Dr. Daniel P. Mass details the types of hand injuries that can be treated in the emergency room, and what needs to be escalated to the operating room. Dr. Mass also provides tips on conducting the initial exam, wound care, splinting and tendon injuries.
[MUSIC PLAYING] This talk is for evaluation and initial treatment of acute hand injuries. So for those of you who work in an emergency room, work in an outpatient setting where patient with acute injuries come in, this is to guide you in what you can do, how to evaluate it, what you can do in treatment, and when you need to refer the patients on. So I do not have any financial relationships of disclosures. And I won't discuss any off-label use. So in most emergency rooms, one third of all patients who visit the emergency room are orthopedic injuries. And one third of those are hand and upper extremity entries. So this is really, it's 18% of all patients that walk into emergency rooms. So we're talking about potentially a lot of patients. And as the population grows older we're going to see more and more orthopedic problems throughout the body, back, hips, knees, and the shoulder and arms. So it's a good knowledge of functional anatomy that helps perform a pain-free evaluation of the patient. And that's a real key. For me when I was in medical school, the very first week of medical school was upper extremity anatomy. And we went through, we stripped the skin off, we went through it and then we had a non-counting examination. So it showed you how much they thought it was worth learning. But it really is very important. Anatomy is still the basis for evaluating most patients for their diseases. That's one, and the other is listening to the patient because they'll often tell you what's wrong if we listen up properly. Now what can be treated in the emergency room or in your office? You can treat superficial lacerations. You can treat nail bed injuries. You can treat small, less than a centimeter or dime-sized finger tip avulsion injuries. You can treat some extensor tendon injuries distal to the middle of the hand. Because the tendons don't retract. You can treat superficial infections and minor burns. What needs to go to the operating room? These are the ones that you need to get consults on-- deep contaminated wounds, major amputations, finger tip avulsions of greater than a dime, all flexor tendon injuries, all nerve injuries, any deep infection and any major trauma. You have to remember that the first physician who treats a patient influences the outcome. So here's a finger. The finger tip is down here, the wrist here, and there was a laceration, not very big, right at the web space on the radial side of this long finger. And it lacerated and was bleeding a lot, and they reached in in the emergency room. And there's a suture. And there's a suture. And they tied off the vessel. Now the problem is that the nerve runs with the vessel, right on top of the vessel. So if it's bleeding, the nerves' been cut. So here you can see the natural elasticity of the vessel and the nerve in the hand. This is what allows us to straighten our fingers and make a full fist. There's natural elasticity so you don't injure by moving your fingers. So we cut the nerve and the vessel and they retract. And we've got about a centimeter and a half to two centimeter retraction. Now during the first 10 days you can overcome that natural elasticity, pull the nerve together, repair it without any tension, and the patient can move the finger while the nerve is healing. But now I've got to resect several millimeters on both sides. And now the nerve is under tension to do a primary repair. Or I can repair it with the finger bent for three weeks and then slowly stretch it out for six weeks, which means basically the patient can't use their hand for six weeks. Now that influences how the patients function. Now there is something else I can do. I can put a nerve graft in there. But that means I have to borrow a nerve from another part of the body. So another place is numb. There's another scar on the arm. So think about what you're doing. If the patient's bleeding, and you can't stop the bleeding it's time to put a pressure dressing on and get a consultation. In the operating room, we use a tourniquet for most of our elective upper extremity surgery. So there's no reason why you can't use a tourniquet in your office, in the emergency room. You just take a blood pressure cuff, you raise the arm. You get some basic drainage. You put the blood pressure cuff on, pump it up to 250 millimeters of mercury. It works better on the forearm, because patients can tolerate it for about 20 minutes. And then clamp it off. And then you can actually do some minor surgery or some wash out. Look in the wound and determine what needs to be done. And then you can close the wound and send it on if need be. So if it's bleeding put a pressure dressing on, elevate it, and put that tourniquet on. Never clamp a bleeder in the office. We still need to know what happened, how it happened, and what's in the environment. If I reach into a sink and cut my hand on a knife, a sharp knife, or a piece of glass in the sink, it's a lot different than if I trip fall and cut my hand in a barn. So we need to know those things because one is a clean environment and one is a contaminated environment. So you have to treat these very different. So what I want all of you to do now is take your arms, rest your arms straight up and down, wrist straight, finger straight and just feel your muscles. You've got tension on both the flexor and extensor muscles. Now just drop your wrist into