Hand injuries

Question 1

What should be asked about in hand trauma?

Answer 1

• Type of injury - Crush, Sharp, Burn
• Protection - Gloves
• Timing of injury - How long (Esp. in amputation)
• Seriousness - De-gloving?

Question 2

What questions are required in cases of wounds to the hand?

Answer 2

• Where
• How long?
• How deep?
• Clean or dirty
• Skin loss
• Exposed structures?

Question 3

What is a subungual haematoma?

Answer 3

This is pooling of blood beneath the nail at the proximal end

Question 4

What are some causes of subungual haematoma?

Answer 4

This is usually caused by quick, blunt trauma to the nail, such as hammering or slamming in a door

Question 5

What can happen to the nail in subungual haematoma?

Answer 5

It may fall off, however, it will grow back

Question 6

How can subungual haematoma present?

Answer 6

Visible blood pooling under nail
Pain if blood exerts pressure

Question 7

How can pressure be released in cases of subungual haematoma?

Answer 7

Trephine - Heated needle placed through the nail

Question 8

What are the 5 types of nailed injury?

Answer 8

• Type I - Soft tissue only (Very end of finger)
• Type II - Soft tissue + Nail
• Type III - Soft tissue + Nail + Bone
• Type IV - Proximal 1/3rd of distal phalynx
• Type V - Proximal to DIPJ

Question 9

How are type I and II nailed injuries managed?

Answer 9

Dressing

Question 10

How are type III nailed injuries managed?

Answer 10

Nailed repair + Bone stabilisation

Question 11

How are type IV and V nailed injuries managed?

Answer 11

If >5mm nailbed then nailed repair + bone stabilisation

If <5mm nailbed then ablate

Question 12

What should be performed in cases of a missing fingertip?

Answer 12

If the tip of the finger is missing, the finger should be terminalised or V-Y flapped, in which a V is cut into the finger and the skin is sewn back up into a Y shape

Question 13

How do flexor tendon injuries most commonly occur?

Answer 13

Injuries to the flexor tendons commonly result from volar lacerations

Question 14

How are flexor tendon injuries classified?

Answer 14

By zone of injury:
Zone I → Finger tips
Zone II → No mans land (Difficult to treat)
Zone III → Lumbrical origin
Zone IV → Carpal tunnel
Zone V → Muscle-tendon junction

Question 15

How will flexor tendon injuries present?

Answer 15

These tendon injuries will lead to loss of active flexion strength or motion of the involved digits

Question 16

What investigations are used in flexor tendon injury?

Answer 16

X-ray (For associated fractures)
USS (To assess lacerations)

Question 17

How are flexor tendon injuries managed?

Answer 17

Management can be conservative, involving wound care and early movement, or surgical, with flexor tendon repair or reconstruction

Question 18

What are some conditions associated with extensor tendon injury?

Answer 18

Mallet finger
Extensor pollucis longus rupture

Question 19

What is mallet finger?

Answer 19

This is an injury in which extensor tendon rupture or an avulsion fracture to the distal phalanx by the extensor tendon leads to resistance to finger extension

Question 20

How will mallet finger present?

Answer 20

Resistance to finger extension
Tenderness
Bruising

Question 21

How is mallet finger managed?

Answer 21

Mallet splinting for 6 weeks (24/7) to keep the finger straight
Avulsion fractures may require surgical wire fixing

Question 22

How is chronic mallet finger managed?

Answer 22

Dermatotenodesis

Question 23

What are some possible causes of extensor pollucis longus rupture?

Answer 23

Rheumatoid arthritis
Colles fracture

Question 24

How can rheumatoid arthritis cause extensor pollucis longus rupture?

Answer 24

An autoimmune attack on the synovium, leads to tendon degeneration and rupture

Question 25

How can extensor pollucis longus present?

Answer 25

Patients will present with loss of function, in which the patient cant extend the thumb at the MCP or IPJ

Question 26

How is a rupture extensor pollucis longus managed?

Answer 26

Tendon transfer

Question 27

How can preceding synovitis be managed in rheumatoid arthritis to prevent tendon rupture?

Answer 27

Synovectomy

Question 28

What is standard burn treatment (Non-finger specific)?

Answer 28

• Respiratory care
• Manage infection
• Rehydrate
• Pain relief

Question 29

What are some hand specific burn treatments?

Answer 29

• Excise damaged skin and perform split skin grafts early
• Aggressive mobilisation to prevent finger stiffness
• Escharotomy - Surgical release of eschar (Thick leathery, ineslastic skin which forms after burns)

Question 30

What is the most common cause of severe mutilating injury?

Answer 30

Industrial accidents causing de-gloving or partial amputation

Question 31

How should severe mutilating injuries be managed initially?

Answer 31

• Preservation of amputated parts in moist gauze and ice
• Early debridement
• Establish bony support
• Establish vascularity
• Repair all tssue
• Establish skin grafts and flaps
• Prevent infection
• Aggressive mobilisation

Question 32

What are soem further management strategies used in severe mutilating injury?

Answer 32

Early involvement with plastics, microsurgery, split skin grafting, possible formal amputation and possible use of prosthetics