Common Hand Injuries Common Hand Infections Braemar Hospital GPCME 1 November 2014
Waikato Hospital Tristram Clinic, 200 Collingwood Street, Hamilton P 07 838 1035 F 07 838 2032 E appts@tristramclinic.co.nz Tauranga Hospital Da Vinci Clinic, 727 Cameron Road, Tauranga P 07 578 5350 F 07 578 5354 E brandon@davinciclinic.co.nz
Overview General Principles Common Hand Infections Nail and pulp Tendons and deep palm Bites Common Hand Injuries Nail and pulp Distal phalanx fractures Metacarpal fractures
General Principles Hands are resistant to infection - is the patient immunosuppressed? Oedema HANDS SWELL!! Drainage of collections Cultures Immobilisation in safe position Elevation Tetanus Antibiotics
Acute Paronychia Commonest infection in hand Infection of nail fold Edge of nail fold red and tender Staph Aureus commonly
Paronychia Treatment Non surgical in early stages Cover staph aureus eg Flucloxicillin Moderate cases Ring Block Elevate nail fold off the nail plate Preserve the nail Severe Cases or any case with pus under the nail Ring block Remove part or all of the nail Incision parallel to the epoychium
Chronic Paronychia Chronic maceration and obstruction of fold Wet work + diabetics Scrapings, culture Candida albicans Topical steroids and anti fungals Diligent finger hygiene Trial of nail preservation
Chronic Paronychia Recurrent or resistant chronic paronychia Nail plate removal Topical and oral antifungal treatment Eponychial marsupialisation (Keyser and Eaton)- epithelialsition
Felon Subcutaneous abscess in distal pulp of finger or thumb Why are felons so painful? What are the common mechanisms? What bacteria cause felon?
Felon Treatment Surgical drainage Ring block Incision of lateral aspect of the pulp Parallel to the nail Mid axial line Never a fish mouth
Suppurative flexor tenosynovitis Penetrating injury Painful Red Swollen finger Pain with passive stretch Whole finger redness
Tendon Sheath Infection Suppurative Tenosynovitis Tendon sheath is a closed compartment Relatively immune protected area Untreated infection can destroy the tendon within hours
Flexor Sheath Mid distal phalanx to distal palmar crease May connect to adjacent finger s sheath May connect to carpal tunnel
Kanaval s Signs of Tenosynovitis Partially flexed finger Tenderness over flexor tendon sheath Differentiates tendon sheath infection vs. septic joint Pain with passive extension 4 th ADDED LATER Fuisiform swelling of finger Allen B. Kanaval, Prof. Of Surg. NorthWestern Univ. Chicago 1912 Mortality in 1912 from hand infection with ascending lymphangitis was upto 30%
Tenosynovitis Treatment Surgical drainage open and irrigate Elevation Splinting I.V. Abs - Flucloxicillin Complications Necrosis of tendon Extension to forearm Median nerve compression Septic shock
Deep potential space infections Web space Mid-palmar space Thenar space Space of Parona
Web space abscess Abscesses may form in the loose tissue of the webspaces and discharge volarly, dorsally or both A collar button abscess describes two pockets of pus connected by a narrow isthmus
Palmar Space Infections Anatomy mid palmar and thenar spaces
Bites Human bite Dog bite Cat bite
Human bite Crush Abrasion Bruising Cellulitis Punch = fight bite Unreliable history Suspect deep injury
Human bite Wide range of bacteria Aerobic and anaerobic Most common are Gram positive cocci Eikenella corrodens Gram -ve bacillis Sensitive to beta lactam antibiotics Eg Amoxicillin / Clavulonic acid Second line Cotrimoxazole + Metronidazole Clindamycin
Cat bite Sharp Puncture wounds Most common Gram Positive Cocci Pasturella maltocida Gram negative Sensitive to Amoxicillin Irrigate Dress don't suture
Dog bite 1 bite per 50 dogs per year in NZ Crushing Tearing injuries Tissue loss Fractures Gram positive cocci
Animal Bites Penetrating innoculum Look for teeth on Xrays Excise edges of wounds and clean Cats Pasturella Multocida Augmentin recommended
Farm yard infections Increased anaerobes Clostridium perfringens Benzyl-Penicillin or Metronidazole
Magic Words Collection requiring drainage Suspected tenosynovitis Diabetic Failed trial of oral antibiotics Tissue loss Heavily contaminated Human bite
Common Hand Injuries
Nail and pulp injuries Subungal haematoma Nail bed laceration Finger tip amputation or near amputation
Nail and finger tip anatomy
Subungal haematoma Crush injury Painful Treatment? Investigations? Referral?
Nail bed laceration Crush injuries +/- underlying fractures Split periosteum exposes bone / fracture Toddlers Siblings Doors Suspect growth plate fractures in children
Nail bed laceration Lacerations are repaired with dissolving sutures (vicryl rapid) Nail is removed for access to nail bed Lacerations across the nail fold are more complex Abrasions heal by secondary intention Nail bed scarring may lead to splitting or separation of the nail Early nail separation can be treated with nail bed grafts from toes
Finger tip amputation
Classification
Principles Define the defect Replace like with like Maintain length Skeletal stability Durable padded cover Restore sensation Early mobilisation Expeditious, simple & reliable Cosmesis Tailored to the patient
Reconstructions Primary closure / terminalisation Secondary intention - Dressings Grafts Local flaps Homodigital Heterodigital Distal flaps
What can be dressed? 1/3 of the pulp = size of nail No exposed bone No Fracture Dress with semi-permeable dressings eg IV3000 Change as needed 2-3 days
Atasoy flap, 1970
Cross finger flap, 1951
Distal phalanx fractures A fracture is a soft tissue injury associated with disruption of the bone
Neck of the distal phalanx
Tuft fracture
Fracture disrupting the extensor insertion
Fracture disrupting the flexor insertion
Metacarpal Fractures
Not all fractures need fixation
Thumb metacarpal Intrinsically unstable Isolated from other supporting bones Fractures of the base (Bennett s, Rolando s) involve the CMC joint and the APL tendon Require anatomic reduction and immobilisation Frequently require fixation to immobilise
Finger Metacarpals Intrinsically stable Supported by adjacent bones and intrinsic muscles Length and alignment needs to be adequate to allow a natural cascade of the fingers A moderate degree of flexion at the fracture site is permissible while retaining good hand function Rotation is an indication for reduction
Degree of flexion Index metacarpal: 5-10 degrees Middle metacarpal: 10-20 degrees Ring metacarpal: 20-30 degrees Little metacarpal: 35-40 degrees
Indications for intervention Compound Fractures Fractures involving the joint Any rotation causing fingers to cross over Multiple metacarpal fractures Severe flexion Moderate flexion where dorsal hand and knuckle are deformed
Managing a metacarpal X-ray to confirm fracture orientation Haematoma block 10mL of 1% lignocaine or 0.75% ropivocaine Manipulation and ulnar gutter spint MCPJ flexion IPJ extension Confirm reduction Rpt X-rays in 1 week
Magic Words Compound Tissue loss Avulsion Amputation Not perfused Rotated Unstable
Waikato Hospital Tristram Clinic, 200 Collingwood Street, Hamilton P 07 838 1035 F 07 838 2032 E appts@tristramclinic.co.nz Tauranga Hospital Da Vinci Clinic, 727 Cameron Road, Tauranga P 07 578 5350 F 07 578 5354 E brandon@davinciclinic.co.nz