2 - Digital Trauma Flashcards
Objectives for digital trauma
- Recognize and understand basic principles of nail trauma and digital fractures.
- Recognize the mechanisms of injury and make appropriate treatment recommendations
Topics in digital trauma
- Emergent Care
- History
- Physical Exam
- X-rays
- Lab
- Treatment
Mechanism of trauma
- Mechanism of trauma is usually direct or indirect trauma most commonly caused by falling objects or stubbing injuries.
Sagittal plane digital injury
- Most frequently observed
- Direct trauma, injury 2nd hyperextension or hyperflexion
- Comminuted type injury
Transverse plane digital injury
- Very frequent
- Abduction - adduction force
- Results in transverse or short oblique fractures
Frontal plane digital injury
- Least frequent
- Predominantly transverse or sagittal plane
- Injury with assoc. rotational or inversion - eversion injuries
Clinical presentation of digital trauma
- Acute Pain
- Discomfort with shoe gear & ambulating
- Ecchymosis and edema present within 2-3 hours
- May see dislocation
Digital fractures
- Fractures of all proximal phalanges are usually oblique or comminuted.
- Transverse pathologic fractures may occur in diseased bone
Treatment of digital injuries Closed injuries
- R.I.C.E.
- Closed Reduction
- Immobilization
Treatment of digital injuries Closed reduction
- Distraction of the digit or fracture, then put it back into alignment
- Then splint or wrap it to keep it in place
- The point of this is to achieve correct alignment of the fracture line before the initiation of bone healing
Treatment of digital injuries Open injuries
- Surgical emergency
- Assess neuro-vascular status
- Tetanus & antibiotics if indicated
- Address soft tissue initially
- Address fracture secondary
Sesamoid fractures
- Not very common
- Need to rule out bifurcate or bipartite
- A mis-step may lead to soft tissue injury of the sesamoids
- Commonly sagittal plane injuries
- Crush injury (comminuted)
Predisposing factors to sesamoid fractures
- Cavus foot
- Metatarsus primus equinus
- Sport activities (repetitive flexion trauma)
- High-heeled shoes
Clinical presentation of sesamoid fractures
- Acute or chronic pain
- Edema & ecchymosis
- Pain w/weightbearing or dorsiflexion
Treatment of sesamoid fractures
- Radiographs
- Relieving direct or indirect pressure
- Surgical intervention
CASE STUDY 1
- A 27 year old female gives the history of kicking a dog gate while upset and inebriated
What is the mechanism of injury?
o Oblique fracture
What should be considered when treatment this injury?
o Comminuted, displaced intra-articular fracture
Why surgical intervention vs conservative treatment?
o Surgical intervention with fixation is the best treatment option due to the comminuted displaced intra-articular fracture
o The patient is young and healthy, so she is a good candidate for surgery
CASE STUDY 2
- 35 year old female presents in the office with a painful right 2nd toe
- Patient gives a history of running 10 miles, but started feeling pain in the toe after 6 miles
- There is a hematoma present under the skin at the proximal nail
- There is redness and swelling, likely due to mechanical trauma, but infection is a possibility
- If the patient presents with this the day of or after the run, it is likely from mechanical trauma
- If the patient presents 3-5 days after the run, it is more likely to be an infection and you could start an antibiotic
- Culture is not necessary in a young healthy patient and prophylactic antibiotics can be started without culture, but if there is an odor or more than blood in the drainage from the hematoma
CASE STUDY 3
- Open fracture of 1st left digit with exposed bone
- Need to look for intact vasculature to determine whether or not you can save the digit
- Cap fill time will give the most information on whether or not blood supply is present in the digit
Nail anatomy
- Nail matrix
- Nail root
- Cuticle
- Nail plate
- Distal edge of nail plate
- Hyponychium
- Nail bed
MALAY CLASSIFICATION SYSTEM
A = Primary onycholysis B = Subungual hematoma C = Simple nail bed laceration D = Complex nail bed laceration E = Nail bed laceration with phalangeal fracture
A = Primary onycholysis
- Separation of nail plate
- Posterior nail fold friction injury (bleeding and sepsis)
Treatment of onycholysis (A)
- Removal of nail plate
- Antisepsis
- Antibiotics as needed
B = Subungual hematoma
- Blood clot
- Must check for fractures
- Treat injury as an open fracture
Treatment of subungual hematoma (B)
- X-rays
- Removal
C = Simple nail bed laceration treatment
- Antibiotics
- Tetanus
- Surgical cleansing and irrigation
- Align the root and nail bed (repair w/ 6.0 absorbable on a traumatic
- Nail plate may be reused if avulsed
D = Complex nail bed laceration
- Same as simple laceration with proximal nail fold defect
Complex nail bed laceration treatment (D)
- Addition of a rotational flap
E = Nail bed laceration with phalangeal fracture treatment
- Same as complex laceration with reduction of subungual fractures
- Removal of bone spicules and nail fragments
Level of tissue loss
- Zone I: Distal to bony phalanx
- Zone II: Distal to the lunula
- Zone III: Proximal to distal end of lunula
Directional planes of tissue loss
- Dorsal (oblique)
- Transverse
- Plantar (oblique)
- Axial (tibial or fibular oblique)
- Central (Gouge)
Treatment of zone I injuries
- Allow wound to granulate
- STSG or FTSG
Treatment of zone II injuries
- Pedicle flaps (direction or plane of injury dictates type of flap)
- Atasoy - type plantar
- Kutler - type biaxial
Look at pictures and know these types of closure flaps
- Atasoy plantar V-Y
- Atasoy-type plantar V-Y
- Kutler type bi-axial V-Y
Treatment of zone III injuries
- Requires primary amputation
- Possible preservation of distal interphalangeal of interphalangeal joint
