CAEP 2011 Nip Tuck or Hack and Slash Plastics on the Front Lines

CAEP 2011
Nip Tuck or Hack and Slash
Plastics on the Front Lines
Kirk Magee MD, MSc, FRCPC
Associate Professor
Dalhousie Department of Emergency
M di i
Medicine
Conflict of Interest
Overview
•
•
•
•
•
•
Anatomy
Assessment
Infections
Finger tips
Tendon Injuries
Fractures and Dislocations
Hand Orientation
Volar
Ulnar
Dorsal
Radial
Ulnar
Anatomy
y
Extensor Tendons
Flexor Tendons and Pulleys
y
Tendon Sheaths
Neurovascular Supply
pp y
Skin and Surface Anatomy
y
Initial Assessment
• ABC’s
• Hemorrhage Control
History
y
• Mechanism of Injury
• Associated Medical Factors
– Handedness
– Livelihood/recreation
Li lih d/
ti
• Infection Risk Risk
– Environment
– Bites
– Tetanus, HIV, HIB
PHYSICAL EXAM
Observation
Sensation
Motor Exam
Ulnar Nerve
Froment’s Sign
Motor Exam
Radial Nerve
Median Nerve
“RUM” Thumb
Radial Nerve
Ulnar Nerve
Median Nerve
Tendon Exam
FD Profundus
FD Superficialis
Remove Rings!
g
INFECTIONS
Paronychia
y
Felon
Ring
g Block
Acute Flexor Tenosynovitis
y
Kanavel’s Signs
1.
1
2.
3.
4.
Uniform
U
if
swelling
lli off th
the di
digit
it
Semiflexed resting position
Tenderness along the tendon
sheath
Marked pain with passive
extension
t
i
Bites
• Copious irrigation
• Prophylactic antibiotics after hand bites
– Amoxicillin/Clavulinic acid
• Doxycycline, ciprofloxacin, sulfamethoxazole
• Avoid primary closure
• Splint
Medeiros IM, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database
of Systematic Reviews 2001, Issue 2. Art. No.: CD001738. DOI:
10.1002/14651858.CD001738
Pitfalls
•
•
•
•
Clenched fist injury
Retained tooth fragments
2 fractures and joint involvement
Rabbies HIV,
Rabbies,
HIV Hepatitis
FINGER TIPS
Subungal
g Hematoma
Remove the nail?
Nail Bed Lacerations
Fingertip
g
p Amputations
p
Indications for Replantation
p
1.
2.
3
3.
4.
Multiple digits
Thumb
Single digits between PIP and DIP
Children
Care of Amputated
p
Part
TENDON INJURIES
Mallet Finger
g
• Ball
Ball-handling
handling
athletes
• Forced
F
d flflexion
i off
the extended distal
phalanx
Mallet Finger
g Management
g
• Splint in slight
hyperextension
yp
for
6-8 weeks
• > 25% of dorsal
articular surface
may require
internal fixation
Flexor Tendon Avulsion
• Rugby-Finger
• Forced
hyperextension of
the fingertip while
FDP in full
contraction
Flexor Tendon Avulsion
• Often presents late
• Inability to flex DIP
• Associated
avulsion
l i ffracture
t
• Su
Surgical
g ca repair
epa
Open
p Tendon Lacerations
• Partial laceration can be masked by
normal tendon exam
• Direct visualization in position of injury
• Tendon
T d retraction
t ti
• Flexor
e o te
tendon
do laceration
ace at o – refer
e e to plastics
p ast cs
• Extensor tendon laceration
– +// repair
i iin ED
– Splint for 6 weeks
FRACTURES
and DISLOCATIONS
DIP and PIP Dislocation
• Usuallyy dorsal
• Closed reduction
• Longitudinal traction and
hyperextension
PIP Dislocation
Volar DIP Dislocation
• Relativelyy uncommon
• Has been described as
irreducible
“irreducible”
• Management controversial
– Closed vs
vs. Open technique
MCP Dislocation
• Rare and usually dorsal
• Index and little finger
most common
• Volar plate entrapment
• Splint and referral for
follow-up
Thumb MCP Dislocation
• Usually dorsal
• Thumb spica for 4
weeks
• Referral to hand
surgeon
Distal Phalanx Fracture
Phalangeal
g
Fractures
• Proximal phalanx has no tendinous
attachments
• Middle phalanx – FDS and extensor
tendon insertion
• Difficult to assess rotational alignment
radiographically
• Anatomic alignment important
Proximal and Middle
Phalangeal Fractures
• 75% are stable and nondisplaced
• Unstable fractures:
– Midshaft transverse
– Spiral
S i l oblique
bli
– Intra-articular
– Extreme comminution
Proximal and Middle
Phalangeal Fractures
Metacarpal
p Fractures
• Head
• Neck
• Shaft
Indications for Surgical
g
Tx
Metacarpal
Head Fracture
Neck Fracture
Shaft Fracture
Index and Middle
10-15°
15°
anatomic
Ring
40-50°
35°
10°
Little
50-70°
45°
20°
• greater than 5°
5 of rotation
• 2-3 mm of shortening
• 1 mm of articular surface step-off
step off
• > 25% articular involvement
“Safe” or Functional Position
Boxer’s Fracture
Gamekeeper’s
p
Thumb
• Skier’s thumb
• Injury
j y to the ulnar
collateral ligament
• Important for pinch
strength
• hyperextension and a
radially directed force
at the thumb MP joint
Gamekeeper’s
p
Thumb
Bennet’s Fracture
• Intra-articular base
fracture
• Dislocation or
subluxation at the
carpometacarpal
joint
Rolando Fracture
• T or Y shaped
fracture of the 1st
metacarpal
• Involves the joint
surface
Bennett’s and Rolando
Management