extension, and you feel that the muscles change tone. And what happens? The fingers automatically flex. So this is a tenodesis effect. And the little fingers' tighter, more bent than the ring finger, than the long finger, than the index finger, and even the thumb is flexed. It's like holding an egg in your hand. So if you have a break in that tenodesis effect, you have a tendon that's not working. Drop the wrist into flexion and again, the natural tension in the body allows the fingers to extend. A break in that and you have an injury to a tendon. So here we now examine for the blood supply. We've all learned about an Allen's test. Classic Allen's test-- pinch off the radial and ulnar artery, have them make a fist several times, blanch the hand, and then lift one or the other to test for vascular supply. Now how often do we do it? Well actually, I did it yesterday in the office. And there was a young lady who had a slow filling ulnar artery and she was complaining of coldness in the ring and little finger. So now we're going to get a formal vascular exam on her. But you can do a digital Allen test just by pushing on the two digital vessels. Very nice trick to make sure that you have adequate blood supply to a finger. So when I was in neurology many years ago and on the neurology service, they came out, they all had pins snapped to their coats and had Q-tips and they tested sensation. Sharp versus can you feel a Q-tip on your finger. But that's actually fairly rudimentary sensation. And you stick somebody and they're going to feel it even if it's feeling the pressure of moving their finger through it. So there are ways of doing this that don't hurt. And so what we do is if you injure a nerve, after half an hour you lose pseudo-motor reflex, which is the ability to sweat and the ability to wrinkle. So how do we test for sweat? If you take plastic pen or wooden pencil and slide it on the half side of the finger versus another finger or the other side of the finger, so it if you have sweat it should stick a little bit. And if you've got no sweat because the nerve injured it should glide like it was on silk or satin. Then you can also test two-point discrimination. Take a paper clip, bend it, hold it at four to five millimeters apart, that's normal two-point discrimination. Anything over 1.5 centimeters or 15 millimeters separation there is just protective sensation. Obviously if you have a nerve injury it should be zero sensation. They shouldn't be able to tell even if you just touch it. But this is a good test to see how bad the nerve injury is in carpal tunnel syndrome. Fractures we always need x-rays in at least two planes. So here's an AP, there you can easily see that fracture. But it doesn't look bad it looks like you just need to maybe tape it to this finger and it'll be OK. But on the lateral, here's the proximal part, here's the distal part, there's about a 45 degree angulation there. So it is more complicated. And it's very important to get your x-rays in two separate planes. Special diagnostic tests include special x-rays. With a laceration, culturing the wounds before you give antibiotics. And then under tourniquet control, exploring the wounds. So how do we block a finger in order to explore the finger or treat the finger if you've got a fracture, nail bed injury? You want to numb the patient up. So here's a picture, here's the finger, the long finger. This is where the digital nerve, at the distal palmar crease, separates into each-- the common digital nerve separates into each separate digital nerve on each side of the web space. So if you go in the middle with a 25 or 27, I prefer 27 gauge needle, and take some Xylocaine or Xylocaine with Epinephrine is the latest thing that we've been doing. Or a combination of Xylocaine and Marcaine and inject it into the flexor tendon sheath. And then angle it slightly to each side. You numb up that finger. And that's an excellent way-- and they'll be numb for six to eight hours, which is really good for draining infections, nail bed injuries, because they'll really appreciate that long term anesthetic. And then if it's a proximal phalanx, you turn the hand over and give a little injection over the dorsum of the metacarpal head. Wrist blocks-- so it's now maybe an injury a little bit more proximal, so your flexor carpi radialis is right here. So if you all bend your fingers 80% of you are going to have a palmaris longus that sticks out. And if you bend your wrist a little bit, just radial to it is your flexor carpi radialis. Between those two and just deep to the fascia is your median nerve. So if you stay right on the ulnar border of your flexor carpi radialis and pop through that fascia, you're just on the radial side of the median nerve. And you deposit three or four cc of Xylocaine with and you'll numb up the median nerve. Over here you can feel your flexor carpi radialis. Put the wrist in slight extension and come under the flexor carpi radialis because your radial ulnar artery is above your ulnar nerve. Go in about half a centimeter with your needle and again you can inject about three or four cc and that will numb up your ulnar nerve. But don't forget that we have nerves on the top of the hand. So over the radial styloid is your dorsal sensory branch of your radial nerve. So give a wheel right there and then a wheel just distal to your ulnar styloid where you get the dorsal sensory branch of your ulnar nerve. So those three, four injections will come should completely numb up your hand. So now someone comes in your office they've had a crush injury or they've had a laceration there, we want to irrigate