EN 14 Hand surgery

Fractures of the
Metacarpals, phalanges
Signes
 Swelling
 Deformity
 Pain
 Crepitation
 Loss of function
Diagnosis
 X-Ray
Treatment
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NONOPERATIVE
Plaster fixation
OPERATIVE FIXATION
K-wire+plaster fixation
Screw fixation
Mini plate
Fixateur externe
Indications for Operative Fixation
of Metacarpal and Phalangeal
Fractures
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Irreducible fractures
Malrotation (spiral and short oblique)
Intra-articular fractures
Subcapital fractures (phalangeal)
Open fractures
Segmental bone loss
Polytrauma with hand fractures
Multiple hand or wrist fractures
Fractures with soft tissue injury (vessel, tendon, nerve,
skin)
 Reconstruction ( osteotomy)
Screw fixation
Plate fixation
Metacarpals
Bennett’s Fracture
Rolando
Boxer’s fracture
Position of the hand
 The functional position
of the hand
 Radiocarpal: 30° dorsal
extension
 MP: 60-90° flexion
 PIP and DIP: 10-15°
flexion
 Safe/intrinsic plus
position (PIP,DIP
extended)
. Fractures of the scaphoideum
 Most commonly fractured
carpal bone
 Young population
 Mechanism:
hyperestension of the wrist
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Symptoms:
Swelling , pain in the
Fossa tabatiere
Pain during the wrist
extension
Diagnosis
X-ray
CT
Herbert
classification
Treatment
 Nonoperative(Bennett plaster
10-12 week)
 Operative
Type of Fracture
Treatment
Stable Fractures, Nondisplaced
Tubercle fracture
Short arm cast for 6 to 8 weeks
Distal third fracture/incomplete fracture
Short arm cast for 6 to 8 weeks
1.Long arm thumb spica cast for 6 weeks, short arm cast for 6 weeks or until CT
confirmed healing, especially for
2.Pediatric patients
3.Sedentary or low-demand patients
4.Preference for nonoperative treatment
Waist fracture
1.Percutaneous or open internal fixation, especially for
2.Active, young, manual worker
3.Athlete, high-demand occupation
4.Preference for early range of motion
Proximal pole fracture, nondisplaced
Percutaneous or open internal fixation
Unstable Fractures
1.Displacement >1 mm
2.Lateral intrascaphoid angle >35°
3.Bone loss or comminution
4.Perilunate fracture-dislocation
5.Dorsal intercalated segmental instability alignment
Dorsal percutaneous/open screw fixation
PSA
cause
 Poor blood circulation!
 Missed fracture
 Insufficiently treated fx
Treatement of the PSA
 OPERATIVE
 screw
 Bone graft+screw
 Pedicled bone graft
Perilunate dislocation
 High-energy trauma
 Palmar/dorsal
 Lunate remain in place
Treatment
 Closed Reduction
and Percutaneous
Fixation
 Open Reduction,
Internal Fixation,
and Ligament Repair
Fractura radii in loco typico
The most common fracture
Fractura radii in loco typico
Swelling
pain
deformity
crepitation
loss of function
Fractura radii in loco typico treatment
„No man’s land”
„Some man’s land”
Verdan zones
Diagnostic
• Checking the movement of all joints
• Isolated profundus and superficial
function
Diagnostic
•Primary repair
•Delayed primary repair
•Secondary reconstruction
•Nicoladoni
•Bunnel
•Kirchmayer
•Kleinert
•Kessler
•Zechner
•Tsuge
•Others
Kessler suture
Kleinert technic
Secondary reconstruction
One stage reconstruction
Two stage reconstruction
Tendon transplantation
Indications:
Segmental tendon loss
Delay in primary repair(late referall, missed diagnosis, scar within the
tendon sheat)
Damaged tendon in zone 2
Palmaris longus tendon
Musculus plantaris tendon
Short foot extensors
Indications:
Crushing injuries associated with underlying
fracture or overlying skin damage
Failure of previous operations
Excessive scarring of the tendon bed
Damaged pulley system
Contracted joints
First phase: silicon rod
implantation
Second phase: tendon
transplantation
Extensor tendon
Mallet Finger
Boutonniere deformity
Microsurgery/ replantation
The basis of the microsurgery:
Magnification
Equipments
Atraumatic suture materials
Transportation of the amputated
part!
 wrap the amputated part in gauze/moistened
with lactated Ringer’s or saline solution/
 put the part in a plastic bag or specimen
container and placing the bag or container on
melting ice
 The amputated part should not be placed
directly on ice! Prevent the frostbite!
