Hand Trauma Update:
2015
Orthopaedic Update 2015
March 21, 2015
Peter Tang, MD, MPH
Director
Hand, Upper Extremity & Microvascular Surgery Fellowship
Associate Professor
Drexel University College of Medicine
Allegheny General Hospital
Outline
• What is a Hand Surgeon?
• Congenital Hand Consults
• Management of:
• Fractures
• Tendon Injuries
• Nerve Injuries
• Vascular Injuries / Replantation
• Complex Injuries
Hand Surgeon’s Area of Expertise
• Most hand surgeons undergo a hand fellowship which is a
1 year training program after residency (orthopaedics,
plastic surgery or general surgery)
• The AGH Hand Division covers injuries and problems from
the fingertip to shoulder (tumors, carpal tunnel)
• Our expertise is site specific so we take care of adults and
children
• We of all orthopaedics surgeons are most delicate with the
soft tissues because we handle nerve and arterial
injuries and provide coverage for soft tissue defects
• Hand surgery is the most challenging because there is little
tolerance for imperfection in the hand and upper extremity
We are looking for congenital
hand consults!
Apert’s Syndrome
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1 : 200,000
Autosomal Dominant Triad
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•
•
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Syndactyly
Maxillary hypoplasia
I (Spade), II (Spoon/Mitten), III (Hoof,
Rosebud)
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•
•
Craniosynostosis
Inter-digital bony union
Single common nail
May be associated with increased
paternal age
We separated thumb and index, middle and ring fingers bilaterally
1 year later . . .
2 yo with radial club hand with Type IIIB hypoplastic thumb
2 yo with radial club hand with Type IIIB hypoplastic thumb
Pollicization
Adult Complex Injuries
Hand Fractures
Incidence and Location
• 10% of all fractures occur in the
hand
• Distal phalanx – 45-30%
• Middle phalanx – 8%
• Proximal Phalanx – 15-20%
• Metacarpal – 30-35%
Middle and Proximal Phalanx
Fractures - Goals of Treatment
• Restore Articular Congruity
• Restore Length
• For every 1 mm of middle phalanx shortening there is 10 deg of DIP lag
• For every 1 mm of proximal phalanx shortening there is 12 deg PIP lag
• Restore finger alignment and rotation
• Allow early finger motion
Surgical Indications
• Finger malrotation (>50%
overlap of adjacent digit) or
angulation (> 10 deg)
• Loss of length
• Intra-articular with joint
incongruity
Loss of Length
38 yo F s/p MVA
Fractures that May Need ORIF
• Comminuted fractures
• Fractures with rotational
deformity
• Not acute fractures
17 yo male goalie got struck by soccer ball on
index finger
17 yo male goalie got struck by soccer ball on
index finger
Tendon Injuries
• Connects the muscle to bone
• Allow movement of bones
• Has to have excursion to function
3 yo girl who got hand caught in
metal gate of elevator
3 yo girl who got hand caught in
metal gate of elevator
3 yo girl who got hand caught in
metal gate of elevator
Nerve Injuries
• Peripheral nerves allow for sensation and
innervate muscle to allow motion
• Goals of treatment with nerve laceration:
• Tension-free primary repair
• When there is a segmental defect
options are:
- Autograft
- Conduit
- Decellular allograft
Digital Nerve Injury
• 43 yo male with laceration. His laceration was repaired in ER and told he
just had a superficial laceration.
Digital Nerve Injury
45 yo male with deep 15 cm left antecubital laceration from machine at work.
Vascular surgery did brachial artery vein repair the week before. No hand
surgeon is at that hospital.
Proximal
Distal
After nerve debridement 5 cm gap. Median nerve diameter was 8 mm.
We reconstructed with 2, 50 mm long x 4-5 mm wide allografts. We used
a combination of 6.0 and 8.0 nylon
Vascular Injuries & Replants
• Definitions:
• Replantation –
reattachment of a body part
that has been totally
severed from the body.
• Revascularization –
reconstruction of damaged
blood vessels in order to
prevent an ischemic body
part from becoming nonviable or necrotic
Replantation
• At level of hand and fingers
arteries and veins
necessitate 10.0 and 11.0
suture and 20x magnification
with a microscope
• For a finger replant need one
artery and preferably 2 veins
(if bad outflow then may need
leeches)
Replant Storage
1. Immerse amputated part in
LR in a plastic bag. Place
bag on ice.
2. Wrap amputated part in a
cloth or gauze moistened
with LR or saline solution.
Place in plastic bag or
sterile cup. Place bag or
cup on ice.
* No dry ice
Replant Ischemia Time
Digit
• Warm ischemia – 12 hrs
• Cold ischemia – 24 hrs
Proximal to Finger
• Warm ischemia – 6 hrs
• Cold ischemia – 12 hrs
Replant Indications
1. Thumbs
2. Multiple digits
3. Metacarpal amputations
(palm)
4. Almost any body part in a
child
5. Wrist or forearm
6. Elbow or proximal arm (only
sharp or moderately avulsed)
7. Single digit distal to FDS
insertions
Replant Contraindications
1. Severely crushed or mangled parts
2. Amputation or injuries at multiple
levels
3. Patients with other serious injuries
or diseases
4. Arteriosclerotic vessels
5. Mentally unstable patient
6. Single finger in adult, proximal to
FDS insertion
7. Prolonged warm ischemia
33 yo male getting home by
motorcycle when he sees fighting
across the street
• I get the call at 12:30 am
• I’m in the hospital by 1 am and the pt is rolling back
to the OR
• The cut is very sharp like a cleaver
• I start working on the thumb on a back table. I make
longitudinal incision are made on the radial and
ulnar sides and the nerve and arteries are identified
• I place sutures in the flexor and extensor tendons
• Dorsally we identify veins
Replant Order of Repair
• Bone – shorten and fixate
• Repair extensor tendons
• Repair flexor tendons
• Anastomose arteries
• Repair nerves (I do nerves
before arteries)
• Anastomose veins
• Obtain skin coverage
6 hours later . . .
