Hand Trauma Update: Outline. Hand Surgeon s Area of Expertise. Orthopaedic Update 2015

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1 Hand Trauma Update: 2015 Orthopaedic Update 2015 March 21, 2015 Peter Tang, MD, MPH Director Hand, Upper Extremity & Microvascular Surgery Fellowship Associate Professor Drexel University College of Medicine Allegheny General Hospital Outline What is a Hand Surgeon? Congenital Hand Consults Management of: Fractures Tendon Injuries Nerve Injuries Vascular Injuries / Replantation Complex Injuries Hand Surgeon s Area of Expertise Most hand surgeons undergo a hand fellowship which is a 1 year training program after residency (orthopaedics, plastic surgery or general surgery) The AGH Hand Division covers injuries and problems from the fingertip to shoulder (tumors, carpal tunnel) Our expertise is site specific so we take care of adults and children We of all orthopaedics surgeons are most delicate with the soft tissues because we handle nerve and arterial injuries and provide coverage for soft tissue defects Hand surgery is the most challenging because there is little tolerance for imperfection in the hand and upper extremity

2 We are looking for congenital hand consults! Apert s Syndrome 1 : 200,000 Autosomal Dominant Triad Craniosynostosis Syndactyly Maxillary hypoplasia I (Spade), II (Spoon/Mitten), III (Hoof, Rosebud) Inter-digital bony union Single common nail May be associated with increased paternal age

3 We separated thumb and index, middle and ring fingers bilaterally

4 1 year later...

5 2 yo with radial club hand with Type IIIB hypoplastic thumb

6 2 yo with radial club hand with Type IIIB hypoplastic thumb Pollicization

7 Adult Complex Injuries

8 Hand Fractures Incidence and Location 10% of all fractures occur in the hand Distal phalanx 45-30% Middle phalanx 8% Proximal Phalanx 15-20% Metacarpal 30-35% Middle and Proximal Phalanx Fractures - Goals of Treatment Restore Articular Congruity Restore Length For every 1 mm of middle phalanx shortening there is 10 deg of DIP lag For every 1 mm of proximal phalanx shortening there is 12 deg PIP lag Restore finger alignment and rotation Allow early finger motion Surgical Indications Finger malrotation (>50% overlap of adjacent digit) or angulation (> 10 deg) Loss of length Intra-articular with joint incongruity

9 Loss of Length 38 yo F s/p MVA Fractures that May Need ORIF Comminuted fractures Fractures with rotational deformity Not acute fractures

10 17 yo male goalie got struck by soccer ball on index finger 17 yo male goalie got struck by soccer ball on index finger Tendon Injuries Connects the muscle to bone Allow movement of bones Has to have excursion to function

11 3 yo girl who got hand caught in metal gate of elevator 3 yo girl who got hand caught in metal gate of elevator 3 yo girl who got hand caught in metal gate of elevator

12 Nerve Injuries Peripheral nerves allow for sensation and innervate muscle to allow motion Goals of treatment with nerve laceration: Tension-free primary repair When there is a segmental defect options are: - Autograft - Conduit - Decellular allograft Digital Nerve Injury 43 yo male with laceration. His laceration was repaired in ER and told he just had a superficial laceration. Digital Nerve Injury

13 45 yo male with deep 15 cm left antecubital laceration from machine at work. Vascular surgery did brachial artery vein repair the week before. No hand surgeon is at that hospital. Proximal Distal After nerve debridement 5 cm gap. Median nerve diameter was 8 mm. We reconstructed with 2, 50 mm long x 4-5 mm wide allografts. We used a combination of 6.0 and 8.0 nylon

14 Vascular Injuries & Replants Definitions: Replantation reattachment of a body part that has been totally severed from the body. Revascularization reconstruction of damaged blood vessels in order to prevent an ischemic body part from becoming nonviable or necrotic Replantation At level of hand and fingers arteries and veins necessitate 10.0 and 11.0 suture and 20x magnification with a microscope For a finger replant need one artery and preferably 2 veins (if bad outflow then may need leeches) Replant Storage 1. Immerse amputated part in LR in a plastic bag. Place bag on ice. 2. Wrap amputated part in a cloth or gauze moistened with LR or saline solution. Place in plastic bag or sterile cup. Place bag or cup on ice. * No dry ice

15 Replant Ischemia Time Digit Warm ischemia 12 hrs Cold ischemia 24 hrs Proximal to Finger Warm ischemia 6 hrs Cold ischemia 12 hrs Replant Indications 1. Thumbs 2. Multiple digits 3. Metacarpal amputations (palm) 4. Almost any body part in a child 5. Wrist or forearm 6. Elbow or proximal arm (only sharp or moderately avulsed) 7. Single digit distal to FDS insertions Replant Contraindications 1. Severely crushed or mangled parts 2. Amputation or injuries at multiple levels 3. Patients with other serious injuries or diseases 4. Arteriosclerotic vessels 5. Mentally unstable patient 6. Single finger in adult, proximal to FDS insertion 7. Prolonged warm ischemia

16 33 yo male getting home by motorcycle when he sees fighting across the street I get the call at 12:30 am I m in the hospital by 1 am and the pt is rolling back to the OR The cut is very sharp like a cleaver I start working on the thumb on a back table. I make longitudinal incision are made on the radial and ulnar sides and the nerve and arteries are identified I place sutures in the flexor and extensor tendons Dorsally we identify veins Replant Order of Repair Bone shorten and fixate Repair extensor tendons Repair flexor tendons Anastomose arteries Repair nerves (I do nerves before arteries) Anastomose veins Obtain skin coverage 6 hours later...

