Dr Nathan StewartDepartment of Plastic and

Reconstructive Surgery Royal Perth Hospital.

Plastic surgery is not cosmetic surgery. Specialty born from the world wars, from

soldiers with devastating injuries that required complex reconstruction.

Plastic surgeons aim to reconstruct both form and function.

Crucial for any trauma unit. Here at RPH our unit does 1/3 of ALL

operating by case numbers.

Breast reconstruction Sarcoma reconstruction Skin cancers

Easily the majority of our work here at Royal Perth.

Why? Because its such a common injury! Front line trauma staff need to

understand the significance of a hand injury.

Communication

Sensation

Employment

Independent Living

Greetings

Gestures

Sign Language

Large area brain structure devoted to touch. Highly sensitive.

Relationships

Use of hands fundamental to most vocations.

Without the use of our hands, most people would find independent living impossible.

Small injury = massive impact to functional ability, employment and employability, cause financial and relationship strains, have severe long term implications.

Simple (and very common) example. Right hand dominant male, mechanic by trade, gets drunk and punches a wall one Saturday night. Presents complaining of a sore hand.

This equals 6-8 weeks off work!! No income for 2 months. How would your finances cope?

Small area – lots to injure. Even small lacerations may cause

functional issues.

Is it cold? Is sensation intact?

Digital Nerves

Arterial bleeding in the finger.

Individual movements to test the function of each tendon.

Also groups of movements that can test for the motor loss from nerve damage.

Dont need to know how to perform these, but useful to ask is there anything the patient obviously cant do or that causes pain?

Fractures Lacerations/Penetrating Injuries Amputations De-gloving Injuries Human (punch) Bites Animal Bites Hand infections

Open or closed?

Open fractures – should have appropriate first aid. Thorough irrigation IV antibiotics Dressings

Closed fractures – some can be manipulated, most require fixation. General rule is to plaster all fractures.

All hand fractures should be seen in clinic.

There is a treatment window of around 10-14 days to fix a fracture.

After this it is very difficult to correct. Should be referred early, to allow time to

get into an elective operating list. ORIFs often moved early. K-Wires stay in

plaster 4 weeks. Healing time of bone the same.

Be carefull with your plasters!! Like anything in medicine, there are

always risks associated with any medical intervention, plastering included.

Plasters must immobilise the joint above and below, maintain a functional position and not be too tight.

If a patient complains of pain in a plaster then always take it off and re-do it.

Very common cause of trauma. Typical culprits –

Regardless of size, always have a high suspicion for more serious injury.

Remember, glass only every stops cutting when it hits bone.

Lacerated tendon when repaired takes 6-8 weeks of healing and hand therapy to recover.

Nerve repairs often take 3-6 months to get some benefit from the repair

Any altered sensation or obvious deep injury should be seen in ED by a surgeon.

Tendons may appear intact but be partially lacerated and “break” about 2 weeks later. Harder to repair at this stage.

Nerves/arteries usually protected in a cast for 2 weeks to heal. Tendons if strong repair for early movement. If a weak repair then 3 weeks in cast.

Hand therapy crucial in healing. 2-3 weeks is classic time for repair to

break.

Can occur at any level. Ability to re-plant / re-vascularise

depends on both the level of amputation and the mechanism.

Once past the distal third of the distal phalanx the vessels are too small to be anastamosed.

Common ED presentation.

Usually the most impressive of ED hand injuries. Ischaemic time critical.

Vessels re-anastomosed and tendons repaired.

Usually go onto aspirin for 3 months. Typically protected by a split for 3 weeks. Sharp clean amputations easier to fix.

Traumatic blunt amputations much more difficult as zone of trauma large. May need grafts to bridge wide areas of vessel and nerve loss.

Can get large areas of skin loss. Typically treated as a skin graft with

original skin, or debrided and skin grafted from the thigh.

Can get contraction of the scar.

Very common. Injury occurs after punching someone in

the mouth. Usually small laceration to the 2nd or 3rd MCPJ. Often extends into the joint with damage to the extensor tendon.

Always requires IVABs and a washout. Common consequences – septic arthritis,

extensor tendon loss.

Usually require at least 1 washout. Sometime multiple.

Tendon cannot be repaired if already infected.

Tendon, although intially intact can be completely destroyed by infection.

Always, always refer.

Cat bites – frequently become infected. Cat teeth puncture like a needle and deposit bacteria at the base to then form an abscess.

Dog bites – easier to treat than cat bites as dog teeth typically tear leaving the wound open and able to be irrigated. Cosmetically more difficult to treat.

Sharks!! – If the patient survives the attack, can be a devastating injury.

Most people only present with cat bites once infected. Always need a washout and debridement.

Dog bites usually present the same day. As for all wounds – good irrigation as soon as possible is the key to limiting infection.

Shark bites – often need resuscitation and control of haemorrhage.

These are commonly as a result of minor trauma.

Rarely can be spontaneous Either way needs prompt review, surgical

drainage if required, strict arm elevation and antibiotics.

Relatively minor appearing injuries can have poor outcomes. Proximal phalanx fractures Tendon lacerations Uncontrolled oedema Scar formation

Contracture of the scar leads to poor mobility.

Those crossing longitudinally across a joint crease likely to cause the most problems.

Massage and hand therapy the solution.

Small area with complex anatomy. No referral is ever a bad referral. Realise that even a 0.5cm lac with a

kitchen knife can 100% lacerate a tendon or nerve. This represents months of treatment and time off work.

Irrigate everything