Hand trauma

For infections - see separate section under 'skin'

Examination

RUN (emergency - OT same day)
- High-pressure injections
- Compartment syndrome
- Amputations
- Deep space infections (flexor tenosynovitis, septic arthritis)
WALK (less urgent - may require care on same day, but not necessarily OT)
- Open fractures
- Joint and carpal bone dislocations
- Open wounds
- Lacerations
- Nail bed injuries
- Lesser infections
  - Paronychia
  - Felon
  - Dorsal subcutaneous abscess
Roll-over (elective)
- Closed fractures
- Tendons, muscle, nerve injuries

Wrap digit in sterile saline-soaked gauze and then inside a sealed plastic bag and put it on ice or in the fridge
12-24 hours to replant is reasonable

Deep space infections

Generally a minor trauma followed by worsening pain
Flexor tenosynovitis
- Purulent infections with a tendon sheath destroy and scar the synovial lining, preventing gliding
- Can propagate infection towards wrist
- Generally gram positive bacteria
- Classically, the four Kanavel signs: fusiform swelling, redness along the finer, tenderness with palpation over flexor tendons, and pain with passive extension of the finger
- Management is surgical, ranging from closed catheter irrigation to open drainage
Bacterial infections within a joint will destroy the articular surfaces
- Staph and strep most common
- Probably treat for MRSA
- Surgically irrigate and drain
Thenar space
- Midpalmar septum, adductor pollicis fascia, adductis insertion
- Incise web space over area of greatest fluctuance
Midpalmar space
- Deep to flexor tendons, between thenar and hypothenar spaces
- Characterised by loss of volar convavity in midpalm
- Careful to avoid injury to local vessels including superficial arch
Hypothenar space
- Uncommon
- Between hypothenar septum and hypothenar muscles
Parona's space
- Distal forearm between pronator quadratus and FDP tendon sheaths
Collar button abscess

Bites injuries including fight-bite

Septic wrist arthritis

Needs aspiration - WCC > 50,000 per mm(3)
- Also analyse for gram stain, aerobic, anaerobic, afb, fungal cultures, cell count, crystals
In children, suspect haematogenous spread - from infectious source somewhere else in body
Suspect gonococcus in adults - ceftriaxone cover

High-pressure injections

ACS

Deep compartment muscles first (FDP and FPL)
- Flex thumb at IPJ or other digits at DIP joints
6 P's
- Sensory nerves are effected first - paraesthesia comes before paralysis
Decompression if pressure is greater than 30mm Hg
- Should be obtained within 5cm of the fracture site
Fasciotomy of all compartments
- Arm - incision directly over biceps
- Forearm - volar curvilinear incision from biceps to carpal tunnel, carried down to relieve pressure on deep muscles. Dorsally, a straight incision made over mobile wad and extensor muscles
- Hand - interossei muscles are relieved from a dorsal incision, hypothenar muscles relieved volarly

Radial - extensor
- Gives off posterior interosseous branch
- Important for fine pincer movements, key pinch
Median
- wrist and finger flexion, intrinsic muscles
- Anterior interosseous branch
Ulnar
- wrist and finger flexion, intrinsic muscles
- Important for heavy lifting, carrying

Ulna
- Anchored to humerus
- 'Flagpole' to the radius, carpus and hand
- Pronation at PRUJ
- Supination at DRUJ
Carpals
- Proximal row - scaphoid, lunate, triquetrum, pisiform - has no tendinous or muscle insertions
- 70% of fractures to carpals are in the scaphoid
Proximal phalanx
- Under control of intrinsics
- Can flex and extend even if PIP is amputated
Middle phalanx
- Insertions from FDS and central slip of extensor
Distal phalanx
- FDP