1. HAND INJURIES

2. GENERAL PRINCIPLES The initial evaluation and primary care of an injured hand are critical It provides the best opportunity to assess accurately the extent of damage and to restore the altered anatomy

3. History Age Hand dominance Occupation Details about the injury Mechanism? Where did the injury occur? How much time has elapsed since the injury? Has any treatment been given and by whom?

4. Examination 1 Local swelling Deformity Angulation Displacement Rotational malalignment

5. Examination 2 Soft tissue injury Open wound Location Skin loss Contamination Damage to nerves, tendons, and blood vessels

6. Investigations Plain radiographs posteroanterior (PA), lateral, and oblique All injuries fractures and joint injuries are missed Computed tomography (CT) scan Magnetic resonance imaging (MRI) Ultrasound

7. SPECIFIC INJURIES Metacarpal and Phalangeal Fractures Thumb Metacarpal Base Fracture- Dislocations Proximal Interphalangeal Joint Fracture-Dislocations Thumb Metacarpophalangeal Joint Collateral Ligament Injuries

8. Metacarpal and Phalangeal Fractures 1 Most are treated nonsurgically Surgical indications include: inability to obtain or maintain an acceptable reduction using closed means displaced articular fractures open fractures multiple hand or wrist fractures fractures in the polytraumatized patient.

9. Metacarpal and Phalangeal Fractures 2 Coronal plane angulation and malrotation may lead to digital overlap Best assessed by physical examination

10. Metacarpal and Phalangeal Fractures 3 With flexion, there should be no digital scissoring, and the injured finger should point to the scaphoid tuberosity.

11. Metacarpal and Phalangeal Fractures 4 Fracture stability depends on: fracture pattern fracture displacement supporting structures

12. Metacarpal and Phalangeal Fractures 5 Displaced oblique, spiral, and articular fractures tend to be unstable

13. Metacarpal and Phalangeal Fractures 6 Surgical Techniques closed reduction and percutaneous fixation using K-wires or screws open reduction K-wires alone interfragmentary compression screws tension band technique plate fixation.

14. Thumb Metacarpal Base Fracture-Dislocations 1 Bennett's fracture fracture-dislocation of 1st CMCJ Rolando's fractures T- or Y-shaped intra-articular fractures frequently require ORIF.

15. Thumb Metacarpal Base Fracture-Dislocations 2 Nondisplaced Bennett's fractures without joint instability are treated with a thumb spica cast Most displaced Bennett's fractures can be reduced closed but require internal fixation.

16. Thumb Metacarpal Base Fracture-Dislocations 3 Anatomic reduction of Bennett's fractures is important to avoid painful carpometacarpal instability and posttraumatic arthrosis.

17. PIPJ Fracture-Dislocations 1 Proximal interphalangeal (PIP) joint fracture-dislocations most often involve the base of the middle phalanx

18. PIPJ Fracture-Dislocations 2 Treatment depends on the amount of articular surface involved: 30% or less usually stable when treated by closed reduction and extension block splinting more than 40% to 50% usually require ORIF more than 60% may require dynamic external fixation

19. Thumb MCPJ Collateral Ligament Injuries 1 Ulnar collateral ligament (UCL) provides stability against radially directed stress Tear = Gamekeeper’s / Skier’s thumb Radial collateral ligament less commonly injuried acute injuries are best managed by immobilization

20. Thumb MCPJ Collateral Ligament Injuries 2 UCL tear may be incomplete or complete Complete UCL tear More than 35º of joint laxity on valgus stress testing, with the joint in 30º of flexion and in extension. XR findings of proximal phalanx volar subluxation and radial deviation Arthrography, ultrasound, and MRI

21. Thumb MCPJ Collateral Ligament Injuries 3 Treatment incomplete tears 3weeks of immobilization complete ligament tears require surgical repair. Anatomic repair performed within 3 weeks of injury will achieve good or excellent results in 90% of patients.

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