Principles of Management Of Hand

Injuries
Dr Bashiru Aminu
MODERATOR DR A. IBRAHIM

Outline
Introduction
Epidemiology
Relevant anatomy
Etiology of hand injuries
Principles of management
Rehabilitation
Complications

Introduction
A prehensile organ
Functions as an

extension of our selves

It is richly provided for in
this function
Has a large
representation in the
motor cortex

Definition
Hand is the part of the upper limb distal to the wrist

Hand injury: defined as any pathological change

occurring in the part of the upper limb distal to the

wrist as a result of exchange of energy between an
individual and his environment

Epidemiology
-Road traffic accident
-Males
-26.9 years average
-artisans
-right hand
-distal phalanges
-50% right hand
dominance
-50% hospital presentation

-Road traffic accident

-hands are involved 1/3
-distal phalanges
-6 million emergency room
visit
-90 million days restricted
work activity
-10 billion dollars loss
yearly

Relevant Anatomy

Relevant Anatomy

Etiology Of Hand Injury

Road traffic accident
Industrial
Domestic
Assault
Sports

Classification
Open or closed
Rank and Wakefield-tidy, untidy, indeterminate
Mutilating injuries-

dorsal injuries, palmar injuries, radial hemiamputation, ulnar hemi-amputation, and distal
amputation

Principles
Resuscitation
History
Examination

Examination

Examination

Examination

Examination

Examination

Investigations

Management Principles
Multidisciplinary
Treatment is directed at structures injured
In emergency situations, the goals of treatment are
Distal circulation
Bone frame work
Skin cover

Intra operative principles

Setting of management in theatre
Aseptic procedure at all times
Good lighting
One surgery where surgeon and assistant must sit

down
Hand table is indispensable
Use of loops or operating microscope is essential
Repair can be one or multi staged

Intra operative principles

Anesthesia
Tourniquet
EUA
Incisions
Bony support
Status of blood vessels

Intra operative principles

vascular
Assess adequacy of collateral
Non critical
-Radial artery alone
Critical injury involves
- Radial & ulnar artery
-Radial or ulnar injury & poor collateral
digital brachial index of 0.7 or more good

Vascular injuries
End to end anastomosis of healthy vessels is goal
Healthy intima must be visualized
Repair should be done outside the zone of injury
Appropriate length of vein grafts are used from the

saphenous vein

Intra operative principles

Primary tendon repair reserved for cleanly cut

tendons.
Delayed primary repair is indicated for tidy,
potentially contaminated wounds
Retraction after 4 weeks produces joint flexion.
In this situation, tendon graft repair may be
required

Intra operative principles

Relative contraindications to immediate

tendon repair include the following:

1. Injuries more than 12 hours old
2. Crush wounds with poor skin coverage
3. Contaminated wounds, especially human bites
4. Tendon loss more than 1 cm
5. Injury at multiple sites along the tendon
6. Destruction of the pulley system

Intra operative principles

A 4-0 coated polyester or braided nylon for the core

suture.
Suture bites of at least 0.7 cm
A peripheral 6-0 nylon suture

Tendon repair

Zones of flexor tendon injuries

Zones of extensor tendon injury

Intra operative principles

Nerve injury
Classification by Sedon:
Neurapraxia
Axonotmesis
Neurotmesis
Accurate approximation of the cut end important

Intra operative principles

Primary nerve repair in 72 hours of injury
Delayed primary repair 72 hours to 14 days
Secondary nerve repairs 14 days or longer after

injury.
The nerve repair must be tensionless.
May use nylon 8-0
PGA, collagen tubes for gaps or nerve grafts for large
gaps

Intra operative principles

Intra operative principles

Primary neurorrhaphy when;

1. The nerve is sharply incised.

2. There is minimal wound contamination.
3. There are no injuries that preclude obtaining
skeletal stability or adequate skin cover.
4. The patient is medically stable to undergo an
operation.
5. Appropriate facilities and instrumentation are
available.

Post operative principles

Wound closure
dressings
Splint

Position of safe immobilization

Post operative principles

Limb Elevation & analgesia
Early physiotherapy when edema subsides
Rehabilitation should start early
Avoid discrimination for successful reintegration
Ergonometric instrumentation
Compensation for loss of limb on employment

Workman's compensation

Workman's compensation

Workman's compensation

Amputation and prosthesis

In general if any four of the following basic six are
irreparably damaged
Skin
Extensor and flexor tendons
Vessels
nerves
Skeleton

Amputation and prosthesis

Lateral (radial)
Ulnar (medial)
Central
Transverse
Impairment geometrically related to proximity
Prosthesis-total, partial, digital or active or passive

Active prosthesis

Total prosthesis

Digital prosthesis

Replantation
Clean
Guillotine
Specific sequence can

vary
1-4 under tourniquet

1. Bony fixation
2. Repair of periosteum
3. Extensor tendon repair
4. Flexor tendon repairs
5. Arterial anastomoses
6. Nerve repairs
7. Venous anastomoses
8. Skin closure

Replantation
Absolute contraindication
Severe associated
injuries
Multiple injury in same
part
Systemic illness

Relative contraindication
Age
Avulsion injury
Prolonged warm
ischemic time
Massive contamination
Psychiatric patient

Complications
Early
1. Infection-fascitis, abscess, dehiscence
2. Compartment syndrome
late
3. Hand stiffness
4. Loss of function
5. Implantation cysts
6. Volkmann contractures
7.

contractures

Prognosis
Severity of injury
Time of presentation
Other associated injuries
Availability of skilled hand surgeon
Physiotherapy

Hand injury severity score

Conclusion
Hand injury is common in our environment
High speed travel, industrialisation, violence, sports
A knowledge of the principles in its management is

important

REFERENCES
Hand injury management-MK Chira
2. Hand injuries- I.I. Onah
1.

3.
4.
5.
6.
7.

Hand injury A U EKERE

Sabiston text book of surgery
Schwartz text book of surgery
Hand injury V.U.E Adiele UPTH
Grabb and Smith`s plastic surgery