the wounds. We don't want to soak it because when we soak a wound in a bucket, the hand is dependent it's going to get more swollen. I don't use Betadine. Betadine tends to be tissue toxic. You can use Betadine on the edges and the rest of the skin but not in the wound itself. Just irrigate. Dilution is the solution to pollution. So if you have a clean wound, it's less than eight hours old, and it's a sharp laceration, you can put a few loose skin sutures in to close it. Do not put any deep stitches in not in an emergency room or in your office. If it's a contaminated wound, which means it's crushed, it's dirty, and even if you wash it out-- or it's greater than eight hours old, because now bacteria's had time to grow, it's a human or animal bite, don't close the wounds. Wash it out. Put a wet dressing on. And get the patient to the operating room. All dressings, wound dressings, should be covered with non-adherent gauze. I like to wet the gauze because as it dries it acts like a wick to draw out any edema fluid. Because what is edema fluid but culture media. And what temperature is the hand? 35 degrees, it's exactly the perfect temperature for growing bacteria. I use a bulky dressing. And I'll split the hand and the wrist and the fingers. The wrist in slight extension. The metacarpal phalangeal joints down like this, looks like 90 degrees but if you got an x-ray it would be about 70 degrees. So you want to go for what looks like 90 degrees. You put your interphalangeal joints in a neutral position. You don't push them straight. You just let them be as straight as they're comfortable. And then you put your thumb in palmar abduction. No one's going to be hurt resting their hand like this for a couple of days until you can reevaluate the wound. So here's a bad splint. What's wrong with this split? This is a colleague of mine a medicine physician who tripped and fell. His finger got caught in a hole. And had a comminuted intra-articular proximal phalanx fracture into the joint. So what's wrong with this? Well is it holding the metacarpal phalangeal joints in flexion? It did originally. But as the hand swelled up, it pulled away from the splint. It's only covering one finger. So there's no side-to-side or rotational stability. So you have to include two fingers in any splint particularly for fractures. And finally you're taping the splint on around the hand and what does that do? It causes venous constriction and lymphatic constriction so you get more swelling. Not a good way of treating your colleague or any other patient. Here's another patient. Same type of fracture volar wrist splint, volar splint. Now this completely blocks the function of the hand. It's not holding the MP joint in flexion. Tape around it will cause swelling and where does it end, Right at the carpal tunnel. Fortunately I'd already released this patient's carpal tunnel, so she didn't develop carpal tunnel syndrome. So before patients leave the emergency room they should get tetanus prophylaxis, unless they've had it in the last 10 years. If they have an open wound, I give them antibiotics. I believe in inexpensive antibiotics. I would use Tetracycline or something like that, just to cover. But we're not used to that anymore, so I try to stick with Keflex because most patients can't cover the cost of the latest third generation antibiotics unless someone else is paying for it. And then give them pain medications. And I don't see anything wrong with Tylenol with codeine for pain, or even Motrin. Because those are things that we can afford. They need to be instructed to elevate to prevent edema, whether it's closed or open. And they need to know that they have a return appointment in a timely manner. So if it's an open injury, three to five days. And if it's a closed fracture, we need to seem within a week. To make sure that the fracture remains aligned. So now we're going to go through different types of injuries. So we have nail bed injuries. Now obviously they're not all this significant. But, sorry, most nail bed entries include a fracture of the distal phalanx. We get subungual hematomas. If you see less than 30 percent subungual hematoma, remember there's nail under the onychonychial fold. Then you don't have to take the nail off. You can remove-- you can just lance the nail with a hot paper clip or if you've got one of those little cautery machines that heat up. You can take an 18 gauge needle on a syringe and use it like a little hand drill. You need to put two to three holes in the nail to keep the drainage. One hole will clot off, so you need to keep it training. And then I put zinc oxide ointment, which nobody has around anymore, so some Silvadene that does the same thing. It's greasy, gooey. But it keeps things draining to take the pressure off. All right and then so that if particularly patients get worried when you come at them with a hot paper clip, it actually doesn't hurt to put a hole in your nail that's pulled away from the nail bed. And the liquid that comes out cools the paper clip down. But patients are worried so it's worth doing a digital block to do this. So here a 100% subungual hematoma. Here you have to take the nail off because, more than likely, the nail bed has a significant laceration in it. And the nail bed itself has to be repaired so that you'll have a nice nail in the future. So what do we do? We can repair the nail with 7-0 chromic, that's a tiny needle, pretty small. It's difficult to do on your own. But it can be done in the emergency room. But nowadays what we're doing is we're just sort of putting the edges together and taking skin glue-- Dermabond