The first toe replantation:
This was the first successful replantation in
Hungary: 1979
In Boston in 1962, Malt and McKhann successfully replanted
the completely amputated arm of a 12-year-old boy
The first major replantation
29th of April 1982 These was the first
successful limb replantation in
Hungary
The type of amputation:
 Total amputation
Replantation
 Partial amputation
Revascularization
The type of the amputation:
 Major amputation
 Minor amputation
the borderline
The sequence of reconstruction the
anatomical structure at major replantation
 Bone
 Vessel
 Nerves
 Muscles
 Skin
The sequence of the reconstruction
at minor replantation
 Bone
 Flexor tendon
 Artery
 Nerves
 Extensor tendon
 Veins
 Skin
2nd toe transfer:
The result of the transplantation:
Nerve injury
Anatomy of the peripheral
nerve
Epineurium
Perineurium
Endoneurium
Fasciculus
Innervation of the skin
n. radialis (ramus superficialis)
n. ulnaris
Dorsal side
n. medianus
Palmar side
Signes of nerve injury
-loss of sensibility
-weakness or paralysis of muscles
-sudomotor and vasomotor paralysis
-positive Tinel sign
Subjective measurement
Loss of pain
sensation/needle/
Fine tactile/Von Frey/
2 Point Discrimination
/Weber/
Pick up test /Moberg/
Objective
measurements
Ninhydrin test
„Resistance”of the skin
/
Dermotest,Sudotester/
Electrodiagnosis
/EMG, ENG/
Classification of Nerve
Injuries(Seddon)
NEURAPRAXIA (nerve not working, anatomy of the nerve is intact)
AXONOTMESIS (axon cutting, basal lamina of Schwann cell is intact)
NEUROTMESIS (nerve cutting)
Methods of suturing(timing)
Primary suture (within 5 days)
Delayed primary suture (up to 3 weeks)
Secondary suture (3 weeks or longer)
Final result
The repaired nerve should be without tension!
Radial nerve pulsy
 „drop hand”
 Treatment
Nerve Repair and Graft
Tendon Transfers
PT to ECRB
FCR to EDC
PL to EPL
Ulnar nerve pulsy
FCU,FDP(ring,little finger)
Hypothenar muscles, all the
interosseous, lumbricals for the ing and
little finger)
Adductor pollicis, FPB (deep part)
Trauma, cubital-, Guyon tunnel, leprosy
Treatment: Static(e.g.Zancolli)
Dynamic(FDS transfer
into the proximal
phalanx)
 Claw hand
deformity
Medial nerve pulsy
FDS, FDP(index, and middle)
APB, oppenens pollicis,
FPB(superfic. head)
PT, FPL, PQ,
Opponensplasties:
-FDS of the ring
finger(Bunnel),
-EIP,
-Abductor digiti
minimi(Huber),
-palmaris longus(Camitz)
„Hand of
Benediction”
Hand infections
Anamnesis
There is always a trauma, sometimes
a microtrauma only..
First night awake!
Predisposing factors
Malnutrition
Alcoholism
Diabetes mellitus
Immun defficiency
Chronic corticosteroid use
The classic signs of inflammation
DOLOR
TUMOR
RUBOR
CALOR
+
FUNCTIO LAESA
PAIN
SWELLING
ERHYTEMA
TEMPERATURE
+
FUNCTION LOSS
Treatment
•Excision of all necrotic tissue
•Open wound treatment
•Immobilization!, early mobilization
•Iv. antibiotic therapy!
Special anatomical considerations
Palmar surface




Thenar
Midpalmar
Hypothenar
Parona’s
Special anatomical considerations
Dorsal surface
Paronychia
Panaritium paraunguale
Panaritium periunguale
Panaritium subunguale
Surgical treatment
Complications
Cutan abscess
Bulla purulenta cuteaneum
Panaritium cutaneum
Treatment
Felon
Panaritium subcutaneum
Abscessus subcutaneus
Treatment
Complications
Tenosynovitis purulenta
Panaritum tendineum
Pyogenic flexor tenosynovitis
Tenosynovitis purulenta
“horseshoe abscess”
Tenosynovitis purulenta
Treatment
Arthritis purulenta
Panaritium articulare
Septic arthritis
Early recognition and
treatment provides a
good function later.
Late diagnosis and
treatment leads the
destruction of the joint.
Osteomyelitis
Panaritium osseale
Ostitis
Pandactylitis
Affects all tissues!
Dorsal phlegmone
Dorsal Subcutaneous
Dorsal Subaponeurotic Space Abscess
Interdigital Web Space Abscess