HT: Trauma Management Flashcards
What are ways hand trauma can occur?
- Laceration
- Crush
- Burn
- High pressure injury
- Fall
- Contact with other objects
- Gunshot
What is the general principle of management
- Understanding anatomy
- Balance between protection of healing and regaining ROM and function
- wound management
What are the 3 stages of wound and tissue healing?
- Inflammatory stage, 0-4/5 days
- Proliferative phase 4-27 days
- Remodelling phase day 25-18 months
What happens during inflammatory stage?
- Blood vessels in wound contract - clot formation
- Blood vessels dilate to allow cells, growth
- 72 hours
What may cause prolonged inflammatory phase?
- Severe tissue trauma
- Poor tissue handling at time of surgery
- Aggressive therapy
- Inappropriate splint/dress
- Infection
What happens due to proliferative/regenerative phase?
- Fibroblastic ativity: rapid collagen synthesis
What happens during remodelling phase?
- Collagen fibres become organised
- Peak tensile strength of scar 60-90 days
What are factors affecting wound healing?
- Diabetes
- Peripheral vascular disease
- Anemia
- Oedema
- Malnutrition
- Steroids
- Patient compliance
- Anti- inflammatory
- Infection
What are the flexor tendon zones?
Recall this Zone 1: FDP only Zone 2: most commonly injured - Laceration to both FDS AND FDP - Prone to scar tissue - Prone to PIP joint contracture - Be mindful of tendon adhesion Zone 3 Zone 4: area of carpal tunnel +/- median and ulnar nerve injuries Zone 5: proximal to CT, +/- nerve and artery
How does a flexor tendon injury occur?
Pulling on something- forced into extension
Like a rugby player
Can occur in zone 1,2,3
Flexor tendon injuries need surgical repair
What are the goals of therapy post op of tendon repair?
- Protect tendon rupture
- Prevent secondary joint contracture
Summarise post op therapy for flexor tendon injury?
- Dorsal blocking splint or cast/ prevent extension
- Immobilisation for unreliable patients
- Early passive mobilisation OR early active mobilisation
Recall days 3-21 post op for flexor tendon repair?
- Avoid wrist/MP extension
- Splint/cast worn full time
- Begin early controlled mobilisation
- Passive IPJ flexion Active IP joint ext
- Gentle active flexion within splint
Recall weeks 4-6 post op
- Progress exercises according to scar density and motion
- Gentle active wrist ROM/ avoid forceful ext
- 5/52 light ADL
- Tendon gliding week 5
Recall
- week 6-8
- week 8-10
- week 12
6-8: DIP flexion, increase ADL, splint for sleep and travel
8-10: discard splint, increase resisted grip exercise, PIP ext splint still required
12: no restriction
Recall the zones and injuries of extensor tendons?
Zone 1- Mallet
Zone 3: central slip
Zone 5-8 laceration
Which zones can be treated conservatively with extensor tendon injuries
Zones 1-3
How do you manage a central slip injury?
- conservative or surgical
- Early Active Mobilisation
- Splint full PIP joint extension, except for exercsies
- 2nd splint to allow for gradually more flexion
- PIP joint flexion progressed 30-70 1-5weeks post op
MAKE sure full active extension present at all stages
How do you manage extensor tendon injuries zones V-VI
- Immobilisation
- Controlled passive
- Active
What is relative early active motion- for extensor repair?
- Injured tendon placed 15-20 deg less relative motion than adjacent tendons at MP joints
- Interconnections will keep tendon safe- more extended than adjacent fingers
Describe nerve regeneration
- Degeneration of nerve distal to injured segment
- Regeneration of axons 1mm/day
What happens to muscles without nerve innervation?
- moderate to servere atrophy within 3 months
- Fibrosis after 1 year
What happens to sensory and sympathetic supply without nerve innervation?
- Loss of sweating
- Skin atrophy
- Loss of protection pain sensation
- May be reinnervated years later
What muscles do radial nerves mainly innervate?
Extensors
What are factors affecting nerve regeneration?
- Age
- Level of injury
- Associated tissue injury
What are post op aims for nerve repair
- Protection
- Scar management
- Patient education
- Desensitisation
- PRevent secondary deformity
- sensory retraining
- Monitor recovery
- Strengthen as recovery occurs
How long to splint from post op for nerve repair?
3/52
- Patient education from hot or sharp objects
What are the aims of splinting post nerve injury?
- Compensate for weak or absent muscles
- Prevent or treat join contracture
What is the management of median nerve injury?
- Maintain palmar abduction
- Night splint to prevent 1st web space contracture
What is the management of ulnar nerve injury?
Prevent MP joint ext contracture
- prevent PIP joint extension contracture
- Passive stretch
- POSI splint night
- Anti claw splint
What is the management of radial nerve injury?
- Prevent long finger and thumb flexor tightness
- Prevent wrist flexion contracture
- Wrist extension splint
- Tenodesis splint
What is the management of radial nerve injury?
- Prevent long finger and thumb flexor tightness
- Prevent wrist flexion contracture
- Wrist extension splint
- Tenodesis splint
Outline treatment of fingertip injury?
- Surgery
- HT
wound care, splint, scar, desensitisation, mobilisation, early functional use