is a brand name. But each of the companies now have their own skin glue. And you just put a drop on. And it seals it, let it dry, and then put a nail or nail substitute on. I used to put sutures in until I realized if I take thin steri-strips and put it 80% around the finger, leave room because the voler's tough, is going to swell from the fracture. And you want to leave room for it to swell. Otherwise you're going to have a patient that's going to complain-- it's like a felon. So here's a small laceration or nail tip injury. And we've just let it granulate in. It's come from here to here. And it takes about six weeks but it will completely heal in with normal skin, normal sensation, not quite normal fat pad. And that's all you need to do. You just need to talk the people through that. Now, if you have a more major amputation like these. Then you have to do something more dramatic and that needs to be done in the operating room. And here we trimmed back the index finger and closed it primarily. And we, because there was enough skin loss, we did a cross finger flap. And that's day one. This is as we're going to separate the two. So here we've got the tenodesis effect. This is a child. You're not going to get a child to move their fingers for you through a laceration. You may not get an adult to do it. But this is a three or four year old. They're not going to be that cooperative. They're in a lot of pain. They're scared. They're mother and/or fathers' in the room. You don't want to go in and stick them with a needle because the parents are not going to be very happy with your as their child increases the tone and level of their screaming, neither will your eardrums. So here we've got the wrist in extension, very much extension. And what do you see? You see that the fingers are slightly bent here. But not as tight as you'd expect for that much extension. So all the superficialis tendons are cut but the profundi are not. Except for the index finger, you see it's sticking out straight. So you have to suspect the profundus to the index finger is cut. You don't have to do anything else to know what's wrong with this patient. This is a pain-free examination of the patient. And then you see something sticking out here. What's the most superficial structure that could be sticking out at the wrist here? And that's the median nerve. So you want it tucked gently. Get the patients sedated. Tuck that in, put a couple of loose stitches in, splint the wrist, and call a surgeon because they need to fix this. Does it need to be done that night if the hand is vascularized? It doesn't need to be done that night, it can be done the next day. So here's a flexor tendon. A primary repair is in the first three days. A delayed primary repair is up to three weeks. And we need to fix them, if they're nerve injuries, within 10 days to do primary repairs of the nerve, and allow the nerve to be repaired without tension to start early motion. All flexor tendon repairs must be done in the operating room. So here's an extensor tendon injury. Right there, there was the laceration, right over the knuckle. In the emergency room, under a little local, under a forearm tourniquet, I made a little cut back. The two edges of the tendon-- one was here, one was here. Able to grab it, put a suture in it, close the skin incision-- that can be done in the emergency room with some nylon. We then put him in a splint. So normally we want to split the MPs in full flexion. This is one time you don't because then the tendons' under tension. So what you do is you bring the wrist into more extension, splint the MPs in about 20 to 30 degrees of flexion, leave the IPs free so that they can get a little wiggle of that extensor tendon without tension. And we do that for four weeks. Unfortunately you can't really see the laceration here but the laceration is here, over the metacarpal, on the extensor pollicis longus. Now the proximal aspect can pull back and actually pull back into the forearm. You don't want to be caught chasing that tendon in the emergency room or in your office. So those need to go to the operating room. Amputations-- this is a thumb that got cut off by a saw, all right. So single digits, in adults, are not put back on except for thumbs. Almost any amputation, except for tip amputations, we try to fix in kids. So if you happen to be there when an amputation comes in, don't put the amputated part on ice. Put the amputated part in wet saline, or Ringer's, in a gauze, in a plastic bag, and float the plastic bag on ice water. You want it like a refrigerator, 35 to 40 degrees. If it's below 32 degrees, you'll actually freeze the microvascular circulation. It's frostbite because there's no circulation to protect it. And then we can't put the finger back on. And now we want to transport quickly. And please don't promise that we are going to be able to fix everything. Because many of these are non-repairable, particularly avulsions, crush injuries. We've learned what we can and can't do. And if there's muscle involved. We have a six hour limitation of warm exposure. So finally we're going to talk about infections. There's six different types of infections, particularly in the hand. Many of them apply to anywhere in the body. They're cellulitis, abscess, infections from bites, paronychia, felons, and supperative flexor tenosynovitis. So cellulitis s is usually a streptococcus infection. It spreads rapidly within 24 hours. And the diagnostic sign is ascending lymphangitis. The treatment is not surgical. The treatment is immobilization. And if you have ascending lymphangitis, IV Nafcillin, and then