Basics of Hand Surgery
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Dr. David Moss
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Basics of Hand Surgery
- 1. Basics of Hand Surgery David Moss, MD Osler Society
- 2. Overview • Physical exam & anatomy • Lacerations • Fractures & Dislocations • Arthritis, Contracture, Deformity • Carpal Tunnel • Infection • On the horizon
- 4. • Distal phalanx • Middle phalanx • Proximal phalanx • Metacarpal • DIP joint • PIP joint • MCP joint
- 5. • Proximal row – Scaphoid – Lunate – Triquetrum – Pisiform • Distal row – Trapezium – Trapezoid – Capitate – Hamate • Radius • Ulna
- 6. Tendons
- 7. • Median – C5-T1 • Ulnar – C7-T1 • Radial – C5-8
- 8. Lacerations
- 9. • A thorough exam can diagnose most injuries. Try to avoid wound exploration • Apply direct pressure to bleeders rather than blindly clamping or tying off vessels
- 10. Assess posture of fingers
- 12. • Assess active motion – Flexor digitorum profundus (FDP) • Ask patient to flex DIP while examiner stabilizes the PIP and MCP in extension – Flexor digitorum sublimus (FDS) • Hold all fingers extended except affected finger, then ask the patient to flex affected finger
- 13. • Assess digital perfusion – Color – Turgor – Capillary refill < 2 seconds – Digital Allen’s test • Nerves – Radial digital nerve – Ulnar digital nerve
- 14. Treatment • Thorough I&D • Tetanus – Booster if > 5 years – Immunoglobulin • >10 year since last immunization • Manure, puncture wounds, wounds >6 hours old • Antibiotics – 1st generation cephalosporin for complex wounds (Cefadroxil, Cephalexin) – 3 – 5 day course
- 15. • Suture of simple superficial lacerations • Surgical repair of complex deep wounds
- 16. Mammalian Bites • 80-90% of all bites are dog bites • I&D and then loose closure • Debride puncture wounds (cats) – do not suture • Consider tetanus and rabies prophylaxis • Antibiotic goal is to cover: – Staphylococci, Streptococci, anaerobes, and Pasteurella species. – Augmentin 875 BID – 3 - 5 day course • Human bites – Fight bite – I&D in OR
- 17. • Dog bites – Staphylococcus species – Streptococcus species – Eikenella species – Pasteurella species – Proteus species – Klebsiella species – Haemophilus species – Enterobacter species – DF-2 or Capnocytophaga canimorsus – Bacteroides species – Moraxella species – Corynebacterium species – Neisseria species – Fusobacterium species – Prevotella species – Porphyromonas species • Cat bites – Pasteurella species – Actinomyces species – Propionibacterium species – Bacteroides species – Fusobacterium species – Clostridium species – Wolinella species – Peptostreptococcus species – Staphylococcus species – Streptococcus species
- 19. • Assess neurovascular status • Reduce dislocations/deformity urgently • Open fractures – Emergency operative care for I&D, IV abx – Not the same operative urgency as lower extremity injuries • Splint for comfort and stability
- 20. Phalanx fractures • Deforming forces – Flexor tendons – Extensor tendons – Difficult to maintain reduction – Operative management often required for displaced fractures – CRPP vs. ORIF • Rotational deformity
- 21. Mallet finger
- 22. Treatment
- 23. Metacarpal fracture • Acceptable angulation up to 40° in some cases • Boxer’s fracture – 5th metacarpal neck
- 24. Scissoring
- 25. Carpal fractures • Scaphoid – TTP in “snuff box” • Thumb spica even if normal x-rays – Poor vascularity • Slow to heal • Non-unions common – MRI can help to diagnose acute non- displaced fractures
- 26. Distal radius fractures • “Colles fracture” • Fall onto outstretched hand • Closed reduction required for displaced fractures • Beware of open fracture – open ulnar puncture
- 27. • Operative intervention for unstable fractures – ORIF now more common than ex fix – Locking technology
- 28. Fragility fracture • Fracture from low-energy events • Hip, spine, proximal humerus, distal radius • DEXA scan • Labs to exclude other causes • Treatment – Bisphosphonates – Hormone replacement
- 30. Ganglion • 60% of hand lesions • Benign fluid filled sac – Not a true cyst – lacks epithelial lining – Glucosamine, albumin, hyaluronic acid, globulin • Communicates with joint or tendon sheath • Women > men = 3:1 • Soft, mobile, transilluminates
- 31. Treatment • Observation – up to 50% spontaneous resolution • Aspiration – +/- steroid injection – >50% recurrence – Avoid aspiration for volar ganglion • Surgical excision – <5% recurrence – Open or arthroscopic
- 32. Basal Joint Arthritis • Symptoms – Pain at base of thumb at carpo-metacarpal joint – Pain with heavy grip and pinch • Lifting pots • Turning keys • X-rays – Spurs/osteophytes – Collapsed joint space
- 33. Treatment • Initial – Thumb spica splint – NSAIDs – Activity modification • Injection – steroid • Surgery – Resect trapezium – +/- LRTI
- 34. Dupuytren’s Contracture • Contracture of palmar fascia • Progressive deformity • Men >> Women • Autosomal dominant • Northern European/ Scandanavian/British
- 36. Treatment • Surgical excision – Painful nodules – Contracture > 30° • Needle aponeurotomy • Collagenase – Injected into cord – Recent FDA approval
- 37. Carpal tunnel syndrome • Median nerve compressed by transverse carpal ligament at wrist
- 38. Symptoms • Pain & numbness • Grip weakness • Women > Men • Nocturnal pain • Only associated occupational risk: – Jack hammer use
- 40. Treatment • R/o cervical etiology • Night splinting • +/- Injection • Surgical release – Open – Endoscopic
- 41. Infection
- 42. Paronychia • S Aureus • Pseudomonas • Candida • Acute treatment: – warm soaks – 1st gen cephalosporin – 3-5 days • Abscess: office I&D
- 43. Felon • Infection of volar distal pulp • Usually S Aureus • Rx – I&D – 1st gen cephalosporin • 3-5 days
- 44. Supporative Flexor Tenosynovitis • Infection of flexor tendon sheath • S Aureus & Gr A Beta Hemolytic Strep
- 45. Kanavel’s Cardinal Signs • Flexed posture • Pain with passive extension • Fusiform swelling – “Sausage digit” • Tenderness along flexor tendon
- 46. Treatment • Emergency I&D • Antibiotics
- 47. What’s New?
- 48. Platelet-Rich Plasma • Autologous blood with platelet concentration > baseline values • Growth factors recruit reparative cells, enhance healing
- 49. Growth Factors in PRP • Platelet-derived growth factor – Platelets Stimulates cell replication, angiogenesis, mitogen for fibroblasts • Vascular endothelial growth factor – Platelets Angiogenesis • Transforming growth factor-β1 – Platelets Key regulator in balance between fibrosis and myocyte regeneration • Fibroblast growth factor – Platelets Stimulates proliferation of myoblasts,angiogenesis • Epidermal growth factor – Platelets Proliferation of mesenchymal and epithelial cells, potentiation of other growth factors • Hepatocyte growth factor – Plasma Angiogenesis, mitogen for endothelial cells, antifibrotic • Insulin-like growth factor-1 – Plasma Stimulates myoblasts and fibroblasts, mediates growth and repair of skeletal muscle
- 51. • Exciting treatment option • Lots of potential • Excellent safety profile • Awaiting definitive supporting evidence
- 52. Thank You