common hand injuries common hand infections -...
TRANSCRIPT
Waikato Hospital
Tristram Clinic, 200 Collingwood Street, Hamilton
P 07 838 1035 F 07 838 2032 E [email protected]
Tauranga Hospital
Da Vinci Clinic, 727 Cameron Road, Tauranga
P 07 578 5350 F 07 578 5354 E [email protected]
Overview
• Common Hand Injuries
• Nail and pulp
• Distal phalanx
fractures
• Metacarpal fractures
• Common Hand Infections
• Nail and pulp
• Tendons and deep palm
• Bites
General Principles
General Principles
• Hands are resistant to infection - is the patient immunosuppressed?
• Oedema – HANDS SWELL!!
• Drainage of collections
• Cultures
• Immobilisation in safe position• Elevation• Tetanus• Antibiotics
Acute Paronychia
• Commonest infection in hand
• Infection of nail fold
• Edge of nail fold red and tender
• Staph Aureus commonly
Paronychia Treatment• Non surgical in early stages
• Cover staph aureus eg Flucloxicillin
• Moderate cases
• Ring Block
• Elevate nail fold off the nail plate
• Preserve the nail
• Severe Cases or any case with pus under the nail
• Ring block
• Remove part or all of the nail
• Incision parallel to the epoychium
Chronic Paronychia• Chronic maceration and obstruction
of fold
• Wet work + diabetics
• Scrapings, culture
• Candida albicans
• Topical steroids and anti fungals
• Diligent finger hygiene
• Trial of nail preservation
Chronic Paronychia
• Recurrent or resistant chronic paronychia
• Nail plate removal
• Topical and oral antifungal treatment
• Eponychial marsupialisation (Keyser and Eaton)-epithelialsition
Felon
• Subcutaneous abscess in
distal pulp of finger or
thumb
• Why are felons so painful?
• What are the common
mechanisms?
• What bacteria cause
felon?
Felon Treatment• Surgical drainage
• Ring block
• Incision of lateral aspect of
the pulp
• Parallel to the nail
• Mid axial line
• Never a “fish mouth”
Suppurative flexor tenosynovitis
• Penetrating injury
• Painful
• Red
• Swollen finger
• Pain with passive stretch
• Whole finger redness
Tendon Sheath Infection
Suppurative Tenosynovitis
• Tendon sheath is a closed
compartment
• Relatively immune
protected area
• Untreated infection can
destroy the tendon within
hours
Flexor Sheath
• Mid distal phalanx to
distal palmar crease
• May connect to adjacent
finger’s sheath
• May connect to carpal
tunnel
Kanaval’s Signs of
Tenosynovitis
• Partially flexed finger• Tenderness over flexor tendon sheath
• Differentiates tendon sheath infection vs. septic joint
• Pain with passive extension• 4th ADDED LATER Fuisiform swelling of finger
• Allen B. Kanaval, Prof. Of Surg. NorthWestern Univ. Chicago 1912• Mortality in 1912 from hand infection with ascending lymphangitis
was upto 30%
Tenosynovitis
• Treatment• Surgical drainage – open and irrigate
• Elevation
• Splinting
• I.V. Abs - Flucloxicillin
• Complications
• Necrosis of tendon
• Extension to forearm
• Median nerve compression
• Septic shock
Web space abscess
• Abscesses may form in the
loose tissue of the webspaces
and discharge volarly, dorsally
or both
• A collar button abscess
describes two pockets of pus
connected by a narrow isthmus
Human bite
• Crush
• Abrasion
• Bruising
• Cellulitis
• Punch = “fight bite”
• Unreliable history
• Suspect deep injury
Human bite
• Wide range of bacteria
• Aerobic and anaerobic
• Most common are
• Gram positive cocci
• Eikenella corrodens – Gram -ve
bacillis
• Sensitive to beta lactam antibiotics
• Eg Amoxicillin / Clavulonic acid
• Second line
• Cotrimoxazole + Metronidazole