once the lymphangitis goes down, they can go home and dicloxacillin orally. An abscess-- so here, there was a little stab right here. And they developed this abscess. The finger has a little flexion. It hurts to fully extend. But it doesn't hurt to just minimally extend the finger. This is like an appendicitis. It needs to be drained. All right we have localizing signs. We have redness, we have localized swelling. But they're almost always staph, and it takes 72 hours to develop. Treatment-- surgical drainage, you can do this in the office. Stay away from the digital nerves. As you see the digital nerves run here and here. So I didn't cross a crease. I just went straight down the center of the finger there. And then they need a second generation cephalosporin or clindamycin, if they have a penicillin allergy. Bites-- human bites, including clenched fists, have mixed floras, including anaerobes and in particular Eikenella corrodens. These infections can develop rapidly. I've taken the patient to an operating room and been there within five to six hours and had grossly cloudy synovial fluid. Diagnostic signs are local pain, redness, swelling, and if you palpate the bottom of the joint away from where they were injured, they'll be tender and painful. That tells you it's in the joint not just above the joint on the dorsum. These need, sorry, these need to be drained, immobilized, and treated it with augmentin or cephalotoxin. Animal bites-- particularly cat and dog bites, include the anaerobic pasteurella multocida. Same diagnostic signs, treatment-- don't close the wounds. Wash it out you can do it in the emergency room. Immobilization of the hand and antibiotics including IV Unasyn and then augmentin. A felon- how did it get this name? It's an infection of the pulp space. And if it's ignored, besides being extremely painful, can either cause osteomyelitis of the distal phalanx or breakthrough the end of the flexor tendon sheath causing a supperative flexor tenosynovitis. It's almost always staphylococcus. And it's amazing how infrequent this occurs considering we all are putting little holes in the tip of our finger. All right, and as you can see here, it's not swollen here. That's where the flexor tendons sheath ends. But it's very swollen, tight, very painful, distal to that aspect. In the emergency room under a digital block or a wrist block, you can drain it. Now if it already has dead skin, drain it through the dead skin. Otherwise I drain it centrally to stay away from the digital nerves. I spread a little bit. I don't push on it. I just let it auto-drain. Soak it a little bit. Then I put a Silvadene dressing on it. And then I have the patient, starting the next today, change the dressing with Silvadene because that keeps it draining and soaking it three times a day. And they go on to a second generation cephalosporin or clindamycin. Paronychia-- probably the most common infection in the hand and these are nail fold infections. Right here it's all swollen, it's white, the skin is dead. Don't make an incision two millimeters away from the nail. Lay the knife right on the nail and pop through just like we see right here. You can see the pus coming out. You don't need to push on it or do anything else. You soak it and you again start-- and you do this under a digital block. Then you start Silvadene and soaks and cephalosporin. The interesting thing is sometimes you get a little redness, you get a little swelling, you get a little pain. You may have had it yourself or someone in your family and it hasn't become pussy. So there's nothing to drain. You're catching it early. You could put them on an antibiotic. And that might help. And the Silvadene-- companies, made by several different companies, aren't absorbed through the skin supposedly. But I can tell you I've treated myself. I've treated my wife. Just put it on, start warm soaks, put it on, and put a Band-Aid on. And I've treated them caught it before they need to be drained. I've never used antibiotics and I've cured most people that way. So finally supprative flexor tenosynovitis is an infection in the flexor tendon sheath. Tiny little stab incision right here in this child, but it was deep. Sometimes you can get it from a bite, particularly a cat bite, which is really sharp, punctures. And it gets into the tendon sheath. It's a synovial, like a joint it-- great culture media, it grows very rapidly. And they can lead to tendon necrosis because the nutrition for the tendon is not through the blood supply, it's through the synovial fluid. As we move our fingers, we pump the nutrition in and out. This is a surgical emergency unless caught really, really early to start antibiotics. So I usually take them to the operating room because I sleep better that way. And they have Kanavel signs. Kanavel was a general surgeon who worked here in Chicago in Cook County Hospital. He described these signs in probably the first book on infection of the hands. From the, I think, 1920s. You get exquisite tenderness over the flexor sheath. Which will run from just distal to the DIP joint to the distal palmar crease, except in the little finger and the thumb where 40 percent will go up to the wrist. You'll have slight flexion at the PIP joint. You'll have exquisite tenderness in passive extension. And that means, just put your nail under their nail and flick it. That a little bit of extension, they will jump. And you'll get this fusiform swelling from just proximal to the nail bed to the metacarpal phalangeal joints. And that's how you diagnose supprative flexor tenosynovitis and you call for assistance at that point.
