Hand and Nailbed Injuries

Question 1

Management of subungal haematoma:

Answer 1

Small and minimally symptomatic= leave alone.

Large (>25%)/ symptomatic = trephine
–> Sterile needle, Hot paperclip, Cautery
- Soak 2-3x daily warm water

Remove nail only if nail not in a normal/good position (+bed repair needed)

Question 2

Indications for nail removal:

Answer 2

Deformed nailbed laceration

Nail avulsion

Large subungal haematoma not amenable to trephination

Open # to distal phalynx + inadequate nailbed coverage (infection risk)

Question 3

Procedure: nailbed repair

Answer 3

• Digital block
• Digital tourniquet
• Grip nail with clamps, blunt dissect off using Iris scissors
• Wash nailbed
• Repair nailbed/ folds with absorbable, 6.0 suture OR Dermabond
• Wash nail with saline
• Reinsert + suture nail
  –> Poke holes + SI, Figure-8

If nail not viable:
-Prosthetic nail
-Sterile foil

If significant disruption to proximal fold (germinal matrix), will need Plastics

DICHARGE:
- Dress with Bactrigras
- Splint
- Consider antis/ADT (eg. associated #)
- Hand Clinic within 1 week

Question 4

Answer 4

‘Mallet Finger’

Loss of distal extensor mechanism: tendon rupture, or avulsion

Extensor splint for 8 weeks

Question 5

Answer 5

‘Jersey Finger’

Rupture of flexor profundus tendon (like a reverse Mallet)

Unlike Mallet finger, this is operative

Question 6

Answer 6

Boutonniere Deformity

Extensor mechanism of finger involves central slip (inserts on mid phalynx) and lateral bands (insert on dist phalynx)

Disruption of central slip = loss of extension at PIPJ, and lateral bands slip down to function as flexors at DIPJ

Question 7

Phalynx #s:

Answer 7

• Most: buddy strap for 3 weeks –> rehab exercises.

K wire if:
- Unstable
- Displaced intra-artic
- >2mm shortening
- >10deg angulation
- Rotational deformity

Question 8

Answer 8

Volar plate avulsion (phalynx)

Buddy strap/ extension splint for 3 weeks

OT only if >40% articular surface involved

Question 9

Answer 9

‘Boxer’s Fracture’
–> 5th metacarpal neck

ACCEPTABLE:
- <20 degrees angulation
- NO rotational deformity

If associated ‘Fight Bite’= admit for antis + washout.

Ulnar gutter splint (or all fingers if other MC affected) + hand clinic.

Question 10

What injuries can result from forced thumb ABduction?

Answer 10

Gamekeeper’s Thumb (Phalynx)
- Ulnar collateral ligament rupture +/- avulsion

Bennet’s Fracture (MC)
- # to base of thumb CMC

–> Thumb spica + hand clinic