acute hand injuries general principal

8/7/2019 acute hand injuries general principal

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Dr. Khizer GhalibPostgraduate Resident

LGH


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Introductiony The hand and fingers are the body parts most often injured

in the workplace.

y Restoration of function is the goal of treatment.

y It is necessary to prevent infection, salvage injured parts,and promote primary healing.

y The surgeon must personally appraise the injury to decidewhich primary procedures can be done safely and whichsecondary procedures may be necessary later.


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H ISTORY1) Exact time of injury

2) First aid given, by whom and where

3) Nature, amount, and time of receiving any medication

4) Exact mechanism of injury

5) Nature, time, and amount of food and liquid taken by thepatient

6) Patient's age, occupation, handedness, and general healthstatus.


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F IRST AIDy A TLS Protocol

y Open wounds should be covered immediately with asterile dressing to prevent further contamination.

y If bleeding is severe, the hand should be elevated withthe patient supine; if not controlled by elevation alone,manual or digital pressure, applied to the woundthrough the dressing, may be sufficient.


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F IRST AIDy B leeding can be controlled quickly by removing an

improperly applied venous tourniquet.

y Elevation and A pneumatic tourniquet may be helpfulto control bleeding with cuff inflated to 100 to 150 mmHg greater than the systolic pressure.

y Hemostats and ligatures should not be used to controlbleeding in the emergency department because thismay damage intact vessels and nerves.


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F IRST EXAMINATIONy To estimate the size of the wound, determine the extent of skin loss

and injury to the deep structures.

y Pain usually limits examination.

y Probing the wound usually is unnecessary.

y The viability of the skin and any gross positional deformity are noted.

y The wound is covered, physical examination is attempted to determinewhich deep structures are functioning ,which must be considereddamaged until proved otherwise.

y A ssessment of each tissue should be orderly; attention is directed firstto the circulation and skin and then to bones, tendons, and nerves.


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F IRST EXAMINATIONy From this first examination, the surgeon should obtain some

idea about the injury and procedures needed

y

Final decision is delayed until the second examination insurgical suite.

y The patient's general medical condition is evaluated.

y A

ntibiotics, sedation, blood transfusions, tetanus prophylaxis,and other measures as indicated.

y B efore sedatives or narcotics, the patient should be advised as tothe extent of the injuries, general plan of treatment, andprognosis, especially possibility of amputation.


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Anesthesiay Depending on the patient's age and general condition,

the severity of the injury, other injuries, the interval

since the last ingestion of food or drink, and whether adistant flap will be necessary, we can use

y A regional block or

y General anesthesia


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Tour niq u ety Tourniquet is necessary for cleaning and inspection,

and for deep structure repair

y If viability of an area of skin is questionable,tourniquet should be used as brief ly as possible.

y For large wound with fractures, elevation for 2 minutesis better than wrapping with an elastic bandage beforeinflation of the tourniquet.


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Cl eansing and D r aping of Handy First aid dressing is removed, sterile pad is placed over the

major wound.

y Uninvolved skin surrounding the wound is shaved.

y Hand is scrubbed with antiseptic soap and water to abovethe elbow. Nails and nail beds are cleansed and trimmed.

y Wound is exposed ,irrigated with normal saline

y Usually, antiseptics are not used in the wound because of potential tissue toxicity.


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Cl eansing and D r aping of Handy Finger is placed in the wound to loosen hematomas or to palpate the

bones

y Depths of the wound should not be rubbed with a sponge or brush.

y Small bleeding vessels , more easily seen under saline solution, areclamped and cauterized.

y Small flaps and tags of devitalized fat and fascia seen floating in thesolution may be removed

y Nerve ends are not dbrided.

y Ragged skin edges may be trimmed, but complete excision of the edgesof the wound usually is unnecessary in the hand.


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Cl eansing and D r aping of Handy Wound is cleaned, carefully searched for foreign materials

y

Cleaning should not be hurried and often may take half of the total operating time to prevent infection.

y Primary healing without infection is necessary to limit the

scar and to allow early reconstruction, if needed.

y A fter cleaning, all instruments, gloves, and drapes used arediscarded, and the hand is redraped


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S ec o nd Examinati o ny Conclusions drawn from the first examination may be

wrong, so suspected tendon and nerve injury may beconfirmed by direct inspection.

y The tissues in the depths of the wound, includingexposed bones, tendons, vessels, and nerves, areassessed in an orderly, anatomical manner to avoiderror.

y Evaluating the skin damage is most important becauseprimary wound closure depends on skin viability.


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ORDER O F TISSUE REPAIR

1. A rtery

2. B one

3. Tendon

4. Nerve


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ARTERIAL INJURIESy In a young person if only one artery is injured without nerve

injury, ligation remains a satisfactory option.

y

In younger and older patients with inadequate circulationthrough the intact artery, especially with nerve injury, repair of the injured artery is preferable.

y If both arteries are transected, repair of both arteries should beperformed

y Injuries to palmar arterial arch and digital arteries requireexploration and micro-vascular repair if circulatory impairmentthreatens digital viability.


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C ONSIDERATIONS F OR SKIN

C LOSUREy Primary skin closure can be done in all sharply incised, clean wounds.

y The purpose of primary skin closure isy

to obtain early healing andy to prevent infection, granulation tissue, edema, and excessive scarproduction.

y Misjudgment may lead to delayed healing as a result of hematoma,swelling, or infection, which may require reopening of wound fordrainage or additional dbridement.

y Wounds not to be closed primarily, includey Severely Crushed andy Highly contaminated


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C ONSIDERATIONS F OR

AMPUTATIONy Only absolute indication for a primary amputation is

Irreversible loss of blood supply to the part

y

Even if amputation is indicated, it is wise to delay it if parts of thefinger may be useful later in a reconstructive procedure.

y A n analysis of the five tissues is helpful in making the decision toamputate. (skin, tendon, nerve, bone, and joint )

If three or more of these five areas require special procedures, such asgrafting of skin, suture of tendon or nerve, bony fixation, or closure of joint, amputation should be strongly considered.

y In children, amputation rarely is indicated unless the part is nonviableand cannot be made viable by microvascular techniques.


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acute hand injuries general principal

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