34 BASIC CARE OF HAND INJURIES
Michael J.V. Gordon M.D., Lawrence L. Ketch M.D.

1. What are the goals of hand repair?

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Functional considerations override cosmesis in the treatment of hand trauma. There are no minor hand injuries. Initial diagnosis and management determine the final result; expert secondary repair cannot overcome primary errors in diagnosis or decision making.

2. What determines the final outcome of a hand injury?

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It is determined by minimal sacrifice of tissue and primary healing accomplished by early wound closure. Minimization of scar tissue by control of edema, prevention of infection, early wound closure, and vigorous physical therapy produce the optimal functional outcome.

3. What factors influence treatment of hand trauma?

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Mechanism, location, and timing of injury; hand dominance; occupation; age; and general health of the patient.

4. How common are occupational hand injuries?

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Hand injuries result in more days lost from work than any other type of occupational injury.

5. What are the essentials of examination of the hand?

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Inspection of position, color, and temperature often reveals the injury. Location suggests possible injury to underlying structures. Motor, sensory, and Doppler ultrasonic examination are confirmatory. All injuries must be radiographed, and surgical exploration provides the definitive diagnosis.

6. How and where should hand injuries be explored?

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Hand wounds should be explored under tourniquet control with adequate analgesia using delicate instruments in a well-lighted surgery suite. Visual magnification is usually mandatory.

7. How is emergency hemostasis of injured hands achieved?

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In the acute setting (outside the operating suite), no tourniquet should be applied, and there should be no blind clamping of any structures. Hemostasis may be achieved by elevation of the extremity and with direct compression of the wound. This approach prevents injury to delicate underlying structures that are tough to see.

8. How are fingertip injuries treated?

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If < 1 cm of pulp is disrupted, the wound will heal spontaneously with daily cleansing and dressing with nonadherent, moist gauze. Larger defects may require a skin graft, which can often be provided by defatting the amputated piece. Bone exposure necessitates flap coverage if digital length is to be maintained. Digital nerves cannot be repaired distal to the distal interphalangeal (DIP) joint.

9. What is the classification system for fingertip amputations?

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Classification for fingertip amputations is based on the amount of remaining sensate volar skin. Although the favorably angulated amputation commonly removes some nail and bone, the volar skin is available for easy coverage. This amputation type is “favorable” for treatment by dressings only, allowing wound repair by contraction and epithelialization. The volarly angulated amputation angle is “unfavorable” for conservative management and usually requires a reconstructive procedure. (Image from Ditmars DM Jr: Fingertip and nail bed injuries. In Kasdan ML (ed): Occupational Hand and Upper Extremity Injuries and Disease. Philadelphia, Hanley & Belfus, 1991, with permission.) (See Figure 34-1.)

Figure 34-1 Fingertip amputations.

10. How are nail bed injuries repaired?

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Repair of the disruption of the germinal matrix must be meticulously approximated under magnification and the nail bed splinted, preferably with the avulsed part. Subungual hematomas should be evacuated by a hot-tipped paperclip or battery-powered electric cautery. Repair of the disruption of the sterile eponychial fold must be maintained for 3 weeks with Xeroform gauze or with the original nail. Often, nail bed disruption cannot be diagnosed without removal of the nail.

11. What is the initial management of flexor tendon?

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Flexor tendon laceration is not an emergency, and repair should not be undertaken in the emergency department. If a hand surgeon is unavailable, the wound should be copiously irrigated and sutured and prophylactic antibiotics instituted. This injury can wait for definitive repair.

12. What is the proper management of an open fracture?

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Open fractures should be cultured and then undergo copious lavage with normal saline or Ringer’s lactate. Broad-spectrum antibiotic coverage should be instituted, and the hand should be splinted in the position of function with a bulky dressing.

13. What is the proper treatment for hand infection?

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The extremity should be immobilized and elevated, and parenteral antibiotics should be given. The patient should be immediately referred for possible surgical drainage.

14. What is the proper management of human bites?

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After cleansing of the wound, a radiograph should be taken. The wound should be left open-never closed. Antibiotics should be started, and the wound should be rechecked at 24 and 48 hours. If evidence of infection is present, parenteral antibiotics should be instituted and referred for possible surgical drainage. The so-called fight bite occurs over the metacarpophalangeal (MCP) joint or proximal interphalangeal joint when a clenched fist is impaled on the front teeth of an adversary. This often inoculates the MCP joint with anaerobic streptococci. When infection is diagnosed, immediate arthrotomy and lavage should be performed.

15. How are injection injuries treated?

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Despite their innocuous appearance, injection injuries may cause profound destruction of hand structures. Any such injury requires immediate hospitalization with prompt and extensive decompression, drainage, and debridement.

KEY POINTS: CARPAL TUNNEL SYNDROME

1. Symptoms: numbness, tingling, pruritus of the palm, thumb, middle, and index fingers.
2. Mechanical cause is compression of median nerve and carpal tendons.
3. Women are affected twice as often as men; the syndrome is more common after 40 years of age.
4. Predilection for people who perform repetitive manual labor.

16. What is carpal tunnel syndrome (CTS)?

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CTS is the most common peripheral compression neuropathy; it is signaled by numbness and tingling of the hand.

17. Is CTS more common in older or younger people? Men or women?

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CTS is more common in people older than age 40 years, but an increasing number of young people with CTS have been reported in recent years, usually those whose jobs involve repetitive manual labor. Women are affected approximately twice as often as men.

18. What are the most preventable causes of deformity in hand injuries?

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Edema and infection lead to increased scarring and restricted function. Prolonged immobilization in a poor position also impairs function, as does delayed skin closure. Failure to obtain a radiograph leads to a missed diagnosis with delay in recognition of an injury.

19. What is the proper emergency department treatment of all hand injuries?

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The patient should be sedated and the wound cultured and irrigated. A thorough examination must be performed and a sterile compression dressing placed. The upper extremity should be splinted, tetanus prophylaxis should be administered, and broad-spectrum antibiotic coverage should be instituted for crush avulsion or heavily contaminated wounds. Radiographs of the hand should always be obtained.

20. What are the guidelines for replantation of an amputated finger?

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There are no absolute guidelines. A microsurgeon who is a member of a replantation team should be consulted. If replantation is planned, parts should not be immersed directly in water or put directly on ice or dry ice. The part should be copiously irrigated, wrapped in a moist sponge, and placed in a sterile plastic container; the plastic container should be placed in an ice-water slurry for transport.

References
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BIBLIOGRAPHY
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