Plastic Surgery: Hand Injuries Flashcards
How to describe #
Open vs closed.
Location: metaphysis (connects epiphysis to diaphysis), diaphysis (mid-part long bone), articular.
Displaced or non-displaced: translation, angulation, shortening, rotation.
Comminution (reduced to multiple fragments)
Mgmt of # based on displacement, etc.
If not displaced –> splint.
Displaced: then reduce then splint. If not reducible or unstable –> OR.
Tx of distal phalanx #
Note that soft tissue injuries associated with crush injuries. Treat with 3 weeks of digital splinting.
Tx proximal and middle phalanx #
Check for rotation, scissoring (overlap of fingers with fist), shortening of digit.
If undisplaced or minimally displaced, closed reduction with buddy tape, splint for 2-3 weeks.
Displaced, unstable, rotational/scissor deformity, etc require perQ pins or ORIF then splint.
Assessment of ulnar collateral ligament injury
Secondary to forced thumb abduction.
Radially deviate joint in full extension. Compare bilaterally.
With UCL rupture, injured side will have no end point. If torn or avulsed from insertion, look for # at base of phalanx of thumb.
What is a boxer’s #?
Extra-articular # of the 5th metacarpal, just proximal to the MCP. (essentially under the pinky below, the joint). Acute angulation of neck of metacarpal of little finger into palm. Often due to blow on the distal-dorsal aspect of closed fist. Lose prominence of metacarpal head. Get volar (palmar) displacement of head. Check for scissoring with fist. Closed reduction, ulnar guttar splint for 2-3 weeks.
What is a Bennett’s #?
# at base of thumb metacarpal. Requires percutaneous pinning, thumb spica x6 wks.
What is a Rolando’s #?
Intra-articular # of the thumb metacarpal.
T or Y shaped #.
Requires ORIF with K wire.
Position required for safe hand splinting
Wrist extended at 45, MCP’s flexed at 60, fingers straight, thumb abducted/in opposition.
Hand # require cast/splint.
Need to prevent late deformity by keeping hand/wrist immobilized with ligaments in stretched position.
Hx taking Q’s for hand injuries
Age, hand dominance, occupation, time/place of accident, mxn of injury, tetanus status.
PEx for hand injuries: what to observe, vascular exam, sensory exam and motor exam (including specific muscles tested), flexor digitorum exam.
Observe: normal cadence, scissoring, bony deformities (mallet, swan neck, boutonniere), bruising/swelling, anatomical structures.
Vascular status: look at radial/ulnar arteries, assess for nerve injuries. Vascular assessment to include Allen’s test, cap refill, temp/skin turgor. If digit devascularlized, repair within 6 hrs.
Sensory nerve assessment:
Median nerve: innervates digits 1 - 3.5 on palmar surface. Test sensation at tip of index (next to thumb) on volar (palmar) side of hand.
Ulnar nerve: innervates digits medial 1.5 fingers on ulnar side. Test sensation at tip of pinky.
Radial nerve: test at dorsal webspace of thumb. Distribution = dorsal side of hand.
Digit nerves: check 2 pt discrimination on each finger. Normally 2-3 mm difference should be detected.
Motor nerve assessment:
Median nerve: flexion of thumb, index and middle finger. Get pt to give OK sign. Push against thumb while it is abducted (have pt place back of hand on flat table, then test the ABDUCTOR POLLICIS BREVIS but having pt lift thumb straight up toward ceiling).
Ulnar nerve: intrinsic hand muscles. ‘Tata.’ Abduction/adduction of fingers. Can get pt to flex DIP or give peace sign. Move index finger in radial direction, tests 1st DORSAL INTEROSSEUS.
Radial nerve: extension of fingers, wrist
Check passive/active ROM wrist, fingers, thumbs. Have pt place palm flat on table and lift thumb (EXTENSOR POLLICIS LONGUS)
Check tendons: flexor digitorum profundus and superficialis. For FDP, single common muscle belly so it pulls on everything. FDS has independent control of each finger with individual muscle bellies. To test, extend out DIP (of finger tested AND all other fingers since since FDP belly!), then test PIPs.
Palpate over bones and look for instability of joints.
Common extensor tendon deformities
Divided into zones; distal have less favorable prognosis compared to proximal.
Mallet finger: DIP flexed with loss of active extension. Rupture of extensor tendon at DIP.
Boutonniere deformity: PIP flexed, DIP hyperextended due to injury to extensor tendon insertion into middle phalanx.
Swan neck deformity: PIP hyperextended, DIP flexed.
Treatment: repair in ER with primary suture repair, 2-3 wks splinting.
Common flexor tendon deformities.
Loss of natural cascade of resting hand (normal = flexion of fingers at rest).
Flexor tendon zones: important for prognosis of tendon lacerations.
No-man’s land: between distal palmar crease and mid-middle phalanx. Recovery of glide between superficialis and profundus ligaments very difficult.
Tx: repear in OR within 2 weeks and avoid excessive immobilization.
Describe Dupuytren’s contracture.
Contraction of the longitudinal palmar fascia resulting in painless nodules and fibrous cords.
Eventually causes flexion contractures at MCP and interphalangeal joints. Does NOT involve flexor tensons.
Affects 4th digit > 5th > 3rd > 1st > 2nd.
Treatment with surgical fasciectomy. Indicated when there is a lack of extension at MCP/PIP. Not indicated if there is palmar pit/nodules/palpable cord but no limitation.
Describe the timing of nerve repairs and expected time for return of function.
Test nerve function before anesthesia given.
Within 14 days of clean injury and without concurrent major issues, do direct repair. If not satisfying these requirements, secondary repair.
Direct: epineural repair of nerves with minimal tension.
Peripheral nerves regenerate at 1 mm/day.