At 3 mos
Complex Injuries
22 yo female high powered rifle
thru arm
22 yo female high powered rifle
thru arm
22 yo female GSW thru arm
22 yo female GSW thru arm
Issues
1. Elbow Motion
2. Nerve Function
22 yo female GSW thru arm
Plan:
1. Elbow Motion
- Elbow contracture either due to inherent joint stiffness or from the skin
graft/triceps scarring
- Our plan was to release the scar and see if the elbow would flex, if not
then perform elbow capsulectomy
- We planned to neurolyse the ulnar nerve to release any external scar to
possibly improve ulnar nerve function in the hand.
- Also, to be able to safely release the posterior humeral scarring we
planned to neurolyse the radial nerve
2. Nerve Function
- She had function of her ulnar FDPs and FCU but had no function of
her ulnar nerve in her hand, so her ulnar nerve had regenerated to the
forearm but it would take 17 mos to reach the hand targets
- To improve her intrinsic hand function we offered her an AIN nerve
end-to-end transfer to her deep motor branch
22 yo female GSW thru arm
22 yo female GSW thru arm
22 yo female GSW thru arm
22 yo female GSW thru arm
22 yo female GSW thru arm
22 yo female GSW thru arm
22 yo female GSW thru arm
22 yo female GSW thru arm
PE:
Elbow motion: - 20/120
0/5 elbow extension
64 yo male shotgun through wrist
11/14/2014
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OR for repeat I&D
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•
ORIF Distal Radius
Spanning Ex-fix
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Median n. repair w/ 6 cm allograft w/ wraps at each repair site
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MF FDP transfer to FPL
MF FDP side-to-side RF FDP
MF FDS side-to-side RF FDS
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VAC assisted closure
Further OR Visits…
•
11/17: Repeat I&D, VAC Change,
•
11/21:
• Repeat I&D
• Open Pinning IF Metacarpal Fx
• Removal distal radius plate and K-wires
• EPL Reconstruction w/ ECRB
• Antibiotic Spacer
• VAC change
•
11/24: OR w/ Dr. White (Plastics)
• Anterolateral thigh fasciocutaneous free flap reconstruction
of Right dorsal wrist and forearm
• Thigh anterolateral flap
12/23/2014
OR 1/19/2015
Thank you !
Contact:
Peter Tang
Cell: 646-251-4958
Email: [email protected]
Radial Club Hand
45 yo male cleaning his .45 . . .
45 yo male cleaning his .45 . . .
45 yo male cleaning his .45 . . .
Injuries include:
• 5th metacarpal bone loss
and base of 4th MC
fracture, hamate fx
• Complete flexor tendon
laceration
• Partial extensor tendon
laceration
• Common digital nerve
injury to RF and SF
with a large gap
• Injury of the motor
branch of the ulnar
nerve with a gap
45 yo male cleaning his .45 . . .
45 yo male cleaning his .45 . . .
45 yo male cleaning his .45 . . .
45 yo male cleaning his .45 . . .
32 yo male with tablesaw injury
Injuries:
- 3rd and 4th common digital arteries
- 3rd and 4th common digital nerves
- RF and SF FDP and FDS
Surgery:
- 4th common digital artery repair
- 3rd and 4th common digital nerve
reconstruction with decellular
allograft
- RF and SF FDP and FDS repair
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-
First post-operative visit he had
necrotic tissue which we believed
was superficial
3 weeks post-operative his hand
started to smell like necrotic tissue
32 yo male with tablesaw injury
Revision Surgery:
-
We debrided the necrotic tissue
leaving a 8 x 6 cm defect
3 of the 4 flexor tendons had pulled
apart
The vascular repair was not flowing
but the fingers were perfused
32 yo male with tablesaw injury
We offered him a revision surgery to rerepair everything and perform a radial
forearm flap vs amputations. We explained
that his function would not necessarily be
good even if he kept the fingers.
32 yo male with tablesaw injury
Revision Surgery:
- We resected the phalanges of the RF and SF and
kept the soft tissue.
- We were not sure which soft tissue to use to cover
the wound. Both flaps were dusky.
- We rotated the hypothenar tissue to help cover the
defect.
- The plan was partial resection of the 5 th metacarpal
but we ended up resected the whole metacarpal to
decrease the size of the defect.
32 yo male with tablesaw injury
72 yo male who cut his thumb with a
tablesaw (guard was up). Transfer
from Allegheny-Valley Hospital
• We find vessels proximally
but could not find any
vessels distally to work
with despite using the
microscope
• We did a revision
amputation and z-plasty to
deepen his first webspace