Evaluation of the Injured Hand. Sanjay K. Sharma, M.D., F.A.C.S Regional Trauma Conference June 2, 2016
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1 Evaluation of the Injured Hand 2016 Regional Trauma Conference June 2, 2016
2 Disclosures Nothing relevant
3 Outline General overview of Hand Trauma Anatomy/Examination Selected Cases
4 History of Hand Surgery WWII No defined service for injured soldiers Sterling Bunnell civilian surgeon developed program for the US Army Surgery of the Hand: 30 years Principles of Management still hold today
5 Incidence of Hand Trauma 2011 National Center for Health Statistics 136 million visits 40.3 million Injury related H&N 11.7% Spine 4% Upper Extremity 18.3% = 7.39 million Wrist/Hand/Finger 11.3% = 4.53 million National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables
6 Economic Impact Annual expense knee and lower limb fractures ($562 million) hip fractures ($532 million), skull-brain injury ($355 million). Productivity costs contributed more to the total costs of hand and wrist injuries (56%) than did direct health-care costs. Hand and Wrist: hand and finger fractures ($278 million), largely due to high productivity costs in the age group of ($192 million). J Bone Joint Surg Am May 2;94(9):
7 Hand Anatomy: Cortical Representation
8 Complex Anatomy
9 The Lingo Dorsal/Volar, Ulnar/Radial Proximal/Distal Where on the hand, which digit, what s exposed?
10 Hand Injury Assessment Prehospital care What ED personnel need to know What Trauma teams need to know
11 Hand General Appearance Tenodesis effect Can assess integrity of tendons when patient is unconscious
12 Hand Exam Hand alignment Fingers should point to scaphoid Assess for malrotation Important for finger and metacarpal fractures
13 Hand Vascular Exam
14 Vascular Assessment Allen Test
15 Tourniquets in Emergency Setting Extensive experience in Military situations Improves limb salvage Improves functional survival Morbidity is minimal Time for tourniquet use unclear. 2 hours max intraoperative JF Kragh, et al MILITARY MEDICINE, 176,7:817,2011 J Trauma. 2008;64:S28 S37
16 Nerve Anatomy
17 Quick assessment Motor I Median nerve Opposition: II Ulnar nerve Intrinsic function Also OK sign III Radial Thumb/Wrist function Sanjay K. Sharma, M.D., F.A.C.S. Evidence-based Comprehensive Approach to Forearm Arterial Laceration Volume 16, Issue 7, December WestJEM Janice N. Thai, MD, et al.
18 Nerve Exam Median nerve Eye of the Hand Sensation to 3 ½ digits Motor to thumb Test index finger pad
19 Nerve Exam Ulnar Nerve Sensation to small and ½ ring finger Intrinsic muscles of hand Cross fingers Adduction against resistance Ulnar
20 Nerve Exam Radial Nerve Sensation to dorsum of hand and thumb Nightstick injuries No motor function Test at 1 st webspace
21 Tendon injuries Extensor Tendon Drooped posture Inability to extend Don t be fooled by intrinsic hand function Lay hand flat on table, then ask to lift finger up
22 Extensor Tendon Injuries
23 Tendon Injuries Flexor tendon Extended posture Unable to form fist High morbidity if not repaired Should be repaired within a week 3 months of rehab
24 Tendon Injuries Identification Extended posture Pain in palm or wrist Zone of injury No Man s Land
25 Tendon Injuries
26 Exam Details ABCs of Trauma Life before Limb Try to save the Hand Quick Hand Examination Including Sensory Assess vascularity Sensibility Anesthetic Gross function Skeletal stability: X-rays
27 Exam Details Commonly associated with high speed injuries Air bags Rollover accidents Auto-pedestrian accidents Crush injuries High index of suspicion
28 Exam Details Evaluations: X-rays Mandatory Nerve Exam Function Tendons Joint alignment Dislocations Skin integrity Crush injury
29 Missed Injuries Head injuries ICU Setting Inadequate/Incomplete exams Assess critical injuries first Secondary survey when awake/alert
30 Poly-Trauma
31 Poly-Trauma
32 Not So Simple injuries
33 Impalement
34
35 Hand Fractures Most can be handled as outpatient or in hospital follow-up Close skin lacerations Open fractures, skin loss, mangled hands to OR ASAP Multi-level injury Bone loss treated with bone grafting
36 Hand Fractures: is it an open Depends on mechanism of injury Contamination Bite wounds Blast/GSW injury Fall/impact with skin laceration Require close follow-up fracture?
37 Vascular/Replantation Highly specialized reconstruction Level 1 Trauma Centers Several rules guide replantation Resources, time, costs Outcomes fair at best
38 2 digit replantation
39 2 digit replantation
40 Soft Tissue Injuries Tendons Nerves Skin Combined Mutilating injures
41 Nerve Injuries Start with Exam Know pattern of innervation Direct repair best if done early Nerve conduits Tendon transfers if muscle loss
42 Median Nerve Injury in Child
43 Fingertip injuries Common consult Less than a postage stamp, can allow to granulate Sew on as a biologic dressing Time and healing
44
45 Other Local flaps
46 Mutilating Hand Injuries Most dramatic High energy injuries Multi-level injuries Skin Tendon Muscle Bone Nerve
47 Mutilating Hand Injuries General Principles Stabilize patient Stabilize Hand Vascular reconstruction Multiple washouts Revision fixation Tendon/Nerve Recon Skin Coverage
48
49 Functional outcome
50 Summary Index of suspicion should be high Knowledge of Hand Anatomy Determine level of expertise required to address Acute injuries Control Hemorrhage Stabilize fractures
51 Thank You
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Lesson Plans and Objectives: Review material for article Prep work for article Picture recovery Review for placement on-line.
Lesson Plans and Objectives: Review material for article Prep work for article Picture recovery Review for placement on-line. After reading the article, the staff will be able to: Define facial trauma
Suture of Tendon Sheath of Hand , , Delayed suture of other tendon of hand , Other Suture of Flexor Tendon of Hand
Coding and Reimbursement Guide for Integra BioFix Amniotic Membrane Allograft, Integra BioFix Plus Amniotic Membrane Allograft & Integra BioFix Flow Placental Tissue Matrix Allograft For Use In Repair