• Clindamycin
Cat bite
• Sharp
• Puncture wounds
• Most common
• Gram Positive Cocci
• Pasturella maltocida• Gram negative
• Sensitive to Amoxicillin
• Irrigate
• Dress don't suture
Dog bite
• 1 bite per 50 dogs per year in NZ
• Crushing
• Tearing injuries
• Tissue loss
• Fractures
• Gram positive cocci
Animal Bites
• Penetrating innoculum
• Look for teeth on Xrays
• Excise edges of wounds and clean
• Cats – Pasturella Multocida
• Augmentin recommended
Farm yard infections
• Increased anaerobes
• Clostridium perfringens
• Benzyl-Penicillin or
Metronidazole
Magic Words• Collection requiring drainage
• Suspected tenosynovitis
• Diabetic
• Failed trial of oral antibiotics
• Tissue loss
• Heavily contaminated
• Human bite
Nail and pulp injuries
• Subungal haematoma
• Nail bed laceration
• Finger tip amputation or near amputation
Nail bed laceration
• Crush injuries +/- underlying
fractures
• Split periosteum exposes bone
/ fracture
• Suspect growth plate fractures
in children
• Toddlers
• Siblings
• Doors
Nail bed laceration• Lacerations are repaired with dissolving
sutures (vicryl rapid)
• Nail is removed for access to nail bed
• Lacerations across the nail fold are more
complex
• Abrasions heal by secondary intention
• Nail bed scarring may lead to splitting or
separation of the nail
• Early nail separation can be treated with
nail bed grafts from toes
Principles
• Define the defect
• Replace like with like
• Maintain length
• Skeletal stability
• Durable padded cover
• Restore sensation
• Early mobilisation
• Expeditious, simple & reliable
• Cosmesis
• Tailored to the patient
Reconstructions
• Primary closure / terminalisation
• Secondary intention - Dressings
• Grafts
• Local flaps• Homodigital
• Heterodigital
• Distal flaps
What can be dressed?
• 1/3 of the pulp = size of nail
• No exposed bone
• No Fracture
• Dress with semi-permeable
dressings
• eg IV3000
• Change as needed 2-3 days
Distal phalanx fractures
• A fracture is a soft tissue injury associated with
disruption of the bone
Thumb metacarpal
• Intrinsically unstable
• Isolated from other supporting bones
• Fractures of the base (Bennett’s, Rolando’s) involve
the CMC joint and the APL tendon
• Require anatomic reduction and immobilisation
• Frequently require fixation to immobilise
Finger Metacarpals
• Intrinsically stable
• Supported by adjacent bones and intrinsic muscles
• Length and alignment needs to be adequate to allow
a natural cascade of the fingers
• A moderate degree of flexion at the fracture site is
permissible while retaining good hand function
• Rotation is an indication for reduction
Degree of flexion
• Index metacarpal: 5-10 degrees
• Middle metacarpal: 10-20 degrees
• Ring metacarpal: 20-30 degrees
• Little metacarpal: 35-40 degrees
Indications for intervention
• Compound Fractures
• Fractures involving the joint
• Any rotation causing fingers to cross over
• Multiple metacarpal fractures
• Severe flexion
• Moderate flexion where dorsal hand and knuckle are
deformed
Managing a metacarpal
• X-ray to confirm fracture orientation
• Haematoma block 10mL of 1% lignocaine or 0.75% ropivocaine
• Manipulation and “ulnar gutter spint”
• MCPJ flexion
• IPJ extension
• Confirm reduction
• Rpt X-rays in 1 week
Waikato Hospital
Tristram Clinic, 200 Collingwood Street, Hamilton
P 07 838 1035 F 07 838 2032 E [email protected]
Tauranga Hospital
Da Vinci Clinic, 727 Cameron Road, Tauranga
P 07 578 5350 F 07 578 5354 E [email protected]