prevent contracture of the oblique retinacular ligament.Hand joints prone to stiffness. Do not immobilize > 3 weeks

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Functional Position for hand fracture splints

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Metacarpal Fractures

Divided into head, neck, shaft

Tx

based on which metacarpal is involved and location of fracture

Acceptable

angulation

varies by location

No degree of malrotation acceptableInspect for open wounds and associated injuriesFight wounds over MCP joint are open until proven otherwiseExtensor tendon can be lacerated and retractedDorsal wounds are almost always open fractures

Slide35

Metacarpal Fractures- General management

Nonoperative

immobilization if -

Nondisplaced

and Stable pattern

No rotational deformity

Acceptable

angulation & shorteningAll F/U within 1-2 weeks with PCP or ortho/hand surgery for splint removal and reevaluation

Slide36

Operative treatment (Hand surgery consult) if

Intra-

articular

 

fxs

Rotational

malalignment

 of digitNeurovascular compromiseSignificantly displaced fracturesMultiple metacarpal shaft fractures Tendon lacerationsHand surgery consult In the ED if available. OP F/U within 5 days If not immediately availableUnacceptable angulation requires reduction and then splintingMetacarpal Fractures- General management

Slide37

 

Acceptable Shaft

Angulation

(degrees)

Acceptable Shaft Shortening (mm)

Acceptable neck

Angulation

Index & Long Finger

10-20

2-5

10-15

Ring Finger

30

2-5

30-40

Little Finger

40

2-5

50-60

Metacarpal Fractures- General

management

Acceptable angulations

Slide38

Reduction technique for Shaft and neck fractures

90 degrees MCP flexion, dorsal pressure through proximal phalanx while stabilizing metacarpal shaft

Metacarpal Fractures- General management

Slide39

Metacarpal Head Fractures

No degree of

articular

displacement acceptable

Majority will require surgical fixation as are

intraarticular

and typically comminuted.

Typically splint in the ER in functional position and then all should F/U with hand surgery within 1-2 weeks.

Slide40

Metacarpal Shaft fracture

Nonoperative

immobilization in the ED if

nondisplaced

acceptable

angulation

no

malrotationshortening (aesthetic problem only)immobilize MCP joints in 70-90 degrees of flexion for 4 weeksUlnar gutter for 4th/5th and radial gutter with thumb opening for 2nd/3rd.Consult Hand surgery for Operative management (ORIF vs. CRPP) Ifopen fractures

unacceptable angulationany

malrotation

multiple fractures

Unable to reduce the fracture

Unacceptable

angulation

must be reduced in the ED before splinting.

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Metacarpal Neck Fractures

Nonoperative

immobilization in the ED if

acceptable degrees of apex dorsal

angulation

immobilize MCP joints in 70-90 degrees of flexion for 4 weeks, leave PIP joints free

Ulnar

gutter for 4th/5th and radial gutter with thumb opening for 2nd/3rdConsult Hand surgery for Operative management (ORIF vs. CRPP) Ifunacceptable angulationopen fracturesany malrotation

intraarticular fractures

Unacceptable

angulation

must be reduced in the ED before splinting.

Slide42

Which splint to use?

Slide43

Proximal/Middle

Phalanx fracture

Splint/Buddy tape

in the ED

E

xtraarticular

< 10° angulation or < 2mm shorteningNo rotational deformityF/U with ortho/hand surgery in 1-2 weeksConsult Hand surgery for Operative managementirreducible or unstable fracture patterntransverse fractures (all angulate

volarly)> 10°

angulation

or 2mm shortening

Rotationally deformed 

Long oblique proximal phalanx fractures

F/U with hand surgery within 1 week if immediately not available

Slide44

Unacceptable

angulation

must be reduced before splinting using a three point technique.

Flex the MCP and PIP joints to 90 degrees.

Apply

gentle traction to reduce the proximal fragment dorsally and the distal fragment

volarly

. The fragment ends should meet at the fracture line.Finger dislocation reduction - https://www.youtube.com/watch?v=y00WjtV_ElUProximal/Middle Phalanx fracture - reduction

Slide45

Proximal phalanx fracture

Middle phalanx fracture

Proximal/Middle Phalanx fracture

Distal Phalanx fracture

Slide46

Distal Phalanx Fracture

No

noperative

reduction and splinting in the ED

most

nondisplaced

fractures

Splint for 3 weeks with joint motion afterwardsF/U with PCP in 1-2 weeksOperative with hand surgery consultConcomitant nail bed injuries/nail matrix damage/complicated fracture.F/U with hand surgery within 1 week for reevaluation

Slide47

Which splint to use?

Slide48

Anesthesia

Techniques for the Hand

Digital block

http://lifeinthefastlane.com/minor-injuries-007/

Hematoma block https://www.youtube.com/watch?v=tjnsdjfwMmY

Median and

Ulnar nerve block https://www.youtube.com/watch?v=6NKkzs9FA5IRadial nerve block https://www.youtube.com/watch?v=PlF4bttKWds

Slide49

Resources

Ortho Bullets

Uptodate

Medscape

Life in the Fast lane

American family Physician

http

://www.aafp.org/afp/2009/0901/p491.htmlYoutube

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THE END