Hand Injuries

Question 1

What kind of things do you want to learn in a patient’s history?

Answer 1

Handedness, occupation, hobbies (musical instruments, art/crafts) and sports
Health = diabetes, arthritis, resp/cardio (may affect anaesthetic)

Question 2

What details about an injury do you want to know?

Answer 2

Crush/sharp/burn, gloves/protective clothing worn, timing (especially if amputation), de-gloving, estimate of level of energy, symptoms (pain, weakness, sensory)

Question 3

What are some important things to examine?

Answer 3

Nails, deformity, swelling, point of tenderness, movement, neurological

Question 4

How should wounds be examined?

Answer 4

Where, how long, how deep, clean/dirty, skin loss, any exposed structures (bone, tendon, foreign bodies), structures at risk (nerves, tendons, bones)

Question 5

What is an example of an injury to the nail?

Answer 5

Subungual haematoma

Question 6

What may be done to relive pain caused by the pressure of a subungual haematoma?

Answer 6

Use a trephine

Question 7

What should be done to the damaged nail?

Answer 7

Nail will eventually fall off (will grow back eventually)

Keep nail if possible = acts as splint, maintains nail bed

Question 8

What are the levels of nail injuries?

Answer 8

1 = soft tissue only
2 = soft tissue and nail
3 = soft tissue, nail and bone
4 = proximal 1/2 of phalanx
5 = proximal to DIP joint

Question 9

How should nail injuries be treated?

Answer 9

Level 1 or 2 = dressing only
Level 3 = repair nail bed and stabilise bone
Level 4 = as above unless < 5mm of nail bed, then ablate

Question 10

What should be done to repair a nail injury if the tip of the finger isn’t available?

Answer 10

Terminalise or perform V-Y flap

Question 11

What are important things to know when assessing a fracture?

Answer 11

Which bones are involved, joint involvement, deformity/rotation, stability

Question 12

What is a Boxer’s fracture?

Answer 12

Fracture of the 5th metacarpal bone near the knuckle = minimal displacement, no rotation, more distal

Question 13

How are Boxer’s fractures treated?

Answer 13

Early mobilisation, buddy strap (tape finger to functioning ajoining finger)

Question 14

What causes Mallet finger?

Answer 14

Injury to thin tendon that straightens the end joint of finger/thumb = resisted finger extension, tenderness, bruising

Question 15

How is Mallet finger treated?

Answer 15

Mallet splint for 24 hrs a day for 6 weeks, occasionally fix large displaced avulsion fragment with wire, dermatotenodesis in chronic cases

Question 16

What are some features of PIP dislocations?

Answer 16

Common injury, vital to be treated quickly

Question 17

How are PIP dislocations treated?

Answer 17

Pull to reduce, buddy strap
Delayed presentation = impossible to reduce, may need fusion
Associated fractures = fixation/stabilisation

Question 18

What is a Bennett’s fracture?

Answer 18

Fracture of the base of the first metacarpal bone which extends into the CMC joint = most common fracture of thumb

Question 19

What are almost always present alongside Bennett’s fractures?

Answer 19

Subluxation or dislocation of the CMC

Question 20

How are Bennett’s fractures treated?

Answer 20

Closed reduction and thumb spica cast immobilisation

Question 21

What are some features of tendon injuries?

Answer 21

Usually caused by penetrating injury, can result in severe loss of function, can be to extensor tendons (back of hand) or flexor tendons (palm of hand)

Question 22

How are tendon injuries treated?

Answer 22

Extensors = may be fixed without open surgery
Flexors = need to be fixed in operating theatre under anaesthetic

Question 23

How do tendon injuries present?

Answer 23

Pain, swelling, unable to bend/flex fingers

Question 24

What are some features of severe mutilating injuries?

Answer 24

Usually industrial, de-gloving and amputation occur

Question 25

What are the principles of treating severe mutilating injuries?

Answer 25

Preserve amputated part on ice
Establish stable bony support and vascularity
Early debridement and repair all tissues (e.g nerves)
Establish skin cover and prevent/treat infection
Aggressive mobilisation

Question 26

How are severe injuries treated?

Answer 26

Early involvement with plastics, microsurgery to repair nerves and vessels, split skin grafts on to healthy tissue, flaps to cover exposed bone

Question 27

When should amputations be considered in severe mutilating injuries?

Answer 27

If injury unreconstructable or if unable to re-establish nerve supply = will need later use of prosthetics

Question 28

What is the standard treatment for burns?

Answer 28

Respiratory support, avoid infection, rehydrate, give pain relief

Question 29

What is the specific treatment for burns on the hands?

Answer 29

Excise damaged skin and perform split skin grafts early, aggressive mobilisation to prevent finger stiffness, escharotomy

Question 30

What is eschar?

Answer 30

Thick, leathery, inelastic skin which can form after burns = may require surgical release to allow movement (escharotomy)