Slide 1 - موقع ومنتديات كلية الطب البشري‎ by zhangyun

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									HAND INJURIES
          HAND INJURIES
• Hand is an organ of grasp as well as
  organ of sensation and expression.
• For optimal function of hand a combination
  of movements of shoulder, elbow and wrist
  are required.
• So hand should never be treated in
  isolation from rest of upper limb.
        Hand biomechanics
• To understand management of hand
  injuries we must understand biomechanics
  of hand
• In biomechanical motion, the hand
  performs 6 basic movements:
            PRECISION PINCH




• Flexion of DIP of IF
  and IP of thumb
        OPPOSITIONAL PINCH




• Pulp of IF and thumb
  brought together
                  KEY PINCH




• Thumb adducted to
  radial side of middle
  phalanx of IF
                 HOOK GRIP



• Finger flexion at IP
  joint and extension at
  MP joint
• The only one that
  does not require
  thumb
               POWER GRASP




• Fingers fully flexed
• Thumb flexed and
  opposed over digits
                SPAN GRASP




• Thumb abducted
• DIP and PIP of digits
  flexed to 30°
               Hand injuries
• Rank and Wakefield classification
  – Tidy injuries
     • Due to sharp agents like glass and knife
     • Cuts are clean cut ad incised
     • Tendons, nerves and blood vessel are involved
  – Untidy injuries
     • Skin is ragged and there may be multiple fractures
     • Needs excision of devitalized tissues.
  – Indeterminable injuries
     • Due to burns and severe crush injuries
TEMPLATE FOR SUCCESS !!
          Patient survival

           Limb survival

           Limb function

 Return back to meaningful lifestyle
         Evaluation of injury
• Careful examination is essential to
  ascertain the extent of injury of
  – Nerves
  – Arteries
  – Tendons
  – Bones
  – joints
• Nerves
  – Assessment may be difficult due to too much
    pain or apprehension
  – Motor testing may be impossible because of
    tendon or bone injury
• Arteries
  – Suspected by profuse bleeding
  – Assessment of distal circulation is important
• Tendons
  – Tendon sheath laceration needs exploration
  – Tendon injury will result in lack of active movement
• Bones
  – Detected clinically and can be confirmed on x-ray
• Joints
  – May be clinically obvious or can be detected during
    exploration
IMMEDIATE MANAGEMENT

• Airway

• Breathing

• Circulation
                REPAIR
Skeletal fixation for stability and to maintain
                      length

                Tendon repair

                Nerve repair

               Vascular repair

              Soft tissue cover
      Principles of technique
• Use of tourniquet
• Anaesthesia general versus regional
• Careful wound toilet by thorough irrigation
• Excision of all devitalized tissue
• Haemostasis after localizing bleeding
  points
• Administration of antibiotics and
  antitetanus toxoid
                 Skin loss
• Finger tip injuries
  – Skin loss only-split thickness skin graft
  – Loss of pulp and bone-local flaps
  – Amputation and primary closure for quick
    return of work
• Skin loss with involvement of deeper
  structure
  – Coverage by flaps on dorsum of hand
  – Full thickness graft on palm to avoid
    contracture
  – If deep structure are exposed needs flaps
    local versus regional versus distant
            Tendon injuries
• Immediate repair of tendons in tidy injuries
• In untidy injuries delay repair to a latter
  date
• Repair tendon sheath if possible
• Needs postoperative splintage and
  physiotherapy
• Bone injuries
  – Rigid fixation by screw and plates
  – k-wire fixation is simple
• Nerve injuries
  – In tidy injuries primary repair is preferable
  – Needs magnification either by loupe or
    microscope
          Postoperative care
• Elevation and prevention of stiffness
  – Compression over fluffy gauze reduces
    oedema
  – Elevation above right heart level to aid gravity
    drainage of blood
  – Start mobilization maximum within 3 weeks
• Position of splinting
  – Metacarpophalangeal joints in 90 degree
    flexion and IP joins fully extended
     ROLE OF
REIMPLANTATION IN
  HAND INJURIES
 WHEN REIMPLANTATION ?
• Functional importance of the part
   – Thumb and multiple fingers reimplant. should be
     attempted
• Level of injury
   – Proximal amputations easier technically for surgeon but
     poorer results than distal amputations
   – Multiple levels of injury - contraindication
• Ischemia time
   – 6 hours warm ischemia / 12 hours cold ischemia
• Expected return of function
   – Good functional results seen with reimplant. of digits
     distal to insertion of FDS, hand at wrist and upper limb at
     distal forearm
 WHEN REIMPLANTATION ?
• Mechanism of injury
  – Most predictive indicator
  – Guillotine amputation better results than avulsion
    amputations
  – Red line sign and Ribbon sign – vein graft may be
    required for this segment of vessel
• Mentally unstable patients
  – Relative contraindication


• Poor general condition of patient
  – absolute contraindication
  – Role of temporary ectopic reimplantation for preservation
    of the amputated extremity
         REIMPLANTATION
Preoperative
  considerations:

• Proper preservation of
  the amputated part
• Proper preservation of
  the amputated stump
  – do not clamp any
    bleeder
  – only compressive
    dressing and elevation
 BURN INJURIES TO HAND
• Basic question: What is the depth of burn ?
  – 1 °/ 2 °superficial / 2 °deep / 3 ° / 4 °

• History:
  – Thermal
     • Hand with extreme sensitivity – usually injury 1 ° or 2
       °superficial
  – Electrical
     • point of contact or earth point
     • Usually 3 ° or 4 ° as it would not be possible to
       release live wire from hand due to spasm of muscles

								
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