17 At 3 mos Complex Injuries 22 yo female high powered rifle thru arm

18 22 yo female high powered rifle thru arm 22 yo female GSW thru arm 22 yo female GSW thru arm

19 Issues 1. Elbow Motion 2. Nerve Function 22 yo female GSW thru arm Plan: 1. Elbow Motion - Elbow contracture either due to inherent joint stiffness or from the skin graft/triceps scarring - Our plan was to release the scar and see if the elbow would flex, if not then perform elbow capsulectomy - We planned to neurolyse the ulnar nerve to release any external scar to possibly improve ulnar nerve function in the hand. - Also, to be able to safely release the posterior humeral scarring we planned to neurolyse the radial nerve 2. Nerve Function - She had function of her ulnar FDPs and FCU but had no function of her ulnar nerve in her hand, so her ulnar nerve had regenerated to the forearm but it would take 17 mos to reach the hand targets - To improve her intrinsic hand function we offered her an AIN nerve end-to-end transfer to her deep motor branch 22 yo female GSW thru arm

20 22 yo female GSW thru arm 22 yo female GSW thru arm 22 yo female GSW thru arm

21 22 yo female GSW thru arm 22 yo female GSW thru arm 22 yo female GSW thru arm

22 22 yo female GSW thru arm PE: Elbow motion: - 20/120 0/5 elbow extension 64 yo male shotgun through wrist

23 11/14/2014 OR for repeat I&D ORIF Distal Radius Spanning Ex-fix Median n. repair w/ 6 cm allograft w/ wraps at each repair site MF FDP transfer to FPL MF FDP side-to-side RF FDP MF FDS side-to-side RF FDS VAC assisted closure

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25 Further OR Visits 11/17: Repeat I&D, VAC Change, 11/21: Repeat I&D Open Pinning IF Metacarpal Fx Removal distal radius plate and K-wires EPL Reconstruction w/ ECRB Antibiotic Spacer VAC change 11/24: OR w/ Dr. White (Plastics) Anterolateral thigh fasciocutaneous free flap reconstruction of Right dorsal wrist and forearm Thigh anterolateral flap

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27 12/23/2014

28 OR 1/19/2015

29 Thank you! Contact: Peter Tang Cell: Radial Club Hand

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31 45 yo male cleaning his yo male cleaning his yo male cleaning his Injuries include: 5 th metacarpal bone loss and base of 4 th MC fracture, hamate fx Complete flexor tendon laceration Partial extensor tendon laceration Common digital nerve injury to RF and SF with a large gap Injury of the motor branch of the ulnar nerve with a gap

32 45 yo male cleaning his yo male cleaning his yo male cleaning his.45...

33 45 yo male cleaning his yo male with tablesaw injury Injuries: - 3 rd and 4 th common digital arteries - 3 rd and 4 th common digital nerves - RF and SF FDP and FDS Surgery: - 4 th common digital artery repair - 3 rd and 4 th common digital nerve reconstruction with decellular allograft - RF and SF FDP and FDS repair - First post-operative visit he had necrotic tissue which we believed was superficial - 3 weeks post-operative his hand started to smell like necrotic tissue 32 yo male with tablesaw injury Revision Surgery: - We debrided the necrotic tissue leaving a 8 x 6 cm defect - 3 of the 4 flexor tendons had pulled apart - The vascular repair was not flowing but the fingers were perfused

34 32 yo male with tablesaw injury We offered him a revision surgery to rerepair everything and perform a radial forearm flap vs amputations. We explained that his function would not necessarily be good even if he kept the fingers. 32 yo male with tablesaw injury Revision Surgery: - We resected the phalanges of the RF and SF and kept the soft tissue. - We were not sure which soft tissue to use to cover the wound. Both flaps were dusky. - We rotated the hypothenar tissue to help cover the defect. - The plan was partial resection of the 5 th metacarpal but we ended up resected the whole metacarpal to decrease the size of the defect. 32 yo male with tablesaw injury

35 72 yo male who cut his thumb with a tablesaw (guard was up). Transfer from Allegheny-Valley Hospital We find vessels proximally but could not find any vessels distally to work with despite using the microscope We did a revision amputation and z-plasty to deepen his first webspace