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Section 2

Surface & pertinent anatomy

Naming the digits

The Birmingham Hand Centre Assessment and Early Management of the Injured Hand University Hospitals Birmingham NHS Foundation Trust

Naming the digits

•Thumb

Naming the digits

•Thumb•Index

Naming the digits

•Thumb•Index•Middle

Naming the digits

•Thumb•Index•Middle•Ring

Naming the digits

•Thumb•Index•Middle•Ring•Small

Skin landmarks

Skin landmarks

•Wrist crease

Skin landmarks

•Wrist crease•Distal palmar crease

Skin landmarks

•Wrist crease•Distal palmar crease•Proximal digital crease

Skin landmarks

•Wrist crease•Distal palmar crease•Proximal digital crease•PIPJ flexor crease

Skin landmarks

•Wrist crease•Distal palmar crease•Proximal digital crease•PIPJ flexor crease•DIPJ flexor crease

Flexor tendon zones

•Zone 1

Flexor tendon zones

•Zone 1•Zone 2

Flexor tendon zones

•Zone 1•Zone 2•Zone 3

Flexor tendon zones

•Zone 1•Zone 2•Zone 3•Zone 4

Flexor tendon zones

•Zone 1•Zone 2•Zone 3•Zone 4•Zone 5

Naming the bones in the hand


Proximal phalanx (P1) of index finger


Middle phalanx (P2) of ring finger


Terminal or distal phalanx (P3) of middle finger


Metacarpal of small finger

Naming the joints

Naming the jointsMetacarpo-phalangeal joint (MCPJ) of index finger

Naming the joints

Naming the jointsProximal interphalangeal joint (PIPJ) of small finger

Naming the joints

Naming the jointsDistal interphalangeal joint (DIPJ) of ring finger

Naming the joints

Naming the jointsMetacarpo-phalangeal joint (MCPJ) of thumb

Naming the joints

Naming the joints

Interphalangeal joint (IPJ) of thumb

Naming the bones in the wrist

Naming the bones in the wrist• Scaphoid

Naming the bones in the wrist• Scaphoid• Lunate

Naming the bones in the wrist• Scaphoid• Lunate• Triquetrum

Naming the bones in the wrist• Scaphoid• Lunate• Triquetrum• Pisiform

Naming the bones in the wrist• Scaphoid• Lunate• Triquetrum• Pisiform• Hamate

Naming the bones in the wrist• Scaphoid• Lunate• Triquetrum• Pisiform• Hamate• Capitate

Naming the bones in the wrist• Scaphoid• Lunate• Triquetrum• Pisiform• Hamate• Capitate• Trapezoid

Naming the bones in the wrist• Scaphoid• Lunate• Triquetrum• Pisiform• Hamate• Capitate• Trapezoid• Trapezium

Surface anatomy of the wrist bones – volar

Surface anatomy of the wrist bones – dorsal

The anatomical snuffbox

Scaphoid tenderness?

Scaphoid tenderness

Flexor retinaculum• Scaphoid tuberosity• Ridge of trapezium• Hook of hamate• Pisiform• “Postage stamp”

The dorsal aspect of the wrist

The extensor compartments of the wrist

• 6 extensor compartments


• 6 extensor compartments•Under extensor

retinaculum


• 6 extensor compartments•Under extensor

retinaculum• Junctura

tendinae


1st APL & EPB2nd ECRL & ECRB3rd EPL4th EDC & EIP5Th EDM6th ECU

The extensor tendons in the digits

The extensor tendons in the digits• Extensor tendon

The extensor tendons in the digits• Extensor tendon• Extensor hood

The extensor tendons in the digits• Extensor tendon• Extensor hood• Sagittal band

The extensor tendons in the digits• Extensor tendon• Extensor hood• Sagittal band• Central slip

The extensor tendons in the digits• Extensor tendon• Extensor hood• Sagittal band• Central slip• Lateral bands

The volar aspect of the wrist

The volar aspect of the hand• FDP

The volar aspect of the hand• FDP• FDS

The volar aspect of the hand• FDP• FDS•Metacarpal head

The volar aspect of the hand• FDP• FDS•Metacarpal head• Flexor

retinaculum

The fibrous flexor sheath• A1 pulley

The fibrous flexor sheath• A1 pulley• A2 pulley

The fibrous flexor sheath• A1 pulley• A2 pulley• A4 pulley

The radial aspect of the wrist

Cutaneous innervation of the wrist & hand

• Superficial radial nerve

•Dorsal branch of ulnar nerve


•Ulnar nerve


•Ulnar nerve•Median nerve


•Ulnar nerve•Median nerve•Motor branch of

median nerve

Cutaneous innervation of the digits

• Trifurcation of the digital nerve

Section 9

What is an emergency referral?

Bleeding• Practically all upper limb bleeding will

stop!

• EXCEPTION: partially injured large artery

• Treat bleeding with elevation and firm dressing

• DO NOT attempt to tie off bleeders in A&E

• RARELY should a tourniquet be used

Amputation•Proximal amputations, speed is of the essence

•Warm ischaemic time <6hours

•This is an emergency

•Quick purposeful action, not cutting corners

ReplantationThe decision of whether to replant lies with the surgeon in conjunction with the patient.

• Urgent transfer, only if the patient is stable• Correct packaging of parts• X-ray limb & amputated part• Cold not frozen• Damp not soggy

De-vascularised parts / doubtful vascularity• Speed important

• Often venously congested

• Align digits correctly

• No tight bandages

• Resting Volar POP for comfort in transit

Compartment syndrome• Interossei

• Flexor compartment forearm

• High index of suspicion

• Examine by stretching muscles of compartment

Hydrofluoric acid burns• Lethal due to precipitation of Ca++

• Calcium gluconate

• pain relieving

• Emergency transfer to regional burns unit

• Accept advice from patient –if they work with the stuff they probably know about it!

High pressure injection injuries• Grease, oil, paint, hydraulic fluid, air• Ischaemia/necrosis

• Mechanical• Toxic effect

• Early transfer

• Early washout

Infections• Calor - warmth

• Rubor - redness

• Tumor - swelling

• Dolor - pain

• Functio laesa

• Pus (or blood) under pressure destroys tissue (necrosis)• Skin, subcutaneous fat, tendon, cartilage….

Infections – flexor sheathKanavel’s signs• Slight flexion• Uniformly swollen• Pain on passive extension• Tenderness along line of sheath

• Management• Elevation• Antibiotics• Surgical washout

Infections – Web-space/Deep Palmar Space• History of FB/ gardening• Fingers separated• Anatomically volar, but most easily seen from

dorsal

• Management• Elevation• Antibiotics• Surgical washout

Infections

Pulp-space (Felon)

Paronychia

• Not usually an emergency• May be able to treat within emergency department

Herpetic Whitlow

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